Embryonic NOTES thoracic sympathectomy for palmar hyperhidrosis: results of a novel technique and comparison with the conventional VATS procedure
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- Zhu, L., Chen, L., Yang, S. et al. Surg Endosc (2013) 27: 4124. doi:10.1007/s00464-013-3079-0
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To avoid the disadvantages of chronic pain and chest wall paresthesia associated with video-assisted thoracic surgery (VATS) procedures, we developed a novel surgical technique for performing sympathectomy by embryonic natural orifice transumbilical endoscopic surgery (E-NOTES) with a flexible endoscope. In this study, we compared the outcomes of E-NOTES with conventional VATS thoracic sympathectomy on palmar hyperhidrosis.
From January 2010 to April 2011, a total of 66 patients with severe palmar hyperhidrosis were treated with thoracic sympathectomy in our department. Thirty-four transumbilical thoracic sympathectomies were performed via a 5-mm umbilicus incision with ultrathin gastroscope, then compared with 32 conventional needlescopic thoracic sympathectomies. Retrospective statistical analysis of a prospectively collected group of patients was performed.
There was no significant difference with regard to gender, mean age, body mass index, and length of hospital stay between the two groups. The operative time for E-NOTES thoracic sympathectomy was longer than that of VATS thoracic sympathectomy (56.4 ± 10.8 vs. 40.3 ± 6.5 min, p < 0.01). No mortality, diaphragmatic hernia, or Horner syndrome was observed in either group. Postoperative questionnaires were returned by all treated patients with a mean time from operation to follow-up of 1.4 ± 0.3 years. All 66 patients receiving sympathectomy reported successful treatment of their palmar hyperhidrosis. Compensatory hyperhidrosis was noticed in 7 (20.1 %) and 6 (18.8 %) patients in the E-NOTES and VATS groups, respectively (p > 0.05). Postoperative pain and paresthesia were significantly reduced in the E-NOTES group at each time interval, and the aesthetic effect of the incision was superior in the E-NOTES group.
Transumbilical-diaphragmatic thoracic sympathectomy is a safe and efficacious alternative to the conventional approach. This novel procedure can further reduce postoperative pain and chest wall paresthesia as well as afford maximum cosmetic benefits by hiding the surgical incision in the umbilicus.
KeywordsEmbryonic NOTESPalmar hyperhidrosisThoracic sympathectomyVideo-assisted thoracic surgery
Thoracic sympathectomy, especially via the needlescopic video-assisted thoracic surgery (VATS) approach, is one of the most commonly performed functional surgeries to treat palmar hyperhidrosis . VATS is an advanced surgical technique that uses 3-mm ports instead of the conventional 10-mm ones. But VATS sympathectomy generally required two to three 3-mm ports on each side of the chest. The first port is placed in the fourth or fifth intercostal space near the anterior auxiliary line and is used as an entrance for the camera, and the instrument ports are typically placed in the midaxillary line in the third or fourth intercostal space. However, postoperative chest pain and paresthesia are still a concern [2, 3]. Additionally, the VATS approach is not suitable for the women with saline or silicone breast implants .
To reduce the operative trauma from chest wall incisions and provide improved cosmesis, we developed a novel surgical technique for performance of sympathectomy by embryonic natural orifice transumbilical endoscopic surgery (E-NOTES). Our previous study showed that E-NOTES sympathectomy was technically feasible and safe in the treatment of primary hyperhidrosis . However, no comparative studies have been conducted to prove that E-NOTES is less painful but equally effective as VATS. The aim of the current study was to investigate any possible differences between the standard treatment of VATS and this novel technique.
Patients and methods
From January 2010 to April 2011, a total of 91 consecutive patients with primary hyperhidrosis, and thus requiring thoracic sympathectomy, were enrolled onto this study. Twenty-five patients who also had axillary hyperhidrosis were excluded from the trial. The remaining 66 patients who reported that the symptoms had severely interfered with their work or social activities were chosen to undergo VATS or E-NOTES. The type of surgery was chosen on the basis of patient preference after the attending surgeon explained the differences between the two procedures.
All patients had tried conservative treatment with numerous topical agents and alternative therapies, without much improvement. Patients who had a history of abdominal or thoracic surgery or who had cardiac diseases, pulmonary infections, and pleural or peritoneal diseases were excluded.
All patients came from the same outpatient clinic and were treated by a single surgical team under the same procedural policy and postoperative care strategy. The trial was approved by institutional review board of Fuzhou General Hospital, and informed consent was obtained from all patients.
All operations were performed with the patient under general anesthesia using a double-lumen endotracheal tube. All of the patients underwent one-stage bilateral T3 thoracic sympathectomy. This was performed at the third rib for ablation of the T3 ganglion, and the diathermy incision was routinely extended laterally for approximately 3 cm on the corresponding costa to include the nerve of Kuntz. A chest X-ray was performed in the recovery room immediately after surgery to ascertain complete lung expansion.
Surgical technique of E-NOTES sympathectomy
Surgical technique of VATS sympathectomy
Data collection and analyses
The clinical data, operation time, perioperative complications, and length of hospital stay were collected from the medical records. Operation time was defined as the time from the skin incision to the end of skin closure. Pain scores were evaluated at 4, 8, and 12 h after surgery using visual analog scales (VAS) from 0 (no pain) to 10 (worst pain ever experienced).
Follow-up examinations were conducted through office visits or telephone/e-mail interviews at 24 h, 1 week, and 1 month after surgery and then subsequently at 6–9-month intervals. Collected data included resolution of symptoms, postoperative complications, whether a recurrence occurred, and satisfaction with aesthetic result. The clinical presentation of compensatory hyperhidrosis (CH) was classified as mild, moderate, or severe . Minor CH is characterized by sweating that occurs in small amounts, i.e., symptoms that do not severely affect the patient’s daily life. Moderate CH is characterized by endurable but noticeably irritating symptoms that do affect the patient’s life. Severe CH is when sweating occurs in large amounts, requiring a change of clothes one or more times a day. Satisfaction with the wound scar was recorded by patients characterizing themselves as satisfied, fair, or dissatisfied.
Statistical analysis was performed by SPSS software, version 13.0 (SPSS, Chicago, IL, USA). All p values reported were two-sided, and p < 0.05 denoted statistical significance. Continuous variables were presented as means ± standard deviations and compared by Student’s t test, whereas categorical variables were evaluated with Fisher’s exact test or the χ2 test.
Comparison of baseline demographics between the two groups
Category or measures
(n = 34)
(n = 32)
Mean ± SD
22.4 ± 5.3
23.2 ± 5.8
Mean ± SD
21.4 ± 3.3
21.7 ± 3.2
Comparison of clinical data between the two groups
(n = 34)
(n = 32)
Operating time (min)
56.4 ± 10.8
40.3 ± 6.5
Mean increase in temperature (°C)
2.5 ± 0.6
2.6 ± 0.7
Postoperative stay (days)
1.4 ± 0.4
1.5 ± 0.4
34 (100 %)
32 (100 %)
5 (14.7 %)
2 (6.3 %)
7 (20.1 %)
6 (18.8 %)
Comparison of postoperative pain and paresthesia, and the cosmetic results between the two groups
(n = 34)
(n = 32)
Pain score (visual analog scale)
4 h after operation
1.4 ± 0.5
3.3 ± 0.7
8 h after operation
3.1 ± 0.7
4.4 ± 0.6
12 h after operation
2.1 ± 0.8
4.1 ± 0.6
1 day after surgery
1 week after surgery
1 month after surgery
Primary palmar hyperhidrosis is a disease characterized by sweating of the palms beyond the physiological needs of the body. It begins in infancy and adolescence, and its cause is unknown. Standing out in its physiopathology is an anomalous stimulus by the sympathetic nervous system on the sweat glands through the paravertebral sympathetic chain . Severe palmar hyperhidrosis may in some cases cause extreme embarrassment or discomfort and can result in significant social disability.
In the VATS procedure, the persistence of postoperative pain remains an unresolved issue. A clinical study of 406 consecutive VATS sympathectomies reported that 93 % of patients had wound pain at the time of discharge, 59.1 % of patients experienced pain of more than 15 days’ duration, and 15 % of patients experienced dysesthesia . With the development of technology in the videoscopic field, needlescopic equipment and instruments have been introduced into clinical practice. The 10-mm-diameter instruments of conventional VATS were replaced by 2- or 3-mm needlescopic equipment. We would expect that the smaller incisions lead to minimized scarring and milder postoperative pain. However, paresthesia was reported in up to 50.0 % of patients after VATS sympathectomy, and it could persist for up to 12 months after surgery . This set of symptoms is generally explained by trauma to the thoracic wall caused while introducing the trocars into the intercostal space.
To minimize operative discomfort, NOTES is considered to be the next logical step . In 2010, Turner et al.  reported a transesophageal thoracic sympathectomy in a porcine model. In their study, they used submucosal endoscopy with mucosal flap. A short, 5-cm submucosal tunnel was created by using the tip of the endoscope and biopsy forceps. Subsequently, they used a needle-knife to incise the muscularis propria of the esophagus and permit entry into the thoracic cavity. A different alternative, presented by Yang et al. , is transoral endoscopic access to the posterior aspects of the thorax in a canine model. Although published series have achieved success in animal experiments, it is clear that many obstacles needed to be overcome when transferring the NOTES technique from animal experiments to human settings in thoracic surgery.
Transumbilical single incision laparoscopy surgery is considered to be a bridge to NOTES [10, 11] because it seems to be safer and more feasible. Keeping this in mind, our group developed transumbilical-diaphragmatic thoracic sympathectomy with an ultrathin flexible endoscope for tackling hyperhidrosis in human patients. E-NOTES thoracic sympathectomy is not a new technique per se, but it is a novel approach to the thoracic cavity surgery and an alternative to the standard thoracic VATS procedure. This study provided a comparison of a standard VATS technique and an E-NOTES procedure. For homogeneity of the patient cohort, we selectively studied only patients presenting with palmar hyperhidrosis and who underwent bilateral T3 sympathectomy. Our results clearly demonstrated that transumbilical-diaphragmatic thoracic sympathectomy is a safe and efficacious alternative to the conventional approach. The outcomes and patient satisfaction of E-NOTES sympathectomy were also consistent with those of other published thoracoscopic sympathectomies [7, 12, 13].
There were also similar complication rates related to the thoracic sympathectomy in both the E-NOTES and VATS groups. The most common side effect is CH, which occurred in the literature from 3 to 98 % [14, 15]. No significant difference between the two groups with respect to the frequency and severity of CH was observed. In our study, CH was noticed in 7 (20.1 %) patients in the E-NOTES group and 6 (18.8 %) patients in the VATS group. Some clinicians believe that the more destructive the procedure, the higher the risk of postoperative severe CH [16–19]. Therefore, we performed only a limited ablation and did not remove any of the sympathetic chain in either group. Postoperative Horner syndrome, which is caused by direct or indirect damage to T1 by current diffusion or excessive traction on the chain during dissection or ablation, was not observed in either group, suggesting that Horner syndrome is rarely induced during T3 sympathectomy.
However, the VAS pain score during the first 12 postoperative hours was significantly higher in patients who underwent VATS. The percentage of patients with paresthesia at various time points after surgery was also significantly higher in the VATS group than in the E-NOTES group. The difference between the two groups, apart from the number of incisions, was that the E-NOTES group lacked a chest wall incision. Thus, the difference in VAS pain score reported and paresthesia experienced by the patients is likely explained by the trauma to the thoracic wall while introducing the trocars into the intercostal space . In addition, the umbilical incision may reduce the stimulation of pain receptors. Decreased pain aside, the transumbilical approach provides a more aesthetically pleasing scar, hidden in the umbilicus.
The E-NOTES thoracic sympathectomy also has some limitations. The operative time for E-NOTES group was longer than that of VATS group. This may in part be due to the lack of experience that cardiothoracic surgeons have in handling flexible endoscopes. Although there was no evidence of thoracic or abdominal organ injury during the operation, the E-NOTES technique potentially increased the risk of intra-abdominal tissue injury.
In our prospective study comparing E-NOTES thoracic sympathectomy with VATS thoracic sympathectomy, we found no significant differences in terms of safety and efficacy between the two groups, but this study did demonstrate that E-NOTES thoracic sympathectomy can further reduce postoperative pain and chest wall paresthesia. In addition, this novel procedure affords maximum cosmetic benefits.
We acknowledge that this study was not randomized, and potential biases may have existed during allocation of surgical procedures. In addition, the follow-up period was short and the number of patients in each group was small. Thus, future large-scale randomized clinical trials should be performed to evaluate the efficacy of E-NOTES thoracic sympathectomy.
This work was supported by the Key Project of Science and Technology of Fujian Province (Grant 2010I0011). We thank Lily Chen for her revision.
Li-Huan Zhu, Long Chen, Shengsheng Yang, Daoming Liu, Jixue Zhang, Xianjin Cheng, and Weisheng Chen have no conflicts of interest or financial ties to disclose.