Download V09 Thoracoscopic Sympathectomy

V09 Thoracoscopic Sympathectomy
What is hyperhidrosis?
Hyperhidrosis is a condition where you
sweat more than you need to. The areas
that are commonly affected include the
palms of your hands, armpits, feet, face
and neck. About 1 in 100 people is affected
by hyperhidrosis. It can often make you
feel embarrassed and anxious.
Your surgeon has recommended a
thoracoscopic sympathectomy. However,
it is your decision to go ahead with the
operation or not. This document will give
you information about the benefits and
risks to help you make an informed
decision.
If you have any questions that this
document does not answer, you should
ask your surgeon or any member of the
healthcare team.
Why does hyperhidrosis happen?
You sweat to regulate the temperature of
your body. The amount you sweat is
controlled by the sympathetic nervous
system (see figure 1). If this system is
overactive, you can sweat more than you
need to.
Spine
Sympathetic
nerves
Ribs
Figure 1
The sympathetic nervous system
The condition can be worse when you are
under emotional stress or in a warm
environment.
There are two types of hyperhidrosis.
• Primary hyperhidrosis - This type is
more common and the cause is not known.
The condition can happen all the time, or
every now and then. Usually the condition
starts when you are a child or teenager,
and may last all your life.
• Secondary hyperhidrosis - This type
causes sweating all over your body. It is
usually caused by a disease that affects
your endocrine (hormonal) system such as
diabetes or having an overactive thyroid
gland. It can also be caused by certain
cancers, the menopause and obesity.
What are the benefits of surgery?
If the operation is successful, you should
stop sweating too much. The operation
can also be used to treat excessive
flushing of the face.
You should be more comfortable in your
social relationships and have a boost in
self-confidence.
Are there any alternatives to surgery?
The following treatments can give
temporary relief to the symptoms of
hyperhidrosis.
• Antiperspirants - Usually people with
armpit (axillary) hyperhidrosis have
already tried strong antiperspirants. These
work by making sweat thicker, which
blocks the skin pores. To be effective, the
antiperspirant needs to be applied
regularly.
• Iontophoresis - This technique uses a
small electric current to stop sweat glands
from working. However, the effect is only
temporary and the treatment needs to be
repeated at least every week.
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• Botox injections - Botox works by
blocking the nerves that control the sweat
glands. The injections need to be repeated
about every six months. The body can
develop resistance to Botox, making the
treatment less effective over time. There
are risks associated with the long-term use
of Botox injections.
• Oral (by mouth) medications - These
work by stopping sweat glands being
stimulated. Symptoms usually improve in
about two weeks. However, there are
unpleasant side effects, including a dry
mouth and blurred vision.
Surgery is the only way to give you lasting
relief of your symptoms.
What will happen if I decide not to have
the operation?
You will continue to sweat too much. If you
have primary hyperhidrosis, it is likely that
your symptoms will continue for the rest of
your life. Your doctor may be able to
recommend a more effective non-surgical
alternative for you.
What does the operation involve?
The sweat glands in your hands, face and
armpits are controlled by nerves in your
chest called the thoracic sympathetic
nerves. There are two chains of nerves,
each controlling one side of your body, so
your surgeon will usually need to perform
the operation on both sides of your chest.
The healthcare team will carry out a
number of checks to make sure you have
the operation you came in for and on the
correct side. You can help by confirming to
your surgeon and the healthcare team
your name and the operation you are
having.
The operation is performed under a
general anaesthetic and usually takes
between half an hour and two hours. You
may also have injections of local
anaesthetic to help with the pain after
surgery. Your surgeon or anaesthetist may
give you antibiotics during the operation to
reduce the risk of infection.
Your surgeon will use a thoracoscopic
technique (‘keyhole’ surgery). They will
usually need to make two or three small
cuts in the upper part of your chest wall
near your armpits so they can insert tubes
(ports) into your chest. Your surgeon will
place surgical instruments through the
ports along with a telescope.
Your surgeon will use gas (carbon dioxide)
to collapse one of your lungs to give room
to identify the nerves. Your surgeon will cut
the nerves using an electric current
(cauterisation) or clamp the nerves using
clips. They will only operate on the nerves
they need to, depending on your
symptoms (see figure 2).
Your surgeon will then inflate your lung,
close the cuts with stitches and perform
the operation again on the other side of
your chest.
Cut
Sympathetic
nerves
Rib
Figure 2
A cut sympathetic nerve
What should
medication?
I
do
about
my
You should make sure your surgeon
knows the medication you are on and
follow their advice.
You may need to stop taking warfarin,
clopidogrel (Plavix) or aspirin before your
operation.
If you are a diabetic, it is important that
your diabetes is controlled around the time
of your operation. Follow your surgeon’s
advice about when to take your
medication.
If you are on beta-blockers to control your
blood pressure, you should continue to
take your medication as normal.
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What can I do to help make the
operation a success?
• Lifestyle changes
If you smoke, try to stop smoking now.
Stopping smoking several weeks or more
before an operation may reduce your
chances of getting complications and will
improve your long-term health.
For help and advice on stopping smoking,
go to www.smokefree.nhs.uk.
You have a higher chance of developing
complications if you are overweight.
For advice on maintaining a healthy
weight, go to www.eatwell.gov.uk.
• Exercise
Regular exercise can reduce the risk of
heart disease and other medical
conditions, improve how your lungs work,
boost your immune system, help you to
control your weight and improve your
mood. Exercise should help to prepare you
for the operation, help with your recovery
and improve your long-term health.
For information on how exercise can help
you, go to www.eidoactive.co.uk.
Before you start exercising, you should ask
a member of the healthcare team or your
GP for advice.
What complications can happen?
The healthcare team will try to make your
operation as safe as possible. However,
complications can happen. Some of these
can be serious and can even cause death.
You should ask your doctor if there is
anything you do not understand. Any
numbers which relate to risk are from
studies of people who have had this
operation. Your doctor may be able to tell
you if the risk of a complication is higher or
lower for you.
The complications fall into three
categories.
1 Complications of anaesthesia
2 General complications of any operation
3 Specific complications of this operation
1 Complications of anaesthesia
Your anaesthetist will be able to discuss
with you the possible complications of
having an anaesthetic.
2 General complications
operation
of
any
• Pain, which happens with every
operation. However, pain after a
thoracoscopic sympathectomy is usually
mild and is easily controlled by simple
painkillers such as ibuprofen and
paracetamol.
• Bleeding during or after surgery. If this
happens, you may need a drain (small
tube) in your chest. Sometimes you may
need another operation to control any
bleeding (risk: 1 in 100).
• Infection of the surgical site (wound).
To reduce the risk of infection it is
important to keep warm around the time of
your operation. Let a member of the
healthcare team know if you feel cold. In
the week before your operation, you
should not shave the area where a cut is
likely to be made. Try to have a bath or
shower either the day before or on the day
of your operation. After your operation, you
should let your surgeon know if you get a
temperature, notice pus in your wound, or
if your wound becomes red, sore or
painful. An infection usually settles with
antibiotics but you may occasionally need
another operation.
• Unsightly scarring of the skin,
although the small cuts usually heal to neat
scars.
• Blood clots in the legs (deep-vein
thrombosis) (risk: 1 in 100), which can
occasionally
move
through
the
bloodstream to the lungs (pulmonary
embolus), making it difficult for you to
breathe (risk: 1 in 150). The healthcare
team will assess your risk. Nurses will
encourage you to get out of bed soon after
surgery and may give you injections,
medication or special stockings to wear.
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3 Specific complications
operation
of
this
• Pneumothorax, where there is air in
the space around the lung as the lung has
failed to inflate completely. Usually a
pneumothorax is small and does not cause
any problems. Sometimes you will need a
tube in your chest to release any air that
has collected in the space around the lung
(risk: 1 in 100). If you suddenly become
short of breath or have severe chest pain
while at home, let your doctor know
straight away.
• Infection in the space around your
lung (risk: 1 in 100). Treatment may
involve draining any infected fluid. If this
happens, you will need to stay in hospital.
• Surgical emphysema, where air leaks
into the tissue under the skin near the ports
(risk: 1 in 40). This is not serious and
usually settles within a few days.
• Cardiac sympathetic denervation
(bradycardia), where your heart rate slows
down. This is usually minor and only 3 in
20 people notice it.
• Horner’s syndrome, where the
sympathetic nerves that control the face
are damaged (risk: 1 in 100). This can
cause your upper eyelid to droop, the pupil
in your eye to shrink and reduced sweating
in your face. The condition can improve
with time but may be permanent.
• Compensatory sweating, where other
parts of your body start to sweat more to
make up for you sweating less in the areas
affected by the operation (risk: 4 in 5). In
most people the symptoms are mild.
However, in some people the symptoms
cause significant discomfort equal to or
worse than their symptoms before the
operation (risk: 1 in 100).
• Gustatory sweating, where you sweat
when you smell or eat food (risk: 3 in 100).
• Failure of the operation (risk: up to 1
in 10). The operation is most effective for
hand sweating, and less effective for
armpit and facial sweating.
• Nerve damage. The ports can damage
the nerves on the ribs causing pain
(neuralgia). This usually settles with time
but you may need to take painkillers.
How soon will I recover?
• In hospital
After the operation you will be transferred
to the recovery area and then to the ward.
You will have a chest x-ray to find out if
your lungs have expanded enough. If you
have a small pneumothorax, you will need
to stay in hospital and have another x-ray
the following day. Most people go home
the day after surgery. However, your
doctor may recommend that you stay a
little longer.
If you are worried about anything, in
hospital or at home, contact a member of
the healthcare team. They should be able
to reassure you or identify and treat any
complications.
• Returning to normal activities
Once at home, if you have severe chest
pain, continued vomiting, a high
temperature lasting more than twelve
hours, sudden breathlessness, or you
cough up more than a tablespoon of blood,
let your doctor know straight away.
You should be able to return to normal
activities after five to seven days. It is
normal to have some discomfort when you
breathe. This usually happens because
your chest wall can get bruised during the
operation.
You should normally not fly for one month
after the operation. If you have a small
pneumothorax, it may get bigger during the
flight making it difficult for you to breathe. If
you want to fly in less than one month, you
should discuss this with your doctor.
Regular exercise should help you to return
to normal activities as soon as possible.
Before you start exercising, you should ask
a member of the healthcare team or your
GP for advice.
Do not drive until you are confident about
controlling your vehicle and always check
with your doctor and insurance company
first.
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• The future
Local information
Most people make a good recovery. If your
hands get very dry, you may need to use a
moisturiser.
Occasionally the hyperhidrosis comes
back (risk: less than 2 in 100). Usually any
symptoms are mild.
You can get information locally from:
Summary
Hyperhidrosis is a condition where you
sweat more than you need to. If your
symptoms cannot be controlled using
simple treatments, a thoracoscopic
sympathectomy should make you more
comfortable
and
boost
your
self-confidence.
Surgery is usually safe and effective.
However, complications can happen. You
need to know about them to help you make
an informed decision about surgery.
Knowing about them will also help to
detect and treat any problems early.
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You may also find the following links
useful.
• www.patient.co.uk
• www.prodigy.nhs.uk/PatientInformation/
• www.patientopinion.org.uk
• www.northamptongeneral.nhs.uk
• www.npsa.nhs.uk/pleaseask
Tell us how useful you found this
document at www.patientfeedback.org
This document is intended for information
purposes only and should not replace advice
that your relevant health professional would
give you.
V09
Issued December 2009
Expires end of December 2010
Further information
• NHS smoking helpline on 0800 022 4
332 and at www.smokefree.nhs.uk
• www.eatwell.gov.uk – for advice on
maintaining a healthy weight
• www.eidoactive.co.uk – for information
on how exercise can help you
• www.aboutmyhealth.org – for support
and information you can trust
• Vascular Society of Great Britain and
Ireland at www.vascularsociety.org.uk
• NHS Direct on 0845 46 47 (0845 606
46 47 – textphone)
www.rcsed.ac.uk
www.asgbi.org.uk
Acknowledgements
Author: Mr Bruce Braithwaite MChir FRCS and Mr
Shane MacSweeney MChir FRCS
Illustrations: Hannah Ravenscroft RM
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