Endoscopic Lumbar Sympathectomy

Lumbar sympathectomy surgery is a procedure used to treat severe plantar hyperhidrosis, but there are many potential dangers that come along with this type of surgery.
Endoscopic Lumbar Sympathectomy

Hyperhidrosis is known to affect around 3% of the American population, and about half of those people will have plantar hyperhidrosis, or excessive sweating on the soles of their feet.[1][2] When someone is diagnosed with primary focal hyperhidrosis, the type of hyperhidrosis that causes excessive sweating on specific areas of the body, they are first directed to use conservative treatments. For those with plantar hyperhidrosis, the conservative treatment options include topical over-the-counter treatments (antiperspirant), iontophoresis for plantar hyperhidrosis, botox for plantar hyperhidrosis and oral medications for hyperhidrosis. For some people with severe plantar hyperhidrosis these treatments, and even combinations of these treatments, do not seem to be enough. At this point, doctors may begin to talk to patients about surgical treatments for primary focal hyperhidrosis. Most of the time a procedure called an endoscopic thoracic sympathectomy is suggested for people who have palmar hyperhidrosis. There is a similar surgical procedure for people with plantar hyperhidrosis called endoscopic lumbar sympathectomy. However, this surgery comes with some very big risks and many sources advise against its use.

What It Is and How It Works

An endoscopic lumbar sympathectomy is a surgery used to stop excessive sweating from overactive sweat glands on the soles of feet by disrupting nerve signals from the sympathetic nervous system to the feet. This essentially blocks sympathetic nerves from telling the eccrine glands on the feet to produce sweat, thereby preventing excessive sweating. The procedure is similar to how an endoscopic thoracic sympathectomy is performed, only it is performed on a lower level of the spine, usually around L3 and L4.[3]

Before surgery, a patient is administered general anesthesia. A surgeon will mark the areas where they are going to make small incisions. The incisions are made somewhere between the end of the rib cage and the top of the hip bone, and a tiny camera is inserted so the surgeon can see inside the body. Once this has been done the surgeon inserts a balloon into the retroperitoneal cavity and inflate it to make room for the surgeon to visualize and carry out the procedure. Once the sympathetic nerve chain is located the surgeon will clamp it (or use another technique to disrupt it) between the T3 and T4 vertebrae. The procedure can be done unilaterally (on one side only) or bilaterally (both sides) depending on the surgeon and the patient’s needs. The surgeon must be extremely careful not to damage other important nerves, the ureters, lymphatic vessels, the lumbar vein, and other anatomy in that region.[3]

Depending on the surgeon, a patient may be allowed to leave several hours after surgery, or they may have to stay in the hospital for a few days.[3] Most patients do experience significant pain which can last for longer than ten days, in some instances it has been to last for up to three months.[2]

Efficacy

The efficacy of endoscopic lumbar sympathectomy surgery needs to be studied further before any final conclusions about the procedure can be drawn. The studies that have been done on the procedure seems to demonstrate that the surgery is effective at reducing sweating of the feet. One study claimed that ELS could eliminate hyperhidrosis symptoms of the feet over 95% of the time. This shows that the surgery is effective, but the same study also reported that over two-thirds of the patients developed unwanted side effects, specifically neuralgia and compensatory sweating. Overall, the study found that even in patients who suffered from side effects, they still had a statistically significant improvement in their quality of life.[4] Another study, which collected data on a group of women undergoing ELS found that 53% of the patients were unhappy with the aesthetic alterations caused by the surgery. The same study reported that overall the patients in the study had an increased quality of life afterward.[2] Endoscopic lumbar sympathectomy appears to be effective at reducing sweating of the feet, but at a high cost, that many deem unnecessary. Interestingly, 60% of patients who undergo endoscopic thoracic sympathectomy, a type of surgical treatment for palmar hyperhidrosis, also sweat significantly less from their feet.[2]

Complications and Dangers of Surgery

There are several complications that can occur during or after ELS surgery, and it is extremely important for patients to take this into consideration. One of the most dramatic side effects of surgery is ejaculatory impotence in men, and it can be assumed that surgery may also affect women’s genitosexual innervation as well. Some surgeons will only perform the surgery on women, but the practice is questionable because they can suffer nerve damage as well.[5] One study said that out of 92 bilateral ELS surgeries only one man suffered impotence, however, that is a rate of higher than 1%.[4] Another complication is compensatory sweating, which is when sweating becomes worse on other areas of the body once sweating on the original problem area is treated. There is a high incidence of compensatory sweating after ELS, with 87.5% of patients developing it in one study.[6] Postoperative neuralgia, which is considered to be pain of the groin, thigh, or back of varying intensity, is probably the third most significant side effect. One study concluded that two-thirds of patients developed either compensatory sweating or neuralgia.[4] There are other surgical dangers that can occur if a surgeon makes a mistake during a procedure as they are operating near vital organs and nerves.

Overall, endoscopic lumbar sympathectomy seems to be an effective procedure that is rife with complications and serious side effects. Patients should be cautious when thinking about this operation, as many doctors who manage hyperhidrosis cases strictly advise against it.

Sources
  1. Pariser, D. M. (2014). Hyperhidrosis (4th ed., Vol. 32). Philadelphia, PA: Elsevier.
  2. De Paula Loureiro, M., De Campos, J., Kauffman, P., Jatene, F. B., Weigmann, S., & Fontanac, A. (2008). Endoscopic Lumbar Sympathectomy for Women: Effect on Compensatory Sweat. Clinics,63(2), 189-196. Retrieved October 1, 2018.
  3. Reisfeld, R. (2010). Endoscopic Lumbar Sympathectomy for Focal Plantar Hyperhidrosis Using the Clamping Method. Surg Laparosc Endosc Percutan Tech, 20(4), 321-236. Retrieved October 2, 2018.
  4. Rieger, R., Pedevilla, S., & Lausecker, J. (2015). Quality of Life After Endoscopic Lumbar Sympathectomy for Primary Plantar Hyperhidrosis. World Journal of Surgery, 39, 905-911. doi:10.1007/s00268-014-2885-4
  5. Collin, J., & Whatling, P. (2000). Treating hyperhidrosis Surgery and botulinum toxin are treatments of choice in severe cases. BMJ, 320(7244), 1221-1222. Retrieved October 2, 2018.
  6. Wolosker, N., Ishy, A., Yazbeck, G., Milanez de Campos, J. R., Kauffman, P., Puech-Leão, P., & JateneII, F. B. (2013). Objective evaluation of plantar hyperhidrosis after sympathectomy. Clinics,68(3), 311-315. doi:10.6061/clinics/2013(03)OA05
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