FischelCDROM
From Corposcindosis
Contents |
Richard J. Fischel MD, Ph.D
Patient Introduction
Hello, I’m Doctor Rick Fischel, the Director of the Chapman Lung Center at Chapman Medical Center in Orange, California. I’ve prepared for you a CD-ROM with educational material regarding three of the specialty procedures that are performed here at the Chapman Medical Center.
I participated in the UC-Riverside/UCLA Biomedical Sciences Program leading to an MD degree at UCLA in 1984. Following that I attended the University of Minnesota, where I completed my residency in general surgery, as well as a fellowship in cardiovascular and thoracic surgery. At that time I also attended the graduate school, and received a Ph.D in immunology and surgery for research done in the field of xenotransplantation.
I’m board certified in both general surgery, and cardiovascular and thoracic surgery. I’m a member of numerous societies including The Society of Thoracic Surgeons, The American College of Surgeons, The 21st Century Cardiothoracic Surgical Society and others that keep me up-to-date and recent with the events going on in thoracic surgery.
I’ve prepared this educational CD-ROM to provide you with information on three of the specialty procedures that we perform here at Chapman Medical Center, the first one being ‘Lung Volume Reduction Surgery’ for the treatment of emphysema, the second being ‘Minimally Invasive Surgery for Hyperhidrosis’, and the third being ‘Video-Assisted Lobectomies’ for the treatment of lung cancer.
I hope that you are able to spend some time to look through these presentations and that they provide you with information that you would like to know or were interested in regarding these specialty procedures. I appreciate your time and thank you very much.
Hyperhidrosis Presentation
I’d like to welcome you to a little talk on video-assisted surgery for essential hyperhidrosis. I’m Dr. Rick Fischel, and I am a thoracic surgeon, and this is one of my specialty procedures that we’ve had very wonderful results with. I’m going to give you a little presentation to sort of talk about it and describe what it is that we do. What I’m going to really do is tell you what we do, how we do it, why we do it that way, what are results are, and why that’s different than what anybody else does. And I think you’ll uh, enjoy this.
Hyperhidrosis, the word itself, really just means ‘too much sweating’. It doesn’t say where, it doesn’t say why, it doesn’t say who’s going to have it. But I like to discuss it . . . we’re talking a lot of times about people who have excessive or dripping sweating from their hands. I call this a ‘non-physiologic type of sweat’. This is not the body trying to cool down. That’s normal sweating, you need to do that to regulate heat. This is sweating that is related to a little nerve inside the body.
It occurs in about 1% of the population, so it’s much more common than people think. A lot of people think that they’re the only person in the world who has it, and then they meet other people when they come and . . . and see me and have other people in the waiting room and they talk about it and realize they’re not alone. And it often runs in families. Okay.
Essential hyperhidrosis - it essentially describes excessive sweating of the hands and feet, it may also include the face, or the armpits. The sweating occurs without any provocation whatsoever, and it is usually worsened with any form of anxiety. One of the key factors that I find in this is that there’s a definite mental connection. Thinking about the sweating, or thinking about your hand, or thinking about meeting somebody and having to give a presentation or shake their hand in public, or something such as that, will cause the problem to get worse. And the more you think about it to try and make it go away, the worse it gets. That’s essentially a . . .a definite diagnosis of essential hyperhidrosis.
Most of the people I meet say they’ve had it for as long as they can remember, and it’s not associated with hypertension, or any of the other things that would make you think of an endocrine disorder. This is a slide that demonstrates a patient with moderately severe hyperhidrosis. You see the shiny white sweat all over the hands. This person’s just resting, they’re not exercising, they’re not doing anything, they’re not even nervous. That’s what this sort of thing is like. Okay.
Where does hyperhidrosis come from? Well as I said, it’s not your body trying to cool down, it is related to a nerve. It’s related to a nerve inside the body called the sympathetic nervous system. That’s part of your ‘fight or flight’ mechanism. That goes back to the cave man days where you had to run to survive. And it makes your heart beat faster, your blood vessels clamp down, and then you sweat. Okay, because the blood vessels clamp down, people may often also notice that their hands or feet are quite cold, and I’ve met several patients who’ve had a diagnosis of a. . .of a problem called Raynaud’s Phenomenon or Raynaud’s Disease where they were told that they had bad blood vessels or tight blood vessels to their hands and they’re cold and it’s really not that, it’s just an over-active sympathetic nervous system, with another manifestation of that problem. Okay.
Everybody has a sympathetic nervous system. In hyperhidrosis the nerve is no different, either to the human eye, or under a microscope. But the problem that occurs is something that we have not really fully defined. I tell people it’s . . . if you picture this being the nerve inside your body [indicates with right forefinger], it’s as if this nerve has its own little thermostat, and the thermostat is set wrong. It’s set too high. So you sweat when you’re not nervous, and if you are nervous you sweat even more. Okay.
Everybody has a sympathetic nervous system. Regular people, when they’re nervous, will sweat from their hands, their feet, their armpits, their face. It’s a sign of nervousness, and it’s one of the reasons that people who have hyperhidrosis, where they can’t control it . . .that’s one of the reasons they hate this problem so much. People think they’re nervous . . . or . . . or . . . or dishonest . . .or something’s wrong. And that’s why they’d like to get rid of it. It’s embarrassing. [refers to video display]
The Differential Diagnosis - Things You Must Rule Out
Thyroid or Adrenal Disease
Again, that’s in someone who maybe, uh, comes to you in their mid-twenties or thirties and says to you, ‘I never used to sweat, now I have sweating’, you rule out that they have anything else wrong. If they tell you they think about it and it gets worse, or that they’ve had it since childhood it’s probably, uh, hyperhidrosis.
The other things listed here . . .[refers to video display]
Many of the patients I’ve seen have been sent for psychiatric evaluation. They’ve been treated for anxiety. Uh, we look at . . .we look for any evidence of diabetes or malignancies, but the classic hyperhidrosis that I’m describing is very easily diagnosed just from the things that I told you about.
Why does this sort of thing happen? Well, most often it’s for no reason whatsoever. Anxiety certainly makes it worse. Sometimes when you have to concentrate on an activity. I do a lot of people who work with computers, and when they think about doing it, their hands start sweating. Lotions can cause it, drinking alcohol, or certain foods can cause it, and some people notice when they’d eat certain foods they may sweat a lot from their face, and we often call that ‘gustatory sweating’.
One of the other types of problems that someone can have from this sympathetic nerve over-activity is actually not sweating at all, but facial blushing. And what I’m going to talk about helps to treat that problem as well.
There are many non-surgical treatments that you can try for this, but in the thousands of patients that I’ve interviewed, most of the time these have not proven to be particularly effective.
Drysol® is the most common one given by dermatologists, but to use this you have to apply it at night, wrap the hand in cellophane, sleep with it, wash it off in the morning. Many of the patients describe that their hands become dry, cracked, they even will bleed, but they still sweat. So it doesn’t really work all that well for people who have serious hyperhidrosis.
The tap-water ionophoresis, also known as a Drionics® device, it’s something that you can soak your hands on, it sends a little electric charge through . . .same thing, sometimes it doesn’t work, and it . . .even if it does you have to use it over and over for the rest of your life.
Something being touted in the literature and in the public eye right now is Botox injections. Most of the patients I know who have had anything to do with this said it was very painful, very expensive, didn’t work that well and didn’t last that long. So it’s not something that I routinely recommend.
There are other things that you can take such as drugs like Robinol®, anti-anxiety drugs, patients have been treated with psychiatric drugs or alcohol soaks . . .all these different things. Most of the time they’re either partially effective or you have to do them over and over and over, and people get tired of it.
What can we do with surgery? Well there’s, uh, several different approaches to doing surgery to treat hyperhidrosis. We’ve known for years that taking out a little piece of that nerve inside the body can treat this problem. It was probably discovered initially . . . some guy had a tumor [gestures toward chest], they took it out and he said, [chuckling] ‘Hey doc, my hand no longer sweats!’ ‘You know, that’s very interesting!’
So they figured it out. But to do this operation used to require a big surgery . . . either opening up the chest. . .that’s a thoracotomy. . .opening up your back, going through the neck, or doing what we do now, which is a video thoracoscopy through tiny little holes.
The video-assisted procedure that we use is a . . . number one here [referring to video display]. . .nerve and ganglia resection. We actually take the piece of nerve out. This copies an operation that’s been performed for over thirty years with excellent results. There are other people who do different things, also through a small hole with a video camera, and they will either burn the nerve, cut the nerve, or clip the nerve, and I’ll discuss how that results, uh, in different, uh, results for this operation.
Well in the modern era, today, what we find is that patients are very aware of minimally invasive surgery. I first got involved with this when a neurosurgeon at Cedars-Sinai, uh, Dr. Marty Cooper, came to me and said, ‘Rick, uh, I’ve been treating patients for twenty-five years for hyperhidrosis’. But what he does is make a four-inch incision in the middle of your back, take all the muscles off your spine, take out a piece of rib on both sides, and then pluck out this little tiny piece of nerve.
The good news is it always worked to cure the sweaty hands. The bad news is it was seven hours of surgery, seven days in the hospital, and seven months to recover from the pain. So he came to me and he said, ‘My patients . . . I still have patients who come to me with this, but they don’t want to have that big operation, because they’ve seen on radio, TV, the internet that somebody can do this through a tiny little hole. So patients want surgery with a little incision, and have refused to have this larger operation.
So we then developed a new approach. So through two little holes the size of a straw, we’re able to do the same operation that has been successful for over twenty-five years. And I think that’s a very important point in what we’re doing. We’re not making this up. We’re not testing something on a nerve that we don’t know what the results will be.
So based on that twenty-five year experience, with removing what’s called the T2 and the T3 ganglia, through the back, that Dr. Cooper did, we noted his results as I mentioned. . .seven hours surgery, seven days in the hospital, it always worked, and over the course of thirty years, he did nearly three-hundred patients with excellent results. Okay.
What we did was then develop a way to do this without having to do that big operation. The patients still go to sleep, but wh . . . it’s a very simple procedure, we’re intubating them with a. . .a very small breathing tube to. . to be asleep. And we then lay them on their tummy. We blow in a little air around the lung to help us see it. And this is what things look like when you’re doing it [refers to display]. You know, this is sort of a . . . a cartoon drawing, but it shows a tiny little, uh, scope down here and a tiny little instrument up there, and we’re actually watching the whole thing on a TV screen. That’s how this kind of surgery is done. So what we do is create two very small little uh, incisions, and the operation now, instead of taking seven hours, takes ten to fifteen minutes on each side. The patients wake up right after the operation, lay around the hospital for a couple of hours to feel better, and go home the same day. We remove the nerve, which in my opinion gives the absolute best results.
This is what it looks like in an operating room, patient’s laying on their tummy, and right here we mark the tip of the scapula. Okay. There’s the tiny little spot where the incision is going to be, and here’s the very thin little instrument that ends up being the camera that we use to do the surgery.
When we’re looking inside the chest, here’s what you see. These are the ribs, and here’s this nerve, it lays right on the surface of the chest. It’s not near the spine. It’s not near anything important, and I tell people it’s like picking candy up off the sidewalk. So what he used to have to go through the back and spend all these hours getting to, we look right in the chest, it’s laying right there.
We use a very special instrument called the harmonic scalpel to take out this nerve. The harmonic scalpel vibrates at ultrasonic speed. It cuts tissues and it creates absolutely no bleeding during the operation, and it generates no heat, which is very important as to causing side-effects, and I’ll talk about that in a moment.
And what we see here is when we’re done, we actually take this piece of nerve right out of the body! Because we do it this way, we’ve had excellent results, we always succeed because we get what exactly we came for, and we prove it by looking at it, uh, on pathology specimen.
We then went and studied our first three hundred and fifty patients with a confirmed diagnosis of hyperhidrosis and to find out what our results were and how they were better uh . . . and/or different than what anybody else was doing. We had uh, a group that ranged anywhere from 9 years old to seventy-two years old with the average age being about twenty-eight years old. Most, uh, it was pretty evenly matched between men and women, and one-third of the patients had a family history of hyperhidrosis in another relative. Most of our patients had tried at least one, if not more surgical, or . . . or non-surgical methods.
The results are what I’m very, very happy with. So far, to this point, out of those three-hundred-and-fifty patients, 100% of the patients wake up from the surgery with warm dry hands that never sweat again. That’s been a fantastic result. We have 100% relief, so far of axillary sweating when we add the addition of taking out the T4 nerve ganglia, 100% relief of facial sweating, and the feet actually get better 70 to 90% of the time.
And people ask me, ‘well, why would that be if you’re taking out a nerve for the hand?’ And what we notice is that people say when their hands sweat, their feet sweat at the same time. So there is a brain-to-hand-to-foot connection. And we interrupt that connection, so most of the time the feet are better. Again most people say, ‘I don’t care. I shake hands with my hand, I don’t shake hands with my feet, if they get better that’s a bonus!’ And we treat it that way. [Gulp]
There are a couple of problems that can happen with this operation, I will talk about those in a moment. But we’ve found is we get about, uh . . . 1 out of 5 patients who will develop a mild and transient problem with some moisture over their chest or their back that’s called ‘compensatory sweating’ and it has tended to go away over the first year in all of the patients that we’ve studied. We’ve also had a 0% incidence of Horner’s syndrome that I’ll describe for you, uh, soon. Okay.
The advantages of doing what we do, based on 25 years of experience of resecting the nerve is that one, we get a 100% cure of hand sweating and a 0% recurrence rate. The other methods of doing this which involve burning, cutting or clipping the nerve are fairly good at treating this. They get about 95% success in treating the hand sweating. But it’s not a hundred per cent. They also get about a 15 to 20% recurrence rate where the problem comes back and you . . .they have to suggest either another operation, or the patient’s just very unhappy.
Axillary sweating’s been very difficult to treat, with any of those burning, cutting or clipping techniques, because those patients all develop severe compensatory sweating if you try to burn the nerve at 2, 3 and 4. But with removing the nerve, we’ve had much better results.
They used to treat, or some people still do treat armpit sweating by removing the . . .the skin of the armpit, taking out the hair, doing liposuction, using botox. All of these things are either uh, disfiguring or painful or ineffective. But a VAT sympathectomy, with removal of the T4 ganglia, so far in our hands, has it . . . resulted in a 100% cure rate of axillary sweating.
The major problems . . .this would be a magic sort of thing if we could take anybody who sweated and take out this tiny little nerve with this ten-minute operation, it would be wonderful.
There are two main problems that can happen with this operation. One is called a Horner’s syndrome, where you essentially get a little bit of a droopy eyelid. Okay. That happens if you get damage to the stellate ganglion. That’s where T1 comes into play. If my finger you pretend is the nerve, and my knuckle here is T2 and T3, those are the pieces that we cut out. If you hurt T1 you can get a Horner’s Syndrome. When someone burns, cuts, or clips the nerve, they utilize heat in this area, and heat can travel down or heat can travel up and you may get a Horner’s Syndrome. And the incident rate is between 1 and 5% with those techniques of getting Horner’s syndrome. We’ve not had that, again, because we use the harmonic scalpel.
The other problem is called ‘Severe Compensatory Sweating’. Now this is where, instead of sweating from your hands, your feet, your face, or your armpits, you sweat from your chest, your back, your legs, or other uncomfortable places. Doing it the way we do, again as I’ve mentioned, we’ve had some mild moistness that has gone away. While doing it with burning cutting or clipping, actually in published papers, has resulted in 90% of the patients getting compensatory sweating, with a third to a half of those patients getting a severe, dripping compensatory sweating.
Other things that can happen are very, very uh . . . uncommon, they are just the standard things that could happen with any surgery. [gulp]
The complications, as I mentioned, with us, doing the video resection with the harmonic scalpel, so far, Horner’s syndrome, we’ve had a 0% incidence. And significant compensatory sweating has been less than 1%. With burn, cut or clip of the nerve, Horner’s syndrome is usually reported at 3 to 4%, with reports up to 20%, and compensatory sweating in up to 90% of the patients.
So there’s something different about what we’re doing with taking out the nerve, that ends up with a better operation with less complications. And that’s why I like what we do. Okay.
What are the reasons for the success of this technique? One, resection of the nerve allows us to look at it under a microscope. We prove that we’ve got it! We never miss! That’s why we’ve got 100% success! Cutting it out mandates that you cut all these little branches that go into the nerve. Our best impression is that these little branches compo . . .control some of the compensatory sweating, and that’s why cutting those branches makes such a difference in people having compensatory sweating after the surgery.
Using the harmonic scalpel lets us do bloodless surgery, and the resected nerve provides about a one-inch gap so the ends never grow back together, and that’s why the disease does not recur.
So in conclusion, what I would say is that a micro-invasive sympathectomy that we do through the tiny little holes is a very safe, and very effective therapy. The micro-invasive nature of the procedure results in a minimal amount of post-operative pain, and the patients recover quite quickly. I tell the story of the patient who had surgery on Friday and went out and played tennis on Saturday. These are very well-tolerated incisions, and most people are back to work at the end of a weekend, after having this surgery.
The harmonic scalpel lets us do the operation safely, and it doesn’t generate any heat so it shouldn’t cause complications. And so far, in our hands, this procedure has been 100% effective for eliminating hand, face, and armpit sweating, because the nerve and its branches are resected and not burned.
So in conclusion, the micro-invasive sympathectomy is effective treatment for hyperhidrosis, with a minimal amount of pain and problems, or morbidity, and rapid patient recovery from surgery. I hope this has been helpful information. Thank you very much.
Hyperhidrosis Surgical Procedure with Ethicon® Harmonic Scalpel
After inserting the trocars and using CO2 insufflation to expose the nerve, the harmonic scalpel is utilized to identify the sympathetic chain at the level of the 2nd and 3rd rib. Dissection is continued longitudinally along the nerve until all afferent and efferent branches, including the ‘Nerve of Kuntz’ are divided. The harmonic scalpel is next utilized to divide the sympathetic chain below the level of the ganglion being resected. The tissue is then elevated from the attaching structures, such as the rib and the underlying inter-costal vein, without causing damage to the vein.
The next step involves identifying the superior border of the 2nd rib, above which you do not wish to proceed to avoid damage to the stellate ganglion. The nerve is again divided with the harmonic scalpel, and further attachments to loose areola tissue are divided utilizing the harmonic scalpel until the nerve is free from attachment and ready for removal from the chest.
The 5-millimeter grasping instrument is inserted through the trocar, and the edge of the resected sympathetic chain is grasped for removal from the chest and deliverance to a pathologist.
