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Brief summary describing the background
and objectives of the trial
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Introduction
Primary hyperhidrosis is characterized by profuse sweating in absence of a stimulus. This differentiates it from secondary hyperhidrosis. Secondary hyperhidrosis is due to many causes for example malignancy, infection, medication, and anxiety disorder (Vorkamp et al., 2010). Although there are false impressions of female predominance. It usually affects males and females. Symptoms are bilateral and symmetrical. The episode starts with abrupt onset, profuse sweating that is maybe related to emotional stress. This usually interferes with the daily activities of the patients (Lear et al., 2007).
Pneumothorax occurred frequently in the past (75%). nowadays the incidence decreased down to .4-2.3% due to new modalities in anesthesia such as double-lumen tube and one-lung ventilation. Surgical emphysema occurred up to 2.7% of the cases around the site of the trocar. Other complications such as atelectasis, lung injury, pleural effusion and bleeding and Horner syndrome have been described (Cameron. 2003). Most patients report sharp pain with deep inspiration postoperatively. Later, it may be aching pain in the back that require opiate analgesia (Gossot et al., 2001). Thoracic sympathetic ganglia extend from stellate ganglia to the 12th thoracic ganglia. They lie on the neck just lateral to the head of the corresponding rib. The T2 sympathetic ganglion is located anterior to the medial portion of the neck of the rib, whereas the ganglia from T3 through T6 are located in front of the heads of corresponding ribs. The T7 through T10 ganglia are located anterior to the radiate ligaments of the costovertebral joints (Stanton-Hicks and Management. 2001).
Radiofrequency ablation of sympathetic ganglia from T2 to T4 is a good alternative to surgery. It is done under sedation and is a minimally invasive procedure, safe, inexpensive, and in the outpatient clinic. But its success rate is still lower than thoracoscopic sympathectomy (Garcia Franco et al., 2011, Purtuloglu et al., 2013). Anatomical variations that present in some patients are major causes of failure and patient satisfaction after thoracoscopic sympathectomy (McCormack et al., 2011). The sympathetic trunk mostly runs against the heads of ribs. but there is a variant in which it runs along the medial side of the heads. Another variant in which it runs between the neck and head (Stanton-Hicks et al., 2008).
For years, we follow pain textbooks and do thermocoagulation of T2 and T3 sympathetic ganglia at the posterior third of T2 and T3 vertebral body with unsatisfactory results as compared by surgery. While the success rate of surgery that hit the sympathetic chain at the head and neck of the 2nd and 3rd rib is 97.8% (Rodríguez et al., 2008).
To the best of our knowledge, there is only one paper that tried this optimum target versus old target (Khalifa and Hegab. 2017). In conventional monopolar radiofrequency ablation (MRFA) technique, the energy exists between the intervention needle tip and a grounding plate so the lesion size become small (Jadon, 2018). Bipolar radiofrequency energy is locally produced between the active and grounding electrodes on needle tip so the size of the lesion become larger than monopolar RF (Gulec, 2017).
Aim of the work and hypothesis
This prospective, randomized, open labelled controlled study is designed to compare the efficacy of thermocoagulation at the head and neck of the 2nd and 3rd ribs in the treatment of severe palmar hyperhidrosis and thoracoscopic sympathectomy. We hypothesize that targeting the head and neck of the 2nd and 3rd rib with percutaneous fluoroscopy-guided bipolar radiofrequency ablation of T2, T3 sympathetic ganglia in palmar hyperhidrosis will increase the efficacy of ablation in comparison to surgery without a significant increase in side effects to provide safe and effective method rather than surgery for hyperhidrosis.
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