DESCRIPTION
Thoracic sympathectomy for the treatment of primary hyperhidrosis (excessive sweating) is performed by either an endoscopic or an open chest procedure. For an open thoracic sympathectomy general anesthesia is used, and an incision is made. The lung is collapsed to allow adequate space for the surgeon to maneuver. Sympathetic nerve ganglions, which transmit signals to the sweat glands, are removed or destroyed. The lung is then re-expanded and the surgical incisions closed.
Endoscopic transthoracic sympathectomy (ETS) is performed under local or general anesthesia. The lung is collapsed for this surgery as well. An endoscope is passed through a trocar. The sympathetic chain is viewed by a video display. The ganglion is identified. The second, third, and / or fourth ganglia are cauterized and cut on the ribs. The temperature of the palmar skin is checked to confirm the success of the surgery. The procedure is repeated on the other side of the chest.
Primary hyperhidrosis is characterized by increased sympathetic activity at the upper thoracic ganglia T2 and T3, with no apparent underlying cause. Secondary hyperhidrosis is the result of a variety of neurological or systemic disease.
Sources report that compensatory hyperhidrosis is common following thoracic sympathectomy.
POLICY
Thoracic sympathectomy for the treatment of primary hyperhidrosis is considered medically necessary if the medical appropriateness criteria are met. (See Medical Appropriateness below.)
Thoracic sympathectomy for the treatment of primary hyperhidrosis with a lack of functional impairment or medical complications associated with the condition is considered investigational.
Thoracic sympathectomy for the treatment of secondary hyperhidrosis is considered investigational.
See also: Botulinum Toxin
MEDICAL APPROPRIATENESS
Thoracic sympathectomy for the treatment of primary hyperhidrosis is considered medically appropriate if ALL of the following criteria are met:
Refractory to medical management with usual dermatologic treatments
Changes that are manifested by macerations of the skin and results in significant functional impairment
NOTE: Significant functional impairment is defined as, but not limited to, any of the following:
Change in types of leisure activities pursued
Decreased amount of time spent working or pursuing leisure activities
Missed outings/events with friends or family
Feeling unhappy, depressed, less confident, or frustrated with some daily activities
Require help to perform tasks otherwise done alone
Purchase additional items or accessories to help complete routine daily activities
ADDITIONAL INFORMATION
A peer review literature search did not provide published data that clinical trials have been done to demonstrate that thoracic sympathectomy improves either primary hyperhidrosis when there is a lack of functional impairment or medical complications associated with the condition or secondary hyperhidrosis.
SOURCES
Bechara, F. G., Gambichler, T., Bader, A., Sand, M., Altmeyer, P., & Hoffmann, K. (2007). Assessment of quality of life in patients with primary axillary hyperhidrosis before and after suction-curettage. Journal of the American Academy of Dermatology, 57 (2), 207-212. (Level 4 - Independent study)
BlueCross BlueShield Association. Medical Policy Reference Manual. (2:2008). Treatment of hyperhidrosis (8.01.19). Retrieved May 9, 2008 from BlueWeb. (30 articles and/or guidelines reviewed)
Boley, T. M., Belangee, K. N., Markwell, S., & Hazelrigg, S. R. (2007). The effect of thoracoscopic sympathectomy on quality of life and symptom management of hyperhidrosis. Journal of the American College of Surgeons, 204 (3), 435-438. (Level 3 - Independent study)
ECRI Institute. Health Technology Information Service. Windows on Medical Technology. (2006, October). Endoscopic thoracic sympathectomy for the treatment of hyperhidrosis. Retrieved May 9, 2008 from ECRI Institute. (93 articles and/or guidelines reviewed)
Hayes. Medical Technology Directory. (2003, April). Endoscopic sympathectomy treatment of hyperhidrosis. Retrieved May 9, 2008 from www.Hayesinc.com/subscribers. (74 article and/or guidelines reviewed)
Hornberger, J., Grimes, K., Naumann, M., Glaser, D. A., Lowe, N. J., Naver, H., et al. (2004). Recognition, diagnosis, and treatment of primary focal hyperhidrosis. Journal of the American Academy of Dermatology, 51 (2), 274-286. (Level 1 - Industry sponsored)
Rzany B, & Spinner DM. Interventions for localised excessive sweating (Protocol for a Cochrane Review). In: The Cochrane Library, Issue 4, 2002. Oxford: Update Software.
Society of Thoracic Surgeons. (2007). Patient information. Hyperhidrosis. Retrieved May 15, 2008 from http://www.sts.org/doc/4097.
Strutton, D. R., Kowalski, J. W., Glaser, D. A., & Stang, P. E. (2004). US prevalence of hyperhidrosis and impact on individuals with axillary hyperhidrosis: Results from a national survey. Journal of the American Academy of Dermatology, 51 (2), 241-248.
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EFFECTIVE DATE |
6/12/2008 |
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ID_BT
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