title: Nonintubated Transareolar Endoscopic Thoracic Sympathectomy with a Flexible Endoscope: Experience of 58 Cases.
abstract: OBJECTIVE
  Natural orifice transluminal endoscopic surgery (NOTES) has recently become a hot spot in the field of minimally invasive surgery. But, most of the procedures are still in the early stages of development and limited to animal experiments. Transareolar endoscopic surgery could work as a viable intermediate step before thoracic NOTES. Under intravenous anesthesia without endotracheal intubation, transareolar endoscopic thoracic sympathectomy (ETS) with a flexible endoscope has rarely been attempted. The objective of this study is to evaluate the feasibility and safety of this novel minimally invasive technique in managing primary palmar hyperhidrosis (PPH).
  
  
  METHODS
  From June 2012 to July 2014, a total of 58 male patients with severe PPH underwent transareolar ETS by use of a flexible endoscope. Under intravenous anesthesia without endotracheal intubation, a flexible endoscope was introduced through the incision on the edge of the areola into the thoracic cavity. The thoracic sympathetic chain was ablated at the level of the fourth rib.
  
  
  RESULTS
  All procedures were successfully performed with a mean operating time of 33.6 ± 8.3 min. All patients regained consciousness rapidly and none of them complained about sore throat after surgery. There were no operative mortality and conversion to open procedure. The symptoms of all patients disappeared as soon as the sympathetic chain was cut off. Fifty six patients (96.6%) were discharged from the hospital on the first postoperative day. The postoperative complications were minor, and no patients developed Horner's syndrome. At 3 months postoperatively, there was no obvious surgical scar on the chest wall, and none of the patients complained about postoperative pain. Compensatory hyperhidrosis (CH) appeared in 19 patients. No recurrent symptoms were observed in our study. One year follow-up revealed an excellent cosmetic result and degree of satisfaction.
  
  
  CONCLUSIONS
  Nonintubated transareolar ETS with a flexible endoscope is a safe, effective and minimally invasive therapeutic procedure, which has the possible advantages of thoracic NOTES and can be performed in routine clinical practice for male PPH patients.
authors.affiliation: Department of Thoracic Surgery, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China.
authors.forename: Jianfeng
authors.initials: J
authors.lastname: Chen
authors.forename: Jianbo
authors.initials: J
authors.lastname: Lin
authors.forename: Yuanrong
authors.initials: Y
authors.lastname: Tu
authors.forename: Min
authors.initials: M
authors.lastname: Lin
authors.forename: Xu
authors.initials: X
authors.lastname: Li
authors.forename: Fancai
authors.initials: F
authors.lastname: Lai
mesh_terms: D000293:Adolescent; D000328:Adult; D002681:China; D004867:Equipment Design; D005240:Feasibility Studies; D006801:Humans; D006945:Hyperhidrosis / Q000175:diagnosis / Q000503:physiopathology / Q000601:surgery*; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009558:Nipples / Q000601:surgery*; D061646:Operative Time; D017060:Patient Satisfaction; D011183:Postoperative Complications / Q000209:etiology; D013546:Sweating; D013562:Sympathectomy / Q000295:instrumentation*; D020708:Thoracoscopes; D013906:Thoracoscopy / Q000295:instrumentation*; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult