Health-related quality of life after thoracoscopic sympathectomy for palmar hyperhidrosis

Single-center experience of thoracoscopic sympathectomy for palmar hyperhidrosis with long-term postoperative questionnaire survey

OBJECTIVES

Thoracoscopic sympathectomy is an effective treatment for palmar hyperhidrosis. However, compensatory hyperhidrosis occurs frequently as a postoperative complication of the procedure. The goal of this study was to elucidate the clinical significance of thoracoscopic sympathectomy using our surgical procedure.

METHODS

Consecutive 151 patients who underwent thoracoscopic sympathectomy for palmar hyperhidrosis were studied. In addition, to investigate patients' satisfaction and long-term quality of life, 111 patients were asked to complete a mailing questionnaire survey, and 84 responded (response rate of 75.7%).

RESULTS

All of the 151 patients reported a reduction in palmar sweating during the immediate postoperative period. None of the patients had pneumothorax, hemothorax, Horner's syndrome, or worsening of bradycardia. Based on the questionnaire, the surgical success rate was 98.8%. None of the patients had a recurrence of palmar hyperhidrosis during the long-term postoperative period. However, compensatory hyperhidrosis was reported in 82 patients (97.6%). In total, 94.0% of patients had high levels of postoperative satisfaction.

CONCLUSIONS

Thoracoscopic sympathectomy is an effective surgical treatment for palmar hyperhidrosis. By contrast, the careful preoperative explanation of compensatory hyperhidrosis is considered to be very important.

Spontaneous ventilation anesthesia combined with uniportal and tubeless thoracoscopic sympathectomy in selected patients with primary palmar hyperhidrosis

Background

To assess the feasibility and safety of tubeless video-assisted thoracoscopic sympathectomy (VATS) with a single 5 mm port under nonintubated, intravenous anesthesia with spontaneous ventilation in selected patients with primary palmar hyperhidrosis (PPH).

Methods

Adults (aged between 18 and 60 years) with moderate or severe PPH symptoms were enrolled. Demographic information and clinical data were obtained from 172 consecutive patients undergoing thoracoscopic surgery for PPH from March 2014 to December 2020. The primary outcomes were the rate of complications, including death, and the intraoperative conversion rate to 3-port VATS. The secondary outcomes were the conversion rate to intubated anesthesia during the operation and the surgical duration and pain score of postoperative day 0.

Results

In total, 172 patients were included with 88 males and 84 females. The median age was was 25 years (IQR:21–30 years). No mortalities or major morbidities occurred in any patient. The overall median surgical duration was 53 min (IQR:37–72 min). The median length of postoperative hospital stay was one day (IQR:one–one day). The median pain score of POD0 was 2 (IQR:2–2). Intraoperative conversion to 3-port VATS followed by drainage tube insertion occurred in one (0.6%) patient due to extensive pleural adhesions. No patients required conversion to intubated anesthesia during surgery. No postoperative mechanical ventilation was noted in any patient.

Conclusions

For selected patients with PPH, tubeless VATS with a single 5 mm port using spontaneous ventilation anesthesia can be considered a feasible and safe operation. The surgical wound is extremely small and the operation time is shorter than the conventional technique.

Trial registration This study was in conformity with the Declaration of Helsinki, and was approved by the National Ethics Committee of the University of the Hong Kong-Shenzhen Hospital (Approval number: [2020]70). We registered the study in the Chinese Clinical Trial Registry (Registration number: ChiCTR2100049063) in 2021.Informed consent was collected from all the participants of this study. URL for this clinical trial registration is: https://www.chictr.org.cn/index.aspx.

Comparison of EQ-5D-3L and metabolic components between patients with hyperhidrosis and the general population: a propensity score matching analysis

PURPOSE

It is important to understand the characteristics of patients with hyperhidrosis, which are different from the general population, for treating hyperhidrosis. Sympathetic overactivity, which might play an important role in hyperhidrosis, can contribute to metabolic diseases and the decreased quality of life (QoL). We compared the metabolic components and health-related QoL between patients with hyperhidrosis and the general population.

METHODS

We conducted a case-control study and compared the characteristics of the patients (N = 196) with hyperhidrosis and propensity score-matched controls (N = 196) selected from the Korean National Health and Nutrition Examination Survey. Metabolic components and EQ-5D-3L (EQ-5D) index were compared using a two-way mixed analysis of covariance after adjusting for confounders.

RESULTS

Patients with hyperhidrosis had significantly higher waist circumference (estimated mean values ± SD for patients and the control group, 85.5  ±  10.8 cm vs 81.3  ±  10.3 cm, p < 0.001), blood pressure (SBP, 121.1  ±  16.9 vs 111.7  ±  10.3, p < 0.001 AND DBP, 77.5  ±  12.8 vs 73.6  ±  8.6, p < 0.001, respectively), fasting glucose (97.1  ±  11.3 vs 91.5  ±  9.2, p < 0.001), and the number of components of metabolic syndrome (1.4  ±  1.3 vs 1.0  ±  1.2, p = 0.002), and significantly lower estimated glomerular filtration rate (144.3  ±  53.2 vs 158.3  ±  55.7, p = 0.002) and EQ-5D values (estimated mean values (standard error) for patients and the control group, 0.92 (0.01) vs 0.97 (0.01), p < 0.001) compared to the control group after adjustment.

CONCLUSION

The patients with hyperhidrosis had more central obesity and unfavorable metabolic parameters and a lower EQ-5D index compared with the general population, emphasizing clinical importance of hyperhidrosis to be cured in aspect of metabolic components as well as patients' QOL.

Effects of clipping endoscopic thoracal sympathectomy at Th4 on cardiopulmonary functions, quality of life and psychosocial functions

BACKGROUND

In this study, we evaluated the cardiopulmonary and psychosocial effects of endoscopic thoracal sympathectomy (ETS) by clipping procedure at the level of Th₄ and effects of ETS on quality of life of patients with hyperhidrosis.

METHODS

We performed a prospective study in 52 patients complaining of local sweating who applied to our clinic. Cardiac maximal treadmill stress test (CMTST), pulmonary function tests, Beck anxiety-depression inventory, Liebowitz social anxiety scale and SF-36 quality of life questionnaires were administered at preoperative period and postoperative 6th month.

RESULTS

In the pulmonary function test, we found a minimal decrease in FEV1, and FEV1/FVC. There were no significant change in 'resting pulse rate', 'resting systolic and diastolic blood pressures' during CMTST between before and after operation. There was a significant difference in peak heart rate before CMTST, post-exercise diastolic blood pressure, and age-predictive maximal heart rate between before and after clipping procedure. In the SF-36 questionnaire, all parameters were improved. In the Beck depression-anxiety inventory and the Liebowitz social anxiety scale significant improvement was achieved in all parameters.

CONCLUSION

ETS by clipping procedure at the Th₄ level is advised to be a safe and effective method for management of hyperhidrosis patients.

Endoscopic thoracic sympathectomy for primary focal hyperhidrosis: impact on psycho-social symptomatology and psychotropic medication use

OBJECTIVES

The tendency for patients with primary focal hyperhidrosis (PFH), characterized by excessive sweating, to experience psycho-social deficits is well documented. In addition, although endoscopic thoracic sympathectomy (ETS) effectively corrects PFH, its role in the psycho-social management of these patients remains unclear. Here, we examined changes in psychiatric symptomatology and psychotropic medication usage in PFH patients following ETS.

METHODS

In total, 106 PFH patients underwent ETS and were compared against 213 matched controls. Information on psychiatric diagnosis and prescription was obtained through a retrospective chart review. Prospectively, PFH patients completed Hyperhidrosis Impact Questionnaires, Leibowitz Social Anxiety Scales and Center for Epidemiological Studies Depression Scales to evaluate pre- and postoperative quality-of-life and psycho-social impairment.

RESULTS

A significantly greater proportion of PFH patients had been prescribed psychotropic medication (37.7%) compared to controls (14.1%) despite no differences in the proportion of psychiatric diagnoses. Following ETS, 52.5% of the PFH patients who were using psychotropic medications reduced their prescription regimen, compared to only 10% of control patients (P < 0.01). Additionally, scores improved dramatically in each Hyperhidrosis Impact Questionnaires category, and in both the Leibowitz Social Anxiety Scales and Center for Epidemiological Studies Depression Scales (P < 0.01).

CONCLUSIONS

We demonstrate that in over half of PFH patients, psychotropic medication usage was discontinued after ETS, which is consistent with our findings on postoperative improvements in Hyperhidrosis Impact Questionnaires, Leibowitz Social Anxiety Scales and Center for Epidemiological Studies Depression Scales scores. Furthermore, our findings suggest that a considerable proportion of PFH patients who experience psychopathology may be doing so secondary to excessive sweating. Thus, improved awareness or recognition of these associations in the diagnosis and management of PFH patients is warranted.

The quality of life and satisfaction rate of patients with upper limb hyperhidrosis before and after bilateral endoscopic thoracic sympathectomy

Background:

Hyperhidrosis is a functional disorder identified by excessive sweating. Its incidence is approximately 1% in any population. Bilateral endoscopic thoracic sympathectomy (BETS) intervention is the definitive treatment of choice for palmar and axillary hyperhidrosis.

Aims and Objectives:

The purpose of this study is to evaluate and compare the quality of life (QOL) and satisfaction rate of patients with upper limb hyperhidrosis before and after BETS surgery and the influence of compensatory hyperhidrosis (CH) on patients’ QOL after surgery.

Settings and Design:

This study is a cross-sectional study designed to generate longitudinal data.

Subjects and Methods:

This study is a cross-sectional study designed to generate longitudinal data pre- and postbilateral BETS prospectively. This study was conducted in the surgery department of University Hospital in Riyadh, Saudi Arabia. Hundred patients with upper limb hyperhidrosis who underwent BETS from 2014 to 2017 were included. A modified and validated QOL questionnaire for hyperhidrosis was completed by the patients themselves in order to compare the QOL for patients both before and after BETS. Patients’ satisfaction and the occurrence of CH were obtained postoperatively.

Statistical Analysis Used:

Data were analyzed using the SPSS^® statistical package for social studies, version 22.0 (SPSS 22; IBM Corp., New York, NY, USA) for Windows^®.

Results:

A total of 100 patients completed the questionnaire; 94% of patients had a positive QOL outcome after the surgery. The mean decrease in QOL scores was −42.0 points toward better QOL. The site of sweating had a significant effect on the patients’ QOL before and after the surgery (P value < 0.001). Moreover, 76% of patients reported a high satisfaction rate.

Conclusion:

Primary hyperhidrosis can negatively impair patients’ QOL in different domains. BETS showed to be an effective option for improving the QOL of patients and it provided both short- and long-term effectiveness in treating upper limb hyperhidrosis. CH did not interfere with the rate of patient satisfaction or their QOL postoperatively.

Anxiety after Sympathectomy in patients with primary palmar hyperhidrosis may prolong the duration of compensatory hyperhidrosis

Background

Compensatory hyperhidrosis (CH) is a frequent side effect after sympathectomy for the treatment of primary palmar hyperhidrosis. We determined the effects of demographic and clinical factors which may increase the duration of CH (DCH).

Methods

One hundred twenty-two patients who had undergone sympathectomies from 2014 to 2016 were retrospectively reviewed. Anxiety was evaluated using the State and Trait Anxiety Inventory score. Follow-up evaluations continued until CH remitted. A Cox proportional hazards model was used to determine the association between DCH and variables.

Results

DCH ranged from 5 to 27 weeks (median, 11.47 weeks). Severe CH (HR = 0.318, 95% CI, 0.136–0.741) and exacerbated anxiety 1 month post-operatively (HR = 0.816, 95% CI, 0.746–0.893) may prolong CH. A positive correlation between post-operative anxiety and DCH was common in patients with moderate or severe CH, and in cases with forearm CH.

Conclusions

Pre- and post-operative anxiety should be evaluated, and anti-anxiety treatment is offered to patients with moderate-to-severe CH to shorten the DCH.

Electronic supplementary material

The online version of this article (10.1186/s13019-018-0736-3) contains supplementary material, which is available to authorized users.

T3 versus T4 thoracoscopic sympathectomy for palmar hyperhidrosis: a meta-analysis and systematic review

BACKGROUND

Palmar hyperhidrosis (PH) is a benign sympathetic disorder that can adversely affect the quality of life of patients. Thoracic sympathectomy (TS) at the T3 or T4 level has been used to treat PH. We aimed to determine the optimal denervation level for TS by comparing the efficacy of T3 TS versus T4 TS in PH patients.

METHODS

We searched the PubMed, Ovid MEDLINE, EMBASE, Web of Science, ScienceDirect, the Cochrane Library, Scopus, and Google Scholar databases for studies comparing T3 versus T4 TS for PH. Clinical end points included symptom resolution, patient satisfaction, and complications.

RESULTS

Of 2201 articles reviewed, 10 (T3 group, 566 patients; T4 group, 629 patients) were selected. T4 TS was associated with a lower incidence of postoperative compensatory sweating, dry hands, and gustatory sweating than T3 TS. No significant difference in symptom resolution or patient satisfaction was found between the T3 and T4 groups.

CONCLUSIONS

T4 TS may be superior to T3 TS in patients with PH. However, this finding should be validated in high-quality, large-scale randomized controlled trials.

Optimal targeting of sympathetic chain levels for treatment of palmar hyperhidrosis: an updated systematic review

BACKGROUND

Palmar hyperhidrosis involves excessive sweating of the palms, with no known etiology. Endoscopic thoracic sympathectomy (ETS) is a safe and effective treatment for palmar hyperhidrosis, but compensatory hyperhidrosis is a common complication after ETS, leading to reduced patient satisfaction and postoperative quality of life. However, the appropriate level of the sympathetic chain to target with ETS to achieve maximum efficacy and reduce the risk of compensatory hyperhidrosis (CH) is controversial. In this systemic review, we investigated the appropriate level of sympathectomy for palmar hyperhidrosis.

METHODS

PRISMA guidelines were implemented to complete a systematic review. We performed a computerized systematic literature search using PubMed and EMBASE from January 1990 to July 2016. We chose the Cochrane Collaboration's tool and the methodological index for non-randomized studies tool for examining study bias.

RESULTS

A total of 4075 citations were identified, of which 91 were eligible for inclusion, including 68 observational studies and 23 comparative trials. In observational studies, sympathectomies showed similar efficacies for curing PH at different levels. However, T2-free groups (i.e., at levels T3, T4, or T3-T4 combined) could render a lower risk of Horner's syndrome (0 vs. 1.21 ± 0.49%, p = 0.036) and CH (28.75 ± 7.25 vs. 57.46 ± 3.86, p = 0.002) compared with T2 involved. In comparative trials, there were 12 studies describing the comparison between T2-free ETS and T2 involved, and 9 of 12 (75%) showed T2-free ETS could reduce the incidence of CH. Overall, lowering the level and limiting the extent of sympathectomy could reduce the incidence of complications.

CONCLUSIONS

Cumulative data from more than 13,000 patients suggest that ETS is a safe, effective, and reproducible procedure with a high degree of patient satisfaction. Currently available evidence suggests that T2-free ETS may reduce the incidence of compensatory hyperhidrosis without compromising success rates and safety.

Thoracic sympathectomy for hyperhidrosis: from surgical indications to clinical results

Sympathectomy and its variations have been performed in thoracic surgery for more than 100 years. However, its indications have undergone profound modifications in this period. Likewise, since then the surgical technique has also evolved dramatically up to the minimally invasive techniques worldwide accessible in present days. Currently, primary hyperhidrosis is, by far, the main indication for thoracic sympathectomy and this procedure is usually carried out thoracoscopically with excellent results. However, until today, hyperhidrosis is a part of thoracic surgery still surrounded by controversy, persisting as an open field over which some confusion still resides regarding its pathophysiology, terms definitions and operative approaches. The aim of this article is to provide a wide but easily comprehensible review of the theme, discussing and clarifying the major concepts with respect to its clinical presentation, all the presently available treatment options and strategies with their potential benefits and risks, the adequate patient selection for sympathectomy, as well as the postoperative clinical results.

Quality of Life Changes Following Surgery for Hyperhidrosis

The best way to evaluate the impact of primary hyperhidrosis on quality of life (QL) is through specific questionnaires, avoiding generic models that do not appropriately evaluate individuals. QL improves significantly in the short term after sympathectomy. In the longer term, a sustained and stable improvement is seen, although there is a small decline in the numbers; after 5 and even at 10 years of follow-up it shows virtually the same numerical distribution. Compensatory hyperhidrosis is a major side effect and the main aggravating factor in postoperative QL, requiring attention to its management and prevention.

Subxiphoid single-incision thoracoscopic bilateral ablative sympathectomy for hyperhidrosis

We describe the first case of severe palmar hyperhidrosis treated with single-incision subxiphoid thoracoscopic ablative sympathectomy, bilaterally, at T3 level. The single-incision subxiphoid thoracoscopic approach required only a 2-cm incision in the upper abdomen. In addition, the technique does not cause postoperative intercostal neuropathy and postoperative pain is minimal as the intercostal space is bypassed. Total operative time was ∼60 min and the volume of blood loss was 10 ml. The patient was discharged from the hospital the next day with complete remission of her symptoms. Excess palmar sweating released after operation and there was no compensatory sweating after a 6-month follow-up.

Social anxiety and functional impairment in patients seeking surgical evaluation for hyperhidrosis

Primary hyperhidrosis is characterized by excessive sweating and often accompanied by social avoidance. Social anxiety disorder (SAD) is characterized by fear and avoidance of social situations, often partly related to fears of showing signs of excessive autonomic nervous system activation, such as sweating. To clarify the relationship of hyperhidrosis and SAD, this study assessed severity of sweating, overall social anxiety and social anxiety due to sweating, and disability in 2 groups: patients seeking surgical treatment for hyperhidrosis (n = 40) and patients seeking treatment for SAD (n = 64). Hyperhidrosis and SAD patients overlapped in severity of overall social anxiety and social anxiety related to sweating. Hyperhidrosis patients reported elevated levels of social anxiety, with mean severity near the threshold for the generalized subtype of SAD, but significantly lower social anxiety than in the SAD patients. Significantly more hyperhidrosis patients than SAD patients attributed most of their social anxiety to sweating (76% vs 20%). Among hyperhidrosis patients, the pattern of correlations of sweating, social anxiety, and disability was consistent with a model of social anxiety as a mediator of sweating-related disability. The overlap of symptoms in patients presenting for treatment of SAD or hyperhidrosis suggests that both social anxiety and sweating should be assessed in these patients and considered as potential targets of treatment.

Predicting improvement after surgery for palmar hyperhidrosis

OBJECTIVES

Endoscopic transthoracic sympathectomy (ETS) is a surgical procedure used to improve Quality of Life (QoL) in patients with treatment resistant palmar hyperhidrosis (PHH). The aim of this study was to test the hypothesis that low preoperative scores on The Everyday Life Questionnaire (EDLQ) would predict QoL improvement after surgery.

MATERIALS AND METHODS

Pre- and post-operative QoL scores from a series of 30 consecutive patients who underwent ETS at our institution were analyzed.

RESULTS

Preoperative QoL scores was a significant predictor of post-operative improvement across all dimensions covered by the questionnaire.

CONCLUSION

Preoperative low QoL can be used as a guide in selecting patients with most improved QoL after ETS.

Quality of life before surgery is a predictive factor for satisfaction among patients undergoing sympathectomy to treat hyperhidrosis

PURPOSE

The objective of this study was to evaluate the postoperative quality of life (QOL) experienced among a group of 1167 patients who underwent video-assisted thoracoscopic sympathectomy (VATS) to treat primary hyperhidrosis, as compared with the presurgical QOL.

METHODS

Between February 2002 and June 2007, 1167 patients who had undergone VATS were surveyed. The majority had presented with palmar hyperhidrosis (794 patients; 68%), while 340 (29%) had presented with axillary hyperhidrosis. Based on data obtained from the QOL protocol applied to all of the patients preoperatively, the patients were divided into two groups according to the level of their QOL: group 1 consisted of 312 patients (27%) with poor QOL and group 2 of 855 patients (73%) with very poor QOL. The same protocol was applied postoperatively, and five different levels of satisfaction were obtained. The same parameters were evaluated for both the palmar and the axillary hyperhidrosis subgroups.

RESULTS

The patients with very poor QOL had much better results in terms of improvement in QOL than did those with poor QOL (P < .05). The same result was observed for both the palmar and axillary hyperhidrosis subgroups (P < .05).

CONCLUSION

The worse the preoperative QOL among patients undergoing sympathectomy to treat primary hyperhidrosis is, the better the postoperative improvement in QOL will be.

Bilateral thoracoscopic T2 to T3 sympathectomy versus botulinum injection in palmar hyperhidrosis

BACKGROUND

Bilateral T2 to T3 thoracoscopic sympathectomy and injection of botulinum toxin-A are presently the most effective modalities in the treatment of primary palmar hyperhidrosis. In this study we evaluated comparative merits of the two therapies.

METHODS

Patients suffering primary palmar hyperhidrosis were treated by either bilateral T2 to T3 thoracoscopic sympathectomy (n = 68) or by injection of botulinum toxin-A (n = 86). The groups were homogeneous for relevant demographic, physiologic, and clinical data. Quantification of sweat production was performed by Minor's iodine starch and glove tests. Subjective changes were assessed by quality of life questionnaires (Hyperhidrosis, Dermatology Life Quality Index, Short Form-36, Nottingham's Health Profile) and patient's satisfaction self-assessment. A cost comparison between groups was also carried out.

RESULTS

No operative mortality or major morbidity was recorded in either group. Minor's test showed a more significant reduction in the surgical group: +94% versus +63% at 6 months and +94% versus +30% at 12 months. Compensatory sweating was significantly greater and long-lasting in the surgical group. All subjective tests improved rapidly and significantly in both groups. After 6 months, results mildly worsened in the surgical group and more significantly in the botulinum group. Patient's satisfaction was initially greater in the botulinum group (p = 0.03), but after 6 months it significantly reversed (p = 0.04). Surgical treatment cost approximately as much as four botulinum treatments.

CONCLUSIONS

Thoracoscopic sympathectomy is superior to botulinum toxin-A injection. The greater initial costs and discomfort are offset by a greater reduction in compensatory sweating.

Diagnosis of palmar hyperhidrosis via questionnaire without physical examination

OBJECTIVES

In order to determine the reliability of a self-administered instrument to diagnose excessive sweating conditions, including palmar hyperhidrosis (PH), we designed two successive questionnaires and compared responses with physical examination and sweat measurement in normal volunteers and a cohort of patients with documented PH. The reliable diagnosis of PH via questionnaire would enable molecular epidemiological studies without the need for physical examination or direct sweat measurement.

METHODS

Subjects self identified as either normal or affected by PH. Each completed one or both questionnaires and underwent physical examination. Sweat production from the thenar eminence and forehead was measured at rest and following mental/emotional stress. Correlation among sweat measurement, physical examination, and questionnaire score was assessed.

RESULTS

Forty-seven subjects enrolled in the study, 29 of whom underwent sweat measurements. The participants' perception of whether they were affected agreed with the examiner's visual and tactile observation of PH in all cases (P < 0.0005). The mean peak sweat rate for those participants with PH was 1.59 mg/cm(2)/min, while that of the normal cohort was 0.37 mg/cm(2)/min (P = 0.001). The mean questionnaire #1 and #2 scores for those participants with PH and the normal cohort was 7.10 versus 0.36 (P = 0.0005) and 5.145 versus 0.045 (P = 0.0005), respectively. Peak sweat rate correlated with questionnaire score (Pearson correlation coefficient = 0.723).

INTERPRETATION

Palmar hyperhidrosis can be accurately diagnosed via questionnaire. Molecular epidemiological studies of PH may be reliably conducted without the need for direct physical examination.

Thoracoscopic sympathectomy for palmar and axillary hyperhidrosis: four-year outcome and quality of life after bilateral 5-mm dual port approach

BACKGROUND

During recent years, thoracoscopic sympathectomy has been the standard treatment for hyperhidrosis. Different surgical techniques have been described without proving their advantages compared with other procedures. This study was designed to evaluate our modification of thoracoscopic sympathectomy and to compare the effectiveness between axillary and palmar hyperhidrosis.

METHODS

Ninety patients with axillary or palmar hyperhidrosis who underwent bilateral thoracoscopic sympathectomy with single-lumen ventilation with a dual 5-mm port approach were followed up for a median of 3.9 (range, 1-6) years. The clinical course and data during the hospitalization and consultation in our outpatient clinic were reviewed. The following parameters were evaluated: clinical improvement, satisfaction, changes in quality of life, and compensatory sweating and gustatory sweating.

RESULTS

The perioperative mortality was 0, and the morbidity was 6.5%. In 81% clinical improvement of sweating was noticed; 55% did not sweat at all. A total of 88% of patients were satisfied with the result of the operation. The rates of compensatory sweating and gustatory sweating were 93.5% and 49.4%, respectively. The result of sympathectomy in patients with palmar hyperhidrosis were significantly better concerning rate of satisfaction (p = 0.006) and improvement of symptoms (p = 0.027) compared with patients with axillary symptoms. Additionally it was found that the compensatory sweating had significantly impacted the satisfaction rating of the operation.

CONCLUSION

Currently different effective surgical approaches for the treatment of hyperhidrosis with improvement rates of more than 80% are available. The quality of the intervention has to be evaluated by changes in quality of life and intensity of compensatory sweating. Thoracoscopic sympathectomy as performed in our institution offers results and complications comparable to previously published trials; however, because of single-lumen ventilation the management is much easier. Therefore, this technique offers an interesting option for the treatment of patients with palmar and axillary hyperhidrosis.

Avaliação de pacientes submetidos a tratamento cirúrgico de hiperidrose palmar quanto à qualidade de vida e ao surgimento de hiperidrose compensatória

OBJETIVO: Avaliar a qualidade de vida e a presença de compensação pós-operatória de pacientes submetidos a simpatectomia torácica. MÉTODOS: Foram avaliados 50 pacientes consecutivos submetidos a tratamento cirúrgico para hiperidrose palmar. Avaliou-se: o motivo principal que levou o paciente a procurar atendimento médico, a realização prévia de tratamento clínico para hiperidrose, incidência e localização corporal de hiperidrose compensatória e sua relação com a personalidade do indivíduo e o grau de satisfação do paciente com o tratamento. RESULTADOS: Entre todos os entrevistados, 27 (54%) relataram que o incômodo pessoal com o suor excessivo, os levou a procurar atendimento médico; 23 (46%) tiveram prejuízo na relação social; 22 (44%) tiveram dificuldade relativa ao ambiente escolar, enquanto 20 (40%) relataram que o incômodo causado pela hiperidrose nas atividades relacionadas ao trabalho levou-o a procurar atendimento médico. 21 (42%) foram considerados tímidos pelas pessoas de seu convívio. 33 (66%) começaram a manifestar a doença na infância (até os 12 anos); 15 (30%) na adolescência e apenas um (2%) na fase adulta. O calor foi responsável pela crise de suor em 17 (34%) pacientes e a ansiedade esteve presente em 19 (38%). Irritação gerava crise de suor em 31 (62%). Hiperidrose compensatória ocorreu em 39 (78%) pacientes, sendo que três (6%) tiveram compensação plantar e 28 (56%) no dorso e oito (16%) simultaneamente no dorso e plantar, 46 (92%) consideram que a qualidade de vida após a operação "melhorou". CONCLUSÃO: O tratamento cirúrgico da hiperidrose melhora a qualidade de vida, porém a hiperidrose compensatória ocorre em quase todos os pacientes.

The correlation between the method of sympathetic ablation for palmar hyperhidrosis and the occurrence of compensatory hyperhidrosis: a review

BACKGROUND

Upper dorsal sympathectomy achieves excellent long-term results in the treatment of primary palmar hyperhidrosis. Compensatory hyperhidrosis (CHH) remains an unexplained sequel of this treatment, attaining in a small percentage of cases disastrous proportions. It has been claimed that lowering the level of sympathectomy (from T2 to T3 and even T4), substituting resection by other means of ablation, and limiting its extend reduce the occurrence of this sequel. This review was designed to evaluate the validity of these claims.

METHODS

A MEDLINE search was performed for the years 1990--2006 and all publications about thoracoscopic upper dorsal sympathectomy for hyperhidrosis were retrieved.

RESULTS

The search identified 42 techniques of sympathetic ablation. However, pertinent data for the present study were reported for only 23 techniques with multiple publications found only for 10. The only statistically valid results from this review point that T2 resection and R2 transection of the chain (over the second rib) ensue in less CHH than does electrocoagulation of T2. Further comparisons were probably prevented due to the enormous disparity in the reported results, indicating lack of standardization in definitions.

CONCLUSIONS

The compiled results published so far in the literature do not support the claims that lowering the level of sympathetic ablation, using a method of ablation other than resection, or restricting the extend of sympathetic ablation for primary palmar hyperhidrosis result in less CHH. In the future, standardization of the methods of retrieving and reporting data are necessary to allow such a comparison of data.

Evidence-based review of the surgical management of hyperhidrosis

The great majority of the currently available evidence supporting sympathectomy for primary hyperhidrosis is observational, coming from a variety of prospective and restrospective clinical series as well as comparative studies. A cumulative experience in over 6000 patients suggests that ETS is a safe, reproducible, and effective procedure, and most patients are satisfied with the results of the surgery. The currently available experimental data comes from clinical trials that compared alternative levels of sympathetic chain disruption; these trials speak only to the relative merits of one surgical technique over another and do not provide an assessment of the overall impact of surgery in the general population of patients with primary hyperhidrosis. Furthermore, it is difficult to compare series and generalizability is compromised by a lack of uniform definitions and measures at both the exposure and outcome levels. There is marked heterogeneity with respect to study population and entry criteria, with significant variability of site and severity of excess sweating as well as the degree of preoperative conservative management of hyperhidrosis before surgical referral. Also the operative approach varies widely among studies, and the optimal procedure remains elusive: unilateral versus staged nonsimultaneous bilateral versus concomitant bilateral sympathectomy; ganglionic resection versus ablation using electrocoagulation or harmonic scalpel; clipping of the chain to maintain reversibility in the event of intolerable symptoms versus permanent disruption. In addition, the lack of uniform outcome measures makes these data difficult to interpret, and standardized metrics of surgical results are necessary, such as objective quantification of sweating by gravimetry or use of the SF-36 Health Survey Questionnaire as an estimate of patient quality of life. A multicenter, adequately powered, randomized controlled trial comparing surgical to medical management of hyperhidrosis is unlikely given the current enthusiasm for same-day thoracoscopic sympathectomy among surgeons, a largely positive literature replete with encouraging results, and well-informed hyperhidrosis patients who want to be cured of a socially debilitating illness. Future clinical trials in this area will likely compare surgical techniques. For such comparisons, procedures must be standardized and outcome measures validated for both symptoms of the disease and surgical complications. Finally, the studies must have large numbers of patients and adequate long-term follow-up if they are to detect differences in results among procedures with very high technical success rates.

Assessment of quality of life in patients with primary axillary hyperhidrosis before and after suction-curettage

BACKGROUND

Focal axillary hyperhidrosis (FAH) is a benign functional disorder that may lead to social and psychologic handicap. Hence, the improvement of quality of life is a major aim of therapy. Several studies evaluating the quality of life before and after application of topical agents, injections with botulinum toxin, and thoracoscopic sympathectomy have been reported. However, changes of quality of life after minimally invasive surgical procedures such as suction-curettage (SC) have not been investigated so far.

OBJECTIVE

We sought to evaluate the quality of life in patients with FAH before and after SC using the validated Dermatology Life Quality Index (DLQI).

METHODS

In all, 51 patients who underwent SC were followed up for 9 months. The DLQI was completed by the patients before and 9 months after surgery. In addition, scores for patient satisfaction and improvement of FAH were applied.

RESULTS

The median DLQI score before treatment was 12 (range: 9-18). Nine months after surgery a significant decrease of the DLQI score was observed (median: 4; range: 2-8) resulting in a relative reduction and improvement of the DLQI score of 63.4% (range: 33-83; P < .05), respectively. A significant sweat reduction was reported in 68.6% of patients experiencing a decrease of sweating of at least 75% after SC. Moreover, 78.4% of the patients were very or completely satisfied with the surgical procedure.

LIMITATIONS

Only severe cases of hyperhidrosis, refractory to conservative therapy, were included. No objective outcome measure (eg, gravimetry) was included.

CONCLUSION

Our data support results of previous studies demonstrating that FAH is associated with considerably reduced quality of life. SC is an effective surgical therapy option that can largely reverse the disabilities experienced by patients with excessive axillary sweating.

Long-term effects of thoracic sympathectomy on microcirculation in the hands of patients with primary Raynaud disease

OBJECTIVE

Videothoracoscopic sympathecomy is a widely used treatment modality in patients with severe Raynaud disease, but the reported late results are less than favorable. There have been no direct studies of the long-term effect of sympathectomy on microcirculation in the hands of these patients.

METHODS

In 25 patients with Raynaud disease treated with videothoracoscopic Th2-Th4 sympathectomy, we performed basal laser-Doppler flowmetry and measured the maximal refilling time after 1-minute occlusion measurements preoperatively and at 1 week, 6 months, and 1, 2, 3, and 5 years after the sympathectomy. The results were compared with the same measurements obtained in the group of 50 healthy individuals.

RESULTS

The patients' symptom severity was assessed by using the visual analogue scale. The basal capillary flow and the maximal refilling time improved after the sympathectomy to a level not different from that seen in the healthy population, and the effect was maintained during the 5-year follow-up period. The patients' symptom severity scores diminished to zero in the early postoperative period and increased to 28% of their initial value 5 years after the operation.

CONCLUSIONS

The videothoracoscopic Th2-Th4 sympathectomy produces excellent and long-lasting improvement of microcirculation function in patients with Raynaud disease. The mild return of symptoms might be due to factors other than the capillary blood flow alterations.

Endoscopic VATS sympathectomy: the uniportal technique

Presentation of the uniportal VATS sympathectomy technique: through a single port incision, a videothoracoscope, a diathermy hook and, if needed, a lung grasper are introduced into the pleural cavity. Upon identification of the sympathetic chain, the relevant ganglia are divided. By extending laterally the dissection, the aberrant accessory sympathetic nerve fibers are also severed. Anatomic variations are illustrated and an overview of the literature is presented.