Long-Term Impact of Endoscopic Thoracic Sympathectomy for Primary Palmar Hyperhidrosis

Incidence and Severity of Compensatory Hyperhidrosis Following Bilateral Sympathectomy

BACKGROUND

Primary hyperhidrosis is a condition caused by an excessive stimulation of sweat glands, leading to a decline in both quality of life and social wellbeing. Thoracic sympathectomy surgery provides a relief of the initial symptoms but poses a risk for developing compensatory hyperhidrosis (CH) in various degrees.

OBJECTIVE

The aim of this study was to assess the occurrence and characteristics of CH post-thoracic sympathectomy.

METHODS

A retrospective cohort study of patients who underwent video-assisted thoracic sympathectomy surgery at level T2-T3 between 2016 and 2022 was conducted. Patients' data were retrieved from medical records and through a telephone interview.

RESULTS

A total of 50 patients (32 males and 18 females) were operated on with a mean ± standard deviation (SD) age of 25.9 ± 7.4 years at the time of surgery for palmoplantar hyperhidrosis. Initial symptoms started in childhood at a mean ± SD age of 11.4 ± 3.3 years. Postoperatively, 39 patients (78%) developed CH, more prevalent in males (64.1%) compared to females (35.8%). This CH mainly affected the back and abdomen (100%), followed by the groin and thighs (28.2%), and, to a lesser extent, the craniofacial area (15.3%). Onset of symptoms occurred within 1 week after surgery in 71.7% of cases, with 71.7% reporting mild to moderate symptoms. CH was significantly associated with higher age at the time of surgery, smoking status, and a longer time lapse in the surgery operation (P value < 0.05).

CONCLUSIONS

Thoracic sympathectomy is an effective procedure with a high success rate. Despite a relatively higher occurrence of CH, most patients experience milder symptoms and express satisfaction, noting that their expectations were met following the surgery.

Efficacy and safety of radiofrequency ablation versus surgical sympathectomy in palmar hyperhidrosis

Radiofrequency ablation (RFA) comparative efficacy of treatments using video-assisted thoracoscopic sympathectomy (VATS) in the long term remains uncertain in patients with palmar hyperhidrosis (PHH). This study aimed to compare the efficacy and safety of RFA and VATS in patients with PHH. We recruited patients aged ≥ 14 years with diagnosed PHH from 14 centres in China. The treatment options of RFA or VATS were assigned to two cohort in patients with PHH. The primary outcome was the efficacy at 1-year. A total of 807 patients were enrolled. After propensity score matching, the rate of complete remission was lower in RFA group than VATS group (95% CI 0.21-0.57; p < 0.001). However, the rates of palmar dryness (95% CI 0.38-0.92; p = 0.020), postoperative pain (95% CI 0.13-0.33; p < 0.001), and surgery-related complications (95% CI 0.19-0.85; p = 0.020) were lower in RFA group than in VATS group, but skin temperature rise was more common in RFA group (95% CI 1.84-3.58; p < 0.001). RFA had a lower success rate than VATS for the complete remission of PHH. However, the symptom burden and cost are lower in patients undergoing RFA compared to those undergoing VATS.Trial Registration: ChiCTR2000039576, URL: http://www.chictr.org.cn/index.aspx .

Robotic sympathetic trunk reconstruction for compensatory sweating after thoracic sympathectomy

Objectives

Endoscopic thoracic sympathectomy may be complicated by the onset of disabling compensatory sweating (CS). The objective of this case series is to report the 2-year outcomes after robotic sympathetic trunk reconstruction (STR) for the reversal of CS in patients who had undergone endoscopic thoracic sympathectomy.

Methods

We prospectively followed-up a total of 23 patients who had undergone robotic STR because of intolerable CS between October 2017 and January 2021. A visual analog scale ranging from 0 to 10 (with 10 indicating the highest degree) was used to assess the severity of CS at different anatomical locations, thermoregulatory alterations, and gustatory hyperhidrosis. Measurements were performed before STR and at 6-month and 2-year follow-up.

Results

The mean age of the study participants was 43.3 ± 7.8 years, and 20 (87%) were men. The reversal procedure was performed after a mean of 19.6 ± 7.8 years from endoscopic thoracic sympathectomy. In all patients, nerve defects were successfully bridged using sural nerves (mean length, 9.7 cm on the right and 9.8 cm on the left). No cases of Horner syndrome were noted. At 6 postoperative months, the severity of CS decreased significantly at all body surface areas. The observed improvements were effectively maintained at 24 post-STR months. There was no evidence of either recurrent hyperhidrosis at the primary site or transition of CS to other anatomical locations. Similar improvements were evident for thermoregulatory alterations and gustatory hyperhidrosis.

Conclusions

Robotic STR is safe and effective in reversing intolerable CS after endoscopic thoracic sympathectomy.

Impact of endoscopic thoracic R4 sympathicotomy combined with R3 ramicotomy for primary palmar hyperhidrosis

Background

Endoscopic thoracoscopic sympathectomy (ETS) is the preferred method for treating primary palmar hyperhidrosis (PPH) that bears the risk of compensatory hyperhidrosis (CH) following surgery. The current study aims to evaluate the effectiveness and safety of an innovative surgical procedure of ETS.

Methods

A survey of the clinical data of 109 patients with PPH who underwent ETS in our department from May 2018 to August 2021 was retrospectively conducted. The patients were organized into two groups. Group A underwent R4 sympathicotomy combined with R3 ramicotomy. Group B underwent R3 sympathicotomy. Patients were followed up to evaluate the safety, effectiveness and the incidence of postoperative CH of the modified surgical approach.

Results

A total of 102 patients completed follow-up, and seven of the total enrolled patients were lost to follow-up, with a loss rate of 6% (7/109). Among these, Group A constitutes 54 cases, group B constitutes 48 cases, and the mean follow-up was 14 months (interquartile range 12-23 months). There was no statistically difference in surgical safety, postoperative efficacy, and postoperative quality of life (QoL) score between group A and group B (p > 0.05). The score of the psychological assessment was higher (p = 0.004) in group A (14.15 ± 2.06) compared to group B (13.30 ± 1.86). The incidence of CH in group A was lower than in group B (p = 0.019).

Conclusion

R4 sympathicotomy combined with R3 ramicotomy is safe and effective for PPH treatment, along with a reduced incidence of postoperative CH rate and improved postoperative psychological satisfaction.

Percutaneous Radiofrequency Sympatholysis in the Treatment of Primary Palmar Hyperhidrosis: A Retrospective Case-Controlled Study of Rib-Based Anatomical Targeting

PURPOSE

To compare the efficacy, adverse reactions, quality of life, and patient satisfaction of percutaneous radiofrequency (RF) thoracic sympatholysis at different rib-based anatomic targets for primary palmar hyperhidrosis (PPHH).

MATERIALS AND METHODS

Patients with PPHH were divided according to the target, namely, the upper edge (Group U) and lateral border (Group L) of the fourth rib; there were 30 patients (mean age, 24.9 years; women, 31, 51.7%) and 60 cases in each group. The Hyperhidrosis Disease Severity Scale (HDSS) and Dermatology Life Quality Index (DLQI) were assessed.

RESULTS

From before RF sympatholysis to 12 months after, the proportion of patients with HDSS Grades III and IV (100%-26.7%) and the DLQI (19.78 ± 5.08 to 4.98 ± 4.18) decreased significantly (P < .001). At 3, 6, and 12 months after RF, the HDSS grades were better in Group L than in Group U (P = .005, .002, and .004). At 6 and 12 months after RF, the DLQI in Group L was lower than that in Group U (P = .012 and .016), and at 1, 6, and 12 months after RF, patient satisfaction was higher than that in Group U (P = .025, .014, and .009). Adverse events were mild; 8 patients (13.3%) demonstrated compensatory hyperhidrosis at 12 months after RF, and there was no difference between the 2 groups (P = .448); neuralgia and pneumothorax also did not differ (P = .522 and .643).

CONCLUSIONS

RF sympatholysis targeting the lateral border of the fourth rib had higher efficacy, better quality of life, and higher patient satisfaction.

Computed Tomography-Guided Percutaneous T4 Thoracic Sympathetic Radiofrequency Thermocoagulation for Primary Palmar Hyperhidrosis: A Retrospective Observational Trial

PURPOSE

To evaluate the efficacy, safety, and patient satisfaction of computed tomography (CT)-guided percutaneous T4 thoracic sympathetic radiofrequency thermocoagulation (RFT) for the treatment of primary palmar hyperhidrosis (PPHH).

MATERIALS AND METHODS

A total of 158 patients who underwent bilateral thoracic sympathetic RFT at the T4 level were analysed. Hyperhidrosis Severity Scale (HDSS), Dermatologic Quality of Life Index (DLQI), patient satisfaction, and adverse events were evaluated within 12 months after RFT.

RESULTS

The mean age of the patients was 25.27 years, and 95 (60.1%) were females. The technical success, defined as planned needle placement and completion of RFT, was 99.4%. After the procedure, 243 hands (77.4%) were completely dry; and 58 hands (18.4%) were partially dry. From before RFT to 12 months after RFT, the proportion of hands with the HDSS grades 3 and 4 from 100% decreased to 31.9%; and that with the DLQI scores D and E from 100% decreased to 4.0% (P < .001). The clinical success rate was 76.6%, and the patient satisfaction rate was 80.8% at 12 months after RFT. During the procedures, there was unilateral local bleeding in two patients (0.6%) and bradycardia in five patients (3.2%); after the procedures, unilateral pneumothorax occurred in 15 patients (4.7%) and closed thoracic drainage was performed in two patients (0.6%); thoracic neuralgia occurred in 24 patients (15.2%). The incidence of compensatory hyperhidrosis (CH) 12 months after RFT was 15.2%.

CONCLUSIONS

CT-guided percutaneous T4 thoracic sympathetic RFT is safe, effective, and minimally invasive for the treatment of PPHH.

LEVEL OF EVIDENCE

Level 2 observational study with dramatic effect.

Clinical Outcomes of Uniportal Versus Multiportal Endoscopic Thoracic Sympathectomy in Patients With Severe Palmar and Axillary Hyperhidrosis

Objective: Palmar and axillary hyperhidrosis is caused by overstimulation of the sympathetic nervous system that control the sweat glands. This study compares the clinical consequences of uniportal and multiportal thoracic endoscopic thoracic sympathectomy (ETS), in cases of severe palmar and axillary hyperhidrosis. Methods: In this retrospective study, forty-one patients who were diagnosed as severe palmar and axillary primary hyperhidrosis were analyzed. These underwent multiportal ETS between 2015 and 2020 at our thoracic surgery clinic. They were divided into two groups, 24 as uniportal (58.5%) and 17 as multiportal (41.5%). They were compared in terms of the length of hospital stay, the initial complications and possible recurrences after three months. Descriptive statistics were used to evaluate stratified and continuous variables. Results: There was no significant difference in moderate pain between the two groups. There was a significant difference between the two groups in terms of 3 days or more hospitalization. There were no significant difference related to the rate of complications such as ptosis, Horner syndrome, increased duration of surgery and recurrence rate of hyperhidrosis 3 months after surgery. Some mild to moderate side effects disappeared spontaneously at 6-month follow-up. Conclusion: The results showed that uniportal and multiportal endoscopic thoracoscopic sympathectomy (EST) are very effective, safe and minimally invasive methods for the treatment of palmar and axillary hyperhidrosis. Compared to the multiportal approach, uniportal EST causes less postoperative pain and less surgical duration.

Knowledge of surgical management of hyperhidrosis among primary care physicians and the general public

OBJECTIVES

Our study examined attitudes towards initial management of hyperhidrosis, willingness to seek surgical consultation and knowledge of an appropriate specialty for surgical consultation among primary care physicians and the general public.

METHODS

An online survey was sent to all general medicine and paediatric residents and attending physicians at our academic medical centre. Participants were provided with a clinical scenario of palmar hyperhidrosis and were asked to select among initial management options and preferences for surgical consultation if patients failed non-operative management. To assess the general public's perspective, workers from Amazon Mechanical Turk were recruited to complete a similar survey.

RESULTS

The majority of primary care physicians (31/53; 58%) would prescribe topical aluminium chloride for palmar hyperhidrosis, whereas 28 of 53 (53%) would refer such patients to dermatology. Twenty-three of 53 (43%) physicians would refer such patients to surgery if conservative management failed: 18 (78%) to plastic surgery, 4 (17%) to general surgery and none to thoracic surgery. The majority of workers (130/205; 63.4%) would seek primary care treatment for palmar hyperhidrosis. Over half (113/205; 55%) would seek surgical consultation if conservative management failed: 65 (58%) general surgery and 15 (13%) neurosurgery, with only 8 (7%) selecting thoracic surgery.

CONCLUSIONS

Neither primary care physicians nor the general public recognize the role of thoracic surgeons in managing primary focal hyperhidrosis when medical management fails. Education of physicians and the public may mitigate this knowledge gap.

A Practical Approach to the Diagnosis and Treatment of Palmar Hyperhidrosis

Palmar hyperhidrosis (PH), a condition characterized by excess sweating of the palms, is a common concern that presents to the plastic surgeon, which can have major impacts on patient confidence and quality of life. While several studies summarize treatment options for hyperhidrosis in general, few outline the therapeutic options available specifically for PH.

Selective T3-T4 sympathicotomy versus gray ramicotomy on outcome and quality of life in hyperhidrosis patients: a randomized clinical trial

Compensatory hyperhidrosis is the leading cause of patients' dissatisfaction after thoracic sympathicotomy. The study aimed to reduce compensatory hyperhidrosis to increase patients’ satisfaction. A prospective randomized study on palmar hyperhidrosis, May 2016–September 2019. Twenty-one patients T₃–T₄ sympathicotomy and 21 T₃–T₄ gray ramicotomy. Data prospectively collected. Analysis at study's end. Focus on the sweating, temperature, quality of life baseline and postoperatively, compensatory hyperhidrosis, hand dryness, patients' satisfaction, and if they would undergo the procedure again and recommend it. No baseline differences between groups. Hyperhidrosis was controlled postoperatively in all patients. No mortality, serious complications, or recurrences. Sympathicotomy worse postoperative quality of life (49.05 (SD: 15.66, IR: 35.50–63.00) versus ramicotomy 24.30 (SD: 6.02, IR: 19.75–27.25). After ramicotomy, some residual sweating on the face, hands, and axillae. Compensatory sweating worse with sympathicotomy. Satisfaction higher with ramicotomy. Better results with ramicotomy than sympathicotomy regarding hand dryness, how many times a day the patients had to shower or change clothes, intention to undergo the procedure again or recommend it to somebody else, and how bothersome compensatory hyperhidrosis was. T₃–T₄ gray ramicotomy had better results than T₃–T₄ sympathicotomy, with less compensatory sweating and higher patients' satisfaction.

Long-Term Outcomes and Course of Compensatory Sweating after Endoscopic Sympathicotomy

BACKGROUND

 Endoscopic thoracic sympathicotomy is an effective approach to the treatment of idiopathic localized hyperhidrosis, and compensatory sweating is the main reason for patient dissatisfaction. Our study discusses both the long-term outcomes of sympathicotomy and the course of compensatory sweating.

METHODS

 Patients with palmar and/or axillary hyperhidrosis who were operated by the same surgical team between January 2008 and December 2014 were included in the study. After at least 5 years (60 months) from operation, patients were questioned about their treatment outcomes by using an original survey form.

RESULTS

 Of the 137 patients included in the study, 88 (64.2%) were female and 49 (35.8%) were male. The mean time from the operation to the survey interview was 80.9 ± 14.1 (64-136) months. After operation, complaints disappeared in 95.1% of the patients, and decreased in 4.9% with palmar hyperhidrosis. Complaints completely disappeared in 12.9% and decreased in 81.7% of the patients with axillary hyperhidrosis. Ninety-seven (70.8%) of the patients described increased sweating in some parts of their body after operation but only 47 reached an uncomfortable intensity. The number of patients who regretted the operation due to the compensatory sweating was 13 (9.5%). The patients' overall scoring of the operation and procedure was calculated as 8.0 ± 2.1 (0-10 points) out of 10.

CONCLUSION

 Endoscopic thoracic sympathicotomy's long-term outcomes are also satisfactory in the treatment of palmar and axillary hyperhidrosis. Compensatory sweating may decrease over time, only a minority of patients will express regret at undergoing the treatment.

Increased Incidence of Premenstrual Syndrome in Females with Palmar Hyperhidrosis

Background: Premenstrual syndrome (PMS) is a common disorder affecting the quality of life of women of reproductive age. In a previous study, sex hormone imbalances and alterations in autonomic function were present in PMS, with parasympathetic dysfunction and sympathetic overactivity during the late luteal phase. Palmar hyperhidrosis (PH) presents with oversweating, heat and emotional stimulation, sympathetic hyperactivity and parasympathetic hypofunction. We hypothesized that the incidence of PMS is increased in females with PH. Methods: Data were retrieved from the Taiwanese National Health Insurance Database. The patients with PH were identified by the International Classification of Disease, 9th Revision, Clinical Modification (ICD-9-CM) disease code 780.8. Female patients matched by age and index day were used as the control group. The incidence of PMS was considered an outcome by the ICD-9-CM disease code 625.4. The factors related to PMS were analyzed by Cox regression. Results: The adjusted hazard ratio for the incidence of PMS was 1.276 (95% confidence interval: 1.05–1.488) in females with PH. Conclusions: This study found a positive correlation between PMS and female PH patients. Patients and physicians must understand the relationship of PMS with autonomic function alterations and other risk factors to prevent this problematic disorder.

Robotic-Assisted Peripheral Nerve Surgery: A Systematic Review

BACKGROUND

 Robotic-assisted techniques are a tremendous revolution in modern surgery, and the advantages and indications were well discussed in different specialties. However, the use of robotic technique in plastic and reconstructive surgery is still very limited, especially in the field of peripheral nerve reconstruction. This study aims to identify current clinical applications for peripheral nerve reconstruction, and to evaluate the advantages and disadvantages to establish potential uses in the future.

METHODS

 A review was conducted in the literatures from PubMed focusing on currently published robotic peripheral nerve intervention techniques. Eligible studies included related animal model, cadaveric and human studies. Reviews on robotic microsurgical technique unrelated to peripheral nerve intervention and non-English articles were excluded. The differences of wound assessment and nerve management between robotic-assisted and conventional approach were compared.

RESULTS

 Total 19 studies including preclinical experimental researches and clinical reports were listed and classified into brachial plexus reconstruction, peripheral nerve tumors management, peripheral nerve decompression or repair, peripheral nerve harvesting, and sympathetic trunk reconstruction. There were three animal studies, four cadaveric studies, eight clinical series, and four studies demonstrating clinical, animal, or cadaveric studies simultaneously. In total 53 clinical cases, only 20 (37.7%) cases were successfully approached with minimal invasive and intervened robotically; 17 (32.1%) cases underwent conventional approach and the nerves were intervened robotically; 12 (22.6%) cases converted to open approach but still intervened the nerve by robot; and 4 (7.5%) cases failed to approach robotically and converted to open surgery entirely.

CONCLUSION

 Robotic-assisted surgery is still in the early stage in peripheral nerve surgery. We believe the use of the robotic system in this field will develop to become popular in the future, especially in the fields that need cooperation with other specialties to provide the solutions for challenging circumstances.

Symptoms of anxiety and depression in patients with primary hyperhidrosis and its association with the result of clinical treatment with oxybutynin

OBJECTIVES

Studies have identified correlations between the psychological characteristics of individuals with primary hyperhidrosis (HH), the degree of sweating, and the quality of life (QoL). This study aimed to evaluate the prevalence of anxiety and depression symptoms in patients with HH before and after oxybutynin treatment.

METHODS

Data were collected from 81 patients. Palmar or axillary HH was the most frequent complaint (84.0%). All patients were evaluated before the medication was prescribed and after five weeks of treatment. The Beck Depression Inventory and Beck Anxiety Inventory were used to evaluate depression and anxiety.

RESULTS

Improvement in HH occurred in 58 patients (71.6%), but there was no improvement in 23 patients (28.4%). The QoL before treatment in all patients was either "poor" or "very poor." Patients who experienced improvement in sweating rates also experienced a greater improvement in QoL than patients who did not experience improvement in sweating at the main site (87.9% vs. 34.7%) (p<0.001). A total of 19.7% of patients showed an improvement in their level of depression, and a total of 46.9% of patients exhibited improvements in their level of anxiety. A significant correlation was observed between sweating and anxiety (p=0.015).

CONCLUSION

Patients with HH who experienced improvements in sweating immediately after treatment with oxybutynin exhibited small improvements in their levels of depression and significant improvements in their levels of anxiety and QoL.

Involvement of activin a receptor type 1 (ACVR1) in the pathogenesis of primary focal hyperhidrosis

The pathogenesis of primary focal hyperhidrosis (PFH) is still not clear. PFH is thought to be a genetic disease. Whether activin A receptor type 1 (ACVR1) is involved in the pathogenesis of PFH is unknown. In this study, the expression of ACVR1 in sweat glands of patients with PAH was detected by western blot and immunofluorescence. The primary sweat gland cells obtained from primary axillary hyperhidrosis (PAH) patients were transfected with acvr1 vector. Cell proliferation, apoptosis and cell cycling of gland cells were measured after transfection with acvr1 vector. The mRNA and protein expression of aquaporin 5 (AQP5) and Na:K:2Cl Cotransporter 1 (NKCC1/SLC12A2) were detected. Our data showed that ACVR1 expression in axillary sweat gland tissue of PAH patients was significantly higher than that of normal control group. The function of ACVR1 was further investigated in the gland cells obtained from PAH patients. Compared with NC group, ACVR1 overexpression significantly promoted the proliferation of sweat gland cells and inhibited the apoptosis of sweat gland cells. Meanwhile, ACVR1 overexpression significantly reduced the percentage of cells in G0/G1 and G2/M phases, and increased the percentage of cells in S phase. In addition, ACVR1 overexpression significantly promoted the expression of AQP5 and NKCC1 at both mRNA and protein levels. Together, ACVR1 expression is related to PFH and ACVR1 overexpression can promote the proliferation of sweat gland cells and inhibit apoptosis by promoting the expression of AQP5 and NKCC1.

Microwave Thermolysis Reduces Generalized and Social Anxiety in Young Adults With Axillary Hyperhidrosis

BACKGROUND AND OBJECTIVE

Hyperhidrosis (HH) is associated with impairments in quality of life (QOL) and elevated anxiety. Microwave thermolysis is a newer treatment that reduces sweating, yet effects on QOL and emotional symptoms have not been examined. Two treatment sessions are recommended to achieve 80% amelioration of clinical HH. We hypothesized that microwave thermolysis would reduce sweat severity, improve QOL, and reduce anxiety in young adults suffering from axillary HH in a prospective clinical trial.

STUDY DESIGN/MATERIALS AND METHODS

We enrolled 24 young adults (mean age = 23.57 years, 54% female) with elevated scores on the Hyperhidrosis Disease Severity Scale. All participants received one session of microwave thermolysis, and 83% received two sessions. Participants completed measures of sweat severity, QOL, generalized anxiety, social anxiety, social avoidance, and anxious/depressive mood symptoms at baseline; post-first treatment; and following second treatment.

RESULTS

At baseline, all participants had severe sweating; 87.5% had impaired QOL, 75% had elevated social anxiety, 50% with generalized anxiety, 48% with social avoidance, and 38% with anxious/depressed mood. Paired samples t tests indicated significant improvements from baseline to first procedure, including decreased sweating (t(21) = 5.68, P < 0.001), improved QOL (t(23) = 4.97, P < 0.001), and decreased generalized anxiety (t(23) = 8.11, P < 0.001), social anxiety (t(22) = 4.55, P < 0.001), mood symptoms (t(21) = 3.81, P = 0.001), and social avoidance (t(22) = 3.12, P = 0.005). After second treatment, further improvements were noted in sweating (t(18) = 3.28, P = 0.004) and QOL (t(18) = 3.83, P = 0.003), and a marginal trend for generalized anxiety (t(19) = 1.96, P = 0.064).

CONCLUSION

There were significant improvements in sweat severity, skin-specific QOL, generalized anxiety, social anxiety, anxious/depressive symptoms, and social avoidance. The majority of the psychosocial benefit appears to emerge after one treatment of microwave thermolysis, whereas the level of sweat severity and QOL continued to show further improvements after a second treatment. Results would suggest that although two microwave thermolysis sessions are needed for maximal treatment optimization of axillary HH, patients may experience significant benefits in improving psychosocial functioning after just one session. Lasers Surg. Med. © 2020 Wiley Periodicals, Inc.

New sympathicotomy for prevention of severe compensatory hyperhidrosis in patients with primary hyperhidrosis

Background

Primary hyperhidrosis (PH) is characterized by excessive and uncontrollable secretion in the eccrine sweat glands of the craniofacial region, armpits, hands, and feet. Sympathicotomy is the most effective treatment for severe PH; however, compensatory hyperhidrosis (CH) remains the most devastating postoperative complication. The purpose of the present study was to suggest a new sympathicotomy method for PH to prevent severe CH.

Methods

From March 2014 to December 2018, a total of 212 patients were included in the study. R2 (53 cases) sympathicotomy for craniofacial hyperhidrosis and R3 (79 cases) or R4 (80 cases) sympathicotomy for palmar hyperhidrosis using the thoracoscopic technique were performed, respectively. Sympathicotomy was performed using two different methods (conventional 145 cases and new 67 cases). Expanded sympathicotomy was performed as the new method (67 cases), which was divided into two groups (partial- and full-expanded sympathicotomy). Operative effectiveness was evaluated by a reduction in percentage of post-operative sweating compared with pre-operative sweating and groups were divided into complete and incomplete sweat reduction characteristics. Complete sweat reduction was defined as sweat reduction ≥80% compared with preoperative sweating. The degrees of CH were classified as negligible, mild bothering (tolerable), and severe bothering (intolerable). Data on preoperative subject characteristics, disease status, operative technique, and postoperative outcomes were gathered using medical records and telephone surveys.

Results

According to sympathicotomy techniques, the conventional procedure (non-expanded sympathicotomy) was performed in 145 cases and the new expanded sympathicotomy procedure was performed in 67 cases (partial-expanded sympathicotomy 28 cases; full-expanded sympathicotomy 39 cases). Craniofacial hyperhidrosis was significantly more prevalent in the older group and in female patients (P<0.001 and P=0.007, respectively). Sympathicotomy was significantly more effective in palmar hyperhidrosis than craniofacial hyperhidrosis (P<0.001). CH was significantly more severe in craniofacial hyperhidrosis than palmar hyperhidrosis after sympathicotomy (P<0.001). In craniofacial hyperhidrosis, there was no significant difference in sweat reduction and CH between conventional and the expanded sympathicotomy techniques (P=0.177 and P=0.474, respectively). In palmar hyperhidrosis, there was no significant difference in sweat reduction between the conventional and the expanded sympathicotomy (P=0.178), however, degree of CH in the conventional technique was significantly more severe than in the expanded technique (P=0.001). Regarding comparison between partial- and full-expanded sympathicotomy, there was no significant difference in sweat reduction between partial-, and full-expanded sympathicotomy; however, CH was significantly more severe in partial-expanded sympathicotomy (craniofacial hyperhidrosis P=0.006; palmar hyperhidrosis P<0.001). Irrespective of hyperhidrosis types, there was no significant difference in sweat reduction between full-expanded and the others (non-expanded and partial-expanded sympathicotomy), however, full-expanded sympathicotomy showed a significantly less degree of CH than non-expanded and partial-expanded sympathicotomy (craniofacial, P=0.002; palmar, P<0.001).

Conclusions

Full-expanded sympathicotomy is a safe and feasible treatment that shows a significant decrease in the degree of CH with the same effect in sweat reduction in both craniofacial and palmar hyperhidrosis. Importantly, no severe CH developed after a full-expanded sympathicotomy without any major postoperative complications.

Impact of Video-Assisted Thoracoscopic Sympathectomy and Related Complications on Quality of Life According to the Level of Sympathectomy

BACKGROUND

Primary hyperhidrosis is defined as excessive sweating of idiopathic etiology, associated with sympathetic hyperactivity, which greatly impacts patients' quality of life (QoL). The definitive treatment for palmar and axillary hyperhidrosis (PAH) is video-assisted thoracic sympathectomy (VATS). The objective of this study was to evaluate the quality of life of patients with PAH before and after VATS according to the level of sympathectomy performed, as well as the presence of compensatory hyperhidrosis (CH) and other complications.

METHODS

All patients who underwent VATS in our vascular surgery department between January 2011 and December 2016 were included in the analysis. From 120 contact attempts, 88 interviews were carried out. Patients were divided into 2 groups according to the intervened thoracic level: high thoracic ganglion (HTG; T2, T2-T3, T2-T3-T4; n = 68) and low thoracic ganglion (LTG; T3, T3-T4, T4; n = 20). The questionnaire evaluated preoperative PAH severity, the presence of CH, preoperative and postoperative QoL, and postoperative satisfaction.

RESULTS

The median age of patients was 29 years, and the median follow-up period was 32 months (IQR of 34 months). Most patients had severe or very severe PAH (97.7%) and preoperative QoL was bad or very bad (95.5%). Postoperatively, QoL was significantly improved in all domains evaluated, with no differences observed between the groups. The overall percentage of complications was 11.4%, mostly pneumothorax, but there was a significantly lower incidence of complications in the HTG group (P = 0.029). Compensatory hyperhidrosis developed in 85.2% of cases, but it was only considered intolerable in 10.2%. The incidence of CH was 82.4% in the HTG group and 95% in the LTG group, with no statistically significant differences between the groups (P = 0.147).

CONCLUSIONS

Palmar and axillary hyperhidrosis severely affects QoL, and video-assisted thoracic sympathectomy was proven to be effective regardless of the target ganglion resected. Although CH was frequent, it was tolerated in most cases.

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

BACKGROUND

Palmar hyperhidrosis (PH) is a common sympathetic disorder that reduces patient' quality of life. Video-assisted thoracoscopic sympathectomy (VTS) is a popular and effective treatment for PH. However, there is substantial controversy about the treatment of PH with VTS at the T3 or T4 level. We will compare the quality metrics of VTS at T3 versus T4 to determine the optimal level for VTS.

METHODS

We will search PubMed, Scopus, Web of Science, Embase, Cancerlit, the Cochrane Central Register of Controlled Trials, and the Google Scholar databases for relevant clinical trials published in any language before March 31, 2019. Randomized controlled trials (RCTs), quasi-RCTs, propensity score-matched comparative studies, and prospective cohort studies of interest, published or unpublished, that meet the inclusion criteria will be included. Subgroup analysis of the type of operation, sex of patient, and ethnicity of patient will be performed.

RESULTS

The results of this study will be published in a peer-reviewed journal.

CONCLUSIONS

The results of this study will provide reliable evidence for the development of optimal treatment strategies for patients with PH. Owing to the characteristics of disease and intervention methods, randomized controlled trials may not be sufficient. We will include high-quality nonrandomized controlled trials, but this may lead to high heterogeneity and may affect the reliability of the results.

PROSPERO REGISTRATION NUMBER

CRD42018116607.