Endoscopic thoracic sympathectomy for primary hyperhidrosis of the upper limbs. A critical analysis and long-term results of 480 operations

Efficacy of Botulinum Toxin in the Treatment of Cutaneous Flushing: A Systematic Review and Meta-Analysis

BACKGROUND

Flushing is a common dermatologic complaint and can be resistant to many treatments. As the utility of botulinum toxin continues to expand, recent data suggest that it may also be a therapeutic option for flushing.

OBJECTIVE

To evaluate the efficacy of botulinum toxin for the treatment of cutaneous flushing.

MATERIALS AND METHODS

A systematic search of Medline, Embase, Cochrane CENTRAL, CINAHL, Scopus, and Web of Science databases was conducted to identify studies evaluating the effect of botulinum toxin on flushing 1 month after treatment. Prespecified outcome measures included a clinical flushing score, dermatology life quality index (DLQI), and erythema index (EI). Meta-analysis was performed to calculate the mean differences in these outcomes before and after treatment at 1-month follow-up.

RESULTS

Nine studies (132 patients) were included in the analysis of this study (2 randomized controlled trials and 7 nonrandomized studies). All studies had a low risk of bias (high quality). The most frequent outcome reported was a clinical flushing score, which significantly decreased by 1.25 points overall (95% confidence interval [CI]: -2.47; -0.04) 1 month after treatment with botulinum toxin. Mean DLQI scores decreased (i.e., improved) by 9.02 points (95% CI: -19.81; 1.77) 1 month after botulinum toxin injections. The EI (measured by Mexameter) before and after botulinum toxin was evaluated in 2 studies; however, not enough statistical information was provided to analyze with meta-analytic techniques.

CONCLUSION

Based on this meta-analysis, botulinum toxin significantly improves clinical flushing scores 1 month after treatment.

Changes in electrodermal activity following sympathicotomy in hyperhidrosis patients

Objectives

The aim of this study was to assess the potential of electrodermal activity (EDA) as a diagnostic tool for preoperative evaluation in hyperhidrosis patients. EDA levels and patterns in different skin areas were investigated before and after endoscopic thoracic sympathicotomy (ETS) and was compared to healthy subjects.

Methods

Thirty-seven patients underwent two days of measurements before and after the operation. Twenty-five (67.5%) of the patients also had a third measurement after six months. Non-invasive EDA measurements, involving skin conductance, were sampled from five different skin areas while patients were at rest in supine and sitting positions or when subjected to stimuli such as deep inspirations, mental challenge, and exposure to a sudden loud sound.

Results

Prior to the operation, hyperhidrosis patients showed higher spontaneous palm EDA variations at rest and stronger responses to stimuli compared to healthy subjects. Patients with facial blushing/hyperhidrosis or combined facial/palmar hyperhidrosis showed minimal spontaneous activity or responses, particularly during mental challenge and sound stimulus. Notably, palm EDA response was abolished shortly following sympathicotomy, although a minor response was observed after six months. Minimal EDA responses were also observed in the back and abdomen postoperatively.

Conclusion

Hyperhidrosis patients showed stronger EDA response to stimuli compared to healthy subjects. Sympathicotomy resulted in the complete elimination of palm EDA responses, gradually returning to a limited extent after six months. These findings suggest that EDA recordings could be utilized in preoperative assessment of hyperhidrosis patients.

Anatomical variations of the thoracic sympathetic ganglions and their effects on sympathicotomy for primary palmar hyperhidrosis

PURPOSE

The results and side effects of sympathicotomy for primary palmar hyperhidrosis (PPH) can vary due to anatomical variations of the sympathetic ganglions. The aim of our study was to clarify anatomical variations of the sympathetic ganglions by near-infrared (NIR) thoracoscopy and determine their effects on sympathicotomy for PPH.

METHODS

The cases of 695 consecutive patients with PPH treated with either R3 or R4 sympathicotomy either by normal thoracoscopy or by NIR fluorescent thoracoscopy between March 2015 and June 2021 were retrospectively reviewed and followed up.

RESULTS

The variation rate of third and fourth ganglions was 14.7% and 13.3% on the right side and 8.3% and 11.1% on the left side. Real T3 sympathicotomy (RTS₃) was more effective than real T4 sympathicotomy (RTS₄) in the short-term and long-term follow-up (p < 0.001 and p < 0.001, respectively). RTS₃ was more satisfactory than RTS₄ in the long-term follow-up (p = 0.03), but no significant difference was found in the short-term follow-up (p = 0.24). The incidence and severity of compensatory hyperhidrosis (CH) in the areas of the chest and back in the RTS₄ group were significantly lower than those in the RTS₃ group according to both the short-term results (12.92% vs. 26.19%, p < 0.001; 17.97% vs. 33.33%, p = 0.002, respectively) and the long-term results (19.66% vs. 28.57%, p = 0.017; 21.35% vs. 34.52%, p < 0.001, respectively).

CONCLUSIONS

RTS₃ may be more effective than RTS₄ for PPH. However, RTS₄ appears to be associated with a lower incidence and severity of CH in the areas of the chest and back than RTS_3. NIR intraoperative imaging of thoracic sympathetic ganglions may improve the quality of sympathicotomy surgeries.

Long-term Outcomes of Endoscopic Thoracoscopic Sympathectomy for Primary Focal Palmar Hyperhidrosis: High Patient Satisfaction Rates Despite Significant Compensatory Hyperhidrosis

BACKGROUND

Endoscopic thoracoscopic sympathectomy (ETS) is the gold standard therapy for primary focal palmar hyperhidrosis (PFPH), resulting in high patient satisfaction rates. The most common side effect of ETS is compensatory hyperhidrosis (CH). Previous studies followed patients' satisfaction degree of surgery and the incidence of CH during a limited follow-up period of 1 to 3 years. The purpose of this study was to investigate the long-term outcomes and patient satisfaction after ETS.

MATERIALS AND METHODS

After approval of our institutional review board, we conducted a retrospective review of all consecutive patients who underwent ETS for PFPH at our institution between 1998 and 2019. Electronic medical records were reviewed for short-term outcomes. Long-term outcomes were collected through telephone questionnaires. Primary outcome was the resolution of PFPH. Secondary outcomes were CH and long-term patient satisfaction.

RESULTS

During the study period, 256 patients underwent ETS to treat primary focal palmar hyperhidrosis at our institution between the years 1998-2019. One-hundred and fifty (58.6%) patients agreed to participate in the study and were included in the final analysis. The mean age was 23.8 (17 to 58) years, 56% were females. The mean follow-up time was 11±6.1 (1 to 22) years. Ninety-four percent reported resolution of PFPH; however, CH was reported by 90% of participants. CH decreased mean patient satisfaction score from 4.8±0.5 to 3.8±2 (P=0.009). This effect was more pronounced in patients with CH of the head and neck (P=0.009). Patients' satisfaction decreased over time from a mean of 4.8±0.4 in the first year after surgery to a mean of 3.7±1.4 12 years or more after surgery (P <0.001). Despite this, 79% of patients reported they would recommend ETS to other patients.

CONCLUSIONS

ETS for PFPH is highly effective and results in high patient satisfaction rates even after long-term follow-up. Despite high rates of postoperative CH, nearly 80% of patients would still recommend the procedure to fellow patients, justifying its reputation as the gold standard treatment for PFPH.

THE PHARMACOLOGICAL TREATMENT AND MANAGEMENT OF HYPERHIDROSIS

INTRODUCTION

Idiopathichyperhidrosis is a dysfunctional disorder involving eccrine sweat glands and its impact on patients' daily quality of life is well-known. Unlike some years ago, when only poor effective and safe therapeutic alternatives were available, nowadays, several emerging pharmacological active substances have gained significant space as treatment options.

AREAS COVERED

The authors report on, in this narrative review, the emerging data from the literature focusing on the pharmacological treatments to draw up a drug treatments flow-chart for patients with idiopathic hyperhidrosis, taking into consideration specific differences among axillary, palmoplantar and craniofacial hyperhidrosis.

EXPERT OPINION

Idiopathic hyperhidrosis, regardless of the site of involvement, remains a functional disorder that places a significant burden on patients. After balancing efficacy against adverse events, systemic therapy, although off-label for all forms of hyperhidrosis can represent an additive therapeutic option for patients with insufficient response to topical treatment according to a step wise therapeutic approach. Until the pathophysiological mechanisms underlying hyperhidrosis are clear, and the etiological therapeutic approach become realistic, the greatest challenge in the therapeutic management of hyperhidrotic patients seems to be the search for the most convenient combination between different therapeutic modalities (topical and systemic agents, and botulinum toxins) to achieve long-term control of the disease symptoms.

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.

Minimally Invasive Sympathicotomy for Palmar Hyperhidrosis and Facial Blushing: Current Status and the Hyperhidrosis Expert Center Approach

Hyperhidrosis, the medical term for excessive sweating beyond physiological need, is a condition with serious emotional and social consequences for affected patients. Symptoms usually appear in focal areas such as the feet, hands, axillae and face. Non-surgical treatment options such as topical antiperspirants or systemic medications are usually offered as a first step of treatment, although these therapies are often ineffective, especially in severe and intolerable cases of hyperhidrosis. In the treatment algorithm for patients suffering from hyperhidrosis, surgical thoracoscopic sympathicotomy offers a permanent solution, which is particularly effective in the treatment of palmar hyperhidrosis and facial blushing. In this review, we describe the current status of thoracoscopic sympathicotomy for palmar hyperhidrosis and facial blushing. In addition, we share the specific treatment approach, technique and results of our Hyperhidrosis Expert Center. Last, we share recommendations to ensure an effective, reproducible and safe application of single-port thoracoscopic sympathicotomy for palmar hyperhidrosis and facial blushing, based on our extensive experience.

Frey's Syndrome: A Review of Aetiology and Treatment

First described by Polish Neurologist Łucja Frey in 1923, Frey's syndrome (FS), or auriculotemporal syndrome, is a rare condition characterised by gustatory sweating, typically encountered as sequelae following invasive head and neck surgery. The pathophysiology of FS can be described by aberrant reinnervation of postganglionic parasympathetic neurons to the surrounding denervated sweat glands and cutaneous blood vessels. Multiple invasive procedures have been associated with FS ranging from salivary gland surgery to burn reconstruction and thoracoscopic sympathectomies. Rarely, FS can be secondary to trauma or non-surgical aetiologies, including diabetes and infection. Physical symptoms vary based on the severity and surface area affected by FS and range from mild symptoms to severe psychosocial morbidity for patients. Surgeons operating in the head and neck, including otolaryngologists, maxillofacial surgeons, and plastic surgeons, should be aware of this potential complication and be up to date with diagnosis and treatment strategies for FS. This review article summarises the literature relating to FS focusing on its aetiologies, symptomatology, prevention, and available treatments, aiming to provide an up-to-date review of this condition for surgeons operating in the head and neck region. Although various treatment options have been suggested, these are often limited to topical agents that require life-long administration for symptom control. Further research is recommended to identify the optimal treatment for this condition and the role of surgery as a treatment for severe or refractory cases.

The efficacy and safety of a fractional microneedle radiofrequency device for the treatment of axillary hyperhidrosis: clinical prospective pilot study

We aimed to evaluate the efficacy and safety of a fractional microneedle radiofrequency device (FMRD) for the treatment of primary axillary hyperhidrosis (PAH). The FMRD adopted insulated microneedles, which could be located at a depth of up to 4.5 mm and deliver a radiofrequency current in a fractional manner. Also, the device could automatically regulate the amount of the delivered energy. Sixteen Korean patients with PAH received two FMRD treatment sessions at a 3-week interval and were followed-up until week 15. The primary outcome was Patient Satisfaction Scale (PSS) score at each visit. Hyperhidrosis Disease Severity Scale (HDSS) and Global Aesthetic Improvement Scale (GAIS) were also assessed. The area and amount of sweat produced were evaluated by specific tests. Mean PSS score significantly improved from 1.6 at week 3 to 2.5 at week 15 by 56%. More than a 50% improvement in sweating assessed by the PSS score was seen in 63% and 50% of patients at weeks 11 and 15, respectively. Mean HDSS score significantly decreased by week 3 and further decreased by week 7. Mean GAIS scores improved from the first follow-up visit at week 3 and improved again at week 7. The mean hyperhidrosis area assessed by starch-iodine test significantly decreased by 36% at week 15 compared with baseline. Mean transepidermal water loss level significantly decreased by 42% at week 15 compared with baseline. No patients experienced any serious adverse events. FMRD can be an effective and safe treatment modality for PAH.

Treatment of Axillary hyperhidrosis

BACKGROUND

Axillary hyperhidrosis characterized by excessive sweating in the axillary regions is a frustrating chronic autonomic disorder leading to social embarrassment, impaired quality of life and usually associated with palmoplantar hyperhidrosis. Identifying the condition and its cause is central to the management.

AIM

The aim of this article is to discuss treatment options for axillary hyperhidrosis.

METHODS

Comprehensive literature search using PubMed and Google Scholar was performed to review relevant published articles related to diagnosis and treatment of axillary hyperhidrosis.

RESULTS

Treatment modalities for axillary hyperhydrosis vary from topical and systemic agents to injectables, newer devices and surgical measures. None except for physical measures using devices or surgery, which destroys the sweat glands to remove them, is possibly permanent and most are associated with attendant side effects.

CONCLUSION

Several treatments including medical and surgical option are available for the treatment of axillary hyperhydrosis. Patient education is important component of its management. Individualized approach of management is necessary for optimal outcome of treatment.

Sympathectomy via a posterior approach after a failed trans-thoracic approach: a case of its use for arrhythmia

OBJECTIVE

Congenital long QT syndrome (LQTS) provides an opportunity for neurosurgical intervention. Medication and implantable cardiac defibrillator (ICD)-refractory patients often require left cardiac sympathetic denervation (LCSD) via anterior video-assisted thoracoscopic surgery (VATS). However, this approach has major pulmonary contraindications and risks, with a common concern in children being their inability to tolerate single-lung ventilation. At Oregon Health & Science University, the authors have developed a posterior approach-extrapleural, minimally invasive, T1-5 LCSD-that minimizes this risk.

METHODS

A 9-year-old girl with LQTS type III presented to the emergency department while experiencing ventricular tachycardia (VT) and ventricular fibrillation (VF) with multiple ICD firings. Medical management failed to resolve the VF/VT. VATS was attempted but could not be safely performed due to respiratory insufficiency. The patient was reintubated for dual-lung ventilation and repositioned prone. Her respiratory insufficiency resolved. Using METRx serial dilating tubes under the microscope, the left T1-5 sympathetic ganglia were sectioned and removed.

RESULTS

Postoperatively, the patient had no episodes of VF/VT, pneumothorax, hemothorax, or Horner syndrome. With mexiletine and propranolol, she has remained largely VF/VT free, with only one VT episode during the 2-year follow-up period.

CONCLUSIONS

Minimally invasive, posterior, extrapleural, T1-5 LCSD is safe and effective for treating congenital LQTS in children, while minimizing the risks associated with VATS.

The etiology, diagnosis, and management of hyperhidrosis: A comprehensive review: Therapeutic options

Hyperhidrosis (HH) is a chronic disorder of excess sweat production that may have a significant adverse effect on quality of life. A variety of treatment modalities currently exist to manage HH. Initial treatment includes lifestyle and behavioral recommendations. Antiperspirants are regarded as the first-line therapy for primary focal HH and can provide significant benefit. Iontophoresis is the primary remedy for palmar and plantar HH. Botulinum toxin injections are administered at the dermal-subcutaneous junction and serve as a safe and effective treatment option for focal HH. Oral systemic agents are reserved for treatment-resistant cases or for generalized HH. Energy-delivering devices such as lasers, ultrasound technology, microwave thermolysis, and fractional microneedle radiofrequency may also be utilized to reduce focal sweating. Surgery may be considered when more conservative treatments have failed. Local surgical techniques, particularly for axillary HH, include excision, curettage, liposuction, or a combination of these techniques. Sympathectomy is the treatment of last resort when conservative treatments are unsuccessful or intolerable, and after accepting secondary compensatory HH as a potential complication. A review of treatment modalities for HH and a sequenced approach are presented.

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.

Right chylothorax after thoracic sympathicotomy: A very rare case

Today, the most common indication for thoracic sympathectomy/ sympathicotomy is primary focal hyperhidrosis. The operation is performed thoracoscopically and usually the approach to the sympathetic chain is conducted through the third and fourth ribs. Although it is performed as a minimally invasive procedure with high success rates, there are also some common complications. In this article, we present a very rare case developing right chylothorax after right thoracic sympathicotomy.

A retrospective review on minimally invasive technique via endoscopic thoracic sympathectomy (ETS) in the treatment of severe primary hyperhidrosis: Experiences from the National Heart Institute, Malaysia

Background: Hyperhidrosis is due to the hyperactive autonomic stimulation of the sweat glands in response to stress. Primary hyperhidrosis is a common yet psychologically disabling condition. This study will describe our experience in managing hyperhidrosis via endoscopic thoracic sympathectomy (ETS).

Methods: The information was obtained from the patient records from 1 ^st January 2011 until 31 ^st December 2016. Pertinent information was extracted and keyed into a study proforma.

Results:  150 patients were operated on but only 118 patients were included in this study. The mean age was 22.9±7.3 years. The majority (54.2%) had palmar-plantar hyperhidrosis and 39.8% had associated axillary hyperhidrosis. Excision of the sympathetic nerve chain and ganglia were the main surgical technique with the majority (55.9%) at T2-T3 level. Mean ETS procedure time was 46.6±14.29 minutes with no conversion. Surgical complications were minimal and no Horner’s Syndrome reported. Mean hospital stay was 3.5±1.05 days. The majority of patients (67.8%) had only one follow-up and only half of the study sample (58.5%) complained mild to moderate degree of compensatory sweating, even though the long-term resolution is yet to be determined by another study. Following ETS, 98.3% of patients had instant relief and resolved their palmar hyperhidrosis. Predictors of CS were sympathectomy level and follow-up. The odds of reporting CS was 2.87 times in patients undergoing ETS at the T2-T3 level compared to those undergoing ETS at the T2-T4 level. The odds of reporting CS was 13.56 times in patients having more than one follow-up compared to those having only one follow-up.

Conclusion: We conclude that ETS is a safe, effective and aesthetically remarkable procedure for the treatment of primary hyperhidrosis  with only half of the patients developing mild to moderate degree of CS. Significant predictors of CS were sympathectomy level during ETS and frequency of follow-up after ETS.

Effectiveness, success rates, and complications of different thoracoscopic sympathectomy techniques in patients with palmar hyperhidrosis

Background

This study aims to investigate the effectiveness, success and complication rates of three different video-assisted thoracoscopic sympathectomy procedures performed for the treatment of primary focal hyperhidrosis; excision, cauterization and clipping.

Methods

We retrospectively evaluated the records of 60 patients (33 males, 27 females; mean age 25.1±6.4 years; range 16 to 43 years) with primary focal hyperhidrosis and treated with videoassisted thoracoscopic sympathectomy between January 2010 and December 2013. The patients were treated bilaterally at the same session: the sympathetic chain and ganglia were excised from the spinal cord segments of T2-T4 in 20 patients (group 1), cauterized in 20 patients (group 2), and clipped in 20 patients (group 3). The procedural success and complication rates were compared among the groups.

Results

Sympathectomy was successfully performed in all patients. The mean operation time was found to be significantly shorter in group 2 (42.5±7.1 min) and group 3 (36.9±7.8 min), compared to group 1 (51.1±8.4 min) (p<0.05). Compensatory hyperhidrosis developed in 17 patients (28.3%) and was comparable among all groups (p<0.05).

Conclusion

Our study results suggest that excision, cauterization, and clipping are effective and reliable in the treatment of primary focal hyperhidrosis. Based on our experience, we believe that sympathectomy with video-assisted excision may be preferable for the treatment of primary focal hyperhidrosis.

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.

Does endoscopic thoracic sympathectomy through clipping procedure have early effects on electrocardiographic parameters?

Background & objectives:

Hyperhidrosis is a pathologic condition of excessive sweating in amounts greater than physiologic needs. Endoscopic thoracic sympathectomy (ETS) is a globally accepted treatment modality for primary palmar and axillary hyperhidrosis. ETS also has distinctive effects on the heart, circulatory and respiratory systems. In this study early effects of ETS on electrocardiographic (ECG) parameters of hyperhidrosis patients were evaluated.

Methods:

Twelve-lead ECGs were performed on 72 patients who were free from cardiovascular, metabolic, neurological and pulmonary diseases and underwent planned ETS because of hyperhidrosis, before and after the procedure within the first 24 h. Heart rate (HR), PR, QT, corrected QT (QTc), QTc/Tpeak-Tend (TpTe) intervals, P-wave and QTc/TpTe dispersions were compared by ECG.

Results:

A total of 72 patients (24.1±6.0 yr, 17 female) were included in the study. The pre-operative HR of patients was significantly higher than post-operative HR of patients (73.8±12.8 vs. 68.1±12.6 beats/ min; P<0.001). The QTc dispersion (QTcd) durations of pre-operative patients were significantly longer than those of post-operative patients (51.5±6.3 vs. 44.9±5.6 msec; P<0.01). The TpTe dispersion value of pre-operative patients was significantly (P<0.001) higher than that of post-operative patients.

Interpretation & conclusions:

Our study showed that ETS through clipping procedure had positive effects on the mechanisms of arrhythmia by reducing HR, QTcd, TpTe and TpTe dispersion parameters of ECG in early periods in hyperhidrosis patients.

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.

A systematic review and meta-analysis of T2, T3 or T4, to evaluate the best denervation level for palmar hyperhidrosis

We systematically reviewed and compared the clinical outcomes of thoracoscopic sympathectomy (TS) at different denervation levels for palmar hyperhidrosis. We searched PubMed, Ovid MEDLINE, EMBASE, Web of Science, ScienceDirect, the Cochrane Library, Scopus and Google Scholar for relevant studies published during 1990-2016. Symptom resolution, patient satisfaction, compensatory sweating (CS), recurrence, dry hands and gustatory sweating were assessed. We selected 13 studies from 2228 for the final analysis. A comparison of T2 vs. T3 TS revealed that T3 TS reduced the risk of CS (95% confidence interval [CI]: 1.36-3.19, p = 0.0007) and moderate-to-severe CS (95% CI: 2.14-7.87, p < 0.0001). No significant differences were found in patient satisfaction, symptom resolution, and incidence of dry hands and gustatory sweating. A comparison of T3 vs. T4 TS revealed that T4 TS reduced the risk of CS (95% CI: 2.87-9.53, p < 0.00001), moderate-to-severe CS (95% CI: 2.54-5.83, p < 0.00001), dry hands (95% CI: 4.07-18.13, p < 0.00001) and gustatory sweating (95% CI: 1.53-7.32, p < 0.003), and improved patient satisfaction. No significant differences were found in symptom resolution and recurrence. T4 TS appears to be more useful than T3 or T2 TS for PH.

Comparative Study of Efficacy and Safety of Botulinum Toxin a Injections and Subcutaneous Curettage in the Treatment of Axillary Hyperhidrosis

BACKGROUND

Primary focal axillary hyperhidrosis is a chronic distressing disorder affecting both the sexes. When the condition is refractory to conservative management, we should go for more promising therapies like intradermal botulinum toxin A (BtxA) injections in the axilla, and surgical therapies like subcutaneous curettage of sweat glands.

AIMS AND OBJECTIVES

The aim of this study is to compare the efficacy, safety and duration of action of intradermal BtxA injections in one axilla and subcutaneous curettage of sweat glands in the other axilla of the same patient with axillary hyperhidrosis.

MATERIALS AND METHODS

Twenty patients (40 axillae) received intradermal BtxA injections on the right side (20 axillae) and underwent tumescent subcutaneous curettage of sweat glands on the left side (20 axillae). Sweat production rate was measured using gravimetry analyses at baseline and at 3 months after the procedure. Subjective analyses were done using hyperhidrosis disease severity scale (HDSS) score at baseline, at 3^rd and 6^th month after the procedure.

RESULTS

At 3 months post-treatment, the resting sweat rate in the toxin group improved by 80.32% versus 79.79% in the subcutaneous curettage method (P = 0.21). Exercise-induced sweat rate in the toxin group improved by 88.76% versus 88.8% in the subcutaneous curettage group (P = 0.9). There was a significant difference in the HDSS score after treatment with both the modalities. There were no adverse events with BtxA treatment compared to very minor adverse events with the surgical method.

CONCLUSION

Both intradermal BtxA injections and tumescent subcutaneous curettage of sweat glands had a significant decrease in the sweat rates with no significant difference between the two modalities. Hence, in resource poor settings where affordability of BtxA injection is a constraint, subcutaneous curettage of sweat glands can be preferred which has been found equally effective with no or minimal adverse events.

Occupation-Related Vascular Disorders of the Upper Extremity

Hypothenar hammer (HH) syndrome and vibration-induced white finger (VWF) syndrome are the main occupation-related vascular diseases of the upper extremity. The clinical presentation is similar to that of Raynaud’s phenomenon. The characteristic history will lead to the appropriate diagnosis being confirmed by angiographic features in HH and by functional tests in VWF. While in HH the underlying cause, which is mostly thought to be an aneurysm of the ulnar artery, might be cured surgically, in VWF only medical treatment offers relief from the symptoms. The knowledge of these entities is necessary to suspect such disorders so that further exposure to risk factors like repetitive hypothenar trauma or work with vibrating hand-held tools can be avoided, which is of great importance for the overall prognosis of these patients.

Selecting the Right Patient for Surgical Treatment of Hyperhidrosis

This article presents a personal view of the indications for surgical treatment of patients with hyperhidrosis based on long clinical experience. Endoscopic thoracic sympathectomy is the preferred opinion for palmar sweating. It is also useful when there is additional axillary sweating but is not the first choice for isolated armpit symptoms. Surgical treatment of craniofacial sweating is much more likely to be followed by undesirable side-effects.

Reoperation for Essential Hyperhidrosis

Palmar hyperhidrosis has a recurrence rate of 0% to 5% after thoracic sympathectomy. From January 1992 to October 1997, thoracic sympathectomy was performed by video-assisted thoracoscopic surgery for hyperhidrosis in 490 patients of whom 5 (2 male and 3 female with a mean age of 20 years) experienced recurrent hyperhidrosis in the early (< 7 days) or late (up to 6 months) postoperative period. All patients had moderate to severe pleural adhesions in the previous sympathectomy sites but no operative complications or crossover to thoracotomy occurred. Surgery resulted in satisfactory outcomes showing that video-assisted thoracoscopic sympathectomy was effective in treating recurrent hyperhidrosis. Prevention of recurrence requires the identification and resection of the second thoracic sympathetic ganglion as well as the Kuntz fibers.

Video-Assisted Thoracoscopic Sympathectomy for Palmar Hyperhidrosis: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVES

Video-assisted thoracoscopic sympathectomy (VTS) is effective in treating palmar hyperhidrosis (PH). However, it is no consensus over which segment should undergo VTS to maximize efficacy and minimize the complications of compensatory hyperhidrosis (CH). This study was designed to compare the efficiency and side effects of VTS of different segments in the treatment of PH.

METHODS

A comprehensive search of PubMed, Ovid MEDLINE, EMBASE, Web of Science, ScienceDirect, the Cochrane Library, Scopus and Google Scholar was performed to identify studies comparing VTS of different segments for treatment of PH. The data was analyzed by Revman 5.3 software and SPSS 18.0.

RESULTS

A total of eight randomized controlled trials (RCTs) involving 1200 patients were included. Meta-analysis showed that single segment/low segments VTS could reduce the risk of moderate/severe CH compared with multiple segments/high segments. The risk of total CH had a similar trend. In the subgroup analysis of single segment VTS, no significant differences were found between T2/T3 VTS and other segments in postoperative CH and degree of CH. T4 VTS showed better efficacy in limiting CH compared with other segments.

CONCLUSIONS

T4 appears to be the best segment for the surgical treatment of PH. Our findings require further validation in more high-quality, large-scale randomized controlled trials.

Surgical Cardiac Denervation Therapy for Treatment of Congenital Ion Channelopathies in Pediatric Patients

Background:

Congenital ion channel disorders, including congenital long QT syndrome (LQTS), cause significant morbidity in pediatric patients. When medication therapy does not control symptoms or arrhythmias, more invasive treatment strategies may be necessary. This study examines our institution’s clinical experience with surgical cardiac denervation therapy for management of these arrhythmogenic disorders in children.

Methods:

An institutional review board–approved retrospective review identified ten pediatric patients with congenital ion channelopathies who underwent surgical cardiac denervation therapy at a single institution between May 2011 and April 2014. Eight patients had a diagnosis of congenital LQTS, two patients were diagnosed with catecholaminergic polymorphic ventricular tachycardia (CPVT). All patients underwent sympathectomy and partial stellate ganglionectomy via video-assisted thoracoscopic surgery (VATS).

Results:

Six of the ten patients had documented ventricular arrhythmias preoperatively, and 70% of the patients had preoperative syncope. The corrected QT interval decreased in 75% of patients with LQTS following sympathectomy. Postoperative arrhythmogenic symptoms were absent in 88% of congenital LQTS patients, but both patients with CPVT continued to have symptoms throughout the duration of follow-up. All patients were alive after a median follow-up period of 10 months.

Conclusions:

Surgical cardiac denervation therapy via VATS is a useful treatment strategy for congenital LQTS patients who fail medical management, and its potential benefit in the management of CPVT is unclear. A prospective comparison of the efficacy of surgical cardiac denervation therapy and implantable cardioverter-defibrillator use in congenital ion channelopathies is timely and crucial.

Quality of life after sympathetic surgery at the T4 ganglion for primary hyperhidrosis: clip application versus diathermic cut

INTRODUCTION

Limited procedures at the T4 ganglion show low rates of compensatory sweating (CS). The aim of the study was to compare endoscopic sympathetic block (ESB) via clip application with endothoracic sympathicotomy (ETS) via diathermy with special regard on patients' quality of life (Qol).

PATIENTS AND METHODS

Treatment success, side effects and patient satisfaction were evaluated in a prospectively gathered database of a tertiary-care referral hospital. Two disease-specific Qol questionnaires were used (Keller, Milanez de Campos).

RESULTS

406 operations were performed in 205 patients (ESB4 N = 114, ETS4 N = 91) with a median follow-up of 12 months. Both procedures improved Qol significantly (P < 0.001) and the degree of improvement was equal in both groups. Palmar and axillary HH were ameliorated after both procedures (P < 0.001). Accordingly, plantar HH decreased after ESB4 (P = 0.002), while remaining unaltered after ETS4. Nineteen patients (9.3%) reported CS and 10 patients (4.9%) judged it as "disturbing". Nine of the latter belonged to the ETS4 group compared to one ESB patient (P = 0.015). Patients developed higher rates of plantar CS after ETS4 compared to ESB4 (P = 0.006). Five patients (2.4%) from both cohorts reported persistence of axillary HH. Recurrence of axillary symptoms was found in 5 ESB4 patients. Satisfaction rates did not differ significantly.

CONCLUSION

Patients' Qol and satisfaction rates are similar in both treatment groups for upper limb HH. Outcome and recurrence rates speak in the favor of ETS4, severity of CS and potential reversibility argue for ESB4.

Comparing two methods of thoracoscopic sympathectomy for palmar hyperhidrosis

BACKGROUND

Hyperhidrosis can cause significant professional and social handicaps. Thoracic endoscopic sympathectomy has become the surgical technique of choice for treating intractable palmar hyperhidrosis and can be performed through multiple ports or a single port. This prospective study compares outcomes between the two methods.

METHODS

The study followed 71 consecutive patients who underwent video-assisted sympathectomy for palmar hyperhidrosis between January 2008 and June 2012. In all patients, the procedure was bilateral and performed in one stage. The multiple-port method was used in 35 patients (group A) and the single-port method in 36 patients (group B). Preoperative, intraoperative, and postoperative variables; morbidity, recurrence; and survival were compared in both groups.

RESULTS

The procedure was successful in 100% of the patients; none experienced a recurrence of palmar hyperhidrosis, Horner syndrome (oculosympathetic palsy), or serious postoperative complications, and none died. No patients required conversion to an open procedure. Residual minimal pneumothorax occurred in two patients (5.7%) in group A and in one patient (2.8%) in group B. Minimal hemothorax occurred in one patient (2.9%) in group A and in three patients (8.3%) in group B. Compensatory hyperhidrosis occurred in seven patients (20%) in group A and in eight patients (22.2%) in group B.

CONCLUSION

No difference was found between the multiple- and single-port methods. Both are effective, safe minimally invasive procedures that permanently improve quality of life in patients with palmar hyperhidrosis.

Thoracoscopic sympathectomy for palmar hyperhidrosis

BACKGROUND

Upper thoracoscopic sympathectomy, obtained either by ablation or resection of the appropriate ganglia, is now the preferred treatment for primary palmar hyperhidrosis. Therefore, we undertook a review to compare the relative efficacy of these two techniques.

METHODS

A Medline search was performed for the years 1974-99 to identify all published studies of thoracoscopic sympathectomy for hyperhidrosis.

RESULTS

In all, 33 studies were identified and divided into two groups-ablation and resection. When the resection method was used, the immediate success rate was 99.76%, whereas the ablation method achieved dry hands in 95.2% of cases (p = 0.00001). Palmar sweating recurred in 0% of patients treated via resection and -4.4% treated with ablation. Ptosis was noted in 0.92% of cases after ablation and in 1.72% after resection (p = 0.017).

CONCLUSIONS

Resection yields superior results, yet the majority of surgeons ablate, probably because it is easier, requires a shorter operating time, leads to fewer cases of Horner's syndrome, and because resympathectomy eventually overcomes initial failure.

Single incision thoracoscopic sympathectomy for palmar and axillary hyperhidrosis

BACKGROUND

Primary hyperhidrosis is characterized by excessive sweating beyond physiological needs. It is a common disease (incidence 2.8%) that causes intense discomfort for patients. In the last decade, advantages of Single-Incision Thoracoscopic Sympathectomy have become clear, particularly in decreasing morbidity of sympathectomy.

PATIENTS AND METHODS

From January 2010 to December 2012, 39 patients (29 females and 10 males) with primary palmar or axillary hyperhidrosis were treated by thoracoscopic sympathectomy. The age ranged from 18 to 40 years with a mean of 26.28 years. We used single incision thoracoscopic electrocoagulation through 10 mm incision for thoracic sympathetic chain (T2-T4).

RESULTS

The mean follow-up was 23.6 ± 14.2 months (range = 4-24 months). A total of 97.42% of patients were satisfied with the results. A total of 72.5% of patients had cure, one patient (2.5%) and another patient (2.5%) presented with recurrent axillary hyperhidrosis. The morbidity was 10.2% with no mortality. Percentage of compensatory sweating and gustatory sweating were 5.1% (p = .353) and 2.5% (p = .552), respectively. The result of sympathectomy in patients with both palmar and axillary hyperhidrosis was significantly better (17, 43.58%) compared to palmar type (14, 35.89%) or axillary type (7, 17.94%).

CONCLUSION

Thoracoscopic sympathectomy is a simple, safe, and cost-effective therapy with good results and low complications.

Long-term outcomes after endothoracic sympathetic block at the T4 ganglion for upper limb hyperhidrosis

BACKGROUND

The aim of this study was to evaluate long-term results, quality of life, satisfaction and compensatory sweating after endothoracic sympathetic block at T4 (ESB4).

METHODS

Patients who underwent an ESB4 procedure for palmar or palmoaxillary hyperhidrosis between 2001 and 2008 were included in a prospective study at a university hospital. Questionnaires devised by Keller and Milanez de Campos were applied to evaluate disease-specific quality of life.

RESULTS

A total of 189 patients underwent 374 ESB4 procedures. Of 174 evaluated patients, 54 (31·0 per cent) had palmar and 120 (69·0 per cent) had palmoaxillary hyperhidrosis. Median follow-up was 92 months. In both groups, treatment successfully reduced hyperhidrosis (P < 0·001) and quality of life increased significantly after ESB4 (P < 0·001), remaining stable after 5 years. Overall satisfaction rates decreased owing to the development of compensatory sweating and recurrence during follow-up. Compensatory sweating affected 41 patients (23·6 per cent), and was severe in 11 (6·7 per cent) of 163 patients at 5-year follow-up; eight of these 11 patients had been treated for palmoaxillary sweating. The severity of compensatory sweating did not deteriorate with time. The severe recurrence rate increased to 11·0 per cent during follow-up, and was twice as common in patients treated for palmoaxillary sweating as in those treated for palmar sweating (13·2 versus 6·1 per cent respectively). Nine reoperations (5·2 per cent) were performed for persistent sweating, recurrence or compensatory sweating.

CONCLUSION

T4 endothoracic sympathetic clip application is safe and effective in patients with upper limb hyperhidrosis, with stable long-term improvements in quality of life.

Endoscopic thoracic sympathectomy for primary hyperhidrosis: a 16-year follow up in a single UK centre

INTRODUCTION

Since the introduction of Endoscopic Thoracic Sympathectomy ( ETS ) by Kux in 1951, the procedure has been performed for treatment of primary hyperhidrosis (PH) of the upper limb. Despite its initial success and minimally invasive nature, the long-term results are yet to be established. The aim of this study is to evaluate the outcome of patients after ETS with particular emphasis on patient satisfaction and its effectiveness over a 16-year period.

METHODS

A patient survey of fifty-one (n = 51) patients who had ETS for PH of palms from 1995 to 2011 was conducted. The data on age, sex, site of the PH, family history, trigger, hospital stay, relief from symptoms, complications, refractory sweating and overall satisfaction with the procedure was analysed with SAS software version 9.1.3.

CONCLUSION

The mean follow-up was 77 months (range, 6-189 months) with equal gender distribution (n = 24 males Vs n = 27 females) and mean age of 19 (range, 13-64 years). The hereditary prevalence was 55%. Forty-six patients (90.2%) reported an immediate (≤24 h) and four patients (7.8%) reported a delay (>24 h) in relief of symptoms. To the best of our knowledge this is longest duration of follow-up reported in the literature.

Nonpharmacological treatments for anxiety disorders

An evidence-based review of nonpharmacological treatments for anxiety disorders is presented. The vast majority of the controlled research is devoted to cognitive behavior therapy (CBT) and shows its efficiency and effectiveness in all the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) anxiety disorders in meta-analyses. Relaxation, psychoanalytic therapies, Rogerian nondirective therapy, hypnotherapy and supportive therapy were examined in a few controlled studies, which preclude any definite conclusion about their effectiveness in specific phobias, agoraphobia, panic disorder, obsessive-compulsive disorder (OCD), and posttraumatic stress disorder (PTSD), CBT was clearly better than psychoanalytic therapy in generalized anxiety disorder (GAD) and performance anxiety Psychological debriefing for PTSD appeared detrimental to the patients in one high-quality meta-analysis. Uncontrolled studies of psychosurgery techniques for intractable OCD demonstrated a limited success and detrimental side effects. The same was true for sympathectomy in ereutophobia. Transcranial neurostimulation for OCD is under preliminary study. The theoretical and practical problems of CBT dissemination are discussed.

Late results of endoscopic thoracic sympathectomy for hyperhidrosis and facial blushing

BACKGROUND

The purpose of this study was to clarify the long-term effects, side-effects and overall satisfaction rates of endoscopic thoracic sympathectomy (ETS) used in the treatment of hyperhidrosis and facial blushing.

METHODS

Some 3015 patients had bilateral ETS from 1989 to 1998. A questionnaire follow-up was used. Some of the patients had participated in a previous follow-up study, and the answers in both surveys were compared.

RESULTS

A total of 1700 patients responded (56·4 per cent); mean(s.d.) follow-up was 14·6(2·4) years. The best result was achieved for palmar hyperhidrosis (95·6 per cent) compared with axillary hyperhidrosis (68·9 per cent), facial hyperhidrosis (83 per cent) and facial blushing (72·8 per cent) (P < 0·001). Compensatory sweating, the main side-effect, was present in 80·0 per cent. Some 6·5 per cent were dissatisfied and 13·5 per cent regretted having the procedure. Patients with palmar hyperhidrosis were more satisfied (86·6 per cent) than those with axillary hyperhidrosis (66·0 per cent), facial hyperhidrosis (74 per cent) or facial blushing (73·5 per cent) (P < 0·001). Women were more satisfied than men (85·4 versus 71·4 per cent; P < 0·001). The procedure regret rate rose from 7·8 per cent in the first survey to 13·5 per cent in the present one.

CONCLUSION

ETS had an excellent and lasting effect on palmar hyperhidrosis. The effect on facial and axillary hyperhidrosis and facial blushing was less rewarding. The procedure regret rate increased over time.

The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis

Significant controversies surround the optimal treatment of primary hyperhidrosis of the hands, axillae, feet, and face. The world's literature on hyperhidrosis from 1991 to 2009 was obtained through PubMed. There were 1,097 published articles, of which 102 were clinical trials. Twelve were randomized clinical trials and 90 were nonrandomized comparative studies. After review and discussion by task force members of The Society of Thoracic Surgeons' General Thoracic Workforce, expert consensus was reached from which specific treatment strategies are suggested. These studies suggest that primary hyperhidrosis of the extremities, axillae or face is best treated by endoscopic thoracic sympathectomy (ETS). Interruption of the sympathetic chain can be achieved either by electrocautery or clipping. An international nomenclature should be adopted that refers to the rib levels (R) instead of the vertebral level at which the nerve is interrupted, and how the chain is interrupted, along with systematic pre and postoperative assessments of sweating pattern, intensity and quality-of-life. The recent body of literature suggests that the highest success rates occur when interruption is performed at the top of R3 or the top of R4 for palmar-only hyperhidrosis. R4 may offer a lower incidence of compensatory hyperhidrosis but moister hands. For palmar and axillary, palmar, axillary and pedal and for axillary-only hyperhidrosis interruptions at R4 and R5 are recommended. The top of R3 is best for craniofacial hyperhidrosis.

Endoscopic lumbar sympathectomy following thoracic sympathectomy in patients with palmoplantar hyperhidrosis

BACKGROUND

Palmoplantar hyperhidrosis is a common disease that leads to significant psychosocial strain for the affected person. Although the treatment of palmar symptoms with endoscopic thoracic sympathectomy (ETS) is clinically established, there are few data on the efficacy of an endoscopic lumbar sympathectomy (ELS) for the elimination of plantar symptoms. Especially the occurrence of unwanted side effects associated with sequential ETS and ELS has not been examined sufficiently.

METHODS

The study includes 130 patients, 8 men and 122 women, with severe palmoplantar hyperhidrosis who were already previously treated with ETS. An average of 28 months after the ETS, bilateral ELS was performed on all patients due to persistent severe plantar hyperhidrosis. After ELS the perioperative morbidity, elimination rate of the plantar hyperhidrosis, the frequency of unwanted side effects, and satisfaction with the result were evaluated. Follow-up examinations were carried out on 96 patients (74%) with a mean follow-up of 37 months (3-90 months).

RESULTS

A total of 260 lumbar sympathectomies were successfully carried out endoscopically. Mortality was zero, intraoperative complications occurred in three (2.3%) patients and postoperative complications in six (4.6%). Plantar hyperhidrosis was eliminated in 93 patients (97%), 3 (3%) patients developed a one-sided recurrence. Seven patients (7%) developed minor compensatory sweating, and in 17 patients (18%) compensatory sweating that existed before the ELS was slightly increased. Transient postsympathectomy neuralgia was observed in 18 patients (19%), and none of the patients showed a sexual function disorder. Altogether, 77 patients (80%) were very satisfied with the postoperative result, and 16 (17%) were partially satisfied.

CONCLUSIONS

The sesequential performance of ELS after ETS appears to be a safe, effective therapy option for patients with severe palmoplantar hyperhidrosis. However, more experience with a larger number of patients and longer follow-up investigations are necessary to confirm the safety of four-limb sympathectomy.

Thoracoscopic sympathectomy

With the advent of videotechnology, sympathectomy has assumed a more important role in the armamentarium of managing diseases of the autonomic system. Currently it is used primarily for hyperhydrosis, although sympathectomy for reflex sympathetic dystrophy (RSD), Raynaud disease and other diseases still are performed, but less frequently. Most of this article will refer primarily to hyperhydrosis patients.

Endoscopic lumbar sympathectomy for plantar hyperhidrosis

Background

The aim of this study was to evaluate the results of endoscopic lumbar sympathectomy for plantar hyperhidrosis.

Methods

A total of 178 endoscopic resections of the lower sympathetic lumbar trunk were carried out in 90 patients (59 men, 31 women) with severe plantar hyperhidrosis. The clinical results, including morbidity and satisfaction rates, were evaluated. Follow-up examination was carried out for all patients after a mean follow-up of 24 (range 3–45) months.

Results

All procedures were carried out endoscopically. There were no deaths and only three patients had a postoperative complication. All patients had evidence of postoperative sympathetic denervation of the feet. In 87 patients (97 per cent) hyperhidrosis was eliminated, but in three (3 per cent) it recurred. Compensatory sweating occurred in 40 patients (44 per cent), postsympathectomy neuralgia in 38 (42 per cent) and one man suffered temporary loss of ejaculation. A total of 86 patients (96 per cent) were very, or partly, satisfied with the result, and 83 (92 per cent) would have the procedure repeated if required.

Conclusion

Endoscopic lumbar sympathectomy was a safe and effective option for patients with severe plantar hyperhidrosis.

Evidence-based consensus development and reduction of rate of endoscopic thoracic sympathectomy: a national study

BACKGROUND

Endoscopic thoracic sympathectomy (ETS) was overused for treating patients with hyperhidrosis in Taiwan.

OBJECTIVES

To determine whether use of evidence and a consensus-building exercise can reduce rates of surgery.

METHODS

We invited all surgeons in Taiwan who performed five or more ETSs per year for treating patients with hyperhidrosis to join this study. A structured questionnaire was mailed to surgeons asking about their management decisions based on clinical scenarios. Then we provided surgeons with evidence synopses and used the Delphi method to reach consensus. We analyzed healthcare utilization data during 2000 to 2005 and calculated total numbers of ETSs performed per 12 months to examine the effect on surgeons' behavior.

RESULTS

Of 155 surgeons invited, 61 (40%) completed this study. They agreed that observation or topical therapy was appropriate for patients with mild palmar hyperhidrosis, whereas ETS was appropriate for children, adolescents, and young and middle-aged adults who had severe symptoms. Surgeons became more willing to recommend botulinum toxin injection after we provided evidence synopses. We found a 52% reduction in mean total ETSs per 12 months in surgeons receiving evidence synopses. A higher percentage of reduction occurred in patients younger than 12 and aged 60 and older.

CONCLUSION

Evidence-based consensus development is helpful in decreasing overuse of ETS in treating patients with hyperhidrosis in Taiwan.

Treatment of axillary hyperhidrosis/bromidrosis using VASER ultrasound

BACKGROUND

Current methods of treatment for axillary hyperhidrosis and/or bromidrosis are palliative (use of topical aluminum chloride or injections of botulinum toxin type A) or surgically based for more permanence (excisional surgery, endoscopic transthoracic sympathectomy, liposuction/curettage). The surgical approaches have mixed effectiveness and incur the risk of significant side effects and complications.

METHODS

Thirteen patients (3 males, 10 females) with significant axillary hyperhidrosis and/or bromidrosis were recruited, treated with the VASER ultrasound, and followed for 6 months. Preoperative assessment of the impact of hyperhidrosis and/or bromidrosis on lifestyle and the degree of sweat/odor were completed. Postoperative assessment of changes relative to lifestyle and degree of sweat/odor reduction and patient and surgeon satisfaction were completed.

RESULTS

Eleven of 13 patients had significant reduction in sweat/odor and had no recurrence of significant symptoms at 6 months. Two patients had a reduction in sweat/odor but not to the degree desired by the patients. No significant complications were noted. A simple amplitude and time protocol was established that provides consistent and predictable therapy. The complete procedure takes less than 1 h to treat two axillae using local anesthetic.

CONCLUSION

The VASER is safe and effective for treatment of axillary hyperhidrosis/bromidrosis. The method is minimally invasive with immediate return to basic activities and only temporary minor restriction of arm movement. At 6 months the treatment appears to be long-lasting, but further follow-up is required for verification of permanence. This method has become the standard of care for the treatment of axillary hyperhidrosis/bromidrosis in the authors' practice.