Compensatory hyperhidrosis following thoracic sympathectomy: a biophysical rationale

Human temperature regulation under heat stress in health, disease, and injury

The human body constantly exchanges heat with the environment. Temperature regulation is a homeostatic feedback control system that ensures deep body temperature is maintained within narrow limits despite wide variations in environmental conditions and activity-related elevations in metabolic heat production. Extensive research has been performed to study the physiological regulation of deep body temperature. This review focuses on healthy and disordered human temperature regulation during heat stress. Central to this discussion is the notion that various morphological features, intrinsic factors, diseases, and injuries independently and interactively influence deep body temperature during exercise and/or exposure to hot ambient temperatures. The first sections review fundamental aspects of the human heat stress response, including the biophysical principles governing heat balance and the autonomic control of heat loss thermoeffectors. Next, we discuss the effects of different intrinsic factors (morphology, heat adaptation, biological sex, and age), diseases (neurological, cardiovascular, metabolic, and genetic), and injuries (spinal cord injury, deep burns, and heat stroke), with emphasis on the mechanisms by which these factors enhance or disturb the regulation of deep body temperature during heat stress. We conclude with key unanswered questions in this field of research.

Thermoregulatory responses in persons with lower-limb amputation during upper-limb endurance exercise in a hot and humid environment

BACKGROUND

Persons with an amputation may have an increased heat strain due to reduced surface area. However, there is limited evidence on the thermoregulatory responses in persons with lower-limb amputation (LLA). Although a previous study reported no difference in their rectal temperatures (Tres) in a hot environment, suggesting compensatory sweating of the intact limb, we examined the thermoregulatory responses of such persons in a hot and humid environment.

OBJECTIVE

To compare the thermoregulatory responses-through changes in Tre, sweat, and oxygen uptake (O2)-between persons with LLA and able-bodied (AB) individuals, in hot and humid environments.

STUDY DESIGN

A nonrandomized control trial.

METHODS

Nine AB men (AB group) and nine persons with LLA group performed the arm ergometer exercise at 60% peak power output intensity for 60 min in a hot and humid environment, and they were tested before and after performing. The O2, Tre and skin temperature, and total body sweating, and local sweating during exercise were measured and compared between the groups.

RESULTS

The changes in O2 and Tre after the endurance exercise did not differ between the groups (ΔTre: AB group, 1.1°C ± 0.5°C; LLA group, 1.2°C ±0.3 °C; P = 0.65), whereas the amount of local sweating of the chest (group effect, P < 0.01 by two-way analysis of variance [group × time], the group effect size was medium, η2 = 0.10) and dehydration rate (AB group, 1.5% ± 0.5%; LLA group, 2.1% ± 0.5%; P = 0.03) were higher in the LLA than in the AB group.

CONCLUSIONS

We compared the thermoregulatory responses of persons with LLA with those of AB individuals in hot and humid environments. Core body temperatures of persons with LLAs during endurance exercise were not different from those of AB men even in hot and humid environments. We found compensatory increases in the sweat rate of the chest and increased dehydration rate in persons with LLA. More sweat potentially means that athletes with LLA need to drink more fulids.

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.

Exercise Thermoregulation with a Simulated Burn Injury: Impact of Air Temperature

The U.S. Army's Standards of Medical Fitness (AR 40-501) states: "Prior burn injury (to include donor sites) involving a total body surface area of 40% or more does not meet the standard." However, the standard does not account for the interactive effect of burn injury size and air temperature on exercise thermoregulation.

PURPOSE

To evaluate whether the detrimental effect of a simulated burn injury on exercise thermoregulation is dependent on air temperature.

METHODS

On eight occasions, nine males cycled for 60 min at a fixed metabolic heat production (6 W·kg) in air temperatures of 40°C or 25°C with simulated burn injuries of 0% (Control), 20%, 40%, or 60% of total body surface area (TBSA). Burn injuries were simulated by covering the skin with an absorbent, vapor-impermeable material to impede evaporation from the covered areas. Core temperature was measured in the gastrointestinal tract via telemetric pill.

RESULTS

In 40°C conditions, greater elevations in core temperature were observed with 40% and 60% TBSA simulated burn injuries versus Control (P < 0.01). However, at 25°C, core temperature responses were not different versus Control with 20%, 40%, and 60% TBSA simulated injuries (P = 0.97). The elevation in core temperature at the end of exercise was greater in the 40°C environment with 20%, 40%, and 60% TBSA simulated burn injuries (P ≤ 0.04).

CONCLUSIONS

Simulated burn injuries ≥20% TBSA exacerbate core temperature responses in hot, but not temperate, air temperatures. These findings suggest that the U.S. Army's standard for inclusion of burned soldiers is appropriate for hot conditions, but could lead to the needless discharge of soldiers who could safely perform their duties in cooler training/operational settings.

A prospective controlled randomized multicenter study to evaluate the severity of compensatory sweating after one-stage bilateral thoracic sympathectomy versus unilateral thoracic sympathectomy in the dominant side

OBJECTIVE

To evaluate the contribution that unilateral thoracic sympathectomy in dominant side or two-stage bilateral thoracic sympathectomy can have as strategies to reduce the incidence of compensatory sweating after sympathectomy for palmar hyperhidrosis.

METHODS

This is a prospective, controlled, randomized multicenter trial of 200 participants with palmar hyperhidrosis, which will be randomized into two arms: (a) one-stage bilateral thoracic sympathectomy (control arm); or (b) unilateral thoracic sympathectomy in dominant side (intervention arm). At six months the participants submitted to unilateral procedure can make the contralateral surgery if they wanted it, creating a third group called two-stage bilateral sympathectomy. Participants will be evaluated for the degree of sweating by the Hyperhidrosis Disease Severity Scale (HDSS) and of quality of life questionnaires.

RESULTS

96 participants out of the 200 proposed have been included so far, with 48 participants randomized to each arm. From the sample 61 (63.5%) are female, with a mean age of 24 (20-32) years. There were exclusive palmar hiperhydrosis in 14 cases (14.5%), palmar and plantar hyperhidrosis in 36 (37.5%) cases, palmar and axillar hyperhidrosis in 12 (12,5%) cases and palmar-axillary-plantar hyperhidrosis in 34 (35,4%) cases. The age at the beginning of the disease was childhood (78%), with mean of time of disease 15 (11-22) years.

CONCLUSIONS

If one or both hypothesis: (a) unilateral sympathectomy in dominant hand is a satisfactory treatment; b) two-stage bilateral sympathectomy causes less compensatory sweating than in one stage are confirmed there is a chance that surgical therapy for palmar hyperhidrosis can be changed for better.

Does Cold Water or Ice Slurry Ingestion During Exercise Elicit a Net Body Cooling Effect in the Heat?

Cold water or ice slurry ingestion during exercise seems to be an effective and practical means to improve endurance exercise performance in the heat. However, transient reductions in sweating appear to decrease the potential for evaporative heat loss from the skin by a magnitude that at least negates the additional internal heat loss as a cold ingested fluid warms up to equilibrate with body temperature; thus explaining equivalent core temperatures during exercise at a fixed heat production irrespective of the ingested fluid temperature. Internal heat transfer with cold fluid/ice is always 100% efficient; therefore, when a decrement occurs in the efficiency that sweat evaporates from the skin surface (i.e. sweating efficiency), a net cooling effect should begin to develop. Using established relationships between activity, climate and sweating efficiency, the boundary conditions beyond which cold ingested fluids are beneficial in terms of increasing net heat loss can be calculated. These conditions are warmer and more humid for cycling relative to running by virtue of the greater skin surface airflow, which promotes evaporation, for a given metabolic heat production and thus sweat rate. Within these boundary conditions, athletes should ingest fluids at the temperature they find most palatable, which likely varies from athlete to athlete, and therefore best maintain hydration status. The cooling benefits of cold fluid/ice ingestion during exercise are likely disproportionately greater for athletes with physiological disruptions to sweating, such as those with a spinal cord injury or burn injuries, as their capacity for skin surface evaporative heat loss is much lower; however, more research examining these groups is needed.

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

Background

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

Methods

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

Results

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

Conclusions

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

Electronic supplementary material

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

Transareolar Single-Port Needlescopic Thoracic Sympathectomy Under Intravenous Anesthesia Without Intubation: A Randomized Controlled Trial

OBJECTIVES

Transareolar single-port needlescopic thoracic sympathectomy under intravenous anesthesia without intubation has rarely been attempted in managing primary palmar hyperhidrosis (PPH). The objective of this study is to evaluate the feasibility and safety of this minimally invasive technique.

MATERIALS AND METHODS

From May 2012 to May 2015, 168 male patients with severe PPH underwent single-port endoscopic thoracic sympathectomy (ETS) and were randomly allocated to groups A or B. Patients in group A underwent nonintubated transareolar ETS with a 2-mm needle endoscope, while those in group B underwent intubated transaxillary ETS with a 5-mm thoracoscope.

RESULTS

All procedures were performed successfully. The palms of all patients became dry and warm immediately after surgery. The mean resuscitation time was significantly shorter in nonintubated patients than in intubated patients. Postoperative sore throat occurred in 4 patients in group A and in 32 patients in group B (P < .01). The mean incision length was significantly shorter in group A than in group B. The mean postoperative pain scores were markedly higher in group B than in group A. The mean cost of anesthesia was considerably lower in nonintubated patients than in intubated patients. The mean cosmetic scores were higher in group A than in group B (P < .01).

CONCLUSIONS

Nonintubated transareolar single-port ETS with a needle endoscope is a safe, effective, and minimally invasive therapeutic procedure, which allows a smaller incision with less pain and excellent cosmetic results. This novel procedure can be performed in a routine clinical practice for male patients with severe PPH.

Long term compensatory sweating results after sympathectomy for palmar and axillary hyperhidrosis

BACKGROUND

Endoscopic thoracic sympathectomy is currently the best treatment for primary upper extremity hyperhidrosis, but the potential for adverse effects, particularly the development of compensatory sweating, is a concern and often precludes surgery as a definitive therapy. This study aims to evaluate long-term results of two-stage unilateral versus one-stage bilateral thoracoscopic sympathectomy.

METHODS

From November 1995 to February 2011, 261 patients with severe palmar and/or axillary hyperhidrosis underwent endoscopic sympathectomy with a follow-up of at least 4 years. One-hundred and twenty-six patients received one-stage bilateral, single port video-assisted thoracoscopic sympathectomy (one-stage group) and 135 patients underwent two-stage unilateral, single-port video-assisted thoracoscopic sympathectomy, with a mean time interval of four months between the procedures (two-stage group).

RESULTS

The mean postoperative follow-up period was 7.2 years (range, 4-9 years). Sixteen patients (12.7%) in the one-stage group and 15 patients (11.1%) in the two-stage group suffered from bradycardia (P=0.15). Recurrences occurred in three patients (2.4%) in the one-stage group and one (0.7%) in the two-stage group (P=0,09). Facial flushing or hyperthermia occurred in eight patients (6.3%) in the one-stage group and 11 (8.1%) of the two-stage group. Compensatory sweating occurred in 27 patients (21.4%) in the one-stage group and six patients (4.4%) in the two-stage group (P=0.0001). However, compensatory sweating recovered in five patients (83.3%) in the two-stage group versus nine (33.35%) in one-stage group during the follow-up period (Log-rank test P=0.016; HR, 7.196; 95% CI, 1.431-36.20). An improvement in postoperative quality of life (QoL) scores was observed in at least 90% of patients at three years after surgery in the one-stage group and at least 95% of patients in the two-stage group (P=0.001).

CONCLUSIONS

Compensatory sweating seems to improve during the follow-up period with a higher recovery rate after two-stage unilateral versus one-stage bilateral sympathectomy for patients with palmar and axillary hyperhidrosis.

Endoscopic thoracic sympathectomy for upper limb ischemia. A 16 year follow-up in a single center

INTRODUCTION

The aim of our study was to evaluate the long term results of Endoscopic Thoracic Sympathectomy (ETS) in the management of upper limb ischemia (ULI).

METHODS

We retrospectively reviewed the records of all consecutive patients who underwent ETS for ULI between January 1994 and May 2009. A standardized questionnaire was used to evaluate the long term success, morbidity and overall patient satisfaction.

RESULTS

Thirty-five patients (20 female, mean age 49 years (range 23-79)) underwent bilateral (n = 9) and unilateral (n = 27) ETS procedures, respectively. Six patients had Primary (idiopathic) Raynaud Disease. Twenty-nine patients had upper limb ischemia secondary to systemic disorders (n = 12), embolic disease (n = 10), occlusion of the arteries of the arm (n = 5) or hypothenar hammer syndrome (n = 2). Tissue loss at time of surgery was present in nineteen patients. Short term beneficial effects were reported by 12 patients (63%). Eleven of the 35 patients experienced a total of 13 complications or adverse events, whereof 11 were minor or transient. Limb salvage was unsuccessful in three patients because of major amputations (n = 2) or severe functional impairment (n = 1). Necrotectomies or minor amputations without functional impairment were performed in 9 patients. Medium or long term follow up (mean 98 months (range 18-198) was available in 19 out of 22 living patients(86%). Long term beneficial effects were reported by 10 (53%). Overall patient satisfaction was 56%. Compensatory sweating was experienced by 11 patients (58%).

CONCLUSION

Although the long term efficacy of ETS in our study was moderate (53%), due to its low invasiveness ETS is a valuable option in the management of ULI.

Treatment of compensatory hyperhidrosis after sympathectomy with botulinum toxin and anticholinergics

PURPOSE

Compensatory hyperhidrosis (CH) is the most common adverse complication of sympathectomy. It often has a major negative impact on life quality. No efficient treatment of CH is available. We report nine cases of CH after sympathectomy, which were treated with botulinum toxin A/B (BTX) and anticholinergics.

METHODS

The patients responded to a dermatology life quality index (DLQI) questionnaire before injections with BTX and 3 weeks after treatment. At the follow-up visit, the participants also ranked the effect of the treatment on a five-grade scale. Three patients had residual sweating after BTX treatment, and received additional anticholinergics at the follow-up visit. Those subjects eventually had a third evaluation with the DLQI.

RESULTS

The DLQI score was, on average, 16.4 before treatment and decreased to 4.8 after BTX injections. Eight out of nine patients were satisfied with the treatment. The average DLQI score decreased to 2.2 when the patients with residual sweating (n = 3) received additional anticholinergics. Adverse events from BTX were mild and temporary, but dry mouth was substantial in one patient using anticholinergics.

CONCLUSIONS

A combination of BTX A/B and anticholinergics alleviated the hyperhidrosis with minor side-effects. We consider this treatment safe, effective, and well tolerated.

Thermometry, calorimetry, and mean body temperature during heat stress

Heat balance in humans is maintained at near constant levels through the adjustment of physiological mechanisms that attain a balance between the heat produced within the body and the heat lost to the environment. Heat balance is easily disturbed during changes in metabolic heat production due to physical activity and/or exposure to a warmer environment. Under such conditions, elevations of skin blood flow and sweating occur via a hypothalamic negative feedback loop to maintain an enhanced rate of dry and evaporative heat loss. Body heat storage and changes in core temperature are a direct result of a thermal imbalance between the rate of heat production and the rate of total heat dissipation to the surrounding environment. The derivation of the change in body heat content is of fundamental importance to the physiologist assessing the exposure of the human body to environmental conditions that result in thermal imbalance. It is generally accepted that the concurrent measurement of the total heat generated by the body and the total heat dissipated to the ambient environment is the most accurate means whereby the change in body heat content can be attained. However, in the absence of calorimetric methods, thermometry is often used to estimate the change in body heat content. This review examines heat exchange during challenges to heat balance associated with progressive elevations in environmental heat load and metabolic rate during exercise. Further, we evaluate the physiological responses associated with heat stress and discuss the thermal and nonthermal influences on the body's ability to dissipate heat from a heat balance perspective.

Expanded level of sympathetic chain removal does not increase the incidence or severity of compensatory hyperhidrosis after endoscopic thoracic sympathectomy

OBJECTIVE

Compensatory hyperhidrosis is a common devastating adverse effect after endoscopic thoracic sympathectomy for patients undergoing surgical treatment of primary hyperhidrosis. We sought to determine whether a correlation existed in our patient population between the level and extent of sympathetic chain resection and the subsequent development of compensatory hyperhidrosis.

METHODS

All patients undergoing endoscopic thoracic sympathectomy in the T2-T3, T2-T4, T2-T5, or T2-T6 levels for palmar or axillary hyperhidrosis at the University of Iowa Hospital and Clinics (n = 97) from January 2004 to January 2013 were retrospectively reviewed.

RESULTS

Differences in the preoperative patient characteristics were not statistically significant among the patients receiving T2-T3, T2-T4, T2-T5, or T2-T6 level resections. Of the 97 included patients, 28 (29%) experienced transient compensatory hyperhidrosis and 4 (4%) complained of severe compensatory hyperhidrosis and required additional treatment. No operative mortalities occurred, and the morbidity was similar among the groups.

CONCLUSIONS

Most patients had successful outcomes after undergoing extensive resection without changes in the incidence of compensatory hyperhidrosis. Therefore, we recommend performing complete and adequate resection for relief of symptoms in patients with primary hyperhidrosis.

Selecting the correct exercise intensity for unbiased comparisons of thermoregulatory responses between groups of different mass and surface area

We assessed whether comparisons of thermoregulatory responses between groups unmatched for body mass and surface area (BSA) should be performed using a metabolic heat production (Ḣprod) in Watts or Watts per kilogram for changes in rectal temperature (ΔTre), and an evaporative heat balance requirement ( Ereq) in Watts or Watts per square meter for local sweat rates (LSR). Two groups with vastly different mass and BSA [large (LG): 91.5 ± 6.8 kg, 2.12 ± 0.09 m2, n = 8; small (SM): 67.6 ± 5.6 kg, 1.80 ± 0.09 m2, n = 8; P < 0.001], but matched for heat acclimation status, sex, age, and with the same onset threshold esophageal temperatures (LG: +0.37 ± 0.12°C; SM: +0.41 ± 0.17°C; P = 0.364) and thermosensitivities (LG: 1.02 ± 0.54, SM: 1.00 ± 0.38 mg·cm−2·min−1·°C−1; P = 0.918) for sweating, cycled for 60 min in 25°C at different levels of Ḣprod (500 W, 600 W, 6.5 W/kg, 9.0 W/kg) and Ereq (340 W, 400 W, 165 W/m2, 190 W/m2). ΔTre was different between groups at a Ḣprod of 500 W (LG: 0.52 ± 0.15°C, SM: 0.92 ± 0.24°C; P < 0.001) and 600 W (LG: 0.78 ± 0.19°C, SM: 1.14 ± 0.24°C; P = 0.007), but similar at 6.5 W/kg (LG: 0.79 ± 0.21°C, SM: 0.85 ± 0.14°C; P = 0.433) and 9.0 W/kg (LG: 1.02 ± 0.22°C, SM: 1.14 ± 0.24°C; P = 0.303). Furthermore, ΔTre was the same at 9.0 W/kg in a 35°C environment (LG: 1.12 ± 0.30°C, SM: 1.14 ± 0.25°C) as at 25°C ( P > 0.230). End-exercise LSR was different at Ereq of 400 W (LG: 0.41 ± 0.18, SM: 0.57 ± 0.13 mg·cm−2·min−1; P = 0.043) with a trend toward higher LSR in SM at 340 W (LG: 0.28 ± 0.06, SM: 0.37 ± 0.15 mg·cm−2·min−1; P = 0.057), but similar at 165 W/m2 (LG: 0.28 ± 0.06, SM: 0.28 ± 0.12 mg·cm−2·min−1; P = 0.988) and 190 W/m2 (LG: 0.41 ± 0.18, SM: 0.37 ± 0.15 mg·cm−2·min−1; P = 0.902). In conclusion, when comparing groups unmatched for mass and BSA, future experiments can avoid systematic differences in ΔTre and LSR by using a fixed Ḣprod in Watts per kilogram and Ereq in Watts per square meter, respectively.

Bilateral single-port sympathectomy: long-term results and quality of life

Object. Video-assisted thoracoscopic sympathectomy is a safe, effective, and minimally invasive procedure for primary hyperhidrosis. This study aims to evaluate long-term results and patients' quality of life and investigate potential variables responsible for compensatory sweating after one-stage bilateral single-port thoracoscopic sympathectomy. Methods. Between 2005 and 2011, 260 consecutive bilateral thoracoscopic sympathectomies were performed in 130 patients for primary palmar and axillary hyperidrosis through one-port access. Residual pain, postoperative complications, recurrence of symptoms, heart rate adjustment, and quality of life were analyzed. Multivariate analysis was performed. Results. No operative mortality and conversion to open surgery were recorded. Mean operative time was 38 ± 5 minutes. Mean hospital stay was 1.1 ± 0.6 days. Eight patients (6%) had unilateral pneumothorax. Twenty-five cases (19%) were complicated by compensatory sweating. Winter and fall were identified as protective factors for compensatory sweating occurrence. Decreased heart rate was observed 1 year after surgery and permanently over the time. No recurrence during the follow-up period (31.5 months) was observed and 90% of patients showed improved quality of life. Conclusions. One-stage bilateral miniuniportal thoracoscopic sympathectomy is a valid and safe treatment for primary hyperhidrosis, achieving definitive and esthetic results, with excellent patients' satisfaction. Compensatory sweating may potentially occur in a season-dependent manner.

Whole body heat loss is reduced in older males during short bouts of intermittent exercise

Studies in young adults show that a greater proportion of heat is gained shortly following the start of exercise and that temporal changes in whole body heat loss during intermittent exercise have a pronounced effect on body heat storage. The consequences of short-duration intermittent exercise on heat storage with aging are unclear. We compared evaporative heat loss (H E) and changes in body heat content (ΔHb) between young (20–30 yr), middle-aged (40–45 yr), and older males (60–70 yr) of similar body mass and surface area, during successive exercise (4 × 15 min) and recovery periods (4 × 15 min) at a fixed rate of heat production (400 W) and under fixed environmental conditions (35°C/20% relative humidity). H E was lower in older males vs. young males during each exercise (Ex1: 283 ± 10 vs. 332 ± 11 kJ, Ex2: 334 ± 10 vs. 379 ± 5 kJ, Ex3: 347 ± 11 vs. 392 ± 5 kJ, and Ex4: 347 ± 10 vs. 387 ± 5 kJ, all P < 0.02), whereas H E in middle-aged males was intermediate to that measured in young and older adults (Ex1: 314 ± 13, Ex2: 355 ± 13, Ex3: 371 ± 13, and Ex4: 365 ± 8 kJ). H E was not significantly different between groups during the recovery periods. The net effect over 2 h was a greater ΔHb in older (267 ± 33 kJ; P = 0.016) and middle-aged adults (245 ± 16 kJ; P = 0.073) relative to younger counterparts (164 ± 20 kJ). As a result of a reduced capacity to dissipate heat during exercise, which was not compensated by a sufficiently greater rate of heat loss during recovery, both older and middle-aged males had a progressively greater rate of heat storage compared with young males over 2 h of intermittent exercise.

Two-stage unilateral versus one-stage bilateral single-port sympathectomy for palmar and axillary hyperhidrosis

OBJECTIVES

Video-assisted thoracoscopic sympathectomy is currently the best treatment for palmar and axillary hyperhidrosis. It can be performed through either one or two stages of surgery. This study aimed to evaluate the operative and postoperative results of two-stage unilateral vs one-stage bilateral thoracoscopic sympathectomy.

METHODS

From November 1995 to February 2011, 270 patients with severe palmar and/or axillary hyperhidrosis were recruited for this study. One hundred and thirty patients received one-stage bilateral, single-port video-assisted thoracoscopic sympathectomy (one-stage group) and 140, two-stage unilateral, single-port video-assisted thoracoscopic sympathectomy, with a mean time interval of 4 months between the procedures (two-stage group).

RESULTS

The mean postoperative follow-up period was 12.5 (range: 1-24 months). After surgery, hands and axillae of all patients were dry and warm. Sixteen (12%) patients of the one-stage group and 15 (11%) of the two-stage group suffered from mild/moderate pain (P = 0.8482). The mean operative time was 38 ± 5 min in the one-stage group and 39 ± 8 min in the two-stage group (P = 0.199). Pneumothorax occurred in 8 (6%) patients of the one-stage group and in 11 (8%) of the two-stage group. Compensatory sweating occurred in 25 (19%) patients of the one-stage group and in 6 (4%) of the two-stage group (P = 0.0001). No patients developed Horner's syndrome.

CONCLUSIONS

Both two-stage unilateral and one-stage bilateral single-port video-assisted thoracoscopic sympathectomies are effective, safe and minimally invasive procedures. Two-stage unilateral sympathectomy can be performed with a lower occurrence of compensatory sweating, improving permanently the quality of life in patients with palmar and axillary hyperhidrosis.