Compensatory sweating after restricting or lowering the level of sympathectomy: a systematic review and meta-analysis

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Methods

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

Results

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

Conclusions

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

Selective block of grey communicantes in upper thoracic sympathectomy. A feasibility study on human cadaveric specimens

Background: Sympathetic chain interruption is the gold standard treatment for essential hyperhidrosis. Postoperative compensatory hyperhidrosis, the main reason for patients' dissatisfaction, is reduced by selectively lesioning white and grey rami communicantes (ramicotomy).Objective: To develop an endoscopic surgical technique that interrupts only T₃ and T₄ grey rami communicantes to minimize compensatory hyperhidrosis.Material and Methods: T₃ and T₄ grey rami communicantes ramicotomy in fifteen cold-preserved cadavers through a uniportal axillary endoscopic approach. The sympathetic chain, its ganglia, and white rami communicantes were left intact. On opening the chest, the sympathetic chain, rami communicantes and ganglia were dissected, photographed, measured and excised for histological examination.Results: Dissecting the grey rami communicantes is feasible as they consistently lie between the intercostal nerve and the homonymous sympathetic ganglion. At some levels, Kuntz nerves, as well as more than one grey ramus communicans, can be found. White rami communicantes are more medial, therefore damaging them can be avoided. Intercostal veins can be obstructive, but these can be controlled via coagulation or clipping if necessary.Conclusion: Uniportal endoscopic selective excision of the T₃ and T₄ grey rami communicantes is feasible without damaging the white rami communicantes, the sympathetic chain or its ganglia. Clipping the grey rami communicantes is technically possible but not reliable due to their thin diameter. This study confirms that T₃ and T₄ grey rami sympathetic block is technically feasible. Its application might reduce compensatory hyperhidrosis, but clinical studies are needed.

Compensatory hyperhidrosis after different surgeries at the same sympathetic levels: a meta-analysis

Background

Different techniques of video-assisted thoracoscopic sympathetic surgery have become the radical treatments for palmar and axillary hyperhidrosis (AH). However, there is no consensus over which technique can make a minimal incidence of compensatory hyperhidrosis (CH). This study was designed to compare the incidence of CH after different techniques at the same sympathetic levels in the treatment of upper limb and facial hyperhidrosis (FH).

Methods

The databases of PubMed, Web of Science, ScienceDirect, Ovid Medline, Embase, and Cochrane Library were searched to identify studies comparing different surgical techniques at the same sympathetic levels for upper limb and FH. The data was analyzed by Revman 5.3 software.

Results

A total of ten studies involving 896 patients were included, of whom 149 underwent sympathectomy, 435 underwent sympathicotomy, and 312 under endoscopic sympathetic clip (ESC). Meta-analysis showed that the difference of incidence of CH and patients' satisfaction was not significant between sympathectomy and sympathicotomy (P=0.05, 0.19, respectively). But, the incidence of CH is significant lower after ESC than after sympathicotomy (OR: 1.58, 95% CI: 1.04-2.38, P=0.03). However, the incidence of moderate/severe CH between these two groups is not significant different (OR: 1.49, 95% CI: 0.93-2.39, P=0.10).

Conclusions

If only CH and the same sympathetic levels concerned, sympathectomy and sympathicotomy is equal for upper limb hyperhidrosis and FH. And, ESC should be recommended for a lower incidence of CH, comparing with 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.

Epidemiologic analysis of prevalence of the hyperhidrosis

Background

The present paper aims to study the prevalence of the various manifestations of hyperhidrosis in patients who sought treatment in a specialized ambulatory in the state of São Paulo.

Objectives

Opposite to previous studies, this paper studies the different combinations of sweating sites, not being restricted to the main complaint site of the patients, but taking into consideration secondary complaints patients may present.

Methods

This was a retrospective approach of a database containing more than 1200 patients in which were mapped: combination of sweating sites, age of onset, age spectrum, mean age, body mass index and gender of patients. Patients were categorized into four groups based on their main sweating site - palmar, plantar, axillary and facial.

Results

We concluded that hyperhidrosis appears frequently in more than one site, being the main complaint that affects the most patients palmar hyperhidrosis, which appears early in the patients during adolescence. When there are two sites of sweating, the most frequent combination is palmar + plantar, and when there are three sites of sweating the most frequent combinations are palmar + plantar + axillary and axillary + palmar + plantar.

Study limitations

This research has casuistics limited to a single care service for patients with hyperhidrosis.

Conclusion

It is necessary to keep in mind that the disease manifests itself mainly in more than one location, with different intensities in each of the patients, generating a significant impairment of their quality of life.

Interventions for Prevention of Intimate Partner Violence Against Women in Humanitarian Settings: A Protocol for a Systematic Review

INTRODUCTION

Humanitarian emergencies and the number of people who are adversely affected are increasing. In such emergencies, the vulnerability of women and girls to gender-based violence increases signifi-cantly and they often experience high levels of intimate partner violence (IPV). There are a limited number of interventions to reduce gender-based violence (GBV) and IPV in the contexts of humanitarian emergencies, and there is uncertainty about the effectiveness of these preventive interventions. This is the protocol for a systematic review that will synthesize the evidence on interventions for primary or secondary prevention of IPV in humanitarian settings, and assess the effect of existing types of IPV-related interventions in these settings.

METHODS AND DESIGN

The PRISMA-P 2015 statement has been used to prepare this report. Studies published from January 2000 to January 2017 will be reviewed with no language limits. Any experimental, quasi-experimental, or controlled trials will be included. A combination of four key concepts, including "IPV" AND "population" AND "humanitarian setting" AND "intervention" will be used in the search and a variety of information sources will be used: (1) bibliographic databases; (2) special databases and grey literature; (3) and the reference lists of eligible studies. Two reviewers will independently screen articles, extract relevant data and assess study quality. Discrepancies will be resolved through consensus. Risk of bias will be assessed using the Cochrane Risk of Bias tool and the quality of evidence will be assessed using the CONSORT checklist. A narrative synthesis will be provided. If a sufficient number of studies are found, their results will be pooled using a random-effects meta-analysis. For dichotomous outcomes, summaries of intervention effects for each study will be provided by calculating risk ratios with 95% confidence interval. Standardized mean differences will be used for continuous outcomes.

DISCUSSION

The review will be useful for IPV management policy and related planning. It will help researchers, policymakers and guideline developers with an interest in reducing violence against women among refugees, internally displaced persons (IDPs), and conflict-affected population.