Can we predict the compensatory hyperhidrosis following a thoracic sympathectomy?

Long-term outcomes and predictors of compensatory sweating after bilateral endoscopic thoracic sympathectomy

OBJECTIVES

Bilateral endoscopic thoracic sympathectomy is an effective treatment for primary hyperhidrosis, yet the causes of its main side effect, compensatory sweating, remain unclear. This study aimed to identify risk factors for compensatory sweating in a long-term follow-up cohort.

METHODS

Patients who underwent bilateral endoscopic thoracic sympathectomy for primary hyperhidrosis between 2010 and 2023 (n = 98) were interviewed, and preoperative data were collected. Compensatory sweating was classified as mild, moderate, or severe according to the Society of Thoracic Surgeons guidelines. Quality of life (QOL) was assessed using the Hyperhidrosis Disease Severity Scale from the International Hyperhidrosis Society. Logistic and ordinal Bayesian regression models were applied to analyse associations between predictors, compensatory sweating outcomes, and QOL.

RESULTS

The procedure achieved an overall effectiveness of 94.38%, with 34.69% of patients reporting compensatory sweating, predominantly mild (26.53%). Nearly all patients (97.95%) experienced a ≥ 50% reduction in sweating, and 94.89% achieved ≥80% reduction. Higher haemoglobin levels and marijuana protected against compensatory sweating incidence and severity. Conversely, smoking and hyperhidrosis involving both hands and axillae increased compensatory sweating risk. Better QOL outcomes were correlated with higher haemoglobin levels and female sex, while worse outcomes were associated with older age, higher body mass index, and axillary involvement.

CONCLUSIONS

Long-term follow-up highlights key predictors for compensatory sweating, emphasizing the importance of tailored preoperative counseling. Identifying at-risk patients, such as smokers and those with low haemoglobin levels, is essential for improving outcomes and managing expectations in the treatment of primary hyperhidrosis.

Which patients are more likely to experience compensatory hyperhidrosis after endoscopic thoracic sympathectomy: a meta-analysis and systematic review

Background

Compensatory hyperhidrosis (CH) is a common consequence of sympathectomy, which can adversely affect patients' quality of life after surgery. Understanding the factors that influence the occurrence of CH and severe compensatory hyperhidrosis (SCH) is crucial for effective management and counseling of patients undergoing this procedure.

Materials and Methods

We registered the protocol in International Prospective Register of Systematic Reviews (CRD42024592389) and following PRISMA guidelines. We searched PubMed, EMBASE, and Web of Science databases for studies published up to September 11, 2024. A systematic literature search identified a total of 10 studies involving 3,117 patients. The primary outcome was the number of CH or SCH. The secondary outcome was the weighted mean difference calculated based on identified related factors. When pooling results or conducting a meta-analysis was not feasible, the study findings were presented in a narrative descriptive format.

Results

The overall incidence of CH was found to be 0.62 (95% confidence interval CI [0.51-0.72]), and four studies totaling 1,618 patients regarding the occurrence of severe compensatory hyperhidrosis, the overall incidence of CH was found to be 0.23 (95% CI [0.12-0.34]). Older age, higher body mass index (BMI) and smoking history correlated positively with CH incidence. In addition, higher BMI level is also associated with the occurrence of SCH (1.20 95% CI [1.01-1.39], p < 0.0001).

Conclusion

The findings of this meta-analysis highlight important demographic and lifestyle factors that contribute to the development of CH and SCH following sympathectomy. Older patients, smokers, and those with higher BMI may be at greater risk for these conditions.

Single-port Thoracoscopic Laser Sympathicotomy for Primary Hyperhidrosis: A Safe and Minimally Invasive Approach With Favorable Short-term Outcomes

OBJECTIVE

Thoracoscopic sympathicotomy is a well-established treatment for severe palmar hyperhidrosis. This study evaluates the safety and efficacy of a novel one-stage, bilateral, single-port laser sympathicotomy with minimal dissection.

METHODS

We retrospectively reviewed 73 patients with severe palmar hyperhidrosis who underwent this novel surgical technique between June 2023 and October 2023. Outcomes included complications, recurrent hyperhidrosis, and compensatory hyperhidrosis (CH). Hyperhidrosis severity was assessed using the hyperhidrosis disease severity score (HDSS).

RESULTS

The mean patient age was 21.3 ± 7.7 years, with a female predominance (52.1%). Sympathicotomy was performed at the T3 level only in 46 patients (63%), with the remaining undergoing sympathicotomy at both T3 and T4 levels. Median cauterization and operating times were 78 seconds and 8.7 minutes, respectively. No complications occurred. Two patients experienced recurrent hyperhidrosis during a median follow-up of 9 months, both were mild (HDSS grade 1). CH developed in 41 patients (56.2%), with all occurring within the first month postoperatively. The most common sites for CH were the back (51.2%), chest (43.9%), thigh (41.5%), abdomen (36.6%), and lower leg (36.6%). The majority of patients with CH (95.1%) reported mild (HDSS grade 1) or moderate (HDSS grade 2) hyperhidrosis. A higher body mass index was a significant risk factor for CH (odds ratio: 1.36, 95% CI: 1.12-1.71 for every 1 kg/m 2 increase).

CONCLUSIONS

This minimally invasive, single-port thoracoscopic laser sympathicotomy appears to be safe and effective for patients with palmar primary hyperhidrosis. Future studies should investigate long-term outcomes and refine the technique to minimize invasiveness even further.

Incidence and Severity of Compensatory Hyperhidrosis Following Bilateral Sympathectomy

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Long term outcomes and risk factors of compensatory hyperhidrosis after thoracoscopic sympathectomy in primary palmar hyperhidrosis patients: a retrospective single-center study

OBJECTIVE

This study aims to evaluate the long-term outcomes of compensatory hyperhidrosis (CH) after thoracoscopic sympathectomy and explore the risk factors affecting postoperative CH in primary palmar hyperhidrosis(PPH) patients.

METHOD

A retrospective analysis was conducted on patients who underwent thoracoscopic sympathectomy in the thoracic surgery department of our hospital from January 2015 to May 2022. Long-term follow-up surveys was conducted to collect data on post-operative satisfaction, PPH recurrence, and CH occurrence. Postoperative CH outcomes were assessed using the HDSS and satisfaction scores scale. Univariate and multivariate logistic regression analyses were used to identify independent risk factors for postoperative CH.

RESULT

A total of 152 patients was included in the final study, with 113 cases in the CH group and 39 cases in the nCH group. The incidence of postoperative CH was 74.3% (113/152), within which 33.6% (38/113) were severe CH. The median follow-up time was 3.1 years(2.5-5.5y) and the median interval of CH onset after surgery was 30 days (14-90d). Univariate analysis showed that body mass index(BMI), surgical time, and transected nerve level are correlated with CH, with statistically significant differences. Multivariate logistic regression analysis indicated a higher BMI (OR = 0.864, 95% CI 0.755-0.989, P < 0.05) is the independent risk factor for the occurrence of CH. There was no statistically significant difference in HDSS scores among CH patients at 1 month, 1 year, and 3 years after surgery.

CONCLUSION

A higher BMI is the independent risk factor for postoperative CH after thoracoscopic sympathectomy. The incidence and severity of postoperative CH kept stable during a long term follow up.

Development of a novel nomogram to predict the risk of severe compensatory sweating following endoscopic thoracic sympathectomy

BACKGROUNDS

Endoscopic thoracic sympathectomy (ETS) is a permanent and effective treatment for primary hyperhidrosis and facial blushing; however, severe compensatory sweating (SCS) remains a devastating complication. We aimed to (i) construct a nomogram to predict the risk of SCS, and (ii) investigate factors associated with the level of satisfaction.

METHODS

From Jan 2014 to Mar 2020, 347 patients underwent ETS by a single surgeon. These patients were asked to complete an online questionnaire regarding primary symptom resolution, level of satisfaction, and development of compensatory sweating. Multivariable analysis was conducted via logistic regression and ordinal regression to predict SCS and satisfaction level respectively. Nomogram was developed based on significant predictors.

RESULTS

In total, 298 (85.9%) patients responded to the questionnaire with a mean follow up of 4.9 ± 1.8 years. Significant factors associated with SCS in the nomogram included older age (OR 1.05, 95% CI 1.02-1.09, P = 0.001), primary indication other than palmar hyperhidrosis (OR 2.30, 95% CI 1.03-5.12, P = 0.04), and current smoking (OR 5.91, 95% CI 2.46-14.20, P < 0.001). The area under receiver operating characteristic curve was 0.713. Multivariable analysis revealed that longer follow up (β = -0.201 ± 0.078, P = 0.01), gustatory hyperhidrosis (β = -0.781 ± 0.267, P = 0.003), primary indication other than palmar hyperhidrosis (β = -1.524 ± 0.292, P < 0.001), and SCS (β = -3.061 ± 0.404, P < 0.001) were independently associated with a lower degree of patient satisfaction.

CONCLUSION

The novel nomogram can provide a personalized numerical risk estimate to assist both the clinician and patient weigh the pros and cons as part of the decision-making process, mitigating the chance of patient dissatisfaction.

Machine learning analysis of primary hyperhidrosis for classification of hyperhidrosis type and prediction of compensatory hyperhidrosis

Background

Although sympathectomy is highly effective for improving symptom, compensatory hyperhidrosis (CH) is a major issue. In this study, characteristics of primary hyperhidrosis were investigated in terms of the heart rate variability (HRV) parameters. Classification of hyperhidrosis type and prediction of CH after sympathicotomy were also determined using machine learning analysis.

Methods

From March 2017 to December 2021, 128 subjects who underwent HRV tests before sympathicotomy were analyzed. T2 and T3 bilateral endoscopic sympathicotomy were routinely performed in patients with craniofacial and palmar hyperhidrosis, respectively. Data collected age, sex, body mass index (BMI), hyperhidrosis type, symptom improvement after sympathicotomy, the degrees of CH after sympathicotomy, and preoperative HRV findings. The independent risk factors associated with the degree of CH after sympathicotomy were investigated. Machine learning analysis was used to determine classification of hyperhidrosis type and prediction of the degree of CH.

Results

Preoperatively, patients with palmar hyperhidrosis presented with significantly larger standard deviation of normal-to-normal (SDNN), root mean square of successive differences (RMSSD), total power (TP), and low frequency (LF) than patients with craniofacial hyperhidrosis after controlling for age and sex (P=0.030, P=0.004, P=0.041, and P=0.022, respectively). More sympathetic nervous predominance was found in craniofacial type (P=0.019). Low degree of CH had significantly greater RMSSD (P=0.047), and high degree of CH showed more sympathetic nervous predominance (P=0.006). Multivariate analysis showed the type and expansion of sympathicotomy were significant factors for CH (P=0.001 and P=0.028, respectively). The neural network (NN) algorithm outperformed and showed a 0.961 accuracy, 0.961 F1 score, 0.961 precision, 0.961 recall, and 0.972 area under the curve (AUC) for classification of hyperhidrosis type. The random forest (RF) model outperformed showed a 0.852 accuracy, 0.853 F1 score, 0.856 precision, 0.852 recall, and 0.914 AUC for prediction of the degree of CH.

Conclusions

The present study showed the machine learning algorithm can classify types and predict CH after sympathicotomy for primary hyperhidrosis with considerable accuracy. Further large-scale studies are needed to validate the findings and provide management guidelines for primary hyperhidrosis.

Predictors of Compensatory Sweating Following Video-Assisted Thoracoscopic Sympathectomy in Primary Palmar Hyperhidrosis

BACKGROUND

Compensatory sweating (CS) is a frequent health concern following treatment of palmar hyperhidrosis using video-assisted thoracoscopic sympathectomy (VATS) and can reduce level of patient satisfaction.

METHODS

A retrospective cohort study including consecutive patients who underwent VATS for primary palmar hyperhidrosis (HH) over a 5-year period was conducted. Various demographic, clinical, and surgical variables were tested for their correlation to postoperative CS through univariate analyses. Variables with significant correlation to outcome were included in a multivariable logistic regression for determining significant predictors.

RESULTS

The study included 194, predominantly male (53.6%), patients. About 46% of patients developed CS, mostly during the first month after VATS. Variables with significant correlation (P < 0.05) to CS included age (20 ± 3.6 years), body mass index (BMI) (mean 27 ± 4.9), smoking (34%), associated plantar HH (50%), and laterality of VATS (40.2% in dominant side). Only level of activity showed a statistical trend (P = 0.055). In multivariable logistic regression, BMI, plantar HH, and unilateral VATS were significant predictors for CS. Using receiver operating characteristic curve, the best cutoff point of BMI for prediction was 28.5, with sensitivity 77% and specificity 82%.

CONCLUSIONS

CS is a frequent health concern early after VATS. Patients with BMI >28.5 and no plantar HH are at higher risk of postoperative CS, and a unilateral dominant side VATS as an initial management step may lessen the risk of CS. Bilateral VATS can be provided for patients with low risk of CS and patients with low satisfaction after unilateral VATS.

Compensatory sweating after thoracoscopic sympathectomy for primary focal hyperhidrosis in children: Are there patient-related risk factors?

INTRODUCTION

Compensatory sweating (CS) is a common complication after thoracoscopic sympathectomy (TS) and is mainly associated with surgical technique. Our aim was to identify potential risk-factors for CS following TS for primary focal hyperhidrosis in children.

METHODS

A retrospective, single-center review of all bilateral TS was performed between 2017 and 2019. Hyperhidrosis disease severity scale was used for pre-operative severity assessment. Post-operative evaluations were performed after three and six months.

RESULTS

More than the 36-month period, 41 patients were submitted to T2-T4 TS, and 25 were females (60.9%). Median age at surgery was 15.5 years. CS was identified at the 3rd month in 17 (41%) children with most in the dorsolumbar region (56%). By the 6th month, there was a significant reduction in CS (41 to 32%, p = 0.02). The probability of resolution of CS by 6 months is about 50% in both the dorsolumbar and abdominal regions. Neither age, gender, body mass index, family history, or concomitant illnesses seemed to influence CS (p > 0.05). Axillary hyperhidrosis appears to be associated with the development of dorsolumbar CS (p = 0.037).

CONCLUSION

Thoracoscopic sympathectomy for PFH is a safe and effective procedure, but compensatory sweating can be a common and debilitating side effect. Age, gender, and body mass index do not appear to influence CS. Axillary hyperhidrosis may be related to the development of dorsolumbar CS.

LEVEL OF EVIDENCE

III.

Does the Sweating Severity of Primary Hyperhidrosis Sites Affect Post-Sympathotomy Results?

BACKGROUND

 Improvement in quality of life (QOL) and patient satisfaction after endoscopic thoracic sympathotomy (ETS) in patients with primary hyperhidrosis may be affected by various factors. We examined whether the preoperative sweating severity of primary hyperhidrosis sites affects postoperative results.

METHODS

 The records of 112 patients who underwent bilateral ETS were reviewed retrospectively. The patients were divided into three groups according to the sweating severity score obtained from all primary hyperhidrosis sites (primary hyperhidrosis severity score [PHSS]) and analyzed comparatively. Group A (PHSS = 1-4) included 22 patients, Group B (PHSS = 5-8) 36 patients, and Group C (PHSS ≥ 9) 54 patients. Outcome measures included QOL prior to surgery, improvement in QOL after surgery, degree of clinical improvement, presence, severity, localization, and site number of reflex sweating (RS) and general patient satisfaction after 6 months of surgery.

RESULTS

 The preoperative QOL of patients with higher PHSS (groups B, C) was worse than other patients (group A). More than 91% of all patients had any level improvement in QOL, and over 96% had slight or great clinical improvement. RS developed in 80% of the patients, mostly in the back, very severe in 8%, and in median two different body areas. The overall patient satisfaction rate was more than 95%. There was no significant difference between the three groups in terms of all postoperative results.

CONCLUSION

 Preoperative sweating severity of primary hyperhidrosis sites does not affect post-sympathotomy results. Surgeons should not be worried when deciding upon surgery, even in patients with high sweating severity.