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

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.

Endoscopic thoracic sympathectomy for primary hyperhidrosis: an over a decade-long follow-up on efficacy, impact, and patient satisfaction

Background

Endoscopic thoracic sympathectomy is a well-known and effective treatment for palmar and axillary primary hyperhidrosis (PHH). Its most frequent drawback and the main complaint among patients who underwent surgery is the appearance of compensatory sweating (CS). To date, no long-term studies using internationally standardized tools have assessed the efficacy and impact of this surgery on patients. In this study we performed a very long-term follow-up of the patients using an internationally validated tool. The aim of this article is to assess the technique as a treatment for hyperhidrosis, focusing on its long-term efficacy, side effects (CS), and patient satisfaction with the procedure.

Methods

A closed cohort study was performed conducting a review of the clinical records to identify 100 consecutive patients who underwent bilateral endoscopic thoracic surgery with a minimum follow-up period of 2 years. Patients with diagnoses other than primary palmar or axillary hyperhidrosis or those for whom follow-up was impossible were excluded. A structured telephone survey, including the International Hyperhidrosis Society "Hyperhidrosis Disease Severity Scale" (HDSS) was conducted for all patients. Data were summarized using median (1st and 3rd quartiles) for quantitative variables and relative and absolute frequencies for qualitative variables. To study the likelihood of a patient recommending the surgery, a Bayesian logistic regression model was used reporting results as odds ratio (OR).

Results

A total of 91 patients were included in the follow-up. The median follow-up duration was 10.66 (5.68, 11.98) years. The most affected zone was the hands (29.67%), and the most common sympathectomy levels were R2 and R3 (68.13%). The overall surgical efficacy rate was of 94.50% and CS appeared in 36.26% of the patients, with 75.76% of these cases being mild and severe in only one patient. In total, 97.8% of patients improved their HDSS score after surgery. The OR of recommending the surgery for a lower HDSS index was 0.24 and 0.18 for the apparition of CS. Despite it, 91.21% of patients recommend the surgery, with an overall satisfaction rate of 93.95%.

Conclusions

Endoscopic thoracic sympathectomy is an effective and safe treatment for palmar and axillary PHH, with a relatively low rate of CS which, when present, is typically mild, making it a highly satisfactory treatment option for patients.

Thoracoscopic resympathectomy for persistent or recurrent palmar hyperhidrosis: single-center experience

BACKGROUND

In case of recurrence or persistent palmar hyperhidrosis, a sympathetic chain resection is suggested, however, many surgeons are still reluctant to offer further intervention because of the inability to predict the efficacy of such a procedure. We analyzed our large series of resympathectomy.

METHODS

Substantive retrospective analysis of 39 patients underwent a resympathectomy (minimally invasive bilaterally sympathetic chain Th2-3 resection). Patients referred from other hospitals or primarily operated at our institution for recurrence or persistence palmar hyperhidrosis were included in the study group.

RESULTS

No intraoperative complications were detected. Reoperation or chest tube positioning was necessary in 2 patients. Twenty-eight patients had a positive response (excellent or good results). Seven patients described a substantial, but not sufficient, reduction of the symptomatology. Four patients were very unsatisfied and regretted the operation.

CONCLUSIONS

Resympathectomy is highly effective procedure for patients who have persistent or recurrent symptoms. However, the indication of the operations should be more dissuasive as possible to avoid the risk of any undesirable psychologically side effects.

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.

Rib-oriented Thoracoscopic Sympathetic Surgery for Hyperhidrosis: Prospective Long-term Results and Quality of Life

BACKGROUND

The optimal thoracoscopic sympathetic surgery for primary palmar and/or axillary hyperhidrosis (PPAH) is still unclear because of lack of uniform technique and qualitative/quantitative scales for definition of results. The aims of this study were to compare long-term outcomes based on the surgical technique and the level of sympathetic trunk interruption by clipping and to assess postoperative compensatory sweating (CS), patients' satisfaction, and quality of life (QoL).

MATERIALS AND METHODS

Between September 2009 and April 2016, 94 patients who underwent 2-stage bilateral thoracoscopic rib-oriented (R) sympathetic clipping were prospectively followed up through the administration of standardized preoperative and postoperative questionnaires.Thirty-four (36.2%) patients underwent single-port transaxillary access instead of the standard two 5-mm incisions. The level of sympathetic clipping for PPAH was R3+4(top and bottom); in patients who complained associated facial or plantar hyperhidrosis R2-bottom and R5-top were clipped, respectively. Seventy-five patients completed bilateral surgery.

RESULTS

There were no significant differences between single-port and biportal video-assisted thoracoscopic surgery in terms of operative times and postoperative results. At a mean follow-up of 72 (SD: 26) months, CS was reported in 42 (56%) patients, severe only in 6 (8%). It was higher in the case of R2-bottom clipping (P=0.03). Thirty-one of 60 (51.6%) patients who had a plantar hyperhidrosis declared an improvement of feet sweating after surgery. Postoperative satisfaction was excellent (86.11% on a 0 to 100 scale) and 95.4% of patients declared an improvement in QoL, which was statistically significant in all evaluated parameters. These results were not related to the level of clipping.

CONCLUSION

Thoracoscopic R3 to R4 clipping appears to be a safe and effective treatment for PPAH. Although postoperative CS was common and higher after R2-bottom clipping, this did not seem to affect patients' satisfaction and improvement in QoL.

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.