Thoracoscopic Sympathicotomy for Disabling Palmar Hyperhidrosis: A Prospective Randomized Comparison Between Two Levels

doi:10.1016/j.athoracsur.2011.07.083

The Annals of Thoracic Surgery

Volume 92, Issue 6, December 2011, Pages 2015-2019

https://doi.org/10.1016/j.athoracsur.2011.07.083 Get rights and content

Background

Thoracoscopic sympathicotomy is highly effective in treating disabling palmar hyperhidrosis. The ideal level to maximize efficacy and minimize the side effect of compensatory hyperhidrosis (CH) is controversial. This study compared sympathicotomy over the second (R2) vs third (R3) costal head relative to these variables in patients with massive palmar hyperhidrosis.

Methods

This prospective, randomized study enrolled 121 patients with disabling palmoplantar hyperhidrosis assigned to bilateral sympathicotomy (sympathetic transection), which was done over R2 in 61 (n = 122 extremities) or R3 in 60 (n = 120 extremities). Patients were questioned at 6 months and at 1 year or more to assess efficacy, side effects, and satisfaction with the procedure.

Results

Sympathicotomy at R2 failed to cure palmar hyperhidrosis in 5 of 122 (4.1%) extremities, but only 2 (1.6%) were to a truly profound dripping level of recurrence. Sympathicotomy at R3 failed to cure palmar hyperhidrosis in 5 of 120 extremities (4.2%), and all were dramatic failures with dripping recurrent sweating. The patients whose palmar hyperhidrosis was not completely cured were aged 19.7 ± 2.5 vs 26.4 ± 8.0 years (p = 0.04). Two R3 patients with failure underwent three redo R2 sympathicotomies, with curative results. R2 patients showed a trend toward a higher level of CH vs R3 patients at 6 months and after 1 year. The CH severity scale was 4.7 ± 2.7 (n = 38) for R2 vs 3.8 ± 2.8 (n = 36) for R3 (p = NS) at 6 months and 4.7 ± 2.5 (n = 43) for R2 vs 3.7 ± 2.8 (n = 37) for R3 (p = NS) after 1 year. Younger age, male sex, and higher levels of preoperative and postoperative plantar sweating were predictors of failed sympathicotomy. Increased age was associated with increased CH.

Conclusions

R2 and R3 sympathicotomy for massive palmoplantar hyperhidrosis are highly effective, with low recurrence and incidences of severe CH. R2 tends to have a higher level of CH vs R3, and a higher incidence of dramatic failures is suggested in R3 patients, for which reoperation at the R2 level will likely be curative.

Section snippets

Material and Methods

A total of 121 consecutive patients with the classic manifestations of disabling palmoplantar hyperhidrosis [6] were prospectively randomized to R2 or R3 sympathicotomy. These manifestations included massive palmar sweating to a dripping or near-dripping level, similar level of plantar sweating, onset in early childhood or puberty, and provocation with ordinary hand lotion. Random allocation was used to assign patients to an R2 or R3 intervention. The demographics of the R2 and R3 groups are

Results

All operations were done as outpatient procedures, and no complications developed, including Horner syndrome, bleeding, pneumothorax, or infection.

Table 2 depicts satisfaction rating for individual sympathicotomy procedures at 6 months and at 12 or more months. More than 90% of both R2 and R3 patients were “very satisfied” with the procedure at 6 months and after 12 months. For R2 procedures, the lesser levels of satisfaction were primarily a result of CH. For R3 procedures, lesser levels of

Comment

Much conflicting opinion exists about the appropriate level and extent of sympathetic intervention for patients with severe palmoplantar hyperhidrosis. Determining the level of the sympathetic intervention, whether R1, R2, R3, or R4, or a combination, and whether a sympathicotomy or sympathectomy (including the ganglion) should be done, fundamentally depends on answering two questions: treatment efficacy and incidence of undesirable side effects, particularly CH.

Although earlier sympathectomy

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Cited by (28)

Predictors of Compensatory Sweating Following Video-Assisted Thoracoscopic Sympathectomy in Primary Palmar Hyperhidrosis
2023, World Neurosurgery
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.
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.
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%.
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.
Long-Term Efficacy of T3 Versus T3+T4 Thoracoscopic Sympathectomy for Concurrent Palmar and Plantar Hyperhidrosis
2021, Journal of Surgical Research
More than 50% of patients with palmar hyperhidrosis (PAH) also have plantar hyperhidrosis (PLH). We compared the long-term results of T3 sympathectomy with those of combined T3+T4 sympathectomy among patients with concurrent PAH and PLH.
We retrospectively analyzed the records of patients with concurrent PAH and PLH who underwent T3 alone or T3+T4 sympathectomy from January 1, 2012, to December 31, 2017. Preoperative and postoperative sweating (hyperhidrosis index) was evaluated through questionnaires, physical examination, and outpatient follow-up. The relief rates and hyperhidrosis index were used as outcome measures to compare the efficacy of the two approaches. Patients’ satisfaction and side effects were also evaluated.
Of the 220 eligible patients, 60 underwent T3 sympathectomy (T3 group), and 160 underwent T3+T4 sympathectomy (T3+T4 group). Compared with the T3 group, the T3+T4 group showed higher symptom relief rates both for PAH (98.75% versus 93.33%, P = 0.048) and PLH (65.63% versus 46.67%, P = 0.01), and a greater postoperative decrease in both hyperhidrosis indices. The rate of severe compensatory hyperhidrosis also increased (10% versus 5%, P = 0.197), although the rates of overall satisfaction were comparable between the groups. The incidence of postoperative pneumothorax requiring chest tube placement and postoperative neuralgia was also similar. There were no cases of perioperative death, secondary operation, wound infection, or Horner syndrome in either group.
Compared with T3 alone, T3+T4 sympathectomy achieved a higher symptom relief rate and a lower hyperhidrosis index. T3+T4 sympathectomy may be a choice for the treatment of concurrent PAH and PLH; however, patients need to be informed that this kind of surgery may increase the risk of compensatory sweating.
T3 versus T4 thoracoscopic sympathicotomy for palmar hyperhidrosis: a meta-analysis and system review
2017, Journal of Surgical Research
Citation Excerpt :
Conventionally, the T2 ganglion was considered the main innervation pathway for the hands, and thus, most TS surgeries were performed at this site.22,23 However, T2 TS was found to be associated with a high incidence of severe CS that adversely affected patients' postoperative quality of life.6-8 The preganglionic fibers to the arm originate from the third to the sixth spinal segments, but mainly from the third and fourth segments.24
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.
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.
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.
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.
Targeting the Sympathetic Chain for Primary Hyperhidrosis: An Evidence-Based Review
2016, Thoracic Surgery Clinics
Citation Excerpt :
At the time of re-ETS, Licht and colleagues70 recommend extending the incision of the parietal pleura a few centimeters laterally to identify and destroy any previously missed accessory NK. In their randomized trial comparing R2 and R3 sympathotomy for palmar hyperhidrosis, Baumgartner and colleagues33 noted early and “dramatic” failure in 3 (5%) of the 60 patients in the R3 group. Two of the 3 patients presented with recurrence of dripping sweat at the palms in the first few weeks after surgery and underwent reoperation at the R2 level, resulting in complete symptomatic relief at 12-month follow-up.
On breast implants, belly button piercings, transumbilical thoracic sympathectomy, and the big picture
2014, Annals of Thoracic Surgery
Endoscopic Thoracic Sympathectomy
2014, Dermatologic Clinics

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Original articleGeneral thoracicThoracoscopic Sympathicotomy for Disabling Palmar Hyperhidrosis: A Prospective Randomized Comparison Between Two Levels

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

Thorac Surg Clin

J Vasc Surg

Ann Thorac Surg

Ann Vasc Surg

Thorac Surg Clin

Thorac Surg Clin

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Vasc Surg

Ann Thorac Surg

Original article
General thoracic
Thoracoscopic Sympathicotomy for Disabling Palmar Hyperhidrosis: A Prospective Randomized Comparison Between Two Levels