Fifteen Years' Experience of Thoracoscopic Sympathetic Chain Interruption for Palmar Hyperhidrosis in Children and Adolescents: Evaluation of Different Techniques.

Background: Thoracoscopic sympathetic chain interruption is a definitive and effective therapy for severe primary palmar hyperhidrosis (PPH). Well-known methods include sympathectomy, sympathotomy, and clipping, but the occurrence of compensatory sweating offsets these methods. This study aims to report our experience with thoracoscopic sympathetic chain interruption in a large group of patients of age <18 years with PPH, focusing on surgical outcomes, complication rates, and patient satisfaction. Patients and Methods: This retrospective study included patients who underwent thoracoscopic sympathectomy, sympathotomy, or clipping for severe PPH between April 2008 and March 2023 at the Pediatric Surgery Department, Al-Azhar University Hospitals. Demographic and clinical data, operative steps, postoperative outcomes, complications, and patient satisfaction were reviewed from the patients' medical records. Results: During the 15-year study period, 420 children with PPH underwent bilateral thoracoscopic sympathetic chain interruption by either sympathectomy, sympathotomy, or clipping, with a sex ratio of 60% being females. The mean ages were 12 ± 3.48, 13 ± 2.45, and 13 ± 2.45 years, respectively. Sympathectomy was performed in 190 patients (45.2%), sympathotomy in 170 patients (40.5%), and clipping in 60 patients (14.3%). All patients had completed follow-up, with mean periods of ∼43 ± 5 months, 45 ± 3 months, and 42 ± 6 months, respectively. Complete palmar dryness was achieved in 405 patients (overall 96.4%) (97.8% after sympathectomy, 97.05% after sympathotomy, and 90% after clipping), whereas 2.1%, 2.9%, and 10% of patients experienced symptom recurrence, respectively, denoting significant statistical differences. Overall, 94 patients (22.4%) experienced compensatory sweating. Eventually, 409 patients (97.4%) were satisfied with the outcome, whereas 11 patients (2.6%) reported dissatisfaction, yet no significant differences found. Conclusion: The presented three modalities of thoracoscopic sympathetic chain interruption for PPH in children and adolescents are safe and effective, with overall very high postoperative satisfaction, despite a relatively high rate of compensatory sweating in sympathectomy group. Other major complications in this age population were scanty.

Robotic sympathetic trunk reconstruction for compensatory sweating after thoracic sympathectomy.

Objectives: Endoscopic thoracic sympathectomy may be complicated by the onset of disabling compensatory sweating (CS). The objective of this case series is to report the 2-year outcomes after robotic sympathetic trunk reconstruction (STR) for the reversal of CS in patients who had undergone endoscopic thoracic sympathectomy. Methods: We prospectively followed-up a total of 23 patients who had undergone robotic STR because of intolerable CS between October 2017 and January 2021. A visual analog scale ranging from 0 to 10 (with 10 indicating the highest degree) was used to assess the severity of CS at different anatomical locations, thermoregulatory alterations, and gustatory hyperhidrosis. Measurements were performed before STR and at 6-month and 2-year follow-up. Results: The mean age of the study participants was 43.3 ± 7.8 years, and 20 (87%) were men. The reversal procedure was performed after a mean of 19.6 ± 7.8 years from endoscopic thoracic sympathectomy. In all patients, nerve defects were successfully bridged using sural nerves (mean length, 9.7 cm on the right and 9.8 cm on the left). No cases of Horner syndrome were noted. At 6 postoperative months, the severity of CS decreased significantly at all body surface areas. The observed improvements were effectively maintained at 24 post-STR months. There was no evidence of either recurrent hyperhidrosis at the primary site or transition of CS to other anatomical locations. Similar improvements were evident for thermoregulatory alterations and gustatory hyperhidrosis. Conclusions: Robotic STR is safe and effective in reversing intolerable CS after endoscopic thoracic sympathectomy.

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 (ß = -0.201 ± 0.078, P = 0.01), gustatory hyperhidrosis (ß = -0.781 ± 0.267, P = 0.003), primary indication other than palmar hyperhidrosis (ß = -1.524 ± 0.292, P < 0.001), and SCS (ß = -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.

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.

Surgical management of compensatory sweating: A systematic review.

Endoscopic thoracic sympathectomy (ETS) surgery is a highly effective treatment of primary hyperhidrosis (PH) for the palms, face, axillae. Compensatory sweating (CS) is the most common and feared side effect of thoracic sympathectomy. CS is a phenomenon characterized by increased sweating in sites distal to the level of sympathectomy. Compensatory sweating is the main problem for which many patients give up surgery, losing the chance to solve their problem and accepting a poor quality of life. There are still no treatments that offer reliable solutions for compensatory sweating. The treatments proposed in the literature are scarce, with low case histories, and with uncertain results. Factors associated with CS are extension of manipulation of the sympathetic chain, level of sympathetic denervation, and body mass index. Therapeutic options include non surgical treatment and surgical treatment. Non surgical treatments include topical agents, botulinum toxin, systemic anticholinergics, iontophoresis. Surgical treatments include clip removal, extended sympathectomy and sympathetic chain reconstruction, although the efficacy is not well-established for all the methods. In this review we provide an overview of the treatments and outcomes described in the literature for the management of compensatory CS, with focus on surgical treatment.

Long-term outcomes of bilateral thoracoscopic T3 sympathectomy for primary focal hyperhidrosis in children.

BACKGROUND: Thoracoscopic bilateral T3 sympathectomy for primary focal palmar hyperhidrosis in children has excellent short-term outcomes. However, data in the literature, on the long-term outcomes of the operation are scarce. METHODS: We conducted a retrospective institutional review of all children and adolescents undergoing T3 bilateral thoracoscopic sympathectomy for primary focal palmar hyperhidrosis between June 2013 and October 2020. We composed a quality of life (QoL) questionnaire evaluating the patient's perception of how much the hyperhidrosis affected their daily life in multiple domains. The questionnaire was completed before the operation and at every postoperative follow-up visit. RESULTS: We operated on 58 patients with a median age of 15 (6-25) years. There were no intraoperative or postoperative complications, and all patients had immediate complete postoperative resolution of their palmar hyperhidrosis. Fifty-three patients (91.4%) had long-term follow-up data available with a median of 2.5 (range 0.1-7.5) years. Two patients (3.4%) experienced recurrence of their palmar hyperhidrosis. Nine patients (15.5%) experienced compensatory hyperhidrosis and required occasional medical management with oral anticholinergics. Two patients reported regretting having undergone the operation. Overall, the mean QoL score improved remarkably, from 42/100 before the operation to 92/100 at 1 month, 89/100 at six months to a year, 97/100 between two and four years, and 80/100 ≥ 5 years after the operation. CONCLUSION: Thoracoscopic bilateral T3 sympathectomy has a high success rate for primary palmar hyperhidrosis in children in the mid- to long-term. Compensatory sweating and recurrence can occur years after the operation, so long-term follow up is mandatory. LEVEL OF EVIDENCE: IV.

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.

Retroperitoneoscopic lumbar sympathectomy for the treatment of primary plantar hyperhidrosis.

BACKGROUND: Primary plantar hyperhidrosis (PPH) is an idiopathic disease, characterized by excessive sweating of the feet. It leads to significant disturbance in private and professional daily lifestyle, due to excessive sweating. The aim of this study is to present the safety, efficacy and procedures of retroperitoneoscopic lumbar sympathectomy (RLS) for treatment of PPH. METHODS: RLS was performed 60 times in 30 patients (18 men, 12 women) with PPH in our institution from May 2019 to October 2020. All procedures were carried out by laparoscopy with retroperitoneal approach. Clinical data including patient demographics and perioperative, postoperative outcomes were evaluated. Recurrence of symptoms, and any adverse effects of surgery were evaluated after 7 to 30 days in outpatient clinic, and thereafter every 6 months. RESULTS: Mean age of patients was 33.6 (± standard deviation 10.8) years. Fourteen and fifteen patients were previously treated with medical therapy or endoscopic thoracic sympathectomy (ETS) respectively. Mean preoperative quality of life (QoL) score of patients was 91.8 (VERY BAD), but postoperative 12 months (QoL) score decreased to 29.1 (MUCH BETTER). There was no serious postoperative complication. During the mean 22 months of follow-up period, no compensatory sweating was observed. CONCLUSIONS: RLS can be a safe and effective surgical treatment for severe PPH, especially for the patients with persistent plantar sweating even after conservative management and ETS. RLS also could be offered to surgeons who are familiar with retroperitoneal space anatomy as feasible surgical treatment for PPH.

Plantar hyperhidrosis associated with primary palmar hyperhidrosis: Outcome following video-assisted thoracoscopic sympathectomy.

INTRODUCTION: Primary palmar hyperhidrosis is an abnormal over-sweating of palms. It is usually associated with plantar hyperhidrosis. Video-assisted thoracoscopic sympathectomy is the treatment of choice for palmar hyperhidrosis; however, it may affect plantar hyperhidrosis. OBJECTIVES: The aim of this study was to evaluate the effect of thoracoscopic sympathectomy on plantar hyperhidrosis. METHODS: This prospective study included patients who presented to the Cardiothoracic Surgery Department with primary palmo-planter hyperhidrosis and received thoracoscopic sympathectomy between January 2014 and December 2018. Preoperatively, patients scored subjectively the degree of palmar and plantar hyperhidrosis on Visual Analogue Scale. Following surgery, scoring was performed at three intervals: 7, 30, and 180 days. Presence of compensatory sweating and its scoring was obtained at the same intervals. Complications and patient satisfaction were recorded. RESULTS: A total of 518 patients were included. Complication rate, excluding compensatory hyperhidrosis, was 2.7%. Preoperative Visual Analogue Scale score for palmar hyperhidrosis was 9.9 ± 3.8 that following thoracoscopic sympathectomy decreased to 0.041 ± 0.2 on the seventh postoperative day. Further decrease to 0.3 ± 0.16 was noted on the 30th day and 180th day postoperatively. Preoperative Visual Analogue Scale score for plantar hyperhidrosis was 9.54 ± 0.66 that following sympathectomy decreased to 2.27 ± 1.67 on the seventh postoperative day. However, slight insignificant increase was noted to become 2.73 ± 1.65 on the 30th day and 6th month postoperatively. Compensatory hyperhidrosis was recorded in 3.9% of patients at 6th month postoperatively. CONCLUSION: Palmar hyperhidrosis is usually associated with plantar hyperhidrosis. Thoracoscopic sympathectomy is an effective and safe treatment for palmar hyperhidrosis. It may completely or partially cure plantar hyperhidrosis.

Over a decade of single-center experience with thoracoscopic sympathicolysis for primary palmar hyperhidrosis: a case series.

BACKGROUND: Primary palmar hyperhidrosis is a severely debilitating condition that can affect patients of any age. We report our experience with thoracoscopic sympathicolysis in a large cohort of children less than 14 years of age. METHODS: All children who underwent thoracoscopic sympathicolysis from April 2005 through January 2017 were evaluated retrospectively. The procedure entailed bilateral bipolar fulguration of the second and third thoracic ganglia with transverse disruption of collateral nerve fibers along the third and fourth rib. Demographic information, as well as postoperative outcome, complications, and satisfaction were analyzed. RESULTS: Over the 12 year study interval, a total of 102 children underwent thoracoscopic sympathicolysis for palmar hyperhidrosis. Complete follow-up was available for 98 patients (median age 12 [range 5-14] years; 38 boys [39%]). Median follow-up was 4 [range 2-12] years. Complete palmar dryness was achieved in 93 (95%) cases. One patient suffered postoperative unilateral ptosis, 6 reported gustatory sweating, and 65 experienced compensatory sweating. Average postoperative rating on a 1 (lowest) to 10 (highest) rating scale was 9, with 97 (99%) patients saying that they would undergo the procedure again. CONCLUSION: Our technique of thoracoscopic sympathicolysis in children was associated with very high postoperative satisfaction, despite a high rate of compensatory sweating and occasional autonomic gustatory sweating. Other more severe complications in this age group were rare.

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.

Microsurgical robotic suturing of sural nerve graft for sympathetic nerve reconstruction: a technical feasibility study.

BACKGROUND: Endoscopic thoracic sympathectomy (ETS) may provide a permanent surgical cure for primary palmar hyperhidrosis. Unfortunately, some patients can experience intensive post-operative compensatory sweating (CS) that ultimately impairs quality of life. Sympathetic nerve reconstruction (SNR) may be used to counteract severe post-operative CS through the restoration of sympathetic pathways. In this case series, we describe the technical feasibility of a robot-assisted micro-peripheral nerve reconstruction method for achieving SNR in patients with post-operative CS. METHODS: Between January 2017 and May 2019, seven cases with severe post-operative CS underwent robot-assisted SNR using a sural nerve graft. We report the pre-operative assessment, the surgical technique, and the clinical outcomes of the study patients. RESULTS: The study sample consisted of five men and two women (median age: 41 years). Primary hyperhidrosis affected the face in one case and the palms in six patients. The median time between ETS and SNR was 20 years. All robotic surgery procedures were successfully accomplished, and neither conversion to open surgery nor the creation of additional ports were required. Sural nerve grafts (median length: 8 cm) were used in all cases, and the median operating time was 10.5 h. There was no operative mortality, with the median length of post-operative hospital stay being 4 days. One patient developed a post-operative pneumothorax-which was treated conservatively. CONCLUSIONS: Our case series demonstrates the safety and clinical feasibility of microsurgical robot-assisted sural nerve grafting for achieving SNR in patients with post-operative CS.

The management of compensatory sweating after thoracic sympathectomy.

OBJECTIVE: The main therapeutic method of treatment for local hyperhidrosis is endoscopic thoracic sympathectomy. Generally, resections of the sympathetic trunk or ganglia are performed between the second rib and sixth rib. However, this procedure can result in compensatory sweating, in which excess sweating occurs on the back, chest, and abdomen. Compensatory sweating has been regarded as a thermoregulatory response and thought to be untreatable. This study suggests that compensatory sweating is not a physiologic reaction and is indeed treatable. METHODS: Eight patients with severe compensatory sweating were treated by observing blood perfusion of the skin with laser speckle flowgraphy, which determines the sympathetic nerves related to the area of skin with compensatory sweating. When intraoperative monitoring with laser speckle flowgraphy indicated the position of compensatory sweating by electrical stimulation of the sympathetic ganglion, ganglionectomy was performed. RESULTS: The skin domain that each sympathetic nerve controls was able to be detected by laser speckle flowgraphy. In all patients, compensatory sweating was resolved after interruption of the ganglia or sympathetic nerves related to compensatory sweating. CONCLUSIONS: Our results demonstrate that compensatory sweating is caused by denatured sympathetic nerves influenced by endoscopic thoracic sympathectomy and is not the result of a physiological response. With laser speckle flowgraphy, the sympathetic nerve related to the sweating of various parts of the body could be identified. The treatment of compensatory sweating on the back, chest, and stomach was previously considered to be difficult; however, compensatory sweating is demonstrated to be treatable with this technique.

The etiology, diagnosis, and management of hyperhidrosis: A comprehensive review: Therapeutic options.

Hyperhidrosis (HH) is a chronic disorder of excess sweat production that may have a significant adverse effect on quality of life. A variety of treatment modalities currently exist to manage HH. Initial treatment includes lifestyle and behavioral recommendations. Antiperspirants are regarded as the first-line therapy for primary focal HH and can provide significant benefit. Iontophoresis is the primary remedy for palmar and plantar HH. Botulinum toxin injections are administered at the dermal-subcutaneous junction and serve as a safe and effective treatment option for focal HH. Oral systemic agents are reserved for treatment-resistant cases or for generalized HH. Energy-delivering devices such as lasers, ultrasound technology, microwave thermolysis, and fractional microneedle radiofrequency may also be utilized to reduce focal sweating. Surgery may be considered when more conservative treatments have failed. Local surgical techniques, particularly for axillary HH, include excision, curettage, liposuction, or a combination of these techniques. Sympathectomy is the treatment of last resort when conservative treatments are unsuccessful or intolerable, and after accepting secondary compensatory HH as a potential complication. A review of treatment modalities for HH and a sequenced approach are presented.

Effectiveness of bilateral clipping of the thoracic sympathetic chain for the treatment of severe palmar and/or axillary hyperhidrosis and facial flushing. / Efectividad de la interrupción de la transmisión nerviosa de la cadena simpática torácica bilateral con clip para el tratamiento de la hiperhidrosis palmar y/o axilar severa y el rubor facial.

INTRODUCTION: Division of the thoracic sympathetic chain is the standard treatment for severe palmar and/or axillary hyperhidrosis and facial flushing. Clipping is an alternative option which allows the block to be reverted in cases of intolerable compensatory sweating. METHODS: This is a prospective study performed to assess: a) results of clipping of the thoracic sympathetic chain in patients with palmar and/or axillary hyperhidrosis and facial flushing; and b) to determine the improvement obtained after removal of the clip in patients with unbearable compensatory sweating. We included 299 patients (598 procedures) diagnosed with palmar hyperhidrosis (n=110), palmar and/or axillary hyperhidrosis (n=78), axillary hyperhidrosis (n=35), and facial flushing (n=76), who underwent videothoracoscopic clipping between 2007 and 2015. RESULTS: 128 men and 171 women were treated, with mean age of 28 years. A total of 290 patients (97.0%) were discharged within 24hours. The procedure was effective in 92.3% (99.1% in palmar hyperhidrosis, 96,1% in palmar and/or axillary hyperhidrosis, 74.3% in axillary hyperhidrosis, and 86.8% in facial flushing). Nine patients (3%) presented minor complications. Compensatory sweating developed in 137 patients (45.8%): moderate in 113 (37.8%), severe in 16 (5.3%) and unbearable in 8 (2.7%). The clip was removed in these 8 patients; symptoms improved in 5 (62.8%), with sustained effect on hyperhidrosis in 4 of them. CONCLUSIONS: Clipping of the thoracic sympathetic chain is an effective and safe procedure. If incapacitating compensatory sweating develops, this technique allows the clips to be removed with reversion of symptoms in a considerable number of patients.

The relation between age and outcomes of thoracic sympathectomy for hyperhidrosis: The older the better.

OBJECTIVE: Several factors may potentially influence the efficacy and patient satisfaction after bilateral thoracic sympathectomy as the treatment for hyperhidrosis, but few studies have specifically analyzed the impact of age on the efficacy of this treatment, the occurrence of compensatory hyperhidrosis (CH), and variations in the quality of life. METHODS: We retrospectively analyzed the effect of age, body mass index, surgical techniques, quality of life before surgery, betterment in the quality of life after surgery, clinical improvement in sweating at the main site, and the occurrence and intensity of CH in patients with hyperhidrosis (n = 1633) who underwent bilateral sympathectomy. RESULTS: Quality of life improved in more than 90% of patients, and severe CH occurred in 5.4%. Age did not affect these outcomes. The older, the greater reduction in sweating, and CH was linked to other variables (body mass index, craniofacial hyperhidrosis, and level of resection). CONCLUSIONS: We observed that patients with old age reported an improvement in sweating in the main site of hyperhidrosis. Sympathectomy outcomes in older patients are similar to those observed in younger patients in terms of quality of life improvement and occurrence of CH.

The relationship between preoperative psychological evaluation and compensatory sweating.

BACKGROUND: This study analyzes the relationship between preoperative psychological states of primary palmar hyperhidrosis patients and postoperative compensatory sweating. METHODS: We evaluated the psychological states of patients with primary palmar hyperhidrosis who received sympathectomy in our hospital from 2016 to 2017. The relationship between preoperative psychological states and postoperative compensatory sweating were assessed using Spearman's rank-order correlation. RESULTS: Fifty-five patients who received R4 + R3 bypass transection accepted the preoperative questionnaire survey; 35 were males and 20 were females. The average age was 24.0 ± 6.3 years (range, 14-44 years). Depression symptoms were present in 21.9% (12/55) of the patients; the incidence of anxiety was almost similar, at 23.7% (13/55). Compensatory sweating occurred in 67.3% (37/55) of the patients; of these, 56.4% (31/55) was mild and 10.9% (6/55) was moderate. None of the patients had severe compensatory sweating. There was no significant relationship between the scores of SDS, SAS, and the incidence of postoperative compensatory sweating (P>0.05). However, the psychoticism scale displayed a strong impact on the degree of compensatory sweating (P<0.05). The higher the degree of psychoticism scale, the more serious the degree of compensatory sweating. CONCLUSIONS: The results of this study showed that patients with primary palmar hyperhidrosis are more likely to have mild or moderate mental disorders, and that postoperative compensatory sweating may impact the satisfaction of surgery. In addition, the personality characteristics of patients are related to compensatory sweating.

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.

Tap water iontophoresis in the treatment of pediatric hyperhidrosis.

AIM OF THE STUDY: The treatment options for localized hyperhidrosis include antiperspirants, anticholinergics, iontophoresis, botulinum toxin and surgery. Tap water iontophoresis (TWI) involves immersing the affected area in tap water and passing a small electrical current through the area. Our aim was to assess the success of this therapy in a pediatric cohort. METHODS: Retrospective case note review of all patients younger than 18years who underwent TWI between 2002 and 2015. Demographic data, number of treatment sessions, side effects and overall success were analyzed. Individuals undergo 7 treatments over 4weeks. A positive outcome was determined as an improvement in symptoms. Pre- and posttreatment hyperhidrosis disease severity scale (HDSS) was measured. Data are presented as mean (range). Statistical analysis was by paired t-test. A P value of <0.05 was regarded as significant. RESULTS: There were 43 patients (30 females) with a mean age of 15 (8-17) years. Palmar and/or plantar hyperhidrosis (PPH) was present in 39/43 (91%) patients. Axillary hyperhidrosis (AH) was present in 19/43 (44%) patients. All patients (with the exception of one) underwent 7 sessions (5-7). Side effects included paresthesia (88%), pruritus (26%), pain (26%), erythema (14%), dryness (12%) as well as vesicle formation and abrasions in one patient (2%). A positive outcome was found in 84% (36/43) of patients. There was a significant reduction in mean HDSS (pre 3.5 vs. post 2; P=0.0001). CONCLUSION: TWI is a safe and effective modality of treatment for both PPH and AH in the pediatric population, with minimal side effects. Pediatric surgeons should offer this treatment option before considering more invasive surgical procedures. LEVEL OF EVIDENCE: IV: Retrospective study.

Thoracoscopic bilateral T3 sympathectomy for primary focal hyperhidrosis in children.

AIM OF THE STUDY: Present our experience in the surgical treatment of primary focal hyperhidrosis of the hands by thoracoscopic bilateral T3 sympathectomy in pediatric patients. METHODS: Retrospective chart review of all patients operated between 2013 and 2015. RESULTS: We operated and included in the study 28 patients, 22 females and 6 males. Mean age was 14 (6-21) years. All patients had previously tried at least one form of medical therapy with no success. All patients were extensively counseled regarding the potential side effects of the sympathectomy. The operations were done in supine position with the arms extended. All patients were intubated with a double-lumen endotracheal tube for sequential lung isolation. We used a 5-mm port for the scope and a 3-mm port for the instruments, both placed in the axilla. The third rib was identified by fluoroscopy. The sympathectomy was done with monopolar cautery. Mean operative time was 43 (25-71) minutes. No chest tubes were used. The incidence of intraoperative or postoperative complications was zero. All patients were discharged within the first 24 postoperative hours. All patients achieved immediate complete postoperative resolution of the palmar hyperhidrosis, sustained in all cases at a median follow-up of 17 (2-34) months. The mean preoperative quality of life score (based on a multifunctional self-assessment questionnaire) was 41/100, whereas after the operation, it was 92/100. Only 1 patient developed temporary compensatory sweating. All patients were satisfied with the result of the operation. CONCLUSION: Thoracoscopic bilateral T3 sympathectomy is a safe and effective treatment for children and adolescents with primary focal hyperhidrosis of the hands who failed medical management and have a very low rate of compensatory sweating. LEVEL OF EVIDENCE: IV.