Produção Nacional
Revisado por pares
The Society of Thoracic Surgeons Expert Consensus for the Surgical Treatment of Hyperhidrosis
2011; Elsevier BV; Volume: 91; Issue: 5 Linguagem: Inglês
10.1016/j.athoracsur.2011.01.105
ISSN1552-6259
AutoresRobert J. Cerfolio, José Ribas Milanez de Campos, Ayesha S. Bryant, Cliff P. Connery, Daniel Miller, Malcolm M. DeCamp, Robert J. McKenna, Mark J. Krasna,
Tópico(s)Thyroid and Parathyroid Surgery
ResumoSignificant controversies surround the optimal treatment of primary hyperhidrosis of the hands, axillae, feet, and face. The world's literature on hyperhidrosis from 1991 to 2009 was obtained through PubMed. There were 1,097 published articles, of which 102 were clinical trials. Twelve were randomized clinical trials and 90 were nonrandomized comparative studies. After review and discussion by task force members of The Society of Thoracic Surgeons' General Thoracic Workforce, expert consensus was reached from which specific treatment strategies are suggested.These studies suggest that primary hyperhidrosis of the extremities, axillae or face is best treated by endoscopic thoracic sympathectomy (ETS). Interruption of the sympathetic chain can be achieved either by electrocautery or clipping. An international nomenclature should be adopted that refers to the rib levels (R) instead of the vertebral level at which the nerve is interrupted, and how the chain is interrupted, along with systematic pre and postoperative assessments of sweating pattern, intensity and quality-of-life.The recent body of literature suggests that the highest success rates occur when interruption is performed at the top of R3 or the top of R4 for palmar-only hyperhidrosis. R4 may offer a lower incidence of compensatory hyperhidrosis but moister hands. For palmar and axillary, palmar, axillary and pedal and for axillary-only hyperhidrosis interruptions at R4 and R5 are recommended. The top of R3 is best for craniofacial hyperhidrosis. Significant controversies surround the optimal treatment of primary hyperhidrosis of the hands, axillae, feet, and face. The world's literature on hyperhidrosis from 1991 to 2009 was obtained through PubMed. There were 1,097 published articles, of which 102 were clinical trials. Twelve were randomized clinical trials and 90 were nonrandomized comparative studies. After review and discussion by task force members of The Society of Thoracic Surgeons' General Thoracic Workforce, expert consensus was reached from which specific treatment strategies are suggested. These studies suggest that primary hyperhidrosis of the extremities, axillae or face is best treated by endoscopic thoracic sympathectomy (ETS). Interruption of the sympathetic chain can be achieved either by electrocautery or clipping. An international nomenclature should be adopted that refers to the rib levels (R) instead of the vertebral level at which the nerve is interrupted, and how the chain is interrupted, along with systematic pre and postoperative assessments of sweating pattern, intensity and quality-of-life. The recent body of literature suggests that the highest success rates occur when interruption is performed at the top of R3 or the top of R4 for palmar-only hyperhidrosis. R4 may offer a lower incidence of compensatory hyperhidrosis but moister hands. For palmar and axillary, palmar, axillary and pedal and for axillary-only hyperhidrosis interruptions at R4 and R5 are recommended. The top of R3 is best for craniofacial hyperhidrosis. Hyperhidrosis is defined as a pathologic condition of excessive sweating in amounts greater than physiologically needed for thermoregulation. It may develop secondary to a variety of medical disorders or it may be primary or cryptogenic, with symptoms such as focal hyperhidrosis usually affecting the palms, axillae, or the feet [1De Campos J.R. Kauffman P. Werebe E.C. et al.Quality of life, before and after thoracic sympathectomy: report on 378 operated patients.Ann Thorac Surg. 2003; 76: 886-891Abstract Full Text Full Text PDF PubMed Scopus (236) Google Scholar]. Additionally, some patients have craniofacial hyperhidrosis, or excessive blushing that is associated with severe emotional, occupational, and social distress. Patients who are overweight (a body mass index of ≥28), have full-body hyperhidrosis, or patients who have secondary causes such as hyperthyroidism, hypertension, diabetes mellitus, infections, brain lesions, and other systemic medical conditions represent some of the conditions that should be diagnosed and treated medically and should not be treated with endoscopic thoracic sympathectomy (ETS). The incidence of hyperhidrosis depends on the culture, on the climate, and on several subjective definitions. It is believed that idiopathic focal hyperhidrosis affects 1% to 3% of the population, with a predominance in countries such as Taiwan that are near the Equator [2Adar R. Kurchin A. Zweig A. Mozes M. Palmar hyperhidrosis and its surgical treatment: a report of 100 cases.Ann Surg. 1977; 186: 34-41Crossref PubMed Scopus (305) Google Scholar, 3Leung A.K. Chan P.Y. Choi M.C. Hyperhidrosis.Int J Dermatol. 1999; 38: 561-567Crossref PubMed Scopus (85) Google Scholar]. Hyperhidrosis affects both sexes equally and affects predominantly adolescents or young adults. Characteristically, the palmar symptoms start in early childhood, axillary symptoms in adolescence, and craniofacial symptoms in adulthood, and often worsen with puberty. There remains significant controversy concerning the optimal surgical therapy for primary hyperhidrosis. That is partially due to the poor definitions of the terms used for both the diagnosis of the problem and for the surgical therapy applied. For instance, video-assisted thoracic surgical sympathicotomy goes by other names, such as sympathotomy or ETS. Some of the terms are not synonymous. Sympathectomy and ganglionectomy refer to total ablation or removal of a segment of the sympathetic chain and ganglia, or both. Sympathicotomy and sympathotomy refer to interruption or simple transection of the sympathetic chain. Sympathetic block refers to a potentially reversible procedure such as clipping of the sympathetic chain or anesthesic injections of the nerve. Selective sympathectomy refers to preservation of the sympathetic chain with ramicotomy (division of the rami communicante). In the following expert consensus document, we provide clinically useful anatomic definitions and standard metrics for symptomatic assessments before and after intervention, from which we generate specific treatment strategies regarding sympathectomy for distinct patterns of hyperhidrosis. Eccrine sweat glands are responsible for hyperhidrosis (although some researchers believe that a mixture of the two [apo/eccrine] glands may play a role in axillary hyperhidrosis) [4Lonsdale-Eccles A. Leonard N. Lawrence C. Axillary hyperhidrosis: eccrine or apocrine?.Clin Exp Dermatol. 2008; 28: 2-7Crossref Scopus (46) Google Scholar]. Eccrine glands are innervated by the sympathetic nervous system but utilize acetylcholine as the primary neurotransmitter. Thermal sweating is controlled by the hypothalamus, whereas emotional sweating is regulated by the cerebral cortex. A sympathetic signal is carried to sweat glands by cholinergic autonomic neurons. In patients with idiopathic (focal) hyperhidrosis, the sweat glands are usually histologically and functionally normal. Although the pathophysiology remains unknown, the cause of hyperhidrosis appears to be an abnormal central response to emotional stress, but it can also occur spontaneously and intermittently. Additionally, there is evidence for a genetic component to hyperhidrosis, and it can be seen in family members [5Kao M.C. Lee W.Y. Yip K.M. Hsiao Y.Y. Lee Y.S. Tsai J.C. Palmar hyperhidrosis in children: treatment with video endoscopy laser sympathectomy.J Ped Surg. 1994; 29: 387-391Abstract Full Text PDF PubMed Scopus (50) Google Scholar, 6Ro K.M. Cantor R.M. Lange K.L. Ahn S.S. Palmar hyperhidrosis: evidence of genetic transmission.J Vasc Surg. 2002; 35: 382-386Abstract Full Text Full Text PDF PubMed Scopus (147) Google Scholar]. A genetic analysis suggests that an allele for hyperhidrosis may be present in 5% of the population, and that 25% of people with one or two copies of the allele will have hyperhidrosis, whereas fewer than 1% of people with two normal alleles will have it. Patients with focal or primary hyperhidrosis have sweating involving the face, palms, soles, or axillae. Generalized sweating suggests a secondary etiology. The most common causes of generalized sweating are excessive heat and obesity. Other causes include systemic diseases such as infections, endocrine disorders, neuroendocrine tumors, malignancy, neurologic disorders, toxins, and previous spinal cord injuries. These sweating episodes can be due to an autonomic dysreflexia, orthostatic hypotension, or posttraumatic syringomyelia. Hyperhidrosis can be attributed to autonomic dysreflexia, which is often triggered by an exaggerated autonomic response to normal stimuli such as bowel and bladder distention or skin irritation. Pathologic gustatory sweating may be caused by sympathetic nerve damage, either due to invasion (Pancoast tumor), diabetic neuropathy, herpes zoster of the preauricular region, or misdirection of autonomic nerve fibers after parotid surgery (Frey's syndrome). Unlike primary hyperhidrosis, patients with generalized, secondary hyperhidrosis usually present as adults and have excessive sweating that occurs both while awake and asleep. Prescription strength antiperspirants, which are thought to work by mechanically obstructing the eccrine sweat gland ducts or by causing atrophy of the secretory cells [7Holzle E. Braun-Falco O. Structural changes in axillary eccrine glands following long-term treatment with aluminium chloride hexahydrate solution.Br J Dermatol. 1984; 110: 399-403Crossref PubMed Scopus (94) Google Scholar, 8Stolman L.P. Treatment of hyperhidrosis.Dermatol Clin. 1998; 16: 863-869Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar] can be tried for patients who do not respond to over-the-counter antiperspirants. These include antiperspirants with 20% aluminum chloride in ethanol (Drysol) or 6.25% aluminum tetrachloride (Xerac). Systemic medical regimens may also be employed in the treatment of hyperhidrosis: anticholinergic agents (glycopyrrolate, propantheline, oxybutinin) are sometimes used; however, the dosage required to reduce sweating also causes development of side effects such as dry mouth, blurred vision, or urinary retention [9Mack G.W. Shannon L.M. Nadel E.R. Influence of beta-adrenergic blockade on the control of sweating in humans.Appl Physiol. 1986; 61: 1701-1705PubMed Google Scholar]. In patients with hyperhidrosis triggered by specific emotional events, beta-blockers or benzodiazepines may be useful for reducing the emotional stimulus that leads to the excessive sweating [10Quraishy M.S. Giddings A.E. Treating hyperhidrosis.BMJ. 1993; 306: 1221Crossref PubMed Scopus (25) Google Scholar]. Drawbacks to using these agents include dispigmentation of the skin, a high rate of contact dermatitis, and necessity of continuous use. Iontophoresis is the introduction of ionized substances through intact skin by the application of direct current. Iontophoresis is most often used for palmar or plantar hyperhidrosis, but a special axillary electrode can be used to treat axillary hyperhidrosis as well. Although there are only limited data from randomized trials, iontophoresis appears to alleviate symptoms in approximately 85% of patients with palmar or plantar hyperhidrosis and is safe and simple to perform [11Dahl J.C. Glent-Madsen L. Treatment of hyperhidrosis manuum by tap water iontophoresis.Acta Derm Venereol. 1989; 69: 346-348PubMed Google Scholar, 12Stolman L.P. Treatment of excess sweating of the palms by iontophoresis.Arch Dermatol. 1987; 123: 893-896Crossref PubMed Scopus (92) Google Scholar]. The drawback is that it is often irritating to the skin, leaves a “pins and needles” feeling, and may cause scaling and fissuring [13Holzle B. Alberti N. Long-term efficacy and side effects of tap water iontophoresis of palmoplanter hyperhidrosis.J Am Acad Dermatol. 1987; 16: 828-832Abstract Full Text PDF PubMed Scopus (53) Google Scholar], and it is very labor intensive. Botulinum toxin type A (Botox) and type B (Myobloc) have been shown to be effective for axillary and palmar hyperhidrosis [14Heckmann M. Ceballos-Baumann A.O. Plewig G. Botulinum toxin A for axillary hyperhidrosis (excessive sweating).N Engl J Med. 2001; 344: 488-493Crossref PubMed Scopus (337) Google Scholar, 15Naumann M. Lowe N.J. Botulinum toxin type A in treatment of bilateral primary axillary hyperhidrosis: randomised, parallel group, double blind, placebo controlled trial.BMJ. 2001; 323: 596-599Crossref PubMed Google Scholar]. Botox blocks the release of neuronal acetylcholine from the presynaptic junction of both neuromuscular and cholinergic autonomic neurons and temporarily can reduce sweat production. Usually it lasts for 3 to 4 months; however, it can last as long as 7 months, until the sudomotor nerve fibers have regenerated [16Glogau R.G. Botulinum A neurotoxin for axillary hyperhidrosis No sweat Botox.Dermatol Surg. 1998; 24: 817-819PubMed Google Scholar, 17Hsu C. Shia S.E. Hsia J.Y. Chuang C.Y. Chen C.Y. Experiences in thoracoscopic sympathectomy for axillary hyperhidrosis and osmidrosis.Arch Surg. 2001; 136: 1115-1117Crossref PubMed Scopus (63) Google Scholar]. Drawbacks include local pain (20 to 40 injections are needed), a temporary effect or abbreviated response, transient weakness of the small hand muscles, and repeated, costly procedures. Over the past year, both the International Society on Sympathetic Surgery (ISSS) and The Society of Thoracic Surgeons (STS) General Thoracic Task Force on Hyperhidrosis decided that an internationally agreed upon nomenclature was needed. It has often been unclear exactly where and how a surgeon interrupted the chain, which has made it almost impossible to compare techniques and results. The nomenclature needs to include the location where the sympathetic chain was interrupted and the method of how it was interrupted. Various anatomic landmarks exist to guide the surgeon in determining the exact level where to divide or clip the chain or ganglia for a sympathectomy. The ISSS and STS committees' consensus was to use a rib- oriented nomenclature. This decision was based on too many patients having mediastinal fat that can obscure clear identification of the specific ganglia and because there are many anatomical variations in the ganglion anatomy. The surgeon may add the ganglia that are interrupted to the operative note as well. In addition, the committees agreed that a description of the type of interruption is required denoting whether the chain was clipped, cut, or cauterized, or a segment removed. An operation can, therefore, be abbreviated as an R2 or an R3 (R referring to rib, and the number referring to which rib). If the chain is clipped on top of the fifth rib, the abbreviation for the operative note would be “clipped R5, top.” If the chain is cauterized on the top and bottom of the fourth rib, the operative note would be “cauterized, top R4, bottom R4.” Using this standardized nomenclature allows surgeons from all over the world to better communicate with one another. In this manuscript, all interruptions that are referred to or recommended are meant to occur on the top of the rib. The literature on sympathectomy for hyperhidrosis must be interpreted cautiously as the definitions are not the same in most papers. Some studies use objective data such as hand temperature postoperatively to determine success, whereas others simply rely on subjective reporting by the patient. Not all studies assess compensatory hyperhidrosis (CH) similarly, or at the same point postoperatively, or quantify the degree of compensatory hyperhidrosis. Standardized preoperative and postoperative questionnaires are needed to objectify the improvement of these patients. An example of the data collection sheets used by de Campos and associates [1De Campos J.R. Kauffman P. Werebe E.C. et al.Quality of life, before and after thoracic sympathectomy: report on 378 operated patients.Ann Thorac Surg. 2003; 76: 886-891Abstract Full Text Full Text PDF PubMed Scopus (236) Google Scholar] in an effort to standardize results can be found at http://www.sts.org/sites/default/files/documents/pdf/expertconsensus/Hyperhidrosis_Suggested_Forms_for_Data_Collection.pdf. The committee recommends that all sites that plan to perform research in this area implement similar data collection, making all subsequent studies more easily interpreted. In addition, because follow-up is a critical part of any research in this field, it is recommended that patients have follow-up appointments or surveys at 1 month, 6 months, 1 year, and yearly thereafter for at least 5 years if possible. For this review, the PubMed database was searched for the terms hyperhidrosis/surgery/VATS sympathectomy and/or endoscopic thoracic sympathicotomy/sympathotomy. The time frame was restricted to articles published between 1990 and June 2009. Endoscopic thoracic sympathectomy for any disorder other than hyperhidrosis was omitted. The databases returned 1,097 references, of which 629 were case reports or series, 102 were clinical trials or comparative studies, 120 were review articles, and 12 were randomized clinical trials pertaining to surgical technique. All of the non–case report articles were reviewed. Selected randomized studies [18Munia M.A.S. Wolosker N. Kaufmann P. de Campos J.R.M. Puech-Leão P. Sustained benefit lasting one year from T4 Instead of T3-T4 sympathectomy for isolated axillary hyperhidrosis.Clinics. 2008; 63: 771-774Crossref PubMed Scopus (42) Google Scholar, 19Liu Y. Yang J. Liu J. et al.Surgical treatment of primary palmar hyperhidrosis: a prospective randomized study comparing T3 and T4 sympathicotomy.Eur J Cardiothorac Surg. 2009; 35: 398-402Crossref PubMed Scopus (70) Google Scholar, 20Yang J. Tan J.J. Ye G.L. Gu W.Q. Wang J. Liu Y.G. T3/T4 thoracic sympathicotomy and compensatory sweating in treatment of palmar hyperhidrosis.Chin Med J. 2007; 120: 1574-1577PubMed Google Scholar, 21Munia M.A. Wolosker N. Kauffman P. de Campos J.R. Puech-Leao P. A randomized trial of T3-T4 versus T4 sympathectomy for isolated axillary hyperhidrosis.J Vasc Surg. 2007; 45: 130-133Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar, 22Li X. Tu Y. Lin M. Fan-Cai L. Chen J. Dai Z. Endoscopic thoracic sympathectomy for palmar hyperhidrosis: a randomized control trial comparing T3 and T2-4 ablation.Ann Thorac Surg. 2008; 85: 1747-1751Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar, 23Katara A.N. Domino J.P. Cheah W.K. So J.B. Ning C. Lomanto D. Comparing T2 and T2-T3 ablation in thoracoscopic sympathectomy for palmar hyperhidrosis: a randomized control trial.Surg Endosc. 2007; : 1767-1771Google Scholar, 24Chang Y.T. Li H.P. Lee J.Y. et al.Treatment of palmar hyperhidrosis: T4 level compared with T3 and T2.Ann Surg. 2007; 246: 330-336Crossref PubMed Scopus (54) Google Scholar, 25Lin T.S. Kuo S.J. Chou M.C. Uniportal endoscopic thoracic sympathectomy for treatment of palmar and axillary hyperhidrosis: analysis of 2000 cases.Neurosurgery. 2002; 51: 84-87Google Scholar] and comparative studies [26Chou S.H. Kao E.L. Lin C.C. Chang Y.T. Huang M.F. The importance of classification in sympathetic surgery and a proposed mechanism for compensatory hyperhidrosis: experience with 464 cases.Surg Endosc. 2006; 20: 1749-1753Crossref PubMed Scopus (101) Google Scholar, 27Gossot D. Galetta D. Pascal A. et al.Long-term results of endoscopic thoracic sympathectomy for upper limb hyperhidrosis.Ann Thorac Surg. 2003; 75: 1075-1079Abstract Full Text Full Text PDF PubMed Scopus (169) Google Scholar, 28Yazbek G. Wolosker N. Kauffman P. Milanez de Campos J. Puech-Leao P. Jatene F.B. Twenty months of evolution following sympathectomy on patients with palmar hyperhidrosis: sympathectomy at the T3 level is better than at the T2 level.Clinics. 2009; 64: 743-749Crossref PubMed Scopus (61) Google Scholar, 29Yazbek G. Wolosker N. de Campos J.R. Kauffman P. Ishy A. Puech-Leão P. Palmar hyperhidrosis—which is the best level of denervation using video-assisted thoracoscopic sympathectomy? T2 or T3 ganglion?.J Vasc Surg. 2005; 42: 281-285Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar] are presented in Table 1. More than half of these reports were eliminated because of the lack of specific details of the operation or of clear-cut definitions regarding the degree of hyperhidrosis preoperatively or postoperatively.Table 1Review of Selected StudiesAuthor, Year [Ref], Journal (No. of Patients)Study Type (Levels Cut)PalmarAxillaFacialImmediate Success RateRate of Compensatory HyperhidrosisaMost series report moderate to severe compensatory hyperhidrosis (CH).Mean Follow-UpbNot provided in all studies. (Months)Yazbek, 2009 [28Yazbek G. Wolosker N. Kauffman P. Milanez de Campos J. Puech-Leao P. Jatene F.B. Twenty months of evolution following sympathectomy on patients with palmar hyperhidrosis: sympathectomy at the T3 level is better than at the T2 level.Clinics. 2009; 64: 743-749Crossref PubMed Scopus (61) Google Scholar], Clinics (59)Randomized clinical trial (R2 vs R3)X100% R2, 97% R36 months postoperative, 67% R2, 90% R3 (but significantly less severe CH)20Liu, 2009 [19Liu Y. Yang J. Liu J. et al.Surgical treatment of primary palmar hyperhidrosis: a prospective randomized study comparing T3 and T4 sympathicotomy.Eur J Cardiothorac Surg. 2009; 35: 398-402Crossref PubMed Scopus (70) Google Scholar], Eur JCTS (141)Randomized clinical trial (R3 vs R4)X100% R3, 94% R477% R3, 56% R418Li, 2008 [22Li X. Tu Y. Lin M. Fan-Cai L. Chen J. Dai Z. Endoscopic thoracic sympathectomy for palmar hyperhidrosis: a randomized control trial comparing T3 and T2-4 ablation.Ann Thorac Surg. 2008; 85: 1747-1751Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar], Ann Thorac Surg (232)Randomized clinical trial (R3 vs R2-R4)X100%10% R2-R4, 3% R3Katara, 2007 [23Katara A.N. Domino J.P. Cheah W.K. So J.B. Ning C. Lomanto D. Comparing T2 and T2-T3 ablation in thoracoscopic sympathectomy for palmar hyperhidrosis: a randomized control trial.Surg Endosc. 2007; : 1767-1771Google Scholar], Surg Endosc (25)Randomized clinical trial (cross-over, same patients received R2-R3 ablation unilaterally, then R2 ablation on other side)X100%80% in both groups; no difference in CHChang, 2007 [24Chang Y.T. Li H.P. Lee J.Y. et al.Treatment of palmar hyperhidrosis: T4 level compared with T3 and T2.Ann Surg. 2007; 246: 330-336Crossref PubMed Scopus (54) Google Scholar], Ann Surg (234)Retrospective (R2, R3, and R4 compared)XNot reported92% R3, 92% R3, 80% R447Yang, 2007 [20Yang J. Tan J.J. Ye G.L. Gu W.Q. Wang J. Liu Y.G. T3/T4 thoracic sympathicotomy and compensatory sweating in treatment of palmar hyperhidrosis.Chin Med J. 2007; 120: 1574-1577PubMed Google Scholar], Chin Med J (163)Randomized clinical trial (R3 v. R4)X100%23.1% R3, 7.1% R413.8Yazbek, 2005 [29Yazbek G. Wolosker N. de Campos J.R. Kauffman P. Ishy A. Puech-Leão P. Palmar hyperhidrosis—which is the best level of denervation using video-assisted thoracoscopic sympathectomy? T2 or T3 ganglion?.J Vasc Surg. 2005; 42: 281-285Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar], J Vasc Surg (60)Randomized clinical trial (R2 vs R3)X100% R3, 97% R286% R2, 90% R3 (but significantly less severe)6Munia, 2008 [18Munia M.A.S. Wolosker N. Kaufmann P. de Campos J.R.M. Puech-Leão P. Sustained benefit lasting one year from T4 Instead of T3-T4 sympathectomy for isolated axillary hyperhidrosis.Clinics. 2008; 63: 771-774Crossref PubMed Scopus (42) Google Scholar], Clinics (64)Randomized clinical trial (R3-4 vs R4)X100%100% R3-R4, 42% R412Munia, 2007 [21Munia M.A. Wolosker N. Kauffman P. de Campos J.R. Puech-Leao P. A randomized trial of T3-T4 versus T4 sympathectomy for isolated axillary hyperhidrosis.J Vasc Surg. 2007; 45: 130-133Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar], J Vasc Surg (62)Randomized clinical trial (R3-R4 vs R4)X100%90% R3-R4, 56% R4Gossot, 2003 [27Gossot D. Galetta D. Pascal A. et al.Long-term results of endoscopic thoracic sympathectomy for upper limb hyperhidrosis.Ann Thorac Surg. 2003; 75: 1075-1079Abstract Full Text Full Text PDF PubMed Scopus (169) Google Scholar], Ann Thorac Surg (382)Prospective (various levels cut)XX100%86.4%45.6Lin, 2002 [25Lin T.S. Kuo S.J. Chou M.C. Uniportal endoscopic thoracic sympathectomy for treatment of palmar and axillary hyperhidrosis: analysis of 2000 cases.Neurosurgery. 2002; 51: 84-87Google Scholar], Neurosurgery (2000)Retrospective (R2 palmar, R3-R4 axillary)XX99%1,720 (86%)51.7Chou 2006 [26Chou S.H. Kao E.L. Lin C.C. Chang Y.T. Huang M.F. The importance of classification in sympathetic surgery and a proposed mechanism for compensatory hyperhidrosis: experience with 464 cases.Surg Endosc. 2006; 20: 1749-1753Crossref PubMed Scopus (101) Google Scholar], Surg Endosc (464)Prospective (facial R2 vs R3; palmar R4; axillary R5)XXX100%Facial 43% R2, 27% R3; axillary 0%17a Most series report moderate to severe compensatory hyperhidrosis (CH).b Not provided in all studies. Open table in a new tab The bulk of the randomized trials and nonrandomized comparisons identified the “ideal candidates” for ETS as those who have onset of hyperhidrosis at an early age (usually before 16 years of age), are young at the time of surgery (usually less than 25 years old), have an appropriate body mass index (<28), report no sweating during sleep, are relatively healthy (no other significant comorbidities), and do not have bradycardia (resting heart rate <55 beats per minute). Only a small percentage of patients should be considered for surgical treatment. Surgical consultation should include the secure diagnosis of primary focal hyperhidrosis, the anatomic locations involved and the amount of hyperhidrosis, and full discussion of the options to surgery and potential complications. The patients should be made aware that the most satisfied patients are those with palmar or palmar-axillary hyperhidrosis, or both. Finally, patients should also be told of the success and failure rates, and long-term results [30Lai C.L. Chen W.J. Liu Y.B. Lee Y.T. Bradycardia and permanent pacing after bilateral thoracoscopic T2-sympathectomy for primary hyperhidrosis.Pacing Clin Electrophysiol. 2001; 24: 524-525Crossref PubMed Scopus (28) Google Scholar]. Often, we offer the patient the option to discuss the procedure and its side effects with another patient who has already undergone the surgery. This is done by a conference call under the Health Insurance Portability and Accountability Act (HIPPA) guidelines, or face to face at the patient's request. Even among patients with palmar hyperhidrosis alone, there remains some controversy. For those who are willing to accept a higher risk of CH because they want their hands to be completely dry, it is suggested that two interruptions in the sympathetic chain are made, at R3 and R4. However, based on the prospective randomized study in 2009 by Liu and associates [19Liu Y. Yang J. Liu J. et al.Surgical treatment of primary palmar hyperhidrosis: a prospective randomized study comparing T3 and T4 sympathicotomy.Eur J Cardiothorac Surg. 2009; 35: 398-402Crossref PubMed Scopus (70) Google Scholar] and the study in 2007 by Yang and colleagues [20Yang J. Tan J.J. Ye G.L. Gu W.Q. Wang J. Liu Y.G. T3/T4 thoracic sympathicotomy and compensatory sweating in treatment of palmar hyperhidrosis.Chin Med J. 2007; 120: 1574-1577PubMed Google Scholar], an R-4 alone interruption may be acceptable for these patients because it limits the degree of CH (although it may lead to moister hands). The patients should be counseled about these differences and participate in the decision-making process. For these reasons, we also recommend the top of R3 sympathectomy alone for patients with isolated palmar hyperhidrosis. Patients with palmar and plantar hyperhidrosis represent a different challenge. Again, two operations can be performed. An R4 interruption alone may reduce the incidence of CH; alternatively, an R4 and R5 intervention is a reasonable option, but leads to drier feet, and hence, is our consensus treatment of choice. Endoscopic thoracic sympathectomy for axillary hyperhidrosis is often less successful and has higher “regret rates” than ETS for palmar hyperhidrosis. A qualitative review shows a trend of lower incidence of CH with fewer interruptions, even when the interruptions are fairly low on the chain [31Herbst F. Plas E.G. Fugger R. Fritsch A. Endoscopic thoracic sympathectomy for primary hyperhidrosis of the upper limbs: a critical analysis and long term results of 480 operations.Ann Surg. 1994; 1: 86-90Crossref Scopus (206) Google Scholar, 32Panhofer P. Zachrel J. Jakesz R. Bischof G. Neumayer C. Improved quality of life after sympathetic block for upper limb hyperhidrosis.Br J Surg. 2006; 93: 582-586Crossref PubMed Scopus (46) Google Scholar, 33Shachor D. Jedeikin R. Olsfanger D. Bendahan J. Sivak G. Freund U. Endoscopic transthoracic sympathectomy in the treatment of primary hyperhidrosis A review of 290 sympathectomies.Arch Surg. 1994; 129: 241-244Crossref PubMed Scopus (100) Google Scholar, 34Chiou T.S. Chen S.C. Intermediate-term results of endoscopic transaxillary T2 sympathectomy for primary palmar hyperhidrosis.Br J Surg. 1999; 86: 45-47Crossref PubMed Scopus (50) Google Scholar]. In a randomized, prospective study of patients with axillary hyperhidrosis, Munia and colleagues [18Munia M.A.S. Wolosker N. Kaufmann P. de Campos J.R.M. Puech-Leão P. Sustained benefit lasting one year from T4 Instead of T3-T4 sympathectomy for isolated axillary hyperhidrosis.Clinics. 2008; 63: 771-774Crossref PubMed Scopus (42) Google Scholar] in 2008 showed that all (100%) patients who underwent R3/R4 ETS experienced greater incidence and severity of CH compared with patients who underwent R4 ETS alone (42%) 1 year after surgery. A study by Chou and as
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