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Background:  The present study aimed to evaluate and compare the efficacy of botulinum toxin type A (BTX-A) injection versus thoracic sympathectomy for idiopathic palmar hyperhidrosis., Methods:  Fifty-one patients with idiopathic palmar hyperhidrosis were treated with either BTX-A injection or thoracic sympathectomy between March 2013 and April 2016. The severity of palmar hyperhidrosis was qualitatively measured via the Hyperhidrosis Disease Severity Scale (HDSS). All patients completed a questionnaire that detailed the time taken for the treatment to work, local or systemic adverse effects, and pre- and post-treatment severity of hyperhidrosis. The efficacy and adverse effects of the two treatments were compared and analyzed., Results:  Hyperhidrosis-related quality of life improved quickly and significantly in the BTX-A group (26 patients) and the sympathectomy group (25 patients). Compared with pre-treatment, the HDSS score significantly reduced after treatment in both groups ( p  < 0.05). All patients in the sympathectomy group had cessation of sweating of the hands after treatment, and this curative effect lasted for 12 months. In contrast, the treatment took more time to work in the BTX-A group, and the curative effect lasted for a much shorter period (3 months). The sympathectomy group had a significantly lesser mean HDSS score than the BTX-A group at 1 week, 3 months, 6 months, 9 months, and 12 months after treatment ( p  < 0.05). The sympathectomy group experienced more complications than the BTX-A group., Conclusion:  For palmar hyperhidrosis, thoracic sympathectomy is more effective and has a longer lasting curative effect than BTX-A injection, but thoracic sympathectomy has more complications., Competing Interests: None., (Georg Thieme Verlag KG Stuttgart · New York.)

Background:  Patients with primary hyperhidrosis present with sweating in two or more sites in nearly 85% of cases. In this study, we examined whether the number of hyperhidrosis sites is related to the surgery outcomes., Methods:  One hundred ninety-three hyperhidrosis patients who underwent bilateral videothoracoscopic sympathectomy after failure or dissatisfaction with clinical treatment were distributed into three groups based on the number of hyperhidrosis sites (one site, two sites, and three or more sites of hyperhidrosis). The primary endpoints in the study were as follows: quality of life prior to surgery, improvement of quality of life after surgery, clinical improvement of sweating, presence or absence of compensatory hyperhidrosis, and general satisfaction after 1 month of surgery., Results:  Patients with two or more hyperhidrosis sites had worse quality of life before surgery than patients with a single hyperhidrosis site. There was an improvement in the quality of life in more than 95% of the patients, clinical improvement in more than 95% of patients, severe compensatory hyperhidrosis in less than 10%, and low general satisfaction after 1 month of surgery in only 2.60% of the patients, with no differences among the three groups., Conclusions:  Patients with more than one preoperative hyperhidrosis site present worse quality of life prior to surgery than those with a single hyperhidrosis site, but the number of hyperhidrosis sites before surgery does not affect surgery outcomes., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background:  Primary hyperhidrosis is a condition that significantly decreases the quality of life (QOL). Thoracic sympathectomy is safe and efficient method of treatment in palmar hyperhidrosis., Objective:  The aim of the study was to evaluate the change in QOL in patients with palmar hyperhidrosis who underwent thoracic sympathectomy., Methods:  The study includes 149 patients (37 men and 112 women) who were treated with bilateral thoracoscopic sympathectomy for primary palmar hyperhidrosis. Subjective and objective evaluation of hyperhidrosis were performed prior to the surgery, 3 and 12 months after the treatment. Control group consists of 305 healthy volunteers (118 men and 187 women). The QOL was measured using Functional Assessment of Chronic Illness Therapy (FACIT) scale., Results:  The average level of palmar hyperhidrosis in the study group prior to surgery was 224.69 ± 179.20 mg/min/m 2 . General QOL (FACIT total) before the surgery was significantly lower in the study group when compared with the control group (66.57 ± 16.33 vs. 91.29 ± 11.13; p  < 0.05). Three months after surgery level of hyperhidrosis decreased significantly and remained at similar level 12 months after the procedure (13.55 ± 15.41 mg/min/m 2 p  < 0.05 and 14.41 ± 18.19 mg/min/m 2 p  < 0.05, respectively). After thoracoscopic sympathectomy, the QOL increased and did not differ when compared with the control group 3 and 12 months after the surgery (90.28 ± 11.13 vs. 91.29 ± 11.13; p  = 0.55 and 89.59 ± 11.34 vs. 91.29 ± 11.13; p  = 0.84, respectively). The highest increase was observed in functional well-being domain (32.25%); however, it was also noticeable in other domains., Conclusion:  Thoracic sympathectomy is an efficient method of treatment in palmar hyperhidrosis which significantly increases patients' QOL especially in a functional domain., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background:  Video-assisted thoracoscopic surgery (VATS) clipping of the sympathetic branch has become the standard approach for the treatment of essential hyperhidrosis when conservative treatment failed. However, this is associated with relevant potential complications such as postoperative compensatory sweating and recurrent sweating. We report the outcome after selective sympathectomy (ramicotomy) through a miniuniportal VATS approach in patients with therapy-refractory palmar and/or axillary hyperhidrosis., Methods:  A total of 51 consecutive patients (37 females, mean age: 30 years, range: 12-64 years) who suffered from therapy-refractory palmar and/or axillary severe hyperhidrosis were included. Data were prospectively collected and retrospectively analyzed. All patients underwent bilateral miniuniportal VATS ramicotomy. Duration of surgery, hospital stay, recurrent, and compensatory sweating were documented., Results:  All patients had palmar sweating, where 51% had additional axillary sweating and 57% had additional plantar sweating. In all patients, selective division of the rami communicantes of the thoracic sympathetic ganglions Th2 to Th5 was performed. The mean duration of bilateral surgery for both sides was 67 ± 2.5 minutes. The mean postoperative hospital stay was 2 ± 1 days. After surgery and at further follow-up (mean: 12 ± 2.5 months), all patients presented dry and warm hands and axillae, without any evidence of compensatory or recurrent sweating. All patients described a remarkable increase in quality of life., Conclusion:  Miniuniportal VATS ramicotomy represents a feasible surgical technique with a very high success and satisfaction rate. Therefore, this approach should be considered as the method of choice for the treatment of patients with severe therapy-refractory palmar and axillary hyperhidrosis., Competing Interests: None to be declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Background:  Primary palmar hyperhidrosis (PPH) is featured by aberrantly perspiration of the hands, which may bring a lot of inconvenience to patient's daily life and work. The purpose of this study is to summarize the clinical effect of needlescopic video-assisted thoracic bilateral T4 sympathicotomy for the treatment of PPH., Patients and Methods:  Between January 2009 and March 2014, 200 patients received needlescopic video-assisted thoracic bilateral T4 sympathicotomy. We, respectively, took two 5-mm incisions in the third intercostal space on the anterior axillary line and in the fifth intercostal space on the middle axillary line. After collapsing left lung, needlescopic exploration was the first step to determine the targeted sympathetic chain through the third intercostal space. Electric coagulation hook was inserted from another port to cut T4 sympathetic chain and the bypassing nerve fibers for 2 to 3 cm along the surface of the fourth rib. Right thoracic cavity was also administered the same procedure. The palmar temperature was recorded before and after sympathicotomy. The symptom improvement, operative complications, patients' recovery, and satisfaction were evaluated., Finding:  One hundred and ninety-seven patients uneventfully received two 5-mm port bilateral sympathicotomy, and another 3 patients with extensive pleural adhesions completed the surgery through enlarging the third intercostal incision to 2 cm without conversion to open surgery. All operative procedures were completed in 15 to 35 minutes. The hospital stay was 2 to 4 days. The palmar temperature increased by 2.0 ± 0.5°C, and hyperhidrosis immediately disappeared in both hands after surgery. The efficacy rate was 100%. The postoperative complications such as hemorrhage, hemopneumothorax, bradycardia, or Horner's syndrome had no occurrence. During 6 to 60 months follow-up, mild compensatory sweating of buttock, back, and thigh occurred in 30 patients (15%) at 2 to 5 days after surgery and gradually disappeared at postoperative 15 to 30 days or longer time. All patients were greatly satisfied with the effect with better confidence and quality of life. Until now, no recurrent palmar hyperhidrosis happened., Conclusion:  Needlescopic video-assisted thoracic bilateral T4 sympathicotomy could reach an excellent and immediate result of treating PPH. It is a safe, convenient, and minimally invasive method appropriate for wide clinical use., Competing Interests: The authors report no conflict of interest., (Georg Thieme Verlag KG Stuttgart · New York.)

Background  Thoracic sympathectomy (TS) is one of the most effective methods of treatment of primary hyperhidrosis. One of the side effects of this procedure is compensatory sweating (CS). Objective  The aim of our study was to evaluate the influence of body mass index (BMI) on CS in patients after TS due to palmar hyperhidrosis. Methods  Data from 157 patients with palmar hyperhidrosis who underwent TS were collected. The patients were subsequently divided in two groups according to their initial BMI: group A, BMI < 25 kg/m 2 , and group B, BMI ≥ 25 kg/m 2 . Objective (gravimetry) and subjective (VAS) measurements of the intensity of hyperhidrosis were taken from the patients' bodies prior to surgery, as well as 3 and 12 months after TS. Results  Average palmar hyperhidrosis levels before the surgery did not differ significantly between the two groups (238.65 vs. 190.15; p  = 0.053). A statistically significant decrease in palmar hyperhidrosis was noted in both groups, both 3 and 12 months after surgery (238.65 vs. 11.86 vs. 13.5; p  < 0.05, and 190.15 vs. 16.67 vs. 11.81; p  < 0.05, respectively). The intensity of sweating over the abdomino-lumbar area differed significantly between the groups before the surgery, both in subjective (1.71 vs. 3.61; p  < 0.05) and objective (13.57 vs. 35.95; p  < 0.05) evaluations. Three months after surgical intervention, an intensification of CS was observed in both the groups; however, no statistically significant differences were observed between the two sets of patients (VAS: 4.58 vs. 5.16; p  = 0.38; gravimetry: 33.87 vs. 53.89; p  = 0.12). Twelve months after TS, CS was higher in the group with an initial BMI ≥ 25 kg/m 2 , both in subjective and objective evaluations (3.23 vs. 4.94; p  = 0.03 and 18.08 vs. 80.21; p  = 0.026, respectively). Conclusion  Patients with a BMI ≥ 25 kg/m 2 experience more severe CS after TS, both in subjective and objective evaluations., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background  Hyperhidrosis is a dysfunction of the autonomic nervous system that results in regional excessive sweating, mostly in the hands, armpits, and feet. A permanent and effective treatment of hyperhidrosis can be achieved by interruption of the thoracic sympathetic chain with endoscopic thoracic sympathectomy (ETS). However, some side effects, particularly compensatory sweating (CS), are the limitations of this procedure. The mechanism of CS and the associated risk factors are still controversial. The aim of this retrospective study was to determine the relationship with various parameters associated with CS in patients undergoing ETS. Materials and Methods  ETS was performed on a total of 95 patients for palmar hyperhidrosis, axillary hyperhidrosis and facial blushing by the same surgeon. The mean age of the patients was 26.41 (± 7) years, and 54 (56.8%) were males. Palmar hyperhidrosis was present in 54 (56.8%) patients, axillary hyperhidrosis in 33 (34.7%) patients, and facial blushing in 8 (8.5%) patients. Moreover, 38 (40%) patients also had plantar sweating. The severity of CS was rated into three scales as less, moderate, and severe. Results  Regarding the severity of CS, 55 (57.9%) patients had no or less CS, 28 (29.5%) had moderate CS, and 12 (12.6%) patients had severe CS. Higher age group had a significant increased risk of severe CS ( p  = 0.03) ( r  = 0.262). Patients with body mass index (BMI) > 25 kg/m 2 had a statistically significantly increased risk of severe CS ( p  = 0.016). Facial blushing resulted in severe CS in a significantly higher proportion of patients than by palmar and axillary hyperhidrosis ( p  = 0.001). The level of surgery was another important risk factor for CS, with the T2 level showing an increased risk of severe CS compared with T3 level ( p  < 0.001). Furthermore, plantar sweating was inversely and significantly related to the development of CS. Patients with plantar sweating had a significantly decreased incidence of developing CS ( p  = 0.015). Conclusion  CS after thoracic sympathectomy for primary hyperhidrosis is the most displeasing and restrictive side effect. This study demonstrates that older age, operation level, facial blushing, and high BMI are risk factors for CS, as have been shown in several similar studies. An interesting finding of the present study is that there was a decreased incidence of CS among patients with plantar sweating. This situation may help us to distinguish high risk for CS before ETS operation., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Georg Thieme Verlag KG Stuttgart · New York.)

Background  Thoracoscopic sympathectomy (TS) was the preferred surgical treatment for palmar hyperhidrosis (PH), but postoperative complications such as compensatory sweating (CS) were common. This study was projected to compare R3 versus R4 TS for treating severe PH. Methods  From April 2009 and March 2015, 106 consecutive patients with severe PH underwent bilateral R3 ( n  = 62) or R4 ( n  = 44) TS at The Second Affiliated Hospital of Nanchang University. The patients were followed up to evaluate symptom resolution, postoperative complications, satisfaction level, and severity of CS. Results  The 106 patients underwent 212 sympathecotomies and were cured with no severe complications or perioperative mortality. The incidence of minor side effects (such as pneumothorax, gustatory sweating, moist hands, and bradycardia) was similar in both groups. More patients had overdry hands in the R3 group than in the R4 group (6/62 vs. 0/44; p  = 0.040). More CS occurred in the R3 group as compared with the R4 group (42/62 vs. 23/44; p  = 0.156). The incidence of moderate-to-severe CS was higher in the R3 group than in the R4 group (14/62 vs. 4/40; p  = 0.045). Most patients were satisfied with the results, except for three (5.84%) in the R3 group and one (2.27%) in the R4 group. Conclusion  PH can be effectively treated by either R3 or R4 TS, with high rates of patient satisfaction. R4 sympathectomy appears to be associated with less severe CS and should be the choice of denervation level., Competing Interests: Conflict of Interest: Wenxiong Zhang, Yiping Wei, Han Jiang, Jianjun Xu, and Dongliang Yu have no conflicts of interest or financial ties to disclose., (Georg Thieme Verlag KG Stuttgart · New York.)

Background  Endoscopic thoracic sympathectomy (ETS) is an effective treatment for primary hyperhidrosis. However, compensatory sweating (CS) may occur in many patients. Sympathetic nerve reconstruction (SNR) can be used to counteract severe CS, but the studies on the effects of SNR are few. Patients and Methods  Nineteen out of 150 SNR patients were contacted by employing a long-term questionnaire. In this questionnaire, different kinds of sweating were evaluated using a four-graded symptom analysis and the visual analog scale before ETS, after ETS, and after SNR. Results  The mean age of the 16 male and 3 female patients at the SNR was 32 years. The mean follow-up was 87 months. According to the long-term questionnaire, the benefit was either excellent (4 patients, 21%), good (3 patients, 15.8%), or reasonable (7 patients, 36.8%) in 14 patients (73.8%), while the benefit was questionable in 1 patient (5.3%). For three patients (15.8%), no benefit was found, and in one patient (5.3%), the situation had deteriorated. Conclusions  Improvement in the side effects of ETS after SNR was found in nearly 75% of the patients. This indicates that SNR can be considered as an alternative treatment for patients with severe CS after ETS that is unresponsive to conservative treatment., Competing Interests: Disclosure: The authors have no conflict of interest or financial ties to disclose., (Georg Thieme Verlag KG Stuttgart · New York.)

Objective: The objective of this study was to evaluate and compare thoracoscopic sympathectomy and sympathicotomy at the third ganglia (T3) level for the treatment of primary palmar hyperhidrosis in terms of initial surgery results, complications, and patient satisfaction., Materials and Methods: Two groups of patient underwent T3 thoracoscopic sympathectomy and thoracoscopic sympathicotomy under general anesthesia using single-lung ventilation via a double-lumen endotracheal tube by the same surgical team for the treatment of severe primary palmar hyperhidrosis or a combination of levels for multiarea between 2008 and 2013. The groups were homogeneous for relevant demographic, physiological, and clinical data. All patients were examined preoperatively and were followed up at 6 months postoperatively. In both groups, patient's satisfaction was evaluated 6 months after surgery by a detailed interview and scored into three grades (1 = very satisfied, 2 = satisfied, and 3 = dissatisfied)., Results: No operative mortality, major intraoperative complication, infections, and Horner syndrome were recorded. There was no treatment failure. The average time of operation was 50 minutes for Group A (sympathectomy) and 36 minutes for Group B (sympathicotomy). Compensatory sweating occurred in 40 patients (89% for Group A and 85.11% for Group B) with a different accumulation of the severity degree. The satisfaction rate was 91.11% for Group A and 93.61% for Group B., Conclusion: There was no significant difference between thoracoscopic sympathectomy and sympathicotomy at the third ganglia (T3) level for the treatment of primary palmar hyperhidrosis in terms of initial surgery results, complications, and patient satisfaction. Neither surgical technique is better than the other one for palmar hyperhidrosis treatment. Development of severe compensatory sweating and postoperative pain are major determinant factors of patient dissatisfaction. Sympathicotomy should be preferred for palmar hyperhidrosis treatment, as it is much technically shorter, simpler to implement, and also easier to learn., (Georg Thieme Verlag KG Stuttgart · New York.)

Background and Objective: Primary palmar hyperhidrosis that arises mostly during puberty and early adolescence has a tremendous impact on the quality of life in patients. This study aimed to investigate the effectiveness of unilateral video-assisted thoracic sympathectomy for dominant hand in these patients., Patients and Methods: From July 2010 to June 2013, 52 patients with primary palmar hyperhidrosis underwent unilateral video-assisted thoracoscopic sympathectomy for dominant hand. We analyzed the outcomes regarding the resolution of symptoms, occurrence of complications, recurrence rate, and compensatory hyperhidrosis, and need of operation for opposite side., Findings: All patients were followed up from 6 to 42 months. Palmar hyperhidrosis was completely alleviated and absolute dryness was achieved in all patients at the same hand after the operation. Palmar hyperhidrosis in the opposite hand was cured to a complete dryness in 24 (46.15%) patients. No change happened in the opposite hand in 22 (42.3%) patients, but an increase was seen in 6 (11.53%) patients. Only seven (13.46%) patients needed to undergo contralateral sympathectomy. Compensatory hyperhidrosis occurred in 13 patients (25%) after unilateral sympathectomy. Another five patients (totally 18, 34.6%) were involved with compensatory hyperhidrosis after contralateral sympathectomy. It was mainly on the trunk in all 18 patients., Conclusion: Unilateral dominant side thoracoscopic sympathectomy for patients with primary palmar hyperhidrosis is an effective, safe, and minimally invasive procedure. Only a small number of patients will eventually require a contralateral sympathectomy in nondominant hand., (Georg Thieme Verlag KG Stuttgart · New York.)

Objective: The aim of the study was to evaluate the sympathectomy procedures for primary hyperhidrosis in terms of complications and effectiveness., Methods: From January 2010 to September 2012 we performed 130 sympathectomies in 65 patients, 27 males (42%) and 38 females (58%). Electrocoagulation was used in 20 procedures (15%), ultrasonic scalpel in 54 (42%), and radiofrequency dissector in 56 (43%). Seven patients (11%) underwent bilateral sympathectomy in the same surgical session, while in 58 (89%) the right surgical approach was delayed 30 days from the first procedure., Results: We noticed 12 complications (9%): (a) chest pain in 6 patients (4 with electrocoagulation, 1 with ultrasonic scalpel, and 1 with radiofrequency dissector), which disappeared in 20 ± 1 day; (b) paresthesias in 3 electrocoagulation patients, was solved in 23 ± 5 days; (c) bradycardia in 1 ultrasonic patient, normalized in 4th postoperative hour; (d) unilateral relapse in 2 electrocoagulation patients after the second side approach, positively treated in 1 patient by resurgery in video-assisted thoracoscopy (VAT). The quality-adjusted life year and the quality of life evaluation revealed a statistically significant improvement (p = 0.02) in excessive sweating and general satisfaction after surgery, with Ultracision and LigaSure showing better findings than electrocoagulation., Conclusion: The latest generation devices offered greater efficacy in the treatment of hyperhidrosis, minimizing complications and facilitating the resumption of normal work and social activity of patients., (Georg Thieme Verlag KG Stuttgart · New York.)

Background: Video-assisted thoracoscopic sympathectomy (VATS) is the gold standard for patients with hyperhidrosis of the upper limbs. The primary aim of this retrospective study was to evaluate the midterm outcome and the degree of satisfaction of patients who underwent single-port VATS., Methods: Forty three patients diagnosed with hyperhidrosis underwent T3, T4 VATS single-port approach, between January 2009 and May 2011. Early and midterm outcome with particular emphasis on patient satisfaction were collected by hospital chart and telephonic interview., Results: The mean follow-up was 14 months. No major perioperative complication occurred except for chylothorax in a case. During the immediate postoperative period, all the patients reported palmar anhydrosis. Compensatory sweating (6.9%) and recurrence of hyperhidrosis (6.9%) are responsible mainly for dissatisfaction. No patients experienced moderate or severe chronic pain., Conclusions: Single-port VATS is a feasible and minimally invasive technique with a low incidence of chronic pain for the treatment of hyperhidrosis. A few patients may experience compensatory sweating and recurrence of hyperhidrosis. The degree of patient satisfaction with the midterm surgical results is high., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: The aim of this study was to compare two different sympathicotomy procedures for primary hyperhidrosis in terms of compensatory sweating, complications, safety and effectiveness., Methods: The data of 78 consecutive patients who underwent bilateral endoscopic thoracic sympathicotomy (156 laterals) for palmar hyperhidrosis between January 2005 and September 2009 were studied retrospectively. The first 29 consecutive patients were treated with a T2-3 sympathicotomy (Group A). After November 2007, all patients (49 patients) were treated with a T3 sympathicotomy alone (Group B). The chest tubes were always removed after checking for pneumothorax with roentgenography. All patients were followed up and evaluated for results, side effects, complications, and satisfaction levels. The differences between the two groups were analyzed., Results: The mean age of the 47 (60.2 %) female and 31 (39.8 %) male patients was 25.2 years. Horner's syndrome and pneumothorax was not detected in either group. The mean follow-up time was 20.82 months (6-52 months). Effectiveness of the procedure at the time of discharge and at follow-up was 100 % and 97.5 %, respectively. There was no significant difference between groups with regard to any analyzed parameter., Conclusion: This study demonstrates that preserving the T2 ganglion is safe, and does not compromise the effectiveness of the procedure. Sympathicotomy has the same success rate as sympathectomy, but requires significantly less dissection and results in less tissue trauma., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: Our aim was to establish a standardized approach for patients with palmoplantar and axillary hyperhidrosis and to compare patient satisfaction and complication rates for two different operations., Materials and Methods: Between 2008 and 2010, 30 patients underwent conventional T3/4 clipping (group A), and 30 underwent only T3 and T6 clipping (group B). Both groups were compared with regard to compensatory sweating (CS), complications, patient satisfaction and recovery of plantar hyperhidrosis., Results: The CS rate was 60 % in group A and 47 % in group B. CS was significantly less in group B compared to group A ( P ≤ 0.001). The plantar hyperhidrosis recovery rate was higher in group B (n = 19) compared to group A (n = 13), but the difference was not statistically significant ( P ≥ 0.299). Patient satisfaction rate was 93.3 % in group A and 96.6 % in group B., Conclusions: Our study showed that T3/6 clipping was as effective as T3/4 clipping for palmar and axillary hyperhidrosis. Our results revealed that this technique is more effective than T3/4 sympathectomy to treat plantar hyperhidrosis., (© Georg Thieme Verlag KG Stuttgart · New York.)