Elsevier

Journal of Surgical Research

Volume 263, July 2021, Pages 224-229
Journal of Surgical Research

Thoracic
Long-Term Efficacy of T3 Versus T3+T4 Thoracoscopic Sympathectomy for Concurrent Palmar and Plantar Hyperhidrosis

https://doi.org/10.1016/j.jss.2020.11.064Get rights and content

Abstract

Background

More than 50% of patients with palmar hyperhidrosis (PAH) also have plantar hyperhidrosis (PLH). We compared the long-term results of T3 sympathectomy with those of combined T3+T4 sympathectomy among patients with concurrent PAH and PLH.

Materials and methods

We retrospectively analyzed the records of patients with concurrent PAH and PLH who underwent T3 alone or T3+T4 sympathectomy from January 1, 2012, to December 31, 2017. Preoperative and postoperative sweating (hyperhidrosis index) was evaluated through questionnaires, physical examination, and outpatient follow-up. The relief rates and hyperhidrosis index were used as outcome measures to compare the efficacy of the two approaches. Patients’ satisfaction and side effects were also evaluated.

Results

Of the 220 eligible patients, 60 underwent T3 sympathectomy (T3 group), and 160 underwent T3+T4 sympathectomy (T3+T4 group). Compared with the T3 group, the T3+T4 group showed higher symptom relief rates both for PAH (98.75% versus 93.33%, P = 0.048) and PLH (65.63% versus 46.67%, P = 0.01), and a greater postoperative decrease in both hyperhidrosis indices. The rate of severe compensatory hyperhidrosis also increased (10% versus 5%, P = 0.197), although the rates of overall satisfaction were comparable between the groups. The incidence of postoperative pneumothorax requiring chest tube placement and postoperative neuralgia was also similar. There were no cases of perioperative death, secondary operation, wound infection, or Horner syndrome in either group.

Conclusions

Compared with T3 alone, T3+T4 sympathectomy achieved a higher symptom relief rate and a lower hyperhidrosis index. T3+T4 sympathectomy may be a choice for the treatment of concurrent PAH and PLH; however, patients need to be informed that this kind of surgery may increase the risk of compensatory sweating.

Introduction

Primary palmar hyperhidrosis (PAH) is a disorder characterized by excessive sweating mainly, but not exclusively, on the palms.1 It often adversely affects patients’ social contact, learning, and occupation and may result in psychological stress of varying degrees. According to a 2007 survey, the prevalence of primary PAH in China was 4.59%, and male and female patients were affected equally.2 Large case series and randomized trials, over the past 25 y, have consistently demonstrated that thoracoscopic interruption of the sympathetic chain is a safe and effective treatment method for focal primary hyperhidrosis.3 However, there were still reports of many cases of postoperative relapse,4, 5, 6, 7 which may be attributed to the presence of bypassing nerve fibers, such as the Kuntz nerve fiber bundle or rami communicantes.

Approximately 70%-80% of patients with PAH also have plantar hyperhidrosis (PLH).8,9 PLH has adverse physical and mental effects as it often cannot be treated sufficiently using conservative measures.10 Thoracic sympathetic chain surgery has a positive impact on PLH in patients who underwent surgery for PAH and were also affected by PLH. Different surgical procedures achieved different rates of PLH relief; T2-T4 sympathectomy and T3-T4 sympathectomy or ganglion block can achieve higher relief rates, but the former can lead to severe postoperative compensatory sweating.9,11, 12, 13, 14, 15 According to the Expert Consensus of the Thoracic Surgeon Association, the naming of thoracic sympathectomy surgery has been standardized, with different procedures recommended to treat primary hyperhidrosis in different body parts,16 but there is no consensus about the treatment of concurrent PAH and PLH.

Our center started thoracic sympathectomy for the treatment of concurrent PAH and PLH in 2010. Combined T3 and T4 (T3+T4) thoracic sympathectomy is the most common approach, followed by sympathectomy of either T3 alone or T4 alone. In this study, we compared the effectiveness of T3+T4 sympathectomy with that of T3 sympathectomy for the treatment of concurrent PAH and PLH.

Section snippets

Ethical considerations

This study was approved by the Ethical Committee of Peking University Shenzhen Hospital, which follows the principles of the Declaration of Helsinki. The Ethics Committee reviewed and approved this study, and all patients signed an informed consent form.

Study design and patients

We retrospectively analyzed the demographic and baseline and follow-up clinical data of patients with concurrent PAH and PLH treated with T3 alone or T3+T4 thoracic sympathectomy from January 1, 2012, to December 31, 2017, in the Department of

Results

From January 1, 2012, to December 31, 2017, 182 patients underwent bilateral T3+T4 sympathectomy, and 73 underwent bilateral T3 sympathectomy in our center.

Patients’ demographic data are shown in Table 1. There were no significant differences regarding age, sex, body mass index, and the distribution of hyperhidrosis sites between the groups. Among the 182 patients who underwent T3+T4 sympathectomy, 160 (87.91%) were successfully followed up, and 22 (12.09%) were lost to follow-up. In the T3

Discussion

Numerous studies have shown that thoracic sympathectomy is a safe, effective, and minimally invasive method for the treatment of PAH.18, 19, 20 Relief rates are as high as 90%-100%, with up to 10% of patients experiencing recurrence after surgery. Some studies have suggested that the presence of abnormal anatomical variant bypassing branches, such as the Kuntz branch4,5 or the rami junction branch,6,7 might contribute to surgical failure and recurrence of PAH. Cutting the rami or Kuntz branches

Conclusions

Compared with T3 sympathectomy alone, combined T3 and T4 sympathectomy improved outcomes of concurrent PAH and PLH patients. Therefore, for these patients, combined T3 and T4 sympathectomy may be an option. However, patients need to be informed that this kind of surgery may increase the risk of severe compensatory sweating.

Acknowledgment

The authors thank Feihu Long and Baokun Chen for their assistance with data collection.

Author contributions: Chenglin Yang and Zifan Li collected data and drafted the manuscript. Huiwen bai, Hailong mao, Jie Xiong Li, and Hao Wu provided study materials and patients’ information. Da Wu and Juwei Mu conceived of the study and participated in its design. All authors read and approved the final manuscript.

Funding: This work was supported by the Sanming Project of Medicine in Shenzhen, China (No.

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    These authors contributed equally to this work.

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