Efficacy and Outcome Prediction of Unilateral Video-Assisted Thoracoscopic Sympathectomy in Primary Palmar Hyperhidrosis: A Comparative Study with Bilateral Sympathectomy

Objective

To compare unilateral dominant-side video-assisted thoracoscopic sympathectomy (U-VATS) with bilateral procedures (B-VATS) in terms of efficacy and complications and to identify predictors of outcome after U-VATS.

Methods

A prospective multicenter cohort study in which patients presented with primary palmar hyperhidrosis were treated by either U-VATS (82 cases) or B-VATS (112 cases). The demographic, clinical, operative, and postoperative findings were collected for all patients and compared in both groups. The factors associated with outcome were identified, and predictors of outcome in U-VATS were investigated to identify best candidates for unilateral sympathectomy.

Results

Both groups were balanced regarding demographic and preoperative clinical data. U-VATS was associated with significantly less postoperative pain and shorter hospital stays. Compensatory sweating was significantly less frequent in U-VATS with significantly better improvement in planter hyperhidrosis. Both groups were comparable as regards recurrence rate, patient satisfaction, and quality of life at 1 year. Preoperative Hyperhidrosis Quality of Life Questionnaire scores predicted outcome in U-VATS, and the best cutoff point was identified.

Conclusions

U-VATS proved to be equally effective as B-VATS with less postoperative pain, shorter hospital stay, less frequent compensatory sweating, and better improvement of planter hyperhidrosis. The results suggest that patients with preoperative Hyperhidrosis Quality of Life Questionnaire scores >80 are better operated via B-VATS, whereas lower scores are indicated for U-VATS.

Introduction

Primary hyperhidrosis is a pathological condition affecting facial, palmar, axillary, and/or plantar regions causing excessive intractable sweating that negatively affects quality of life.^1,2 Palmar hyperhidrosis (PmH) is the most significant type due to its heavy social, occupational, and emotional ramifications. Bilateral video-assisted thoracoscopic sympathectomy (B-VATS) is the most commonly performed procedure for treating PmH and is considered the gold standard.3, 4, 5 However, in a significant proportion of patients, a poorly understood condition known as compensatory sweating (CS) can develop and adversely influence the quality of life.6, 7, 8, 9 Moreover, several authors have found that VATS was associated with significant increases in heart rate variability, sympathovagal imbalance, and disturbances in bronchomotor tone.10, 11, 12, 13, 14, 15 Although these changes were reported as subclinical, their long-term effects on highly active subjects were not sufficiently studied. According to a recent randomized study, these changes were likely associated with the extent of denervation.¹⁶

To reduce the occurrence of adverse events after VATS, some authors adopted the 2-staged VATS. This involves operating on the dominant side before operating on the contralateral one to allow for a definitive thermoregulatory effect to be attained via regeneration of communicating and accessory fibers, thus reducing CS.¹⁷ Several studies have reported increased patient satisfaction and other improvements with significantly lower rates of CS in 2-stage unilateral dominant-hand VATS (U-VATS) compared with single-stage B-VATS.18, 19, 20 Other studies reported satisfaction in the majority of patients and improvement of contralateral limb sweating with U-VATS only.^21,22

The aim of the current study was 2-fold: to evaluate U-VATS compared with B-VATS in terms of efficacy and postoperative complications and to determine outcome predictors after U-VATS in order to determine the best candidates for unilateral procedures.