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Ann Thorac Surg 2004;78:427-431
© 2004 The Society of Thoracic Surgeons

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Original article: general thoracic

Severity of compensatory sweating after thoracoscopic sympathectomy

^a Department of Cardiothoracic Surgery, Skejby Sygehus, Aarhus University Hospital, Aarhus, Denmark

Accepted for publication February 20, 2004.

^* Address reprint requests to Dr Licht, Department of Cardiothoracic Surgery, Odense University Hospital, Sdr Boulevard 29, DK-5000 Odense C, Denmark
e-mail: licht{at}dadlnet.dk

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
BACKGROUND: Compensatory sweating is a well-known side effect after sympathectomy for hyperhidrosis. It is often claimed to correlate with the extent of sympathectomy, but results from the literature are conflicting, and few have actually considered differences in the intensity of compensatory sweating.

METHODS: A total of 158 patients underwent thoracoscopic sympathectomy for primary hyperhidrosis or blushing, or both. Sympathectomy was performed bilaterally at Th2 for facial hyperhidrosis/blushing (n = 49), Th2-3 for palmar hyperhidrosis (n = 62), and Th2-4 for axillary hyperhidrosis (n = 47).

RESULTS: Follow-up by questionnaire was possible in 94% of patients after a median of 26 months. Compensatory sweating occurred in 89% of patients and was so severe in 35% that they often had to change their clothes during the day. The frequency of compensatory sweating was not significantly different among the three groups, but severity was significantly higher after Th2-4 sympathectomy for axillary hyperhidrosis (p = 0.04). Gustatory sweating occurred in 38% of patients, and 16% of patients regretted the operation.

CONCLUSIONS: Compensatory and gustatory sweating were remarkably frequent side effects after thoracoscopic sympathectomy for primary hyperhidrosis. We found no significant difference between the level of sympathectomy and the occurence of compensatory sweating. However, it appears that this is the first study to demonstrate that severe sweating is significantly more frequent after Th2-4 sympathectomy for axillary hyperhidrosis. We encourage informing patients thoroughly about these side effects before surgery.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Primary hyperhidrosis is a pathophysiologic condition of unknown etiology characterized by perspiration beyond physiologic needs. It most often affects the palms of the hands, the axillae, or the face and may be a severe professional, psychological, and social burden to many patients. Medical management is often frustrating, and the response generally transient [1]. Surgical therapy is effective and is based on interruption of transmission of impulses from sympathetic ganglia to the eccrine sweat glands. From more than 200 papers on thoracoscopic sympathectomy published in the English literature over the past 25 years, it is now clear that video-assisted thoracoscopic sympathectomy is the treatment of choice [2, 3].

Compensatory sweating is the most common side effect, but the reported frequencies vary considerably. It is generally believed to be a thermoregulatory mechanism, and the extent of sympathectomy is said to influence its frequency, but published results are conflicting. Furthermore, only a minority of studies have discussed differences in the severity of compensatory sweating. In the present follow-up study, we decided to investigate both the occurrence and the severity of compensatory sweating after thoracoscopic sympathectomy for primary hyperhidrosis or facial blushing.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
During a 6-year period (January 1997 to January 2003), 158 patients were treated at our institution for isolated or combinations of palmar or axillary hyperhidrosis or facial hyperhidrosis or blushing as shown in Figure 1. In the latter group, all patients suffered from blushing and 6 also complained of facial hyperhidrosis. Objective methods for quantifying sweating before surgery were not applied. The indications for operation were disabling hyperhidrosis or blushing as defined by the patient. Seventeen patients who underwent sympathectomy for other indications (eg, angina pectoris or Raynaud's syndrome) were not enrolled.

View larger version (13K): [in this window] [in a new window]   Fig 1. Patients were treated for isolated or combinations of palmar or axillary hyperhidrosis or blushing with or without facial hyperhidrosis.

Questionnaires were mailed to all patients for follow-up except for 3 patients who had emigrated and 1 who did not have a mailing address. All patients were asked to mark their disability, both professionally and socially, from their symptoms before surgery (very much, some, or none at all), and to mark the effect they had achieved from the operation (excellent, satisfactory, some effect, or no effect). Patients were asked to comment on occurrence and location of any compensatory sweating defined as excessive sweating after the operation that was considered abnormal. In an attempt to assess the severity of compensatory sweating, our patients were asked if they had to change clothes sometime during the day because of this side effect. Further, patients were asked whether they had developed any gustatory sweating defined as facial sweating when eating certain foods. Finally, they were asked if they were satisfied with or regretted the operation.

Statistical analysis included cross-tabulation implemented in the SPSS 10.1 statistical software package (SPSS, Chicago, IL). All p values less than 0.05 were considered statistically significant.

Surgical techniques
All patients were operated on in the supine position with abduction of both arms under single-lumen intubated anesthesia. Two ports were made. The first incision (5 mm) was made anteriorly in the hairline. The endotracheal tube was briefly disconnected by the anesthesiologist to deflate the lung when the pleural cavity was entered to avoid damaging the lung parenchyma. A 5-mm blunt-tip trocar was introduced for the use of a 0-degree videothoracoscope (Olympus Winter & Ibe, Hamburg, Germany). An additional 5-mm trocar was placed posteriorly in the hairline for the introduction of electrocautery or a ultrasonic scalpel. The sympathetic chain was identified at the level of the crossing of the second, third, and fourth costal heads. The parietal pleura was opened, and the sympathetic chain was transected. The incision was extended laterally for approximately 2 cm on the second costa to include any accessory nerve fibers from the ganglion to the brachial plexus (the nerve of Kuntz). In the first 50 patients, we used unipolar electrocautery to transect the sympathetic chain, and in the remaining patients we used an ultrasonic scalpel (Ultracision; Ethicon EndoSurgery, Cincinatti, OH). The procedure was performed bilaterally on the second costa (Th2) for facial hyperhidrosis or blushing (n = 49), on the second and third costa (Th2-3) for palmar hyperhidrosis (n = 62), and on the second, third, and fourth costa (Th2-4) for axillary hyperhidrosis (n = 47). All procedures were completed by insertion of a 14-mm chest tube through the trocar, and the lung was reinflated under visual control. The chest tube was aspirated while the anesthesiologist ventilated the patient manually, exerting continuous positive pressure for a few seconds, to prevent pneumothorax before the drain was subsequently removed. The surgical wound was closed with a Steri-Strip (3M Health Care, St Paul, MN).

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
The median time spent in the operating room was 1 hour and 5 minutes (range, 35 minutes to 3 hours and 20 minutes). The median duration of the surgical procedure was 20 minutes (range, 10 minutes to 1 hour and 55 minutes). No conversion to open technique was necessary, and there was no operative mortality. One patient with persistent unilateral symptoms of palmar hyperhidrosis after sympathectomy was successfully treated at reoperation 1 week later. In 4 patients unilateral Horner's syndrome developed, and was permanent in 2. Information on the postoperative chest roentgenogram was available from 157 charts: a pneumothorax was visible in 40 (25%). Ten patients (6%) required chest tube drainage, and 3 (2%) were successfully aspirated. In the remaining 27 patients (17%), all of whom were asymptomatic, the pneumothorax was treated conservatively; and the following day, 16 cases had resolved completely. The last 11 patients were discharged because their pneumothorax had not progressed. No hemothorax was encountered, but 1 patient had a pleural empyema, which was treated with chest tube drainage. The median hospital-stay was 2 days (range, 1 to 12), and the median postoperative hospital stay was 1 day (range, 0 to 6). Eighty percent of all patients had been discharged from the hospital by postoperative day 1.

One hundred and thirty-three patients (84%) returned the questionnaire immediately. Another 15 patients returned the questionnaire after a reminder giving a total of 148 answered questionnaires (94%). Six patients (4%) did not return the questionnaire despite the reminder. The median follow-up time was 26 months (range, 1 to 72). All patients answered the question about social disability because of their primary symptoms: very much in 140 cases (95%), and some in 8 cases (5%). The question of professional disability was answered by 146 patients: very much in 134 cases (92%), some in 11 cases (7%), and none in 1 case (1%).

Overall outcome after surgery is shown in Table 1. Patients who underwent a Th2-3 sympathectomy for palmar hyperhidrosis were the most satisfied (p < 0.001). Six patients described mild recurrent symptoms after an otherwise excellent result after Th2 sympathectomy for facial blushing (n = 4) or satisfactory result after Th2-4 sympathectomy for axillary hyperhidrosis (n = 2). Eleven patients who had no effect from the operation originally presented with blushing (n = 7), palmar hyperhidrosis (n = 1), and axillary hyperhidrosis (n = 3). Compensatory sweating occurred in 131 patients (89%), and was located on the abdomen in 83 patients (63%), the back in 90 patients (69%), the lower extremities in 56 patients (43%), and the chest in 26 patients (20%). Forty-six patients (35% of patients who had compensatory sweating) answered that they often had to change clothes during the day because of this side effect. Table 2 shows the frequency of compensatory sweating in the three groups; it was not significantly different (p = 0.10). In Table 3, however, it is seen that the severity of compensatory sweating was significantly higher after Th2-4 sympathectomy for axillary hyperhidrosis (p = 0.04). Gustatory sweating occurred in 56 patients (38%) and was not significantly different between the three levels of sympathectomy (p = 0.49). Twenty-three patients (16% of 147 patients who answered the question) regretted the operation because of side effects (n = 11) or lack of effect from the operation (n = 6), or both (n = 6).

	Comment

Top Abstract Introduction Patients and methods Results Comment References

It may be argued that thoracoscopic sympathectomy for hyperhidrosis is merely a cosmetic procedure, but our results indicate that nearly all patients who seek surgical therapy are very disabled by their symptoms, both professionally and socially. Our results also demonstrate that the vast majority of patients are satisfied after the operation. Indeed, in a leading article, Hederman [2] stated that patients who have sweating severe enough to cause significant occupational or social difficulties and who have been cured by sympathectomy are among the most grateful that surgeons will encounter in the course of their work. Most patients describe their life as "completely changed" by the operation even though there are well-known side effects.

During the immediate postoperative period, chest pain, hemothorax, pneumothorax, and Horner's syndrome may occur, but in most reports these complications are considered rare, transient, and self-limiting. In our series, we had 4 cases of Horner's syndrome, 2 of which were permanent. Possible mechanisms include misidentification of the second rib, thermal injury after electrocautery, or traction on the sympathetic trunk during resection [4]. However, we did not exert traction during simple transection, and 1 case occurred after use of an ultrasonic scalpel. Postoperative pneumothorax was also seen more frequently among our patients than previously reported. Despite perioperative measures to prevent pneumothorax, a routine postoperative chest roentgenogram revealed a pneumothorax in 25% of patients, but only 8% required chest tube drainage. In fact, several patients received a chest tube even though they were asymptomatic because their pneumothorax was more than 3 cm on the chest roentgenogram. We have since abandoned this practice and place a chest tube only in case of symptoms.

Compensatory and gustatory sweating appear to be more permanent postsympathectomy complications in most of the 200 papers that have been published in the English literature over the past 25 years. The reported frequencies of compensatory sweating vary considerably, however, despite a seemingly similar operation. While most papers describe this side effect in 30% to 70% of patients, some investigators claim that they have not encountered compensatory sweating after sympathectomy [6], and others see it in almost all patients [7–11]. It has been speculated since 1960 that compensatory sweating may be a thermoregulatory mechanism by which the sweat glands attempt to compensate for loss of secretory tissue, and for that reason it has been proposed that the occurrence of sweating is related to the extent of sympathectomy [2, 12]. Consequently, several authors have suggested that limiting the extent of sympathectomy may reduce the occurrence of compensatory sweating [2, 12–14]. Conversely, others reported that even a limited sympathectomy resulted in compensatory sweating in almost all patients [8, 9], and a recent study found that an extensive sympathectomy caused less compensatory sweating compared with a more limited resection [15]. Finally, some authors believe that the extent of sympathectomy does not affect the occurrence of compensatory sweating [8, 16].

Only a minority of the published studies have distinguished between varying degrees of compensatory sweating after thoracic sympathectomy. Their frequency of embarassing or disabling compensatory sweating varies between 1.2% and 90% of patients [3, 10, 11, 17–21]. Most often severity is arbitrarily defined as sweating or severe sweating, but one study provided an objective measure as "the need to change underwear more than twice a day" [10]. Two of the studies investigated whether severity of compensatory sweating was related to the extent of sympathectomy. One study reported less severe compensatory sweating after a limited sympathectomy at the expense of a higher recurrence rate [17], and the other did not find any correlation between extent of sympathectomy and degree of compensatory sweating [21].

Our results demonstrate that compensatory sweating is a very common side effect, occurring in almost 89% of patients; and in 35% it was so severe that they often had to change their clothes during the day. Apparently, the majority of our patients accepted compensatory sweating as a side effect, because their answer to the question on the results of the operation was excellent or satisfactory. Sixteen percent regretted the operation, but this figure is possibly higher because 4% did not return the questionnaire. We found no significant difference between the extent of sympathectomy and the occurrence of compensatory sweating. However, we discovered that severe sweating was significantly more frequent after Th2-4 sympathectomy for axillary hyperhidrosis, and it appears that this result has not been reported before. We strongly emphasize that our study cannot distinguish between "extent of sympathectomy" and "location of primary hyperhidrosis" as the primary factor responsible for compensatory sweating because they are intimately tied together as cofactors. Ultimately, a prospective randomized trial may be necessary to distinguish between the two.

The reported incidence of compensatory sweating after thoracic sympathectomy varies widely. This variability could reflect that patient populations are heterogenous or have undergone different surgical procedures, but it is likely to be a consequence of different definitions of compensatory sweating. While some authors count only cases in which massive overperspiration occurs, others consider even a slight increase in perspiration as compensatory sweating [4]. One study only considered compensatory sweating to be a complication if the patient complained or when further treatment was required [22]. In addition, previous studies only dealt with perception of increased compensatory sweating because quantitation was not done. Whether there is an increased level of compensatory sweating or merely an increase in the subjective discomfort has yet to be determined; for example, someone with severe palmar sweating cured by sympathectomy would most likely tolerate a great amount of new back sweating postoperatively, whereas someone with mild axillary sweating and the same amount of new back sweating postoperatively would not be satisfied with the result. Finally, compensatory sweating may vary with the intensity of questioning and the thoroughness of follow-up [16], and may be affected by geographic location, working environment, humidity, temperature, and season [8, 23]. Nevertheless, 89% of our patients suffered from compensatory sweating even though we live in a temperate geographical zone, and they continued to do so after a median follow-up time of 26 months. A similar long-term result was recently published by Gossot and associates [11] and contrasts with others who claim that compensatory sweating often subsides over time [23, 24].

Gustatory sweating is another well-recognized side effect after thoracic sympathectomy. The causes are obscure, but it has been speculated that it may be caused by sprouting of vagal nerve fibers into the severed sympathetic chain [25]. Similar to compensatory sweating, the reported frequency of gustatory sweating varies considerably in the literature. Some authors do not mention it [6, 7], others do not encounter this side effect [26] or find a very low frequency [18], but it occurs in as many as 50% of patients [27]. It occurred in 38% of our patients and was particularly related to spicy foods or food with moderate acidity such as apples or oranges. There is no generally accepted pathophysiologic explanation for this phenomenon.

This study confirms that gustatory and compensatory sweating are frequent side effects after thoracoscopic sympathectomy, and we believe it is crucial to inform patients thoroughly before surgery. In particular, our study suggests that patients who are scheduled for an extensive sympathectomy because of axillary hyperhidrosis should be warned about the risk of severe compensatory sweating. The main disadvantages of conventional surgical approaches have been their irreversibility. Promising new surgical approaches are emerging in which the sympathetic trunk is not transected but instead is treated by endoscopic clamping, which exerts a force on the sympathetic trunk sufficient to interrupt nerve transmission [28–30]. Clamping appears to be at least as safe and effective as the earlier cauterization techniques [28]; and in some patients with intolerable compensatory sweating, that side effect improved from the reverse operation [29, 30].

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Peter B. Licht Hans K. Pilegaard Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Licht, P. B. Articles by Pilegaard, H. K. Search for Related Content PubMed PubMed Citation Articles by Licht, P. B. Articles by Pilegaard, H. K. Related Collections Mediastinum