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Ann Thorac Surg 2005;80:461-466
© 2005 The Society of Thoracic Surgeons

Original article: General thoracic

Health-Related Quality of Life After Thoracoscopic Sympathectomy for Palmar Hyperhidrosis

Kojiro Kumagai, MD * , Harumi Kawase, MD, PhD, Minoru Kawanishi, MD, PhD

Department of Anesthesiology, Fujita Health University, School of Medicine, Banbuntane-Hotokukai Hospital, Nakagawa-ku Nagoya, Japan

Accepted for publication March 4, 2005.

* Address reprint requests to Dr Kumagai, Department of Anesthesiology, Fujita Health University, School of Medicine, Banbuntane-Hotokukai Hospital, 3-6-10 Otobashi, Nakagawa-ku Nagoya, 454-8509, Japan (Email: kojirokum{at}aol.com).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 Notice From the American...
 References
 
BACKGROUND: Palmar hyperhidrosis is a benign functional disorder regarded as a psychological and social handicap. Improvement of the quality of life is a major goal of treatment. However, little attention has been given to quality of life after thoracoscopic sympathectomy, which is the first line of treatment for palmar hyperhidrosis. This study investigated the impact of thoracoscopic sympathectomy on subjective health-related quality of life (HRQoL) and psychological properties.

METHODS: Forty patients who underwent thoracoscopic sympathectomy were followed up for 6 months. The HRQoL measures were the Medical Outcomes Study Short Form 36 (SF-36), the Spielberger State Trait Anxiety Inventory (STAI), and the Zung Self-Rating Depression Scale (SDS). Patients were administered these questionnaires before procedure and then again at 1, 3, and 6 months after sympathectomy.

RESULTS: A comparison between the current sample and Japanese normative data for the SF-36 showed mild impairment of HRQoL before sympathectomy. However, it also showed significant improvement of the social functioning domain after sympathectomy. While there was worsening of the bodily pain and role physical domains 1 month after sympathectomy, both domains recovered in 3 months. The results of STAI showed significant improvement of both trait and state anxiety after sympathectomy. However, the results of SDS showed patients remained neurotic.

CONCLUSIONS: This study is the first to show the pattern of impairment in health status and therapeutic impact in palmar hyperhidrosis patients. Hyperhidrosis is associated with impaired HRQoL. It was also demonstrated that thoracoscopic sympathectomy is safe, minimally invasive, and improves HRQoL, even if compensatory hyperhidrosis occurs.


   Introduction
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 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 Notice From the American...
 References
 
Palmar hyperhidrosis is a benign functional disorder of excessive perspiration, which causes both a psychological and social handicap [1–3]. Perspiration beyond physiological needs is elicited spontaneously, and increased in response to emotional stimuli or stressful situations. Moreover, palmar hyperhidrosis may lead to emotional problems and hinder daily activities [3, 4].

Thoracoscopic sympathectomy is a simple, fast, safe, and minimally invasive treatment for palmar hyperhidrosis [5–7]. The therapeutic results are excellent with a low recurrence rate. After the introduction of thoracoscopic sympathectomy, patients have received numerous benefits, including early postoperative pain relief, short hospital stay, and good cosmesis [8]. However, compensatory hyperhidrosis is a very common side effect and may lead to decreased patient satisfaction [8, 9]. To date, attention has been focused mainly toward operative techniques [3, 9–12] and the influence on the autonomic nervous system [13, 14]. The outcomes have been evaluated only with improvement of the symptoms and patient satisfaction for thoracoscopic sympathectomy [5, 8, 15].

Health-related quality of life (HRQoL) measures, obtained through validated patient-oriented tools, are now considered essential in the evaluation of treatments [16]. The Medical Outcomes Study Short Form 36 (SF-36) has been used to assess HRQoL for a variety of medical conditions [16–21]. Nevertheless, there is a paucity of data assessing subjective HRQoL and psychological properties after sympathectomy for palmar hyperhidrosis. Therefore, little is known about the impact of this procedure and complications associated with broader measures of subjective well-being and quality of life. The aim of this prospective study was to evaluate HRQoL and intermediate-term outcomes in patients with palmar hyperhidrosis after thoracoscopic sympathectomy, based on standardized, validated measures. The value of self-report scales in predicting anxiety and depression was also assessed.


   Patients and Methods
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 Patients and Methods
Results
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After institutional approval and written informed consent, 42 consecutive patients with palmar hyperhidrosis (16 males and 26 females), scheduled for elective thoracoscopic sympathectomy operation were enrolled in this prospective trial. All of the patients were in good health, with thyroid function tests all within normal limits. The average age of the patients was 29.7 years (range, 18 to 55). They averaged 10.6 years of education. Sixty-seven percent of the patients had never married, with the remainder (33%) being married. All patients complained incapacitating hyperhidrosis since childhood or adolescence, and considered themselves disabled. Their main complaint was hand sweating. The distribution of symptoms showed that 3 patients (7%) complained of sweating over their hands alone; 14 (33%), of craniofacial sweating; 35 (83%), axillae; 28 (67%), planter; and 17 (40%), blushing. Thirty-seven patients (88%) had tried nonsurgical treatments, such as medications and topical powders, which were either transient or insufficient. No objective method to measure sweating except thermography was used. The indications for thoracoscopic sympathectomy consisted of educational, learning, and professional handicaps, as well as severe social and emotional distress with palmar hyperhidrosis.

Anesthetic Management and Operative Technique
The procedure was performed under general anesthesia with double-lumen endotracheal intubation. The patient was placed in a half-sitting position as bilateral access was easily acquired without repositioning. A 1-cm incision was made in the third intercostal space below the axilla. An electroresectoscope was then inserted between the ribs. Once the sympathetic trunk at the neck of the ribs was identified, targeted T-2, T-3 ganglia were electrocauterized. After successful sympathectomy, a 8F chest tube was inserted. The tube was then removed after the lung was fully inflated. The wound was closed with subcutaneous sutures for cosmetic reasons. The same procedure was then performed at the contralateral site. All procedures were performed by the same surgeons (K.M. and K.K.). A chest roentgenogram was checked 3 hours after surgery and again the next morning. Thermography was performed before and after the surgery. Patients were placed in the supine position, in a warm, quiet, dim room. The room temperature was set between 21° and 25°C.

Assessments
Three self-administered questionnaires were carried out before surgery for preoperative assessment.

The Medical Outcomes Short Form 36 is a generic health-related quality of life instrument [16]. It has proven useful in comparing general and specific populations across countries, evaluating the relative load of different diseases, and differentiating treatment outcome [16]. It assesses eight dimensions of quality of life: physical function, role limitation caused by physical impairment, bodily pain, general health, vitality, social function, role limitation caused by emotional impairment, and mental health. Each domain is scored separately on a 0 to 100 scale, in which higher scores correspond to better quality of life.

The Spielberger State Trait Anxiety Inventory (STAI) is a self-administered instrument used to measure both anxiety resulting from acute stressors (state anxiety [STAI-S]) and intrinsic levels of anxiety irrespective of any particular acute stressor (trait anxiety [STAI-T]) [22]. It had previously been translated and validated in Japan [23]. The STAI-S consists of 20 items that ask respondents to report how they feel at a particular moment in time, and the STAI-T consists of 20 statements that ask respondents to report on their general feeling of well-being. The STAI-S is usually administered along with the STAI-T using the same scale, a 4-point Likert scale ranging from almost never (1) to almost always (4), with the higher score indicating a higher level of anxiety.

The Zung Self-Rating Depression Scale (SDS) is a self-report measure of depression [24]. It had previously been translated and validated in Japan [25, 26]. It contains 20 items assessing different symptoms of depression, such as depressed mood, feelings of guilt, decreased appetite and sleep disorders. Although the scores are not meant to offer strict diagnostic guidelines, but rather denote depressive symptoms, the SDS has been shown to be valid in clinical use. The score of SDS ranges from 20 (no depression) to 80 (major depression).

These three instruments are the most widely used, and adequate reliability and validity estimates have been established in many studies.

Postoperative outcome analysis was based on these three questionnaires sent to all patients at 1-, 3-, and 6-month follow-up. Patients were also asked to evaluate improvement in symptoms and degree of satisfaction as follows: 1, unreservedly satisfied; 2, partially satisfied; and 3, not satisfied. Postoperative complications including compensatory hyperhidrosis were also noted. Compensatory hyperhidrosis was graded as follows: 1, absent; 2, minor; 3, embarrassing; and 4, disabling [7, 9].

Statistics
The health-related quality of life data for the whole group were compared with Japanese normative population data for each of the individual domains of the SF-36. The data were then used to derive sex and decade-of-age specific estimates of the mean and standard deviation of SF-36 scores for each domain. The observed SF-36 domain scores were then Z transformed. Thus, the scores for each subject were calculated as the number of standard deviations away from the age decade and sex-specific mean in the normal population. These Z scores were then compared using analysis of variance (ANOVA) followed by repeated measures ANOVA. Bonferroni correction was utilized for multiple comparisons. Results are reported as mean ± SD. The one-tailed Wilcoxon rank test was used to compare scores on the STAI and SDS. Differences were considered statistically significant at the 5% level. Analysis was performed with Stata statistical software.


   Results
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Palmar skin temperature (mean ± SE) on thermography before and after sympathectomy was 27.9 ± 0.2° and 33.1 ± 0.3°, respectively. All patients showed an increase in temperature (2° to 8.5°, mean 5.3°) and displayed the disappearance of sweating, indicating that the sympathectomy was successful. There were no deaths or major perioperative complications. Two patients were unable to be contacted for follow-up. The operation time ranged between 29 and 62 minutes with a mean of 42 minutes. Postoperative complications included pneumothorax in 1 patient. Permanent or transient Horner’s syndrome did not occur in any case. Compensatory hyperhidrosis occurred in all cases within 1 month after surgery (Table 1). Five patients noticed a change in their taste or gustatory sweating. There was no recurrence of palmar hyperhidrosis at 6 months. Patient satisfaction rates are shown in Table 2. No patients regretted undergoing sympathectomy.


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  		Table 1. Compensatory Hyperhidrosis Grade
 

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  		Table 2. Satisfaction Rate
 
Health impact was examined by the SF-36. Figure 1 shows a comparison with normative data by domain, expressed as a reduction of the Z score from age- and sex-matched with Japanese normative data. Before sympathectomy, the Z scores were depressed (i.e., lower QOL) in all the SF-36 domains except the physical functioning and bodily pain domains in patients with palmar hyperhidrosis. This finding revealed a close relationship between the presence of palmar hyperhidrosis and a generally worse subjective perception of health status.



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  		Fig 1. Medical Outcomes Study Short Form 36 measures (BP = bodily pain; GH = general health; MH = mental health; PF = physical functioning; RE = role-emotional; RP = role-physical; SF = social functioning; VT = vitality): Z score compared with age- and sex-matched norms. *p < 0.01 versus preoperative. Dotted bars = preoperative; up-down slashed bars = 1 month; crosshatched bars = 3 months; down-up slashed bars = 6 months.

 
After sympathectomy, the most striking impact was seen in the social functioning domain. The Z score in the social functioning domain improved significantly at 3 months and 6 months (Fig 1). One month after surgery, the Z scores in the bodily pain and physical role domains were significantly depressed (-0.62, p < 0.01; and -1.05, p < 0.05, respectively). However, they were recovered at 3 months after surgery. The Z scores in the other domains did not change significantly throughout the period of assessment.

Table 3 presents STAI and SDS scores. Patients with palmar hyperhidrosis demonstrated higher levels of both trait and state anxiety according to the STAI. After sympathectomy, both trait and state anxiety were reduced significantly compared with their preoperative levels; however, they were still higher than the general population. The SDS scores were above the reference value, indicating that patients with palmar hyperhidrosis have more neurotic feelings than the general population. The SDS scores were more or less stable after sympathectomy, indicating that patients remained neurotic.


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  		Table 3. Results of Psychological Tests
 

   Comment
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 Abstract
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 Patients and Methods
 Results
 Comment
Notice From the American...
 References
 
Ours is the first study to evaluate HRQoL longitudinally in patients with palmar hyperhidrosis. This prospective study showed that HRQoL assessment by the SF-36 health survey can provide valid information about the general health status of patients with hyperhidrosis before and after thoracoscopic sympathectomy. These health status differences between the current sample and the Japanese normal population indicate how palmar hyperhidrosis decreases a person’s perception of his or her HRQoL. After sympathectomy, the most striking impact on HRQoL was seen in the social functioning domain when compared with preoperative data. It was found that the deteriorated social functioning domain of HRQoL improved significantly after sympathectomy. Patients were asked about postoperative pain in SF-36. The findings of deterioration of the bodily pain and physical role domains 1 month after sympathectomy and recovery at 3-month follow-up underline the importance of postoperative care. While thoracoscopic sympathectomy is considered to be minimally invasive, we do know that further acute pain management could improve early postoperative health status. Conversely, the impact of sympathectomy on other domains was insignificant. The vitality and mental health domains remained reduced throughout this study. The SF-36 is a nonspecific generic instrument, which was clearly able to differentiate between before and after sympathectomy. Therefore, this study would help to identify possible benefits of thoracoscopic sympathectomy that have not yet been demonstrated, for the evaluation of postoperative outcome data.

Sympathectomy has been carried out by electrocautery or by resection. Although the resection method yielded superior results, the cauterization method has been preferred rather than resection because of a simple and quick procedure [27]. Thus, we performed sympathectomy with the ablative technique. Compensatory hyperhidrosis is the most common side effect after sympathectomy [3, 9, 28–30]. Gossot and associates [9] claimed that the amount of compensatory hyperhidrosis was lower when cauterization was utilized than resection. It has also been proposed that the degree of compensatory hyperhidrosis depends on the extent of sympathectomy. Thus, we limited electrocautery of the ganglia at T-2 and T-3. However, it was unknown as to what extent compensatory hyperhidrosis influences patients’ HRQoL and satisfaction. Previous studies have reported that compensatory hyperhidrosis was "embarrassing" and "bothering" [5, 15]. Gossot and colleagues [5] emphasized the importance of giving both oral and written information without minimizing the problem. We also gave both oral and written information about compensatory hyperhidrosis. However, several investigators have insisted that compensatory hyperhidrosis was not very embarrassing to the patients and was usually better tolerated and less debilitating than palmar hyperhidrosis [3, 31]. With regard to the HRQoL at the 6-month follow-up evaluation, data from this study showed improvement in the social functioning and no worsening in other domains, despite compensatory hyperhidrosis having appeared by this time in all cases. Therefore, it can be concluded that compensatory hyperhidrosis does not influence negatively as palmar hyperhidrosis does.

We also studied psychological properties of patients. Our findings indicated that patients with palmar hyperhidrosis have very high levels of both trait and state anxiety, and that excessive sweating and severe social and occupational difficulties resulting from this might further increase inherent anxiety. It is plausible that anxiety could be elicited by excessive sweating, whereas palmar hyperhidrosis is regarded as an autonomically mediated anxiety phenomenon. Alleviation of psychological tension by sympathectomy might be a reason why anxiety is reduced postoperatively. Additionally, the significant predictive value of the STAI implies that this test may be useful for evaluation of treatment outcomes. Another interesting finding was that SDS scores remained higher among hyperhidrosis patients throughout the whole of this study, indicating a neurotic disposition rather than a depressive one. In the literature, hyperhidrotic patients were reported to be rarely anxious or neurotic, which did not agree with our findings [32]. However, Lerer and coworkers [32] utilized the Taylor Manifest Anxiety Scale. Thus, the use of a different instrument might explain this discrepancy. Thus, it can be inferred that psychological factors seem to be of great importance.

The satisfaction rate declined with time. This is because patients become accustomed to their new condition and forget about their previous handicap, even if they are initially satisfied with relief from excessive perspiration. However, 100% of patients were unreservedly or partially satisfied with the outcome, which was consistent with previous reports [5, 9, 15].

The SF-36 is a well recognized tool for evaluation of health status [33, 34]. Expressing individual domains as Z scores allows for variation in SF-36 with age and sex, without multivariate adjustment. It also allows expression of scores parametrically and direct comparison of the results between the eight domains, although the distribution of actual SF-36 scores is often not Gaussian [35].

The present study has several limitations. First, the sample was composed of only 40 patients. The findings should be generalized with care. Second, it only illustrates intermediate-term outcomes. There is a possibility that some aspects of HRQoL hereafter would deteriorate as well as satisfaction rates. These concerns will be further investigated in the longitudinal phase of the project, which is currently under way. Third, SF-36 was utilized, a generic instrument for health assessment to measure treatment outcomes. However, comprehensive assessment of treatment outcomes requires both generic and disease-specific instruments [36, 37]. De Campos and colleagues [38] devised a specific questionnaire. Further evaluation of perspiration-specific measures, including studies of reliability and validity, is expected for accurate and consistent assessment.

In summary, two conclusions can be drawn. First, patients with palmar hyperhidrosis showed significant impairment of HRQoL as measured by patient-oriented evaluation. From follow-up evaluation, it appears that thoracoscopic sympathectomy is not only safe and minimally invasive, but also improves HRQoL, despite compensatory hyperhidrosis. Second, it was demonstrated that, in addition to traditional measures such as of improvement of symptoms and patient satisfaction, generic measures including SF-36, SDS, and STAI could prove useful for providing a broader view and comprehensive evaluation of thoracoscopic sympathectomy outcomes of patients with palmar hyperhidrosis.


   Notice From the American Board of Thoracic Surgery Regarding Trainees and Candidates for Certification Who Are Called to Military Service Related to the War on Terrorism
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The Board appreciates the concern of those who have received emergency calls to military service. They may be assured that the Board will exercise the same sympathetic consideration as was given to candidates in recognition of their special contributions to their country during the Vietnam conflict and the Persian Gulf conflict with regard to applications, examinations, and interruption of training. If you have any questions about how this might affect you, please call the Board office at (312) 202-5900.

Timothy J. Gardner, MD

Chairman

The American Board of Thoracic Surgery


   References
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 Abstract
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 Comment
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 References
 

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