Journal of Surgical Research 156, 110–115 (2009) doi:10.1016/j.jss.2009.04.015
Transection of More Than One Sympathetic Chain Ganglion for Hyperhidrosis Increases the Severity of Compensatory Hyperhidrosis and Decreases Patient Satisfaction1 Benny Weksler, M.D.,*,2 Gayley Blaine, M.S.N., C.R.N.P.,* Zemilson B. B. Souza, M.D.,† and Rodrigo Gavina, M.D.† *Thomas Jefferson University Hospital, Philadelphia Pennsylvania; and †Hospital Quinta D’Or, Rio de Janeiro, Brazil Submitted for publication January 7, 2009
Sympathectomy (ETS) is an effective treatment for hyperhidrosis (HH), but compensatory hyperhidrosis (CH) is a common side effect. We reviewed our experience with 200 patients. Two hundred patients were retrospectively analyzed. Patients completed a questionnaire regarding their postoperative symptoms [% improvement score (IS), CH score], and their level of dissatisfaction, which was assessed as a function of regretting the choice to undergo ETS. Significance set at P £ 0.05. There were 123 (61.5%) females. Mean age was 28.2 ± 7.4. Follow-up (mo) was 20.9 ± 12.1. One ganglion was transected in 112 (56%) patients (G1), and more than one in 88 (G2). Overall, 157 (78.5%) patients had CH, 88 (74.1%) patients in G1 and 74 (84.1%) in G2, P [ 0.06. Patients in G2 had a higher CH score (4.1 ± 2.7 versus 3.0 ± 2.5, P < 0.01), and a higher number of patients regretting surgery (11.4% versus 3.6%, P [ 0.05). Multivariate analysis showed age, high CH score, and surgery on T2 as independent predictors of patient’s dissatisfaction (P < 0.05). Patients with more than one ganglion transected demonstrate a trend toward a higher incidence of CH, a significantly higher CH score, and are more dissatisfied with ETS. Age, surgery on T2, and high CH score are independent predictors of patient’s dissatisfaction. Ó 2009 Elsevier Inc. All rights reserved. Key Words: hyperhidrosis; sympathectomy; compensatory hyperhidrosis; rubor; sympathetic chain.
1 Presented at the 4th Annual Academic Surgical Congress, Fort Myers, Florida, February 4, 2009. 2 To whom correspondence and reprint requests should be addressed at Division of Cardiothoracic Surgery, Thomas Jefferson University Hospital, 1025 Walnut St. Suite 607, Philadelphia, PA 19107. E-mail: [email protected]
0022-4804/09 $36.00 Ó 2009 Elsevier Inc. All rights reserved.
Hyperhidrosis is defined as excessive sweating, beyond physiologic need, in response to thermal or emotional stimuli. It can be defined as primary (idiopathic or essential) or secondary, caused by disease, such as hyperthyroidism, pheochromocytoma, central nervous system lesions, or other diseases. Primary hyperhidrosis (HH) is usually localized to the hands, axillae, face or feet, but may sometimes be generalized. It is a benign disease with disabling social consequences and a welldefined burden to the patient’s social and professional life. The incidence of hyperhidrosis is reported as approximately 2.8% of the population of the Western world with peak incidence at the late second and early third decades of life . The incidence in men and women is the same; however women are more likely to seek medical attention, which may explain the higher incidence of female patients in most surgical series [2–8]. Endoscopic thoracic sympathectomy (ETS) became popular in the 1990s with the advent of fiberoptic technology, and is currently recommended as the surgical procedure of choice for hyperhidrosis . From the 1990s on, sympathectomy became a common method to treat palmar, axillary, and facial hyperhidrosis, as well as rubor facialis. The efficacy and positive impact of ETS on quality of life compared with patients who do not undergo surgery is well established, and supports the use of ETS for the treatment of HH . Compensatory hyperhidrosis (CH) is the most common side effect of ETS, and occurs postoperatively in 30% to 100% of patients [2–4, 7, 8, 11–15]. Although difficult to define, CH is the increase in sweating in other body areas after ETS. It is more common in the torso,
WEKSLER ET AL.: COMPENSATORY HYPERHIDROSIS AND PATIENT SATISFACTION AFTER SYMPATHECTOMY
thighs, and legs, but can occur in any area of the body not denervated by ETS. Most series fail to quantify CH, and frequently patients do not refer to CH unless specifically asked. Therefore, the factors affecting the incidence and severity of CH are not well understood, although several different possibilities have been raised. The most commonly cited factors affecting incidence and severity of CH are age (younger patients show less severe and lower incidence of CH) [16, 17]; T2 sympathectomies (higher incidence and severity of CH) [15, 18]; and the extent of sympathectomy, with more levels operated on associated with worse CH [11, 19, 20]. CH is a major cause for regret after ETS, and represents a challenge to surgeons and patients when weighing the outcomes and possible complications after ETS. Current literature suggests that 4%–16% of all patients undergoing ETS will later regret the surgical procedure [11, 13, 20]. In the last few years, our group has been operating on patients with palmar, axillary, and facial HH, as well as rubor facialis. We routinely perform a T2 sympathectomy for facial HH and rubor facialis, T3 sympathectomy for palmar HH, and T3 and T4 sympathectomy for axillary HH. In patients with multiple sites, we combine multiple levels of sympathectomy. We hypothesized that patients with more than one level sympathectomy will experience subjectively worse CH, and are less satisfied with results from their surgery. We analyzed our experience with 200 consecutive patients operated on by a single surgeon, using subjective reports of postoperative CH and satisfaction with the decision to undergo ETS. MATERIALS AND METHODS This is a retrospective study based on a prospective database. Institutional review board approval was obtained and written informed consent was waived. Two hundred consecutive patients were included. All underwent ETS, performed by the same surgeon, between June of 2003 and May of 2007. Patients were interviewed in July of 2007, and a standard questionnaire was applied, asking each individual to score his/her postoperative resolution of symptoms (improvement score, IS), with complete resolution being scored as 100% and no resolution being scored as 0%. Failure of the procedure was defined as IS equal to or less than 50%. Compensatory hyperhidrosis was graded from 0 to 10, 10 being an unbearable symptom and 0 being no symptom at all. The presence of CH was defined as any score above 0. Patients were also asked to identify the sites of their CH, and to score the severity of the symptom for each site. Finally, patients were asked if they would consider doing the procedure again, or if they regretted undergoing surgery, and why. The same investigator conducted all interviews, in order to maintain similar dialogues and definition of symptoms.
Surgical Procedure Patients had ETS done under general anesthesia with a single lumen endotracheal tube in the supine position with the arms extended. Two 5 mm ports were inserted at the third and the fifth intercostal
space at the mid axillary line, and CO2 was insufflated to a pressure of 6 mm of Hg. After inspection of the pleural cavity, the first rib was identified. Usually, there is a fat pad on top of the first rib, and it cannot be easily visualized. Palpation with an instrument facilitates proper identification. The sympathetic chain was recognized and identified at its crossing with the neck of each rib. Sympathicotomy:  was performed by transecting the sympathetic chain at the neck of the second, third, or fourth rib for a T2, T3, or T4 sympathicotomy, respectively. The periosteum of the rib was incised for approximately 2 cm laterally from the sympathetic chain to transect any rami communicans (Nerve of Kuntz). After the sympathicotomy was completed, a small catheter was inserted into the pleura, and all CO2 and air removed from the pleural cavity. The catheter was removed while the lungs were being inflated to a positive pressure of 25 mmHg. The contralateral side was operated on using the same technique, with the same level sympathectomy.
Statistics All data reported is mean 6 standard deviation of the mean. Means were compared using Student’s t-test. Nominal variables were compared using Pearson c2. Logistic regression and linear regression were used for univariate and multivariate analysis, and results of B or Exp(b) (effect) reported as the 95% confidence interval. SPSS statistical software version 17 (SPSS, Chicago, IL) was used for all statistical analysis. Significance was set at P 0.05, and when P was less than 0.01, it was reported as 0.01. We defined two groups of patients; group 1 had sympathicothomy of only one level, and group 2 had sympathicotomy of more than one level.
There were no deaths or conversion to open procedure. All patients were reached and responded to our questionnaire. Mean follow-up time interval was 20.9 6 12.2 mo. There were 123 women (61.5%) and 77 men (38.5%). Mean age in years was 28.2 6 7.4. The most common site of hyperhidrosis was palmar with 156 (78%) patients, followed by plantar hyperhidrosis with 135 (67.5%) patients, axilla with 85 (42.5%) patients, cranio-facial hyperhidrosis in 22 (11%), rubor facialis in 7 (3.5%), and bromo hidrosis in 7 (3.5%). Most patients complained of hyperhidrosis in two sites (119 patients, 59.5%). An equal number of patients complained TABLE 1 Patient Characteristics Number (%) Age (mean 6 sd) Females Palmar hyperhidrosis Plantar hyperhidrosis Axillary hyperhidrosis Facial hyperhidrosis Rubor facialis Bromo hidrosis 1 site hyperhidrosis 2 sites hyperhidrosis 3 Sites hyperhidrosis 4 sites hyperhidrosis
28.2 6 7.4 123 (61.5) 156 (78) 135 (67.5) 85 (42.5) 22 (11) 7 (3.5) 7 (3.5) 40 (20) 119 (59.5) 40 (20) 1 (0.5)
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TABLE 2 Sympathetic Chain Levels Transected
N Female Age (mean 6 sd) CH Score (mean 6 sd)
16 8 (50%) 32 6 6.4 3.9 6 .5
96 68 (70.8%) 28.1 6 7.4 2.9 6 2.5
7 3 (42.9%) 33.7 6 4.6 6.4 6 1.8
77 42 (54.6%) 26.9 6 7.2 3.9 6 2.7
4 2 (50%) 33.7 6 10.5 4.25 6 4
CH score ¼ compensatory hyperhidrosis score.
of symptoms in one or three sites (40 patients each, 20%), and one patient complained of symptoms in four site (0.5%). Table 1 summarizes patients’ characteristics. The most common operation performed was sympathicotomy of only one level, in 112 patients (56%), followed by a two level sympathectomy in 84 patients (42%), and three levels in four patients (2%). Table 2 is a summary of sympathetic chain levels transected during sympathicotomy. Overall, 24 patients (12%) had some form of complication, the most common being unilateral upper limb transitory neuritis (Table 3). Compensatory hyperhidrosis was present in 157 patients (78.5%), and the mean score was 3.51 6 2.7 for all patients. However, among patients with CH, the score was 4.5 6 2.2, and it was considered severe (score 7) in 28 patients (14% of all patients), moderate (score <7, 4) in 72 patients (36% of all patients), and mild (score <4 and >0) in 57 patients (28.5% of all patients). The most common sites of CH are shown in Table 4. Improvement scores as graded by patients per site are displayed in Table 5. The best results were achieved in patients with palmar hyperhidrosis and bromo hidrosis, and the worse in patients with axillary hyperhidrosis. Although we did not operate on patients for plantar hyperhidrosis, we include the results for completion sake. The majority of patients (187, 93.5%) were satisfied with
their surgical results. A total of 13 patients (6.5%) regretted being submitted to ETS, the majority (11 patients 84.6%) due to severe CH. Other causes of regret were pain and recurrent symptoms in one patient each. Based on the number of levels transected during sympathectomy, patients were classified into two groups: group 1 had sympathicotomy of only 1 level, and group 2 had sympathicotomy of more than one level. The patients’ characteristics in each group are described in Table 6. Overall, 83 patients (74.1%) in group 1 had CH compared with 74 patients (84.1%) in group 2 (P ¼ 0.06). CH score was significantly higher in patients in group 1 compared with patients in group 2 (3.0 6 2.5 versus 4.1 6 2.7, P < 0.01). Satisfaction with the procedure was also higher in patients in group 1 compared with patients in group 2 (96.4 versus 89.8, P ¼ 0.05). A summary of those results is presented in Table 7. We conducted a univariate and a multivariate analysis to further clarify the factors leading to the incidence of CH, the CH score, and regret after ETS. Results are presented in Tables 8, 9, and 10. Age was the only independent predictor of CH in multivariate analysis. Age and sympathectomy on more than one level were independent predictors of a high CH score, and operations on T2 and a high CH score were independent predictors of patient dissatisfaction after surgery. DISCUSSION
ETS is safe and highly effective in the treatment of HH. The approach is predicated on the interruption of
Complications Complication Neuritis lasting >4 wk
N (%) 10 (5%)
Pneumothorax requiring chest tube Non resolution of symptoms requiring reoperation
Temporary Horner’s syndrome Wound infection Drug allergy Respiratory failure requiring admission to ICU
All patient were symptom free at last follow-up
One patient with facial hyperhidrosis and one with palmar hyperhidrosis
1 (0.05) 1 (0.05) Allergy to pain medication 1 (0.05) Patient smoked up to the day of surgery. Did not require intubation
Sites of CH Site
Back Abdomen Chest Legs Thighs Groin Feet Gluteus Perineum
127 (63.5) 96 (48) 53 (26.5) 37 (18.5) 31 (15.5) 7 (3.5) 7 (3.5) 4 (2) 1 (0.5)
WEKSLER ET AL.: COMPENSATORY HYPERHIDROSIS AND PATIENT SATISFACTION AFTER SYMPATHECTOMY
Satisfaction After ETS by Site of Primary Complaint Site
IS (mean 6 sd)
Palmar hyperhidrosis Bromo hidrosis Rubor facialis Craniofacial hyperhidrosis Axillary hyperhidrosis Plantar hyperhidrosis
97.8 6 10.8 97.1 6 7.6 96.4 6 12.1 93 6 19.0 86.4 6 22.4 39.1 6 31.6
2 (1.3) 0 0 2 (10) 10 (11.8) 101 (70.1)
IS ¼ improvement score. Failure: number of patients reporting 50% or less improvement in their symptoms.
impulses transmitted to eccrine sweat glands in the hand, axillae, and craniofacial areas. We describe the postoperative experiences of 200 consecutive, unselected patients operated on for HH and rubor facialis. While most patients were operated on for palmar HH, craniofacial and axillary HH are well represented. The analysis on this diverse population allows us to account for several different variables that may be important for the postoperative occurrence of CH and patient’s dissatisfaction (regret). Although highly effective in improving quality of life in patients with HH, ETS still poses challenges to surgeons and patients. CH, a common side effect of surgery, is a disturbing symptom that leads to patient’s dissatisfaction. One common explanation for CH is the simple redistribution of sweat from areas denervated by ETS to areas still under sympathetic control . Accordingly, the total amount of sweat produced by the body does not change, but it is redistributed to other areas, causing the sensation of increased overall sudoresis. While attractive, this hypothesis seems overly simplistic considering the wide variation in the incidence of CH in the different series. Another interesting hypothesis is that CH is caused by the interruption of the feedback mechanism to the hypothalamus. Afferent signals from different body parts are transmitted through the sympathetic chain as positive and negative feedback signals. Interruption of one or more of the sympathetic ganglia causes interruption in the negative feedback mechanism with a predominance of positive feedback. However, if the sympathectomy is at the level of the fourth sympathetic ganglia, both the second and third
CH and Patient Satisfaction
CH CH score Regret surgery
83 (74.1%) 3.0 6 2.5 4 (3.6%)
74 (84.1%) 4.1 6 2.7 9 (10.2%)
0.06 0.01 0.05
CH is defined as any score above zero.
ganglia are still intact, with a predominance of negative feedback stimuli. Results from the proponents of this theory could not fully support this hypothesis . It is probable that the mechanism of CH is multifactorial and, thus, difficult to quantify. Our cohort shows an incidence of CH of 78.5% and an incidence of patients regretting surgery of 6.5%, which is well within the current reports in the literature [2, 3, 8, 11–15, 20]. Our initial data analysis showed that patients with transection of more than one level of the sympathetic chain during ETS reported a higher CH score and a higher dissatisfaction rate. Probing the data further, it became clear that dissatisfaction and the CH score are highly correlated, and dissatisfied patients will clearly show a higher CH score. Milanez de Campos  retrospectively evaluated patients who were operated on for axillary HH, and found that operating on T4, as opposed to T3/T4, decreases the incidence and severity of CH, improving patients satisfaction. The same group  was able to demonstrate similar results on a randomized trial of patients submitted to T4 ETS only versus patients submitted to T3/T4 ETS. Chang , compared T4 sympathectomy with T2/T3 sympathectomy for palmar HH. Multivariate analysis confirmed that a less extensive sympathectomy was the only factor predicting the extent (severity) of CH, and that the severity of CH and palmar over dryness predicted patient’s dissatisfaction. This study could not isolate the effect of T2 sympathectomy on CH or dissatisfaction. Others have also shown that restricting the extent of the sympathectomy will decrease either the incidence and/or the severity of CH [11, 23, 24]. However, Leseche  could not demonstrate differences in the incidence TABLE 8 Factors Leading to the Presence of CH After ETS
N (%) Age (mean 6 sd) Female (%) n.s., P > 0.05.
112 (56) 28.6 6 7.3 76 (67.9)
88 (44) 27.7 6 7.4 41 (46.6)
Age Male gender T2 >1 level
1.07 1.22 2.40 0.54
1.01–1.13 0.60–2.46 0.69–8.40 0.27–1.10
0.01 0.58 0.17 0.09
1.07 1.05 1.79 0.49
1.01–1.13 0.50–2.20 0.49–6.59 0.23–1.03
0.01 0.89 0.38 0.06
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TABLE 9 Factors Affecting CH Score After ETS Univariate Factor
Age Male gender T2 >1 level
0.20 0.14 0.16 (–0.20)
95% CI 0.26–0.13 >0.28–1.54 0.18–2.33 (–1.78)–(–0.31)
of CH or severe CH among patients undergoing resection of two, three, or more than three ganglia. In a multivariate analysis, age was the only factor predicting the incidence of CH, with younger patients having less CH. It appears that age is an important factor in the development of CH, and Cohen , studying 223 pediatric patients, reported an incidence of CH of les than 10%, and dissatisfaction of less than 2%, numbers significantly better than in the adult population, and recommended early sympathectomy on children suffering from HH. Dewey  was an early investigator to suggest the operations on T2 increased the severity of CH, and decreased patient’s satisfaction. This has been shown by different investigators. Reisfeld , clipping the sympathetic chain at T3/T4 as opposed to T2/T3, decreased CH severity, and improved patient’s satisfaction. In a randomized trial, Yazbek  clearly showed that avoiding the T2 ganglia improved the incidence and severity of CH, and improved patient satisfaction. Strategies to minimize CH and thereby lower postoperative CH score will certainly improve patient’s satisfaction with ETS. It is not clear how to achieve this goal, however, our data suggest that operating early on affected patients, minimizing extensive sympathectomy, and avoiding operations on T2 when possible, may lead to a reduction in the incidence and severity of CH, and improve patients’ satisfaction. This approach poses difficult choices for surgeons and patients. For example, patients with rubor facialis or craniofacial HH for whom T2 sympathectomy or sympathicotomy is TABLE 10 Factors Affecting Patient’s Satisfaction After ETS Univariate
0.003 0.04 0.02 0.005
0.19 0.10 0.11 (–0.20)
0.02–0.13 (–0.20)–1.28 (–0.21)–1.93 (–1.77)–(–0.32)
0.01 0.15 0.12 0.01
indicated should be informed of their high risk for dissatisfaction related to CH, in spite of the fact that their presenting symptoms will resolve in almost 100% of the cases, as shown by us and others . In other instances, such as axillary hyperhidrosis, surgeons should limit the sympathectomy to T4, as opposed to T3 and T4, decreasing the amount of sympathetic chain affected and, in consequence, decreasing CH score and dissatisfaction. A controversial recommendation would be to treat HH early, operating on patients while still young, at puberty or even prior to the onset of puberty. In summary, ETS is safe and effective procedure for HH and rubor. The main side effect is CH, which is tolerable by most patients. Less than 10% of patients will report regret over having surgery. Limiting the extent of the sympathectomy, avoiding the T2 ganglia, and operating early on patients with HH and rubor, will bring a reduction in the incidence and severity of CH, and provide patients with a higher level of satisfaction after the surgical procedure.
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0.59 0.24 0.04 0.35 1.0 0.01
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