The results of a long term follow-up of bilateral single port sympathicotomy in primary hyperhidrosis - should we perform this surgery

Research article
The Results of a Long-Term Follow-up of Bilateral Single Port
Sympathicotomy in Primary Hyperhidrosis: Should We Per-
form This Surgery?
Timuçin ALARa*
, İsmail Ertuğrul GEDİKa
Abstract
Background: Hyperhidrosis (HH), which refers to excessive sweating of the body in response to temperature or
emotional stimuli rather than physiological stimuli, can adversely affect quality of life. In this prospective study,
we investigated the long-term effects, development of complications, and patient satisfaction among those who
underwent bilateral single-port endoscopic thoracic sympathecotomy (ETS) for HH.
Methods: Thirty-one patients who underwent bilateral single-port endoscopic thoracic sympathicotomy (ETS)
for HH between January 200 and November 2014 were enrolled in this study. The patients wer1e followed up
until July 2017. Patient satisfaction in terms of the primary complaint (PC) and complications, such as compen-
satory hyperhidrosis (CH), in the short and long term were recorded.
Results: The mean follow-up period was 60.6 ± 12.8 (min: 40, max: 89) mo postoperatively. When both the
short- and long-term results were evaluated together, CH had no effect on patient satisfaction. However, per-
sistence of the PC in both the short (p = 0.020) and long term (p = 0.001) had a significant effect on satisfaction.
Conclusion: The most important factor affecting patient satisfaction was PC persistence. Thus, further studies
should be performed to enlighten this complication. even though it may remit with time. Whether ETS is a per-
manent treatment that cannot successfully treat PC, possible complications and the ability to cope with them
will seem to be open to debate as the most important issues that surgeons will have to face in the near future.
Keywords: Complication; hyperhidrosis; surgery; sympathicotomy
INTRODUCTION
Hyperhidrosis (HH) can be described as excessive
sweating of the body that exceeds physiological needs
[1]
. Hyperhidrosis may be primary or secondary. Prima-
ry HH is the result of to overactivity of the sympathetic
nervous system, whereas secondary HH is caused by
various factors, such as malignancies, endocrine dis-
orders (e.g., thyrotoxicosis), and some medications [1-3]
.
Primary HH affects facial, palmar, axillary, and plantar
regionsofthebody,exhibitingregionalandsymmetrical
involvement patterns due to sympathetic nervous sys-
tem overactivity [1,2]
.
Hyperhidrosismaybetreatedviamedicalorsurgicalap-
*Corresponding author: Timuçin ALAR
Mailing address: Department of Thoracic Surgery, Çanakkale On-
sekiz Mart University Medical Faculty, Çanakkale Onsekiz Mart
Universitesi Tıp Fakultesi Gogus Cerrahisi Anabilim Dalı Terzioglu
Girisi, Çanakkale,17100,Turkey.
E-mail: timalar@yahoo.com
Received: 24 October 2019 Accepted: 25 November 2019
proaches. Endoscopic thoracic sympathecotomy (ETS)
is the most commonly used type of surgical treatment
today.Thesurgerycanbeperformedinavarietyofways,
such as dissecting the sympathetic chain in the thoracic
region, thermal damage via electrocautery, or clipping.
Among various ETS-related complications, which in-
clude a hemo-pneumothorax, Horner’s syndrome, and
bradycardia,themostimportantintermsofbothpatient
and physician satisfaction is compensatory hyperhidro-
sis (CH) [4,5]
.
In this prospective study, we investigated the rate of
complications, such as CH, and PC persistence in the
long-term postoperative period following bilateral sin-
gle port ETS and the effects of these complications on
patient satisfaction.
METHODS
Patients who had undergone single port ETS between
January2010andNovember2014atÇanakkaleOnsekiz
Mart University Medical Faculty Thoracic Surgery Clinic
were prospectively followed up until July 2017. During
outpatient clinical examinations and telephone inter-
a
Department of Thoracic Surgery, Çanakkale Onsekiz Mart University Medical Faculty, Çanakkale, 17100, Turkey.
Creative Commons 4.0
Clin Surg Res Commun 2019; 3(4): 26-30
DOI: 10.31491/CSRC.2019.12.041
Timuçin ALAR et al 26

views, the patients were questioned about changes in
CH and their PC in the postoperative period and their
satisfaction with the operation.
In the 6 mo prior to the single port ETS, all the patients
had received medical treatment. Despite this treatment,
none of the patients experienced improvements in their
PC. Prior to surgery, informed consent was obtained
fromeachpatient.InpatientswithHHaffectingmultiple
areas, only the area most affected was treated. The ETS
was performed using a 10-mm 0-degree thoracoscope
(Karl Storz 26034 AA) with a 6-mm working channel
under general anesthesia via a double-lumen endotra-
cheal tube. After the patient had been positioned in the
lateral decubitus position, a single thoracoport (width:
10.5 mm) was inserted into the thorax through a sin-
gle incision of 11 mm at the intersection of the fourth
intercostal space and mid-axillary line (Figure 1). The
sympathetic chain was cauterized by endoscopic elec-
trocautery from the T2 for fascial hyperhidrosis, T3 for
palmar hyperhidrosis, T4 for axillary hyperhidrosis,
and T5 for plantar hyperhidrosis. In addition, during
the sympathecotomy of the T2-T3, the presence of the
nerve of Kuntz was verified, and the nerve tissue was
cauterized. The rib bed was cauterized laterally for an
additional 2 cm to allow the dissection of possible by-
passing nerve fibers. After hemorrhage control, the air
in the pleural cavity was evacuated via a small catheter.
The incision line was closed by subcutaneous suturing,
and the same procedure was repeated on the other side.
On the postoperative first day, the patients were eval-
uated by a physical examination, posterior-anterior
chest X-ray, hemogram, and blood biochemistry tests.
Patients whose physical examination and examination
resultsrevealednoabnormalitiesweredischargedfrom
the hospital on the first postoperative day. The patients
were referred to the outpatient clinic on the seventh
postoperative day and reevaluated via a physical exam-
ination and posterior-anterior chest X-ray. In the third
postoperative month and again in the third postopera-
tiveyear,allthepatientswereinterviewedbytelephone.
They were questioned about their HH status, CH status,
and satisfaction with the operation. They were asked to
rate their HH at the site of the PC from 0 to 10, where 0
represented no sweating, and 10 represented the most
severe sweating.
The follow-up times were from the date of the opera-
tion to the last follow-up date (July 2017), expressed in
months.Subsequently,cutoffvaluesat48,60,and72mo
were coded as a dichotomous variable for those below
and above the follow-up period. The following parame-
ters were coded as dichotomous variables: CH, PC, and
patient satisfaction. In terms of the latter, on the day of
the interview, the patients were asked whether, given
the choice, they would undergo the surgery again. The
CH and PC intensities were coded as continuous vari-
ables ranging from 1 to 10.
The data were then transferred to a digital medium. The
normal distribution matching of the continuous vari-
ables was examined for the frequency and distribution
of variables. The relations between the continuous vari-
ableswereanalyzedusingappropriatecorrelationtests,
and the relations between the dichotomous variables
were analyzed using a chi-square test and, if necessary,
Fisher’s exact test. In all the analyses, statistical signifi-
cance was accepted as a p-value of < 0 .05. The absolute
p values are given for the analysis results.
RESULTS
Thirty-one patients who underwent bilateral single
port ETS at Çanakkale Onsekiz Mart University Medi-
cal Faculty Chest Surgery Clinic between January 2010
and November 2014 were included in the study. Sixteen
(51.6%) of the patients were males, and 15 (48.4%)
were females. The mean age of the patients was 24.13 ±
4.64 (min: 13, max: 34) y. In terms of the site of the PC,
it was craniofacial in 6.5% (n = 2) of cases, palmar-facial
in 12.9% (n = 4) of cases, palmar in 67.7% (n = 21) of
cases, axillary in 9.7% (n = 3) of cases, and palmoplantar
in 3.2% (n = 1) of cases.
The postoperative complications were a pneumothorax
in one patient and a hemopneumothorax in one patient.
Tube thoracostomy was performed in the patient who
developedahemopneumothorax,andairevacuationvia
thoracentesiswasperformedintheotherpatient.Allthe
other patients were discharged on the first postopera-
tive day. Thus, the average duration of the hospital stay
was 1.13 ± 0.56 (min: 1, max: 4) d. The mean follow-up
period was 60.6 ± 12.8 (min: 40, max: 89) mo postop-
eratively.
When the patients were questioned about their PC sta-
tus, 10 (32.3%) of the 31 patients responded that their
Figure 1. Thoracoscope Insertion Through Single Port Incision.
ANT PUBLISHING CORPORATION
Published online: 27 December 2019

PC was not resolved. The remaining 21 cases respond-
ed that their PC was in remission. Among patients with
a persistent PC, the most frequent site was palmar HH
(Table 1).
When the patients were asked about their CH status in
the postoperative third-month, 15 (48.4%) of the 31
patients reported that they had developed CH. When
questioned about the severity of the CH, the severity
ranged from 3–10, with the most frequent CH site being
the dorsal region (Tables 2 and 3).
At the time of the final interview in July 2017, the pa-
tients were questioned about their satisfaction with the
surgery. Six (19%) of the 31 patients were dissatisfied
withthesurgery,and81%ofpatientsweresatisfied.Five
ofthesix(83%)patientswhowerenotsatisfiedwiththe
surgeryhaddevelopedCH,andthePCwasunresolvedin
five of these six (83%) cases (Tables 4 , 5). In total, sev-
en patients indicated that if given the choice today, they
would not have the surgery. Two of these seven patients
developed CH postsurgery, and the PC was unresolved
in the other five cases. One patient who was satisfied
with the surgery reported that he would not undergo
this surgery today. This patient had some relief from his
PC, but it was not completely resolved.
When the long-term follow-up of the cases was exam-
ined, the PC was resolved in two patients, and CH devel-
opedinthreepatients.Intotal,therewere8(25%)cases
of PC persistence and 18 (58%) cases of CH persistence.
PersistenceofthePCaffectedpatientsatisfactioninboth
the short (p = 0.007) and long term (p = 0.001). In con-
trast, CH had no effect on patient satisfaction in either
the short (p = 0.083) or long term (p = 0.359).
DISCUSSION
Although the precise pathophysiological mechanism in
HH is not known, excessive stimulation of thermoregu-
latory and emotional sweating control centers or exces-
sive secretion of acetylcholine by the sympathetic ner-
vous system in response to stimulation of these centers
may play a role [3]
. Individuals with primary HH, which
usually begins in childhood or adolescence, generally
consult a physician because of psychosocial problems
caused by HH [6]
.
Medical therapy options for HH include topical or sys-
temic antiperspirants, iontophoresis, botulinum toxin
injections, laser therapy, and microwave therapy[6]
. Top-
ical antiperspirant agents consist of a 20% solution of
aluminum hydrochloride [7]
. Topical and systemic forms
of anticholinergics include glycopyrrolate and oxybu-
tynin [7]
. Iontophoresis is the treatment of choice for
palmoplantar HH. The treatment is based on the prin-
ciple that the palmoplantar zone is kept in tap water
in which a low voltage electrical current is applied for
about 30 min [8,9]
. Botulinum toxin A injections are used
as a treatment for both palmoplantar and axillary HH.
These provide a longer remission time than any other
medical treatment, with remission of HH for about 6 mo
Region n %
Craniofacial 1 10
Palmar 5 50
Axillary 3 30
Plantar 1 10
Total 10 100
Table 1. Regional Distribution of Ongoing Hyperhidroses.
Severity n %
3 1 6.8
4 2 13.3
5 2 13.3
6 2 13.3
7 3 20
8 3 20
10 2 13.3
Total 15 100
Table 2. The Distribution of the Severity of Compensatory
Hyperhidrosis.
Location n %
Dorsal 9 60
Abdomen 3 20
Chest 3 20
Total 15 100
Table 3. The Regional Distribution of Compensatory Hyperhidrosis.
Primary complaint
- + Total
Satisfaction
No 1 5 6
Yes 20 5 25
Total 21 10 31
Table 4. Primary Complaint versus a Satisfaction Cross Table.
*p > 0.05, Fisher’s exact test value 0.007.
Compensatory Hyperhidrosis
- + Total
Satisfaction
No 1 5 6
Yes 15 10 25
Total 16 15 31
Table 5. Compensatory Hyperhidrosis versus a Satisfaction.
*p > 0.05, Fisher’s exact test value 0.083.
DOI: 10.31491/CSRC.2019.12.041

post-treatment [10]
. In terms of laser treatment, a neody-
niumyttriumaluminumgarnetlaserisusedforHH[11]
.In
microwave therapy, thermolysis of eccrine sweat glands
is conducted. The main difference of this method is that
it is irreversible [12]
. The main disadvantage of medical
treatments for HH as compared to surgical treatment is
that medical therapy offers only a temporary solution
to an ongoing problem, and the treatments have to be
repeated. An important advantage of medical therapy
versus surgical treatment is the absence of CH, which is
acomplicationofsurgery.Forthisreason,allHHpatients
are advised to receive medical treatment for at least 6
mo before considering surgery. If the medical treatment
is unsuccessful, with success defined as patient satisfac-
tion, surgery is an option. In the present study, none of
the patients had satisfactory outcomes prior to under-
going surgery.
CH, a complication of ETS, refers to excessive sweating
affecting various parts of the bodys. The mechanism un-
derlying the development CH is not known. Although
some authors have argued that this condition develops
because of negative feedback stimuli of the sympathetic
chain cannot reach the hypothalamus, there is no scien-
tific evidence to support this hypothesis [13,14]
. Approxi-
mately 3–98% of patients develop CH after ETS, and it
is most commonly observed in the trunk area. It is not
possible to predict who may develop CH and how severe
it may become [4,5,13,15]
. Although some studies showed
that a sympathecotomy at the T2 level or a sympathec-
tomy at multiple levels and older age increased the risk
of developing CH, other studies contradicted these find-
ings [13,16-18]
. In our study, in the short term, the rate of
CH was 48%, whereas it was 58% in the long term. CH
developed most commonly in the trunk region, similar
to the scientific literature on this subject.
Previous research reported that the development of CH
and PC persistence were the two most important fac-
tors affecting patient satisfaction after ETS operations.
In the literature, the reported rates of PC persistence
range from 0 to 21.4% [13,17,19]
. The rates in the present
study were comparable to those found in the literature,
with rates of 32% in the short-term follow up and 25%
in the long-term follow up. An interesting finding in the
present study was that PC persistence was the most im-
portant factor affecting patient satisfaction in the long
term.
In previous studies on HH, the postoperative follow-up
period was less than 1 y, with most follow-ups lasting
approximately 6 mo. Thus, knowledge is limited on the
status of HH among these patients over the long term.
In the present study, the patients were followed up for
a mean of 60 mo. As shown by the results, an increase
in the rate of CH did not increase patient satisfaction. In
contrast,whileadecreaseinPCwasobserved,therewas
alsoadecreaseinthepatientsatisfaction.Thus,themost
important factor affecting patient satisfaction was con-
tinuation ofthePCincontrasttoourcurrentknowledge.
Accordingtoapreviousstudy,theresultsofintermittent
unilateralETSforreducingCH,whichaffectspatientsat-
isfaction in the short term, are promising, although the
duration of the follow-up in the study was only 1 y [20]
.
However,thehospitalcostsassociatedwithintermittent
unilateralETSseemtobedisadvantages,withtheproce-
dure requiring two surgeries, two anesthesia sessions,
and two hospitalizations. We believe that the primary
goal of surgery should be complete resolution of the PC.
Self-remission of the PC with age should also be seen as
a disadvantage for the ETS [21]
. The possibility that the
PC may regress in time, combined with the fact that PC
persistence rather than CH affects patient satisfaction,
casts doubts on the feasibility of ETS for HH.
The present study has some limitations. The number
of cases (N = 31) may be considered low as compared
with that in other studies on ETS. In addition, we did
compare the ETS method with medical treatment meth-
odsintermsofpatient satisfaction.Furthermore,wedid
not use standardized questionnaires to assess quality
of life and patient satisfaction with ETS. Thus, the an-
swers we obtained in our interviews may be considered
“subjective.” As with all forms of “satisfaction,” the term
“patient satisfaction” is subjective. The development of
standardized questionnaires on quality of life and pa-
tientsatisfactionwithETSwouldimprovetheobjectivity
of patient responses.
CONCLUSION
ForHH,ETSistheonlytreatmentthathasbeenprovento
be successful in the long term. The two most important
factors affecting patient satisfaction after ETS are the
continuation of the PC and CH. Intermittent unilateral
ETS may be considered an alternative surgical approach
for CH, although the likelihood of CH may increase in the
long term. Furthermore, the PC of HH may regress with
age. This treatment should be described as temporary
(at least until the end of the adolescence period) rath-
er than permanent. The decision whether to perform
this surgery is up to the surgeon. However, the decision
whether to be treated with surgery for HH should be the
patients after all these data have been conveyed.
DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and de-
sign of the study and performed data analysis and inter-
pretation: Alar T and Gedik İ E.
Performed data acquisition, as well as provided admin-
istrative, technical, and material support: Alar T and
ANT PUBLISHING CORPORATION
Published online: 27 December 2019

Gedik İ E.
Conflicts of interest
Allauthorsdeclarethattherearenoconflictsofinterest.
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DOI: 10.31491/CSRC.2019.12.041

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