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Changes in the quality of life following surgery for hyperhidrosis

April 2020
Shanghai Chest 4:20-20

DOI:10.21037/shc.2019.12.03

Authors:

Davide Patrini

University College London Hospitals NHS Foundation Trust

Iulia Bujoreanu

Imperial College London

Savvas Lampridis

Imperial College London

José Ribas Milanez De Campos

University of São Paulo

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Hyperhidrosis is characterized by diaphoresis that is unrelated to the physiological thermo-regulatory requirements of the body. Primary hyperhidrosis is caused by an idiopathic overactivity of the sympathetic nervous system and can affect the axillae, in more than half of the cases, palms, soles and face. As a result, patients may develop psychologic disorders, such as anxiety and depression, or experience impaired quality of life (QOL). Set of indicators were therefore introduced to describe the relationship between QOL post-surgery for hyperhidrosis and daily life. Recently a World Health Organization study group developed a questionnaire made of 100 question ranging from physical, psychological, environmental and spiritual aspects (WHOQOL0-100); this has been followed by a shorter one (WHOQOL BREF) easier to be completed maintaining the same standard of psychometric assessment. This is made of 26 questions covering the same aspects as the WHOQOL-100 representing however a generic tool to assess QOL. Nevertheless there are other QOL indicators that have to be considered when assessing the impact of primary hyperhidrosis (PH) and postoperative status following surgery for PH.

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Page 1 of 5

Introduction

Hyperhidrosis is characterized by diaphoresis that

is unrelated to the physiological thermo-regulatory

requirements of the body. Primary hyperhidrosis is caused

by an idiopathic overactivity of the sympathetic nervous

system and can affect the axillae, in more than half of

the cases, palms, soles and face (1). As a result, patients

may develop psychologic disorders, such as anxiety and

depression, or experience impaired quality of life (QOL).

It is estimated that approximately 1–1.6% of the

population in the United Kingdom and the US seek medical

advice for excessive sweating (2). Recently, a sample of the

US population was studied using a questionnaire, which

aimed to establish the patient’s self-perception in relation to

their sweat. The authors found that the prevalence of self-

reported hyperhidrosis was as high as 4.8% and only 51%

of these patients had tried talking about this problem with a

healthcare professional (1).

Disease can range in severity and QOL is a main

indicator for physical, mental and emotional well-being.

As excessive sweating is associated with discomfort and

embarrassment, this interferes with the activities of daily

living and affects work, leisure and social activities. The

psychosocial aspect must not be left aside; patients with

palmar primary hyperhidrosis, may struggle to manipulate

Review Article

Changes in the quality of life following surgery for hyperhidrosis

Davide Patrini1, Iulia Bujoreanu2, Savvas Lampridis1, José Ribas Milanez de Campos3, Benedetta Bedetti4,

Hugo Veiga Sampaio da Fonseca3, David Lawrence1, Paulo Kauffman5,6, Nelson Wolosker5,6

1Thoracic Surgery Division, University College London Hospitals (UCLH), London, UK; 2Department of Cancer and Surgery, Imperial College

London, London, UK; 3Thoracic Surgery Division, Heart Institute/Clinics Hospital from University of São Paulo Medical School, São Paulo, Brazil;

4Thoracic Surgery Division, Malteser Hospital, Bonn, Germany; 5Vascular Surgery Division, Albert Einstein Israelite Hospital, São Paulo, Brazil;

6Vascular and Endovascular Division, Clinics Hospital from University of São Paulo Medical School, São Paulo, Brazil

Contributions: (I) Conception and design: D Patrini, JRM de Campos; (II) Administrative support: D Lawrence; (III) Provision of study material

or patients: P Kauffman, N Wolosker; (IV) Collection and assembly of data: B Bedetti, HVS da Fonseca; (V) Data analysis and interpretation: I

Bujoreanu, S Lampridis; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Mr. Davide Patrini, MD. UCLH in Westmoreland St. 16-18 Westmoreland St., W1G 8PH London, UK.

Email: davide.patrini@nhs.net.

Abstract: Hyperhidrosis is characterized by diaphoresis that is unrelated to the physiological thermo-

regulatory requirements of the body. Primary hyperhidrosis is caused by an idiopathic overactivity of the

sympathetic nervous system and can affect the axillae, in more than half of the cases, palms, soles and face. As

a result, patients may develop psychologic disorders, such as anxiety and depression, or experience impaired

quality of life (QOL). Set of indicators were therefore introduced to describe the relationship between QOL

post-surgery for hyperhidrosis and daily life. Recently a World Health Organization study group developed a

questionnaire made of 100 question ranging from physical, psychological, environmental and spiritual aspects

(WHOQOL0-100); this has been followed by a shorter one (WHOQOL BREF) easier to be completed

maintaining the same standard of psychometric assessment. This is made of 26 questions covering the same

aspects as the WHOQOL-100 representing however a generic tool to assess QOL. Nevertheless there are

other QOL indicators that have to be considered when assessing the impact of primary hyperhidrosis (PH)

and postoperative status following surgery for PH.

Keywords: Hyperhidrosis; sympathectomy; quality of life (QOL); surgery

Received: 29 September 2019; Accepted: 29 November 2019; Published: 10 April 2020.

doi: 10.21037/shc.2019.12.03

View this article at: http://dx.doi.org/10.21037/shc.2019.12.03

Shanghai Chest, 2020Page 2 of 5

papers and other similar materials. The perception for this

condition is not suffered only by the patients but also to

those around them triggering anxiety, suffering leading to

isolation without considering the fact that this condition

can be also be considered disabling or even dangerous in

certain aspect of the professional sphere.

Axillary primary hyperhidrosis is the most common

type and it also has a debilitating social impact. Bechara

et al. assessed fifty-one patients with axillary primary

hyperhidrosis. Following nine months of treatment, QOL

questionnaires were used to evaluate the outcomes. The

conclusion was that surgical therapy could reduce by almost

80% the disabilities caused by excessive axillary PH (3).

Craniofacial primary hyperhidrosis, with or without

blushing, is considered embarrassing on a social and

professional level. It can also be associated with social

phobia and anxiety disorders, and it can aggravate

psychiatric disorders. We can conclude that craniofacial PH

has a deep impact in the psychic of the patient considering

the steep decrease in QOL observed (4).

Whereas no evidence is given that primary hyperhidrosis

is a psychiatric disorder, these individuals might be at an

increased risk of developing certain psychological disorders

such as anxiety (5). For this reason, QOL assessments

are a valid indicator of psychosocial impact in primary

hyperhidrosis.

Minimally invasive thoracic sympathectomy (VATS) is

considered to be the safest and most effective treatment of

PH both in adults and children. Although different studies

suggest that the surgical management can be offered in

the treatment of patients from the age of five, VATS is

classically offered to in children over 7 in order to restore

stable psychomotor development (6).

Evaluation of the QOL in patients with

hyperhidrosis

Different studies applied adapted questionnaires to assess

QOL following sympathectomy for primary hyperhidrosis

(7-10). Questionnaires like the Medical Outcomes Study

Short Form 36 (SF-36), the Spielberger State Trait Anxiety

Inventory (STAI), the Zung Self-Rating Depression Scale

(SDS), and the Dermatology Life Quality Index (DLQI):

despite the easy applicability and relatively good validation

through clinical studies, these adapted questionnaires are

limited in primary hyperhidrosis due to its complexity and

specicity. Despite their limitations, the benets of VATS

in improving QOL in primary hyperhidrosis patients are

unquestionable, especially when evaluating the emotional

and social aspects in the patient experience.

As a consequence to accurately assess QOL in patients

with primary hyperhidrosis we strongly believe that a

specic questionnaire is required. Amir et al. describes the

early stages of preparing a specic health questionnaire to

assess the impact of primary hyperhidrosis on the QOL

of these patients (11). We therefore developed the first

questionnaire specically tailored to assess QOL in patients

with primary hyperhidrosis following VATS.

The initial design by Amir et al. included two psychology

students interviewing primary hyperhidrosis surgery

candidates from fifteen to thirty-five years old from a

wide range of social backgrounds. Patients were then

invited to include all the situations they think are affected

by the primary disorder ranging from work, personal,

interpersonal and leisure. The interviewers assisted by

a multidisciplinary team of psychologist, psychiatrist

and surgeon reviewed all the interviews identifying four

domains as the most important: social, functional, social

and emotional. Emotion was divided into two areas: “self-

emotional”, the assessment of how primary hyperhidrosis

emotionally impacts patients; and “other-emotional”, to

evaluate patients’ feeling about what the outer environment

think about their problem. These areas were further dened

by taking into consideration the various situations in which

primary hyperhidrosis decisively interfered in the QOL

of patients. However, a major downside of the Amir et al.

study, recognized by the authors, was selection bias, as it

looked at patients with more severe disease.

Methods

Specic QOL questionnaire for hyperhidrosis: our experience

Considering our previous studies, we decided to split our

questionnaire into four domains: functional social, personal,

self-emotional and we also included special conditions that

may have an impact on QOL. The rst QOL questionnaire

assessment was performed prior to the patient’s initial

consultation. Each patient received a handbook with

information about primary hyperhidrosis and the different

options of clinical and surgical treatment. Additional

information included: expected results, complications, and

post-operative complications. Following consultation and

physical examination, surgical indication was confirmed

and patient electively was booked for surgery. In the first

30 postoperative days, patients answered the second part

Shanghai Chest, 2020 Page 3 of 5

of the questionnaire. The last postoperative questionnaire

was delivered telephonically by a nurse—an independent

observer without access to patient's records, after a

minimum period of ve years.

In order to evaluate the efcacy of treatment for primary

hyperhidrosis is important to compare variations of QOL

and its various aspects at different follow up periods. The

protocol described below was based on analysis of QOL

questionnaires proposed by the expert consensus of the

Society of Thoracic Surgeons published in the Annals

of Surgery in 2011 for surgical treatment of primary

hyperhidrosis (12).

A proposed QOL questionnaire is shown in full in

Figure 1 and is based on an article which received 107

citations in Web of Science® and 134 citations in Scopus® (13).

Results

30 days follow-up

In a period between 1995 and 2002, 403 patients (62%

female and 38% male) underwent VTS at Hospital

das Clínicas from Universidade de São Paulo and were

followed up with assessments of QOL, using the proposed

questionnaire. The level of surgical resection of the

sympathetic chain was decided according the localization of

symptoms.

Furthermore, 217 (57%) patients complained of plantar

and palmar hyperhidrosis; 95 patients (25%) of palmar,

axillary, and plantar hyperhidrosis; 60 patients (15.7%) of

only axillary symptoms; and 25 patients (6.5%) of facial

symptoms.

Responses were divided as follows: “Better” in “Much

better” and “Slightly better”; “Worse” in “Slightly worse”

and “Much worse”.

Results showed that 292 (72.4%) “Much better”; 95

(23.6%) “Slightly better”; 12 (3.0%) “Same”; four (1.0%)

“Slightly worse”; and zero (0%) “Much worse”. From these

responses, 387 (96.1%) patients reported improvement in

QL in the immediate postoperative period.

Thorough analysis of questionnaire demonstrated that

in the preoperative period, 87.6% of patients rated QOL

as “Bad” or “Very bad”. Thirty days later, 96% classified

QOL as “Better” or “Slightly better”, despite in a very short

follow up time.

Among the proposed fields, we found that the most

affected was the “functional-social”, i.e., the one that relates

to practical matters of everyday life. This observation was

made in both early and late follow-up (13). Moreover, this

domain was one of the most chosen as first and second

options. Thus, this questionnaire shows how primary

hyperhidrosis negatively affects almost all daily activities.

The ‘personal’ domain was also significantly improved, as

patients gained much more confidence in their personal

relationships soon after surgery. Another important nding

to highlight is that the second most chosen domain was the

“emotional” one, indicating that the patients were extremely

pleased to no longer justify their symptoms or face rejection

from others.

Discussion

Of note, Amir et al. reported on three parameters, which

have also been investigated in our study population, with

rather interesting results. The rst is associated with gender.

In their study, women exhibited an initial decline in the

score for most domains of QOL compared to men, apart

from the emotional component. A possible explanation for

this difference is the increased likelihood for women to seek

early medical advice to limit the impact on their emotional

sphere. Contrariwise, it could be assumed that men tend

to be more tolerant of aesthetically unpleasant conditions.

Nevertheless, in our study there was no significant

association between QOL scores and gender, with similar

variation in the total distribution in both men and women.

The timing of symptoms also plays a big role: we noticed

that in patients suffering from primary hyperhidrosis

since childhood the QOL scores were significantly lower

comparing to patients whose autonomic dysfunction started

after puberty, adolescence or childhood: the earliest is the

exposure to stressful social situations related to primary

hyperhidrosis, the lightest is the perception to frustrating

and embarrassing situations related to the excessive

sweating. Corroborating this view, primary hyperhidrosis

patients find it increasingly difficult to live or to get used

to “embarrassing situations”. Thus, the level of QOL

decreases as patients live with the condition longer. In

our sample, we identified a similar trend as the responses

to QOL questionnaires correlated to patient age. QOL

improvement tends to be more notable in patients under 18

years of age.

The third relevant observation is that in the functional

social domain, the distress perceived is relative to the

damage suffered. Anxiety plays also a role pushing patients

to look for a more aggressive and denitive treatment. Amir

ad co-authors highlighted that surgeons should consider

Shanghai Chest, 2020Page 4 of 5

Figure 1 Proposed quality of life questionnaire.

Shanghai Chest, 2020 Page 5 of 5

these facts when assessing a patient for surgery in order also

to foresee the impact of surgery. To analyze the outcome,

the simplest way is to have patients choosing among the

three domains according to their preference. In each case,

an idea of which domain had the biggest improvement on

QOL would be elucidated.

Conclusions

Specific questionnaires are to be considered the best way

to evaluate the impact of Primary Hyperhidrosis on the

QOL, avoiding generic models that are not taking into

consideration the variability among individuals. These

tailored questionnaires should include four domains:

functional, social interpersonal and emotional.

Our data conrmed that the QOL improves signicantly

in the short term following surgical sympathectomy. In the

longer term a sustained improvement is seen but further

data are required to better assess the QOL after 5 and

10 years.

Acknowledgments

None.

Footnote

Conicts of Interest: The authors have no conicts of interest

to declare.

Ethical Statement: The authors are accountable for all

aspects of the work in ensuring that questions related

to the accuracy or integrity of any part of the work are

appropriately investigated and resolved.

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doi: 10.21037/shc.2019.12.03

Cite this article as: Patrini D, Bujoreanu I, Lampridis S,

de Campos JRM, Bedetti B, da Fonseca HVS, Lawrence

D, Kauffman P, Wolosker N. Changes in the quality of life

following surgery for hyperhidrosis. Shanghai Chest 2020;4:20.

Evaluation of the quality of life 10 years after bilateral thoracoscopic sympathicotomy in subjects with primary focal hyperhidrosis

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Full-text available

Jul 2024

Introduction/Objective. Primary focal hyperhidrosis (PFH) is an idiopathic condition where excessive sweating affects one or more body regions, including axillae, palms, soles, and/or face. Most studies on quality-of-life focus on the period up to one year after bilateral thoracoscopic sympathectomy (BTS). This study aims to determine the 10-year trend in quality of life among patients from the Republic of Serbia with palmar-plantar-axillary primary focal hyperhidrosis, treated with BTS at the R3-R4 level. A secondary goal is to ascertain the existence of compensatory sweating. Methods. All patients underwent a standardized BTS in a single act, through the cutting of ganglia with ultrasonic scissors at the R3-R4 level. For data collection, patients completed the "Hyperhidrosis Quality of Life Questionnaire (HQLQ)," and the Hyperhidrosis Disease Severity Scale (HDSS), preoperatively, postoperatively within 30 days, and 10 years after BTS. Results. The total sample consisted of 103 subjects who completed all three questionnaires. Considering the improvement in Quality of Life (QoL) from the group excellent, good, and average, the postoperative improvement was immediately postoperative in 88.4% of patients, while in the ten-year period, it was 87.4%. No statistically significant differences were found between the assessment of life satisfaction after 30 days and 10 years after BTS. Out of the total number of operated patients, two patients (1.94%) characterized their compensatory sweating as very pronounced. Conclusion. After 10 years from BTS, the QoL remains at an exceptionally high level, with an annual trend of decline of about 0.1%. Keywords: sympathicotomy, sweat, video-assisted thoracoscopic surg

Long-term Outcomes of Endoscopic Thoracoscopic Sympathectomy for Primary Focal Palmar Hyperhidrosis: High Patient Satisfaction Rates Despite Significant Compensatory Hyperhidrosis

Article

Sep 2022

Background: Endoscopic thoracoscopic sympathectomy (ETS) is the gold standard therapy for primary focal palmar hyperhidrosis (PFPH), resulting in high patient satisfaction rates. The most common side effect of ETS is compensatory hyperhidrosis (CH). Previous studies followed patients' satisfaction degree of surgery and the incidence of CH during a limited follow-up period of 1 to 3 years. The purpose of this study was to investigate the long-term outcomes and patient satisfaction after ETS. Materials and methods: After approval of our institutional review board, we conducted a retrospective review of all consecutive patients who underwent ETS for PFPH at our institution between 1998 and 2019. Electronic medical records were reviewed for short-term outcomes. Long-term outcomes were collected through telephone questionnaires. Primary outcome was the resolution of PFPH. Secondary outcomes were CH and long-term patient satisfaction. Results: During the study period, 256 patients underwent ETS to treat primary focal palmar hyperhidrosis at our institution between the years 1998-2019. One-hundred and fifty (58.6%) patients agreed to participate in the study and were included in the final analysis. The mean age was 23.8 (17 to 58) years, 56% were females. The mean follow-up time was 11±6.1 (1 to 22) years. Ninety-four percent reported resolution of PFPH; however, CH was reported by 90% of participants. CH decreased mean patient satisfaction score from 4.8±0.5 to 3.8±2 (P=0.009). This effect was more pronounced in patients with CH of the head and neck (P=0.009). Patients' satisfaction decreased over time from a mean of 4.8±0.4 in the first year after surgery to a mean of 3.7±1.4 12 years or more after surgery (P <0.001). Despite this, 79% of patients reported they would recommend ETS to other patients. Conclusions: ETS for PFPH is highly effective and results in high patient satisfaction rates even after long-term follow-up. Despite high rates of postoperative CH, nearly 80% of patients would still recommend the procedure to fellow patients, justifying its reputation as the gold standard treatment for PFPH.

Impacto psicológico de la hiperhidrosis primaria

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Full-text available

May 2023

La hiperhidrosis primaria es una patología frecuente que representa un motivo de consulta dermatológica común, se caracterizada por una sudoración excesiva en regiones axilares, plantares, palmares o craneofaciales que aparece generalmente en la pubertad o en la adolescencia, sus portadores con frecuencia desarrollan discapacidad psicológica como síntomas de depresión, ansiedad y auto aislamiento social. Objetivo. Identificar el impacto la hiperhidrosis primaria produce en la calidad de vida de los pacientes, mediante el análisis de la efectividad de tratamientos disponibles para la mejora de síntomas generados antes su padecimiento. Metodología. En la revisión sistemática se recopiló información científica en Pubmed, Scopus y Taylor & Francis, la información obtenida fue de artículos originales y metaanálisis comprendido entre enero de 2011 a diciembre de 2022, la ecuación de búsqueda "hiperhidrosis", “psicología”, “salud mental” y "calidad de vida. Resultados. Se obtuvo 127 fuentes entre PubMed, Scopus, Taylor & Francis, se revisó y eliminó los duplicados y los artículos carentes de información de interés, seleccionando 41 artículos, y posteriormente se aplicó a los artículos restantes los criterios de inclusión y exclusión, obteniéndose finalmente 8 artículos para el análisis. Conclusión. El principal impacto psicológico de la hiperhidrosis primaria es la ansiedad y la depresión, las cuales se pueden evidenciar con mayor prevalencia en pacientes de sexo femenino y la repercusión principal en la vida diaria es el aislamiento social, donde el apoyo de sus familiares juega un papel importante en las recuperaciones del paciente, además se desconoce la causa directa de la enfermedad, siendo su causa multifactorial.

Hyperhidrosis: an update on prevalence and severity in the United States

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Full-text available

Dec 2016
ARCH DERMATOL RES

Current published estimates of the prevalence of hyperhidrosis in the United States are outdated and underestimate the true prevalence of the condition. The objectives of this study are to provide an updated estimate of the prevalence of hyperhidrosis in the US population and to further assess the severity and impact of sweating on those affected by the condition. For the purposes of obtaining prevalence, a nationally representative sample of 8160 individuals were selected using an online panel, and information as to whether or not they experience hyperhidrosis was obtained. The 393 individuals (210 female, 244 non-Hispanic white, 27 black, mean age 40.3, SE 0.64) who indicated that they have hyperhidrosis were asked further questions, including body areas impacted, severity of symptoms, age of onset, and socioemotional impact of the condition. Current results estimate the prevalence of hyperhidrosis at 4.8 %, which represents approximately 15.3 million people in the United States. Of these, 70 % report severe excessive sweating in at least one body area. In spite of this, only 51 % have discussed their excessive sweating with a healthcare professional. The main reasons are a belief that hyperhidrosis is not a medical condition and that no treatment options exist. The current study’s findings with regard to age of onset and prevalence by body area generally align with the previous research. However, current findings suggest that the severity and prevalence are both higher than previously thought, indicating a need for greater awareness of the condition and its associated treatment options among medical professionals.

Epidemiology of Hyperhidrosis in Two Population-Based Healthcare Databases

Article

Oct 2017

Background: Population-based and clinical case reports of hyperhidrosis (HH) provide prevalence estimates that vary widely across reported studies due to differences in case ascertainment. Objective: In this study, we specify diagnosis, symptom, and prescription codes for HH in order to estimate incidence and prevalence for the United Kingdom and the United States. Methods: Data from U.K. and U.S. healthcare databases were analyzed to ascertain HH cases and estimate incidence and prevalence from healthcare records during calendar years 2011 through 2013. Results: Based on 2013 data for the U.S. and U.K., between 1.0% and 1.6% of these populations have healthcare records indicating diagnosis or treatment of HH. Women accounted for approximately 60% of incident and prevalent cases in both databases. Limitations: Since the case ascertainment methods rely on available data for those seeking healthcare, we may have underestimated the number of HH cases in both countries. Conclusion: Findings represent a plausible estimate for incidence and prevalence of HH among persons seeking medical care for excessive sweating. Improved practices for identifying HH in clinical settings may increase the sensitivity and specificity of future studies and improve characterization and quantification of the population burden of this significant disease.

Hyperhidrosis in social anxiety disorder

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Jan 2002
PROG NEURO-PSYCHOPH

The Society of Thoracic Surgeons Expert Consensus for the Surgical Treatment of Hyperhidrosis

Article

May 2011

Significant controversies surround the optimal treatment of primary hyperhidrosis of the hands, axillae, feet, and face. The world's literature on hyperhidrosis from 1991 to 2009 was obtained through PubMed. There were 1,097 published articles, of which 102 were clinical trials. Twelve were randomized clinical trials and 90 were nonrandomized comparative studies. After review and discussion by task force members of The Society of Thoracic Surgeons' General Thoracic Workforce, expert consensus was reached from which specific treatment strategies are suggested. These studies suggest that primary hyperhidrosis of the extremities, axillae or face is best treated by endoscopic thoracic sympathectomy (ETS). Interruption of the sympathetic chain can be achieved either by electrocautery or clipping. An international nomenclature should be adopted that refers to the rib levels (R) instead of the vertebral level at which the nerve is interrupted, and how the chain is interrupted, along with systematic pre and postoperative assessments of sweating pattern, intensity and quality-of-life. The recent body of literature suggests that the highest success rates occur when interruption is performed at the top of R3 or the top of R4 for palmar-only hyperhidrosis. R4 may offer a lower incidence of compensatory hyperhidrosis but moister hands. For palmar and axillary, palmar, axillary and pedal and for axillary-only hyperhidrosis interruptions at R4 and R5 are recommended. The top of R3 is best for craniofacial hyperhidrosis.

Transthoracic Endoscopic Sympathectomy for Palmar Hyperhidrosis in Children and Adolescents: Analysis of 350 Cases

Article

Sep 1999

Torng-Sen Lin

Primary palmar hyperhidrosis (PH) often commences in childhood and adolescence and can be a disabling condition. There are few reports regarding endoscopic sympathectomy for PH in children and adolescents. Therefore, I present our experience with transthoracic endoscopic sympathectomy (TES) in treating PH in children and adolescents. From July 1994 to March 1998, a total of 350 patients underwent TES. There were 93 males and 257 females with a mean age of 12.9 years (range 5-17 years). All patients were placed in a half-sitting position under single-lumen intubated anesthesia. We performed ablation of the T2 ganglion using either a 6- or an 8-mm 0 degree thoracoscope (Karl Storz Company, Germany) via one 0.8-cm incision just below each axilla. Among these 350 patients, 699 sympathectomies were performed. Usually, TES was accomplished within 15 minutes (range 7-20 minutes). The surgical complications were minimal: one pneumothorax and one segmental lung collapse. There were no surgical deaths. With a mean postoperative follow-up period of 25 months (range 5-44 months), the result of TES was highly satisfactory in 331 patients (94.6%), although 301 patients (86%) developed compensatory sweating of the trunk and lower limbs, the distribution being the axillae (12%), back (86%), abdomen (48%), or lower limbs (78%). The recurrence rates of palmar hyperhidrosis were 0.6% in the first year, 1.1% in the second year, and 1.7% in the third year. Transthoracic endoscopic sympathectomy is a safe and effective method for treating PH in children and adolescents.

Impairment in quality of life among patients seeking surgery for hyperhidrosis (excessive sweating): Preliminary results

Article

Feb 2000
ISR J PSYCHIATR REL

The present paper describes the initial stages of the development and administration of a short, disease-specific, health related questionnaire to assess the impact of suffering from hyperhidrosis (excessive sweating) on the Quality of Life (QoL) of patients who are anticipating surgery for this disorder. The study was performed in two stages: 1. The life domains in which the condition impairs QoL were assessed by in-depth interviews with 10 patients suffering from hyperhidrosis. 2. A questionnaire covering five life domains was built based on these interviews. 3. This questionnaire was administered to 48 patients, 30 females and 18 males between the ages 15 and 48. Results showed that subjective QoL was significantly lower among females in four of the five life areas and that duration of the condition correlates with a lower quality of life. A regression analysis showed that the subjective suffering of the patients was explained mainly by social aspects. The questionnaire is a novel attempt to assess QoL in a disorder with strong esthetic and social consequences and could improve communication between patients and their physicians.

Video-assisted Transthoracic Sympathectomy in the Treatment of Primary Hyperhidrosis: Friend or Foe?

Article

Aug 2000
SURG LAPARO ENDO PER

The authors hypothesize that palmar hyperhidrosis is a systemic manifestation of abnormal sudomotor function; consequently, thoracoscopic sympathectomy to alleviate symptoms in the hands may result in heat dissipation because sweating is transferred to other sites. To investigate this phenomenon and to determine whether it adversely affects patient satisfaction, a standard questionnaire was administered to 626 patients who underwent sympathectomy at a university-associated public hospital between 1991 and 1998; only patients treated at least 6 months before questionnaire distribution were included in the study. Replies were received from 336 (53.7%) individuals. The surveyed patients underwent bilateral T2, T3 (palmar sweating), or T3, T4 (axillary sweating) sympathectomy by a standard video-assisted transthoracic technique. Main outcome measures included the incidence of dry hands, compensatory sweating, chest pain, upper-limb muscle weakness, shortness of breath, and gustatory phenomena; in addition, patient perception of the success of the surgical procedure was assessed. After sympathectomy, 97.3% (P < 0.0001) and 29.2% (P < 0.001) of patients reported significant improvement in palmar hyperhidrosis and axillary sweating, respectively. Postsurgery, severe compensatory sweating was experienced in 90% of patients (P < 0.0001). The sites of compensatory sweating were the back (75%), abdomen (51%), feet (23%), groin and thigh (13%), chest (13%), and axillae (8%). Transient whole-body sweating for no apparent reason was experienced in 30% of patients. Thirty-seven patients (11%) regretted having undergone the surgical procedure. In contrast, 25% and 64% of patients were either satisfied or very satisfied with the outcome of the procedure. From the survey results, the authors conclude that palmar hyperhidrosis is a systemic manifestation of abnormal sudomotor function and that thoracic sympathectomy may alleviate symptoms in a large proportion of patients. However, for some individuals, compensatory sweating may prove to be an equally troublesome handicap. Because the occurrence of severe compensatory sweating is unpredictable, a reversible sympathectomy may be desirable.

Improvement in quality of life after bilateral trans-thoracic endoscopic sympathectomy for palmer hyperhidrosis

Article

May 2001
Hawaii Med J

To evaluate the efficacy of bilateral transthoracic endoscopic sympathectomy (TES), in alleviating symptoms and improving quality of life for patients in Hawaii. Retrospective cohort study. Patients who had undergone TES were evaluated by phone interview and the SF-36 questionnaire to assess improvements in symptoms and the development of compensatory hyperhydrosis. SF-36 scores were divided into 8 scales and evaluated by one-tailed t-test. Since 1999, eight patients (five women and three men, mean age 27.4 years old, range 15-41 yrs) underwent TES without significant complication. Length of hospital stay was less than one day for all patients except one, who stayed four days. Estimated operative blood lost was less than 100 ml and no blood transfusions were required. No Horner's syndrome was suffered. After a mean follow-up of 7.0 months (range 1.2-15.8 months), none of the patients had recurrent symptoms in the palms but all reported moderate compensatory hyperhydrosis located mainly in the trunk and lower extremities (two patients). SF-36 scores showed significant improvements in social functioning (p < 0.005), mental health (p < 0.049), and role-physical (p < 0.020) along with an increase in bodily pain (p < 0.012). Although TES resulted in some bodily pain and compensatory hyperhydrosis; these elements were outweighed by the improvement in palmar symptoms, social, mental, and role physical functioning, and overall quality of life.

Quality of life evaluation following endoscopic transthoracic sympathectomy for upper limb and facial hyperhydrosis

Article

Jan 2001
Ann Chir Gynaecol

In this prospective cohort study, the outcome of bilateral endoscopic transthoracic sympathectomy (ETS) was assessed using the Dermatology Life Quality Index (DLQI) questionnaire. 10 consecutive patients who underwent two-stage bilateral ETS for primary hyperhydrosis were assessed. Two patients had concomitant facial blushing. Symptomatic improvement was achieved in all patients. Statistical analysis (one-tailed Wilcoxon rank test) demonstrates a significant (p < 0.05) step-wise improvement in quality of life after each stage. This has not previously been described for two-stage bilateral ETS and confirms the suitability of this technique in the definitive management of refractory primary hyperhydrosis.

Quality of life, before and after thoracic sympathectomy: Report on 378 operated patients

Article

Oct 2003
ANN THORAC SURG

Thoracic sympathectomy is indicated to treat primary hyperhidrosis. The objective is to analyze the results and complications of thoracic sympathectomy and propose a questionnaire to assess the quality of life of patients. Between October 1995 and March 2002, 378 patients were evaluated. Sixty-two percent were female, with a mean age of 26.8 years old (range 9 to 70 years old). There were 57.4% patients with palmar-plantar hyperhidrosis; 25% with palmar, plantar, and axillary hyperhidrosis; 15.7% with pure axillary hyperhidrosis; and 6.5% with craniofacial hyperhidrosis. General anesthesia was used in 97.3%, epidural with sedation in 2.7%. The sympathetic chain was resected in 12.5%, thermal ablation with the electrical scalpel was performed in 66.3%, and with the harmonic scalpel in 21.2% of the patients. Successful sympathectomies were performed in 90.3% of the patients; the follow-up was from 1 to 60 months (mean 12.4 +/- 8.3 months). The recurrence rates were 8.2% for palmar hyperhidrosis, 13.7% for pure axillary hyperhidrosis, 27.5% of which were reoperated successfully. Improvement of the plantar hyperhidrosis was also registered in 58%. Horner's syndrome was reported in 1% with regression in half of them after 30 days. No mortality or serious complications were observed, nor the need to convert to thoracotomy. Of the total number of patients, 93.4% answered the quality of life questionnaire, 86.4% of whom noted improvement after the procedure. Thoracic sympathectomy is a simple, effective, safe method for the treatment of hyperhidrosis, resulting in an improved quality of life for patients. The questionnaire documents this change.