title: Thoracoscopic sympathicotomy for disabling palmar hyperhidrosis: a prospective randomized comparison between two levels.
abstract: BACKGROUND
  Thoracoscopic sympathicotomy is highly effective in treating disabling palmar hyperhidrosis. The ideal level to maximize efficacy and minimize the side effect of compensatory hyperhidrosis (CH) is controversial. This study compared sympathicotomy over the second (R2) vs third (R3) costal head relative to these variables in patients with massive palmar hyperhidrosis.
  
  
  METHODS
  This prospective, randomized study enrolled 121 patients with disabling palmoplantar hyperhidrosis assigned to bilateral sympathicotomy (sympathetic transection), which was done over R2 in 61 (n = 122 extremities) or R3 in 60 (n = 120 extremities). Patients were questioned at 6 months and at 1 year or more to assess efficacy, side effects, and satisfaction with the procedure.
  
  
  RESULTS
  Sympathicotomy at R2 failed to cure palmar hyperhidrosis in 5 of 122 (4.1%) extremities, but only 2 (1.6%) were to a truly profound dripping level of recurrence. Sympathicotomy at R3 failed to cure palmar hyperhidrosis in 5 of 120 extremities (4.2%), and all were dramatic failures with dripping recurrent sweating. The patients whose palmar hyperhidrosis was not completely cured were aged 19.7 ± 2.5 vs 26.4 ± 8.0 years (p = 0.04). Two R3 patients with failure underwent three redo R2 sympathicotomies, with curative results. R2 patients showed a trend toward a higher level of CH vs R3 patients at 6 months and after 1 year. The CH severity scale was 4.7 ± 2.7 (n = 38) for R2 vs 3.8 ± 2.8 (n = 36) for R3 (p = NS) at 6 months and 4.7 ± 2.5 (n = 43) for R2 vs 3.7 ± 2.8 (n = 37) for R3 (p = NS) after 1 year. Younger age, male sex, and higher levels of preoperative and postoperative plantar sweating were predictors of failed sympathicotomy. Increased age was associated with increased CH.
  
  
  CONCLUSIONS
  R2 and R3 sympathicotomy for massive palmoplantar hyperhidrosis are highly effective, with low recurrence and incidences of severe CH. R2 tends to have a higher level of CH vs R3, and a higher incidence of dramatic failures is suggested in R3 patients, for which reoperation at the R2 level will likely be curative.
authors: Doctors Outpatient Surgery Center, Fountain Valley, California, USA. f.baumgartner@earthlink.net
authors: Fritz J
authors: FJ
authors: Baumgartner
authors: Maria
authors: M
authors: Reyes
authors: Grant G
authors: GG
authors: Sarkisyan
authors: Alicia
authors: A
authors: Iglesias
authors: Elizabeth
authors: E
authors: Reyes
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D006801:Humans; D006945:Hyperhidrosis / Q000601:surgery*; D008297:Male; D011446:Prospective Studies; D012008:Recurrence; D012086:Reoperation; D013562:Sympathectomy / Q000379:methods*; D013906:Thoracoscopy / Q000379:methods*; D055815:Young Adult