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Compensatory Hyperhidrosis After Thoracic Sympathectomy
Source: Lancet

Volume: 351

Number: 9098

Page Number: 231

Comments: 

Author: R. Adar

Extract: 

The commonest indication for upper dorsal sympathectomy (UDS) is palmar hyperhidrosis, beautifully described by Charles Dickens as it affected Uriah Heep, a character in David Copperfield. When severe, palmar sweating interferes with daily activities and social contacts. Surgical removal or ablation of T2 and T3 sympathetic ganglia will stop palmar sweating.

Since the introduction of thoracoscopic UDS, the procedure has become safer, with fewer general surgical complications. But this less invasive approach has had no effect on the sequelae of the sympathetic denervation, such as compensatory hyperhidrosis, gustatory abnormalities, phantom sweating, and some pulmonary and cardiovascular reactions.

The commonest of these complications is the compensatory increase in sweating in other areas of the body, notably chest, abdomen, and buttocks. It occurs to some extent in most patients, the reported incidence varying with the intensity of questioning and the thoroughness of the follow-up examination. IN a recent report by B.T. Andrews and J.A. Rennie, focusing specifically on compensatory sweating, the complication affected 36 (86%) of 42 patients after thoracoscopic UDS for palmar hyperhidrosis. On the basis of a semiquantitative subjective analogue scale, the compensatory sweating was classified as severe in 10 patients, but most patients preferred the complication to the state of their palms before UDS.

However, every surgeon treating large numbers of patients with palmar hyperhidrosis by UDS encounters a small proportion with an extremely severe, sometimes devastating, degree of compensatory sweating. This complication is severe enough for some people, especially those living in a warm climate or engaged in heavy physical activities, to regret ever having had the operation. From experience at the Chaim Sheba Medical Center this severe form affects around 1%.

Like several of the other sequelae and side-effects of UDS, the pathophysiological mechanisms underlying compensatory hyperhidrosis are incompletely understood, even though it is thought to be a truly compensatory feature related to thermoregulation of the body. Some clinicians claim that limiting the extent of the sympathectomy to the T2 ganglion will reduce compensatory sweating, but others disagree. Experience at the Chaim Sheba is that severe compensatory sweating can occur even after a limited unilateral procedure, and that it is completely unpredictable.

Unpredictability is also the hallmark of the other sequelae of the sympathetic denervation. But most of these side-effects result at worst in a minor degree of discomfort, and some fade with time, whereas severe compensatory sweating can continue unabated. It is irreversible, and there is no known effective treatment. Because UDS is done to improve quality of life, surgeons ought to warn potential candidates for this procedure specifically of the possibility of this rare but unpleasant result when securing informed consent for the operation.
