Introduction

Palmar hyperhidrosis (PHH) is a fairly common condition for which there is no efficient medical remedy. Thoracoscopic sympathectomy (TS), a surgical procedure based on the interruption of transmission of impulses from the sympathetic ganglia to the sweat glands, offers a permanent cure of PHH. Although it successfully resolves excessive palmar perspiration, TS bears a considerable long-term cost postoperatively, that of compensatory sweating (CS). We recently published our long-term postoperative results following TS [1]. We had unexpectedly found, for what we believe to be the first time, an apparent difference in the postoperative satisfaction rate between children and adults. That finding motivated us to address the issue of such a possible difference between children and older patients in greater depth. In the current study, we compared the scores for long-term success, satisfaction and complication rates between children and adolescents and adults who had undergone TS 2–8 years earlier (January 1997–December 2004).

Materials and methods

We reviewed the medical charts of 533 patients who had undergone TS and who were followed-up for more than 24 months at the Hillel Yaffe Medical Center (HYMC, Hadera, Israel) Bnai Zion Medical Center (BZMC, Haifa, Israel) and the Soroka Medical Center (SMC, Beersheba, Israel) between January 1998 and December 2004. We asked these individuals to reply to a detailed telephone questionnaire on the surgical success rate, the postoperative satisfaction, and any postoperative long-term complications, with emphasis on any subsequent CS. We then compared the answers of the participating children (≤14 years of age) to those of the compliant adolescents and adults (≥15 years of age).

The surgical technique in all three centers was similar. We used one 10 mm camera with a working 5-mm channel (Karl Storz, GmbH and Co., Tuttlingen, Germany) through which a hook was introduced. The sympathetic chain was ablated on the second and the third ribs for PHH, and on the fourth rib as well for axillary hyperhidrosis. The procedure was done bilaterally in all cases. These operations were performed by one senior pediatric surgeon in HYMC, by two senior pediatric surgeons in SMC and by two senior pediatric surgeons and one senior general surgeon in BZMC. Each surgeon was highly experienced in performing the procedure.

Statistical analysis and IRB approval

Data analysis was performed with Pearson’s Chi-square test as appropriate for categorical variables. Significance was set at P < 0.05. The study was approved by the Institutional Review Board of the Hillel Yaffe Medical Center.

Results

A total of 325 patients complied in responding to the questionnaires, of whom 116 were children (8–14 years of age, median = 13) and 209 were adolescents and adults (15–41 years of age, median = 18). The length of follow-up ranged between 2 and 8 years. There were 193 females (female/male ratio 1.46). Three-hundred and twelve responders (96.3%) reported complete or reasonable symptomatic relief. There was no difference in the reported prevalence of sweaty hands between the children and the older patients. The long-term postoperative satisfaction was 92.2% for the children, but only 80.7% for the adolescents and adults (P = 0.005). One-hundred and six children (92.1%) responded that they would have undergone the operation in retrospect compared to 163 (77.6%) of the others (P = 0.001) (Table 1).

Table 1 Long-term postoperative satisfaction and retrospective decision to undergo the operation
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Compensatory sweating was a frequent long-term consequence. It appeared in 266 (81.8%) of the patients, with a significant difference between the older 185 (88.5%) patients and the 81 (69.8%) children (P < 0.001) (Table 2). The severity of CS was also different between the two age groups: the CS was absent or mild in 63 (54.3%) children compared to 79 (38.0%) adolescents and adults (P = 0.004), and moderate or severe in 53 (45.7%) children and in 130 (62.0%) of the others (P = 0.004) (Table 3).

Table 2 Extent of compensatory sweating (CS)
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Table 3 Severity of compensatory sweating (CS)
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About half of the patients with CS reported that they did not suffer from it or considered that the problem was mild. The quality of life, however, was moderately diminished in 68 (26.9%) and severely diminished in 64 (24.1%) of the patients, with no difference between the younger and older ones (Table 4).

Table 4 Diminished quality of life by compensatory sweating (CS)
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The CS was located at the back in 148 (69.5%) patients, in the soles of the feet in 105 (49.3%), in the abdomen in 49 (23%), in the chest in 15 (7%), and in the face in 12 (5.6%). It involved more than one area in 69% of the patients. When CS was present, it appeared almost immediately following the procedure in 56% of the patients, by 3 months postoperatively in 84.4%, and by 6 months postoperatively in most of them.

The extent of the CS increased with time in 12.8% of the group, but it diminished in 20.8% of children compared to 10.5% of the older patients (P = 0.034), usually within the first two postoperative years (Table 5). Only 55.6% of the patients answered that question.

Table 5 Change in the severity of compensatory sweating (CS) with time
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Discussion

Severe PHH has a considerable negative effect on the affected individual’s quality of life [2]. TS is a well-established operative procedure that reduces the extent of perspiration from excessive to normal in the vast majority of patients. Such was the case in our study of the patients and in the ones reported in the literature [3–5]

With the exception of CS, the long-term morbidity associated with TS is relatively low [5–7]. CS is the most common side effect, primarily affecting the back, the soles and the torso, and it is the main reason for patient’s dissatisfaction [8, 9]. Indeed, despite having dry hands as a result of surgery, patients may report only moderate satisfaction, dissatisfaction or even regret having undergone the operation because of the appearance of CS [10–12]. The specific rate of CS in some recent series ranged between 60 and 90%, and it was considered as being severe in one-third of them [13–16]. Our rate of CS was 81.8%, with a significant difference between children (69.8%) and adults (88.5%). We do not know if this was because of physiological or adaptive reasons. The level of sympathectomy and facial hyperhydrosis (HH) were mentioned as factors affecting outcome following TS [9, 17, 18], but as far as we know, being a child has not been previously mentioned as one of these factors. The reason for our finding might be a secondary effect of the sympathectomy. In addition to the symptomatic relief, dry hands may improve some of the obstacles to the social acceptance of younger patients, such as having copybooks with sweaty streaks, embarrassing slippery accidents in sports activities, etc. These obstacles, if not treated, can potentially aggravate PHH with time. By relieving many of them, sympathectomy improves some of the stress effects that aggravate primary hyperhidrosis. One can expect that the reduction in the stress load may have some secondary effect on CS as well.

The overall satisfaction in children was very high (92.2%), and only 7.9% of them would not have agreed to the operation in retrospect. The adults were less satisfied, with 22.4% of them not having undergone the operation in retrospect. Operative satisfaction is the net result of operative success, the rate, severity and ability of CS to negatively affect quality of life and a variable that might potentially change with time. Our operative success in children as well as in adolescents and adults was high, but the rate of CS and its severity were significantly higher in the older patients. Furthermore, the rate of decrease of CS with time was double for the children compared to that of the adolescents and adults. Greater social pressure and vulnerability to their peers’ opinion of them may be some of the reasons for the children’s attitudes. Sympathectomy relieves many of the obstacles to social acceptance and puts an end to embarrassing accidents in many daily activities. The social pressure on adults is different, and adults have far greater choices in the activities that suit them, with far more opportunities to avoid situations in which sweating is inconvenient or provokes humiliation by others.

There is no effective medical remedy for PHH. The surgical alternative was offered only after the surgeon was convinced that the patient’s quality of life had been seriously compromised for a considerable length of time and that all other efforts to improve it, e.g., antiperspirants, iontophoresis, hypnosis, acupuncture, etc., had failed. Surgery was scheduled only after the suitable candidate was given a clear explanation of the potential operative risks—especially the high risk of having CS that may, in some cases, be worse than the original PHH. We do not encourage our patients to undergo the operation. On the contrary, we express our reluctance to perform it because of the 70% potential of the occurrence of CS. Having said that, once the patient and his/her parents decide upon the surgical alternative, we recommended doing TS as early as possibly because: (1) PHH is not a self-limiting condition and so there is no reason to extend the patient’s suffering; (2) the chances of CS and the degree of its severity are significantly lower in children younger than 14 years; (3) the postoperative satisfaction is very high in children younger than 14 years (>92%) and it is significantly higher than in older patients. The youngest patient who presented to us with PHH and who wanted to undergo this procedure was 8 years old. We think that TS can be offered to children from this age onwards, once the patient and his/her parents fulfill the above-mentioned operative criteria. It should be borne in mind that Israel is a hot country, and it is estimated that nearly 1% of its population (∼70,000 people) suffers from some degree of PHH [19].

The compensatory effect appears to be a dynamic process [5, 10, 16]. It developed immediately following the procedure in 50% of our affected patients, after 3 months in 80%, and after three additional months in 90%. The severity of the CS did not change with time in 73% of our patients. It increased in severity in 12.8% and decreased in severity in 20.8% of the children, but only in 10.5% of the adults within 2 years postoperatively. This phenomenon may also reflect a possible positive long-term secondary effect of dry hands on young people. Only 148 out of 266 (55.6%) patients, however, answered the questions concerning CS dynamics. The difficulty in recalling this change may be due to the gradual nature of the change and the relatively long time that had elapsed since any change had occurred.

Although CS may significantly diminish one’s quality of life (39 out of 116 children, 96 out of 209 adults, Table 4), 30/39 (76.9%) of the children and 55/96 (57.3%) of the adults with severe CS were still satisfied in the long term. This paradoxical response was also witnessed by others [16–18, 20] and it may be considered a testimony to how unbearable was the preoperative PHH.

This study has two main weaknesses. First, it shares the usual limitations of a retrospective study. Second, the collected data are subjective, and there was no objective test to validate the patient’s feelings about his/her quality of life or the severity of CS. In addition, some of the subjective responses depended upon relatively long-term recollection of how much time had elapsed after surgery before CS appeared.

In conclusion, our findings showed that although TS succeeded in considerably reducing excessive PHH in the vast majority of patients of all ages, the rate of CS was shown to be high, albeit significantly lower and milder in children. Despite the high rate of CS associated with TS, most of the children, in contrast to the adolescents and adults, were gratified with the effect the procedure that had on their daily lives and most of them would have undergone the operation in retrospect. The postoperative intensity of CS decreased in children twice as often as in adults within 2 years after surgery. Therefore, we recommend that when needed, TS should be done as early as possible.