Category: Sympathectomy

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Robotic selective thoracic sympathectomy for hyperhidrosis: refined technique and anatomical variation

Multimed Man Cardiothorac Surg. 2026 Oct 14;2026. doi: 10.1510/mmcts.2026.094.

ABSTRACT

Primary hyperhidrosis substantially impairs quality of life. Conventional sympathectomy risks compensatory hyperhidrosis through trunk disruption, whilst selective sympathectomy preserves the trunk while dividing preganglionic and postganglionic fibres. We describe a technique refinement and a previously undescribed anatomical variant. A 23-year-old man had severe refractory palmar, axillary, plantar and gustatory hyperhidrosis (SSDS 4) profoundly affecting his confidence, social functioning and mental wellbeing, despite conservative management. He underwent staged bilateral robotic selective dorsal thoracic sympathectomy. Preganglionic and postganglionic fibres were divided from the top of T2 to T4 with trunk preservation. Refinements included resection from the top of the second rib, minimal diathermy with sharp dissection and non-touch technique using Maryland bipolar forceps. On the right, a postganglionic ramus ascending retrogradely from a displaced T3 ganglion into the third intercostal space was identified, previously undescribed in the literature, requiring dissection across the fourth rib to prevent hypothesized residual axillary hyperhidrosis. Both stages were completed 1 month apart, drain-free, with next-day discharge. There was complete symptom resolution, no Horner’s syndrome and no compensatory hyperhidrosis at follow-up.

PMID:42872462 | DOI:10.1510/mmcts.2026.094

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Endoscopic thoracic sympathectomy for primary palmar hyperhidrosis: ten-year clinical outcomes and a phenomenology-informed interpretation of body experience

Psychol Health Med. 2026 Oct 12:1-21. doi: 10.1080/13548506.2026.2746787. Online ahead of print.

ABSTRACT

Primary focal hyperhidrosis (PFH) is a chronic condition of excessive sweating disproportionate to thermoregulatory need, with substantial social and occupational burden. We evaluated outcomes of endoscopic thoracic sympathectomy (ETS)-symptom severity, quality of life, satisfaction, compensatory hyperhidrosis (CH), and recurrence-and interpreted dissatisfaction among patients who developed CH through a phenomenological lens. This retrospective single-centre cohort study included 72 patients who underwent ETS for PFH between January 2013 and December 2021, assessed preoperatively and at years one and five using the HDSS, DLQI, and Gillespie satisfaction scale. Sympathectomy level, technique, CH, recurrence, and psychosocial avoidance behaviours were recorded. Normality was rejected on Shapiro-Wilk testing; Wilcoxon signed-rank, Mann-Whitney U, chi-square, and Fisher’s exact tests were applied, with effect sizes as rank-biserial correlation (r) and Cramér’s V. The study received ethics approval (3 June 2026-39804) and adheres to the STROBE checklist. The cohort comprised 72 patients (44 male/28 female; mean age 22.8 ± 5.2 years; disease duration 7.3 ± 2.8 years). Palmar localisation predominated (63.9%); 90.3% avoided handshaking preoperatively. Mean HDSS declined from 3.29 ± 0.74 to 1.65 ± 0.96 at year five (p<0.001;r = 0.83); 61.5% reached HDSS = 1. Mean DLQI fell from 3.83 ± 0.67 to 1.94 ± 1.07 (p<0.001;r = 0.84); DLQI≥4 dropped from 68.1% to 7.7%. Five-year satisfaction was 76.6%. CH developed in 13 patients (18.1%), graded by level-T2 72.7%, T3 10.4%, T3-T4 0%(χ2 = 26.98;p<0.001; V = 0.61). Five-year DLQI was 3.23 ± 1.17 with CH versus 1.62 ± 0.77 without (p<0.001;r = 0.73); 84.6% of CH patients were undecided or regretful versus 7.8% without (p<0.001). Recurrence was 5.6%. ETS achieves durable symptom control and well-preserved long-term satisfaction in PFH. Marked dissatisfaction among patients who develop CH indicates that body-related awareness and social functioning are, for a meaningful subset, as decisive as physiological control. T2 sympathectomy should be reserved for clear anatomical indications, and informed consent should address the lived significance of CH beyond statistical risk disclosure.

PMID:42861922 | DOI:10.1080/13548506.2026.2746787

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Radiofrequency Ablation for Refractory Palmar and Plantar Hyperhidrosis: A Case Report

Anesth Pain Med. 2026 Feb 28;16(1):e172975. doi: 10.5812/aapm-172975. eCollection 2026 Feb 28.

ABSTRACT

INTRODUCTION: Palmar and plantar hyperhidrosis (PH) is characterized by sweat production that far exceeds thermoregulatory needs and often has substantial effects on daily functioning, social interaction, and mental health. The condition results from sympathetically mediated overstimulation of the eccrine glands, which are innervated by unmyelinated cholinergic C-type fibers. Radiofrequency ablation (RFA) offers a minimally invasive approach to symptom control in refractory PH through heat-mediated disruption of these sympathetic fibers. Reports describing staged upper- and lower-limb RFA for combined palmar and plantar disease in a single patient remain uncommon; this is the primary reason for presenting this case.

CASE PRESENTATION: A 21-year-old man (American Society of Anesthesiologists physical status I) presented with a 10-year history of progressive palmar and plantar hyperhidrosis that had not shown durable responses to conservative or prior interventional treatment. He used topical aluminum chloride for 2 months without meaningful benefit and subsequently underwent 2 sessions of palmar botulinum toxin injections 5 months apart, which reduced palmar sweating by an estimated 50 – 60% for approximately 2 months per session; the lower limbs were not treated. Eighteen months before the current admission, he underwent RFA of the right thoracic sympathetic chain at another center. This produced approximately 80% improvement in palmar sweating, although sweating persisted along the ulnar nerve distribution; the benefit lasted only approximately 4 months, after which symptoms recurred to baseline. During the present admission, staged RFA was performed bilaterally at L3, with different lower-limb protocols selected in advance based on the prior treatment response and the greater severity of plantar sweating on the left. Seven days later, bilateral RFA was performed at T3. At the 2-week, 1-month, and 7-month follow-up visits, the patient reported no compensatory sweating or change in cutaneous sensation. By his own assessment, overall sweating of the palms and soles was reduced by approximately 90% from baseline, with a satisfaction score of 9/10 and subjectively improved quality of life.

CONCLUSIONS: Staged RFA targeting both the thoracic and lumbar sympathetic chains appears to be a reasonably safe palliative option for patients with refractory combined palmar and plantar hyperhidrosis, with a more favorable complication profile than surgical sympathectomy. This case is considered reportable because it involves combined, staged treatment of both the upper and lower limbs in a single patient.

PMID:42763681 | PMC:PMC13589454 | DOI:10.5812/aapm-172975

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A retrospective study comparing T3 ganglionectomy and R4 sympathicotomy for reducing compensatory hyperhidrosis in primary palmar hyperhidrosis

J Thorac Dis. 2026 Jun 30;18(6):592. doi: 10.21037/jtd-2026-0904. Epub 2026 Jun 26.

ABSTRACT

BACKGROUND: Despite the high surgical success rate, postoperative compensatory hyperhidrosis (CH) remains a persistent concern in the treatment of primary palmar hyperhidrosis using endoscopic thoracic sympathectomy (ETS). This study aims to compare the early clinical outcomes of two surgical techniques-T3 ganglionectomy and R4 sympathicotomy-to determine which approach minimizes CH occurrence and enhances patient satisfaction.

METHODS: A retrospective analysis of medical records was conducted on patients who underwent either T3 ganglionectomy or R4 sympathicotomy for primary palmar hyperhidrosis at Gangnam Severance Hospital from January 2023 to December 2023. Demographic data and postoperative outcomes were evaluated. CH and degree of satisfaction were assessed during outpatient visits at 3 weeks and 3 months after surgery.

RESULTS: In this study, 44 patients underwent T3 ganglionectomy and 225 patients underwent R4 sympathicotomy. There were no statistically significant differences in baseline characteristics (age, sex, body mass index, smoking history, and family history) or operative complications between the two groups. However, CH at 3 weeks and 3 months after surgery was significantly lower in T3 ganglionectomy group [4 (9.1%) vs. 143 (63.6%); P<0.001, 5 (11.4%) vs. 150 (66.7%); P<0.001]. Additionally, patient satisfaction was significantly higher in the T3 ganglionectomy group compared to the R4 sympathicotomy group (P<0.001).

CONCLUSIONS: T3 ganglionectomy exhibited superior surgical outcomes in terms of both CH and patient satisfaction for primary palmar hyperhidrosis when compared to R4 sympathicotomy. Nonetheless, a larger prospective study with long-term follow-up is necessary to validate these findings.

PMID:42444879 | PMC:PMC13358477 | DOI:10.21037/jtd-2026-0904

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T2-sparing vs T2-including sympathectomy for hyperhidrosis: a meta-analysis on compensatory sweating

J Cardiothorac Surg. 2026 Jun 25;21(1):445. doi: 10.1186/s13019-026-04464-4.

ABSTRACT

BACKGROUND: Sympathectomy is the definitive treatment for primary hyperhidrosis, offering high success rates. However, compensatory sweating (CS) remains a frequent and distressing complication. The level of ganglionic resection, particularly the inclusion of T2, may influence CS incidence, but evidence remains inconsistent.

METHODS: A systematic search of PubMed, Embase, and the Cochrane Library was conducted up to July 2025, to identify studies comparing T2-sparing versus T2-including sympathectomy for primary hyperhidrosis. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using random-effects models. Heterogeneity was assessed using the I2 statistic. For outcomes with significant heterogeneity, leave-one-out sensitivity analyses were performed.

RESULTS: Eleven studies involving 3,090 patients were included. Of these, 47.2% underwent T2-sparing sympathectomy and 52.8% underwent T2-including procedures. T2-sparing sympathectomy was associated with a significantly lower incidence of overall CS (OR 0.38; 95% CI 0.21-0.67; p = 0.0009; I2 = 65%) and severe CS (OR 0.43; 95% CI 0.28-0.64; p < 0.0001; I2 = 19%). Subgroup analyses confirmed consistent results across both randomized and non-randomized studies, as well as across short-term (≤ 12 months) and long-term (> 12 months) follow-up periods. Sensitivity analyses confirmed the robustness of the findings. No publication bias was detected.

CONCLUSIONS: T2-sparing sympathectomy was associated with a significantly lower incidence of CS. These findings support avoiding T2 when feasible to minimize postoperative morbidity. Further prospective studies are needed to confirm these results.

PMID:42351253 | DOI:10.1186/s13019-026-04464-4

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Ultra-Minimally Invasive Medical Thoracoscopic Sympathectomy for Primary Palmar Hyperhidrosis

Ann Thorac Surg Short Rep. 2026 Mar 13;4(2):733-736. doi: 10.1016/j.atssr.2025.12.024. eCollection 2026 Jun.

ABSTRACT

Endoscopic thoracic sympathectomy is an effective treatment of primary palmar hyperhidrosis. Currently, single-port thoracoscopy is the primary surgical approach. Ensuring efficacy and safety, reducing surgical obstacles, minimizing tissue damage, and enhancing cosmesis and aesthetics of the surgical incision are focal in clinical research on endoscopic thoracic sympathectomy. Herein, we report a simple and minimally invasive surgical technique that avoids collisions due to the telescope and endodissector crossing in single-port thoracoscopic surgery. This refers to the application of medical thoracoscopy combined with nonintubation anesthesia and perfusion index monitoring in the treatment of primary palmar hyperhidrosis.

PMID:42267010 | PMC:PMC13245509 | DOI:10.1016/j.atssr.2025.12.024

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Risk factors for compensatory hyperhidrosis following CT-guided percutaneous radiofrequency sympathectomy: A retrospective observational study

Medicine (Baltimore). 2026 May 22;105(21):e48976. doi: 10.1097/MD.0000000000048976.

ABSTRACT

Compensatory hyperhidrosis (CH) is a significant complication following surgery for primary hyperhidrosis, impairing patients’ postoperative experience and quality of life. Radiofrequency sympathectomy (RFS) is one of the main minimally invasive surgeries for hyperhidrosis, yet high-risk factors and patient experiences of postoperative CH are rarely reported. This retrospective observational study (Strengthening the Reporting of Observational Studies in Epidemiology compliant) aimed to identify significant risk factors for CH after RFS and to develop a dynamic nomogram for individualized risk prediction. A total of 410 primary hyperhidrosis patients who underwent RFS between January 2018 and March 2023 were enrolled. A CH database was established via systematic follow-up to track postoperative sweating patterns. Detailed clinical assessments included the Numeric Rating Scale (NRS), Hyperhidrosis Disease Severity Scale (HDSS), and Hospital Anxiety and Depression Scale (HADS). Advanced statistical techniques, including logistic regression analysis, were used to identify potential risk factors for CH. Of the 410 patients, 281 (68.5%) developed CH, with 105 (25.6%) reporting moderate-to-severe symptoms. Multivariate analysis revealed 4 significant predictors of CH: male gender (odds ratio [OR] = 1.69); higher NRS scores (OR = 1.16); lower immediate postoperative HDSS (OR = 0.48); higher preoperative HADS scores (OR = 1.11). A dynamic, web-based nomogram was also developed to provide personalized CH risk prediction. Male gender, higher intraoperative NRS scores, lower immediate postoperative HDSS, and higher preoperative HADS scores were identified as independent risk factors. The constructed dynamic nomogram enables individualized risk prediction and supports clinicians in providing personalized preoperative counseling and perioperative management for patients undergoing RFS.

PMID:42175438 | DOI:10.1097/MD.0000000000048976

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Analysis of all video-assisted thoracic sympathectomy for hyperhidrosis over 9 years in Brazil: trends, costs and in-hospital mortality over 200 million inhabitants

Ann Vasc Surg. 2026 May 19:S0890-5096(26)00376-6. doi: 10.1016/j.avsg.2026.05.070. Online ahead of print.

ABSTRACT

BACKGROUND: Primary hyperhidrosis (HH) causes substantial functional and psychosocial impairment. While anticholinergic therapy has become first-line treatment, video-assisted thoracic sympathectomy (VATS) remains the only definitive option for patients with refractory disease. Large-scale, real-world data on the safety and utilization of VATS for HH at a national level remain limited.

METHODS: We conducted a nationwide retrospective analysis including all patients who underwent VATS for HH in Brazil between 2015 and 2023. Data were obtained from publicly available governmental databases encompassing both public and private healthcare systems. Procedure volumes, demographic characteristics, regional distribution, reimbursement, in-hospital mortality, and healthcare-sector differences were analyzed.

RESULTS: A total of 26,980 VATS procedures for HH were performed during the study period. Most patients were female (64.5%) and aged 15-39 years (82.7%). Procedures were predominantly performed in the private healthcare system (75.3%), with marked regional concentration in the Southeast (48.3%) and South (29.5%) regions. Overall in-hospital mortality was extremely low (0.048%) and did not differ significantly between public and private sectors. Despite similar safety profiles, the mean cost per procedure in the private system was substantially higher, resulting in more than 90% of total national expenditures.

CONCLUSIONS: In this nationwide cohort of nearly 27,000 procedures, VATS sympathectomy for primary hyperhidrosis demonstrated an low mortality rate across both public and private healthcare systems, supporting its role as a safe definitive surgical therapy when appropriately indicated. The marked disparities in access and cost highlight important system-level differences but do not appear to compromise procedural safety.

PMID:42162859 | DOI:10.1016/j.avsg.2026.05.070

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The use of an objective method (continuous exosomatic electrodermal activity without external stimuli) to evaluate patients with hyperhidrosis undergoing video-assisted sympathectomy

Einstein (Sao Paulo). 2026 Apr 27;24:eAO1266. doi: 10.31744/einstein_journal/2026AO1266. eCollection 2026.

ABSTRACT

OBJECTIVE: To analyze continuous exosomatic electrodermal activity (EDA) without external stimuli (EDAcw) in patients with primary hyperhidrosis before and after sympathectomy.

METHODS: This prospective study included 28 participants, categorized into two groups. The first group comprised 18 patients with palmoplantar hyperhidrosis who underwent bilateral thoracic sympathectomy. The second group (control) consisted of 10 patients. Two questionnaires were administered: the Control Group completed them once, whereas the Sympathectomy Group completed them preoperatively, and on the first and thirtieth postoperative days. Sweating was evaluated by measuring EDAcw using an MP36R biosensor. Measurements were obtained from the hands and feet for 5 min without external stimuli in an air-conditioned environment and were performed preoperatively, and on the first and thirtieth postoperative days. Anthropometric, clinical, and surgical data were collected, and no significant sociodemographic differences were observed between the groups.

RESULTS: In the Sympathectomy Group, quality of life improved, and sweating reduced. During preoperative assessment, EDA was higher in the hands and feet of patients with hyperhidrosis than in the Control Group. Postoperatively, EDA in the hands decreased, with 100% of the patients showing a decrease in sweating. For the feet, 67% of the patients reported reduced sweating, and 44% showed a statistically significant decline in EDA.

CONCLUSION: Continuous exosomatic EDA measurement without external stimuli is a suitable method for assessing patients with palmoplantar hyperhidrosis and shows appropriate clinical correlation.

PMID:42054168 | DOI:10.31744/einstein_journal/2026AO1266

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Advances in pharmacological treatment and management of hyperhidrosis

Expert Opin Pharmacother. 2026 Mar 23:1-10. doi: 10.1080/14656566.2026.2642213. Online ahead of print.

ABSTRACT

INTRODUCTION: Hyperhidrosis is a functional disorder characterized by excessive sweat production beyond physiological needs for thermoregulation, significantly impairing quality of life, affecting physical comfort, psychological well-being, social interactions, and work productivity.

AREAS COVERED: This review focuses on evidence-based therapeutic options for hyperhidrosis. Topical treatments (glycopyrronium bromide, glycopyrronium tosylate, aluminum salts), systemic therapy (oral oxybutynin), injectable approaches (botulinum toxin), iontophoresis, and surgical interventions (local excision, sympathectomy) are discussed in detail. Clinical studies demonstrate that topical and systemic agents are effective for localized and multisite forms, respectively, while botulinum toxin offers strong efficacy for focal hyperhidrosis. The review also addresses combination strategies, treatment tolerability, cost-effectiveness, and patient-centered approaches.

EXPERT OPINION: Managing hyperhidrosis requires a nuanced, individualized strategy that balances symptom control, safety, patient preferences, and quality of life. Combination therapies and flexible treatment sequencing can reduce early reliance on invasive procedures. Despite therapeutic advances, widespread adoption is limited by heterogeneous guidelines, off-label use, and under-recognition of psychosocial impact. Future research should focus on prospective, large-cohort studies, standardized outcome measures, and development of selective, well-tolerated therapies. While a universal cure is unlikely, sustained symptom control and meaningful improvement in quality of life represent realistic objectives.

PMID:41871366 | DOI:10.1080/14656566.2026.2642213