Essential or primary hyperhidrosis affects between 0.5
and 1% of the population . It is characterized by
profuse sweating on the palmar surface of the hands,
armpits, groin and feet, which can have psychological
consequences. It is a problem of sympathetic dysregulation that may have
an underlying genetic component.
To control their sweat production, patients initially
try non-surgical therapies, such as anticholinergic
drugs, topical astringents and/or absorbing powders,
biofeedback, iontophoresis or botulinum toxin injections. However, unless their symptoms are
mild, these approaches are rarely successful and the
problem persists.
After unsuccessfully attempting at least one nonsurgical
therapy, many patients then seek a surgical approach to manage their hyperhidrosis.
Surgical sympathectomies have been carried out for
more than 100 years [10], and have been available for
the treatment of hyperhidrosis in the last decades [1,
5, 11, 16]. In the 1990s, advancement in endoscopic
techniques revolutionized sympathetic surgery,
allowing the surgeon to view the sympathetic ganglia
through a small incision.
Instead of permanently transecting or cauterizing
the sympathetic trunk, some surgeons now apply
clamps [17]. These clamps generate pressure on the
sympathetic ganglia, which blocks the transmission of
sympathetic impulses. The advantage of the clamps is
that they can be removed [18], or repositioned [3], if the
postsurgical side effects are intolerable. The clamping
method (the term ‘‘clamping’’ is used as ‘‘clipping’’
could be conceived as cutting) may be more successful
than permanent sympathetic cauterization [18] and
has no greater incidence of adverse effects [23].
Endoscopic thoracic sympathectomy is now the
standard procedure chosen by physicians for the
treatment of severe hyperhidrosis [9, 11, 13, 15, 21]. It
is safe and successful in almost 98% of cases, only 1–
2% of patients experience recurrence of their hyperhidrosis
[16, 23, 28]. All patients develop some degree
of compensatory sweating after surgery. In most this
is mild and tolerable; however, in 3–5% of patients it
is severe and intolerable [7]. Endoscopic thoracic
sympathectomy is minimally invasive, reducing
postoperative pain, and can be performed on an
outpatient basis [23, 28].
Although the surgical techniques have been refined,
there is still debate as to exactly what level the
sympathectomy should be performed. In retrospective
analysis of a large cohort of patients undergoing
endoscopic thoracic sympathectomy for hyperhidrosis,
the results of clamping at either the T2–T3 level or
