Long-term follow-up in quality of life before and after endoscopic thoracic sympathicotomy in 367 patients with palmar hyperhidrosis

Introduction

Palmar hyperhidrosis (PH) is a benign functional disorder resulted from excessive secretion of exocrine glands on the palms (1). Excessive sweating might cause embarrassment especially under occupational or social stress. PH may lead to emotional difficulty and hinder daily activities, and ultimately, deterioration in quality of life (QOL).

There are many treatment options for palmar hyperhidrosis, including topical therapies, oral medications, iontophoresis, or thoracic sympathicotomy (2,3). According to The Society of Thoracic Surgeons, thoracic sympathectomy is the treatment of choice for patients with primary hyperhidrosis given its safety and effectiveness (4).

Symptomatic improvement has been the primary outcome of many previous studies regarding endoscopic thoracic sympathicotomy (ETS). Nowadays, the issue of QOL is receiving considerable attention (5), especially the long-term change after particular medical intervention. Besides, many previous studies assessed QOL with scales in general nature (6-8). In other words, there is a paucity of study evaluating QOL with questionnaire specified for patients with PH. Thus, we conducted a cross-sectional study, using a specific questionnaire, to evaluate QOL before and after ETS in patients with PH. We present the following article in accordance with the STROBE reporting checklist (available at https://apm.amegroups.com/article/view/10.21037/apm-21-2860/rc).

Methods

Study design

This study enrolled a cohort of 367 patients with PH who underwent ETS in Guangdong Provincial People’s Hospital between March 2018 and March 2019. During this period, 498 patients underwent ETS for PM and were surveyed. Among them, 402 responded to the questionnaire before surgery and 35 patients were lost from follow-up. Inclusion criteria as follow: (I) age between 12 and 60 years old; (II) severe palmar sweating was the major complaint with or without sweating in other body sites; (III) patients with strong urge for surgery; (IV) patients who can literally understand and answer the questionnaire. Patients without surgical treatment or those who were not suitable for surgery because of severe pleural adhesions were excluded. Patients were excluded if they refused to participate. Preoperative assessment on QOL was collected at the admission to hospital, while the postoperative QOL was evaluated after a median follow-up of 14 months [interquartile range (IQR), 9–21 months] after the completion of ETS. The link of questionnaire was sent to the patients via WeChat after obtaining their informed consent to participate. Completion of the questionnaire did not result in any benefit or financial compensation for respondents. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Institutional Review Board of Guangdong Provincial People’s Hospital (No. 2020-268H) and informed consent was obtained from all individual participants and minors’ legal guardian/next of kin.

Surgical technique

Bilateral and sequential sympathicotomy were performed in all cases in the same setting. Single lumen endotracheal intubation with general anesthesia was the standard technique. All patients were in a semi-supine position at 30°–45° to the operating table with the abduction of both upper limbs. One 5 mm incision was made in each hemithorax in the third intercostal space along anterior axillary line. Carbon dioxide was inflated through 5 mm Trocar to create artificial pneumothorax. After exclusion of severe pleural adhesions by the thoracoscope, electrocoagulation hook was introduced through the same incision. Sympathicotomy at level R4 was performed using electrocoagulation hook and extended 2 cm laterally at levels R3 and R4 to include Kuntz’s nerve. Aspirator was connected to the Trocar, which was removed after endoscopic confirmation of full lung re-expansion. Incisions were sutured or adhered by medical glue. Then, the patient was shifted to the recovery room and a postoperative chest X-ray was done routinely before their discharge from hospital.

Construction of QOL questionnaire for PH

QOL is defined as the subjective perception of an individual’s general well-being, including functional, personal, emotional, and special circumstances parameters. In the current study, QOL questionnaire for PH were adapted from de Campos Questionnaire (9) to evaluate the QOL before and after surgery in all participants (detailed in supplementary material). Eleven Likert five-scale questions fell into five different domains, including general rating (Question 1), functional/social domain (Question 2-6), personal domain (Question 7-8), emotional domain (Question 9-10), and special circumstances (Question 11). The answers to Likert scale Question 2-11 were then used to construct a total score of QOL for every individual patients. The total score of QOL ranged from 10–50, where “excellent”, “good”, “moderate”, “poor”, “very poor” were designated as 1 to 5 points, respectively. A lower total score indicated a higher level of QOL. The pilot study was conducted enrolling 50 patients underwent ETS in March 2018. We found a Cronbach’s alpha of 0.909 for the questionnaire. Goodness-of-fit indices for the questionnaire indicated an acceptable model fit (Chi squared/degrees of freedom ratio =2.163, comparative fit index =0.913).

Statistical analysis

Demographic and clinical data except for age were summarized as frequency and percentage. Results were given as median (Md) with IQR. Differences of QOL before and after ETS were compared by Wilcoxon rank-sum test. Differences of the score of preoperative QOL (QOLpre) or postoperative QOL (QOLpost) according to PH severity were examined by Kruskal-Wallis rank sum test. Correlation between compensatory hyperhidrosis (CH) and QOL was examined by Spearman rank correlation test. A P value of less than 0.05 was considered to indicate a statistically significant difference. All data analysis was performed using SPSS version 21 (IBM Corp, Armonk, NY, USA).

Results

Patients characteristics

A total of 367 patients underwent ETS between March 2018 and March 2019 were included in this analysis. Median follow-up time was 14 months (IQR, 9–21 months) after surgery. The mean age was 25.1±4.5 years (range, 14 to 47 years old); and 180 (49%) patients were females. The self-reported preoperative severity of hyperhidrosis was intolerable in 48.2% patients and barely tolerable in 51.8% patients. Almost half of the patients (178/367, 48.5%) had previously received conservative treatment elsewhere, however, with no obvious improvement. The detail breakdown of the distribution of hyperhidrosis and some of other main characteristics were shown in Table 1. After receiving ETS, the palmar sweating was disappeared in 60.22% patients and alleviated in 36.51% patients (Figure 1). However, what stood out in Figure 1 was the high rate of exacerbation of sweating on the back, thigh, buttocks, and chest.

Figure 1 Evolution of hyperhidrosis of each location after surgery.

Long-term change in quality of life

QOL was examined by QOL questionnaire for PH. Significant reduction of general QOL score was found after surgery (Md =2.0, IQR, 2.0–3.0) in comparison with the score prior to surgery (Md =4.0, IQR, 3.0–4.0; P<0.001). The median of QOLpost was 20.0 (IQR, 13.0–23.0), and it was significantly lower when compared with QOLpre (Md =40.0, IQR, 37.0–45.0; P<0.001). After thoracic sympathicotomy, the greatest reduction of QOL score was observed in personal domain (52.6%); however, it was also noticeable in other domains (Table 2). In summary, 90.7% of the patients achieved a better QOL after the surgery.

Considering the final surgical results, 90 patients (24.5%) were very satisfied with the outcome of the operation; 163 patients (44.4%) were satisfied; 96 patients (26.2%) were basically satisfied. Only 4.9% of the patients were not satisfied after the procedure attributing to CH, surgical cost, or pain (Table 3). In addition, 335 participants (91.3%) were willing to recommend the surgical treatment for other patients with PH.

Quality of life and severity of palmar hyperhidrosis

According to the severity scale of PH (10), the proportions of patients who had severe (defined as ‘sweat was in the shape of drops when palms sweated’), moderate (defined as ‘palmar sweat was profuse enough to drench a handkerchief’) and mild (defined as ‘palms were frequently moist’) PH were 65.4%, 32.2% and 2.5%, respectively. Table 4 revealed that QOLpre is higher in patients with more severe PH before ETS. Moreover, there was a significant difference of QOLpre between moderate group (Md =38.5, IQR, 34.8–42.0) and severe group (Md =42.0, IQR, 38.0–46.0; P<0.001). However, there was no significant difference among QOLpost regardless of the severity of PH (P=0.946).

Postoperative quality of life and compensatory hyperhidrosis

CH was present in 94.6% cases after ETS. The most common location was the back (85.0%), but CH also emerged on the chest, thigh, buttocks, or other regions (Table 5). Among the patients who presented with CH, only 9.5% considered it was severe. Moreover, there was a weak but significant positive correlation between postoperative QOL score and the severity of CH (Figure 2), which was examined using the Spearman correlation analysis (rs =0.14; P=0.009).

Figure 2 Postoperative QOL score compared with severity of CH. Examined by the Spearman correlation analysis (rs=0.14; P=0.009). QOL, quality of life; CH, compensatory hyperhidrosis; QOLpost, the score of postoperative quality of life.

Discussion

Patients with excessive sweat production were often restricted in both their private and professional lives, and QOL was affected. Surgical treatment does bring a long-term resolution to the difficulties. In this study, the QOL questionnaire for PH was applied among 367 patients. The present study elicited three main findings. First, it was found that the deteriorated QOL improved significantly in personal, functional/social, special circumstances, and emotional domains. Second, this study revealed that, postoperative QOL was not affected by preoperative severity of PH. Finally, CH may be an important factor affecting the QOL of PH patients after ETS, as QOL after surgery was negatively correlated to the severity of CH.

ETS is a safe and effective treatment for PH (4,11). It is able to locate the sympathetic chain accurately, provide cosmetic result, shorter length of hospital stay, and less bodily pain. To achieve the optimal therapeutic effect, in addition to the reduction of palmar sweating, patients’ satisfaction and QOL should also be comprehensively evaluated. Divisi and colleagues described an overall 93.3% satisfactory rate after ETS (12). Similarly, 95.1% of the participants reported satisfaction in the present study. As regards the remaining 18 patients who dissatisfied, 77.8% reported moderate to severe CH.

Several researches applied modified questionnaires to evaluate QOL of patients with PH (2,6,13). Such questionnaires include Functional Assessment of Chronic Illness Therapy Scale (FACIT), Medical Outcomes Study Short Form 36 (SF-36), Spielberger State Trait Anxiety Inventory (STAI). They were widely used, easy to apply, and reliable. However, these questionnaires were not designed specifically for PH. It is believed that de Campos Questionnaire is a specific scale to accurately assess QOL in patients with PH. Publications by Horslen (14) and de Campos (9) revealed that 86% and 86.4% of the patients achieved a significant better QOL after the operation, respectively. As we found in our study, about 90% reported a better QOL. Significant improvement was found postoperatively in all evaluated domains of QOL. These findings are in agreement with those obtained by earlier studies (9,15). The greatest improvement was observed in the personal domain, which indicated patients found less PH-related difficulty in common interaction or intimate touching with other people. It was valuable that the improvement in QOL sustained for a long-term period after receiving ETS.

It is particularly important to recognize the factors determining the QOL of patients with PH, which may be applied to specify certain actions to be taken to provide them with an adequate comfort of life. de Campos et al. suggested that the major factors affecting patients’ QOL were the type of hyperhidrosis and side effects (9). However, preoperative severity of PH did not make a difference to postoperative QOL. Although poorer QOL was reported by patients with more severe PH before surgery, all patients reported better QOL at a similar level.

CH is one of the most common (11.0–96.2%) side effects after sympathicotomy (16,17). CH was embarrassing and bothering, and it can be so severe that patients may require several changes of clothes during the day (17). CH emerged on the back, chest, thigh, buttocks, and other sites. As is well-known, there are a variety of methods to evaluate CH. Some objective methods were proposed, such as VapoMeter or Doppler scanning of skin perfusion (18,19). However, most studies used subjective methods to evaluate CH via questionnaires, which leading to an inconsistent and a very wide range of prevalence across studies (16,20). Therefore, it is essential to recommend a consolidated appraising method, which can be easily and internationally applied.

Still, it is controversial as to what extent CH influences patients’ QOL (6). It was stated that CH did not significantly alter QOL (21,22), whereas results presented here are different. Significantly positive correlation between CH and postoperative QOL score was tested by the Spearman correlation analysis (rs=0.14; P=0.009) (Figure 2). This result may be explained by the fact that, CH was one of the factors negatively influencing postoperative QOL. Surgical success can be reflected from the QOL improvements after surgery (20). Evan after a 10-year follow-up, a sustained and stable improvement was seen regarding quality of life in patient after surgery (5). Despite the correlation between CH and QOL, satisfaction and significant improvement of QOL was reported by patients after sympathicotomy. Substantial cases of CH were subclinical, since they require no specific treatment. Although CH could be an underlying cause for discontent postoperatively, it is still preferred over the distress experienced from PH.

It is necessary to warn all patients with PH, who consider sympathicotomy, about the unpleasant effects of CH, which are difficult to control with currently available therapies. Although some researchers had been discussing the prevention of CH by modified procedures (23,24), the practical effects required confirmation by further studies. Jeong and coworkers had proposed a predictive procedure by using local anesthesia to detect compensatory hyperhidrosis before sympathectomy. This approach may be useful in guiding patients’ decisions about sympathectomy (25). Although the detailed mechanism was unclear, Divisi and colleagues consider that CH as a failure of feedback mechanism of the sectioned chains and para-physiological rearrangement of sweating in other parts of the body (12). In another way, multiple hyperhidrosis distribution presented preoperatively were indicated to be associated with clinically bothersome CH (20). Reducing the negative effects of CH to patients became imperative. Preoperatively, surgeon should inform the patient of a relatively high incidence of CH, and the possibility of occurring anywhere. Patients’ knowledge about the severity of CH and the permanent characteristic of surgery should be ensured. Postoperatively, proper psychological counselling is necessary for those with severe CH, since extremely disruptive psychologic state had been reported in some patients (11).

Although sympathicotomy resulted in some bodily pain (the proportions of patients who had mild, moderate, and severe postoperative wound-related pain were 48.5%, 25.8%, and 10.4%, respectively in this study) and side effects like CH, these drawbacks were outweighed by the improvement in QOL of the four domains. We believed that, even though CH is unpredictable, exhaustive inform by surgeon can influence patients’ satisfaction positively.

There are several limitations in the present study. First, although clearly defined in our questionnaire, the postoperative report of transient hyperhidrosis or compensatory hyperhidrosis was not formally evaluated by surgeons, which impaired the reliability of these results. Second, QOL after surgery was evaluated only once. However, several studies have suggested that the incidence and severity of CH could change over time (20,26-28). Third, our study only involved patients at a single center, which might limit the generalizability of our results. Therefore, a prospective study involved multiple centers with regular follow-up in the future is ideal.

Nevertheless, this study confirmed the benefit of ETS to patients’ QOL and subjective well-being. The QOL questionnaire for PH was proved to be highly effective, easily understood and applied. It was able to dynamically evaluate QOL before and after sympathicotomy.

In conclusion, ETS can significantly improve PH patients’ QOL, which sustains for a long period of time. Despite different severities of PH and a correlated QOL might be observed preoperatively, patients could generally reach a similar level of improved QOL after ETS. ETS is a safe and simple procedure, yet reducing CH or the negative impact of CH is still part of our main objective in the future clinical practice.

Acknowledgments

We thank all patients for their participation in this study.

Funding: This work was supported by the 2020 Guangdong Provincial Special Project for Popularization of Science and Technology Innovation (grant No. 2020A1414070007).

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://apm.amegroups.com/article/view/10.21037/apm-21-2860/rc

Data Sharing Statement: Available at https://apm.amegroups.com/article/view/10.21037/apm-21-2860/dss

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-21-2860/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the Institutional Review Board of Guangdong Provincial People’s Hospital (No. 2020-268H) and informed consent was obtained from all individual participants and minors’ legal guardian/next of kin.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Nawrocki S, Cha J. The etiology, diagnosis, and management of hyperhidrosis: A comprehensive review: Etiology and clinical work-up. J Am Acad Dermatol 2019;81:657-66. [Crossref] [PubMed]
2. Dobosz L, Stefaniak T. Evaluation of Quality of Life: Functional Assessment of Chronic Illness Therapy after Thoracic Sympathectomy for Palmar Hyperhidrosis. Thorac Cardiovasc Surg 2019;67:420-4. [Crossref] [PubMed]
3. Grabell DA, Hebert AA. Current and Emerging Medical Therapies for Primary Hyperhidrosis. Dermatol Ther (Heidelb) 2017;7:25-36. [Crossref] [PubMed]
4. Cerfolio RJ, De Campos JR, Bryant AS, et al. The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis. Ann Thorac Surg 2011;91:1642-8. [Crossref] [PubMed]
5. de Campos JR, da Fonseca HV, Wolosker N. Quality of Life Changes Following Surgery for Hyperhidrosis. Thorac Surg Clin 2016;26:435-43. [Crossref] [PubMed]
6. Kumagai K, Kawase H, Kawanishi M. Health-related quality of life after thoracoscopic sympathectomy for palmar hyperhidrosis. Ann Thorac Surg 2005;80:461-6. [Crossref] [PubMed]
7. Wang HY, Zhu YJ, Liu J, et al. The relationship between preoperative psychological evaluation and compensatory sweating. J Cardiothorac Surg 2018;13:42. [Crossref] [PubMed]
8. Shayesteh A, Janlert U, Nylander E. Hyperhidrosis - Sweating Sites Matter: Quality of Life in Primary Hyperhidrosis according to the Sweating Sites Measured by SF-36. Dermatology 2017;233:441-5. [Crossref] [PubMed]
9. de Campos JR, Kauffman P, Werebe Ede C, et al. Quality of life, before and after thoracic sympathectomy: report on 378 operated patients. Ann Thorac Surg 2003;76:886-91. [Crossref] [PubMed]
10. Lai FC, Tu YR, Li YP, et al. Nation wide epidemiological survey of primary palmar hyperhidrosis in the People's Republic of China. Clin Auton Res 2015;25:105-8. [Crossref] [PubMed]
11. Chen J, Liu Y, Yang J, et al. Endoscopic thoracic sympathicotomy for primary palmar hyperhidrosis: A retrospective multicenter study in China. Surgery 2019;166:1092-8. [Crossref] [PubMed]
12. Divisi D, Zaccagna G, Imbriglio G, et al. Video-assisted thoracoscopic sympathectomy versus modified Wittmoser method in surgical management of primary hyperhidrosis. J Cardiothorac Surg 2020;15:133. [Crossref] [PubMed]
13. Vazquez LD, Staples NL, Sears SF, et al. Psychosocial functioning of patients after endoscopic thoracic sympathectomy. Eur J Cardiothorac Surg 2011;39:1018-21. [Crossref] [PubMed]
14. Horslen LC, Wilshire CL, Louie BE, et al. Long-Term Impact of Endoscopic Thoracic Sympathectomy for Primary Palmar Hyperhidrosis. Ann Thorac Surg 2018;106:1008-12. [Crossref] [PubMed]
15. Soares TJ, Dias PG, Sampaio SM. Impact of Video-Assisted Thoracoscopic Sympathectomy and Related Complications on Quality of Life According to the Level of Sympathectomy. Ann Vasc Surg 2020;63:63-67.e1. [Crossref] [PubMed]
16. Du X, Zhu X, Wang T, et al. Compensatory hyperhidrosis after different surgeries at the same sympathetic levels: a meta-analysis. Ann Transl Med 2018;6:203. [Crossref] [PubMed]
17. Wolosker N, Milanez de Campos JR, Fukuda JM. Management of Compensatory Sweating After Sympathetic Surgery. Thorac Surg Clin 2016;26:445-51. [Crossref] [PubMed]
18. Larson DL. Definitive diagnosis and management of axillary hyperhidrosis: the VapoMeter and suction-assisted arthroscopic shaving. Aesthet Surg J 2011;31:552-9. [Crossref] [PubMed]
19. Yang SH, Tsai JC, Kao MC. Laser Doppler scanning study of palmar skin perfusion for patients with hyperhidrosis before and after thoracic sympathectomy. Surg Neurol 2006;66:S48-51. [Crossref] [PubMed]
20. Bryant AS, Cerfolio RJ. Satisfaction and compensatory hyperhidrosis rates 5 years and longer after video-assisted thoracoscopic sympathotomy for hyperhidrosis. J Thorac Cardiovasc Surg 2014;147:1160-1163.e1. [Crossref] [PubMed]
21. Silva SLD. Sobrinho, Fiorelli RKA, Morard MRS. Evaluation of the quality of life of patients with primary hyperhidrosis submitted to videothoracoscopic sympathectomy. Rev Col Bras Cir 2017;44:323-7. [PubMed]
22. Baroncello JB, Baroncello LR, Schneider EG, et al. Evaluation of quality of life before and after videothoracoscopic simpathectomy for primary hyperhidrosis. Rev Col Bras Cir 2014;41:325-30. [Crossref] [PubMed]
23. Han JW, Kim JJ, Kim YH, et al. New sympathicotomy for prevention of severe compensatory hyperhidrosis in patients with primary hyperhidrosis. J Thorac Dis 2020;12:765-72. [Crossref] [PubMed]
24. Weksler B. Is there light at the end of the tunnel for patients with severe compensatory hyperhidrosis? J Thorac Cardiovasc Surg 2017;154:e117. [Crossref] [PubMed]
25. Jeong JY, Park HJ, Park JK, et al. Predictive procedure for compensatory hyperhidrosis before sympathectomy: preliminary findings. Thorac Cardiovasc Surg 2014;62:434-8. [Crossref] [PubMed]
26. Rodríguez PM, Freixinet JL, Hussein M, et al. Side effects, complications and outcome of thoracoscopic sympathectomy for palmar and axillary hyperhidrosis in 406 patients. Eur J Cardiothorac Surg 2008;34:514-9. [Crossref] [PubMed]
27. Yano M, Kiriyama M, Fukai I, et al. Endoscopic thoracic sympathectomy for palmar hyperhidrosis: efficacy of T2 and T3 ganglion resection. Surgery 2005;138:40-5. [Crossref] [PubMed]
28. Menna C, Ibrahim M, Andreetti C, et al. Long term compensatory sweating results after sympathectomy for palmar and axillary hyperhidrosis. Ann Cardiothorac Surg 2016;5:26-32. [PubMed]