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Clinical Review

Diagnosis and management of hyperhidrosis

BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f6800 (Published 25 November 2013) Cite this as: BMJ 2013;347:f6800

Rapid Response:

Re: Diagnosis and management of hyperhidrosis

We read with interest the review article by Benson et al on treatment for hyperhidrosis. The patient should be informed and given the choice of different minimally invasive approaches to sympathectomy, including conventional video-assisted thoracic surgery (VATS) which utilizes incisions of 5 to 10 mm in length, or specialized technique of needlescopic VATS which have incisions of 3mm only. [1] More recently, single incision (uniportal) VATS sympathectomy has been reported which may further reduce surgical access trauma. [2] Furthermore, the choice of sympathectomy (usually referred to excision of a section of the nerve) or sympathicotomy (interruption of the nerve) should also be discussed with the patient. The advantage of sympathectomy is that recurrence of hyperhidrosis is less likely, but may be associated with more severe compensatory hyperhidrosis. [1,3]

Prior to performing surgical sympathectomy, another important consideration is the patient’s resting pulse rate. The Society of Thoracic Surgeons guidelines suggest that patients with a resting heart rate lower than 55 per min are unsuitable for this procedure because of potential exacerbation of bradycardia following sympathectomy. [3] In addition, patients should be warned that there is some evidence sympathectomy may affect cardiac ejection fraction based on echocardiographic findings, which may consequently reduce peak exercise performance. Such warning would be particular prudent for athletes considering this surgical procedure. [4]

Finally, although patients should be warned of the irreversible nature of the surgical procedure, in highly specialized centers, reversing the sympathectomy by nerve graft can be attempted for those with severe side effects of compensatory hyperhidrosis. [5] In the current environment of medical litigation, we can never be too careful in our consent for an essentially lifestyle surgical procedure.

References:
1. Ng CSH, Lau RWH, Wong RHL, Yim APC. Evolving Techniques of Endoscopic Thoracic Sympathectomy: Smaller Incisions or Less? The Surgeon 2013;11:290-291
2. Ng CSH, Yeung ECL, Wong RHL, Kwok WT. Single-port Sympathectomy for Palmar Hyperhidrosis with VasoView HemoPro 2 Endoscopic Vein Harvesting Device. J Thorac Cardiovasc Surg. 2012 Nov;144(5):1256-7
3. Cerfolio RJ, De Campos JR, Bryant AS, Connery CP, Miller DL, DeCamp MM, McKenna RJ, Krasna MJ. The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis. Ann Thorac Surg 2011;91(5):1642-8
4. Cruz JM, Fonseca M, Pinto FJ, Oliveira AG, Carvalho LS. Cardiopulmonary effects following endoscopic thoracic sympathectomy for primary hyperhidrosis. Eur J Cardiothorac Surg 2009;36(3):491-6
5. Wong RHL, Ng CSH, Wong JKW, Tsang S. Needlescopic video-assisted thoracic surgery for reversal of thoracic sympathectomy. Interact CardioVasc Thorac Surg 2012;14:350-2

Competing interests: No competing interests

19 December 2013
Calvin S.H. Ng
Cardiothoracic Surgeon
Rainbow W.H. Lau, Randolph H.L. Wong
The Chinese University of Hong Kong
Dept of Surgery, Prince of Wales Hospital, Shatin , Hong Kong