Anatomical clipping of sympathetic nerve to reduce compensatory sweating in primary hyperhidrosis: a novel technique

Federico Raveglia, Marcello Costa Angeli, Marco Scarci


Background: Hyperhidrosis (HP) is a pathological condition presenting with extreme perspiration exceeding physiological range. At present, several treatments for HP are available, however, is common opinion that thoracoscopic sympathetic nerve trunk interruption is the most effective approach in terms of duration and outcomes. Its most feared side effect is excessive sweating emerging in a new body area that can be as embarrassing as the original form of HP that required surgery. It is generally thought that interruption of the nerve at a higher level including severing it at several level is more likely to determine dry skin whereas low resection tend to prevent compensatory hyperhidrosis (CH) occurrence. We reviewed our experience to determine the optimal nerve target level for sympathectomy in order to achieve patients’ satisfaction.
Methods: We retrospectively collected data from patients who underwent surgical sympathetic nerve interruption for HP from 2001 to 2018 at our division. Since surgical strategy and technique have been modified over the years, patients were categorized in 4 groups depending on the period of surgery. Our primary outcome was sweating improvement. Secondary outcomes were CH onset, degree of satisfaction, complications and recurrences. Follow-up was up to 18 months.
Results: We consecutively operated on 2,725 patients (1,438 male and 1,287 female) with a mean age of 28 and a range between 15 and 72 years. From 2001 to 2003, 132 patients underwent non selective nerve dissection at the upper margin of 3rd rib. From 2003 to 2012, 643 patients underwent selective nerve clipping at the upper margins of predetermined ribs in accordance with specific skin area. From 2012 to 2018, 1,582 patients underwent selective nerve clipping at the lower pole of predetermined ganglia. Sweating management and degree of satisfaction progressively improved in the 4 groups, whereas disturbing CH shifted from 72% to 3%.
Conclusions: Selective ganglia interruption by titanium clips is a satisfactory option that guarantee successful management of excessive sweating and is associated with tolerable CH. Careful preoperative patient evaluation is mandatory to define correct surgical strategy that should be always decided in accordance with patient keeping into consideration the benefits on sweating reduction versus the risk of troubling CH.