Primary palmar hyperhidrosis: double-stage three levels clipping

We have read with great interest the article by Ishy et al. concerning the video-assisted treatment of hyperhidrosis [1].

Primary palmar hyperhidrosis (PH) is a condition characterized by oversecretion of the eccrine sweat glands, resulting in heavy sweating in the palms. PH has a strong negative impact on social and professional life. The therapeutic options for the management of hyperhidrosis have traditionally been non-surgical. These include topical antiperspirants, anti-cholinergic drugs, iontophoresis and, more recently, botulinum toxin injections. These methods seldom give sufficient relief, their effects are transient, compliance rates are low and they are not without associated side-effects. Since the open surgical procedures are unattractive [2], there is interest in improving surgical management using modern minimally-invasive techniques [3]. Thoracoscopic sympathectomy is, actually, a safe and effective method of managing these patients but controversy remains regarding surgical procedures as follows:

1. Sympathectomy level: sectioning at the level of the second (T2), third (T3) and fourth (T4) posterior costal arches.

2. Techniques for VATS: chain resection, transection, cauterization or clipping.

3. The occurrence of postoperative compensatory hyperhidrosis (CH) which remains an untoward and common problem.

Irrespective of the level of sympathectomy, clipping allows a potential advantage in terms of reversibility in case of compensatory oversecretion, although this was not observed in our series of 25 patients. In our institution, unlike the resection procedures reported by Ishy et al. [1], in all cases we performed a three-level clipping sympathectomy, as the axillary and palmar hyperhidrosis were always associated. Moreover, we prefer double-stage surgery, due to potentially lethal complications reported in the literature with the single-stage technique [4]. In conclusion, based on our complications rate and CH of 0% at 24 months, we support the hypothesis that the best treatment for PH is double-stage three level clipping.

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