Blunted sudomotor reactivity in fibromyalgia is associated with levels of depression.

OBJECTIVES: Assessment of sudomotor function by distal electrochemical skin conductance (ESC) can provide an index of peripheral neuropathy. This study explored ESC in fibromyalgia (FM) patients, controlling for tricyclic antidepressant use and body mass index, and its association with the clinical severity of the disease. METHODS: ESC, clinical symptoms and an index of central pain sensitisation derived from pressure algometry were explored in thirty-three fibromyalgia patients and 33 healthy women. RESULTS: ESC was significantly lower in fibromyalgia patients than healthy participants. About 51% of patients exhibited moderate-to-severe ESC dysfunction, indicative of possible neuropathy. However, ESC was not related to any indicators of clinical severity, nor to algometry. ESC only correlated with depression levels; the group differences in ESC disappeared after controlling for depression. Finally, ESC was asymmetric in the overall sample, with lower values seen in the right hand relative to the left one. CONCLUSIONS: The greater prevalence of sudomotor dysfunction in fibromyalgia patients is consistent with the presence of neuropathy in subgroups of patients, and with the basic heterogeneity of the disorder. However, neuropathy does not appear helpful for determining the clinical features of the disorders, or the level of central sensitisation measured by pressure algometry. Future studies including patients with fibromyalgia suffering and not suffering from depression as well as patients with depression but free from chronic pain, are required to identify the role of depression in the observed low ESC levels.

Long-Term Efficacy of T3 Versus T3+T4 Thoracoscopic Sympathectomy for Concurrent Palmar and Plantar Hyperhidrosis.

BACKGROUND: More than 50% of patients with palmar hyperhidrosis (PAH) also have plantar hyperhidrosis (PLH). We compared the long-term results of T3 sympathectomy with those of combined T3+T4 sympathectomy among patients with concurrent PAH and PLH. MATERIALS AND METHODS: We retrospectively analyzed the records of patients with concurrent PAH and PLH who underwent T3 alone or T3+T4 sympathectomy from January 1, 2012, to December 31, 2017. Preoperative and postoperative sweating (hyperhidrosis index) was evaluated through questionnaires, physical examination, and outpatient follow-up. The relief rates and hyperhidrosis index were used as outcome measures to compare the efficacy of the two approaches. Patients' satisfaction and side effects were also evaluated. RESULTS: Of the 220 eligible patients, 60 underwent T3 sympathectomy (T3 group), and 160 underwent T3+T4 sympathectomy (T3+T4 group). Compared with the T3 group, the T3+T4 group showed higher symptom relief rates both for PAH (98.75% versus 93.33%, P = 0.048) and PLH (65.63% versus 46.67%, P = 0.01), and a greater postoperative decrease in both hyperhidrosis indices. The rate of severe compensatory hyperhidrosis also increased (10% versus 5%, P = 0.197), although the rates of overall satisfaction were comparable between the groups. The incidence of postoperative pneumothorax requiring chest tube placement and postoperative neuralgia was also similar. There were no cases of perioperative death, secondary operation, wound infection, or Horner syndrome in either group. CONCLUSIONS: Compared with T3 alone, T3+T4 sympathectomy achieved a higher symptom relief rate and a lower hyperhidrosis index. T3+T4 sympathectomy may be a choice for the treatment of concurrent PAH and PLH; however, patients need to be informed that this kind of surgery may increase the risk of compensatory sweating.

Disrupted local innervation results in less VIP expression in CF mice tissues.

Vasoactive Intestinal Peptide (VIP) is the major physiological agonist of the Cystic Fibrosis Transmembrane conductance Regulator (CFTR) chloride channel activity. VIP functions as a neuromodulator and neurotransmitter secreted by neurons innervating all exocrine glands. VIP is also a potent vasodilator and bronchodilator that regulates exocrine gland secretions, contributing to local innate defense by stimulating the movement of water and chloride transport across intestinal and tracheobronchial epithelia. Previous human studies have shown that the rich intrinsic neuronal networks for VIP secretion around exocrine glands could be lost in tissues from patients with cystic fibrosis. Our research has since confirmed, in vitro and in vivo, the need for chronic VIP exposure to maintain functional CFTR chloride channels at the cell surface of airways and intestinal epithelium, as well as normal exocrine tissues morphology [1]. The goal of the present study was to examine changes in VIP in the lung, duodenum and sweat glands of 8- and 17-weeks old F508del/F508del mice and to investigate VIPergic innervation in the small intestine of CF mice, before important signs of the disease development. Our data show that a low amount of VIP is found in CF tissues prior to tissue damage. Moreover, we found a specific reduction in VIPergic and cholinergic innervation of the small intestine. The general innervation of the primary and secondary myenteric plexus was lost in CF tissues, with the presence of enlarged ganglionic cells in the tertiary layer. We propose that low amount of VIP in CF tissues is due to a reduction in VIPergic and cholinergic innervation and represents an early defect that constitutes an aggravating factor for CF disease progression.

Distribution characteristics of sweat gland nerve fibres in normal humans identified by acetylcholinesterase histochemical staining.

OBJECTIVE: To quantitatively analyze distribution characteristics of sweat gland nerve fibres (SGNF) in normal Chinese individuals for obtaining a reference for early diagnosis of peripheral neuropathy. PATIENTS AND METHODS: Skin biopsy samples were collected from 192 normal Chinese individuals and divided into six, four and two groups according to anatomic sites, age and gender, respectively. SGNF morphology was observed and SGNF density (SGNFD) was determined. RESULTS: There was a significant difference in SGNFD among different anatomic sites, age and gender. A degressive tendency was observed from proximal to distal anatomic sites. SGNFD was the lowest in subjects in the 21-40-year-old age group, but was the highest in subjects in the >61-year-old age group. Overall, SGNFD fluctuated with age. SGNFD in males was significantly higher than that in females. CONCLUSIONS: Distribution characteristics of SGNF in normal individuals may serve as a reference for early diagnosis of nerve fibre damage.

Diagnostic utility of small fiber analysis in skin biopsies from children with chronic pain.

INTRODUCTION: Small fiber neuropathies (SFN) are associated with a reduction in quality of life. In adults, epidermal nerve fiber density (END) analysis is recommended for the diagnosis of SFN. In children, END assessment is not often performed. We analyzed small nerve fiber innervation to elucidate the potential diagnostic role of skin biopsies in young patients with pain. METHODS: Epidermal nerve fiber density and sudomotor neurite density (SND) were assessed in skin biopsies from 26 patients aged 7 to 20 years (15 female patients) with unexplained chronic pain. The results were compared with clinical data. RESULTS: Epidermal nerve fiber density was abnormal in 50% and borderline in 35% of patients. An underlying medical condition was found in 42% of patients, including metabolic, autoimmune, and genetic disorders. DISCUSSION: Reduction of epidermal nerve fibers can be associated with treatable conditions. Therefore, the analysis of END in children with pain may help to uncover a possible cause and guide potential treatment options.

The management of compensatory sweating after thoracic sympathectomy.

OBJECTIVE: The main therapeutic method of treatment for local hyperhidrosis is endoscopic thoracic sympathectomy. Generally, resections of the sympathetic trunk or ganglia are performed between the second rib and sixth rib. However, this procedure can result in compensatory sweating, in which excess sweating occurs on the back, chest, and abdomen. Compensatory sweating has been regarded as a thermoregulatory response and thought to be untreatable. This study suggests that compensatory sweating is not a physiologic reaction and is indeed treatable. METHODS: Eight patients with severe compensatory sweating were treated by observing blood perfusion of the skin with laser speckle flowgraphy, which determines the sympathetic nerves related to the area of skin with compensatory sweating. When intraoperative monitoring with laser speckle flowgraphy indicated the position of compensatory sweating by electrical stimulation of the sympathetic ganglion, ganglionectomy was performed. RESULTS: The skin domain that each sympathetic nerve controls was able to be detected by laser speckle flowgraphy. In all patients, compensatory sweating was resolved after interruption of the ganglia or sympathetic nerves related to compensatory sweating. CONCLUSIONS: Our results demonstrate that compensatory sweating is caused by denatured sympathetic nerves influenced by endoscopic thoracic sympathectomy and is not the result of a physiological response. With laser speckle flowgraphy, the sympathetic nerve related to the sweating of various parts of the body could be identified. The treatment of compensatory sweating on the back, chest, and stomach was previously considered to be difficult; however, compensatory sweating is demonstrated to be treatable with this technique.

Association of small fiber neuropathy and post treatment Lyme disease syndrome.

OBJECTIVES: To examine whether post-treatment Lyme disease syndrome (PTLDS) defined by fatigue, cognitive complaints and widespread pain following the treatment of Lyme disease is associated with small fiber neuropathy (SFN) manifesting as autonomic and sensory dysfunction. METHODS: This single center, retrospective study evaluated subjects with PTLDS. Skin biopsies for assessment of epidermal nerve fiber density (ENFD), sweat gland nerve fiber density (SGNFD) and functional autonomic testing (deep breathing, Valsalva maneuver and tilt test) were performed to assess SFN, severity of dysautonomia and cerebral blood flow abnormalities. Heart rate, end tidal CO2, blood pressure, and cerebral blood flow velocity (CBFv) from middle cerebral artery using transcranial Doppler were monitored. RESULTS: 10 participants, 5/5 women/men, age 51.3 ± 14.7 years, BMI 27.6 ± 7.3 were analyzed. All participants were positive for Lyme infection by CDC criteria. At least one skin biopsy was abnormal in all ten participants. Abnormal ENFD was found in 9 participants, abnormal SGNFD in 5 participants, and both abnormal ENFD and SGNFD were detected in 4 participants. Parasympathetic failure was found in 7 participants and mild or moderate sympathetic adrenergic failure in all participants. Abnormal total CBFv score was found in all ten participants. Low orthostatic CBFv was found in 7 participants, three additional participants had abnormally reduced supine CBFv. CONCLUSIONS: SFN appears to be associated with PTLDS and may be responsible for certain sensory symptoms. In addition, dysautonomia related to SFN and abnormal CBFv also seem to be linked to PTLDS. Reduced orthostatic CBFv can be associated with cerebral hypoperfusion and may lead to cognitive dysfunction. Autonomic failure detected in PTLDS is mild to moderate. SFN evaluation may be useful in PTLDS.

Needlescopic Video-Assisted Thoracic Bilateral T4 Sympathicotomy for the Treatment of Primary Palmar Hyperhidrosis: An Analysis of 200 Cases.

BACKGROUND: Primary palmar hyperhidrosis (PPH) is featured by aberrantly perspiration of the hands, which may bring a lot of inconvenience to patient's daily life and work. The purpose of this study is to summarize the clinical effect of needlescopic video-assisted thoracic bilateral T4 sympathicotomy for the treatment of PPH. PATIENTS AND METHODS: Between January 2009 and March 2014, 200 patients received needlescopic video-assisted thoracic bilateral T4 sympathicotomy. We, respectively, took two 5-mm incisions in the third intercostal space on the anterior axillary line and in the fifth intercostal space on the middle axillary line. After collapsing left lung, needlescopic exploration was the first step to determine the targeted sympathetic chain through the third intercostal space. Electric coagulation hook was inserted from another port to cut T4 sympathetic chain and the bypassing nerve fibers for 2 to 3 cm along the surface of the fourth rib. Right thoracic cavity was also administered the same procedure. The palmar temperature was recorded before and after sympathicotomy. The symptom improvement, operative complications, patients' recovery, and satisfaction were evaluated. FINDING: One hundred and ninety-seven patients uneventfully received two 5-mm port bilateral sympathicotomy, and another 3 patients with extensive pleural adhesions completed the surgery through enlarging the third intercostal incision to 2 cm without conversion to open surgery. All operative procedures were completed in 15 to 35 minutes. The hospital stay was 2 to 4 days. The palmar temperature increased by 2.0 ± 0.5°C, and hyperhidrosis immediately disappeared in both hands after surgery. The efficacy rate was 100%. The postoperative complications such as hemorrhage, hemopneumothorax, bradycardia, or Horner's syndrome had no occurrence. During 6 to 60 months follow-up, mild compensatory sweating of buttock, back, and thigh occurred in 30 patients (15%) at 2 to 5 days after surgery and gradually disappeared at postoperative 15 to 30 days or longer time. All patients were greatly satisfied with the effect with better confidence and quality of life. Until now, no recurrent palmar hyperhidrosis happened. CONCLUSION: Needlescopic video-assisted thoracic bilateral T4 sympathicotomy could reach an excellent and immediate result of treating PPH. It is a safe, convenient, and minimally invasive method appropriate for wide clinical use.

Evaluation of Quality of Life: Functional Assessment of Chronic Illness Therapy after Thoracic Sympathectomy for Palmar Hyperhidrosis.

BACKGROUND: Primary hyperhidrosis is a condition that significantly decreases the quality of life (QOL). Thoracic sympathectomy is safe and efficient method of treatment in palmar hyperhidrosis. OBJECTIVE: The aim of the study was to evaluate the change in QOL in patients with palmar hyperhidrosis who underwent thoracic sympathectomy. METHODS: The study includes 149 patients (37 men and 112 women) who were treated with bilateral thoracoscopic sympathectomy for primary palmar hyperhidrosis. Subjective and objective evaluation of hyperhidrosis were performed prior to the surgery, 3 and 12 months after the treatment. Control group consists of 305 healthy volunteers (118 men and 187 women). The QOL was measured using Functional Assessment of Chronic Illness Therapy (FACIT) scale. RESULTS: The average level of palmar hyperhidrosis in the study group prior to surgery was 224.69 ± 179.20 mg/min/m2. General QOL (FACIT total) before the surgery was significantly lower in the study group when compared with the control group (66.57 ± 16.33 vs. 91.29 ± 11.13; p < 0.05). Three months after surgery level of hyperhidrosis decreased significantly and remained at similar level 12 months after the procedure (13.55 ± 15.41 mg/min/m2 p < 0.05 and 14.41 ± 18.19 mg/min/m2 p < 0.05, respectively). After thoracoscopic sympathectomy, the QOL increased and did not differ when compared with the control group 3 and 12 months after the surgery (90.28 ± 11.13 vs. 91.29 ± 11.13; p = 0.55 and 89.59 ± 11.34 vs. 91.29 ± 11.13; p = 0.84, respectively). The highest increase was observed in functional well-being domain (32.25%); however, it was also noticeable in other domains. CONCLUSION: Thoracic sympathectomy is an efficient method of treatment in palmar hyperhidrosis which significantly increases patients' QOL especially in a functional domain.

Efficacy of Miniuniportal Video-Assisted Thoracoscopic Selective Sympathectomy (Ramicotomy) for the Treatment of Severe Palmar and Axillar Hyperhidrosis.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) clipping of the sympathetic branch has become the standard approach for the treatment of essential hyperhidrosis when conservative treatment failed. However, this is associated with relevant potential complications such as postoperative compensatory sweating and recurrent sweating. We report the outcome after selective sympathectomy (ramicotomy) through a miniuniportal VATS approach in patients with therapy-refractory palmar and/or axillary hyperhidrosis. METHODS: A total of 51 consecutive patients (37 females, mean age: 30 years, range: 12-64 years) who suffered from therapy-refractory palmar and/or axillary severe hyperhidrosis were included. Data were prospectively collected and retrospectively analyzed. All patients underwent bilateral miniuniportal VATS ramicotomy. Duration of surgery, hospital stay, recurrent, and compensatory sweating were documented. RESULTS: All patients had palmar sweating, where 51% had additional axillary sweating and 57% had additional plantar sweating. In all patients, selective division of the rami communicantes of the thoracic sympathetic ganglions Th2 to Th5 was performed. The mean duration of bilateral surgery for both sides was 67 ± 2.5 minutes. The mean postoperative hospital stay was 2 ± 1 days. After surgery and at further follow-up (mean: 12 ± 2.5 months), all patients presented dry and warm hands and axillae, without any evidence of compensatory or recurrent sweating. All patients described a remarkable increase in quality of life. CONCLUSION: Miniuniportal VATS ramicotomy represents a feasible surgical technique with a very high success and satisfaction rate. Therefore, this approach should be considered as the method of choice for the treatment of patients with severe therapy-refractory palmar and axillary hyperhidrosis.

Six-Month Comparative Analysis Monitoring the Progression of the Largest Diameter of the Sweating Inhibition Halo of Different Botulinum Toxins Type-A.

BACKGROUND: Excessive sweating is a clinical condition that can be improved with type-A botulinum toxin (BTX-A). OBJECTIVES: To evaluate and compare the largest diameter of sweating inhibition halo (SIH) of 5 different commercially available BTX-A, in five different doses, in a 6-month-long clinical evaluation. METHODS: Twenty-five adult female volunteers were injected in the dorsal trunk area with both 100 units (100UI) and 500 units (500UI) BTX-A products, reconstituted in a ratio of 1:2.5 IU, respectively. Products were applied in five different concentrations (1:2.5U, 2:5U, 3:7.5U, 4:10U, and 5:12.5U). After 30, 60, 90, 120, 150, and 180 days, a starch-iodine test was performed to obtain the largest diameter of each SIH. RESULTS: The higher the number of units used, the larger the SIH p < 0.05 for all BTX-A. However, Botox®, Botulift®, Dysport®, and Prosigne® have pretty likewise SIH along the study, with some few differences for some doses and months between one and another. However, Xeomin® is the BTX-A with the smallest SIH, in comparison with all others, in any dose and period. CONCLUSIONS: Differences were observed among all brands of BTX-As, based on dose and time after injection. Xeomin® provides the smallest SIH in comparison with others BTX-A.

Number of Preoperative Hyperhidrosis Sites Does Not Affect the Sympathectomy Postoperative Results and Compensatory Hyperhidrosis Occurrence.

BACKGROUND: Patients with primary hyperhidrosis present with sweating in two or more sites in nearly 85% of cases. In this study, we examined whether the number of hyperhidrosis sites is related to the surgery outcomes. METHODS: One hundred ninety-three hyperhidrosis patients who underwent bilateral videothoracoscopic sympathectomy after failure or dissatisfaction with clinical treatment were distributed into three groups based on the number of hyperhidrosis sites (one site, two sites, and three or more sites of hyperhidrosis). The primary endpoints in the study were as follows: quality of life prior to surgery, improvement of quality of life after surgery, clinical improvement of sweating, presence or absence of compensatory hyperhidrosis, and general satisfaction after 1 month of surgery. RESULTS: Patients with two or more hyperhidrosis sites had worse quality of life before surgery than patients with a single hyperhidrosis site. There was an improvement in the quality of life in more than 95% of the patients, clinical improvement in more than 95% of patients, severe compensatory hyperhidrosis in less than 10%, and low general satisfaction after 1 month of surgery in only 2.60% of the patients, with no differences among the three groups. CONCLUSIONS: Patients with more than one preoperative hyperhidrosis site present worse quality of life prior to surgery than those with a single hyperhidrosis site, but the number of hyperhidrosis sites before surgery does not affect surgery outcomes.

Differential Innervation of Secretory Coils and Ducts in Human Eccrine Sweat Glands.

BACKGROUND: Previous studies demonstrate that eccrine sweat glands are innervated by both cholinergic and adrenergic nerves. However, it is still unknown whether the secretory coils and ducts of eccrine sweat glands are equally innervated by the sympathetic nerve fibers. To well understand the mechanisms on sweat secretion and reabsorption, the differential innervation of secretory coils and ducts in human eccrine sweat glands was investigated in the study. METHODS: From June 2016 to June 2017, six human skins were fixed, paraffin-embedded, and cut into 5 µm-thick sections, followed by costaining for nerve fiber markers protein gene product 9.5 (PGP 9.5), tyrosine hydroxylase (TH) and vasoactive intestinal peptide (VIP), and eccrine sweat gland markers K7, S100P, and K14 by combining standard immunofluorescence with tyramide signal amplification (IF-TSA). Stained sections were observed under the microscope, photographed, and analyzed. RESULTS: The fluorescent signals of PGP 9.5, TH, and VIP were easily visualized, by IF-TSA, as circular patterns surrounding eccrine sweat glands, but only PGP 9.5 could be observed by standard IF. The IF-TSA method is more sensitivity than standard IF in detecting antigens expressed at low levels. PGP 9.5, TH, and VIP appeared primarily surrounding the secretory coils and sparsely surrounding the sweat ducts. CONCLUSION: Sweat secretion is mainly controlled by autonomic nerves whereas sweat reabsorption is less affected by nerve activity.

Impact of Thoracoscopic T2 Sympathectomy on Patients With Primary Palmar and Axillary Hyperhidrosis.

BACKGROUND: There are different techniques for thoracoscopic sympathectomy for management of primary hyperhidrosis. Each technique has the advantage of giving good surgical results, but may cause complications, which depend on the level of sympathectomy used in each technique. METHODS: From October 2012 to August 2016, a total number of 120 patients (of primary palmar and axillary hyperhidrosis) were enrolled in this prospective randomized study. Patients were randomized preoperatively and divided into 2 groups: group A (underwent T2, T3, and T4 sympathectomy) and group B (underwent T3 and T4 sympathectomy) with 1 year of follow-up. Improvement of palm sweating, development of complications, patient satisfaction, and quality of life were evaluated. RESULTS: Family history was positive in 33 patients (55%) in group A and in 31 patients (52%) in group B. All patients had improvement of hand sweating. Overdry hands were significant in group A (p = 0.032). Compensatory sweating was significant in group A after the first month (p = 0.016), after 6 months (p = 0.022), and after 12 months (p = 0.025). In group B, very satisfied patients were significant after 6 and 12 months (p = 0.002 and 0.000, respectively). CONCLUSIONS: Limited sympathectomy to the level of T3 and T4 has the same therapeutic effect obtained by T2, T3, and T4 sympathectomy with less complications, greater patient satisfaction, and better quality of life. It should be the technique of choice for treatment of primary palmar and axillary hyperhidrosis.

Quantification of sweat gland innervation in patients with Fabry disease: A case-control study.

INTRODUCTION: Hypohidrosis and heat intolerance, frequently reported by men and women with Fabry disease (FD), is thought to be related not only to the deposition of globotriaosylceramide (Gb3) in eccrine sweat glands, but also to reduced sweat gland sympathetic innervation. METHODS: We performed a case-control study to compare the density of sweat gland innervation between patients with FD and healthy controls by examining lower leg skin punch biopsies. We used a standardized grid of circles superimposed upon the immunofluorescent specimen to create a simple pattern of circles over the sweat gland. Nerve fibers that crossed within the circles were manually counted ("crossed circles"). Nerve fibers that touched the edge of the circle but did not enter were spared ("uncrossed circles"). The percentage of crossed circles from all circles was determined. RESULTS: Biopsy specimens were available of 37 FD patients (median age 44 years, 19-67; n = 18 men) and 16 controls (median age 48 years, 24-83, n = 7 men). Totally there were 153 sweat glands from FD patients and 63 from controls, in which innervation was quantified. While mean sweat gland innervation per biopsy did not differ between the entire FD cohort and controls, data stratification for the reported sweating phenotype revealed a stepwise lower innervation in women with FD and hypohidrosis (n.s.) and anhidrosis (p < .05) compared to women reporting normal sweating. CONCLUSION: Sweat gland innervation is reduced in women with FD and anhidrosis compared to female patients without sweating impairment. Loss of sweat gland innervation may play a role in FD associated anhidrosis, at least in women.

Retroperitoneoscopic lumbar sympathectomy for plantar hyperhidrosis.

OBJECTIVE: The objective of this study was to assess the reduction in quality of life (QoL) caused by the persistence of primary plantar hyperhidrosis (PPH) symptoms and the level of satisfaction in PPH patients after retroperitoneoscopic lumbar sympathectomy (RLS). The efficacy, safety, and procedure of bilateral RLS in both sexes are also described in this study. METHODS: This is a longitudinal study of consecutive patients who sought specific treatment from a private practitioner for severe PPH as classified on the Hyperhidrosis Disease Severity Scale (HDSS) from October 2005 to October 2014. The patients were asked to report the symptoms of PPH experienced in the immediate preoperative period and to complete a standardized QoL questionnaire developed by de Campos at least 12 months after RLS. Disease outcomes, recurrence of symptoms, and any adverse effects of surgery were evaluated after 30 days and at least 12 months after RLS. RESULTS: Lumbar sympathectomy was performed 116 times in 58 patients; 30 days after surgery, PPH was resolved in all patients. Three patients (5.2%) reported transient thigh neuralgia, and 19 (32.7%) reported transient paresthesia in the lower limbs. There were no reports of retrograde ejaculation. At a minimum of 12 months after RLS, 49 of the 58 patients had fully and correctly answered the follow-up questionnaire and noted a mild (HDSS 2) to moderate (HDSS 3) increase in pre-existing compensatory sweating. One patient had a PPH relapse within 6 months. Improvement in QoL due to the resolution of PPH was reported in 98% of the 49 patients. None of the operations necessitated a change in the laparotomy approach, and none of the patients died. CONCLUSIONS: RLS is safe and effective for the treatment of severe PPH in both sexes. There were no reports of retrograde ejaculation after resection of L3 and L4 ganglia. There was a mild to moderate increase in compensatory sweating in about half of the patients, but without any regret or dissatisfaction for having undergone the surgery because of a significant improvement in QoL.

R3 versus R4 Thoracoscopic Sympathectomy for Severe Palmar Hyperhidrosis.

Background Thoracoscopic sympathectomy (TS) was the preferred surgical treatment for palmar hyperhidrosis (PH), but postoperative complications such as compensatory sweating (CS) were common. This study was projected to compare R3 versus R4 TS for treating severe PH. Methods From April 2009 and March 2015, 106 consecutive patients with severe PH underwent bilateral R3 (n = 62) or R4 (n = 44) TS at The Second Affiliated Hospital of Nanchang University. The patients were followed up to evaluate symptom resolution, postoperative complications, satisfaction level, and severity of CS. Results The 106 patients underwent 212 sympathecotomies and were cured with no severe complications or perioperative mortality. The incidence of minor side effects (such as pneumothorax, gustatory sweating, moist hands, and bradycardia) was similar in both groups. More patients had overdry hands in the R3 group than in the R4 group (6/62 vs. 0/44; p = 0.040). More CS occurred in the R3 group as compared with the R4 group (42/62 vs. 23/44; p = 0.156). The incidence of moderate-to-severe CS was higher in the R3 group than in the R4 group (14/62 vs. 4/40; p = 0.045). Most patients were satisfied with the results, except for three (5.84%) in the R3 group and one (2.27%) in the R4 group. Conclusion PH can be effectively treated by either R3 or R4 TS, with high rates of patient satisfaction. R4 sympathectomy appears to be associated with less severe CS and should be the choice of denervation level.

Influence of Body Mass Index on Compensatory Sweating in Patients after Thoracic Sympathectomy due to Palmar Hyperhidrosis.

Background Thoracic sympathectomy (TS) is one of the most effective methods of treatment of primary hyperhidrosis. One of the side effects of this procedure is compensatory sweating (CS). Objective The aim of our study was to evaluate the influence of body mass index (BMI) on CS in patients after TS due to palmar hyperhidrosis. Methods Data from 157 patients with palmar hyperhidrosis who underwent TS were collected. The patients were subsequently divided in two groups according to their initial BMI: group A, BMI < 25 kg/m2, and group B, BMI ≥ 25 kg/m2. Objective (gravimetry) and subjective (VAS) measurements of the intensity of hyperhidrosis were taken from the patients' bodies prior to surgery, as well as 3 and 12 months after TS. Results Average palmar hyperhidrosis levels before the surgery did not differ significantly between the two groups (238.65 vs. 190.15; p = 0.053). A statistically significant decrease in palmar hyperhidrosis was noted in both groups, both 3 and 12 months after surgery (238.65 vs. 11.86 vs. 13.5; p < 0.05, and 190.15 vs. 16.67 vs. 11.81; p < 0.05, respectively). The intensity of sweating over the abdomino-lumbar area differed significantly between the groups before the surgery, both in subjective (1.71 vs. 3.61; p < 0.05) and objective (13.57 vs. 35.95; p < 0.05) evaluations. Three months after surgical intervention, an intensification of CS was observed in both the groups; however, no statistically significant differences were observed between the two sets of patients (VAS: 4.58 vs. 5.16; p = 0.38; gravimetry: 33.87 vs. 53.89; p = 0.12). Twelve months after TS, CS was higher in the group with an initial BMI ≥ 25 kg/m2, both in subjective and objective evaluations (3.23 vs. 4.94; p = 0.03 and 18.08 vs. 80.21; p = 0.026, respectively). Conclusion Patients with a BMI ≥ 25 kg/m2 experience more severe CS after TS, both in subjective and objective evaluations.