T4 sympathectomy for palmar hyperhidrosis: looking for the right operation
Tarek Mahdy, MD, Tamer Youssef, MD, Hesham Abd Elmonem, MD, Waleed Omar, MD, and Atef Abd Elateef, MD,

Mansoura, Egypt

Most surgeons still perform T2 or T2--3 sympathectomy for palmar hyperhidrosis (PH), but both of these
treatments can cause severe side effects. Some recent articles advocating T4 sympathectomy have obtained
satisfactory results. The aim of this study was to compare the outcomes of 3 different levels of
sympathectomy. Between July 2003 and July 2006, we treated 60 patients (20 men and 40 women,
mean age 26 years) who suffer from palmar hyperhidrosis by endoscopic thoracic sympathectomy (ETS).
Patients were divided into 3 groups according to the level of sympathectomy: ETS2, ETS3, and ETS4 (20
patients in each group). Data were collected by review of medical charts, outpatient clinic notes, and
telephone interviews. Patients were asked whether they considered their symptoms to be ‘‘cured’’ or
‘‘unchanged.’’ The degree of hand dryness was assessed subjectively. Postoperative complications (wound
infection, chest pain, and Horner’s syndrome) were assessed. Any occurrence of gustatory sweating,
rhinitis, presence and region of reflex compensatory sweating, and recurrence was noted. Patient
satisfaction was assessed. Treatment success at follow-up was 90% for the ETS2, 95% for ETS3
patients, and 100% for the ETS4 patients. In the ETS2 and ETS3 groups, a higher rate of overdryness
of limbs was observed (35% and 20%, respectively). The compensatory sweating was mild in the ETS4
group, whereas moderate-to-severe reflex sweating was more common in the ETS2 and ETS3 groups.
About 40% of ETS2 groups and 25% of ETS3 group patients were unsatisfied with their operation.
All patients of the ETS4 group were satisfied with the outcome. In conclusion, ETS4 sympathectomy
is an effective method for treating PH and it decreases the rate of compensatory hydrosis (CH).
(Surgery 2008;143:784-9.)
From the Mansoura Faculty of Medicine, Department of Surgery, Mansoura University, Mansoura, Egypt