Videoscopic Sympathectomy in Hyperhidrosis

A safe and effective procedure - Systematic review

Canha MB (marta.canha@gmail.com), Costa TFC (tiago_costa_25@hotmail.com), Cunha L

(sllcunha@hotmail.com), Esteves RARS (ritasaesteves@hotmail.com), Fonseca DJNO (diana-

nunes-@hotmail.com), Grilo JPLA (joao_grilo93@hotmail.com), Júlio SAVT

(sar.adriana@hotmail.com), Melo AF (auroramelo@hotmail.com), Moleiro AFO

(anafomoleiro@gmail.com), Teixeira BIC (bicteixeira@hotmail.com), Tomás AS

(ana.tomas_@hotmail.com), Paulo TM (telmo.moedas@hotmail.com).

Adviser: Sampaio SMM, Class 5 (1st year of Medicine) Faculty of Medicine, University of Porto

ABSTRACT

Hyperhidrosis is not considered to be a disease. Instead, it is referred as a condition

characterized by dysfunctional sweating. There has always been a lot of controversy about the

medical solutions for this problem and a lot of research is still being done. However, currently the

most accepted solution is the ETS – Endoscopic Thoracic Sympathectomy.

Our goal was to gather all the reliable information about the ETS, its results and complications

for treating hyperhidrosis existing in the databases already established.

In order to achieve the goal, a systematic review was conducted to evaluate the complication

rates and results of videoscopic sympathectomy in hyperhidrosis. The units of analysis were

researched articles in the defined databases. There were obtained 395 articles from Pubmed which

were analyzed and submitted to the inclusion criteria. In the end we had 168 articles. Then, they were

analyzed in small groups and all the data with relevance for our article was collected with the help of

a table built in SPSS. After making an interpretation of the studies and reports found on Pubmed, it

was expected a low number of complication rates in comparison to other treatment modalities that

are available, and a considerable number of successful results in the treatment of hyperhidrosis.

Finally, when all the articles were read and analyzed, and all the results were compiled, our

conclusion is that the ETS has high levels of success and satisfaction, improves the life quality of the

1

patients and, even though the most frequent complications are return of hyperhidrosis and

compensatory hyperhidrosis, the ETS can be a very good option of treatment for those who suffer of

hyperhidrosis.

KEY-WORDS

- Sympathetic nervous system - Sweat gland diseases – Hyperhidrosis – Sympathectomy – Results –

Complications – Endoscopy –Videoscopy - Thorascopy

INTRODUCTION: BACKGROUND AND JUSTIFICATION

Sweating is a physiological process essential for survival, but when it exceeds the needs for

thermoregulation it is named hyperhidrosis.

Hyperhidrosis is not defined in terms of the amount of sweat, but as dysfunctional sweating. It

can be classified as either primary or secondary.1 In this work we focus only on the primary one. It

appears on several parts of the body, usually on the axillas, palms, soles, and forehead (sites with a

high density of sweat glands)2. Patients with hyperhidrosis do not have more glands; the glands are

over-stimulated or more active. It is the sympathetic nervous system that is responsible for the

stimulation of the sweat glands using acetylcholine as neurotransmitter.1 Most patients with primary

hyperhidrosis present it during their childhood or adolescence.3

Primary palmar hyperhidrosis is a hereditary disorder, with variable penetrance and there is no

proof of sex-related transmission. However, this does not exclude other possible causes.4

Hyperhidrosis brings many negative consequences to the affected people and, in some cases,

it leads to social isolation5. This condition has a prevalence of nearly 3%.2

There are some treatment modalities to this condition such as application of topical agents,

iontophoresis and videoscopic sympathectomy (in severe cases).6 This last procedure is effective,

simple, and requires only an overnight study. It is recommended as the method of choice for surgical

treatment of upper extremity hyperhidrosis.7

The sympathetic chain extends from the base of the cranium to the coccyx. The thoracic

section of the sympathetic trunk is formed by 12 ganglia.8 Videoscopic sympathectomy consist in the

interruption of the sympathetic chain that can be achieved using electrocautery, resection

(endoscopic scissors, laser, ultrasonic scalpel), or metal clips.9 It is important to choose the

appropriate level, to make the cut, in order to obtain the best surgical result (Fig.1) .10

2

Due to the incidence and consequences of this condition on population and due to the lack of

information about it, we consider to be relevant our attention on this theme. So, we worked on a

systematic review, focused on the results and complications of this treatment modality to

hyperhidrosis, the Videoscopic Sympathectomy.

RESEARCH QUESTION AND AIMS

We have defined a research question to guide our systematic review: What are the results and

complications of videoscopic sympathectomy in hyperidrosis?. With this question we want to turn our

research clear: for example, choosing our participants (we only used original articles and not

comments to another articles) and methods. We hope to answer it the best way possible, to achieve

a good outcome.

In order to achieve the answer to this question we set up some aims, intrinsic to our systematic

review. Our main objective is to understand if videoscopic sympathectomy is a good option for the

treatment of hyperhidrosis, taking in account the results and complications of the surgery. This major

goal was supported by two smaller ones: evaluate complication and result rates (this helped us to

achieve our main goal).

PARTICIPANTS AND METHODS

The design of our systematic review involved a complex process with few steps. At first we

had to define our problem and our goal. And then it was made a procedure in order to select and

analyze the articles.

3

Figure 1. Current indications of the level of thoracic sympathectomy in the treatment of localized hyperhidrosis.

The participants to our systematic review (that are our unit of analysis) were original articles

from one database: PubMed. This articles had to be original (for example, written by a doctor, based

on his clinical trials) and not other reviews or comments to other articles.

The articles found weren’t all included, there was a strict inclusion criteria list that had to be

followed:

- The papers had to be written based on original data (this means that other systematic reviews,

comments to other papers, etc, were excluded);

- The papers were only included if written after the videoscopic sympathectomy’s development;

- If the articles weren’t available using the UP credentials, they were excluded;

- Were only included articles written in English, French, Portuguese or Spanish.

To simplify and clear the work, a slam was filled, based on it we concluded weather the article

would be included.

So, to answer our research question and to achieve our aims we followed a study design,

which was synthesis study, and then concluded about the results and complications of Videoscopic

Sympathectomy.

In Pubmed we defined the following query: "hyperhidrosis"[MeSH Terms] AND

("endoscopy"[MeSH Terms] OR endoscopic [TextWord] OR thorascocopic[All Fields] OR

videoscopic[All Fields]) AND ("sympathectomy"[MeSHTerms] OR sympathectomy[Text Word]) AND

("complications"[AllFields] OR results[All Fields]). As we obtained 395 articles we decided to collect

them all to avoid the exclusion of some interesting article.

Then we collected those articles and divided it into groups of two people. Each group read the

title and abstract of the article and applied the inclusion criteria. In case the article was included, they

had to read the entire article and apply again the inclusion criteria. If the article was included, they

had to collect the needed data from it, which was described in a table in order to all the groups collect

the same data. In the end all the collected were statistically analyzed. To achieve this goal we used

the SPSS in which pie charts, tables and histograms were done, depending on the variable we

wanted to analyze. The ones that had histograms also requested the realization of the K-S test to see

whether or not they were distributed normally. For most of the variables was prepared a frequency

table where it was possible to observe various data, such as mean and median, and from that were

extracted the results with statistical relevance for the variable in question. The last step was the

dissemination of the obtained results.

The variables (both quantitative and qualitative) that were crucial to evaluate were the results

and complications that come from the surgery. The variables we collected through the analysis of

articles so that we could draw conclusions from the articles were type of study, number of

participants, average age, the patient’s sex, effectiveness, efficiency, satisfaction (scale and 4

measure, success (scale and measure), location of the incisions, number of incisions, type of

anesthesia, removal technique of sympathetic trunk, burning technique of sympathetic trunk,

complications, Horner’s Syndrome (percentage and time until it arises), return of Hyperhidrosis

(percentage and time until it arises), Compensatory Hyperhidrosis (percentage and time until it

arises), Hemothorax (percentage and time until it arises), paralysis of upper limb (percentage, time

until it arises and duration), cosmetic failures (percentage), mortality (percentage and time after

surgery until dead).

With the inclusion steps, 33 articles that had not original data were excluded (8.4%), the fact

that the article was not written in a proper language eliminated 36 articles and the cause that

excluded more articles was the UP credentials (less 168 articles – 39.7%). In the end we had 168

articles. The year that was marked like the one in witch there were more articles published was 2005,

as well as 2007, 2008 and 2009 and most of the articles were written in English.

After reading the whole paper of the included articles, we excluded 52 of them. The reason of

that exclusion was, in most of the cases, the absence of data with interest for analysis. The total of

analyzed articles was 116.

RESULTS, TABLES AND GRAPHICS

It is expected that our systematic review can really compile the existing and relevant

information about Hyperhidrosis in order to understand if it is a good option of treatment. This ease of

access brings obvious benefits, providing the most relevant published information related to this

condition, and requiring substantial less search time.

In our systematic review were included articles considered to be relevant after the application

of the criteria for inclusion set by the group, which integrates information from different authors and

scientific studies. The large number of sources found, makes our systematic review very general.

Of the 395 articles collected in the survey 168 were included in the study and 227 excluded,

the main reasons for no admission (exclusion) were the UP credentials (Figure 2). The great majority

of the collected articles were written in English, a minority were written in Portuguese, French and

Spanish (Figures 4 and 5). A considerable amount of articles was excluded because they were

written in other languages. There were a considerable part of the articles that were based on original

data (Figure 3). About the included articles we can say that the mean of the included articles’

publication year was 2004, 66 in a 95% confidence interval (Figure 6).

5

6

39,7 %

Articles without UP credentials

Articles with UP credentials

UP Credentials

Figure 2. Pie chart concerning the initial articles, showing the percentage of articles with UP credentials (60,3%) and without UP credentials (39,7%). n=395

No

Yes

Original data

8,4 %

91,6 %

Figure 3. Pie chart concerning the initial articles, showing the percentage of articles with original data (91,6%) and without original data (8,4%). n=395

English

Portuguese

Spanish

French

Others

Figure 4. Pie chart concerning the initial articles, showing the relation between the different languages the articles presented. n=395

Language

Language

Figure 5. Graph comparing the languages of the researched articles and the language of the included articles. n=395

345

162

1 0 7 5 16 0

36

Included articles

Initial articles

In order to compile and understand the information obtained in the several articles collected

we had to apply different statistic means, each one specifically adapted to the variables in study. It’s

important to refer that once we have chosen to show some histograms, we used the median as a

summary measure because the distribution of the sample on each one of them wasn’t normal.

Analyzing the type of study, we verified that 40,52% were clinical trials, 35,34% were cohort

and 24,14% were from other type (Figure 7).

Then, concerning the number of participants of the several studies analized (Figure 8) we had

a median of 192.We observe that the majority of the studies use less than 500 patients.

About the mean age of the participants, we have a highest prevalence among 25 to 30 years-

old (mean of 27,28) – Figure 9. This number fits in the prevalence between 25 and 64 years that was

already referred in our review before.

7

Year of publication of the included articles

Figure 6. Graph concerning the included articles. n=168

Figure 7. Pie chart representing the type of studies analyzed. n=116; Cohort=41; Clinical trial=47; Others=28

Types of study

According to Figure 10 most of studies were with both men and women, which makes sense

once this condition is not sex related. Besides this, there were some articles that referred sex

discrimination (about 4%). While we were analyzing the articles we realized that some

complementary treatments were used, like endoclips, psychotherapy and botox, although 33,33%

only used ETS (Figure 11).

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Figure 8. Histogram indicating the number of participants used in the studies of the analyzed articles. n=113; median=90; maximum=2200; minimum=8

Figure 9. Histogram demonstrating the mean age of the participants used in the analyzed articles. n=88, median=27,3; maximum=44; minimum=15,5.

Figure 10. Pie chart representing the gender of the participants used in the analyzed articles. n=111

Number of participants Mean age

Gender of participants Number of participants

Figure 11. Pie chart representing the complementary treatment to which the participants, used in the analyzed articles, were subjected prior to the ETS. n=111

As shown in Figure 12 we also realized that this treatment was generally satisfactory (median

of satisfaction is 88,3%). About the success of this surgery we can say that it has high rates,

presented with a median of 95%, as it is clearly demonstrated in Figure 13.

Quality of life wasn’t referred at many articles, but the ones in which it was present (16

articles) referred that was an improvement in the quality of life of the patients submitted to

videoscopic thoracic sympathectomy.

As any other surgery this specific one is also inherent to some consequences. Some articles

indicated Horner’s syndrome: it appeared at some but not many patients. Most of the studies had

less than 4% affected with this (Figure 14). On the other hand, hyperhidrosis returned to some

patients, but few articles show a high prevalence (Figure 15).

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Figure 12. Histogram with the percentage of satisfaction achieved by the participants, used in the analyzed articles, relatively to the ETS . n=54; median=88,3%; maximum=100%; minimum=0%

Satisfaction

Figure 13. Histogram with the percentage of success relatively to the ETS. n=35; median=95%; maximum=100%; minimum=2,40%

Success

Besides this, compensatory hyperidrosis was very frequent and it was identified in the patients

which started over sweating at other body part (Figure16). In Figure 17 is easy to understand that

hemothorax was also referred at 21 articles and it also had a low appearance.

The pie chart at Figure 18 shows the other complications that became visible after surgery.

24,14% of the articles didn’t referred any complication. Besides this, pneumothorax was referred at

37,93% of the articles and then, with a low percentage, it appeared nevralgy, chronic rhinitis,

chilothorax, etc.

We analyzed the number of incisions in order to study the surgery technique (Figure 19). The

number of incisions most frequently used was 2 (around 67%). One incision was also used (referred

in 28% of the articles) and only 4% used 3 incisions.

10

Figure 14. Histogram with the percentages of Horner’s Syndrome incidence in the participants used in the analyzed articles. n=35; median=1%; maximum=10%; minimum=0%

Horner’s syndrome Return of hyperhidrosis

Figure 15. Histogram with the percentages of return of hyperhidrosis incidence in the participants used in the analyzed articles. n=39; median=5%; maximum=70%; minimum=0%

11

Figure 18. Pie chart demonstrating the percentages of other complications after surgery, referenced by the participants used in the analyzed articles. n=116

Figure 19 – Pie chart with the proportion of the number of incisions used in this surgical technique in the participants used in the analyzed articles. n=82

Compensatory hyperhidrosis

Figure 16. Histogram with the percentages of compensatory hyperhidrosis incidence in the participants used in the analyzed articles. n=78; median=69,45%; maximum=100%; minimum=0%

Hemothorax

Figure 17. Histogram with the percentages of heothorax incidence in the participants used in the analyzed articles. n=21; median=1,30%; maximum=25%; minimum=0%

Other complications Number of incisions

There were some difficulty in analyzing the section level of the sympathetic trunk because

there was a high variability of data; despite this, the most used section level was T2-T3 (21,1%) and

T2, T3 and T4 (15,8%).

In table 1 it is analyzed the data of the nerve elimination technique. This surgery can be done

using either nerve section technique (referred to be used by 52 articles) or nerve burn technique

(referred to be used by 30 articles).

Frequency Percent Valid Percent

Section 41 35,3% 57,7%

Burn 19 16,4% 26,8%

Both 11 9,5% 15,5%

No reference in the article 45 38,8% -

Total 116 100% 100%

Although the results obtained, there will always exist missed information on the one hand

because it is impossible to analyze all published information available in all databases existing, and

in the other hand because some important details can be ignored by a bad judgment on the

application of selection criteria. So, we are aware of the limits of our results but we will be careful and

rigorous in the selection of the information in order to give validity to the results.

The dissemination of these results, in a long-term, will bring up the awareness of the

population to the fact that this condition so uncomfortable can be rolled back. Thus, constitutes an

important point to the individual's intellectual development.

DISCUSSION

Our systematic review showed that, despite frequent complications, the levels of success and

satisfaction are high and the quality of live improves with this technique, so it shows that it can be a

good option of treatment for people who suffer of hyperhidrosis.

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Table 1. Table with the analyse of the ETS surgical technique done in participants used in the analyzed articles. n=71

After analyzing the articles, we conclude that the most frequent complications are return of

hyperhidrosis and compensatory hyperhidrosis. So, this systematic review led us to reflect and

conclude that, in order to get better results in videoscopic sympathectomy, it could be carried out an

investigation to find out the reason of the great frequency of compensatory hyperhidrosis. The next

step would be trying to reduce the compensatory hyperhidrosis in this kind of surgery.

We are pleased with the work developed and we think the main goal we had established was

achieved.

ACKNOWLEDGEMENTS

We gratefully acknowledge Professor Sérgio Sampaio for the help and support that gave us

along the work.

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APPENDIX

References of the included articles

1. Wolosker N [et al.]. Evaluation of quality of life over time among 453 patients with hyperhidrosis

submitted to endoscopic thoracic sympathectomy. Journal of Vascular Surgery. 2012; 55(1): 154-

156.

2. Baumgartner FJ [ et al.]. Thoracoscopic sympathicotomy for disabling palmar hyperhidrosis: a

prospective randomized comparison between two levels. Ann Thorac Surg. 2011; 92: 2015-2019.

3. Smidfelt K, Drott C. Late results of endoscopic thoracic sympathectomy for hyperhidrosis and facial

blushing. British Journal of Surgery. 2011; 98: 1719–1724.

4. Atkinson JLD [et al.]. Endoscopic transthoracic limited sympathotomy for palmar-plantar

hyperhidrosis: outcomes and complications during a 10-year period. Mayo Clinic Proceedings. 2011;

86(8): 721-729

5. Currie AC, Evans JR, Thomas PRS. An analysis of the natural course of compensatory sweating

following thoracoscopic sympathectomy. International Journal of Surgery. 2011; 9: 437-439.

6. Vazquez LD, Staples NL, Sears SF, Klodell CT. Psychosocial functioning of patients after

endoscopic thoracic sympathectomy. European Journal of Cardio-thoracic Surgery. 2011; 39: 1018-

1021

7. Boscardim PC, Oliveira RA, Oliveira AA, Souza JM, Carvalho RG. Thoracic sympathectomy at the

level of the fourth and fifth ribs for the treatment of axillary hyperhidrosis. J Bras Pneumol. 2011;

37(1): 6-12

8. Scognamillo F [et al.]. T2–T4 sympathectomy versus T3–T4 sympathicotomy for palmar and

axillary hyperhidrosis. Clin Auton Res. 2011; 21: 97–102.

9. Rieger R, Loureiro MP, Pedevilla S, Oliveira RA. Endoscopic lumbar sympathectomy following

thoracic sympathectomy in patients with palmoplantar hyperhidrosis. World Journal of Surgery.2011;

35: 49–53

10. Wolosker N [et al.]. Quality of life before surgery is a predictive factor for satisfaction among

patients undergoing sympathectomy to treat hyperhidrosis. Journal of Vascular Surgery. 2010; 51(5):

1190-1194

15

11. Prasad A, Ali M, Kaul S. Endoscopic thoracic sympathectomy for primary palmar hyperidrosis. Surgical

endoscopy. 2010; 24(8): 1952-1957.

12. Coelho M, Kondo W, Stunitz LC, Branco Filho AJ, Branco AW. Bilateral retroperitoneoscopic lumbar

sympathectomy by unilateral access for plantar hyperhidrosis in women. Journal of laparoendoscopic &

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14. Rieger R, Pedevilla S, Pöchlauer S. Endoscopic lumbar sympathectomy for plantar hyperhidrosis. The

British journal of surgery. 2009; 96(12):1422-1428.

15. Fibla JJ, Molins L, Mier JM, Vidal G. Effectiveness of sympathetic block by clipping in the treatment of

hyperhidrosis and facial blushing. Interactive cardiovascular and thoracic surgery. 2009; 9(6):970-972.

16. Freeman RK, Van Woerkom JM, Vyverberg A, Ascioti AJ. Reoperative endoscopic sympathectomy for

persistent or recurrent palmar hyperhidrosis. The Annals of thoracic surgery. 2009; 88(2): 412-416.

17. Sugimura H, Spratt EH, Compeau CG, Kattail D, Shargall Y. Thoracoscopic sympathetic clipping for

hyperhidrosis: long-term results and reversibility. The Journal of thoracic and cardiovascular surgery. 2009;

137(6): 1370-1376.

18. Ureña A, Ramos R, Masuet C, Macia I, Rivas F, Escobar I, Villalonga R, Moya J. An assessment of plantar

hyperhidrosis after endoscopic thoracic sympathicolysis. European journal of cardio-thoracic surgery: official

journal of the European Association for Cardio-thoracic surgery. 2009; 36(2): 360-363.

19. Araújo CA, Azevedo IM, Ferreira MA, Ferreira HP, Dantas JL, Medeiros AC. Compensatory

sweating after thoracoscopic sympathectomy: characteristics, prevalence and influence on patient

satisfaction. J Bras Pneumol. 2009; 35(3): 213-20.

20. Bachmann K, Standl N, Kaifi J, Busch P, Winkler E, Mann O, Izbicki JR, Strate T.

Thoracoscopic sympathectomy for palmar and axillary hyperhidrosis: four-year outcome and quality

of life after bilateral 5-mm dual port approach. Surg Endosc. 2009; 23(7):1587-93.

21. Cruz J, Sousa J, Oliveira AG, Silva-Carvalho L. Effects of endoscopic thoracic sympathectomy

for primary hyperhidrosis on cardiac autonomic nervous activity. J Thorac Cardiovasc Surg. 2009;

137(3):664-9.

22. Liu Y, Yang J, Liu J, Yang F, Jiang G, Li J, Huang Y, Wang J. Surgical treatment of primary

palmar hyperhidrosis: a prospective randomized study comparing T3 and T4 sympathicotomy. Eur J Cardiothorac Surg. 2009; 35(3):398-402.

16

23. Li X, Tu YR, Lin M, Lai FC, Chen JF, Miao HW. Minimizing endoscopic thoracic sympathectomy

for primary palmar hyperhidrosis: guided by palmar skin temperature and laser Doppler blood flow.

Ann Thorac Surg. 2009; 87(2):427-31.

24. Tetteh HA, Groth SS, Kast T, Whitson BA, Radosevich DM, Klopp AC, D'Cunha J, Maddaus MA, Andrade RS. Primary palmoplantar hyperhidrosis and thoracoscopic sympathectomy: a new

objective assessment method. Ann Thorac Surg. 2009; 87(1):267-74.

25. Munia MA, Wolosker N, Kaufmann P, de Campos JR, Puech-Leão P. Sustained benefit

lasting one year from T4 instead of T3-T4 sympathectomy for isolated axillary hyperhidrosis. Clinics (Sao Paulo). 2008; 63(6):771-4.

26. Walles T, Somuncuoglu G, Steger V, Veit S, Friedel G. Long-term efficiency of endoscopic

thoracic sympathicotomy: survey 10 years after surgery. Interact Cardiovasc Thorac Surg. 2009;

8(1):54-7.

27. Rathinam S, Nanjaiah P, Sivalingam S, Rajesh PB. Excision of sympathetic ganglia and the

rami communicantes with histological confirmation offers better early and late outcomes in Video

assisted thoracoscopic sympathectomy. J Cardiothorac Surg. 2008; 13;3:50.

28. Buraschi J. Videothoracoscopic sympathicolysis procedure for primary palmar hyperhidrosis in

children and adolescents. Arch Argent Pediatr. 2008; 106(1):32-5.

29. El-Dawlatly A [et al.]. Pain relief following thoracoscopic sympathectomy for palmar hyperhidrosis:

a prospective randomised double-blind study. Middle East journal of anesthesiology. 2008;

19(4):757-65.

30. Mahdy T [et al.]. T4 sympathectomy for palmar hyperhidrosis: looking for the right operation.

Surgery. 2008; 143(6):784-9.

31. Al-Tarshihi MI [et al.]. Complications of video assisted thoracoscopic sympathectomy for primary

hyperhidrosis. Saudi medical journal. 2008; 29(6):863-6.

32. Fibla JJ [et al.]. Results of videothorascopic sympathectomy in the treatment of facial redness

and hyperhidrosis in 41 patients. Cirugía española. 2008; 83(5):256-9.

33. Licht PB [et al.]. Endoscopic thoracic sympathectomy for palmar hyperhidrosis: a randomized

control trial comparing T3 and T2-4 ablation. Invited commentary. The Annals of thoracic surgery.

2008; 85(5):1751-2.

17

34. Li X [et al.]. Endoscopic thoracic sympathectomy for palmar hyperhidrosis: a randomized control

trial comparing T3 and T2-4 ablation. The Annals of thoracic surgery. 2008; 85(5):1747-51.

35. Sciuchetti JF [et al.]. Results, side effects and complications after thoracoscopic sympathetic

block by clamping. The monza clinical experience. Clinical autonomic research : official journal of the

Clinical Autonomic Research Society. 2008; 18(2):80-3.

36. Black SA [et al.]. Thorascopic sympathectomy performed using laser. Annals of the Royal College

of Surgeons of England. 2008; 90(2):142-5.

37. Wolosker N [et al.]. Is sympathectomy at T4 level better than at T3 level for treating palmar

hyperhidrosis? Journal of laparoendoscopic & advanced surgical techniques. 2008; 18(1):102-6.

38. Steiner Z, Cohen Z, Kleiner O, Matar I, Mogilner J. Do children tolerate thoracoscopic

sympathectomy better than adults? Pediatr Surg Int. 2008; 24(3):343-7.

39. Jeganathan R, Jordan S, Jones M, Grant S, Diamond O, McManus K, Graham A, McGuigan J.

Interact Cardiovasc Thorac Surg. Bilateral thoracoscopic sympathectomy: results and long-term

follow-up. Interactive cardiovascular and thoracic surgery. 2008; 7(1): 67-70.

40. Yang J, Tan JJ, Ye GL, Gu WQ, Wang J, Liu YG. T3/T4 thoracic sympathectomy and

compensatory sweating in treatment of palmar hyperhidrosis. Chin Med J (Engl). 2007;

120(18):1574-7.

41. Montessi J, Almeida EP, Vieira JP, Abreu Mda M, Souza RL, Montessi OV. Video-assisted

thoracic sympathectomy in the treatment of primary hyperhidrosis: a retrospective study of 521 cases

comparing different levels of ablation. J Bras Pneumol. 2007; 33(3): 248-54.

42. Assalia A, Bahouth H, Ilivitzki A, Assi Z, Hashmonai M, Krausz MM. Thoracoscopic

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