Fifteen Years’ Experience of Thoracoscopic Sympathetic Chain Interruption for Palmar Hyperhidrosis in Children and Adolescents: Evaluation of Different Techniques

Abstract

Background:

Thoracoscopic sympathetic chain interruption is a definitive and effective therapy for severe primary palmar hyperhidrosis (PPH). Well-known methods include sympathectomy, sympathotomy, and clipping, but the occurrence of compensatory sweating offsets these methods. This study aims to report our experience with thoracoscopic sympathetic chain interruption in a large group of patients of age <18 years with PPH, focusing on surgical outcomes, complication rates, and patient satisfaction.

Patients and Methods:

This retrospective study included patients who underwent thoracoscopic sympathectomy, sympathotomy, or clipping for severe PPH between April 2008 and March 2023 at the Pediatric Surgery Department, Al-Azhar University Hospitals. Demographic and clinical data, operative steps, postoperative outcomes, complications, and patient satisfaction were reviewed from the patients’ medical records.

Results:

During the 15-year study period, 420 children with PPH underwent bilateral thoracoscopic sympathetic chain interruption by either sympathectomy, sympathotomy, or clipping, with a sex ratio of 60% being females. The mean ages were 12 ± 3.48, 13 ± 2.45, and 13 ± 2.45 years, respectively. Sympathectomy was performed in 190 patients (45.2%), sympathotomy in 170 patients (40.5%), and clipping in 60 patients (14.3%). All patients had completed follow-up, with mean periods of ∼43 ± 5 months, 45 ± 3 months, and 42 ± 6 months, respectively. Complete palmar dryness was achieved in 405 patients (overall 96.4%) (97.8% after sympathectomy, 97.05% after sympathotomy, and 90% after clipping), whereas 2.1%, 2.9%, and 10% of patients experienced symptom recurrence, respectively, denoting significant statistical differences. Overall, 94 patients (22.4%) experienced compensatory sweating. Eventually, 409 patients (97.4%) were satisfied with the outcome, whereas 11 patients (2.6%) reported dissatisfaction, yet no significant differences found.

Conclusion:

The presented three modalities of thoracoscopic sympathetic chain interruption for PPH in children and adolescents are safe and effective, with overall very high postoperative satisfaction, despite a relatively high rate of compensatory sweating in sympathectomy group. Other major complications in this age population were scanty.

Introduction

Primary hyperhidrosis (PH) is characterized by the excessive secretion of sweat glands, often triggered by emotions, leading to profuse sweating in the palms, armpits, feet, and back. Primary hyperhidrosis appears to be related to dysfunction of the thermoregulatory ability of the autonomic nervous system.¹

Primary hyperhidrosis has a significant adverse effect on both social and professional domains. Affected individuals tend to experience embarrassment and distress when engaging in activities, such as handshaking and writing on paper.²

In 1978, Kux performed video-assisted thoracoscopic sympathectomy (VATS) in 63 patients with PH, which entailed denervation of sympathetic ganglia R2, R3, and R4.³ Subsequently, multiple studies have provided robust evidence that VATS represents a minimally invasive and effective approach to managing PH with a high degree of safety.^4–7

Since the introduction of VATS, there has been ongoing discourse regarding the implementation of specific modifications to surgical protocols. These modifications have consistently aimed to reduce complications and achieve better outcomes, while shortening operative periods and hospital stays. This study assessed the thoracoscopic management of PPH in a large cohort of patients of age <18 years. It focuses on the long-term outcomes of sympathetic chain interruption procedures, specifically sympathectomy, sympathotomy, and clipping.

Patients and Methods

This retrospective study was conducted at the Pediatric Surgery Department of Al-Azhar University Hospitals. Patients of both sexes of age <18 years with significant bilateral palmar hyperhidrosis managed by simultaneous thoracoscopic bilateral sympathetic chain interruption between April 2008 and March 2023 were included in this study. Patients with secondary hyperhidrosis, those older than 18 years of age at the time of surgery, those who underwent sympathetic chain interruption rather than thoracoscopy, and those who underwent thoracoscopic sympathetic chain interruption for causes other than PPH were excluded. Demographic and clinical data of the patients were reviewed from their medical records. Patient eligibility for intervention was determined preoperatively, according to the Hyperhidrosis Disease Severity Scale (Table 1). Operative steps and postoperative data, including the length of hospital stay and complications, were also reviewed. Patients were categorized into three groups according to the surgical technique adopted: sympathectomy, sympathotomy, and clipping. Patients were followed-up in the outpatient department by the concerned physicians who were the authors of this study. The primary outcome was the acquisition of palmar dryness, whereas perioperative complications, compensatory sweating, patient satisfaction, and recurrence rate were secondary outcomes. This study was approved by the Institutional Review Board and Ethics Committee (IRB1-3-2023-0000059) and was registered at ClinicalTrials.gov (ID: NCT06113978). Preoperatively, all individuals or their parents who participated in this study provided written informed consent.

Table 1.

Hyperhidrosis Disease Severity Scale

	Hyperhidrosis Disease Severity Scale
1	My sweating is never noticeable and never interferes with my daily activities
2	My sweating is tolerable but sometimes interferes with my daily activities
3	My sweating is barely tolerable and frequently interferes with my daily activities
4	My sweating is intolerable and always interferes with my daily activities

A score of 3 or 4 indicates severe hyperhidrosis, while a score of 1 or 2 indicates mild or moderate hyperhidrosis.

Surgical procedures

General anesthesia was administered by an experienced anesthesiologist who used one-lung ventilation anesthesia to control the patient’s O₂-enriched ventilation using a low-volume/high-frequency technique, with alternating brief periods of apnea. The patient was placed in semi-Fowler position—the dorsal decubitus position with the arms abducted and fixed at 90°. The trunk was elevated by 30°–40°, as elevation helped to displace the lungs downwards. A slight bed elevation at the knee level was useful to safely place the patients and prevent them from slipping during the procedure.

To access the thoracic cavity, we performed two-port video-assisted thoracoscopy using two 3-mm ports via two mini-incisions. The camera port (30° scope) was placed laterally at the fourth or fifth intercostal space (depending on the patient’s age) at the mid-axillary line. The second port (for electrocautery instruments) was medially positioned in the third intercostal space at the anterior axillary fold created by the pectoralis major muscle, as this approach provided excellent aesthetic results. A CO₂ pneumothorax pressure of 5–8 mmHg was used according to the patient’s age and body built. The posterior parietal pleura was incised immediately above the neck of third rib and further dissected to identify the thoracic sympathetic chain.

A—Thoracoscopic sympathectomy

After identification of the sympathetic chain, mobilization and dissection at the level of the superior border of the third rib were performed. Transection and excision of sympathetic chain segments T3 and T4 were performed using electrocoagulation.

B—Thoracoscopic sympathotomy

After identification of the sympathetic chain, mobilization and dissection at the level of the superior border of the third rib were performed. Then, transection of the sympathetic chain at the level of T3 was done using an electrocautery hook.

C—Thoracoscopic clipping

The sympathetic chain was mobilized and isolated at the level of the T3 ganglion. Then, interruption without transection was done, using metallic (Titanium) clips applied across the trunk of the sympathetic chain.

In all procedures

Concomitant Kuntz nerve fibers, when identified, were cut by extending the electrocautery incision by ∼3 cm transversely from medial to lateral over the posterior parietal pleura and periosteum along the third and fourth ribs. Necessary hemostasis was achieved, the lungs were tested for air leaks, insufflated CO₂ was evacuated under direct vision of complete assisted lung inflation (by positive end-expiratory pressure of 25 cm H₂O) without the need for chest tube insertion, the ports were then removed, and the port sites were closed using absorbable subcuticular sutures.

Postoperatively, analgesics (NSAID) were administered, and routine chest radiographs were obtained for all patients to rule out significant pneumothorax. The patients were discharged mostly on the same operative day or the next morning. Patients’ medical records were evaluated retrospectively for postoperative complications, the degree of success, compensatory sweating, recurrence, and patient satisfaction.

Statistical analysis

Data were collected, revised, coded, and entered into the Statistical Package for Social Sciences (SPSS) version 23 software (IBM Corp, Armonk, NY, USA). Qualitative data were presented as numbers and percentages, whereas quantitative data were presented as means, standard deviations, and ranges when their distribution was found to be parametric. Independent t-tests and chi-square tests were used to compare the groups. Statistical differences were considered significant at P < .05.

Results

This study included 420 children underwent thoracoscopic sympathetic chain interruption for palmar hyperhidrosis by either sympathectomy (n = 190), sympathotomy (n = 170), or clipping (n = 60). with a sex ratio of 60% for females and 40% for males for the different procedures. Mean age was 12 ± 3.48, 13 ± 2.45, and 13 ± 2.45 years, and mean body mass index (BMI) of 23 ± 2.45, 23 ± 0.65, and 24 ± 0.15 kg/m², respectively. None of the patients underwent conversion to open technique. Complete follow-up was performed for all 420 patients, with a mean follow-up period of approximately 43 ± 5, 45 ± 3, and 42 ± 6 months, respectively. There were no significant differences in the demographic and clinical data between the groups (Table 2).

Table 2.

Patients’ Demographic Data

Result	Sympathectomy (n = 190)	Sympathotomy (n = 170)	Clipping (n = 60)	Test value^a	P value
Female	114 (60%)	102 (60%)	36 (60%)	0.00	>.999
Male	76 (40%)	68 (40%)	24 (40%)	0.00	>.999
Age mean (year)	12 ± 3.48	13 ± 2.45	13 ± 2.45	3.15	.071
BMI (kg/m²)	23 ± 2.45	23 ± 0.65	24 ± 0.15	7.15	.091
Follow-up (months)	43 ± 5	45 ± 3	42 ± 6	5.344	.25

P value > .05, Nonsignificant; P value < .05, Significant; P value < .01, highly significant.

Chi-square test.

BMI, body mass index.

Complete palmar dryness was achieved in 97.8% of sympathectomy cases, 97.05% of sympathotomy cases, and 90% of clipping cases, whereas 2.1%, 2.9%, and 10%, respectively, experienced symptom recurrence, with significant differences between all groups regarding the success and recurrence rates (Table 3). Twenty-one patients had intraoperative bleeding that was managed by suction and electrocauterization. Also, 21 cases reported pneumothorax that spontaneously resolved within 8–18 hours. Postoperatively, 6 patients (2, 3, and 1, respectively) developed port-site infection, and there were no cases of Horner’s syndrome in any of the studied groups. In total, 94 patients experienced compensatory sweating (Table 4). Compensatory sweating was only mild after the clipping technique, whereas it ranged from mild-to-moderate to severe after the sympathectomy and sympathotomy techniques (Table 5). The affected areas were the upper back (57%), thighs (35%), and axillae (8%). In our cohort, only 11 patients (2.6%) were dissatisfied (4 in the sympathectomy group, 5 in the sympathotomy group, and 2 in the clipping group) (Table 6).

Table 3.

Difference Between the Groups According to Rate of Success

Result	Sympathectomy (n = 190)		Sympathotomy (n = 170)		Clipping (n = 60)		Test value^a	P value
Result	No	%	No	%	No	%	Test value^a	P value
Treatment success	186	97.8	165	97.05	54	90	8.582	.014^a
Over dry	0	0	0	0	0	0	0	1
Recurrence	4	2.1	5	2.9	6	10	8.582	.014^a

P value > .05, Nonsignificant; P value < .05, Significant; P value < .01, highly significant.

Chi-square test.

Table 4.

Differences Between the Groups According to Incidence of Complications

Complications	Sympathectomy (n = 190)		Sympathotomy (n = 170)		Clipping (n = 60)		Test value^a	P value
Complications	No	%	No	%	No	%	Test value^a	P value
Pneumothorax	10	5.2	9	5.1	2	3.3	0.410	.815
Bleeding	10	5.2	9	5.1	2	3.3	0.410	.815
Horner’s syndrome	0	0	0	0	0	0	0	1
Port-site infection	2	1.05	3	1.7	1	1.6	0.351	.839

P value < .05, Nonsignificant; P value < .05, Significant; P value < .01, highly significant.

Chi-square test.

Table 5.

Difference Between the Groups According to Compensatory Sweating

Compensatory Sweating at 6th post-op month	Sympathectomy (n = 190)		Sympathotomy (n = 170)		Clipping (n = 60)		Test value^a	P value
Compensatory Sweating at 6th post-op month	No	%	No	%	No	%	Test value^a	P value
None	142	74.7	136	80	48	80	1.659	.436
Mild	24	12.6	15	8.8	12	20	5.270	.072
Moderate	16	8.4	10	5.8	0	0	5.615	.060
Severe	8	4.2	9	5.2	0	0	3.224	.199

P value > .05, Nonsignificant; P value < .05, Significant; P value < .01, highly significant.

Chi-square test.

Table 6.

Difference Between the Groups According to Patients’ Satisfaction

Satisfaction	Sympathectomy (n = 190)		Sympathotomy (n = 170)		Clipping (n = 60)		Test value^a	P value
Satisfaction	No	%	No	%	No	%	Test value^a	P value
Very satisfied	166	87	151	88.8	56	93.3	1.702	.427
Satisfied	20	10.5	14	8.2	2	3.3	3.579	.217
Dissatisfied	4	2.1	5	2.9	2	3.3	0.386	.825
Very dissatisfaction	0		0		0		0	1

P value > .05, Nonsignificant; P value < .05, Significant; P value < .01, highly significant.

Chi-square test.

Discussion

PPH is a relatively common problem in children and adolescents that causes psychological and physical discomfort. In severe cases, it negatively affects self-esteem and daily life activities, and interferes with social engagement.⁸ It results from exaggerated thoracic sympathetic outflow, causing hand sweating over the physiological thermoregulatory process.²

Patient- and procedure-related factors that affect outcome, patient satisfaction, and the occurrence of compensatory sweating have been studied in previous studies, including age, sex, BMI, family history, craniofacial involvement, level of resection, and number of resected ganglia.

It appears that PPH is predominant in females. In the current study, female patients accounted for 60% of cases (Table 2). Similarly, 67% of the patients were female in Leiderman’s study.⁹ In Kapuller et al.’s¹⁰ series, 61% of patients were female.

Different medical conservative therapies have been tried for the treatment of PPH, including aluminum chloride salt–based antiperspirants;¹¹ iontophoresis, which improves 80% of cases but requires repeated sessions and may cause burn injury and paresthesia;¹² biofeedback techniques; botulinum toxin A injection, which relieves symptoms for only a mean of 7 months before the effect disappears and sweating recurs;¹³ systemic anticholinergic drugs such as oxybutynin, which improves 60%–90% of cases but requires long-term use and causes dry mouth and throat due to decreased secretions;¹⁴ glycopyrrolate, which improves 67%–90% of cases; and methantheline bromide.^15,16 Calcium-channel blockers and clonidine¹⁷ were used for the same purpose. These systemic medical treatments, to be effective, should be used on a long-term basis, but, on the other hand, they may exert intolerable side effects. They only provide transient relief of symptoms in the mild form, but are inevitably useless in severe forms of primary hyperhidrosis.

Surgical treatment by sympathetic chain interruption represents the last resort after failure/intolerance to medical conservative therapies, especially in moderate and severe cases that were eligible for our study.^10,18

Thoracoscopic sympathetic chain interruption, either by resection, transection, or clipping, is the surgical treatment of choice for the almost permanent resolution of primary hyperhidrosis, achieving a success rate of approximately 95%. The idea depends on interruption of nerve impulses discharge from the thoracic sympathetic ganglia to the eccrine sweat glands. This approach has gained increasing worldwide acceptance during the past 3 decades with various refinements of technical modalities, method of ablation, level, and number of dorsal ganglions tackled.^10,19,20

The thoracoscopic approach has all the advantages of minimally invasive surgery, including feasibility, safety, magnified view of the surgical field and sympathetic chain, short operative time, less postoperative pain, excellent cosmetic results, short hospital stay, and earlier return to school, and full ordinary life activities.

The purpose of the procedure is to achieve an acceptable degree of hypo/anhidrotic hands so that the patient can cope with the required daily life activities and engage in social relations (handshaking, writing, public sports, etc.), especially when performed as early as possible.²⁰

Upregulation of sympathetic flow after denervation results in compensatory sweating in areas above or below the hypo/anhidrotic area, which is the most common side effect of the procedure. This will act as a guide for good patient selection and accurate preoperative patient/parent counseling regarding the expected side effects of the procedure.

Regarding patient-related risk factors for the prediction of postoperative compensatory sweating, Carvalho et al.,²¹ found that preoperative axillary hyperhidrosis was associated with postoperative compensatory sweating in the dorsolumbar region. They reported that age, sex, BMI, comorbidities, and family history were not significant risk factors.

In contrast, Leiderman et al.,⁹ investigated the association between age and outcomes of thoracoscopic sympathectomy in a large group of patients with hyperhidrosis and concluded that the older the age, the better the improvement of primary sweating and quality of life postoperatively, while the occurrence and severity of compensatory sweating were linked to other factors (body mass index, craniofacial hyperhidrosis, and level of resection). They reached this conclusion based on subjective data, although most of their patients were children and adolescents. Similarly, Woo et al.,²² included patients of age from late teens until the late third decade and found that age ≥20 years was associated with the occurrence of postoperative compensatory sweating, and the use of anti-adhesive agents may decrease the recurrence rate after thoracoscopic sympathectomy for palmar–axillary hyperhidrosis.

Clipping interruption of the sympathetic chain has been utilized since 2016 after publication of this adopted technique by expert consensus.²³ Clipping is an advantageous procedure because it is reversible, allowing reversal of sympathetic denervation if significant troublesome compensatory sweating occurs postoperatively (simply by thoracoscopic removal of the clips, permitting nerve regeneration).¹⁹

The clipping technique was followed with only a mild degree of compensatory sweating, whereas it reached a moderate-to-severe degree after sympathectomy and sympathotomy, although no significant difference was reported. This is consistent with the results of previous studies. Leiderman et al.,⁹ reported no compensatory sweating in 30%, mild in 42.7%, moderate in 17.6%, and great in 5% of cases.

In agreement with our study, Adorisio et al.,¹⁸ reported that unilateral sequential thoracoscopic sympathetic chain clamping (by clips) is a safe and very effective procedure for the treatment of PPH in the pediatric age group. This procedure has a very low complication rate and low risk of postoperative compensatory sweating (12%) in comparison to bilateral simultaneous attack of the sympathetic trunk, and results in improvement of quality of life.

In the literature, partial improvement or recurrence is reported in up to 10% of cases.^24,25 In the present study, recurrence was recorded in 2.1%–10% of cases, mainly after clipping.

Regarding complications, we reported pneumothorax and bleeding in 3%–5% of cases and port-site infection in 1%–1.7% of cases. Leiderman et al.,⁹ reported pneumothorax in 8% of cases (¾ of them required thoracic drainage for 1–5 days), 0.25% had venous bleeding, 0.06% had self-limited arterial bleeding without need for reoperation or blood transfusion, 0.12% had axillary hematoma; 0.12% had bradycardia, 0.06% had tachycardia at the immediate postoperative period, 0.06% developed Horner syndrome (recovered in 6 months), and 0.06% had thoracic vein thrombophlebitis. Kapuller et al.,¹⁰ reported pneumothorax in 3.5% and venous bleeding in 0.3% of the cases.

In the current study, we found no significant differences among the three surgical modalities in complications and patient satisfaction. We found that 87%–93.3% of cases were very satisfied with the surgical outcome. Similarly, Kapuller et al.,¹⁰ reported complete satisfaction (95.2%), moderate satisfaction (0.64%), and dissatisfaction (4.16%) in their cases.

From the authors’ point of view, sympathectomy and sympathotomy were superior to clipping in terms of success rate (sufficient improvement in sweating) and recurrence.

Points of weakness and future recommendations

This study is retrospective and depends on the collection of data from medical files. No validated quality-of-life questionnaire was used. However, as the study describes a 15-years experience in applying three different surgical modalities to a large number of pediatric patients with sufficient follow-up time, we believe our results are meaningful and can be used to shed light on the peculiarities of managing PPH by thoracoscopic sympathetic chain interruption in this young age group. However, large-scale, high-quality, prospective, randomized controlled trials are required to validate these results.

Conclusion

Thoracoscopic sympathetic chain interruption by resection, transection, or clipping is a safe and effective procedure for the treatment of the devastating problem of primary hyperhidrosis in children and adolescents, with significant differences between all groups regarding the success and recurrence rates. Similar results have been found regarding complication rate, compensatory sweating, and patient satisfaction.

Footnotes

Acknowledgment

Portions of this article were formally submitted as an academic protocol for registration of the study on ClinicalTrials.gov. The web link is: https://classic.clinicaltrials.gov/ct2/show/NCT06113978. ClinicalTrials.Veeva (ctv) is a free resource provided by Veeva systems. It published the current clinical trial unexpectedly as a part of its public benefit mission, without any request from the authors. The web link is: .

Ethical Consideration

The study design was approved by the Institutional Review Board and the ethics committee of the hospitals and met all the guidelines of their responsible governmental agency. The study was performed according to the ethical standards of the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.

Authorship

The authors attest that they met the current ICMJE criteria for authorship.

Authors’ Contributions

M.A., M.D., and M.-A.M.: Study conception and design; M.A., M.A., and M.M.: Data acquisition; A.S., Y.A., and Y.M.: Analysis and data interpretation; M.H., A.A., and M.M.: Drafting of the article; M.D., M.-A.M., and M.A.: Critical revision. All authors have read and approved the final manuscript.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

References

Elshahawy

, Shamseldin

, Akl

. Thoracoscopic sympathectomy for treatment of primary hyperhidrosis in children: A randomized comparative study between clipping and electrocautery techniques. Al-Azhar Int Med J, 2021; 2(3):37–42; doi: 10.21608/aimj.2021.58825.1408

Deng

, Tan

, Jiang

, et al. Optimization of sympathectomy to treat palmar hyperhidrosis: The systematic review and meta-analysis of studies published during the past decade. Surg Endosc, 2011; 25(6):1893–1901; doi: 10.1007/s00464-010-1482-3

Kux

. Thoracic endoscopic sympathectomy in palmar and axillary hyperhidrosis. Arch Surg, 1978; 113(3):264–266; doi: 10.1001/archsurg.1978.01370150036005

Neumayer

, Bischof

, Függer

, et al. Efficacy and safety of thoracoscopic sympathicotomy for hyperhidrosis of the upper limb. Results of 734 sympathicotomies. Ann Chir Gynaecol, 2001; 90(3):195–199. PMID: 11695794.

Gossot

, Kabiri

, Caliandro

, et al. Early complications of thoracic endoscopic sympathectomy: A prospective study of 940 procedures. Ann Thorac Surg, 2001; 71(4):1116–1119; doi: 10.1016/s0003-4975(01)02422-5.6

Katara

, Domino

, Cheah

, et al. Comparing T2 and T2-T3 ablation in thoracoscopic sympathectomy for palmar hyperhidrosis: A randomized control trial. Surg Endosc, 2007; 21(10):1768–1771; doi: 10.1007/s00464-007-9241-9

de Andrade Filho

, Kuzniec

, Wolosker

, et al. Technical difficulties and complications of sympathectomy in the treatment of hyperhidrosis: An analysis of 1731 cases. Ann Vasc Surg, 2013; 27(4):447–453; doi: 10.1016/j.avsg.2012.05.026

Cameron

. Selecting the right patient for surgical treatment of hyperhidrosis. Thorac Surg Clin, 2016; 26(4):403–406; doi: 10.1016/j.thorsurg.2016.06.004

Leiderman

DBD

, Milanez de Campos

, Kauffman

, et al. The relation between age and outcomes of thoracic sympathectomy for hyperhidrosis: The older the better. J Thorac Cardiovasc Surg, 2018; 156(4):1748–1756; doi: 10.1016/j.jtcvs.2018.05.084

10.

Kapuller

, Mares

, Mordehai

, et al. Thoracoscopic upper thoracic sympathectomy for primary palmar hyperhidrosis in children and adolescents: A ten-year experience. Pediatric Endosurgery Innovative Tech, 2004; 8(2):109–112; doi: 10.1089/1092641041360878

11.

Woolery-Lloyd

, Valins

. Aluminum chloride hexahydrate in a salicylic Acid gel: A novel topical agent for hyperhidrosis with decreased irritation. J Clin Aesthet Dermatol, 2009; 2(6):28–31. PMID: 20729946; PMCID: PMC2923959.

12.

Kim

, Kim

, Lee

, et al. Treatment of palmar hyperhidrosis with tap water iontophoresis: A randomized, sham-controlled, single-blind, and parallel-designed clinical trial. Ann Dermatol, 2017; 29(6):728–734; doi: 10.5021/ad.2017.29.6.728

13.

Mannava

, Mannava

, Nazir

, et al. Treatment of palmar hyperhidrosis with botulinum neurotoxin a. J Hand Surg Am, 2013; 38(2):398–400; doi: 10.1016/j.jhsa.2012.11.005

14.

Wolosker

, Passos Teivelis

, Krutman

, et al. Long-term results of oxybutynin treatment for palmar hyperhidrosis. Clin Auton Res, 2014; 24(6):297–303; doi: 10.1007/s10286-014-0264-8

15.

Hosp

, Hamm

. Safety of available and emerging drug therapies for hyperhidrosis. Expert Opin Drug Saf, 2017; 16(9):1039–1049; doi: 10.1080/14740338.2017.1354983

16.

Grabell

, Hebert

. Current and emerging medical therapies for primary hyperhidrosis. Dermatol Ther (Heidelb), 2017; 7(1):25–36; doi: 10.1007/s13555-016-0148-z

17.

Gelbard

, Epstein

, Hebert

. Primary pediatric hyperhidrosis: A review of current treatment options. Pediatr Dermatol, 2008; 25(6):591–598; doi: 10.1111/j.1525-1470.2008.00782.x

18.

Adorisio

, Davoli

, Ceriati

, et al. Effectiveness of unilateral sequential video-assisted sympathetic chain blockage for primary palmar hyperidrosis in children and adolescents. Front Pediatr, 2022; 10:1067141; doi: 10.3389/fped.2022.1067141

19.

Miller

, Bryant

, Force

, et al. Effect of sympathectomy level on the incidence of compensatory hyperhidrosis after sympathectomy for palmar hyperhidrosis. J Thorac Cardiovasc Surg, 2009; 138(3):581–585; doi: 10.1016/j.jtcvs.2009.03.05920

20.

Mol

, Muensterer

. Over a decade of single-center experience with thoracoscopic sympathicolysis for primary palmar hyperhidrosis: A case series. Surg Endosc, 2021; 35(7):3313–3319; doi: 10.1007/s00464-020-07769-0

21.

Carvalho

, Marinho

, Barbosa-Sequeira

, et al. Compensatory sweating after thoracoscopic sympathectomy for primary focal hyperhidrosis in children: Are there patient-related risk factors? J Pediatr Surg, 2022; 57(2):203–206; doi: 10.1016/j.jpedsurg.2021.10.036

22.

Woo

, Kim

, Kang

, et al. Patient experience and prognostic factors of compensatory hyperhidrosis and recurrence after endoscopic thoracic sympathicotomy. Surg Endosc, 2022; 36(11):8340–8348; doi: 10.1007/s00464-022-09284-w

23.

Cerfolio

, De Campos

, Bryant

, et al. The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis. Ann Thorac Surg, 2011; 91(5):1642–1648; doi: 10.1016/j.athoracsur.2011.01.105

24.

Sinha

, Kiely

. Thoracoscopic sympathectomy for palmar hyperhidrosis in children: 21 years of experience at a tertiary care center. Eur J Pediatr Surg, 2013; 23(6):486–489; doi: 10.1055/s-0033-1337117

25.

Zhang

, Yu

, Jiang

, et al. Video-Assisted Thoracoscopic Sympathectomy for Palmar Hyperhidrosis: A Meta-Analysis of Randomized Controlled Trials. PLoS One, 2016; 11(5):e0155184; doi: 10.1371/journal.pone.0155184