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While endoscopic thoracic sympathectomy (ETS) offers a permanent option for palmar hyperhidrosis, the risk of compensatory sweating following the operation is a serious consideration.

The ideal patients for ETS are "people that have only purely hand sweating -- nothing else," Eric Vallières, MD, a thoracic surgeon at the Swedish Cancer Institute in Seattle, told 番茄社区, followed by those with sweating of the hand and feet.

In patients with hyperhidrosis in several areas, Vallières will tell them, "'Listen we can make your hands dry, but the rest of your body... it's going to be the same and/or worse' and I let them decide."

Vallières said that roughly one in five patients he sees goes through with ETS. The rest opt out either due to insurance denial -- if they have not failed prior treatments, say -- or because of characteristics of their hyperhidrosis that don't make them an ideal fit. The operation can run roughly $10,000 for a patient paying out of pocket, though some clinics that strictly perform ETS -- often referred to as "sweatshops" -- are able to offer the intervention for several thousand dollars less.

The 20% who do undergo ETS have usually had no success with more conservative therapies such as antiperspirants or an "electrical bath" known as iontophoresis. Some patients have been treated with botulinum toxin (Botox), had two or three prior treatments (which each typically last 6 to 8 months), but are looking for another option due to efficacy or cost.

A y in the Annals of Thoracic Surgery from Vallières and colleagues examined 8-year quality-of-life outcomes among 96 eligible patients treated with ETS for hyperhidrosis at the Swedish Cancer Institute. Of the 58 patients who consented to the study and who responded to a survey, improved quality of life and ability to perform tasks were reported in 84% and 86% of patients, respectively.

"This is one of the surgeries that has the highest impact on how happy these individuals are for a very, very simple surgery," Vallières said. "They can still use their hands, can still shake hands."

Compensatory sweating was reported in 84% of respondents following ETS (78% minor, 22% severe). Of these, 49% said it occurred daily and 37% said it occurred weekly. Only 22% reported that the compensatory sweating was more disruptive than their hyperhidrosis before surgery, according to the research.

All patients (19 of 19) who had previously exhibited hyperhidrosis in other parts of the body developed compensatory sweating, while 77% (30 of 39) of those with strictly palmar hyperhidrosis developed the side effect.

Sweating occurred predominantly in the lower back and chest, the feet, and under the breast in women, with less frequent areas including the groin and back of the knees, said Vallières. "But these areas are a lot easier to hide socially than the hands," he said. Gustatory sweating has also been reported in other studies.

Vallières explained that patients with low resting heart rates might not be a good fit for ETS. Though none were seen in the study, he noted that cases have been reported where patients' heart rates slowed down so much that a pacemaker was required. "But most of the patients we see here don't fall in this category," he said.

Patients with hyperhidrosis of the hands can often be among the most "compromised," Adelaide A. Hebert, MD, a dermatologist at the University of Texas Health McGovern Medical School in Houston, told 番茄社区. "If they work on the computer and they sweat a lot, they can short out their keyboard, they can ruin their phone."

But not all agree with the use of ETS for patients with palmar hyperhidrosis.

"I'm not a big fan of surgery," Hebert commented, noting that she often sees ETS-treated patients for compensatory sweating. "The surgeon does the surgery, but then if the patient gets compensatory hyperhidrosis, they don't manage it. They just send it to somebody else."

Hebert acknowledged that while in these cases patients did not get the results they had hoped for, the sweating that occurs in other areas can be severe. "For example they might get it in the groin, and they'll look like they've wet their pants -- that's not socially acceptable, so it really can be very challenging for them," she said.

"I really urge the provider to go look at the history of endoscopic thoracic sympathectomy," Hebert said. The operation, which was first invented in Sweden by a team of surgeons in the mid-1980s, was banned in the country in 2003 following patient deaths and lawsuits from former ETS-treated patients. "I think that's very telling," she said.

Berthold Rzany, MD, ScM, a dermatologist of the Rzany & Hund clinic in Germany, also cited compensatory sweating as a reason to recommend against ETS for palmar hyperhidrosis. "It does not occur in all patients," he told 番茄社区, "but we all know very severe cases who are very difficult to treat."

Rzany warned that if a third of the body becomes affected by compensatory sweating, treatment with botulinum toxin is no longer an option.

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