Efficacy of Thoracoscopic Sympathectomy Including Asymmetric Resection for Treating Palmar Hyperhidrosis : A Retrospective Study

Efficacy of Thoracoscopic Sympathectomy Including Asymmetric Resection for Treating Palmar Hyperhidrosis : A Retrospective Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficacy of Thoracoscopic Sympathectomy Including Asymmetric Resection for Treating Palmar Hyperhidrosis : A Retrospective Study Luoyu Lian, Jinlong Huang, Wenshan Hong, Dongliang Lin, Weiqing Zhang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4545410/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective:This study aims to retrospectively evaluate the effectiveness of single-segment thoracic sympathotomy in treating palmar hyperhidrosis. Methods:We conducted a retrospective study at our center from January 2018 to January 2022. A total of 226 patients with palmar hyperhidrosis, who underwent single-segment endoscopic sympathectomy, were divided into R3, R4, and asymmetric segment groups (R3 / R4 group). We analyzed the effectiveness, side effects, and patient satisfaction of the three treatments through telephone and online patient consultations. Results: All groups experienced similar surgery duration, hospital stay, and blood loss. The R3 group (104 patients) had the lowest recurrence rate (1 case), followed by the R4 group (92 patients, 3 cases), and the R3/R4 group (30 patients, 1 case). Compensatory hyperhidrosis was observed in 21 cases in the R3 group and 19 in the R4 group. The R3/R4 group reported compensatory hyperhidrosis in 24 cases, mostly Grade I and II. Satisfaction was highest in the R3 group, closely followed by the R3/R4 group and then the R4 group. This indicates that both R3 and R4 single-segment resections are effective, with R3 showing higher patient satisfaction and lower recurrence, and the asymmetric R3/R4 approach also proving to be a viable option. Conclusion: Single-segment resection of either R3 or R4 can effectively manage palmar hyperhidrosis. Patients who underwent R3 resection experienced fewer recurrences and reported higher satisfaction than those who underwent R4 resection. Furthermore, compensatory hyperhidrosis didn't notably rise. Asymmetric single-segment resection, with its thicker vascular coverage, is also a viable treatment option. Palmar Hyperhidrosis Thoracic Sympathotomy Asymmetric Single-Segment Resection Compensatory Hyperhidrosis Patient Satisfaction Figures Figure 1 Introduction Palmar hyperhidrosis, also known as palmar-plantar hyperhidrosis, is a functional disorder characterized by excessive secretion of sweat glands in the hands, often associated with overactivity of the sympathetic nervous system. Although the exact pathomechanism has not been fully elucidated, studies suggest that enhanced central nervous system control over sympathetic ganglia may be a key factor[ 1 ]. Hyperhidrosis not only affects the daily life of patients but can also lead to social and psychological issues. It is estimated that the prevalence in the United States is about 4.8%[ 2 ], and among adolescents in coastal areas of China, the prevalence is 4.36%[ 3 ]. Currently, the treatment modalities for hyperhidrosis are diverse, encompassing topical agents, iontophoresis, botulinum toxin injections, oral medications, and surgical options[ 4 ]. While treatments such as topical agents, iontophoresis, botulinum toxin injections, and oral medications can alleviate palmar hyperhidrosis to some extent, they are generally short-lived and associated with a high recurrence rate, rendering them ineffective for long-term eradication of the condition. Consequently, these methods are primarily suitable for mild cases of palmar hyperhidrosis. Endoscopic thoracic sympathectomy (ETS), owing to its minimally invasive nature, rapid recovery, and long-term satisfactory outcomes, has emerged as the preferred surgical approach for treating primary palmar hyperhidrosis[ 5 , 6 ]. Despite the risk of compensatory hyperhidrosis, the majority of patients report satisfaction with the surgical results. The debate over the optimal level for interrupting the sympathetic chain during ETS continues. Some studies advocate for an R3 sympathicotomy, which involves cutting the sympathetic chain at the level of the 3rd rib, leading to drier hands[ 7 ]. Others suggest that an R4 sympathicotomy, interrupting the chain at the 4th rib, may decrease the risk of compensatory sweating[ 5 ]. In our clinical practice, the decision between R3 and R4 sympathicotomy is personalized based on the patient's symptoms and expectations. During surgical procedures, we have encountered cases where vascular structures over the R3 or R4 sympathetic trunk pose a risk of intraoperative bleeding. To address this, we have employed a novel approach: performing an asymmetric sympathicotomy when anatomical complexities are present. This method, sparingly reported in the literature, is the focus of our study, aiming to assess its feasibility and efficacy. Patients and Methods 2.1 General Information Data were collected for retrospective analysis from 231 patients treated with thoracoscopic surgery for primary palmar hyperhidrosis at the Department of Thoracic Surgery, Quanzhou First Hospital, between January 2018 and January 2022. Out of these, 226 cases met the inclusion criteria. Five cases were excluded from the analysis due to loss to follow-up: four were due to incorrect contact information, and one patient explicitly declined further participation. The demographic breakdown of the cohort includes 125 males and 101 females, aged between 13 to 50 years, with an average age of 22.6 ± 5.9 years. The duration of symptoms ranged from 3 to 34 years, averaging at 14.0 ± 5.3 years. Severity classification adhered to the Lai method, which categorizes the condition based on palm moisture and sweat volume. According to this method, severe cases are characterized by sweat droplets that resemble raindrops, moderate cases are identified by sweat that can soak through a handkerchief, and mild cases are defined as conditions where the palm skin is moist without a change in the surface skin temperature[ 8 ]. Comorbid hyperhidrosis was observed in 179 patients with plantar, 13 with lumbar, 14 with axillary, and 1 with craniofacial hyperhidrosis. Table 1 Demographic and Clinical Characteristics of Patients Undergoing Sympathectomy Characteristics R3 group R4 group R3 / R4 group F P-value Number of Cases (N) 104 92 30 Age (years, mean ± SD) 22.9 ± 6.4 21.1 ± 4.9 22.5 ± 6.5 2.45 0.088 Gender (Males/Females) 59:45 46:46 20:10 2.70 0.259 Duration of Symptoms (years, mean ± SD) 14.7 ± 5.3 14.1 ± 5.1 13.7 ± 5.9 1.53 0.218 Severity of Palmar Hyperhidrosis Severe 94 73 30 0.005 Moderate 9 17 0 0.010 Mild 1 2 0 0.603 Distribution of Comorbid Hyperhidrosis Plantar 79 74 26 0.414 Lumbar 3 9 1 0.097 Axillary 4 8 2 0.370 Craniofacial 0 1 0 0.481 Surgical intervention involved bilateral R3 sympathicotomy (104 patients), bilateral R4 sympathicotomy (92 patients), and bilateral asymmetric sympathicotomy (30 patients, with one side R3 and the other R4), following the ISSS and STS committees' consensus on standardized nomenclature[ 5 ]. Asymmetric sympathicotomy was selected in cases where intraoperative findings indicated a high risk of bleeding from the sympathetic nerve stem, necessitating an immediate adjustment from the standard sympathicotomy plane. All patients underwent a comprehensive medical history review, electrocardiogram, and chest X-ray to exclude systemic causes of hyperhidrosis such as hyperthyroidism. The study adhered to ethical guidelines, with informed consent obtained from all participants and approval from the institutional review board of Quanzhou First Hospital. The detailed clinical data are summarized in Table 1 . 2.2 Surgical Method A standardized single-port thoracoscopic approach was utilized for all 226 patients diagnosed with palmar hyperhidrosis. Under general anesthesia, vital signs including pulse, blood pressure, heart rate, and blood oxygen saturation were continuously monitored. Palm thermometers were placed to observe temperature changes indicative of successful sympathectomy during the surgery. Patients were positioned in a semi-sitting posture with a 60-degree elevation and arms abducted to 90 degrees to facilitate surgical access, as shown in Fig. 1 (a) . Incisions were tailored to gender: a 6mm incision in the third intercostal space on the mid-axillary line for females, and at the bilateral areolar margin for males, following standard disinfection and draping protocols. The surgical process began on the right side, with the anesthesiologist inducing a temporary cessation of ventilation to allow for artificial pneumothorax and subsequent lung collapse. A 5mm trocar and thoracoscope were then inserted to enable visualization of the sympathetic chain. Sympathicotomy was performed at the predetermined rib level, and Kuntz fibers and communicating branches were transected. In 30 patients undergoing different plane resections, anomalous vein branches or intercostal vessels were observed during the procedure, covering the plane intended for resection (refer to Fig. 1 (b) ). To avoid potential vein damage and bleeding, the plane was altered, with the original resection continuing on the opposite side. Monitoring of temperature changes in the ipsilateral hand was conducted to confirm the effectiveness of the sympathetic trunk transection. After the procedure, a chest tube was inserted under slight negative pressure to aid in lung re-expansion, which was confirmed before wound closure. Chest X-rays were performed within 6 to 24 hours postoperatively to confirm the absence of any complications. 2.3 Postoperative Follow-Up Postoperative follow-up was conducted through telephone and online surveys, as detailed in follow-up Appendix A . The follow-up protocol included the following components: Symptom Improvement: Assessment of the improvement in symptoms of palmar hyperhidrosis was conducted. The degree of improvement was recorded based on patient feedback. Recurrence of Symptoms: The presence of recurrent palmar hyperhidrosis symptoms was monitored, with recurrence defined as a return to moderate or severe symptomatology. Compensatory Hyperhidrosis (CH): The occurrence, location, severity, and temporal changes in CH were evaluated. The severity of CH was classified using Li's grading system[ 3 ], where Grade I represents only moist skin without significant sweating or discomfort; Grade II involves increased sweating without substantial discomfort; Grade III includes profuse sweating that remains tolerable; and Grade IV consists of severe sweating that interferes with daily and social activities, causing considerable physical and psychological distress, also referred to as disabling CH. Bilateral Symptom Variation: Any differences in the postoperative outcomes between the two hands were noted, including specific manifestations if the effects varied. Other Complications: The incidence of any other complications, such as Horner's syndrome, taste sweating, bleeding, pneumothorax, and pneumomediastinum, were recorded. Patient Satisfaction: Satisfaction with the surgical outcome was gauged using a scale from 0 (very dissatisfied) to 10 (very satisfied), with patients rating their initial impression post-surgery. 2.4 Statistical Analysis The statistical analysis was performed using IBM SPSS Statistics software, version 26.0. Continuous variables were expressed as mean ± standard deviation (M ± SD). Categorical variables were summarized as frequencies and percentages. The Chi-square test was utilized for comparisons of categorical data, with Fisher's Exact Test employed as an alternative for cells with expected frequencies less than 5 or when dealing with small sample sizes. One-way Analysis of Variance (ANOVA) was employed for the analysis of continuous variables across multiple groups. A P-value < 0.05 was predetermined as the threshold for statistical significance. Results 3.1 Perioperative Results In this study, 226 patients underwent bilateral single-segment thoracoscopic sympathectomy. The procedures were successful without serious intraoperative complications such as death or massive bleeding. The average operation time for bilateral procedures was 49.8 ± 7.1 minutes. Postoperatively, all patients experienced complete resolution of hand sweat symptoms, with hands feeling significantly drier and warmer compared to preoperative conditions. The average postoperative hospital stay was brief, lasting only 1.0 ± 0.3 days. Table 2 Perioperative Conditions Characteristics R3 group R4 group R3 / R4 group P-Value Operation time (min) 49.4 ± 7.1 50.6 ± 7.0 48.6 ± 7.4 0.310 Length of stay (day) 1.0 ± 0.1 1.1 ± 0.4 1.0 ± 0.0 0.465 Amount of bleeding < 10ml < 10ml < 10ml Perioperative complications pneumothorax 1 2 0 0.603 subcutaneous emphysema 15 12 4 0.959 pleural effussion 0 1 0 0.481 Minor postoperative complications were noted, including pneumothorax in 3 patients (1.3%), which resolved with either observation or routine closed chest drainage, and subcutaneous emphysema in 31 patients (13.7%), which resolved spontaneously. One patient (0.4%) experienced a small amount of pleural effusion, resolving within a month. Importantly, no major complications like incision infection or Horner's syndrome were observed. All patients were able to resume normal activities within a week of discharge. Detailed perioperative data are presented in Table 2 . 3.2 Follow-up Results Follow-up assessments conducted a year post-surgery via telecommunication and online platforms revealed significant findings. Out of the 226 patients, 10 instances of postoperative recurrence (4.4%) were recorded. Compensatory hyperhidrosis post-surgery was observed in 160 cases (70.8%), with 3 cases (1.3%) being categorized as severe. The distribution of compensatory hyperhidrosis was predominantly in the feet, legs, chest, waist, and back. The highest rate of satisfaction post-operation was noted in the R3 group, followed closely by the R3/R4 group and the R4 group. The detailed results of the follow-up, including the extent, location of compensatory hyperhidrosis, and patient satisfaction, are elaborated in Tables 3 and Table 4 . Table 3 Post-operative effect table Characteristics R3 group (n = 104) R4 group (n = 92) R3 / R4 group (n = 30) P-value Cases of Recurrence 3 6 1 0.444 Compensatory hyperhidrosis 66 70 24 0.205 Degree of compensatory hyperhidrosis Grade I 48 48 17 0.516 Grade II 19 19 5 0.859 Grade III 2 0 1 0.295 Grade IV 0 0 0 Postoperative compensatory hyperhidrosis site Foot, leg 60 49 12 0.231 Chest, waist and back 54 50 22 0.108 Armpit 1 10 0 0.596 Head and face 1 4 1 0.544 Patient Satisfaction 8.5 ± 1.0 7.9 ± 1.7 8.1 ± 1.0 0.024 Table 4 Postoperative Satisfaction Scores Characteristics Degree of satisfaction(mean ± SD) P(interblock) P (Group R3 VS Group R4 ) P (Group R3 VS Group R3 / R4) P (Group R4 VS Group R3 / R4) The R3 group (n = 104) 8.5 ± 1.0 0.000 0.000 0.515 0.038 The R4 group (n = 92) 7.9 ± 1.9 R3 / R4 group (n = 30) 8.1 ± 1.3 Discussion Hyperhidrosis, a disorder of the autonomic nervous system with an unclear etiology, is primarily characterized by excessive activity of the sweat glands in the hands, leading to pronounced sweating. Additionally, patients often experience hyperhidrosis in other areas such as the feet and armpits. Given the relatively high prevalence of hyperhidrosis and its significant impact on quality of life, the condition has increasingly garnered attention. Currently, non-surgical treatments for hyperhidrosis, such as oral medications, botulinum toxin injections, and iontophoresis, are mainly suitable for patients with mild to moderate symptoms. However, these treatments typically offer short-term relief and may be associated with side effects like pain and recurrence[ 4 ]. Since 1992, with the successful application of video-assisted thoracoscopic sympathectomy by Landreneau et al. [ 9 ] for the treatment of hyperhidrosis, this method has become the mainstream for moderate to severe cases. Thoracoscopic sympathectomy is not only considered an effective treatment for hyperhidrosis, but also, due to its minimally invasive nature, has been widely accepted and applied in clinical practice. In 1997, a study by Andrews et al.[ 10 ] found that the incidence and severity of compensatory sweating were closely related to the extent of the surgery, indicating that high-level and extensive sympathectomy increased the risk of compensatory sweating. To address this issue, in 2001, Lin et al.[ 11 ] proposed the Lin-Telaranta criteria, which recommended blocking only the fourth thoracic sympathetic nerve segment. This approach has shown better outcomes in the treatment of hyperhidrosis, with a lower incidence of postoperative compensatory sweating. According to the 2011 consensus of the American Society of Thoracic Surgeons, for palmar hyperhidrosis, the optimal surgical choice is R3 sympathectomy, with R4 sympathectomy also being a reasonable option. The difference between the two is that R3 sympathectomy can achieve the driest hands but comes with a relatively higher risk of compensatory hyperhidrosis (CH), whereas R4 sympathectomy may result in slightly moister hands[ 5 ]. A systematic review study in 2017 found no significant difference between T3 and T4 in terms of patient satisfaction, symptom resolution, dry hands, and the incidence of gustatory sweating. However, T4 sympathectomy reduced the risk of compensatory sweating and increased satisfaction, making it a better choice[ 12 ]. The debate over whether R3 or R4 sympathectomy is the optimal level is not conclusively resolved by different studies, possibly due to our idealized interpretation of R3 or R4 sympathectomy as the direct resection of the third or fourth sympathetic ganglion (G3 or G4). In actual surgical practice, due to the difficulty in accurately determining the location of the sympathetic ganglia, surgeons perform the resection on the sympathetic chain corresponding to the surface of the third or fourth rib. Research indicates that the third sympathetic ganglion (G3 or G4) may descend to the surface of the next rib[ 7 ], meaning that what is considered R4 sympathectomy in surgery might actually be the resection of the third sympathetic ganglion (G3). This anatomical variation could reduce the observed clinical differences between R3 and R4 sympathectomy. Based on our team's clinical observations and the results of this study, we found that both R3 and R4 sympathectomies can be considered as treatment options for patients with severe palmar hyperhidrosis. In terms of compensatory hyperhidrosis, there was no significant difference between these two methods. However, in terms of patient satisfaction and postoperative recurrence, R3 sympathectomy seemed to be superior to R4 sympathectomy. This may be due to a portion of patients in the T4 group experiencing postoperative recurrence, failing to achieve the expected results, thereby affecting their satisfaction. Although the R3 group had a higher proportion of compensatory hyperhidrosis, this did not seem to significantly affect patient satisfaction postoperatively. Considering that the resolution of palmar hyperhidrosis significantly improves the quality of life, compensatory hyperhidrosis is considered within an acceptable range. In our study, there were four cases that demonstrated postoperative differences in the effects on the hands. These four patients underwent bilateral asymmetric sympathectomies (R3/R4), and in postoperative follow-ups, they reported that the hand on the R4 sympathectomy side was slightly moist, while the hand on the R3 sympathectomy side was very dry. This finding highlights the different effects of cutting the sympathetic nerve at different segments, further confirming that R3 sympathectomy leads to drier hands compared to R4 sympathectomy. Based on our team's experience, both R3 and R4 sympathectomies are effective in treating palmar hyperhidrosis. While R3 sympathectomy can result in drier hands, it may be accompanied by higher compensatory hyperhidrosis; whereas R4 sympathectomy, though resulting in slightly moist hands, tends to have less compensatory hyperhidrosis. Therefore, the choice between R3 and R4 sympathectomy should be based on the specific situation and preferences of the patient, and doctors need to explain in detail the pros and cons of both surgical methods, assisting patients in making the most suitable decision for themselves. During the surgical procedure, we observed that in some patients, the sympathetic nerve chain was covered by the intercostal veins, increasing the risk and complexity of the surgery. Although meticulous dissection and careful operation helped to reduce the risk of intraoperative bleeding, it also prolonged the surgery time and increased trauma to the patient. Particularly, once bleeding occurs during surgery, due to the small incision and limited space in endoscopic surgery, it becomes difficult to achieve hemostasis under the scope. In such cases, it might be necessary to stop the bleeding through a small incision or open chest surgery, which not only prolongs the surgery time and increases the risk of bleeding but may also lead to serious consequences. Moreover, whether it is through a small incision assistance or open chest hemostasis, it contradicts the original intention of minimally invasive surgery, potentially exacerbating the patient's trauma and reducing the satisfaction with the surgery. In Gossot's study[ 13 ], they analyzed early complications in 940 cases of sympathetic nerve resection and found that 25 cases (5.3%) experienced bleeding due to intercostal vein injury, with the amount of bleeding ranging between 300 to 600 milliliters. These bleeding events were associated with difficulties in vascular constriction and control. Although the bleeding was successfully controlled via thoracoscopy, in some cases, a 10mm trocar needle was required to aspirate blood to prevent lung expansion. In a retrospective study by Jianfeng and others on 10,275 thoracoscopic surgeries, they found 39 cases of intraoperative bleeding, accounting for 0.4% of the total, including 2 patients who bled from the azygos vein branch, with bleeding reaching 300 to 500 milliliters within one minute; the bleeding was successfully stopped by immediately using titanium clips to block the vein. The remaining 37 cases with minor bleeding were controlled by electrocoagulation[ 14 ]. Although these bleeding events were ultimately controlled under thoracoscopy, they undoubtedly increased the trauma and risk of the surgery. Therefore, when choosing the surgical site, we prefer to avoid intercostal spaces with a high risk of bleeding and select those with a relatively lower risk of bleeding for the operation. In our study, we surveyed 30 patients in the R3/R4 group, of which 20 underwent right-sided R3 and left-sided R4 sympathectomy, and 10 underwent right-sided R4 and left-sided R3 sympathectomy. We noticed a higher proportion of right-sided R3 resections, which might be related to the predominant distribution of the umbilical vein branches in the right R4 area. Our findings indicate that both bilateral asymmetric single-stage resections (R3/R4) and bilateral symmetric resections effectively treat palmar hyperhidrosis, with no significant difference in compensatory hyperhidrosis incidence compared to the individual T3 or T4 groups. Among the 30 patients, 4 reported different sensations in each hand, further confirming that R3 resection might lead to a drier hand sensation. All 30 surgeries were successfully completed, leading us to believe that choosing not to cauterize accompanying vessels and instead performing R3/R4 sympathectomy is a viable option to avoid unnecessary risks during the surgical process. This study is a retrospective, single-center analysis, involving a limited number of R3/R4 sympathectomy cases. Therefore, our conclusions may be subject to the limitations of a small sample size and statistical biases. Despite these limitations, our findings suggest that R3 sympathectomy shows better performance in terms of patient recurrence rates and satisfaction compared to R4 sympathectomy, without a significant increase in the incidence of compensatory hyperhidrosis. Additionally, our results indicate that bilateral asymmetric single-segment resection is an effective and safe alternative when encountering thicker vessels covering the resection plane during surgery. Future studies should include larger sample sizes and multi-center data to further validate our findings and explore the response of different patient populations to surgical techniques. Declarations Ethics Approval and Consent to Participate: This study, titled "Efficacy Analysis of Single-Stage Thoracoscopic Sympathetic Nerve Disruption in the Treatment of Palmar Hyperhidrosis," received ethics approval from the Institutional Review Board of Quanzhou First Hospital (Approval No. 泉一伦《2022》201号). Informed consent was obtained from all participants or their legal guardians, as applicable. For minors under 16 years of age, consent was specifically obtained from parents or legal guardians. Consent for Publication: Written informed consent was obtained from all subjects (or their legal guardians) for the publication of their personal and clinical details along with any identifying images in this study. All patient names have been removed from the text, figures, tables, and images. Identifying facial features in the images have been completely removed using white boxes, in accordance with the journal's guidelines. Competing Interests: The authors declare that they have no competing interests. Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Contribution Dr. Luoyu Lian was the principal investigator and was primarily responsible for the conception and design of the study, data collection, analysis, interpretation of data, and drafting the manuscript. All other authors assisted in data collection and reviewed the manuscript for important intellectual content. All authors read and approved the final manuscript. Data Availability Data generated or analyzed during this study are available from the corresponding author, Dr. Luoyu Lian, on reasonable request due to privacy and ethical restrictions. References Nawrocki S, Cha J. The etiology, diagnosis, and management of hyperhidrosis: A comprehensive review. J AM ACAD DERMATOL. 2019;81(3):657–66. Doolittle J, Walker P, Mills T, Thurston J. Hyperhidrosis: an update on prevalence and severity in the United States. ARCH DERMATOL RES. 2016;308(10):743–9. Li X, Chen R, Tu Y, Lin M, Lai F, Li Y, Chen J, Ye J. Epidemiological survey of primary palmar hyperhidrosis in adolescents. Chin MED J-PEKING. 2007;120(24):2215–7. Chudry H. The treatment of palmar hyperhidrosis – a systematic review. INT J DERMATOL. 2022;61(11):1303–10. Cerfolio RJ, De Campos JRM, Bryant AS, Connery CP, Miller DL, DeCamp MM, McKenna RJ, Krasna MJ. The Society of Thoracic Surgeons Expert Consensus for the Surgical Treatment of Hyperhidrosis. Ann Thorac Surg. 2011;91(5):1642–8. Liu Y, Weng W, Tu Y, Wang J. Chinese expert consensus on the surgical treatment of primary palmar hyperhidrosis (2021 version). Chin MED J-PEKING. 2022;135(11):1264–71. Pei G, Meng S, Yang Y, Wang X, Liu Q, Wang S, Huang Y. Anatomical variations of the thoracic sympathetic ganglions and their effects on sympathicotomy for primary palmar hyperhidrosis. CLIN AUTON RES. 2023;33(2):111–20. Lai Y-T, YLCC. Complications in Patients with Palmar Hyperhidrosis Treated with Transthoracic Endoscopic Sympathectomy. NEUROSURGERY 1997(41):110–115. Landreneau RJMMHS. Video-assisted thoracic surgery: basic technical concepts and intercostal approach strategies. Ann Thorac Surg. 1992;54(4):800–7. Andrews BTRJ. Predicting changes in the distribution of sweating following thoracoscopic sympathectomy. Br J Surg. 1997;84(12):1702–4. Lin CCTT. Lin-Telaranta classification: the importance of different procedures for different indications in sympathetic surgery. Ann Chir Gynaecol 2001(90):161–6. Zhang W, Yu D, Wei Y, Xu J, Zhang X. A systematic review and meta-analysis of T2, T3 or T4, to evaluate the best denervation level for palmar hyperhidrosis. SCI REP-UK 2017, 7(1). Gossot D, Kabiri H, Caliandro R, Debrosse D, Girard P, Grunenwald D. Early complications of thoracic endoscopic sympathectomy: a prospective study of 940 procedures. ANN THORAC SURG. 2001;71(4):1116–9. Chen J, Liu Y, Yang J, Hu J, Peng J, Gu L, Deng B, Li Y, Gao B, Sheng Q et al. Endoscopic thoracic sympathicotomy for primary palmar hyperhidrosis: A retrospective multicenter study in China. SURGERY 2019, 166(6):1092–1098. Additional Declarations No competing interests reported. Supplementary Files AppendixA.doc Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4545410","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":313553986,"identity":"0019afa8-ab0d-4e22-a610-7fe99c5b3d96","order_by":0,"name":"Luoyu 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Fujian Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Weiqing","middleName":"","lastName":"Zhang","suffix":""},{"id":313553991,"identity":"920256e8-0592-4c38-847d-68651457bf8b","order_by":5,"name":"Zhendong Xu","email":"","orcid":"","institution":"Quanzhou First Hospital Affiliated to Fujian Medical University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Zhendong","middleName":"","lastName":"Xu","suffix":""}],"badges":[],"createdAt":"2024-06-07 10:14:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4545410/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4545410/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":59434827,"identity":"c7b9f292-5284-44b5-923d-56d35488d19a","added_by":"auto","created_at":"2024-07-01 19:05:31","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1137454,"visible":true,"origin":"","legend":"\u003cp\u003eThe surgical diagram based on \u003cstrong\u003e(a)\u003c/strong\u003e Surgical position, and \u003cstrong\u003e(b)\u003c/strong\u003e Abnormal azygos vein branches covering the sympathetic nerve\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4545410/v1/1e4788721efc979e2f7fb3a8.png"},{"id":61386859,"identity":"787a9e3e-9361-49e6-a47b-4a6c07af8196","added_by":"auto","created_at":"2024-07-30 07:16:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2166704,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4545410/v1/1a4acfab-cf75-4252-b530-ef3a46f5f992.pdf"},{"id":59434824,"identity":"9bc31991-fc9e-4e97-9eb2-132de1097206","added_by":"auto","created_at":"2024-07-01 19:05:29","extension":"doc","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":44032,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixA.doc","url":"https://assets-eu.researchsquare.com/files/rs-4545410/v1/0cc5226c132f04f05d6647c2.doc"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy of Thoracoscopic Sympathectomy Including Asymmetric Resection for Treating Palmar Hyperhidrosis : A Retrospective Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePalmar hyperhidrosis, also known as palmar-plantar hyperhidrosis, is a functional disorder characterized by excessive secretion of sweat glands in the hands, often associated with overactivity of the sympathetic nervous system. Although the exact pathomechanism has not been fully elucidated, studies suggest that enhanced central nervous system control over sympathetic ganglia may be a key factor[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Hyperhidrosis not only affects the daily life of patients but can also lead to social and psychological issues. It is estimated that the prevalence in the United States is about 4.8%[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], and among adolescents in coastal areas of China, the prevalence is 4.36%[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCurrently, the treatment modalities for hyperhidrosis are diverse, encompassing topical agents, iontophoresis, botulinum toxin injections, oral medications, and surgical options[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. While treatments such as topical agents, iontophoresis, botulinum toxin injections, and oral medications can alleviate palmar hyperhidrosis to some extent, they are generally short-lived and associated with a high recurrence rate, rendering them ineffective for long-term eradication of the condition. Consequently, these methods are primarily suitable for mild cases of palmar hyperhidrosis. Endoscopic thoracic sympathectomy (ETS), owing to its minimally invasive nature, rapid recovery, and long-term satisfactory outcomes, has emerged as the preferred surgical approach for treating primary palmar hyperhidrosis[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Despite the risk of compensatory hyperhidrosis, the majority of patients report satisfaction with the surgical results.\u003c/p\u003e \u003cp\u003eThe debate over the optimal level for interrupting the sympathetic chain during ETS continues. Some studies advocate for an R3 sympathicotomy, which involves cutting the sympathetic chain at the level of the 3rd rib, leading to drier hands[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Others suggest that an R4 sympathicotomy, interrupting the chain at the 4th rib, may decrease the risk of compensatory sweating[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In our clinical practice, the decision between R3 and R4 sympathicotomy is personalized based on the patient's symptoms and expectations.\u003c/p\u003e \u003cp\u003eDuring surgical procedures, we have encountered cases where vascular structures over the R3 or R4 sympathetic trunk pose a risk of intraoperative bleeding. To address this, we have employed a novel approach: performing an asymmetric sympathicotomy when anatomical complexities are present. This method, sparingly reported in the literature, is the focus of our study, aiming to assess its feasibility and efficacy.\u003c/p\u003e"},{"header":"Patients and Methods","content":" \u003cp\u003e2.1 General Information\u003c/p\u003e \u003cp\u003eData were collected for retrospective analysis from 231 patients treated with thoracoscopic surgery for primary palmar hyperhidrosis at the Department of Thoracic Surgery, Quanzhou First Hospital, between January 2018 and January 2022. Out of these, 226 cases met the inclusion criteria. Five cases were excluded from the analysis due to loss to follow-up: four were due to incorrect contact information, and one patient explicitly declined further participation. The demographic breakdown of the cohort includes 125 males and 101 females, aged between 13 to 50 years, with an average age of 22.6\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9 years. The duration of symptoms ranged from 3 to 34 years, averaging at 14.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3 years. Severity classification adhered to the Lai method, which categorizes the condition based on palm moisture and sweat volume. According to this method, severe cases are characterized by sweat droplets that resemble raindrops, moderate cases are identified by sweat that can soak through a handkerchief, and mild cases are defined as conditions where the palm skin is moist without a change in the surface skin temperature[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Comorbid hyperhidrosis was observed in 179 patients with plantar, 13 with lumbar, 14 with axillary, and 1 with craniofacial hyperhidrosis.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and Clinical Characteristics of Patients Undergoing Sympathectomy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eR3 group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eR4 group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eR3 / R4 group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of Cases (N)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.088\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (Males/Females)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59:45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46:46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20:10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.259\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of Symptoms (years, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.1\u0026thinsp;\u0026plusmn;\u0026thinsp;5.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.218\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eSeverity of Palmar Hyperhidrosis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSevere\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.005\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.010\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.603\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003eDistribution of Comorbid Hyperhidrosis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlantar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"3\" rowspan=\"4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.414\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLumbar\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.097\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAxillary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.370\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCraniofacial\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.481\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSurgical intervention involved bilateral R3 sympathicotomy (104 patients), bilateral R4 sympathicotomy (92 patients), and bilateral asymmetric sympathicotomy (30 patients, with one side R3 and the other R4), following the ISSS and STS committees' consensus on standardized nomenclature[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Asymmetric sympathicotomy was selected in cases where intraoperative findings indicated a high risk of bleeding from the sympathetic nerve stem, necessitating an immediate adjustment from the standard sympathicotomy plane.\u003c/p\u003e \u003cp\u003eAll patients underwent a comprehensive medical history review, electrocardiogram, and chest X-ray to exclude systemic causes of hyperhidrosis such as hyperthyroidism. The study adhered to ethical guidelines, with informed consent obtained from all participants and approval from the institutional review board of Quanzhou First Hospital. The detailed clinical data are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e2.2 Surgical Method\u003c/p\u003e \u003cp\u003eA standardized single-port thoracoscopic approach was utilized for all 226 patients diagnosed with palmar hyperhidrosis. Under general anesthesia, vital signs including pulse, blood pressure, heart rate, and blood oxygen saturation were continuously monitored. Palm thermometers were placed to observe temperature changes indicative of successful sympathectomy during the surgery.\u003c/p\u003e \u003cp\u003ePatients were positioned in a semi-sitting posture with a 60-degree elevation and arms abducted to 90 degrees to facilitate surgical access, as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e(a)\u003c/b\u003e. Incisions were tailored to gender: a 6mm incision in the third intercostal space on the mid-axillary line for females, and at the bilateral areolar margin for males, following standard disinfection and draping protocols.\u003c/p\u003e \u003cp\u003eThe surgical process began on the right side, with the anesthesiologist inducing a temporary cessation of ventilation to allow for artificial pneumothorax and subsequent lung collapse. A 5mm trocar and thoracoscope were then inserted to enable visualization of the sympathetic chain. Sympathicotomy was performed at the predetermined rib level, and Kuntz fibers and communicating branches were transected.\u003c/p\u003e \u003cp\u003eIn 30 patients undergoing different plane resections, anomalous vein branches or intercostal vessels were observed during the procedure, covering the plane intended for resection (refer to Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003cb\u003e(b)\u003c/b\u003e). To avoid potential vein damage and bleeding, the plane was altered, with the original resection continuing on the opposite side.\u003c/p\u003e \u003cp\u003eMonitoring of temperature changes in the ipsilateral hand was conducted to confirm the effectiveness of the sympathetic trunk transection. After the procedure, a chest tube was inserted under slight negative pressure to aid in lung re-expansion, which was confirmed before wound closure. Chest X-rays were performed within 6 to 24 hours postoperatively to confirm the absence of any complications.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e2.3 Postoperative Follow-Up\u003c/p\u003e \u003cp\u003ePostoperative follow-up was conducted through telephone and online surveys, as detailed in follow-up \u003cb\u003eAppendix A\u003c/b\u003e. The follow-up protocol included the following components:\u003c/p\u003e \u003cp\u003eSymptom Improvement: Assessment of the improvement in symptoms of palmar hyperhidrosis was conducted. The degree of improvement was recorded based on patient feedback.\u003c/p\u003e \u003cp\u003eRecurrence of Symptoms: The presence of recurrent palmar hyperhidrosis symptoms was monitored, with recurrence defined as a return to moderate or severe symptomatology.\u003c/p\u003e \u003cp\u003eCompensatory Hyperhidrosis (CH): The occurrence, location, severity, and temporal changes in CH were evaluated. The severity of CH was classified using Li's grading system[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], where Grade I represents only moist skin without significant sweating or discomfort; Grade II involves increased sweating without substantial discomfort; Grade III includes profuse sweating that remains tolerable; and Grade IV consists of severe sweating that interferes with daily and social activities, causing considerable physical and psychological distress, also referred to as disabling CH.\u003c/p\u003e \u003cp\u003eBilateral Symptom Variation: Any differences in the postoperative outcomes between the two hands were noted, including specific manifestations if the effects varied.\u003c/p\u003e \u003cp\u003eOther Complications: The incidence of any other complications, such as Horner's syndrome, taste sweating, bleeding, pneumothorax, and pneumomediastinum, were recorded.\u003c/p\u003e \u003cp\u003ePatient Satisfaction: Satisfaction with the surgical outcome was gauged using a scale from 0 (very dissatisfied) to 10 (very satisfied), with patients rating their initial impression post-surgery.\u003c/p\u003e \u003cp\u003e2.4 Statistical Analysis\u003c/p\u003e \u003cp\u003eThe statistical analysis was performed using IBM SPSS Statistics software, version 26.0. Continuous variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (M\u0026thinsp;\u0026plusmn;\u0026thinsp;SD). Categorical variables were summarized as frequencies and percentages. The Chi-square test was utilized for comparisons of categorical data, with Fisher's Exact Test employed as an alternative for cells with expected frequencies less than 5 or when dealing with small sample sizes. One-way Analysis of Variance (ANOVA) was employed for the analysis of continuous variables across multiple groups. A P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was predetermined as the threshold for statistical significance.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e3.1 Perioperative Results\u003c/p\u003e \u003cp\u003eIn this study, 226 patients underwent bilateral single-segment thoracoscopic sympathectomy. The procedures were successful without serious intraoperative complications such as death or massive bleeding. The average operation time for bilateral procedures was 49.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1 minutes. Postoperatively, all patients experienced complete resolution of hand sweat symptoms, with hands feeling significantly drier and warmer compared to preoperative conditions. The average postoperative hospital stay was brief, lasting only 1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.3 days.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePerioperative Conditions\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eR3 group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eR4 group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eR3 / R4 group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOperation time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49.4\u0026thinsp;\u0026plusmn;\u0026thinsp;7.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e48.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.310\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of stay (day)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.465\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmount of bleeding\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;10ml\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003ePerioperative complications\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epneumothorax\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.603\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003esubcutaneous emphysema\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.959\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epleural effussion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.481\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMinor postoperative complications were noted, including pneumothorax in 3 patients (1.3%), which resolved with either observation or routine closed chest drainage, and subcutaneous emphysema in 31 patients (13.7%), which resolved spontaneously. One patient (0.4%) experienced a small amount of pleural effusion, resolving within a month. Importantly, no major complications like incision infection or Horner's syndrome were observed. All patients were able to resume normal activities within a week of discharge. Detailed perioperative data are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e3.2 Follow-up Results\u003c/p\u003e \u003cp\u003eFollow-up assessments conducted a year post-surgery via telecommunication and online platforms revealed significant findings. Out of the 226 patients, 10 instances of postoperative recurrence (4.4%) were recorded. Compensatory hyperhidrosis post-surgery was observed in 160 cases (70.8%), with 3 cases (1.3%) being categorized as severe. The distribution of compensatory hyperhidrosis was predominantly in the feet, legs, chest, waist, and back. The highest rate of satisfaction post-operation was noted in the R3 group, followed closely by the R3/R4 group and the R4 group. The detailed results of the follow-up, including the extent, location of compensatory hyperhidrosis, and patient satisfaction, are elaborated in Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePost-operative effect table\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eR3 group (n\u0026thinsp;=\u0026thinsp;104)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eR4 group (n\u0026thinsp;=\u0026thinsp;92)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eR3 / R4 group (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCases of Recurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.444\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCompensatory hyperhidrosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.205\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003eDegree of compensatory hyperhidrosis\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.516\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.859\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.295\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrade IV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e \u003cp\u003ePostoperative compensatory hyperhidrosis site\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFoot, leg\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.231\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChest, waist and back\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.108\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eArmpit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.596\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHead and face\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.544\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient Satisfaction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.024\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePostoperative Satisfaction Scores\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDegree of satisfaction(mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eP(interblock)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP (Group R3 VS Group R4 )\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP (Group R3 VS Group R3 / R4)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP (Group R4 VS Group R3 / R4)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe R3 group (n\u0026thinsp;=\u0026thinsp;104)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e8.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.515\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.038\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThe R4 group (n\u0026thinsp;=\u0026thinsp;92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e7.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eR3 / R4 group (n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e8.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eHyperhidrosis, a disorder of the autonomic nervous system with an unclear etiology, is primarily characterized by excessive activity of the sweat glands in the hands, leading to pronounced sweating. Additionally, patients often experience hyperhidrosis in other areas such as the feet and armpits. Given the relatively high prevalence of hyperhidrosis and its significant impact on quality of life, the condition has increasingly garnered attention. Currently, non-surgical treatments for hyperhidrosis, such as oral medications, botulinum toxin injections, and iontophoresis, are mainly suitable for patients with mild to moderate symptoms. However, these treatments typically offer short-term relief and may be associated with side effects like pain and recurrence[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSince 1992, with the successful application of video-assisted thoracoscopic sympathectomy by Landreneau et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] for the treatment of hyperhidrosis, this method has become the mainstream for moderate to severe cases. Thoracoscopic sympathectomy is not only considered an effective treatment for hyperhidrosis, but also, due to its minimally invasive nature, has been widely accepted and applied in clinical practice.\u003c/p\u003e \u003cp\u003eIn 1997, a study by Andrews et al.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] found that the incidence and severity of compensatory sweating were closely related to the extent of the surgery, indicating that high-level and extensive sympathectomy increased the risk of compensatory sweating. To address this issue, in 2001, Lin et al.[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] proposed the Lin-Telaranta criteria, which recommended blocking only the fourth thoracic sympathetic nerve segment. This approach has shown better outcomes in the treatment of hyperhidrosis, with a lower incidence of postoperative compensatory sweating.\u003c/p\u003e \u003cp\u003e According to the 2011 consensus of the American Society of Thoracic Surgeons, for palmar hyperhidrosis, the optimal surgical choice is R3 sympathectomy, with R4 sympathectomy also being a reasonable option. The difference between the two is that R3 sympathectomy can achieve the driest hands but comes with a relatively higher risk of compensatory hyperhidrosis (CH), whereas R4 sympathectomy may result in slightly moister hands[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. A systematic review study in 2017 found no significant difference between T3 and T4 in terms of patient satisfaction, symptom resolution, dry hands, and the incidence of gustatory sweating. However, T4 sympathectomy reduced the risk of compensatory sweating and increased satisfaction, making it a better choice[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The debate over whether R3 or R4 sympathectomy is the optimal level is not conclusively resolved by different studies, possibly due to our idealized interpretation of R3 or R4 sympathectomy as the direct resection of the third or fourth sympathetic ganglion (G3 or G4). In actual surgical practice, due to the difficulty in accurately determining the location of the sympathetic ganglia, surgeons perform the resection on the sympathetic chain corresponding to the surface of the third or fourth rib. Research indicates that the third sympathetic ganglion (G3 or G4) may descend to the surface of the next rib[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], meaning that what is considered R4 sympathectomy in surgery might actually be the resection of the third sympathetic ganglion (G3). This anatomical variation could reduce the observed clinical differences between R3 and R4 sympathectomy.\u003c/p\u003e \u003cp\u003eBased on our team's clinical observations and the results of this study, we found that both R3 and R4 sympathectomies can be considered as treatment options for patients with severe palmar hyperhidrosis. In terms of compensatory hyperhidrosis, there was no significant difference between these two methods. However, in terms of patient satisfaction and postoperative recurrence, R3 sympathectomy seemed to be superior to R4 sympathectomy. This may be due to a portion of patients in the T4 group experiencing postoperative recurrence, failing to achieve the expected results, thereby affecting their satisfaction. Although the R3 group had a higher proportion of compensatory hyperhidrosis, this did not seem to significantly affect patient satisfaction postoperatively. Considering that the resolution of palmar hyperhidrosis significantly improves the quality of life, compensatory hyperhidrosis is considered within an acceptable range.\u003c/p\u003e \u003cp\u003eIn our study, there were four cases that demonstrated postoperative differences in the effects on the hands. These four patients underwent bilateral asymmetric sympathectomies (R3/R4), and in postoperative follow-ups, they reported that the hand on the R4 sympathectomy side was slightly moist, while the hand on the R3 sympathectomy side was very dry. This finding highlights the different effects of cutting the sympathetic nerve at different segments, further confirming that R3 sympathectomy leads to drier hands compared to R4 sympathectomy. Based on our team's experience, both R3 and R4 sympathectomies are effective in treating palmar hyperhidrosis. While R3 sympathectomy can result in drier hands, it may be accompanied by higher compensatory hyperhidrosis; whereas R4 sympathectomy, though resulting in slightly moist hands, tends to have less compensatory hyperhidrosis. Therefore, the choice between R3 and R4 sympathectomy should be based on the specific situation and preferences of the patient, and doctors need to explain in detail the pros and cons of both surgical methods, assisting patients in making the most suitable decision for themselves.\u003c/p\u003e \u003cp\u003eDuring the surgical procedure, we observed that in some patients, the sympathetic nerve chain was covered by the intercostal veins, increasing the risk and complexity of the surgery. Although meticulous dissection and careful operation helped to reduce the risk of intraoperative bleeding, it also prolonged the surgery time and increased trauma to the patient. Particularly, once bleeding occurs during surgery, due to the small incision and limited space in endoscopic surgery, it becomes difficult to achieve hemostasis under the scope. In such cases, it might be necessary to stop the bleeding through a small incision or open chest surgery, which not only prolongs the surgery time and increases the risk of bleeding but may also lead to serious consequences. Moreover, whether it is through a small incision assistance or open chest hemostasis, it contradicts the original intention of minimally invasive surgery, potentially exacerbating the patient's trauma and reducing the satisfaction with the surgery.\u003c/p\u003e \u003cp\u003eIn Gossot's study[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], they analyzed early complications in 940 cases of sympathetic nerve resection and found that 25 cases (5.3%) experienced bleeding due to intercostal vein injury, with the amount of bleeding ranging between 300 to 600 milliliters. These bleeding events were associated with difficulties in vascular constriction and control. Although the bleeding was successfully controlled via thoracoscopy, in some cases, a 10mm trocar needle was required to aspirate blood to prevent lung expansion. In a retrospective study by Jianfeng and others on 10,275 thoracoscopic surgeries, they found 39 cases of intraoperative bleeding, accounting for 0.4% of the total, including 2 patients who bled from the azygos vein branch, with bleeding reaching 300 to 500 milliliters within one minute; the bleeding was successfully stopped by immediately using titanium clips to block the vein. The remaining 37 cases with minor bleeding were controlled by electrocoagulation[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Although these bleeding events were ultimately controlled under thoracoscopy, they undoubtedly increased the trauma and risk of the surgery. Therefore, when choosing the surgical site, we prefer to avoid intercostal spaces with a high risk of bleeding and select those with a relatively lower risk of bleeding for the operation.\u003c/p\u003e \u003cp\u003eIn our study, we surveyed 30 patients in the R3/R4 group, of which 20 underwent right-sided R3 and left-sided R4 sympathectomy, and 10 underwent right-sided R4 and left-sided R3 sympathectomy. We noticed a higher proportion of right-sided R3 resections, which might be related to the predominant distribution of the umbilical vein branches in the right R4 area. Our findings indicate that both bilateral asymmetric single-stage resections (R3/R4) and bilateral symmetric resections effectively treat palmar hyperhidrosis, with no significant difference in compensatory hyperhidrosis incidence compared to the individual T3 or T4 groups. Among the 30 patients, 4 reported different sensations in each hand, further confirming that R3 resection might lead to a drier hand sensation. All 30 surgeries were successfully completed, leading us to believe that choosing not to cauterize accompanying vessels and instead performing R3/R4 sympathectomy is a viable option to avoid unnecessary risks during the surgical process.\u003c/p\u003e \u003cp\u003eThis study is a retrospective, single-center analysis, involving a limited number of R3/R4 sympathectomy cases. Therefore, our conclusions may be subject to the limitations of a small sample size and statistical biases. Despite these limitations, our findings suggest that R3 sympathectomy shows better performance in terms of patient recurrence rates and satisfaction compared to R4 sympathectomy, without a significant increase in the incidence of compensatory hyperhidrosis. Additionally, our results indicate that bilateral asymmetric single-segment resection is an effective and safe alternative when encountering thicker vessels covering the resection plane during surgery. Future studies should include larger sample sizes and multi-center data to further validate our findings and explore the response of different patient populations to surgical techniques.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics Approval and Consent to Participate:\u003c/strong\u003e \u003cp\u003e This study, titled \"Efficacy Analysis of Single-Stage Thoracoscopic Sympathetic Nerve Disruption in the Treatment of Palmar Hyperhidrosis,\" received ethics approval from the Institutional Review Board of Quanzhou First Hospital (Approval No. 泉一伦《2022》201号). Informed consent was obtained from all participants or their legal guardians, as applicable. For minors under 16 years of age, consent was specifically obtained from parents or legal guardians.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for Publication:\u003c/strong\u003e \u003cp\u003e Written informed consent was obtained from all subjects (or their legal guardians) for the publication of their personal and clinical details along with any identifying images in this study. All patient names have been removed from the text, figures, tables, and images. Identifying facial features in the images have been completely removed using white boxes, in accordance with the journal's guidelines.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting Interests:\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eDr. Luoyu Lian was the principal investigator and was primarily responsible for the conception and design of the study, data collection, analysis, interpretation of data, and drafting the manuscript. All other authors assisted in data collection and reviewed the manuscript for important intellectual content. All authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData generated or analyzed during this study are available from the corresponding author, Dr. Luoyu Lian, on reasonable request due to privacy and ethical restrictions.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNawrocki S, Cha J. The etiology, diagnosis, and management of hyperhidrosis: A comprehensive review. J AM ACAD DERMATOL. 2019;81(3):657\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDoolittle J, Walker P, Mills T, Thurston J. Hyperhidrosis: an update on prevalence and severity in the United States. ARCH DERMATOL RES. 2016;308(10):743\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi X, Chen R, Tu Y, Lin M, Lai F, Li Y, Chen J, Ye J. Epidemiological survey of primary palmar hyperhidrosis in adolescents. Chin MED J-PEKING. 2007;120(24):2215\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChudry H. The treatment of palmar hyperhidrosis \u0026ndash; a systematic review. INT J DERMATOL. 2022;61(11):1303\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCerfolio RJ, De Campos JRM, Bryant AS, Connery CP, Miller DL, DeCamp MM, McKenna RJ, Krasna MJ. The Society of Thoracic Surgeons Expert Consensus for the Surgical Treatment of Hyperhidrosis. Ann Thorac Surg. 2011;91(5):1642\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu Y, Weng W, Tu Y, Wang J. Chinese expert consensus on the surgical treatment of primary palmar hyperhidrosis (2021 version). Chin MED J-PEKING. 2022;135(11):1264\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePei G, Meng S, Yang Y, Wang X, Liu Q, Wang S, Huang Y. Anatomical variations of the thoracic sympathetic ganglions and their effects on sympathicotomy for primary palmar hyperhidrosis. CLIN AUTON RES. 2023;33(2):111\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLai Y-T, YLCC. Complications in Patients with Palmar Hyperhidrosis Treated with Transthoracic Endoscopic Sympathectomy. \u003cem\u003eNEUROSURGERY\u003c/em\u003e 1997(41):110\u0026ndash;115.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLandreneau RJMMHS. Video-assisted thoracic surgery: basic technical concepts and intercostal approach strategies. Ann Thorac Surg. 1992;54(4):800\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAndrews BTRJ. Predicting changes in the distribution of sweating following thoracoscopic sympathectomy. Br J Surg. 1997;84(12):1702\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin CCTT. Lin-Telaranta classification: the importance of different procedures for different indications in sympathetic surgery. Ann Chir Gynaecol 2001(90):161\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZhang W, Yu D, Wei Y, Xu J, Zhang X. A systematic review and meta-analysis of T2, T3 or T4, to evaluate the best denervation level for palmar hyperhidrosis. SCI REP-UK 2017, 7(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGossot D, Kabiri H, Caliandro R, Debrosse D, Girard P, Grunenwald D. Early complications of thoracic endoscopic sympathectomy: a prospective study of 940 procedures. ANN THORAC SURG. 2001;71(4):1116\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen J, Liu Y, Yang J, Hu J, Peng J, Gu L, Deng B, Li Y, Gao B, Sheng Q et al. Endoscopic thoracic sympathicotomy for primary palmar hyperhidrosis: A retrospective multicenter study in China. \u003cem\u003eSURGERY\u003c/em\u003e 2019, 166(6):1092\u0026ndash;1098.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Palmar Hyperhidrosis, Thoracic Sympathotomy, Asymmetric Single-Segment Resection, Compensatory Hyperhidrosis, Patient Satisfaction","lastPublishedDoi":"10.21203/rs.3.rs-4545410/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4545410/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjective:This study aims to retrospectively evaluate the effectiveness of single-segment thoracic sympathotomy in treating palmar hyperhidrosis.\u003c/p\u003e\n\u003cp\u003eMethods:We conducted a retrospective study at our center from January 2018 to January 2022. A total of 226 patients with palmar hyperhidrosis, who underwent single-segment endoscopic sympathectomy, were divided into R3, R4, and asymmetric segment groups (R3 / R4 group). We analyzed the effectiveness, side effects, and patient satisfaction of the three treatments through telephone and online patient consultations.\u003c/p\u003e\n\u003cp\u003eResults: All groups experienced similar surgery duration, hospital stay, and blood loss. The R3 group (104 patients) had the lowest recurrence rate (1 case), followed by the R4 group (92 patients, 3 cases), and the R3/R4 group (30 patients, 1 case). Compensatory hyperhidrosis was observed in 21 cases in the R3 group and 19 in the R4 group. The R3/R4 group reported compensatory hyperhidrosis in 24 cases, mostly Grade I and II. Satisfaction was highest in the R3 group, closely followed by the R3/R4 group and then the R4 group. This indicates that both R3 and R4 single-segment resections are effective, with R3 showing higher patient satisfaction and lower recurrence, and the asymmetric R3/R4 approach also proving to be a viable option.\u003c/p\u003e\n\u003cp\u003eConclusion: Single-segment resection of either R3 or R4 can effectively manage palmar hyperhidrosis. Patients who underwent R3 resection experienced fewer recurrences and reported higher satisfaction than those who underwent R4 resection. Furthermore, compensatory hyperhidrosis didn't notably rise. Asymmetric single-segment resection, with its thicker vascular coverage, is also a viable treatment option.\u003c/p\u003e","manuscriptTitle":"Efficacy of Thoracoscopic Sympathectomy Including Asymmetric Resection for Treating Palmar Hyperhidrosis : A Retrospective Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-01 19:05:22","doi":"10.21203/rs.3.rs-4545410/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"83f0e8cb-379e-4214-a3e8-338b011267c0","owner":[],"postedDate":"July 1st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-30T07:08:29+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-01 19:05:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4545410","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4545410","identity":"rs-4545410","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}