Limited endoscopic thoracic sympathetic block for hyperhidrosis of the upper limb: reduction of compensatory sweatng by clipping T4

Background: Endoscopic thoracic sympathicotomy of T2 to T4 (ETS 2–4) has evolved into an effective treatment for severe hyperhidrosis of the upper limb. Complications such as bleeding or Horner’s syndrome are rare, but side effects such as compensatory and gustatory sweating occur in 30–50% of patients. Following the Lin-Telaranta classification, we aimed to reduce these side-effects by clipping T4 solely [endoscopic thoracic sympathetic block (ESB 4)]. We present our experience and clinical results using this method, with emphasis on patients’ quality of life. Methods: A total of 176 procedures (91 patients) were carried out in the ETS 2–4 group and 103 procedures (53 patients) in the ESB 4 group: 60.4 and 43.4% had palmar hyperhidrosis, 8.8 and 5.7% had isolated axillary, and 30.8 and 50.9% had combined manifestations, respectively. Follow-up was 22.1 months (obtained from 79.1% of patients) for the ETS 2–4 group and 7.5 months for the ESB 4 group (obtained from 88.7%). Results: The success rate was similar for both groups: 87.9 and 64.5% had completely dry limbs, 9.9 and 35.5% (p < 0.0002) were nearly dry, and 2.1 and 0% remained wet. (ETS 2–4 vs ESB 4). Although the armpits remained slightly humid in more patients in the ESB 4 group, 100% stated full satisfaction. Complications did not differ significantly. However, compensatory sweating (55.6 vs 8.5%, p = 0.0002) and gustatory sweating (33.3 vs 2.1%, p = 0.0019) were markedly reduced (ETS 2–4 vs ESB 4). Quality of life was assessed by a hyperhidrosis index, which significantly improved in most patients. Conclusions: ETS 2–4 and ESB 4 have similar success rates in the treatment of upper limb hyperhidrosis. The major side effects of compensatory and gustatory sweating were effectively reduced by the limited method of clipping T4, and patients’ satisfaction and improvement in quality of life were remarkable.