Optimization of sympathectomy to treat palmar hyperhidrosis: the systematic review and meta-analysis of studies published during the past decade

The systemic review and meta-analysis of the studies published during the past 10 years was designed to optimize the surgical procedures of video-assisted thoracoscopic sympathectomy (VTS) to treat palmar hyperhidrosis (PH). Citations from 2000 to 2010 were included regarding the following aspects: selection of ganglia level for VTS, comparison of different techniques for VTS, evaluating clinical efficacy of intraoperative intrapleural analgesia, and postoperative intrapleural drainage. Major clinical outcomes are defined as: cases with postoperative resolution of symptoms, total cases with postoperative compensatory hyperhidrosis (CH), cases with severe or moderate CH, satisfied cases, evaluation of postoperative pain, and postoperative pneumothorax. Systemic review indicates that T3 and T3-4 sympathectomy had the "best" clinical efficacy. Meta-analysis suggests that efficacious rates of PH are nearly similar compared with multiple and single ganglia sympathectomy (100 vs. 95.6%). However, single-ganglia sympathectomy can render a lower risk of total CH compared with multiple-ganglia block. Risk of moderate/severe CH has a similar trend. Additionally, single-ganglia sympathectomy is more potent to satisfy patients postoperatively. One randomized, controlled trial (RCT) that compared different techniques for VTS indicated that the overall success rate of the operation was 95% and the differences were not statistically significant. Two RCTs indicated that there were significant differences between trial group (intraoperative intercostal nerve blocks using bupivacaine) and control group regarding the attenuation of postoperative pain. One RCT suggested that there was no significant difference with or without pleural drainage regarding the incidence of postoperative residual pneumothorax. T3 sympathectomy is supposed to be recommended for the treatment of PH regardless of using various techniques. Intraoperative intrapleural analgesia using bupivacaine or bupivacaine plus epinephrine is effective to prevent postoperative pain. Pleural drainage after VTS should be abandoned.