Huo-Li (Vita) Chuang, M.D.

Vice President and Chief-in-Department of Neurosurgery, 

Ten Chan General Hospital, Chun-Li ,Taiwan,R.O.C.

   Today, people become more and more concerned about their living qualities at the same time with continual advances in medical technology, more and more hyperhidrosis patients are turning for operational treatments. Areas prone to hyperhidrosis attack include palms, facial area, armpits and insole, and this paper is written to help enlighten all about this disease, hyperhidrosis.

Question 1:What is hyperhidrosis? Why I sweat more than others?

Answer: Hyperhidrosis refers to a disease of excessive secretion of sweat. By and large, hyperhidrosis can be attributed to two causes: Primary and Secondary. A Primary case is one devoid of any particular etiology except the idiosyncrasy, just as some people are born to be taller, some other fatter, inherently so. A hyperhidrotic patient is in most cases one whose autonomic responses are stronger than other people, since the autonomic nerve system controls sweat gland secretion and blood vessel contraction, that is why a hyperhidrotic patient, when in a nervous condition, or even in a hot or tense environment, will sweat more than average fellow, they may even turn chill or cold on the skin, and with crackled skin as a result of vessel contraction. As of today only patients who are essential hyperhidrotic on the palms are fit for surgical treatments, whereas treatment of secondary cases is basically dependent upon the diagnosis of etiological causes.

Question 2: How many hyperhidrosis patients in general people? Is that an inherited disease?

Answer: According to locally procured surveys, out of every three hundred youngsters there is one severe hyperhidrotic case, the rate of attack is approx. 0.3%, of which attribution due to inheritance accounts for roughly 12%, more than often several members of a same family suffer from hyperhidrosis, whereby a conclusion may be drawn that hyperhidrosis is an inherited disease, but then there are also patients none of whose family kinfolks suffers from hyperhidrosis, with such patients inheritance factor is certainly ruled out.

Question 3: Under what conditions a hyperhidrotic patient must be treated surgically?

Answer: Hyperhidrosis is basically an idiosyncratic issue, and the decision as to surgical treatment depends largely on patient’ s subjective response to excessive sweating. Generally speaking, a patient would not ask for surgical treatment unless excessive palm sweating constitutes a nuisance in interpersonal dealings, at work or at study. For instance, a student who sweats excessively on the palm will have to rub his hands dry every once in a while when doing his homework, not to mention the doubling of palm sweating while taking a test in the classroom, resulting in wetting the test sheet. The same effect is seen when attending a piano lesson , leaving keys on the piano as if splashed with water all the while , and the trouble and annoyance increase with age from day to day, the worse is yet to come when older. The patient dreads it shaking hands with other people , let alone holding a beloved one hand in hand , that bringing about sentimental intimidation which means a real block in social intercourses. One who is struck with such a disease can hardly proceed with ease jobs requiring exquisite skills like drawing, electrical undertaking . Previous theories that a child who sweats excessively  would get cured when turning older simply can hardly find justification in practice. Clinical studies have indicated instead that children with hyperhidrotic symptoms duly treated at preschool age will find themselves easier adjusted in study and making friends , relieved from unnecessary, uncalled for mental barriers. With what is made possible in medical standards today, teenager kids older than six who are graders can very well accept surgical therapies without much ado .

Question 4:What therapies are there recommended to treat hyperhidrosis?

Answer: Hyperhidrosis, being a case essentially due to overstrenuousness of the autonomic nerve system, must be treated with focus placed on said autonomic nerve system. Following various hearsay recipes, anecdotal medicaments and even acupunctural treatments help little. Treatment of hyperhidrosis follows either surgical approach or medical approach. By the internal medicine approach, the practice is given in drug ointment or electrophoresis, while efforts as such can bring about short term anti-sweating effects It takes longer time than worth the while, prescription of oral dosage of autonomic prohibitor can produce but localized effect at the expense of incurring bodywise side effects altogether. Up to the present day, the only way to eradicate the disease is still through surgical operation, it has to be noted in particular that operational treatment of hyperhidrosis can only be executed by experienced neurosurgeon, to be safe and prudent .

Question 5: How does a surgical operation on hyperhidrosis proceed?

Answer: Different approaches apply, including: Dorsal Sympathectomy, Percutaneous streotactic sympathectomy or the lastly introduced endoscopic sympathectomy. The so-called Dorsal Sympathectomy proceeds by cutting an opening approx. 10 cm on the patient’s back, and that followed by dissecting a rib on either side, thence dissecting the second autonomic nerve on either side, still, this approach, involving rather large scar and trauma and prolonged operation hours, prolonged rehabilitation, is seldom employed nowadays. With Percutaneous streotactic sympathectomy the theme is to undermine the second thoracic autonomic nerve through electric heating or chemical intervention, although leaving no apparent scar after operation, due to rather high recurrence rate, presently only very few doctors still have recourse to this method. By comparison, the endoscopic sympathectomy approach has become the mainstream of surgical treatment choice of hyperhidrosis.

Question 6: How does an Endoscopic Sympathectomy Operation take place?

Answer: What appears to be with best effects and best acceptable to specialty physicians on the whole is the Thoracic Endoscope-Aided Sympathectomy, under general anaesthesis, the surgeon cuts an opening approx. 0.2cm on the armpit under each of both shoulders of the patient, to form an artificial pneumothorax through which the thoracic endoscope is introduced into patient’s chest way in to reach the second autonomic nerve where cauterization is applied to finish. The cauterization will generally  last 1to 3 minutes, but with anesthesia prior to and subseqnent to the operation taken into account, it will take a total of 60 minutes. Patient who receives the operation need not be hospitalized, but will have to take a rest for a couple of hours at the Recover Room once awakened from operational anesthesia, who may be discharged for home and take drugs at home once feeling well, and who may resume normal routine work or study after about half day’s rest, the patient may of course then take a bath as he usually does. The patient will later return to the out-patient clinic for a check on the wound, no suturing stitch required. The wound is so small that it is no longer apparent in a week, almost invisible still later on, the course of the operation is so simple that fo we the success rate of the operation is well-nigh 100% with low recurrence and very minimal inflictions, so it is truly a very ideal operational approach.  

Still, endoscopic operation is not recommended on patients who had once suffered from lung inflammation or trauma, resulting in oversticking of the lung to the chest wall, still, such a situation may not have been identified even against chest X-ray examination before an operation takes place where the oversticking is too tight the second best alternative is the dorsal dissection method, and the doctor should keep patient’s finfolk in close contact on that matter. 

Question 7:What are the probable risks associated with an operation? 

Answer: With any operation there lies a risk, including, for example, allergy to anaesthesic medicaments and the operation itself, etc. An endoscopic autonomic nerve operation may incur injuries like pneumothorax, hematothorox, thoracic atheroma, injury of the lung, and artery. Still, against some twenty thousand precedents throughout Taiwan and the several hundred precedents we have at our hospital complications as such or similar accidents had but rarely occurred, the chances being less than one out of a total of 100 cases, in addition, an experienced and conscientious surgeon will always proceed with an operation on charge carefully from the beginning through the closing, to fully protect patient’s safety, again, as with any surgical operation, a risk does always exist, allergic reaction to anaesthe-sic medicaments, for example, still, with experienced doctor present the occurence rate is suppressed to well below 0.1%

Questing 8: What are the possible side effects of a hyperhidrosis            operation?

Answer: The most significant side effect of a hyperhidrosis operation is that of compensatory sweating, that is, sweat which is originally perspired manually is discharged elsewhere other than the hands, such as back, belly or thigh, etc.. Symptom as such is more remarkable in summer, but since sudation which was formerly concentrated in the palm of a hand is now spread in larger area torso and thigh, a change like that won’t constitute very much a nuisance. 

Generally, patients who have received the operation all feel relieved to see that their palms are no longer as wetty and moisture-ridden as ever before, so they would accept without complaint compensatory sweating by way of  back or the thigh only a minority of them find the compensatory sweating unbearable. The lesser the ranging of autonomic nerve nodes that is spoilt by the operation, the slighter the compensatory sudation  will be in the post-operation period. Still, once compensatory sweating takes place, it can’t be remedied by any means what-soever, this is a point the patient must take into account well before he accepts the operatio. Still another possible side effect is reduced sudation on the facial area, drooping eyelids and dwindled pupil, which, while it is still less frequent a rarity, is a possibility the patient must be informed of prior to receiving an operation.

Question 9:What is the rate of success of treatment or hyperhidrosis and complications associated with the disease?

 Answer: The rate of success of a hyperhidrossis operation, as of today, exceeds 98%, reasons for failure include antecedents of pneumonia, trauma or other thoracic diseases giving occasion to adhesion of pleural and lung, which precludes endoscopic examination of autonomic nerves and that renders an operation futile, such an instance often beguiles chest X-ray examinations, and difficulty of the operation increases for obese or bulky patients. At our hospital, over ninety percents of patients having received a hyperhidrosis operation have felt satisfied with the operation, their hand palms turned dry and warm, insole largely improved too, but not as satisfactory as the palm, only, a minority felt disgruntled with compensatory perspiration, only rare cases were seen with complications because of the operation, such complications were mostly observable afterwards and treated accordingly.

Question 10: How to take care or perspiration which occurs on the front, face, armpit, and on the foot?

Answer: Ladies who perspires to an excess on the front and face will see a makeup on the face like a panel due to sweating, those who perspires a lot under the armpit complicated with inherent body odor are more miserable indeed, still, excessive perspiration on the front, face and armpit area can be eradicated by endoscope-aided autonomic nerve operation.

         Since that the autonomic nerve that controls facial sweat glands is also affiliated to the second thoracic autonomic nerve, so an operation will also eradicate the facial hyperhidrosis condition too, so to speak, an endoscope—aided autonomic nerve operation can be employed to uniquely or concomitantly resolve facial hyperhidrosis.

      In dealing with common body odor which comes about as a result of the secretion of bacterially degraded armpit sudatory glands, traditionally antibiotics is prescribed, treatments like application of anti-sweating agents and deodorizing agents can have but transitory effects. In more recent years treatments of body odors coming from armpit overpersperations by endoscope-aided autonomic nerve operations have proven every effective, but in case of body odor not accompanied with armpit oversweating, it is recommendable to refer to plastic surgeon for armpit surgery for treatment.

          Typically, one who is a hyperhidrosis patient often suffers insole overpersperation, and that means poor insole sanitation as evidenced in a stinking foot or Hong Kong Foot. Since that the sweating gland on the sole is also controlled by the waist autonomic nerve node which has due function on the urinary and reproductive systems, once impaired these system would suffer from malfunctioning, there is no medical profession, here in this country or elsewhere which would undertake to undermine waist autonomic nerve node simply in order to treat sole hyperhidrosis, fortunately, however, with more than two thirds of patients having received surgical treatment on hyperhidrosis significant improvement on sols perspiration was evinced as well, somewhat improvement on sole perspiration was also noted in the other one third, still there are cases, however small, (approx. 1.4%)with compensatory oversweating evidenced from the sols area.

Question 11:What is the feature of Hyperhidrosis operation offered at Ten Chan General Hospital?

Answer: Currently there are hospitals where 10mm thoracic endoscope is employed for convenience of operation, to reduce the pain on the part of our patients we have introduced ultra thin operational thoracic endoscope with dia. As narrow as 2mm only, thus greatly minimizes the wound and post-operate ional pain. A comparison of the two endoscopes by size is illustrated below; the conventional 10mm model versus the super mini-size 2mm model currently in use at Ten Chan General Hospital at Chun-Li.

Question 12: How much will an endoscopic sympathectomy operation cost?

Answer :It is presently covered by the National Health Insurance Program. So that the patient who has Taiwan Insurance will but have to pay one tenth of the total cost due, around NT$200. For people come from other country without Taiwan health Insurance, you have to pay as much as NT: 30000 or $ 1500, for surgery and anesthesia.