One hundred patients with primary palmar hyperhidrosis (HH) underwent bilateral upper dorsal sympathectomy (UDS) by the supraclavicular approach. Pre-operative epidemiological and clinical data are described. The immediate and late results, as well as the complications and side-effects are detailed. Follow-up was completed on 93 patients between four and 50 months after the operation (average 18 months). Of 93 patients, 91 had drying of the hands. In 58% some moisture returned to the hands but in no case did the hyperhidrotic state recur. Subjective patient evaluation was excellent or good in 83 patients (89%) and only one patient (a technical failure) was completely dissatisfied. Reasons for some degree of dissatisfaction with operation were mainly compensatory HH in non denervated areas, and Horner's syndrome. Compensatory HH usually decreased with passage of time and, permanent Horner's syndrome occurred in 8% of patients (4% of procedures). Technical failure can be avoided by use of frozen section examination intraoperatively. For severe cases of palmar HH that cause social, professional and emotional embarassment, bilateral simultaneous UDS by the supraclavicular approach is the procedure of choice: Morbidity is small, and almost all patients enjoy improved quality of life after the operation.

This report provides a detailed description of the operative technique, anatomical variations, and surgical pitfalls of supraclavicular upper dorsal sympathectomy for paimar hyperhidrosis, based on experience with performance of a simultaneous bilateral operation in 155 patients between 1971 and 1976. The denervation is preganglionic and is confined to removal of T2 and Ts ganglia. Frozen section examination of the specimen is useful in preventing technical failure. Persistent Homer's syndrome occurred in 8% of the patients and is the main complication of the procedure. The advantages of the supraclavicular approach are ease of performing a bilateral procedure, few pulmonary complications because of the extrapleurai approach, minimal overall morbidity, and good results in relieving palmar hyperhidrosis.Cervico-dorsal sympathectomy via the supraclavicular approach was first performed by Bruning in 1922 [1]. Leriche, in 1934, first advocated this procedure for the treatment of palmar hyperhidrosis [2] and Telford, in 1935, was the first to describe a preganglionic procedure performed by this approach [3,4], now commonly referred to as the Telford operation. Upper dorsal sympathectomy is accepted as the treatment of choice for severe palmar hyperhidrosis.The present report summarizes our experience in the performance of 308 upper dorsal sympathectomies in 155 patients with severe palmar hyperhidrosis. Our procedure is a modification of the Telford operation. The approach is supraclavicular, but the sympathetic denervation differs from that advocated by Telford. Figure 1 shows the anatomy of the denervation that is intended to cut the sympathetic fibers to the upper extremity, while sparing the

Background and Objectives: Implanted central venous access ports are frequently used. Spontaneous break and catheter transection are serious but rare complications of permanent subclavian catheters. We report our experience with this serious complication and identify possible warning signs. Materials and Methods: Between 1990 and 1996, 285 permanent subclavian catheters were placed at the Sheba Medical Center, Tel Hashomer, Israel. Results: We evaluated the patient population for this complication and searched for possible warning signs. A total of 12 patients (4.2%) with this complication were identified, 8 with transection and distal embolization and 4 with a partial tear only. The pinch-off sign was noted as an early warning in only 5 patients. All other patients developed symptoms only immediately before the diagnosis of this complication. The mean duration from insertion to identification of tear or transection was 9.6 months (range 1-24 months). Conclusion: Awareness and clinical suspicion are most important in identification and prevention of this serious complication. Catheters should be taken out when treatment is completed or after 12 months in order to prevent catheter breaks.