Endoscopic lumbar sympathectomy was a safe and effective option for patients with severe plantar hyperhidrosis.

Conclusion:In patients with severe plantar hyperhidrosis, endovascular lumbar sympathectomy is safe and effective.Summary: Primary plantar hyperhidrosis is characterized by excessive secretion by eccrine sweat glands of the feet. The etiology is unknown and symptoms include cold cyanotic skin, skin maceration, bacterial and fungal infection, and bromidrosis (foul-smelling feet). Interrupting innervation of the sweat glands stops sweat secretion and has been used since the 1920's to treat hyperhidrosis. Whereas lumbar sympathectomy has been used to treat plantar hyperhidrosis, use of this operation for this condition is relatively infrequent. The authors' present data regarding potential benefit of lumbar sympathectomy in patients with plantar hyperhidrosis treated with an endoscopic approach. Ninety patients had 178 endoscopic resections of lower sympathetic lumbar trunks for an indication of severe plantar hyperhidrosis. There were 59 men and 31 women. Mean follow up was 24 (range, 3-45) months. There were no perioperative deaths. Only three patients had post operative complications.The procedure is performed under general anesthesia with the patient in a hyper-extended flank position. Projection of lumbar vertebral bodies on the anterior abdominal wall was marked fluoroscopically. Retroperitoneoscopy was performed using three trocars with continuous carbon dioxide insufflations. The lumbar sympathetic trunk is exposed at the level of third and fourth lumbar vertebral bodies. Metal clips are placed above and below transaction sites and the sympathetic trunk resected between the clips, along with ganglia for L3 and/or L4. Evidence of postoperative sympathetic deintervention of the feet was present in all patients. In 97% (n ϭ 87), hyperhidrosis was eliminated. It recurred in 3%. Postsympathetic neuralgia occurred in 42% and compensatory sweating in 42%. One patient had temporary loss of ejaculation. Ninety-six percent said they were very or partly satisfied and 92% would have the procedure repeated if required.Comment: Conservative treatment of hyperhidrosis can improve symptoms. However, it is usually ineffective in severe cases and certainly does not affect long term outcome of the disease. Complications of postsympathetic neuralgia and compensatory sweating were both frequent in this series. Postsympathetic neuralgia however was minor and temporary and only one patient had severe compensatory sweating. Permanent sexual dysfunction appears unlikely as long as sympathectomy is below the level of third or fourth lumbar vertebral body. The technique appears to be reasonable treatment for patients with severe plantar hyperhidrosis.

Video-assisted thoracoscopic resection of the sympathetic chain from T2 to T4-5 is safe and effective and leads in almost 100% of cases to the elimination of palmar and axillary hyperhidrosis. In contrast to the excellent results in patients with palmar-plantar and palmar-axillary hyperhidrosis, outcome in patients with isolated axillary hyperhidrosis was impaired by a high rate of disturbing compensatory sweating.