Patient satisfaction after ETS

back, abdomen, thighs and buttocks, and most of
the patients answered that it occurred more after
exercising and in summer. For the question ofwhether they took some countermeasures against
sweat, the answers included changing clothes andunderwear often, placing a towel between the skinand underwear, not wearing a T-shirt that is easily
seen through, using deodorant spray, wrapping a
towel around the lower back, trying not to sweat,
wiping off the skin often, cooling the body usinga refrigerant, etc.

• Are there any mental changes before and after thesurgery?
ABC
DEECD• Were you anxious about the surgery?
ABCDE

Most of the patients answered that there were nofeelings of inconvenience in their daily lives after
the surgery compared with preoperative conditions. Twenty-one patients (60%) answered thatthey had psychologically become positive, which
was considered a high number (Fig. 4). As forthe operated areas after surgery, most patients answered that they had no pain and were not overly
disturbed or bothered by it.

Very anxious
Slightly anxiousNo opinion
Not very anxious
Not anxious at all

2131154E ABDC

Fig. 5. Anxieties over the surgery for palmar hyperhidrosis.

Surgery for hyperhidrosis
Nineteen patients (54.3%) answered that theyhardly felt anxious about the surgery, which was arather high rate, but 15 patients (42.9%) reported
some degree of anxiety (Fig. 5). Regarding theside effects except for CS, 11 patients (31.4%) answered that they experienced some type of sideeffects, including dry hands, a cold sense in thehands, hypesthesia, etc., and most of them had indefinite complaints.

• Rate your level of satisfaction with the surgery on ascale of 10 to 100.
Average: 79.4 points (scale of 10–100)• If you were consulted by someone who has asimilar degree of palmar sweating, how would you
describe this surgey?

Postoperative satisfaction

A I would recommend the surgery 13
B I would discuss the surgery
16
C No opinion
4
D I would rather not talk about
the surgery
1
E I would not talk about the surgery 1

The assessment of the satisfaction of the surgery
on a 100-point scale was 79.4 points (10–100points) on average. For the question that asked
whether they would like to tell other patients withpalmar hyperhidrosis about the present surgicalmethod, 13 patients answered that they would liketo recommend it, and 16 patients said would liketo tell them about it, a total of 29 patients (82.9%)
for both. Thus, it was clear that many of the patients wished that some sort of information about
treatment with surgery would be provided (Fig. 6).

DECA B

Fig. 4. Daily life.

Current daily life

Fig. 6. Overall assessment of thesurgery for palmar hyperhidorsis.

Became negative3
Became slightly negative 2
Unchanged
9Became slightly positive 10
Became positive
11AB

57

H. Nakamura et al.

back, chest, abdomen, and thigh. In this survey,
CS also developed in 97.1% of the patients, and82.9% of the patients answered that they weredisturbed because it was more than they had expected before the surgery. According to an analysis of a questionnaire in 40 patients by Libson etal. (2007), 6 patients (15%) answered that theyregretted having surgery for CS seriously affecting their quality of life, therefore surgeons should
be careful when selecting patients to undergo thistreatment. We also came to realize the importance of preoperative explanations in regard toCS, and it will be necessary to improve this pointin the future. Regarding methods to minimize
CS, Schmidt et al. (2006) and Kwong et al. (2008)
reported that blocking at the level of Th2 enhanced CS according to analyses of the blocking
sites of thoracic sympathetic nerves, and Jaffer etal. (2007) also described that CS frequently developed by blocking at the level of Th2 for facial
hyperhidrosis and erythromania. Moreover, Lichtand Pilegaard (2004) reported that CS developed
to a large degree in axillary hyperhidrosis witha large blocked area from the levels of Th2 to 4.
Therefore, for non-severe palmar hyperhidrosis,blocking only Th3 and avoiding blocking Th2
can be taken into consideration. Moreover, Linet al. (1998) and Chou et al. (2006) recommend areversible clipping method as a blocking method.
However, Miller and Force (2008) considered theeffect of the clipping method to be uncertain, as
there is also a possibility of recurrence, while CS
is irreversible even with clipping, and he goes on
to describe that it is safer to carefully perform asympathetectomy after determining whether CS
is significant by temporarily performing a sympathetic nerve block before surgery. Regarding theabove problems, the findings and recommendations remain controversial. There is also a reportthat CS is an allowable adverse effect and it is desirable to have surgery at an early stage by adulthood (Steiner et al., 2007). Thus, the relationshipbetween ETS and CS has not yet been elucidated.
Under these circumstances, a report by Fujita etal. (2002) that perioperative temperature or bloodDiscussion
With the widespread use of thoracoscopy, ETS forpalmar hyperhidrosis has developed quite dramatically (Kux, 1978; Chen et al., 1994; Okabayashi
et al., 1999). However, the largest problem continues to be CS which occurs as an adverse effectand many patients gradually experience this problem after they return to their daily lives. Therefore, in order to find out the true satisfaction levelof patients who had ETS, it is important to study
the degree of sweating after at least one monthafter hospital discharge (Andrews and Rennie,
1997). In this study, the efficacy of ETS and thedegree of CS were studied by surveying the longterm patient satisfaction using a questionnaire after surgery.
The average postoperative observation period was 33 months, and as for the amount ofpalmar sweating, it completely stopped in 82.9%of the patients and occurred slightly in 17.1%,
thus showing the positive effects of ETS in all of
the patients. The average rate for patient satisfaction was 79.4 out of 100 points, and 82.9% of thepatients wished to be provided with some sort of
information about ETS for people who had thesame problems with palmar hyperhidrosis. It isbelieved that these results show that ETS is sufficiently accepted as a treatment for palmar hyperhidrosis. On the other hand, 7 out of 35 patients(20%) gave a satisfaction level of 50 points or
less, and CS which was more than they expected
was observed in all 7 of these patients. Amongthem, 1 patient who reported a satisfaction scoreof 10 points had severe CS and answered that it
was good that palmar sweating stopped but CS
became a new problem and this patient thus regretted having undergone the surgery. Hirakawa
et al. (2004) reported the frequency of CS torange from 7% to 98.6% according to numerous
reports, but it is believed that this disparity resultsfrom differences in the definition of CS, and it
essentially develops in all patients to a greater or
lesser degree and most frequently occurs on the58

Patient satisfaction after ETS

flow differences in finger tips correlates with CS
and a report by Bonde et al. (2008) on the objective assessment of the amounts of sweating while
applying sweat stimulation with a method called
ventilated capsule technique are very interestingfindings. It is believed that assessing the degreeof CS as well as accurately estimating it preoperatively and then utilize that data for selecting
optimal treatment protocol remains an important
study for the future.
In general, it has been reported that a patient
who demonstrates more sweating from heat thanfrom mental strain tends to demonstrate more CSregardless of the operative method (Hirakawa etal., 2004). Meticulous attention is therefore needed for a patient who tends to “naturally sweat a lot
over the entire body.” Okabayashi et al. (2004)
cited a guideline with 10 items as key points forthe preoperative explanation and described that it
was particularly important to thoroughly explain
the occurrence of CS and the irreversibility of thepresent surgery. We are now planning to makeuse of the knowledge we obtained according to
the results [especially the patient satisfaction scoreof 79.4 points, CS development of 97.1% and that
29 patients (82.9%) answered they were disturbed
because it was more than they expected] of thisquestionnaire about appropriate countermeasuresthat patients can take against CS in the future, as
well as providing a sufficient explanation about
CS for patients with palmar hyperhidrosis andalso obtaining informed consent before performing any surgical procedures.
Palmar hyperhidrosis appears to be increasing in modern society due to the recent upsurge instress. It is a disorder strongly affected by familial factors, but there is still no definitive treatment
for it, and treatment should therefore be selectedaccording to the patients wishes and desires asa rule. It is believed that there are many potential patients with palmar hyperhidrosis, and theproblem is serious, particularly for junior highschool, high school and university students, but
the analytical results of the this questionnaire
showed that the problem of postoperative CS was

more serious than has been previously thought.
Therefore, many believe that treatment needs tobe carefully selected after achieving a better understanding of the effectiveness and problems associated with ETS for palmar hyperhidrosis.

Acknowledgments: This research was supported by aGrant on Tottori-Prefecture Region-Specific Diseases
from Tototori Prefecture, Japan.
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Received May 14, 2008; accepted July 22, 2008
Corresponding author: Hiroshige Nakamura, MD60