Abstract
Background
Despite the high surgical success rate, postoperative compensatory hyperhidrosis (CH) remains a persistent concern in the treatment of primary palmar hyperhidrosis using endoscopic thoracic sympathectomy (ETS). This study aims to compare the early clinical outcomes of two surgical techniques—T3 ganglionectomy and R4 sympathicotomy—to determine which approach minimizes CH occurrence and enhances patient satisfaction.
Methods
A retrospective analysis of medical records was conducted on patients who underwent either T3 ganglionectomy or R4 sympathicotomy for primary palmar hyperhidrosis at Gangnam Severance Hospital from January 2023 to December 2023. Demographic data and postoperative outcomes were evaluated. CH and degree of satisfaction were assessed during outpatient visits at 3 weeks and 3 months after surgery.
Results
In this study, 44 patients underwent T3 ganglionectomy and 225 patients underwent R4 sympathicotomy. There were no statistically significant differences in baseline characteristics (age, sex, body mass index, smoking history, and family history) or operative complications between the two groups. However, CH at 3 weeks and 3 months after surgery was significantly lower in T3 ganglionectomy group [4 (9.1%) vs. 143 (63.6%); P<0.001, 5 (11.4%) vs. 150 (66.7%); P<0.001]. Additionally, patient satisfaction was significantly higher in the T3 ganglionectomy group compared to the R4 sympathicotomy group (P<0.001).
Conclusions
T3 ganglionectomy exhibited superior surgical outcomes in terms of both CH and patient satisfaction for primary palmar hyperhidrosis when compared to R4 sympathicotomy. Nonetheless, a larger prospective study with long-term follow-up is necessary to validate these findings.
Keywords: Primary palmar hyperhidrosis, endoscopic thoracic sympathectomy (ETS), T3 ganglionectomy, R4 sympathicotomy, compensatory hyperhidrosis (CH)
Highlight box.
Key findings
• Occurrence of compensatory hyperhidrosis (CH) (at 3 weeks and 3 months post-surgery) was significantly lower in primary palmar hyperhidrosis patients who underwent T3 ganglionectomy compared to R4 sympathicotomy.
• Postoperative satisfaction was significantly higher in primary palmar hyperhidrosis patients who underwent T3 ganglionectomy compared to R4 sympathicotomy.
What is known and what is new?
• Although endoscopic thoracic sympathectomy (ETS) has shown to be effective, postoperative CH remains to be an issue.
• Among the various ETS techniques, R4 sympathicotomy is the most commonly used technique. However, this study shows T3 ganglionectomy should be considered as it may minimize postoperative CH and superior patient satisfaction.
What is the implication and what should change now?
• R4 sympathicotomy, although has been shown to be effective, in an effort to minimize postoperative CH and achieve greater patient satisfaction, T3 ganglionectomy should be considered and adopted.
Introduction
Endoscopic thoracic sympathectomy (ETS) is recognized as a definitive treatment for primary palmar hyperhidrosis, a condition characterized by excessive sweating of the palms causing significant discomfort in daily life. When compared to non-surgical treatment methods, ETS has demonstrated remarkable effectiveness and long-lasting results (1-3).
While ETS has shown to be effective, compensatory hyperhidrosis (CH)—a significant complication—remains prevalent. Although the severity of CH varies among individuals, it can significantly diminish the quality of life and reduce post-surgery satisfaction. Consequently, addressing postoperative CH is a critical concern for surgeons.
Among the various ETS techniques used to treat primary palmar hyperhidrosis, R4 sympathicotomy stands out as the most commonly utilized approach, as it has been established to maximize efficacy and patient satisfaction while minimizing the postoperative CH. However, it is important to note that even with this technique, some degree of CH may still manifest.
Hence, in an ongoing effort to minimize or eliminate CH, this study aims to evaluate and compare the satisfaction levels and incidence of postoperative CH associated with two ETS techniques: T3 ganglionectomy and R4 sympathicotomy. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0904/rc).
Methods
Patients
We conducted a retrospective analysis of patients who underwent ETS—either R4 sympathicotomy or T3 ganglionectomy—for primary palmar hyperhidrosis at Gangnam Severance Hospital from January 2023 to December 2023. Using electronic medical records, we obtained information on patients’ characteristics and surgical outcomes.
Patients were referred to Gangnam Severance Hospital from local clinics for surgical treatment of primary palmar hyperhidrosis. Surgery was offered to patients who met the established indications for operative treatment of hyperhidrosis and who desired surgical management at our hospital. All patients were thoroughly informed about the risk of CH before surgery.
Patients with significant comorbidities, financial barriers, or suspected risk of serious perioperative complications were not considered candidates for surgery. In particular, patients with a history of empyema or suspected severe pleural adhesions were excluded. In our cohort, there were no patients with diabetes mellitus, hypertension, or other significant underlying diseases, because patients with such conditions were not offered surgical treatment.
The primary outcomes of this study were the presence and severity of postoperative CH, as well as patient satisfaction. Additionally, the secondary outcome was a comparison between postoperative outcomes and complications. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study received approval from the local institutional review board at Gangnam Severance Hospital in Korea (IRB No. 3-2025-0052) and the requirement for informed consent was waived due to its retrospective nature.
Surgical technique
All patients, under general anesthesia, underwent ETS using bilateral simultaneous two-portal video-assisted thoracoscopic surgery (VATS). The procedure involved creating two 3 mm incisions on each side: one for the 2 mm thoracoscope at the 4th intercostal space (ICS) along the anterior-axillary line, and another for instruments at the 4th ICS on the mid-axillary line. Carbon dioxide insufflation at 5mmHg pressure was employed to deflate the lung. During T3 ganglionectomy, the pleura was carefully opened between the third and fourth ribs. The white ramus communications, originating from the 3rd intercostal nerve, was meticulously traced toward the sympathetic trunk. At both rostral and caudal ends of the T3 ganglion, the T3 ganglion was disconnected from the sympathetic trunk. Similarly, the gray and white communicans were interrupted at their points of entry and exit into the ganglion using cautery. For R4 sympathicotomy, the sympathetic nerve just above the midpoint of the 4th rib was cauterized, extending horizontally by 2cm to ensure thorough nerve transection. Anti-adhesive material (InterBlock 5 mm, sodium hyaluronate–based material, BioPlus Co., Ltd., Seongnam, South Korea) was applied to the transected nerve areas in both procedures. Finally, a 10-Fr chest tube was placed in the pleural cavity, and routine chest radiography was performed postoperatively for early detection of pneumothorax.
The key anatomical and technical differences between T3 ganglionectomy and R4 sympathicotomy are illustrated in Figure 1.
Figure 1.
Schematic comparison of T3 ganglionectomy and R4 sympathicotomy. T3 ganglionectomy involves resection of the sympathetic ganglion itself, which may allow complete removal despite anatomical variation in ganglion location. In contrast, R4 sympathicotomy is performed by transecting the sympathetic chain at the fourth rib level; however, anatomical variation or inaccurate transection may result in incomplete interruption of the sympathetic pathway.
CH and satisfaction
CH is defined as new-onset or increased sweating in body areas not primarily affected before surgery, occurring after ETS. CH was assessed during routine outpatient follow-up visits at 3 weeks and 3 months after surgery via surveys. The severity of CH was categorized as follows: none; mild (not bothersome); moderate (sometimes bothersome); severe (often bothersome); or very severe (intolerable). We measured severity of CH using the Hyperhidrosis Disease Severity Score (HDSS). Patient satisfaction was also evaluated at 3 months postoperative outpatient visit using the same survey-based follow-up protocol. Patients were asked to rate their overall satisfaction with the surgical outcome with the following categories: very satisfied; satisfied; moderately satisfied; dissatisfied; or very dissatisfied.
Statistical analysis
Demographic and clinical data were presented as the mean ± standard deviation (SD) or frequency (percentage), as appropriate. Using independent two-sample t-tests and chi-square tests, a comparison of patients’ baseline characteristics was made. A significance level was set at P<0.05. All statistical analyses were conducted using SAS version 9.4 (SAS Institute Inc., Cary, NC, USA).
Artificial intelligence use statement: ChatGPT (OpenAI) was used only for English language revision and improvement of manuscript readability. No AI tool was used for data collection, data analysis, or generation of study results.
There were no missing data for the variables analyzed in this study.
Results
Patients’ characteristics and surgical outcomes
In this study, 44 patients underwent T3 ganglionectomy, while 225 patients underwent R4 sympathicotomy. There were no statistically significant differences in baseline characteristics (age, sex, body mass index, smoking history, and family history) between the two groups. Additionally, operation time and hospital stay did not differ significantly (Table 1). There were no surgical-related complications or mortality in both groups.
Table 1. Baseline characteristics and operative results for T3 ganglionectomy and R4 sympathicotomy groups.
| Variables | T3 ganglionectomy, n=44 | R4 sympathicotomy, n=225 | P value |
|---|---|---|---|
| Age, years | 22.8±2.8 | 23.1±3.1 | 0.51 |
| Male | 22 (50.0) | 154 (68.4) | 0.21 |
| BMI, kg/m2 | 22.17±2.75 | 22.45±2.88 | 0.67 |
| Smoking history | 6 (13.6) | 29 (12.9) | 0.71 |
| Positive family history | 9 (20.5) | 34 (15.1) | 0.25 |
| Follow-up, months | 6 [3, 8] | 8 [3, 10] | 0.99 |
| Operation time, minutes | 32.2±5.2 | 31.2±4.8 | 0.80 |
| Hospital day, days | 1 | 1 | 0.99 |
Data are presented as mean ± standard deviation, median [interquartile range] or frequency (percentage). BMI, body mass index.
CH and satisfaction
At 3 weeks after surgery, T3 ganglionectomy group had 4 cases (9.1%) of mild CH (HDSS grade I). In contrast, the R4 sympathicotomy group showed a significantly higher occurrence of CH (P<0.001), with 143 cases (63.6%). Among these, 3 cases (1.3%) were categorized as severe (HDSS grade III); 28 cases (12.4%) were categorized as moderate (HDSS grade II), and 112 cases (49.8%) as mild (HDSS grade I). At 3 months post-surgery, T3 ganglionectomy group had an additional case, totaling 5 patients (11.4%) with mild CH (HDSS grade I). In the R4 sympathicotomy group, 7 more cases emerged, resulting in a total of 150 patients (66.7%) with CH, which is significantly higher than the T3 ganglionectomy group (P<0.001). Specifically, 118 patients (52.4%) had HDSS grade I; 29 patients (12.9%) had HDSS grade II; and 3 patients (1.3%) had HDSS grade III (Table 2).
Table 2. Comparison of compensatory hyperhidrosis between the two groups at 3 weeks and 3 months after surgery.
| Variables | T3 ganglionectomy, n=44 | R4 sympathicotomy, n=225 | P value |
|---|---|---|---|
| CH, 3 weeks | <0.001 | ||
| None | 40 (90.9%) | 82 (36.4%) | |
| Mild (HDSS I) | 4 (9.1%) | 112 (49.8%) | |
| Moderate (HDSS II) | – | 28 (12.4%) | |
| Severe (HDSS III) | – | 3 (1.3%) | |
| Very severe (HDSS IV) | – | – | |
| CH, 3 months | <0.001 | ||
| None | 39 (88.6%) | 75 (33.3%) | |
| Mild (HDSS I) | 5 (11.4%) | 118 (52.4%) | |
| Moderate (HDSS II) | – | 29 (12.9%) | |
| Severe (HDSS III) | – | 3 (1.3%) | |
| Very severe (HDSS IV) | – | – |
CH, compensatory hyperhidrosis; HDSS, Hyperhidrosis Disease Severity Score.
Patient satisfaction was significantly higher in the T3 ganglionectomy group compared to the R4 sympathicotomy group (P<0.001). All patients in the T3 ganglionectomy group reported being “very satisfied”, whereas 117 patients (52%) reported “very satisfied”, 103 patients (45.8%) reported “satisfied”, and 5 patients (2.2%) reported “moderately satisfied” in the R4 sympathicotomy group (Table 3).
Table 3. Patient satisfaction between the two groups at 3 months after surgery.
| Variables | T3 ganglionectomy, n=44 | R4 sympathicotomy, n=225 | P value |
|---|---|---|---|
| Satisfaction | <0.001 | ||
| Very satisfied | 44 (100%) | 117 (52%) | |
| Satisfied | – | 103 (45.8%) | |
| Moderate | – | 5 (2.2%) | |
| Dissatisfied | – | – |
Discussion
Our study demonstrated significantly favorable results for the T3 ganglionectomy group compared to the R4 sympathicotomy group in terms of CH and patient satisfaction. Both groups had no surgery-related complications, and there was no statistically significant difference in operation time. Based on our study, T3 ganglionectomy appears to be a clearly advantageous technique for treating palmar hyperhidrosis.
CH remains a major concern after ETS, despite ETS being recognized as a definitive treatment for primary palmar hyperhidrosis. Recent studies have also investigated predictors and risk factors for postoperative CH after ETS (4-6). Among ETS procedures, R4 sympathicotomy is commonly used due to its lower incidence of CH compared to other levels of sympathetic chain cutting (7-9). However, long-term follow-up studies, including Woo et al., have shown that nearly 50% of patients experience CH, leading to an 80% reduction in satisfaction (10). Thus, it remains uncertain whether R4 sympathicotomy is the ideal ETS technique.
Although the pathogenic mechanism of CH is complex and not fully understood to date, some theories exist. Lin et al. suggested that ETS disrupts the reflex arc to the hypothalamus, resulting in dysfunctional sweating throughout the body (11). Chen et al. explored the excitability of thoracic sympathetic ganglia but found no statistically significant correlation with CH (12).
Considering the location of thoracic ganglia, R4 sympathicotomy can yield heterogenous surgical outcomes (13). Variations include partial T3 ganglion resection, pure sympathetic trunk resection between T3 and T4 ganglia, or partial T4 ganglion resection. Individual differences in thoracic ganglion position (level, height, etc.) may contribute to variations in CH (14-16). In contrast, T3 ganglionectomy consistently shows homogenous results by completely interrupting all communicating ramus, preventing afferent and efferent fiber signals.
In our study, T3 ganglionectomy did not appear to be disadvantageous compared to R4 sympathicotomy in terms of the risk of perioperative bleeding or surgical complexity. Additionally, there was no significant difference in surgical duration, and complications, such as bleeding, did not manifest. This favorable outcome may be attributed to the use of Endo-Scissors for cauterization. Ablation using cauterization also allowed for complete resection of the communicating ramus during T3 ganglionectomy, potentially contributing to shorter surgical duration. Additionally, precise localization of the T3 ganglion is critical during T3 ganglionectomy. As Zhang et al. suggested, the T3 ganglion is commonly found at either the 3rd ICS (68%) or the distal surface of the 4th rib (32%) (16). In our study, we did not encounter any cases where the T3 ganglion was located at the 3rd rib. By identifying the communicating ramus connecting the 3rd intercostal nerve to the sympathetic trunk, most T3 ganglia were easily located and excised with a relatively straightforward procedure. However, it is essential to avoid injury to the T2 ganglion and intercostal nerve during this procedure.
This study is subject to potential sources of bias, including selection bias inherent to its retrospective design and reliance on patient-reported outcomes. In addition, the marked imbalance in sample size between the T3 ganglionectomy group and the R4 sympathicotomy group (44 vs. 225) should be considered when interpreting the results, as it may limit between-group comparability. At our institution, R4 sympathicotomy was initially the standard surgical technique. However, because CH remained a major postoperative concern, we have been gradually transitioning to T3 ganglionectomy and are currently accumulating clinical data on this approach. These factors may have influenced the observed differences between the groups. Other limitation includes its retrospective nature and reliance on patient-reported outcomes for CH and satisfaction. Early results may not predict long-term changes. Additionally, we did not measure CH sites. As this study was conducted at a single institution, the generalisability of the findings may be limited, and caution is required when applying these results to other populations or clinical settings. Nevertheless, as a single-center study comparing T3 ganglionectomy and R4 sympathicotomy, our findings are promising and warrant further evaluations into the role of ETS.
Conclusions
In conclusion, among ETS procedures for primary palmar hyperhidrosis, T3 ganglionectomy yielded significantly better results in terms of satisfaction and CH compared to R4 sympathicotomy. However, given the retrospective single-center design and the imbalance in group size, larger prospective studies with long-term follow-up are needed to validate these findings.
Supplementary
The article’s supplementary files as
Acknowledgments
None.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study received approval from the local institutional review board at Gangnam Severance Hospital in Korea (IRB No. 3-2025-0052) and the requirement for informed consent was waived due to its retrospective nature.
Footnotes
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0904/rc
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0904/coif). The authors have no conflicts of interest to declare.
Data Sharing Statement
Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0904/dss
References
- 1.Bell D, Jedynak J, Bell R. Predictors of outcome following endoscopic thoracic sympathectomy. ANZ J Surg 2014;84:68-72. 10.1111/ans.12098 [DOI] [PubMed] [Google Scholar]
- 2.Cerfolio RJ, De Campos JR, Bryant AS, et al. The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis. Ann Thorac Surg 2011;91:1642-8. 10.1016/j.athoracsur.2011.01.105 [DOI] [PubMed] [Google Scholar]
- 3.Chen J, Liu Y, Yang J, et al. Endoscopic thoracic sympathicotomy for primary palmar hyperhidrosis: A retrospective multicenter study in China. Surgery 2019;166:1092-8. 10.1016/j.surg.2019.05.039 [DOI] [PubMed] [Google Scholar]
- 4.Lin ZY, Lin M. Which patients are more likely to experience compensatory hyperhidrosis after endoscopic thoracic sympathectomy: a meta-analysis and systematic review. PeerJ 2025;13:e19097. 10.7717/peerj.19097 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Nachira D, Vita ML, Napolitano AG, et al. Predictors of Compensatory Sweating and Satisfaction Following Endoscopic Thoracic Sympathetic Chain Clipping for Palmar/Axillary Hyperhidrosis. J Clin Med 2025;14:326. 10.3390/jcm14020326 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Luo P, Wang J, Chen Q, et al. A predictive model for postoperative compensatory hyperhidrosis in primary palmar hyperhidrosis: a retrospective cohort study. J Thorac Dis 2025;17:11253-61. 10.21037/jtd-2025-1562 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Huang Y, Liu Y, Zou W, et al. Impact of endoscopic thoracic R4 sympathicotomy combined with R3 ramicotomy for primary palmar hyperhidrosis. Front Surg 2023;10:1144299. 10.3389/fsurg.2023.1144299 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Joo S, Lee GD, Haam S, et al. Comparisons of the clinical outcomes of thoracoscopic sympathetic surgery for palmar hyperhidrosis: R4 sympathicotomy versus R4 sympathetic clipping versus R3 sympathetic clipping. J Thorac Dis 2016;8:934-41. 10.21037/jtd.2016.03.57 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Liu Y, Weng W, Tu Y, et al. Chinese expert consensus on the surgical treatment of primary palmar hyperhidrosis (2021 version). Chin Med J (Engl) 2022;135:1264-71. 10.1097/CM9.0000000000002198 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Woo W, Kim BJ, Kang DY, et al. Patient experience and prognostic factors of compensatory hyperhidrosis and recurrence after endoscopic thoracic sympathicotomy. Surg Endosc 2022;36:8340-8. 10.1007/s00464-022-09284-w [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Lin CL, Yen CP, Howng SL. The long-term results of upper dorsal sympathetic ganglionectomy and endoscopic thoracic sympathectomy for palmar hyperhidrosis. Surg Today 1999;29:209-13. 10.1007/BF02483008 [DOI] [PubMed] [Google Scholar]
- 12.Chen J, Lin J, Tu Y, et al. Nonintubated Transareolar Endoscopic Thoracic Sympathectomy with a Flexible Endoscope: Experience of 58 Cases. Ann Thorac Cardiovasc Surg 2016;22:12-9. 10.5761/atcs.oa.15-00241 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Chung IH, Oh CS, Koh KS, et al. Anatomic variations of the T2 nerve root (including the nerve of Kuntz) and their implications for sympathectomy. J Thorac Cardiovasc Surg 2002;123:498-501. 10.1067/mtc.2002.119340 [DOI] [PubMed] [Google Scholar]
- 14.Pei G, Meng S, Yang Y, et al. Anatomical variations of the thoracic sympathetic ganglions and their effects on sympathicotomy for primary palmar hyperhidrosis. Clin Auton Res 2023;33:111-20. 10.1007/s10286-023-00932-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Weng W, Li X, Pei G, et al. Anatomical variation of sympathetic ganglia in R4+R5 sympathicotomy for primary palmar axillary hyperhidrosis. J Thorac Dis 2023;15:3106-14. 10.21037/jtd-22-1782 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Zhang B, Li Z, Yang X, et al. Anatomical variations of the upper thoracic sympathetic chain. Clin Anat 2009;22:595-600. 10.1002/ca.20803 [DOI] [PubMed] [Google Scholar]