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to the specific end organ. Sympathectomy has been likened to building a dam on the tributaries. As the
flow of the central sympathetic activity remains unchanged, building a greater number of dams may cause
the river to overflow through the open tributaries. This overflow of sympathetic activity through the intact
sympathetic nerves, may be the analogy that best describes the condition of compensatory hyperhidrosis.
In theory, by building fewer dams and allowing the flow of sympathetic activity to dissipate before building
new dams, the rate of overflow in terms of compensatory hyperhidrosis may decrease. Compensatory
hyperhidrosis may also dissipate. This hypothesis prompted the investigation of the role of staged bilateral
selective dorsal sympathectomy.

INDICATIONS FOR SYMPATHECTOMY
Indications for sympathectomy include: intractable angina, arrhythmias, cardiomyopathy, complex
regional pain syndrome, erythromelalgia, and some pancreatic and other painful abdominal pathologies,
thromboangiitis obliterans (Buerger’s disease), microemboli, primary Raynaud’s phenomenon and
Raynaud’s phenomenon secondary to collagen diseases, paraneoplastic syndrome, frostbite, and
vibration syndrome [20,24] . Presently, the most common indication for thoracic sympathectomy is primary
hyperhidrosis, especially affecting the palm, and to a lesser degree, axilla and face, and for facial blushing.

[25]
Hyperhidrosis results from excessive stimulation of the eccrine glands . Eccrine glands, which are present
throughout the body, are most prevalent in the palms, axillae, and the plantar regions. Consequently,
hyperhidrosis most commonly presents in the hands, axilla, and the feet. The upper extremity is most
[26]
commonly affected, where 43% of patients have a combination of palm and axillary hyperhidrosis . In
37% of patients, hyperhidrosis is localized to the axilla and in 20% only to the hand. Hyperhidrosis is
seen in 1% of the population in the West. There is a high incidence in people of Japanese ancestry and
Jews of North African, Yemeni, and Balkan descent. Although most cases of hyperhidrosis are idiopathic,
secondary hyperhidrosis can be the result of hyperthyroidism, obesity, anxiety disorders, menopause,
[27]
carcinoid syndrome, lymphoma, pheochromocytoma, diabetes, and tuberculosis .

Therapeutic options for the treatment of hyperhidrosis
A number of approaches have been advocated for the management of hyperhidrosis.

Nonsurgical management
Aluminum chloride, glutaraldehyde, and tannic acid have been used as topical agents with disappointing
results.

Since the sweat glands are innervated by the sympathetic postganglionic nerves and have acetylcholine
as the primary neurotransmitter, systemic anticholinergics have been advocated to block postganglionic
acetylcholine receptors . Anticholinergic agents work by competitive inhibition of acetylcholine at
[28]
the muscarinic receptor. Since, muscarinic receptors are present throughout the central and autonomic
nervous system, the use of anticholinergics can be associated with widespread and varied side effects.
Also, there are differences in the side effect profile of the different anticholinergic agents. Glycopyrrolate
is a quaternary amine that has limited passage across lipid membranes such as the blood-brain barrier.
Therefore, in contrast to agents such as atropine or scopolamine, which are tertiary amines and can easily
penetrate lipid barriers, glycopyrrolate has fewer central nervous system side effects and may have less
[29]
effect on the heart rate at lower doses . Glycopyrrolate, oxybutynin and methantheline bromide are
the most commonly used anticholinergics for the treatment of hyperhidrosis . The most common side
[30]
effect is dry mouth due to inhibition of salivary glands. Other side effects include: constipation, nausea,
vomiting, bloating, loss of taste, mydriasis, cycloplegia, dry eyes, blurred vision, photophobia, reduced
phlegm, urinary retention, erectile dysfunction, loss of libido, arrythmias, headache, dizziness, insomnia,
drowsiness, confusion, seizures, pruritus, and urticaria. In addition, concurrent use with other medications