This retrospective, cross-sectional study encompassed most of the Brazilian population, analyzing a comprehensive sample of 26,980 VATS performed nationwide between 2015 and 2023. The analysis included both public and private healthcare systems, providing a broad and representative overview of surgical practice across diverse socioeconomic and geographic contexts. To date, this study represents the longest and first nationwide cohort evaluating VATS for HH, offering robust epidemiological insight into the distribution, accessibility, and outcomes of definitive surgical treatment for HH throughout Brazil.

Data were obtained from national databases—DATASUS, which records all publicly funded procedures, and D-TISS, which compiles private healthcare data—ensuring near-complete national coverage (excluding only out-of-pocket cases), as reporting is mandatory for reimbursement. Additionally, population data from the Brazilian Institute of Geography and Statistics (IBGE) and complementary epidemiological sources were integrated, allowing precise demographic stratification and the calculation of standardized rates that strengthen the validity and comparability of the findings.

Over nine years, a total of 26,980 VATS were performed in Brazil, mainly in the private system (75.25%). Annual volumes in the private setting historically hovered around 2,500 cases, while the public sector contributed approximately 900 procedures. However, in 2020– 2021, these figures declined to nearly 1,500 in the private sector and just 300 in public hospitals, a downturn likely associated with the COVID-19 pandemic. (32) Since then, the numbers have partially rebounded, but not yet to pre-pandemic levels—perhaps in part due to evolving HH treatment strategies in Brazil. Today, many patients seeking care for HH are first managed medically with oxybutynin, which leads to clinical improvement for a substantial fraction and may reduce the necessity for surgical intervention.(1,21)

There is no comprehensive nationwide database to reliably enumerate VATS for HH. Available reports stem from institutional or regional case series (e.g., University of Maryland, Barrow Neurological Institute) and lack full national coverage. In contrast, Brazil remains unique in having a national epidemiological account of all VATS, derived from its public and private health system databases. In other countries, such as Taiwan or in European nations, data are usually limited to high-volume centers or regional registries, again lacking nationwide scope. (4,33) Because of this, no study to date has comprehensively used U.S. administrative hospital databases (e.g., NIS or SID) to estimate the total burden of thoracic sympathectomy for HH across the country.

Although such databases are often used in epidemiologic research, they encounter limitations in distinguishing surgical indications, capturing outpatient or outpatient-like procedures, and reliably coding HH as the operative rationale. Therefore, future methodological work is needed to develop and validate algorithms (based on diagnosis and procedure codes) to identify sympathectomy for HH in these large databases—and thereby enable cross-national comparisons of surgical practice over time.

Our data reveal significant differences between the public and private sectors. In the public, the rates ranged from 15.06% to 33.97%. After adjusting for population size, VATS rates remained higher in the private sector, though the gap has increased, and the private system now performs VATS at an estimated rate 12 times that of the public system. (17,34)

This disparity suggests that patients in the public system have longer wait times than those in the private system, and this may also be attributed to factors such as personal preferences or barriers to accessing surgery. (34)

Consistent with previous reports, there was a predominance of female patients undergoing VATS. (17) While the prevalence of HH is similar between sexes, women tend to seek treatment more frequently, partly due to aesthetic and psychosocial concerns. (35) In a public-only Brazilian series, women represented about 65% of patients undergoing sympathectomy. (17,35) Similarly, a multicenter clinical trial reported that 63.5% of patients undergoing surgery for HH were female. (12) Added to that, in our present study, 57.6% of patients were female, with a statistically significant difference observed in both sectors (p < 0.001).

In terms of age, HH is recognized as a condition that affects younger individuals, often manifesting during childhood or adolescence, yet many patients delay treatment until young adulthood. (18) In a multicenter clinical trial, the mean age of presentation was 24 years. (12) In Brazilian data from São Paulo, 66.2% of VATS were performed on patients aged 20-39 years, (35) and in national SUS analyses, more than 80% of patients fell between 15 and 59 years old. (36) In Taiwan, the highest prevalence rates were observed in the 20-29 age group. (33)

Those with HH generally seek care to improve their quality of life;(13) however, many wait until symptoms intensify, often during their economically active years or occasionally when prompted by family during childhood. This results in prolonged periods of personal, social, and psychological burden before access to treatment is achieved. (9,16)

In our dataset, we observed that younger patients (15–29 years) were predominantly treated within the public sector, whereas the private sector exhibited a greater proportion of older patients (20-39 years). This pattern may reflect differential access to early, non-surgical therapies (e.g. topical, oral, or minimally invasive treatments) in the private system, delaying or reducing the need for surgery in younger individuals. Conversely, adults in private care may have greater awareness, financial resources, and access to specialized centers, leading them to opt for surgical intervention more readily. These dynamics suggest a complex interplay between disease natural history, patient preferences, and structural access to care.

Regional analysis revealed that VATS procedures in the private sector significantly exceeded those performed in the public sector, particularly in the Southeast and South regions, where 77.97% of all procedures were concentrated. This should be explained by the fact that these regions possess the country’s highest economic productivity, population density, and Human Development Index (HDI), as well as a more robust private healthcare sector compared with other parts of Brazil. Overall, VATS rates per one million inhabitants were markedly higher in the South and Southeast, while lower rates were observed in the North, a pattern that likely reflects underlying disparities in health policy, hospital infrastructure, and patient demographics.(37,38)

Another key contributing factor is the uneven distribution of thoracic surgeons, which further accentuates regional variation in procedure rates. The South had the highest density of thoracic surgeons, with 9.14 per million inhabitants, followed by the Southeast (7.10), the Midwest (5.32), the Northeast (3.65), and the North (2.80). Thus, regions with higher economic capacity, HDI, and surgeon density were responsible for the largest VATS volumes. (39)

When analyzing the funds allocated and reimbursed for VATS in private and public systems between 2015 and 2023, we observed that the private sector accounted for over 92% of total investment in these years, highlighting a profound imbalance in financial engagement. Moreover, the per-procedure reimbursement in the private sector is approximately 4.2 times higher than in the public system, according to the adjusted cost model.

This disproportion suggests that public institutions may be structurally undercompensated for these procedures, risking underfunding or cost absorption by hospitals. The estimated yearly increase of 3.1 % in average VATS cost further compounds this gap, as inflation, technological advances, and rising input costs progressively erode public sector margins. (37) The dominance of private investments also points to potential inequities in access; patients with private coverage or financial means are more likely to receive interventions, while those dependent on public may face delayed or restricted access to care. (38) Overall, these financial dynamics underscore how structural funding and reimbursement policies can directly influence procedural volume, care quality, and equitable distribution of advanced vascular or thoracic services in Brazil.

The mortality related to VATS procedures in Brazil between 2015 and 2023 exhibited an exceptionally low death rate of 10 fatalities across all cases, yielding an overall mortality of just 0.048%. There were five deaths in public over 6,678 procedures and five deaths in private over 20,302 procedures, suggesting a numerically higher mortality rate in the public system (749 deaths per million) compared to the private (246 deaths per million). However, this difference did not reach statistical significance. The estimated odds ratio (3.04; 95 % CI 0.70–13.21) hints at a trend toward greater relative risk in the public system, but the wide confidence interval underlines the uncertainty arising from the small number of events.

These results align with the perception that VATS is a safe minimally invasive modality when performed at experienced centers, reflected in international data showing low surgical mortality for thoracoscopic procedures. The same was observed in previous studies. (17) In a 2004 study, nine perioperative deaths were described: five from massive intrathoracic hemorrhage, three from anesthetic complications during mechanical ventilation, and one of undetermined cause. (40) Other retrospective and prospective cohorts reported no mortality following. (9,16)

Mortality is a crucial parameter to assess in any form of medical treatment; however, on its own, it does not capture the full range of surgical risk — including major complications, conversion to open surgery, length of hospital stays, and long-term outcomes — which were not studied in this work because such data were unavailable in the databases.