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Dec 11 08 5:56 PM
Review Drawbacksof endoscopic thoracic sympathectomy T. A. Ojimba and A. E. P. Cameron The Suffolk Vascular Unit, Ipswich Hospital, Heath Road, Ipswich IP4 5PD, UK Correspondence to: Mr A. E. P. Cameron (e-mail: Ian.cameron@ipswichhospital.nhs.uk) Background: Endoscopic thoracic sympathectomy (ETS) has come into widespread use for palmar hyperhidrosis and other complaints of the upper limb and of the head and neck, but there are concerns about its safety. This review highlights the operative complications and long-term side-effects that may occur. Methods: A Medline search was carried out using the terms 'thoracoscopic sympathectomy', 'endoscopic thoracic sympathectomy' and 'complications'. References from identified articles were handsearched for further relevant articles. The senior author's experience and personal communications were also taken into account. Results and conclusion: No death following ETShas ever been reported in the literature, but nine anecdotal fatalities are known, five resulting from major intrathoracic bleeding and three from anaesthetic mishap. Significant intrathoracic bleeding may occur in up to 5 per cent of patients but only a minority require thoracotomy; pneumothorax occurs in 2 per cent of patients and two instances of brain damage are known. In the longer term compensatory hyperhidrosis is extremely common and 1-2 per cent of patients regret having had surgery because of its severity. Horner's syndrome, on the other hand, is rare. Improvements in instrumentation, adequate training and careful patient selection may help reduce thedrawbacksof ETS. Paper accepted 10 December 2003 Published online 3 February 2004 in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.4511 Introduction Endoscopic thoracic sympathectomy (ETS) was first described in 1942 by the English surgeon Hughes 1 , and then independently by Goetz and Marr 2 from South Africain 1944. In 1954 Kux (who may have performed the first operation in 1937) described his experience of more than 1400 procedures 3 . However, ETSremained rare until the introduction of video-endoscopic techniques into other branches of surgery in the 1980s. Since then it has become the preferred method of performing upper dorsal sympathectomy. The original indication for ETSwas palmar hyperhidrosis, but more recently the procedure has been performed for symptoms such as facial sweating and blushing. As with open operations, ETSis of only limited benefit in patients with vascular disorders such as Raynaud's disease; for axillary sweating, injection of botulinum toxin may be the preferred treatment 4 . The purpose of this review is not to discuss the results of ETS in any of these conditions, but to focus on its drawbacks. A Medline search was done using the keywords 'sympathectomy' and 'endoscopic'; all papers identified were analysed for reported complications. In addition, the senior author (A.E.P.C.) has obtained anecdotal information from other sources, including discussions at a recent meeting of the International Society for Sympathetic Surgery held in Erlangen, Germany, in May 2003. The mortality and morbidity associated with ETS deserve special consideration for the following reasons. First, the majority of patients undergoing ETSare aged less than 30 years and so may suffer serious social and economic disadvantages for many years as a result of any complication. Second, ETSis viewed by some as a 'lifestyle' procedure, without clear medical indication and so akin to aesthetic plastic surgery; from such a standpoint any complication is unwarranted and to be greatly deprecated. Third, ETSis often actively sought by patients who have read in the media about the benefits that may accrue from the procedure; such sources rarely report the dangerous complications that may occur. Finally, there is a need to inform other surgeons and anaesthetists of Copyright 2004 British Journal of Surgery Society Ltd British Journal of Surgery 2004; 91: 264-269 Published by John Wiley & Sons Ltd Drawbacksof endoscopic thoracic sympathectomy 265 potential difficulties. In experienced hands ETSis generally a safe operation that appears straightforward to perform. However, obtaining the required level of skill is not easy and the inexperienced may be lulled into a false sense of security, especially if unaware of pitfalls. Mortality No death has ever been reported in any published series in the literature. However, the authors know anecdotally of nine deaths following ETS. Five patients died from excessive haemorrhage. Massive intrathoracic bleeding occurred in two instances following trocar insertion, the trocar lacerating the subclavian artery with death ensuing from hypovolaemic shock. This perhaps reflects inexperience in trocar insertion. One of these two deaths occurred early in the history of ETS, but the other happened recently. In another patient an intercostal vein was damaged; diathermy cauterization was employed initially but the patient rebled profusely and died despite thoracotomy. Excessive bleeding was again the cause of death in the last two instances, but the details are not available to the authors. Anaesthetic problems led to death in three patientsin whom a double-lumen tube had been employed for endobronchial single-lung ventilation; the operation on the first side was completed uneventfully and the anaesthetist considered that the lung on this side had re-expanded adequately and so proceeded to collapse the contralateral lung. All three patients went on to develop severe and unrecognized hypoxia and subsequently died; in
Review
Drawbacksof endoscopic thoracic sympathectomy
T. A. Ojimba and A. E. P. Cameron
The Suffolk Vascular Unit, Ipswich Hospital, Heath Road, Ipswich IP4 5PD, UK Correspondence to: Mr A. E. P. Cameron (e-mail: Ian.cameron@ipswichhospital.nhs.uk)
Background:
Endoscopic thoracic sympathectomy (ETS) has come into widespread use for palmar
hyperhidrosis and other complaints of the upper limb and of the head and neck, but there are concerns about its safety. This review highlights the operative complications and long-term side-effects that may occur.
Methods:
A Medline search was carried out using the terms 'thoracoscopic sympathectomy', 'endoscopic
thoracic sympathectomy' and 'complications'. References from identified articles were handsearched for further relevant articles. The senior author's experience and personal communications were also taken into account.
Results and conclusion:
No death following ETShas ever been reported in the literature, but nine
anecdotal fatalities are known, five resulting from major intrathoracic bleeding and three from anaesthetic mishap. Significant intrathoracic bleeding may occur in up to 5 per cent of patients but only a minority require thoracotomy; pneumothorax occurs in 2 per cent of patients and two instances of brain damage are known. In the longer term compensatory hyperhidrosis is extremely common and 1-2 per cent of patients regret having had surgery because of its severity. Horner's syndrome, on the other hand, is rare. Improvements in instrumentation, adequate training and careful patient selection may help reduce thedrawbacksof ETS.
Paper accepted 10 December 2003 Published online 3 February 2004 in Wiley InterScience (www.bjs.co.uk). DOI: 10.1002/bjs.4511
Introduction
Endoscopic thoracic sympathectomy (ETS) was first described in 1942 by the English surgeon Hughes
1
, and
then independently by Goetz and Marr
2
from South
Africain 1944. In 1954 Kux (who may have performed the first operation in 1937) described his experience of more than 1400 procedures
3
. However, ETSremained
rare until the introduction of video-endoscopic techniques into other branches of surgery in the 1980s. Since then it has become the preferred method of performing upper dorsal sympathectomy. The original indication for ETSwas palmar hyperhidrosis, but more recently the procedure has been performed for symptoms such as facial sweating and blushing. As with open operations, ETSis of only limited benefit in patients with vascular disorders such as Raynaud's disease; for axillary sweating, injection of botulinum toxin may be the preferred treatment
4
.
The purpose of this review is not to discuss the results
of ETS in any of these conditions, but to focus on its
drawbacks. A Medline search was done using the keywords 'sympathectomy' and 'endoscopic'; all papers identified were analysed for reported complications. In addition, the senior author (A.E.P.C.) has obtained anecdotal information from other sources, including discussions at a recent meeting of the International Society for Sympathetic Surgery held in Erlangen, Germany, in May 2003.
The mortality and morbidity associated with ETS
deserve special consideration for the following reasons. First, the majority of patients undergoing ETSare aged less than 30 years and so may suffer serious social and economic disadvantages for many years as a result of any complication. Second, ETSis viewed by some as a 'lifestyle' procedure, without clear medical indication and so akin to aesthetic plastic surgery; from such a standpoint any complication is unwarranted and to be greatly deprecated. Third, ETSis often actively sought by patients who have read in the media about the benefits that may accrue from the procedure; such sources rarely report the dangerous complications that may occur. Finally, there is a need to inform other surgeons and anaesthetists of
Copyright
2004 British Journal of Surgery Society Ltd
British Journal of Surgery 2004; 91: 264-269
Published by John Wiley & Sons Ltd
265
potential difficulties. In experienced hands ETSis generally a safe operation that appears straightforward to perform. However, obtaining the required level of skill is not easy and the inexperienced may be lulled into a false sense of security, especially if unaware of pitfalls.
Mortality
No death has ever been reported in any published series in the literature. However, the authors know anecdotally of nine deaths following ETS. Five patients died from excessive haemorrhage. Massive intrathoracic bleeding occurred in two instances following trocar insertion, the trocar lacerating the subclavian artery with death ensuing from hypovolaemic shock. This perhaps reflects inexperience in trocar insertion. One of these two deaths occurred early in the history of ETS, but the other happened recently. In another patient an intercostal vein was damaged; diathermy cauterization was employed initially but the patient rebled profusely and died despite thoracotomy. Excessive bleeding was again the cause of death in the last two instances, but the details are not available to the authors.
Anaesthetic problems led to death in three patients
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