internet archive was unable to pull this because of TXT bots..but did find acached version...submitting it in chunks (many names we will find familiar)

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 the
drawbacksof 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 patients

in 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