requiring thoracotomy. Bleeding usually arises from
intercostal veins disrupted during dissection of the
sympathetic chain, but may also occur at the site of
trocar insertion. One false aneurysm of an intercostal
artery has been reported - an unusual complication. The
patient collapsed following aneurysm rupture 6 weeks
after ETS and required emergency thoracotomy

14

. There

is one anecdotal report of cardiac puncture requiring
thoracotomy and suture. Chylothorax may arise from
laceration of an accessory thoracic duct but seems to be
very uncommon. Gossot et al.

8

reported two instances; one

patient required postoperative tube drainage and parenteral
nutrition for 6 days, and the other leak was recognized
at surgery and the thoracic duct clipped. The recent
Brazilian series contained one case

7

. Wound haematomas

and infection are uncommon after ETS, and most authors
do not use prophylactic antibiotics.

Severe postoperative pain is more frequent than is

generally recognized. Many centres perform short-stay
surgery that may lead to underestimation of how much
pain results from ETS. Most patients have quite sharp
pain, especially on deep inspiration, for a few hours after
operation, but a significant minority have a slightly later
but more constant ache in the dorsal area, which may
occasionally require opiate analgesia

8

. Trocar site pain

may be reduced by local anaesthetic infiltration before
insertion, the use of smaller-diameter ports, and a single-
port technique. Some authors also report neuralgia along
the ulnar aspect of the arm. Fortunately, this usually
disappears after about 6 weeks

8

, but in one series it

occurred in 8 per cent of patients and required treatment
with tricyclic drugs

7

.

Rebound sweating is a curious and unexplained tempo-

rary recurrence of sweating that was also well known to
surgeons performing open 'cervical' sympathectomy

15

. It

occurs in about 31 per cent of patients following ETS

16

.

Patients should be warned that it may happen to avoid anx-
iety that the procedure has failed. Intraoperative cardiac

arrest is a serious complication that is often attributed
to stimulation of the stellate ganglion. However, Lin
et al.

17

reported two cardiac arrests during T2-3 sym-

pathectomies. Both patients were successfully resuscitated.
One brachial plexus injury has been reported after ETS

18

.

Long-term morbidity

By far the commonest problem is compensatory sweating.
'Some of our patients have stated emphatically that the
secretion of sweat has been considerably more profuse in
areas not affected by the operation . . . the remark has been
so frequently made that the possibility of compensatory
hypersecretion cannot be excluded.' This quote from Ross
in 1933

19

demonstrates that compensatory sweating has

been recognized since the early days of sympathectomy.
With conventional ETS its incidence is high, rates of
97 per cent

20

and 100 per cent

8

being reported. In one

study of children and adolescents, compensatory sweating
was noted in 86 per cent

21

. Its distribution varies; in a

long-term follow-up from Vienna

9

compensatory sweating

affected the foot in 32 per cent, the face in 27 per cent
and the trunk in 20 per cent, but others have reported
the trunk to be the commonest site

20

. When severe,

it affects the buttocks and popliteal fossa. Sweating of
such severity occurs in 1-2 per cent of patients and is the
commonest reason for regretting the operation. Still, the
severity and extent of compensatory sweating may change
during follow-up, with one study noting spontaneous
improvement in 94 per cent of patients within 9 months
of ETS

20

. Of those with concomitant pedal hyperhidrosis,

40 per cent have a reduction in foot sweating after
ETS

22

. A more extensive sympathectomy is commonly

believed to lead to increased compensatory sweating

22

,

although a recent study cast doubt on this

23