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Dec 11 08 6:01 PM
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
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
. 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
, but in one series it
occurred in 8 per cent of patients and required treatment with tricyclic drugs
.
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
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
. 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
. 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
,
although a recent study cast doubt on this
23
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