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Dec 11 08 6:12 PM
8,12,32 or national surveys 13 . Compensatory sweating is the major drawback of ETS. Treatment of this sweating by drugs such as glycopyrrolate or by injection of botulinum toxin is unsatisfactory, and reconstruction using nerve grafts is a major undertaking 33 . Clearly, it would be better to avoid compensatory sweating in the first place; current work is focusing on different methods of performing ETS, by clipping rather than cutting 34 , for example, or by concentrating the surgical attack at different levels of the chain for different conditions 35 . Such work is hampered by a lack of a standard definition of compensatory sweating and an accurate objective method for its measurement. It is unlikely that any randomized clinical trial will emerge; the best one can hope for is accurate standardized recording of the outcome of ETS in future published work. A similar problem surrounds the other long-term conse- quences of the operation. For example, the term Horner's syndrome is used as a shorthand for various degrees of ocular complication, ranging from imperceptible miosis to unsightly ptosis. Again, new methods of performing ETS, such as with the harmonic scalpel 36 , have not yet been shown to affect the incidence. Current knowledge suggests that Horner's syndrome is due to misidentification of the T2 ganglion, to excessive traction on the chain, or to exces- sive use of diathermy 8 . These technical problems should be reducible by careful surgery. The traditionally closed world of medicine has been revolutionized by the internet. This has the advantage of allowing a patient to obtain information about his or her condition and to seek treatment directly from a provider. The disadvantage is that the internet is unregulated and doubt must exist about the quality of information given on websites promoting ETS. A quick perusal of bulletin boards shows that there are patients who are very unhappy following ETS and who seek to have the operation banned. In addition to the consequences of ETS discussed above, patients report lethargy, depression, temperature intolerance, weakness, continuing pain, limb swelling, lack of libido, decreased physical and mental reactivity, oversensitivity to sound, light and stress, poor circulation, cold hands and feet, and weight gain. The fact that Copyright 2004 British Journal of Surgery Society Ltd www.bjs.co.uk British Journal of Surgery 2004; 91: 264-269 Published by John Wiley & Sons Ltd 268 T. A. Ojimba and A. E. P. Cameron these symptoms cannot be accounted for mechanistically does not make them any less real to the sufferer. As a counterpoint it is well to remember that most patients are pleased with the outcome of ETS. Finally, it is reassuring to note that not a single death has been reported in any published series. This suggests that in experienced centres ETS is, indeed, a safe procedure. However, a note of caution is necessary. It is truly difficult to estimate the mortality rate associated with ETS, first because the total number of operations performed is not known and, second, because there is no mechanism whereby deaths must be reported. The deaths discussed above were recognized through informal means and there are certain to be others. It is to be hoped that the new International Society of Sympathetic Surgery will encourage full reporting of mortality and morbidity. References 1 Hughes J. Endothoracic sympathectomy. Proc R Soc Med 1942; 35: 585-586. 2 Goetz RH, Marr JAS. The importance of the second thoracic ganglion for the sympathetic supply of the upper extremities.Clin Proc 1944; 3: 102-114. 3 Kux E. Thorakokoskopische Eingriffe am Nervensystem. Georg Thieme: Stuttgart, 1954. 4 Whatling PJ, Collin J. Botulinum toxin injection is an effective treatment for axillary hyperhidrosis. Br J Surg 2001;88: 814-815. 5 Collin J, Whatling PJ. Treating hyperhidrosis. Surgery and botulinum toxin are treatments of choice in severe cases.BMJ 2000; 320: 1221-1222. 6 Lee L-S, Lin C-C, Chung H-C, Au C-F, Fang H-T. A survey on anaesthesia for thoracoscopic sympathetic surgeryin treatment of hyperhidrosis palmaris in Taiwan. Ann ChirGynaecol 2001; 90: 209-211. 7 Leao LEV, de Olivera R, Szulc R, Mari J deJ, Crotti PLR, Goncalves JJS. Role of video-assisted sympathectomy in thetreatment of primary hyperhidrosis. Sao Paulo Med J 2003;121: 191-197. 8 Gossot D, Kabiri H, Caliandro R, Debrosse D, Girard P, Grunenwald D. Early complications of thoracic endoscopicsympathectomy: a prospective study of 940 procedures. AnnThoracic Surg 2001; 71: 1116-1119. 9 Herbst F, Plas EG, Fugger R, Fritsch A. Endoscopic thoracic sympathectomy for primary hyperhidrosis of the upper limbs.A critical analysis and long-term results of 480 operations.Ann Surg 1994; 220: 86-90. 10 Buscher HCJL, Jansen JBMJ, van Dongen R, Bleichrodt RP,
8,12,32
or national
surveys
13
. Compensatory sweating is the major drawback
of ETS. Treatment of this sweating by drugs such as glycopyrrolate or by injection of botulinum toxin is unsatisfactory, and reconstruction using nerve grafts is a major undertaking
33
. Clearly, it would be better to
avoid compensatory sweating in the first place; current work is focusing on different methods of performing ETS, by clipping rather than cutting
34
, for example, or
by concentrating the surgical attack at different levels of the chain for different conditions
35
. Such work is hampered
by a lack of a standard definition of compensatory sweating and an accurate objective method for its measurement. It is unlikely that any randomized clinical trial will emerge; the best one can hope for is accurate standardized recording of the outcome of ETS in future published work.
A similar problem surrounds the other long-term conse-
quences of the operation. For example, the term Horner's syndrome is used as a shorthand for various degrees of ocular complication, ranging from imperceptible miosis to unsightly ptosis. Again, new methods of performing ETS, such as with the harmonic scalpel
36
, have not yet been
shown to affect the incidence. Current knowledge suggests that Horner's syndrome is due to misidentification of the T2 ganglion, to excessive traction on the chain, or to exces- sive use of diathermy
8
. These technical problems should
be reducible by careful surgery.
The traditionally closed world of medicine has been
revolutionized by the internet. This has the advantage of allowing a patient to obtain information about his or her condition and to seek treatment directly from a provider. The disadvantage is that the internet is unregulated and doubt must exist about the quality of information given on websites promoting ETS. A quick perusal of bulletin boards shows that there are patients who are very unhappy following ETS and who seek to have the operation banned. In addition to the consequences of ETS discussed above, patients report lethargy, depression, temperature intolerance, weakness, continuing pain, limb swelling, lack of libido, decreased physical and mental reactivity, oversensitivity to sound, light and stress, poor circulation, cold hands and feet, and weight gain. The fact that
Copyright
2004 British Journal of Surgery Society Ltd
www.bjs.co.uk
British Journal of Surgery 2004; 91: 264-269
Published by John Wiley & Sons Ltd
268
T. A. Ojimba and A. E. P. Cameron
these symptoms cannot be accounted for mechanistically does not make them any less real to the sufferer. As a counterpoint it is well to remember that most patients are pleased with the outcome of ETS.
Finally, it is reassuring to note that not a single
death has been reported in any published series. This suggests that in experienced centres ETS is, indeed, a safe procedure. However, a note of caution is necessary. It is truly difficult to estimate the mortality rate associated with ETS, first because the total number of operations performed is not known and, second, because there is no mechanism whereby deaths must be reported. The deaths discussed above were recognized through informal means and there are certain to be others. It is to be hoped that the new International Society of Sympathetic Surgery will encourage full reporting of mortality and morbidity.
References
1 Hughes J. Endothoracic sympathectomy. Proc R Soc Med
1942; 35: 585-586.
2 Goetz RH, Marr JAS. The importance of the second thoracic
ganglion for the sympathetic supply of the upper extremities.Clin Proc 1944; 3: 102-114.
3 Kux E. Thorakokoskopische Eingriffe am Nervensystem. Georg
Thieme: Stuttgart, 1954.
4 Whatling PJ, Collin J. Botulinum toxin injection is an
effective treatment for axillary hyperhidrosis. Br J Surg 2001;88: 814-815.
5 Collin J, Whatling PJ. Treating hyperhidrosis. Surgery and
botulinum toxin are treatments of choice in severe cases.BMJ 2000; 320: 1221-1222.
6 Lee L-S, Lin C-C, Chung H-C, Au C-F, Fang H-T. A
survey on anaesthesia for thoracoscopic sympathetic surgeryin treatment of hyperhidrosis palmaris in Taiwan. Ann ChirGynaecol
2001; 90: 209-211.
7 Leao LEV, de Olivera R, Szulc R, Mari J deJ, Crotti PLR,
Goncalves JJS. Role of video-assisted sympathectomy in thetreatment of primary hyperhidrosis. Sao Paulo Med J 2003;121: 191-197.
8 Gossot D, Kabiri H, Caliandro R, Debrosse D, Girard P,
Grunenwald D. Early complications of thoracic endoscopicsympathectomy: a prospective study of 940 procedures. AnnThoracic Surg 2001; 71: 1116-1119.
9 Herbst F, Plas EG, Fugger R, Fritsch A. Endoscopic thoracic
sympathectomy for primary hyperhidrosis of the upper limbs.A critical analysis and long-term results of 480 operations.Ann Surg 1994; 220: 86-90.
10 Buscher HCJL, Jansen JBMJ, van Dongen R, Bleichrodt RP,
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