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.

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