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Ann Thorac Surg 2001;71:1116-1119
© 2001 The Society of Thoracic Surgeons

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Original article: general thoracic

Early complications of thoracic endoscopic sympathectomy: a prospective study of 940 procedures

^a Thoracic Department, Institut Mutualiste Montsouris, Paris, France

Accepted for publication December 18, 2000.

Address reprint requests to Dr Gossot, Thoracic Department, Institut Mutualiste Montsouris, 42 Bd Jourdan, F-75014 Paris, France
e-mail: dominique.gossot{at}imm.fr

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. Thoracic endoscopic sympathectomy (TES) has become the surgical technique of choice for treating intractable palmar hyperhidrosis and is usually considered as a simple and safe procedure. To evaluate the complication rate of TES, we conducted a prospective study of peri- and postoperative complications.

Methods. From 1995 to 1999, 467 consecutive patients were operated on for upper limb hyperhidrosis. There were 164 men and 303 women, ranging in age from 15 to 59 years (mean 31 years). In all but 5 cases, the procedure was bilateral. Eleven patients underwent a reoperation for failure; thus the total number of sympathectomies was 940. The procedure was performed in two stages in 182 patients and in one stage in 267 patients. All patients were seen 1 month after the operation.

Results. There was no mortality. The mean postoperative hospital stay was 2.3 days in the group of patients who were operated on in two stages and 1.1 day in patients who were operated on in one stage. There were three major complications: one tear of the right subclavian artery and two chylothoraces. There were 25 cases (5.3%) of bleeding (300 to 600 mL) during dissection of the sympathetic trunk due to injury to an intercostal vein; in all cases it was controlled thoracoscopically. There were 12 pneumothoraces (1.3%) after removal of chest tubes. All of these were unilateral. Four required chest drainage for a period of less than 24 hours. One patient had a mild pleural effusion. Four patients had a unilateral partial Horner Syndrome (0.4%) that disappeared within 3 months in 2 patients. The other 2 patients were lost to follow-up. One patient complained of rhinitis.

Conclusions. Although morbidity was low, significant complications of TES occurred. Patients should be clearly warned that TES is not as minor a procedure as usually asserted. Complications as well as adverse effects should be considered when discussing this surgical indication.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Thoracic endoscopic sympathectomy (TES) has become the preferred method for treating intractable palmar hyperhidrosis. It has been popularized by European [1–3] and Asian teams [4] reporting a 95% to 99% success rate. Although some recent papers have called for caution with respect to adverse effects such as compensatory sweating [5–7], TES is usually seen as a simple and safe procedure with a short postoperative hospital stay. It has even been proposed as an outpatient procedure [8]. This reputation of safe and benign procedure leads patients and/or physicians to ask for TES without attempting medical therapy. To evaluate the complication rate of TES, we prospectively recorded our results in a series of 940 consecutive sympathectomies.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
From 1995 to 1999, 467 patients were operated on for upper limb hyperhidrosis. All were operated on by a single surgeon. There were 164 men and 303 women, ranging in age from 15 to 59 years (mean 31 years). In all but 5 cases, the procedure was bilateral. Eleven patients underwent a reoperation for failure; thus the total number of sympathectomies was 940.

The technique has been previously described [9]. The procedure was performed under general anesthesia and selective tracheal intubation. No CO₂ insufflation was used. We used a 5-mm, 0 degree telescope and two additional 3-mm ports for microinstruments. The mediastinal pleura was opened and the sympathetic chain was dissected, severed, and removed from the second thoracic ganglion (T2) to the fourth (T4) or fifth ganglion (T5), depending on whether the axillae were involved. Dissection was carried out with high-frequency cautery except at the level of T2, where no coagulation was used to prevent current diffusion to the stellate ganglion.

In 69 patients, a technique of selective sympathectomy was performed. Hence, the main trunk was preserved and only the Rami Comunicantes were divided, according to the description of R. Wittmoser [10]. This technique aimed at reducing the rate of compensatory sweating. Because of the high recurrence rate [9], it was abandoned and we went back to a complete division of the sympathetic chain. All 11 reoperations were in this group of patients.

At the end of the procedure, a 15F chest tube was left in place for a few hours. It was removed after checking the chest roentgenogram and the patients were usually discharged the morning after surgery. All patients received an analgesic prescription and a recommendation form. They were advised to see their general practitioner in case of severe pain to receive a prescription of opioid analgesics. In the beginning of our experience, the procedure was performed in two stages after an interval of 2 weeks (182 patients); then both sides were done as a one-stage procedure (267 patients). All patients were seen 1 month after the operation. Complications were recorded in a database (File-Maker Pro, Claris, Santa Clara, CA) at the time of discharge and on the day of consultation.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
There was no mortality. The mean postoperative stay was 2.3 days in the group of patients who were operated on in two stages and 1.1 day for those operated on in one stage. The success rate was 100% for palmar hyperhidrosis. In the group of patients operated on according to the Wittmoser technique, there were 11 unilateral relapses. Despite some intraoperative difficulties due to pleural adhesions, resecting the sympathetic trunk was always possible and all 11 reoperations were successful.

Intraoperative complications
In 1 patient, the endoscopic approach was impossible on one side because of tight pleural adhesions. The procedure was not converted to open surgery.

There were three major complications. One patient had a tear of the right subclavian artery in the beginning of our experience. It was caused by sliding of the hook during the opening of the mediastinal pleura. An immediate axillary thoracotomy was performed and the tear was sutured. The postoperative course was uneventful and the patient was discharged 4 days later. In 2 patients a chylothorax occurred, one on the left side [11] and one on the right side. The left sided chylothorax was diagnosed only 3 days after the patient had been discharged. It was treated by chest drainage and total parenteral nutrition. The effusion stopped totally after 6 days. The right chylothorax was diagnosed intraoperatively. Two clips were applied on the lymphatic duct. The patient was discharged after 2 days once it was confirmed that the chest drainage was not productive after resumption of oral intake.

There were 25 cases (5.3%) of significant bleeding (300 to 600 mL) during dissection of the sympathetic trunk due to injury to an intercostal vein. The amount of lost blood was not related to the vessel diameter but to the fact that the vessel usually retracted and was difficult to control. In all cases the hemorrhage was controlled thoracoscopically. However, one 3-mm port had to be changed to a 10-mm port because a 3-mm suction tube was inefficient. In addition, in case of long lasting aspiration with a 5-mm suction tube, we had to use a 10-mm trocar to avoid lung inflation. No patient needed blood transfusion.

No other intraoperative complication occurred. Eventually the rate of major intraoperative complications was 3/940 (3/1000) and the total rate was 28/940 (2.9/100).

Postoperative complications
There were 12 pneumothoraces (1.3%) after removal of chest tubes. All of these were unilateral. Four required chest drainage for less than 24 hours. One patient had a mild pleural effusion that resolved after physiotherapy.

Four patients had a unilateral partial Horner syndrome (0.4%). Two recovered within 3 months; the other 2 patients were lost to follow-up. One patient complained of rhinitis.

Although pain was not systematically recorded in our files, it was present in most patients for 2 to 4 weeks. Many patients complained of severe dorsal pain that required prescription of morphinics. Some patients reported pain along the internal aspect of one or both arms during several weeks. This pain always disappeared spontaneously. Three patients mentioned that they would not have been operated on had they known that the postoperative course was so painful. In 1 patient who was scheduled to undergo a two-stage procedure, this was the reason for declining the second operation.

Excluding postoperative pain and the other above-mentioned problems, the total postoperative morbidity was 2/100.

Side effects
At 1 month, 236 patients (50.5%) complained of compensatory sweating. This was considered by patients as acceptable (67%), disturbing (25%), or debilitating (8%).

Of the patients, 33% experienced hand dryness. This condition always improved after some months; no patient found it disturbing. Improvement or even cure of the associated plantar hyperhidrosis was observed in 29% of the patients.

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
Thoracic sympathectomy is an established operation. Although the endoscopic approach was described many years ago [10], it became popular only at the end of the 1980s. TES is now considered the method of choice because of its low morbidity and short hospital stay. The success rate for palmar hyperhidrosis is more than 95% in most reports [1–3, 8, 9, 12–14] and the complication rate is significantly lower than with a conventional open approach [15]. It is therefore considered by patients—seeking information on many dedicated Internet web sites—as a minor and benign procedure. Recently some authors have pointed out the underestimated incidence of adverse effects such as troublesome compensatory sweating [4–6]. The rate of intra- and perioperative complications, although limited, should also be taken into consideration.

There was no mortality in our series as in other recent large series. However, lethal complications have been reported in the literature. Cameron [16] has reported two cases of cerebral edema related to the use of intrapleural CO₂ insufflation. One patient died and the other suffered major neurologic sequellae. Gas insufflation is frequently used by some laparoscopist surgeons, although excessive caution should be used to avoid mediastinal hyperpressure and its consequences. Some surgeons perform thoracoscopy with airtight laparoscopic cannulae, which may worsen the situation because these do not allow air to be released if an intrapleural hyperpressure occurs.

In our series three potentially serious complications were noticed: one tear of the subclavian artery and two chylothoraces. All resolved without sequelae and after a short stay. Cameron [16] has reported another case of subclavian artery injury that required 34 units of blood and that led to secondary graft interposition. Lange [17] reported a case of serious damage to the brachial plexus early in his experience with TES. He stressed the fact that, despite his extensive experience with conventional thoracic sympathectomy, the endoscopic approach made him "lose his way" by misjudging the direction of the nerve fibers. A chylothorax is rare and is more related to anatomical features than to surgical experience. Because it is due to the tear of an accessory duct, it usually remains moderate and can be cured by simple chest drainage and medical therapy [11, 18].

Postoperative Horner’s syndrome (HS) is rare but is found in almost all series. It can be total or partial (without miosis). It is caused by a direct or indirect damage to T1, ie, current diffusion or excessive traction on the nerve during dissection. Postoperative rhinitis is another symptom associated with a T1 lesion [15]. In our series we had four cases of partial HS (0.4%) and one of rhinitis. The reported rate of HS ranges from 0% to more than 3% [2, 15]. Most authors agree than the endoscopic approach reduces the rate of HS because of better visualization. Zacherl and colleagues [15] found a significant difference between the open approach (4.6%) and the endoscopic approach (2.2%). As the magnification of the telescope allows for a much better view of the sympathetic chain and ganglion, one may wonder why HS is still observed. The cause may be the following: (1) diffusion of monopolar HF current to the stellate ganglion; (2) excessive traction on the nerve during dissection, temporarily stretching it; or (3) inadequate localization of the second rib.

The first cause (diffusion of current) can theoretically be avoided by using bipolar or ultrasonic technology. Unfortunately, none of these devices are available with a 3-mm diameter. If operating with microinstruments, we therefore recommend not to use HF when coming close to the apex. In our experience, the mild oozing that is observed when severing the nerve without the help of diathermy has never become a concern. In case of persistent oozing we sometimes introduce a microhemostatic gauze, which is applied on the sympathectomy bed. This maneuver has always been sufficient. The second cause (excessive traction) is the most difficult to prevent. One has to pay attention not to pull on the sympathetic chain or to leave the grasping forceps on the nerve and to release the sympathetic trunk during dissection. The third cause (misdetermination of the second rib) is also an issue. Theoretically, the first rib is not identified from within the thorax. However, some authors claim that it can be seen or at least palpated [19]. We have found it sometimes difficult to determine whether the uppermost visible rib was the first or the second, especially in thin and slim patients. The fat pad that usually covers the inferior part of the stellate ganglion may be lacking. In these cases, it seems preferable to stay away from the apex. Kopelman and colleagues [19] have shown that the rate of HS decreases with experience. However, the four cases of HS that we observed in our series occurred respectively in patients 114, 117, 190, and 389, which is not in favor of a learning curve. We have observed a 1.3% rate of pneumothorax, as in all series (Table 1). Four patients needed redrainage.

At 1 month, 236 patients (50.5%) complained of compensatory sweating. However, definite conclusions cannot be drawn from these data. It has been our experience that some patients seen 1 or 2 months after the operation are satisfied and do not complain of excessive sweating, but do so 1 year later. Conversely, some patients initially complain of disturbing compensatory sweating and do much better after some months. Therefore, estimating precisely the rate of compensatory sweating would require a thorough follow-up of at least 3 years after surgery [2]. This survey is in process. It is expected that the true rate of compensatory sweating will be somewhat higher than the one found at early consultation, as pointed out by Andrews and Rennie [5] who have found this side effect in 85% of their patients.

Currently TES remains the most efficient treatment for upper limb hyperhidrosis. However, considering possible side effects as well as rare but significant complications, patients should be clearly warned that TES is not a minor procedure. From the surgeon’s standpoint, TES is usually considered to be a straightforward procedure; however, experience in endoscopic surgery is essential to cope with a possible intraoperative difficulty [17, 19]. Anesthesia must be done by an anesthesiologist experienced in thoracic surgery and CO₂ insufflation must be proscribed. Adequate equipment is another important component of a safe operation: (1) laparoscopic trocars must be abandoned (two cases of subclavian artery injury reported in the literature are related to trocar insertion [13, 16]); (2) microinstruments should be preferred to conventional 5-mm laparoscopic or thoracoscopic instruments because they are better adapted to the size of nervous structures; and (3) optimal visualization must be obtained (Table 2).

	References

Top Abstract Introduction Patients and methods Results Comment References

1. Drott C., Göthberg G., Claes G. Endoscopic transthoracic sympathectomy: an efficient and safe method for the treatment of hyperhidrosis. J Am Acad Dermatol 1995;33:78-81.[Medline]
2. Herbst F., Plas E.G., Függer 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.[Medline]
3. Rex L., Drott C., Claes G., Göthberg G., Dalman P. The Boras experience of endoscopic thoracic sympathectomy for palmar, axillary, facial hyperhidrosis and facial blushing. Eur J Surg 1998;164:23-26.[Medline]
4. Lin C.C., Mo L.R., Lee S.M., Ng S.M., Hwang M.H. Thoracoscopic T2-sympathectomy block by clipping: a better and reversible operation for treatment of hyperhidrosis palmaris. Experience in 326 cases. Eur J Surg 1998;164:13-16.[Medline]
5. Andrews B.T., Rennie J.A. Predicting changes in the distribution of sweating following thoracoscopic sympathectomy. Br J Surg 1997;84:1702-1704.[Medline]
6. Bonjer H.J., Hamming J.F., du Bois N.A.J.J., van Urk H. Advantages of limited thoracoscopic sympathectomy. Surg Endosc 1996;10:721-723.[Medline]
7. Dohayan A. Transaxillary thoracoscopic sympathectomy experience in a hot climate: management of the dominant hand. Surg Laparosc Endosc 1999;5:317-321.
8. Hsia J., Chen C., Hsu C., Shai S., Yang S. Outpatient thoracoscopic limited sympathectomy for hyperhidrosis palmaris. Ann Thorac Surg 1999;67:258-259.[Abstract/Free Full Text]
9. Gossot D., Toledo L., Fritsch S., Célérier M. Thoracoscopic sympathectomy for upper limb hyperhidrosis: looking for the right operation. Ann Thorac Surg 1997;64:975-978.[Abstract/Free Full Text]
10. Wittmoser R. Thoracoscopic sympathectomy and vagotomy. In: Cuschieri A., Buess G., Perissat J., eds. Operative manual of endoscopic surgery. New York: Springer Verlag, 1992:110-133.
11. Gossot D. Chylothorax after thoracic endoscopic sympathectomy. Surg Endosc 1996;10:949.[Medline]
12. Byrne J., Walsh T.N., Hederman W.P. Endoscopic transthoracic electrocautery of the sympathetic chain for palmar and axillary hyperhidrosis. Br J Surg 1990;77:1046-1049.[Medline]
13. Duarte J., Kux P. Improvements in video-endoscopic sympathectomy for the treatment of palmar, axillary, facial and palmar hyperhidrosis. Eur J Surg 1998;164:9-11.
14. Shachor D., Jedeikin R., Olsfanger D., Bendethan J., Sivak G., Freund U. Endoscopic transthoracic sympathectomy in the treatment of primary hyperhidrosis. Arch Surg 1994;129:241-244.[Abstract/Free Full Text]
15. Zacherl J., Imhof M., Huber E., et al. Video assistance reduces complication rate of thoracoscopic sympathectomy for hyperhidrosis. Ann Thorac Surg 1999;68:1177-1181.[Abstract/Free Full Text]
16. Cameron A.E. Complications of endoscopic sympathectomy. Eur J Surg 1998;164:33-35.
17. Lange J.F. Inferior brachial plexus injury during thoracoscopic sympathectomy. Surg Endosc 1995;9:830.[Medline]
18. Cheng W., Chang C., Lin T. Chylothorax after endoscopic sympathectomy: case report. Neurosurgery 1994;35:330-331.[Medline]
19. Kopelman D., Hashmonai M., Ehrenreich M., Assalia A. Thoracoscopic sympathectomy for hyperhidrosis: is there a learning curve?. Surg Laparosc Endosc 1998;8:370-375.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Dominique Gossot Denis Debrosse Dominique Grunenwald Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Gossot, D. Articles by Grunenwald, D. Search for Related Content PubMed PubMed Citation Articles by Gossot, D. Articles by Grunenwald, D. Related Collections Mediastinum