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ETS Surgery: Complications
Compensatory hyperhidrosis
Gustatory and phantom sweating, transient post-ETS
hyperhidrosis
Horner’s syndrome, neuralgia, and cardiac effects
Recurrence of hyperhidrosis
Other surgical complications
Compensatory hyperhidrosis
Compensatory hyperhidrosis is excessive sweating of the
abdomen, chest, back, thighs, and face,[6,72]
usually in response to increased temperature.[46] This is the
most common complication following ETS, reported to occur
at an average rate of about 60%, with a range of 3% to 98%.[46]
Higher rates have been reported from countries with warmer
climates, such as in Asia and the Middle East.[46,82]
The sweating can be severe for 10% to 40% of patients.[10]
Although it has been written that compensatory sweating diminishes
with time, several series have documented continued symptoms
with longer-term follow-up.[46] In one series of 270 patients
followed for a mean of 15 years postsympathectomy, 67% still
complained of compensatory sweating, and overall satisfaction
fell from an initial level of 96% to 67%.[55]
It is possible that patients begin to notice compensatory
sweating some time after ETS, as they are initially more aware
of the marked reduction of their primary hyperhidrosis.[46]
The mechanism for compensatory sweating is unclear; the
most likely explanation is that sweating in the trunk increases
to compensate for the lack of sweating from the denervated
areas in order to maintain thermoregulation.[82]
The occurrence of decreased sweating in other areas not innervated
by the ganglia treated by ETS suggests that the response to
ETS is more complex. The soles are the most common area with
decreased sweating post-ETS, and, along with the axillae and
palms, sweating from these areas could be under cortical control,
separate from the hypothalamic centers involved in thermoregulation.[72]
It has also been proposed that ganglion destruction affects
axons of neurons in the interomediolateral spinal cord, which
could lead to cell death or re-organization, changing the control
of the sympathetic system by the spinal cord and higher, leading
to increased sympathetic tone in the other body areas not
treated by ETS.[10]
Some studies suggest that the extent of sympathectomy may
be related to the incidence of compensatory sweating. Unilateral
ETS to treat the dominant hand was associated with a lower
incidence of compensatory sweating.[46]
Eight of 10 patients who had simple disconnection of the T2
ganglion from the stellate ganglion complained only of mild
increased sweating in other body areas.[10]
However, in one series there was no difference in incidence
of this side effect in groups with T2 and T2-T3 sympathectomy.[82]
Gustatory and phantom sweating, transient post-ETS hyperhidrosis
Several other types of sweating are seen post-ETS for which
the etiology is also unclear. Gustatory sweating, or facial
sweating due to spicy or other foods, occurs in 17% to 57%
of patients.[6,72,82]
One explanation for this phenomenon is that aberrant regeneration
of sympathetic nerves leads to an anastomosis with the sympathetic
trunk and the vagus.[6,82]
Another possibility is overactivity of the still-intact or
regenerated sympathetic nerve fibers to the face.[6]
Another poorly understood post-ETS phenomenon is phantom
sweating, in which patients sense sweat coming out of the skin
pores without actual sweating. This occurs in 4% to 48% of
patients by 18 months after surgery.[72,106]
Up to a third of patients have several days of increased
sweating following initial dryness from day 3 to day 5 after ETS.
This phenomenon is thought to be due to degeneration of the
postganglionic fibers, which leads to a transient increase
in activity of the sweat glands. Patients should be warned
in advance of this possibility.[72]
Horner’s syndrome, neuralgia, and cardiac effects
Horner’s syndrome—unilateral upper eyelid ptosis,
pupil constriction, and facial anhidrosis—can occur
as a temporary post-ETS complication or can be permanent. The
incidence of transient Horner’s syndrome can be as high
as 0.8%.[72]
Permanent Horner’s syndrome occurs in up to 0.1% of cases.[72]
Possible causes include an anatomic variation of the stellate
ganglion, mistaking the stellate ganglion for the ganglion
targeted by ETS, or electric current delivered to the stellate
ganglion during electrocautery of the chain below.[82]
One group found a much lower rate of Horner’s syndrome
when ETS was done with video assistance, presumably because of improved intraoperative visualization.[152]
Neuralgia or pain in the limb denervated by sympathectomy
occurs in up to 32% of patients some time after the procedure
and is transient.[72]
Bilateral T2-T4 sympathectomy reduces the systolic blood
pressure without affecting diastolic blood pressure and lowers the heart
rate at rest and during exercise.[72]
Recurrence of hyperhidrosis
Recurrence of excessive sweating occurs in about 1% of patients
in the first year following the procedure and in about 2% to
5% in subsequent years.[55,72,106]
Possible causes for recurrence include an inadequate ablation
or resection or nerve regeneration post-ETS. Nerve regeneration
has been seen at second operations.[106]
Other possible etiologies for recurrence include unrecognized
anatomic variations such as residual sympathetic pathways
to the affected limb, such as a C8 or T1 contribution to peripheral
nerve fibers or a Kuntz nerve.[72,106]
Other surgical complications
Postoperative pneumothorax occurs in 2% to 3% of patients
and is less likely when ETS is done with video assistance
or smaller thoracoscopes.[127,151,152]
Chest tube drainage is needed on occasion.[151]
Hemothorax occurred in 0.3% of patients in the largest published
series.[72]
Two cases of cardiac arrest during the procedure have
been reported, both responding to resuscitation; sympathetic
nerve stimulation has been shown to increase the risk for
arrhythmia in patients with prolonged QT syndrome.[72]
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