What are the possible complications of endoscopic sympathectomy for axillary hyperhidrosis?

Updated: Feb 12, 2019
  • Author: Richard H S Karpinski, MD, FACS; Chief Editor: Gregory Gary Caputy, MD, PhD, FICS  more...
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Answer

In addition to the problems seen after chest procedures such as bleeding, infection, incisional problems, and pneumothorax, patients who have undergone ETS can also experience compensatory sweating, gustatory sweating, Horner syndrome, eyelid ptosis, and cardiac effects similar to beta-adrenergic blockade.

However, compensatory sweating is the main limitation of sympathetic surgery. In compensatory sweating, patients note increased perspiration over the trunk and upper thighs, especially in hot weather. Compensatory sweating may decrease with time, and most patients find it less objectionable than the hyperhidrosis for which they sought treatment. If patients are questioned carefully, compensatory sweating can be noted in as many as 75% of patients undergoing sympathectomy.

It has been believed that the number of levels interrupted and inclusion of the T2 ganglion in the resection increase the likelihood of severe compensatory sweating. (Current practice would usually employ T2 resection for facial symptoms, T3 for palmar, and T4-T5 for axillary.)

However, a retrospective study by Gunn et al indicated that in patients who undergo endoscopic thoracic sympathectomy for primary hyperhidrosis, the risk of developing compensatory hyperhidrosis may not be influenced by the extent of the surgery. The study, of 97 patients who underwent the procedure for palmar or axillary hyperhidrosis, found that the incidence of compensatory hyperhidrosis did not differ between patients based on whether they underwent resection at the T2-T3, T2-T4, T2-T5, or T2-T6 levels. Only 4 of the study’s patients reported severe compensatory hyperhidrosis. [21]

Gustatory sweating is a rare sequela of ETS. These patients experience the sensation of sweating when they eat, although no excessive sweat is actually produced.

Postoperative Horner syndrome may occur if portions of the stellate ganglion are removed or coagulated. This is fairly uncommon after ETS since the stellate ganglion is well protected by the dome of the pleura. Eyelid ptosis also may occur following ETS.

Following an extensive thoracic sympathectomy (especially one extending down to T5), cardiac effects may occur similar to those produced by beta-adrenergic blockade.

An incomplete sympathectomy may fail to produce symptomatic relief. Failure to find nerves of Kuntz, if present, also may lead to a suboptimal result; these extraganglionic sympathetic pathways are present in at least 10% of patients and must be sought carefully during the resection procedure.


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