Thoracic autonomic nervous system surgery current application—a survey among members of the European Society of Thoracic Surgeons

Introduction

Thoracic autonomic nervous system surgery is based on interrupting the adrenergic action of the central nervous system. The first surgery on the thoracic sympathetic chain was performed by Alexander in 1889 (1) and was initially proposed to improve circulation in the extremities (2), while Kotzareff is credited with performing the first cervical sympathectomy for hyperhidrosis in 1920 (3). The first physiological perspective of sympathectomy in cardiovascular disease was published by Goetz in 1948 (4). With the advent of video-assisted thoracic surgery (VATS), the thoracoscopic approach became the gold standard. Similarly, sympathetic chain resection or the clipping technique became the most popular strategies (5). Over time, the indications have evolved: Jonnesco extended its use to exophthalmic goiter (6); Franck to glaucoma, idiotism and hyperthyroidism (7). However, many of these indications have become obsolete and palmar hyperhidrosis (PH) is now the most common (8). Several papers have been published to finally define the correct indications and techniques, but evidence is still scarce due to the lack of high-quality data. In conclusion, there are no guidelines, and the debate is still open. To assess the current clinical practice among thoracic surgeons, the European Society of Thoracic Surgeons (ESTS) decided to survey its members to obtain a state-of-the-art overview of thoracic autonomic nerve surgery. We present this article in accordance with the CROSS reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1167/rc).

Methods

The survey consisted of 29 questions grouped into 4 topics (demographics, preoperative assessment, surgical technique, follow-up). As this was an interview with surgical members of the European Society of Thoracic Surgeons, not involving patients or sensitive data, no consent was required. Multiple choice responses were formatted to avoid ambiguous and uninformative responses. Some questions allowed for multiple answers. Four final questions investigated the use of a database and whether members felt it was appropriate to implement a shared database. Finally, an additional question assessed interest in participating in future studies. This study was conducted in accordance with the Declaration of Helsinki (as revised in 2013).

Of the 1,683 ESTS members, 1,677 were successfully informed of the survey by email. The questionnaire was available from December 2022 to February 2023. It was submitted using the www.surveymonkey.com format, after approval by the ESTS Council. During this period, 3 email reminders were sent to encourage completion of the survey before the study closed. All responses were voluntary and anonymous. If a member completed the questionnaire twice, only the first attempt was considered. If a member stated that they did not practice sympathetic surgery, any subsequent response was not included.

Demographic data and IP address allow us to detect repeated responses. If a member completed the questionnaire twice, only the first attempt was considered. If a member stated that they did not practice sympathetic surgery, any subsequent response was not included. Data are presented as numbers and percentages. Categorical variables were tested using the χ² test or Fisher’s exact test for expected values less than 5, as appropriate.

Statistical analysis

Data analysis was aimed at investigating any significant difference in the observed frequencies in favor of nerve resection or clipping for each condition at different nerve target levels (relative to the upper rib margin: R). Our aim was to understand whether respondents tended to adopt a preferred nerve block technique. In terms of nerve target, we looked at the level at which blocks are usually performed for both cutting and clipping techniques.

Results

From December 5, 2022, to February 27, 2023, a total of 123 actual respondents (response rate 7%) started the questionnaire. Everyone practiced thoracic autonomic nervous system surgery but one. One member fulfilled the survey twice. Therefore, the final number of responses that we considered was 121. Raw results for each question are reported in the supplementary file (Appendix 1 https://cdn.amegroups.cn/static/public/10.21037jtd-24-1167-1.pdf). Demographics are reported in Table 1 and Figure 1.

Figure 1 Worldwide distribution of members who completed the questionnaire.

Enrolment and preoperative assessment

Thoracic autonomic nervous system surgery was used to treat hyperhidrosis/facial flushing in 120 (99%) responders, and both cardiac and vascular disease in 36 (30%) responders. General practitioners and dermatologists were the specialists most likely to refer patients to thoracic surgeons, according to 81 respondents. Self-referral was mentioned by 78 respondents. Of those performing thoracic autonomic nervous system surgery for hyperhidrosis/facial flushing, only 3% said they performed more than 75 cases per year, another 3% between 51 and 75 cases per year, 15% between 26 and 50, 36% between 10 and 25, 43% less than 10 cases per year. Conversely, for cardiac and vascular conditions, only 11% and 3% respectively reported performing more than 10 (but never more than 26) operations per year. Palmar and axillary conditions were treated surgically by 94% and 74% of respondents respectively, followed by facial flushing (43%) and craniofacial hyperhidrosis (CFH) (24%). Catecholaminergic ventricular tachycardia refractory to conventional therapy, long QT syndrome (LQTS) and arrhythmias were treated in 50%, 42% and 36% of responders respectively. Raynaud’s syndrome and thromboangiitis obliterans (Buerger’s disease) were treated in 83% and 36% of responders, respectively. Seventy-four out of 120 (61%) surgeons said they selected patients with hyperhidrosis based on personal experience, 20% used the Hyperhidrosis Quality of Life Scale (HDSS), 10% used the Hyperhidrosis Quality of Life Index (HidroQol) and 1.00% used the Dermatology Life Quality Index (DLQI).

Surgical technique

Biportal thoracoscopy was chosen by 50%, 58% and 50% of surgeons for hyperhidrosis/facial flushing, cardiac and vascular disease respectively, followed by uniportal (31%, 67% and 9%) and triportal (8%, 11% and 8%); The choice to operate on both sides during the same operation was made by 63%, 50% and 28% of the respondents, while the choice to operate on one side at a time was made by 12%, 9% and 31% for hyperhidrosis/facial flushing, cardiac and vascular diseases respectively. One-lung ventilation with or without intrapleural CO₂ was used by 73%, 89% and 81% of surgeons for hyperhidrosis/facial flushing, cardiac and vascular disease, respectively, while single-lumen intubation was used by 23%, 11% and 17% of surgeons. While awake surgery was performed by 4%, 0% and 3% of responders respectively. Nerve transection was chosen by 66%, 64% and 58% of respondents for hyperhidrosis/blushing, cardiac and vascular disease respectively, followed by nerve transection for hyperhidrosis/blushing alone (21%). In contrast, ganglion excision was the second choice for treating heart disease (25%) and vascular disease (31%) (Figure 2). A percentage of respondents (8%, 3% and 11% for the three conditions treated respectively) stated that they did not always use the same technique but modified it from time to time according to the needs and symptoms of the individual patient. Data analysis showed a significance (P<0.05) in favor of nerve transection for several hyperhidrosis/blushing, cardiac and vascular conditions (Tables 2-4). In terms of nerve target, for PH, R3 was preferred for cutting and clipping by 72% and 33% of the 120 responders, respectively, followed by R4 (56% and 27%), R2 (19% and 8%) and R5 (6% and 3%). For axillary hyperhidrosis (AH), level R4 was preferred by 58% and 28% of respondents, followed by R3, R5 and R2.

Figure 2 Distribution of surgical techniques used to obtain sympathetic nerve block.

For facial flushing, R2 (46% and 28%) was followed by R3, R4 and R5, as well as for CFH (Figure 3). The same questions were asked for each of the cardiac and vascular conditions (Figures 4,5). In addition, statistical analysis was performed to determine whether there was a significant difference between the frequencies with which a particular nerve target level was selected for each pathological condition. Given an R-level, from R2 to R6, and a surgical technique, we compared each condition to determine which was statistically more frequent. The results showed a significant (P<0.005) difference in the frequency with which different conditions were reported for each target level, whether clipping or cutting. Respondents always preferred nerve block at R2 in CFH and facial blushing (FB) over PH and AH, R3 in PH and AH over FB and CFH, R4 in AH over PH, FB and CFH, R5 in AH over FB and CFH. We report that in the R4 nerve resection group, the surgeons surveyed preferred FB and CFH over AH and PH as indicated for the clipping group. Data were also analyzed for hyperhidrosis/blushing, cardiac and vascular disease (supplementary files are Available at: https://cdn.amegroups.cn/static/public/10.21037jtd-24-1167-2.pdf, https://cdn.amegroups.cn/static/public/10.21037jtd-24-1167-3.pdf, https://cdn.amegroups.cn/static/public/10.21037jtd-24-1167-4.pdf). We also investigated surgeons’ opinions on the role of robotic-assisted thoracic surgery (RATS) and 6 of them responded that RATS will soon replace VATS in this surgery.

Figure 3 The frequency with which each nerve target level (R) was selected for each condition and surgical technique in hyperhidrosis.

Figure 4 Frequency of each nerve target level (R) for each condition and technique in vascular conditions. Three lines overlap each other and all on the 0 line on the ordinates. The lines for R7, R9, R10, and >R10 fully coincide at the 0% level on the y-axis.

Figure 5 Frequency of each nerve target level (R) for each condition and technique in cardiac conditions. Three lines overlap each other and all on the 0 line on the ordinates. The lines for R6, R9, R10, and >R10 fully coincide at the 0% level on the y-axis.

Perioperative management

Regarding chest drain management, 37% did not place a chest drain perioperatively, 36% removed it in the operating room and discharged the patient, 12% removed it on postoperative day (POD)-1 and discharged the patient, 7% removed the drain in the ward on the day of surgery and discharged the patient on POD-1, 4% removed it in the ward on POD-0 and then discharged the patient.

Follow-up

Pneumothorax was the most common complication reported by respondents (72%), followed by Claude Bernard Horner syndrome (32%), hemothorax and persistent air leak (24%), Harlequin syndrome (12%), chylothorax (4%) and empyema (0.83%). A total of 66% respondents experienced severe compensatory sweating in less than 10% of cases, 14% in 10–20% of cases, 3% in 20–30% of cases and 3% in more than 30% of cases. For severe compensatory sweating, 53% of respondents usually preferred non-invasive medical approaches such as oxybutynin or even referral to a dermatologist. Only 13% of respondents said they preferred a surgical approach, such as nerve declipping (8%), nerve reconstruction (3%) and diffuse sympathectomy (2%).

Sixty-three (53%) of respondents reported using a hyperhidrosis/blushing follow-up database. Of those, 37% investigated the level of patient satisfaction and in this case 29% recorded a satisfaction rate >90%. Finally, 94% agreed with the usefulness of a common database and 88% agreed with the need for guidelines.

Discussion

There is still considerable controversy in the current literature regarding the correct indications and techniques for thoracic autonomic nervous system surgery. The lack of comprehensive, homogeneous and randomized data is one of the main reasons for the lack of guidelines. The recommendations published in 2011 (9) are still the most authoritative support available. In this scenario, we designed the present survey to investigate the current habits of the ESTS community. The aim of this survey was to give a broad description of the whole possible panorama of thoracic autonomic nervous system surgery. Within this framework, two main areas can be distinguished. The first was mainly aimed at obtaining demographic information to understand which pathologies were most commonly treated and by which specialists, and the second was mainly focused on surgical technique and strategy to assess whether there was homogeneity of action.

The response rate was approximately 7%, which is lower than data reported in the literature on online surgical surveys [average response rate of 53.3%±24.5%, in surveys of healthcare professionals (10)], while previous ESTS surveys ranged from 8% to 23%. This result may indicate a lack of interest in the survey or that few surgeons are performing the technique. This could also be since the respondents were spread all over the world, but mainly in Europe, North America and Brazil, and not with the same distribution of hyperhidrosis prevalence, which varies in different parts of the world. In fact, the global prevalence of hyperhidrosis ranged from 2.8% to 4.8% in the United States, while in Asia it was estimated to be 13.95% in Japan and 18.4% in China (11). While this low response rate makes our survey less representative, it is also an indication that this issue, which is the domain of the thoracic surgeon, is under-reported. In addition, to better understand these data, it is worth noting that almost all respondents confirmed that they performed this type of surgery, thus representing a community of experts.

In 2022, Lee et al. published a paper on the knowledge of surgical management of hyperhidrosis among primary care physicians and the general public in the USA (12). The results were dramatic, concluding that neither primary care physicians nor the general public recognize the role of thoracic surgeons. On the contrary, our survey showed that general practitioners and dermatologists are the main referring physicians for hyperhidrosis, followed by cardiac and vascular surgeons for the pathologies in their field.

Primary hyperhidrosis/facial flushing was the most represented area of interest, treated by 99% of respondents, whereas only 30% performed this surgery for cardiac or vascular disease. In terms of volume, two data emerged: (I) the low number of procedures performed per surgeon (only 26 surgeons reported more than 25 cases per year); (II) the predominance of hyperhidrosis/facial flushing cases; 89% and 97% of those treating cardiac and vascular pathology, respectively, performed fewer than 10 cases per year. These data are consistent with the literature, but the low volumes recorded contrast with the high incidence of hyperhidrosis in the global population and some large population series (13). We would argue that there is a selection bias towards surgeons performing sympathectomies in this survey (99% of respondents), these are the surgeons who have general practitioners and dermatologist colleagues who understand the role of the thoracic surgeon in these patients. However, the remaining 93% of ESTS members may not have appropriate referral pathways for these patients due to a lack of knowledge from GPs or dermatologists.

Sympathetic blockade is widely used for palmar, axillary and facial hyperhidrosis, but indications are still controversial due to side effects (14). PH is the main indication for nerve block, while AH has been considered for surgery with VATS advent, also because medical therapy also guarantees good results. For CFH, surgery is considered the last option due to frequent side effects. Sympathetic blockade for blushing is less commonly used despite good results, probably because of the high complication rate (15). Our survey is consistent with this trend, as 94% of respondents performed surgery for PH, 74% for AH and only 24% for facial hyperhidrosis. FB was treated by 43% of surgeons.

Nowadays, thoracic surgery of the autonomic nervous system has little place in cardiac pathology. Regarding arrhythmias, its role is still considered useful only in selected patients. Nerve block is re-emerging as a possible adjunctive therapy for ventricular resistant arrhythmias (16) in patients who do not respond to conventional medications. In channelopathies (LQTS and CPVT), the threshold for sympathetic block is somewhat lower (17,18). Recent paediatric guidelines (19) recommend cardiac sympathectomy for ventricular tachycardia (VT) or VT/fibrillation storm refractory to antiarrhythmic drugs, LQTS and catecholaminergic polymorphic VT. Criteria are still unclear regarding (I) patient selection and (II) bilateral versus left-sided approach (20). The emerging scenario among ESTS members is that only 30% of all responders performed thoracic autonomic nervous system surgery for cardiac dysfunction, 50% for ventricular resistant arrhythmias and 42% for LQTS. Furthermore, although the role of sympathetic denervation in cardiac functionally altered conditions has been highlighted (21), only 17% of responders chose to perform ganglion ablation.

Sympathetic surgery is not indicated in vascular obstructive patterns, whereas a benefit has been demonstrated in Buerger’s disease (22). In spastic ischaemia, sympathetic surgery may improve ulceration or gangrene symptoms in advanced stages (23). Raynaud syndrome is the one that benefits most from sympathetic surgery in advanced stages, but the benefits are temporary (24). Only 30% of respondents underwent sympathetic surgery for vascular disease: 83% for Raynaud syndrome, 36% for Buerger’s disease and 31% for vasculitis. In addition, 44% referred patients for surgery for chronic pain syndromes.

Both two-stage unilateral and single-stage bilateral approaches are effective and safe; the single-stage bilateral approach is probably associated with a lower incidence of compensatory sweating (25). This approach also seems to be preferred by our respondents. Data on surgery without a chest tube are poor (26). Respondents were also divided, with 37% saying they did not use a chest tube, and of those who did, the majority (45 members) preferred to remove it at the end of the operation. The core of sympathetic surgery is the nerve activity block. According to the STS expert consensus (9), this can be achieved by either cutting or clipping the nerve, as there is no clear advantage in terms of success and recurrence rate (27). Cutting is usually performed with electrocautery, but the use of energy devices has also been described. Some authors have argued that clipping should be preferred because it may offer reversibility in cases of poor satisfaction, such as severe compensatory sweating. However, the efficacy of clip removal is still controversial (28). Cerfolio et al. (9) stated that the failure of reversibility is probably related to perineural damage, which is usually irreversible. Although both techniques are widely used, ESTS responders seem to prefer cutting over clipping for most hyperhidrosis, cardiac and vascular conditions.

The correct level of interruption remains controversial, but it is generally accepted that the lower the interruption, the lower the risk of compensatory sweating. For this reason, R2 block has gradually been abandoned in favor of R2-free surgery, except in the case of flushing. However, the final correct target level (from R2 to R6) for each condition has not yet been defined. Again, the STS consensus (9) suggested the following pattern: (I) PH: R3 interruption; (II) R4 and R5 interruption for palmar-axillary, palmar-axillary-plantar, or AH alone; (III) R3 for patients with CFH without blushing. Our data suggest that a representative proportion of respondents followed this consensus. In fact, regardless of technique, surgeons preferred a different target level depending on the affection to be treated.

According to the literature, the most common complications are Bernard-Horner syndrome (0.7–3% of cases), pneumothorax requiring pleural tube drainage (1%), pleural effusion (1%), acute bleeding or delayed hemothorax (1%), chylothorax and persistent intercostal neuralgia (1%) (9). Our respondents experienced the same complications as above, but pneumothorax seems to be the most common. Severe compensatory sweating is the most feared side effect after sympathectomy for hyperhidrosis (9). Its incidence depends on several variables and ranges from 3.0% to 98.0% (29). Our results seem encouraging, since 66% of the responders had severe compensatory hyperhidrosis in less than 10% of cases and only a few (3%) in more than 30% of cases. Interestingly, only 13% of surgeons used surgery in cases of severe compensatory sweating, preferring a medical strategy despite the poor results. Unfortunately, only 52% of respondents said they had set up a patient follow-up database. In addition, only 70% of the databases recorded patient satisfaction. We believe that patient satisfaction is just as important in hyperhidrosis management as success or adverse event rates. In fact, paradoxically, there is often an apparent discrepancy between a high satisfaction rate and severe compensatory sweating (30). Most respondents answered that RATS will not replace VATS, despite encouraging recent literature (31).

Since the lack of conclusive evidence in this area is due to the difficulty of comparing data from different series that are not very homogeneous, we believe that the solution may lie in the adoption of a common database. This should be designed to collect comparable information (e.g., using numerical scales) on preoperative patient characteristics, surgical techniques, and outcomes in terms of sweating management, compensatory sweating in specific body areas, and patient satisfaction. An international database could also ensure a significant number of enrolled patients in a scenario characterized by limited case numbers. This survey seems to confirm that respondents agree with our opinion. The study has potential limitations: (I) the data suffer from non-response bias: surgeons who perform sympathetic surgery are more likely to participate; (II) the results may not be representative of the entire ESTS community (the so-called “volunteer effect”); (III) participants may change their opinion as a result of participating in a study.

Conclusions

Our results do not constitute recommendations but simply reflect current clinical practice among ESTS and are also very limited by the low percentage of members who responded to the questionnaire. The data, limited to the results of our survey, revealed a behaviour that is fairly consistent with the literature and can be briefly summarized as follows: sympathetic surgery is most commonly used for hyperhidrosis/FB disorders (mainly palmar and AH), the R3–R4 block is generally the most commonly used, while the R2 block is generally preferred for facial flushing. Despite these indications of preference, a heterogeneity of responses was noted in each section of the questionnaire, indicating an absence of common behavior on the part of respondents. While this phenomenon is a consequence of the lack of common recommendations or guidelines, it also points to an absolute need. However, our questionnaire also reveals a worrying lack of data collection, particularly in terms of follow-up, for which it will be difficult to obtain hard evidence in the coming years. Our final message is therefore an invitation, addressed specifically to the scientific societies involved, to (I) promote the involvement of thoracic surgeons in these pathologies through cross-training events; (II) promote a data collection programme at international level to collect as much data as possible and, above all, in a homogeneous manner.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CROSS reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1167/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1167/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1167/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1167/coif). H.F.B. reports that he receives consulting fees from Medtronic and Johnson & Johnson. N.M.N. reports that she had leadership roles within the ESTS and advisory board participation for 2 companies J&J and AZ, and had received payment from Medela about Educational event 2022. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are responsible for all aspects of the work to ensure that questions about the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). As this was an interview with surgical members of the European Society of Thoracic Surgeons, not involving patients or sensitive data, no consent was required.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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