Survey reveals diverse practices in thoracic sympathetic surgery across Europe

Background: Thoracic autonomic nervous system surgery is mainly used for hyperhidrosis/facial flushing, whereas cardiac and vascular indications are limited. The literature remains controversial regarding the correct indications and surgical technique, with the lack of homogeneous data being a major limitation. We designed a survey to investigate current practice among members of the European Society of Thoracic Surgeons (ESTS).

Methods: A 29-question ad hoc questionnaire was available to all ESTS members from December 2022 to February 2023. It included questions on demographics, indications, preoperative evaluation, technique, complications and follow-up. A descriptive analysis of the data is presented.

Results: The response rate was 7% and 121 of 123 valid responses were analysed. Sympathetic surgery was performed for hyperhidrosis/facial flushing, cardiac and vascular disease in 99%, 29% and 29% of respondents respectively. Palmar hyperhidrosis was the most common, followed by axillary, facial flushing and craniofacial hyperhidrosis. Catecholaminergic ventricular tachycardia was more common than long QT syndrome and Raynaud's over Buerger's disease. Data analysis showed that members preferred nerve cutting to clipping (66%, 64% and 58% for hyperhidrosis/facial flushing, cardiac and vascular disease respectively). Preference for the target level of nerve block varied significantly depending on the condition addressed. For most responders (65%), severe compensatory sweating was an adverse event, occurring in less than 10% of treated cases. Only 52% used a database for follow-up.

Conclusions: Current practice in sympathetic surgery in ESTS responders is consistent with the available evidence, although it is characterized by great heterogeneity in almost all aspects. A database could help to standardize patient selection, surgical techniques and follow-up, and provide the basis for future multi-institutional trials.

Key findings

• This survey has described the habits of a small group of respondents among European Society of Thoracic Surgeons members in the management of thoracic autonomic nervous system surgery.

• Response rate was 7%.

• Sympathetic surgery was adopted for hyperhidrosis/facial blushing, cardiac and vascular diseases by 99%, 29% and 29% of responders. Palmar was the most frequent hyperhidrosis condition, followed by axillary, facial blushing, and craniofacial hyperhidrosis.

• Members prefer nerve cutting over clipping.

• Nerve block target level preference changed significantly based on each addressed affliction.

What is known and what is new?

• Despite many publications in the literature, there are no guidelines for thoracic autonomic nervous system surgery.

• Despite a good level of agreement with the only consensus statement in the world literature, there was a heterogeneity of responses in each section of the questionnaire in this study's result.

What is the implication, and what should change now?

• Our results suggest the need for a common database that could help standardise patient selection, surgical techniques and follow-up, and provide the basis for future multi-institutional trials.