To study the time course of ipsilateral shoulder pain after thoracic surgery with respect to incidence, pain intensity, type of pain (referred versus musculoskeletal), and surgical approach. Prospective, observational cohort study. Odense University Hospital, Denmark. Sixty patients for major lung resection. Postoperative observation of ipsilateral shoulder pain. Postoperative numeric rating scale score of shoulder pain and thoracic pain and postoperative examination of the sites of shoulder pain for musculoskeletal involvement (muscle tenderness on palpation and movement) with follow-up 12 months after surgery. Clinically relevant pain was defined as a numeric rating scale score>3. Of the 60 patients included, 47 (78%) experienced ipsilateral shoulder pain, but only 25 (42%) reported clinically relevant shoulder pain. On postoperative day 4, 19 patients (32%) still suffered shoulder pain, but only 4 patients (7%) had clinically relevant pain. Four patients (8%) still suffered shoulder pain 12 months after surgery. In 26 patients (55%), the shoulder pain was classified as referred versus 21 patients (45%) who suffered shoulder pain of the musculoskeletal type. Shoulder pain of the musculoskeletal type was significantly more intense (p = 0.0008) than referred shoulder pain. Only a subset of patients has clinically relevant shoulder pain after postoperative day 2. Chronic shoulder pain is a minor problem after lobectomy and previously may have been overestimated. Ipsilateral shoulder pain of the musculoskeletal type is more intense than referred ipsilateral shoulder pain.

Knowledge about the impact of Low-Molecular-Weight Heparin (LMWH) on the coagulation system in patients undergoing minimal invasive lung cancer surgery is sparse. The aim of this study was to assess the effect of LMWH on the coagulation system in patients undergoing Video-Assisted Thoracoscopic Surgery (VATS) lobectomy for primary lung cancer. Sixty-three patients diagnosed with primary lung cancer undergoing VATS lobectomy were randomized to either subcutaneous injection with dalteparin (Fragmin^®) 5000 IE once daily or no intervention. Coagulation was assessed pre-, peri-, and the first two days postoperatively by standard coagulation blood test, thromboelastometry (ROTEM^®) and thrombin generation. Patients undergoing potential curative surgery for lung cancer were not hypercoagulable preoperatively. There was no statistically significant difference in the majority of the assessed coagulation parameters after LMWH, except that the no intervention group had a higher peak thrombin and a shorter INTEM clotting time on the first postoperative day and a lower fibrinogen level on the second postoperative day. A lower level of fibrin d-dimer in the LMWH group was found on the 1. and 2.postoperative day, although not statistical significant. No differences were found between the two groups in the amount of bleeding or number of thromboembolic events. Use of LMWH administered once daily as thromboprophylaxis did not alter the coagulation profile per se. As the present study primarily evaluated biochemical endpoints, further studies using clinical endpoints are needed in regards of an optimized thromboprophylaxis approach.

Axillary hyperhidrosis affects approximately 1.4% of the population. Medical management is often frustrating, and the response generally transient. Surgical methods include thoracoscopic sympathectomy or sympathicotomy and local axillary surgery such as suction-curettage or en-bloc skin resection. Many case series with retrospective follow-up are available in the literature, but no comparative studies between surgical techniques have been published. During a 9-year period, two groups of consecutive patients with isolated axillary hyperhidrosis underwent thoracoscopic sympathicotomy (n = 49) or local axillary surgery (n = 47) at the same university hospital, depending on referral or preference. Patients received identical questionnaires to investigate local effect and side effects after surgery. Questionnaires were returned by 92% after a median of 26 months, with no significant difference between the two groups. Local effect was significantly better after axillary surgery compared with sympathicotomy (p < 0.001), but mild recurrent axillary symptoms were significantly more frequent after axillary surgery (51% versus 5%, p < 0.001). Compensatory and gustatory sweating were significantly more frequent after sympathicotomy (84% versus 25%, p < 0.001; and 54% versus 26%, p = 0.01, respectively). Outcome after surgery for isolated axillary hyperhidrosis was significantly better after local surgical treatment compared with sympathicotomy. Local effect was better and side effects fewer, but milder recurrent symptoms were more frequent. Compensatory sweating also occurs after local axillary surgery and has not been reported before. Our results suggest that local axillary surgery is preferable for isolated axillary hyperhidrosis and that R2-R3 or R2-R4 sympathicotomy should be discouraged. Sympathicotomy should only be considered for patients who have additional palmar hyperhidrosis.

Thoracoscopic sympathectomy is now used routinely to treat patients with disabling primary hyperhidrosis or facial blushing. Published results are excellent, but side effects, such as compensatory sweating, are also very frequent. The surgical techniques used and the levels of targeting the sympathetic chain vary tremendously. Most surgeons transect or resect the sympathetic chain, but application of a metal clip that blocks transmission of nerve impulses in the sympathetic chain is used increasingly worldwide. This approach offers potential reversibility if patients regret surgery, but the question of reversibility remains controversial. Two recent experimental studies found severe histological signs of nerve damage 4–6 weeks after clip removal, but they only used conventional histopathological staining methods. Thoracoscopic clipping of the sympathetic trunk was performed in adult sheep, and the clip was removed thoracoscopically after 7 days. Following another 4 weeks (n = 6) or 12 weeks (n = 3), the sympathetic trunks were harvested and analysed by conventional and specific nerve tissue immunohistochemical stains (S100, neurofilament protein and synaptophysin). The contralateral sympathetic chains were used as controls. Conventional and immunohistochemical stains demonstrated severe signs of neural damage on the operated side 4 weeks after clip removal. After 12 weeks, these changes had decreased markedly and conventional histology had almost normalized. Conventional and immunohistochemical stains confirmed that application of metal clips to the sympathetic chain caused severe histological damage in the sympathetic trunk that remained visible 4 weeks after clip removal. However, after 12 weeks, these signs of damage had clearly decreased, which suggests in theory that application of metal clips to the sympathetic chain is a reversible procedure if only the observation period is prolonged. Further studies with longer periods between application and removal as well as investigations of nerve conduction should be encouraged, because we do not know whether histological reversibility at cellular level translates into physiological reversibility and possible correlation of nerve trauma with the duration of the applied clip.