1. Aetna considers thoracoscopic sympathectomy medically necessary for any of the following conditions:

   1. Causalgia; or
   2. Raynaud's disease; or
   3. Shoulder-hand syndrome; or
   4. Some types of visceral pain (e.g., chronic pancreatic pain and cancer-derived visceral abdominal pain); or
   5. Vascular occlusive disease; or
   6. Intractable, disabling primary hyperhidrosis (excessive sweating) when all of the following are met (see also CPB 0504 - Hyperhidrosis (Hyperhydrosis))

      1. Iontophoresis or electrophoresis, (e.g., Drionic® device) is ineffective (see CPB 0229 - Iontophoresis) (a trial of botulinum toxin can be substituted for iontophoresis in persons with predominantly axillary hyperhidrosis -- see CPB 0113 - Botulinum Toxin); and
      2. Significant disruption of professional and/or social life has occurred because of excessive sweating; and
      3. Topical aluminum chloride or other extra-strength antiperspirants are ineffective or result in a severe rash; and
      4. Unresponsive or unable to tolerate pharmacotherapy prescribed for excessive sweating (e.g., anti-cholinergics, beta-blockers, benzodiazapines) if sweating is episodic.

2. Aetna considers thoracoscopic sympathectomy cosmetic for excessive spontaneous facial blushing.  Facial blushing (flushing) is considered a cosmetic indication as it does not result in functional impairment.

3. Aetna considers thoracoscopic sympathectomy experimental and investigational for all other indications becasue its effectiveness for indications other than the ones listed above has not been established.

4. Aetna considers left thoracoscopic sympathectomy experimental and investigational for cardiac denervation in persons with ventricular arrhythmias because the effectiveness of this approach has not been established.

See also CPB 0031 - Cosmetic Surgery.

A report by the Finnish Office of Health Technology Assessment systematically evaluated the literature on the safety and effectiveness of thoracoscopic sympathectomy for treatment of sweating and for treatment of social phobia (Malmivaara et al, 2005).  Thoracoscopic sympathectomy aims to reduce excessive sweating of the face and hands and facial flushing by interrupting stimulation of sweat glands by the sympathetic nervous system.  The treatment is performed as an endoscopic procedure, where the upper thoracic chain of the sympathetic nerve trunk is transsected or clamped.

The authors stated that it is difficult to conduct even a qualitative synthesis of studies of thoracoscopic sympathectomy, due to poor reporting of patient characteristics and variation among studies in the reporting of outcomes (Malmivaara et al, 2005).  In addition, the authors found most of the studies to be of poor methodologic quality.  The authors stated, however, that available literature suggests that thoracoscopic sympathectomy reduces excessive sweating of the palms and facial flushing.  Patient satisfaction was reported as good or moderately good.  The authors identified only 1 study that followed subjects for more than 2 years.

The reported rates of acute post-operative complications following endoscopic thoracic sympathetomy varided widely among studies studies (Malmivaara et al, 2005).  Acute post-operative complications, some severe, occurred in as many as 10 % of subjects.  The most commonly reported chronic complication was compensatory sweating below the breast level, often with substantial resultant disability.  Other chronic complications included dryness of the face or palms and gustatory sweating.  The authors noted that, due to wide variation in the reporting of complications, it is probable that these complications have been under-reported in most series.

The authors concluded that "due to lack of controlled trials there is no reliable evidence for the effectiveness of endoscopic thoracic sympathectomy for excessive sweating in the face and hands or for flushing of the face" (Malmivaara et al, 2005).  The authors also found no reliable evidence of the effectiveness of endoscopic thoracoscopic sympathectomy for social phobia.  The authors concluded that endoscopic thoracic sympathectomy is associated with significant immediate and long-term adverse effects.

A follow-up article to the FinOHTA assessment (Malmivaara et al, 2007) re-affirmed these earlier findings, concluding that: "The evidence for the effectiveness of ETS [endoscopic thoracic sympathectcomy] is weak.  The intervention is associated with severe immediate complications in some patients and persistent adverse effects for many."  The methodological quality and the reporting of clinically relevant characteristics were poor.  The quality scores of the included studies ranged from 0 to 8; only 3 studies scored 6 or more.  The authors stated that blushing and excessive sweating decreased after ETS in all studies, but no further details were reported.  Complications following ETS included pneumothorax and/or haemothorax and Horner's syndrome in some patients in almost all studies.  Compensatory excessive sweating was observed in 50 % or more of patients in 13 of the 15 studies, and was considered to cause significant disability in 3 to 15 % of those who experienced it.

A review by the Royal Australasian College of Surgeons (Watt et al, 2009) concluded that "[a] lack of high quality randomised trial evidence on ETS means that it is difficult to make a judgment on the safety and effectiveness of this technique", and that "[t]here is potentially a number of safety issues associated with this procedure."

Patients with palmar hyperhidrosis who fail topical therapies and iontophoresis, and who do not tolerate or get relief from botulinum toxin, can be treated effectively with endoscopic thoracic sympathectomy (Smith, 2008).  Side effects, especially compensatory hyperhidrosis in other parts of the body, may reduce long-term patient satisfaction with this procedure.  Endoscopic thoracic sympathectmy can also be used for axillary hyperhidrosis, but the relapse rate is high.

Hofferberth et al (2014) reported the outcomes of a single-institution experience using video-assisted thoracoscopic left cardiac sympathetic denervation as an adjunctive therapeutic technique in pediatric and young adult patients with life-threatening ventricular arrhythmias.  These investigators conducted a retrospective clinical review of all patients who underwent left cardiac sympathetic denervation by means of video-assisted thoracoscopic surgery at the authors’ institution.  From August 2000 to December 2011, a total of 24 patients (13 with long QT syndrome, 9 with catecholaminergic polymorphic ventricular tachycardia, and 2 with idiopathic ventricular tachycardia) were identified from the cardiology database and surgical records.  There were no intra-operative complications.  The median post-operative length of stay was 2 days (range of 1 to 32 days).  There were no major peri-operative complications.  Longer-term follow-up was available in 22 of 24 patients at a median follow-up of 28 months (range of 4 to 131 months).  Sixteen (73 %) of the 22 patients experienced a marked reduction in their arrhythmia burden, with 12 (55 %) becoming completely arrhythmia-free after sympathectomy.  Six (27 %) of the patients were non-responsive to treatment; each had persistent symptoms at follow-up.  The authors concluded that video-assisted thoracoscopic left cardiac sympathetic denervation can be safely and effectively performed in most patients with life-threatening ventricular arrhythmias.  They stated that this minimally invasive procedure is a promising adjunctive therapeutic option that achieves a beneficial response in most symptomatic patients.  These preliminary findings need to be validated by well-designed studies.