The amount of compensatory sweating depends on the patient, the damage that the white rami communicans incurs, and the amount of cell body reorganization in the spinal cord after surgery.
Other potential complications include inadequate resection of the ganglia, gustatory sweating, pneumothorax, cardiac dysfunction, post-operative pain, and finally Horner’s syndrome secondary to resection of the stellate ganglion.
www.ubcmj.com/pdf/ubcmj_2_1_2010_24-29.pdf

After severing the cervical sympathetic trunk, the cells of the cervical sympathetic ganglion undergo transneuronic degeneration
After severing the sympathetic trunk, the cells of its origin undergo complete disintegration within a year.

http://onlinelibrary.wiley.com/doi/10.1111/j.1439-0442.1967.tb00255.x/abstract

Spinal cord infarction occurring during thoraco-lumbar sympathectomy
J Neurol Neurosurg Psychiatry 1963;26:418-421 doi:10.1136/jnnp.26.5.418

Friday, February 11, 2011

Sympathectomy is one of the causes or Orthostatic Hypotension

Causes of Orthostatic Hypotension

Peripheral

Amyloidosis

Diabetic, alcoholic, or nutritional neuropathy

Familial dysautonomia (Riley-Day syndrome)

Guillain-Barré syndrome

Paraneoplastic syndromes

Pure autonomic failure (formerly called idiopathic orthostatic hypotension)

Surgical sympathectomy

http://www.merckmanuals.com/professional/sec07/ch069/ch069d.html

Thursday, February 10, 2011

Why do surgeons still advertise ETS for axillary sweating?

Apocrine Gland: One of two types of sweat gland, located in several places including the armpits, face and groin. The sweat produced is normally oil based as opposed to common water based sweat and is rarely affected by Sympathectomy.

http://www.hyperhidrosis.us/hyperhidrosis-glossary.php

cervical ganglionectomy produces a significant reduction in the noradrenergic innervation of ip- silateral extraparenchymal arteries

Immediately following experimentation the cerebral vessels were examined
for the presence of noradrenergic fibers. The results of the study demonstrate that:
(1) superior cervical ganglionectomy produces a significant reduction in the noradrenergic innervation of ipsilateral extraparenchymal arteries;
(2) the peripheral sympathetic nervous system contributes to overall cerebral vascular resistance primarily by affecting resistance in extraparenchymal arteries; and
(3) as a result, it determines the contribution of the extraparenchymal arteries tooverall cerebral blood flow autoregulation.
1975;6;284-292 Stroke

Autonomic neuropathy simulating the effects of sympathectomy

Autonomic neuropathy simulating the effects of sympathectomy as a complication of diabetes mellitus. Diabetes 1955;4:92-97.
Odel HM, Roth GM, Keating FR,

interrupting sympathetic efferent fibers innervating the heart and baroreflex

The results suggest that cardiac sympathectomy induced by epidural anesthesia can suppress partially baroreceptor function by interrupting sympathetic efferent fibers innervating the heart during high levels of epidural anesthesia, but that lumbar sympathectomy during epidural anesthesia is unlikely to affect baroreceptor activity.
Baroreflex control of heart rate during cardiac sympathectomy by epidural anesthesia in lightly anesthetized humans.

Dohi S, Tsuchida H, Mayumi T
Anesth Analg 1983; 62:815-20.

Baroreflex sensitivity, measured as cardiac acceleration in response to nitroglycerin, was significantly lower (p < style="font-weight: bold;">The results suggest that baroreflex-mediated response to decreases in arterial pressure is dependent on the integrity of the sympathetic nervous system.

Baroreflex control of heart rate during high thoracic epidural anaesthesia. A randomised clinical trial on anaesthetised humans.
Goertz A, Heinrich H, Seeling W
Anaesthesia 1992; 47:984-7.

causes of autonomic dysfunction - sympathectomy

Patients with progressive autonomic dysfunction (including diabetes) have little or no increase in plasma noradrenaline and this correlates with their orthostatic intolerance (Bannister, Sever and Gross, 1977). In patients with pure autonomic failure, basal levels of noradrenaline are lower than in normal subjects (Polinsky, 1988). Similar low values are observed in patients with sympathectomy and in patients with tetraplegia. (p.51)

The finger wrinkling response is abolished by upper thoracic sympathectomy. The test is also abnormal in some patients with diabetic autonomic dysfunction, the Guillan-Barre syndrome and other peripheral sympathetic dysfunction in limbs. (p.46)

Other causes of autonomic dysfunction without neurological signs include medications, acute autonomic failure, endocrine disease, surgical sympathectomy . (p.100)

Anhidrosis is the usual effect of destruction of sympathetic supply to the face. However about 35% of patients with sympathetic devervation of the face, acessory fibres (reaching the face through the trigeminal system) become hyperactive and hyperhidrosis occurs, occasionally causing the interesting phenomenon of alternating hyperhidrosis and Horner's Syndrome (Ottomo and Heimburger, 1980). (p.159)

Disorders of the Autonomic Nervous System
By David Robertson, Italo Biaggioni
Edition: illustrated
Published by Informa Health Care, 1995
ISBN 3718651467, 9783718651467

Some secondary effects of sympathectomy; with particular reference to disturbance of sexual function

N Engl J Med. 1951 Jul 26;245(4):121-30.
WHITELAW GP, SMITHWICK RH.

PMID: 14853048 [PubMed - indexed for MEDLINE]

Safety and Ethics in Healthcare

"...professionals may adopt unreasonable practices. Practices may develop in professions, particularly as to disclosure, not because they serve the interests of the clients, but because they protect the interests or convenience of members of the profession. The court has an obligation to scrutinize professional practices to ensure that they accord with the standard of reasonableness imposed by the law."
Incresingly, the question is not whether the defendant's conduct conforms with the practices of the profession, but whether it conforms with standards of reasonableness. (p. 150)

The right of patients self-determination is well entrenched both in law and in ethical codes. Respect for patient autonomy now occupies centre stage in medical ethics. In considerin patient autonomy one needs to think about truth telling, confidentiality, privacy, disclosure of information and consent. Each is important and all have important implications for healthcare professionals. (p. 167)

Safety and Ethics in Healthcare: A Guide to Getting it Right
By Bill Runciman, Alan Merry
Published by Ashgate Publishing, Ltd., 2007
ISBN 0754644375, 9780754644378

Wednesday, February 9, 2011

Bilateral sympathectomy produced fatal heart block in a few of their experiments

Mendlowitz. Schauer, and Gross4 pointed out that the heart rate became slower after removal of the sympathetic chain, but this bradycardia was only temporary. Bilateral sympathectomy produced fatal heart block in a few of their experiments.

American Heart Journal
Volume 22, Issue 4, October 1941, Pages 545-548

bradycardia and other cardiac complications are common side effects?

The most common side effects of sympathectomy are compensatory sweating, gustatory sweating and cardiac changes including decreasing heart rate, systolic-diastolic and mean arterial pressure. The mechanism of bradycardia and other cardiac complications that develop after thoracic sympathectomy are still unclear.

http://tipbilimleri.turkiyeklinikleri.com/abstract_54802.html

Tuesday, February 8, 2011

"It is a lie that sympatholysis (sympathectomy) may specifically cure patients

with unqualified "reflex sympathetic dystrophy". This was already stated by the father of sympathectomy, Rene Leriche, more than half a century ago.
...it is not an error. but a lie. While conceptual errors are not only forgivable, but natural to inexact medical science, lies, particularly when entrepreneurially inspired are condemnable and call for a peer intervention.

J. Neurology (1999) 246: 875-879

sympathectomy reduces fear - interferes with a range of emotional responses


"Experiements in animals demonstrate that sympathectomy may retard averse conditioning. (DiGusto and King, 1972), most likely because sympathectomy reduces fear."
Clinical Neuropsychology 2003

Monday, February 7, 2011

There is potentially a number of safety issues associated with this procedure

"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. There is potentially a number of safety issues associated with this procedure. ASERNIP-s suggests that a full systematic review including all available comparative and case series information, together with clinical inpuut, should be undertaken to provide up-to-date and comprehensive assessment of the safety and effectiveness of ETS." (ASERNIP-s Report No. 71, August 2009)

Elective surgery associated with unacceptable complications

Most of the difficulties associated with hyperhidrosis surgery are due to unavoidable side effects and unforeseeable and unacceptable complications. Careful patient selection is important before surgery so surgeons can avoid some of these pitfalls. Patients should also be fully informed of all potential side effects and complications before surgical treatment.
http://www.ncbi.nlm.nih.gov/pubmed/18557592

Based on the case reported and systematic literature review sympathectomy seems to have at best a temporary effect

Conclusions: Based on the case reported and systematic literature review, chemical sympathectomy seems to have at best a temporary effect, limited to cutaneous allodynia. Despite the popularity of chemical sympatholysis, only few patients and poorly defined outcomes are reported in the literature, substantiating the need for well-designed studies on the effectiveness of the procedure.
Clinical Journal of Pain:
December 2001 - Volume 17 - Issue 4 - pp 327-336

After sympathectomy for hyperhidrosis, very severe discomfort and hyperhidrosis occurred with alarming frequency and intensity

"After thoracoscopic sympathectomy for hyperhidrosis, very severe discomfort and hyperhidrosis in the neighboring non-sympathectomized regions occurred with alarming frequency and intensity."
(p.879)

Cousins and Bridenbaugh's Neural Blockade in Clinical Anesthesia and Pain Medicine by Michael J Cousins, Phillip O Bridenbaugh, Daniel B Carr, and Terese T Horlocker
Wolters Kluwer Health
Edition: 4 - 2008

Cautiously worded, yet it still means the same: ETS = Lobotomy

Knowledge of the elimination of embarrassing physical symptoms in social situations helps the patient to expose himself to formerly impossible situations, and success in them also causes psychological symptoms to subside. But the relief of psychological symptoms may also be due to direct a biological effect of the operation on the anxiety-mediating areas in the nervous system. The only meaningful side effect is compensatory sweating of the trunk, but not even that is significant when modern surgical method are used. (sic!)

http://informahealthcare....0.1080/08039480310000266

Sunday, February 6, 2011

nerve damage as 'cure'

What the surgeons tell you: (is not always based on scientific evidence)

"The procedure is extremely effective for palmar and axillary hyperhidrosis. The endoscopic technique is very safe and is curative in 98% of patients."

" Thoracoscopic sympathectomy afforded almost instantaneous cures for PH, with marked improvement in 100% for whom the sympathectomy was done."
(CENTER FOR THE CURE (sic!) OF HYPERHIDROSIS

http://curesweatypalms.com/Hyperhidrosis_Surgical_Treatment.htm

Systematic reviews, long term follow-ups of patients tell a different story. The many forums on the internet with stories of injured patients tell a different story.

Sympathectomy leads to calcinosis

Of 20 patients who had no evidence of calcinosis pre-operatively, 11 developed medial calcification after unilateral operation exclusively on the side of sympathectomy. In seven patients calcinosis was detected in both feet after bilateral operation. In conclusion, sympathetic denervation is one of the causes of Monckeberg's sclerosis regardless of diabetes mellitus.

Goebel FD, Fuessl HS.
Diabetologia. 1983 May;24(5):347-50.

"Lifestyle" surgical procedure carries unrecognized risk of complications.”

Wiley & Sons, Inc, news release - 2004

"Lifestyle" surgical procedure carries unrecognized risk of complications.”
Hoboken, NJ: John Wiley & Sons, Inc, British Journal of Surgery, Feb 5, 2004

Side effects were common

UK Review of ETS surgery

We did not identify any controlled trials or cohort studies. The evidence about effectiveness, based on three case series, was therefore very limited. The main weakness of these studies was their lack of a comparison group and their resulting inability to exclude a placebo response to surgery. In addition, the methods of assessing outcome were poorly described and not validated, and the range of outcomes assessed was limited. The studies provided very limited evidence that sympathectomy improves blushing. Side effects were common.
London: Bazian Ltd (Editors), Wessex Institute for Health Research and Development, University of Southampton 2003: 11

The practice of surgical and chemical sympathectomy is based on poor quality evidence, uncontrolled studies and personal experience

Cochrane Database Syst. Review
”The practice of surgical and chemical sympathectomy is based on poor quality evidence, uncontrolled studies and personal experience.“
Cochrane Database Syst Rev. 2003;(2):CD002918.

The intervention leads to severe immediate complications in some of the patients

Finnish Review

Conclusions: The evidence of the effectiveness of ETS is weak due to a lack of randomized trials. The intervention leads to severe immediate complications in some of the patients, and to persistent side-effects for many of the patients.
UniversityofOuluand FinnishOfficeforHealthTechnologyAssessment
FinnishOfficeforHealthTechnologyAssessment
UniversityofHelsinki and FinnishOfficeforHealthTechnologyAssessment
UniversityofCopenhagenand FinnishOfficeforHealthTechnologyAssessment

poor* evidence is available about ETS as regards side effects, risks, and short-term effects

Swedish Review

The findings by SBU Alert show that poor* evidence is available about ETS as regards side effects, risks, and short-term effects. There is no* scientific evidence demonstrating the long-term results of the method or its cost effectiveness in relation to other methods.
(Swedish Council on Technology Assessment in Health Care (SBU), the Medical Products Agency, the National Board of Health and Welfare, and the Federation of Swedish County Councils.
Published: 1999-08-30 Revised: 2002-09-30

Reported success stories on ETS are "prone to bias and have significant methodological problems"

Australian Review of ETS surgery - 2001

The four case series were not critically appraised because they are prone to bias and have significant methodological problems. These studies represent level IV evidence according to the NHMRC criteria and one should not draw firm conclusions from their findings.

To date, the benefits or side effects associated with endoscopic thoracic sympathectomy for treating facial blushing have not been properly evaluated and reported.

Further research using a well-designed controlled trial is warranted to assess the efficacy of endoscopic thoracic sympathectomy for treating facial blushing.

Centre for Clinical Effectiveness - Monash

There is potentially a number of safety issues associated with this procedure

Australian Review of ETS surgery

"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. There is potentially a number of safety issues associated with this procedure. ASERNIP-s suggests that a full systematic review including all available comparative and case series information, together with clinical inpuut, should be undertaken to provide up-to-date and comprehensive assessment of the safety and effectiveness of ETS." (ASERNIP-s Report No. 71, August 2009)

pathophysiology of cervical and upper thoracic sympathetic surgery

What your ETS or ESB surgeon will not tell you during the consultation:

T(2)-T(3) ganglionectomy significantly decreases pulse rate and systolic blood pressure, reduces myocardial oxygen demand, increases left ventricular ejection fraction and prolongs Q-T interval. A certain loss of lung volume and decrease of pulmonary diffusion capacity for CO result from sympathectomy. Histomorphological muscle changes and neuro-histochemical and biochemical effects have also been observed.

Clin Auton Res. 2003 Dec;13 Suppl 1:I40-4.

Instead, you will be told:

"Usually the surgery is used to treat sweating in the palms or face. The surgery stops or turns off the nerve signals that tell the part of the body to sweat too much."
http://www.nlm.nih.gov/medlineplus/ency/article/007291.htm

or this:

"The procedure turns off the signal that tells the body to sweat excessively. It is usually done on patients whose palms sweat much more heavily than normal."

or this:

"This method does not involve the cutting of the sympathetic nerves. Instead, the surgeon interrupts their activity by applying a titanium clamp to the nerve, thus stopping their activity. The clamp exerts pressure on the nerve and the signals the nerve produces don’t reach the sympathetic nerve endings. This is method that has a positive effect in the sense that the sympathetic ganglia are not destroyed. This leaves the patient with the possibility of having the nerves reconstructed in the future by simply removing the titanium clamp."
http://www.hyperhidrosis.us/ets.php

All the above statements are carefully crafted to make the surgery appear harmless, easy and safe. Yet, ETS and ESB procedures disrupt the nerve signals not only to the sweat glands but other structures and systems in the body, most notably the heart, resulting in Bradycardia in patients, who are unaware that they are signing up for a surgery that potentially will impact on their neurocardiology.

prevents them from responding to reflex or emotional changes in the central nervous system

“...cervical sympathectomy or some pathological condition, isolates all these sympathetic ganglion cells from the central nervous system and prevents them from responding to reflex or emotional changes in the central nervous system.
Cunningham's Manual of Practical Anatomy: Volume III: Head, Neck and Brain (Oxford Medical Publications) 1986

Parallels between Lobotomy and Sympathectomy

Both surgeries were obscure and unpopular until a "minimally invasive" version led to mass-marketing.

Both surgeries featured positive stories in the media. Walter Freeman had several glowing write-ups in the New York Times and Life Magazine.

Both surgeries featured dubious published studies touting the safety and effectiveness. One very large 1962 study said that 28% had been cured by lobotomy, another 25% significantly improved, 20% showed no change (from lobotomy!!) 4% died, and only 2% were made worse off.

The doctors treated the patients as throw-away people and were only concentrating on the potential good, and to hell with those who were much worse off afterwards.

The procedure increasingly was done on less and less serious cases and it was done on people who didn't have problems severe enough for a Last Resort procedure.

Bad results were ignored or hidden. People were ashamed and embarrased that they had done the procedures. A famous example: Rosemary Kennedy

The doctors thought they were heros. Portuguese neurologist Egas Moniz got the Nobel Prize for his work with Lobotomy, a prize that the families are trying to have revoked.

It took a very long time for the public to finally realize how barbaric and innaproprate and destructive this surgery really was. It looks like it might take just as long for widespread acceptance of the destructiveness of ETS

In both instances medical professionals were reluctant to openly criticize their colleagues or speak up about undisclosed harmful effects of the procedure.

http://etsandreversals.yuku.com/reply/9783/Lobotomy-Barbaric-surgery#reply-9783