Endoscopic thoracic sympathectomy
Encyclopedia
Endoscopic thoracic sympathectomy (ETS) is a surgical procedure where certain portions of the sympathetic nerve trunk are destroyed. ETS is used to treat hyperhidrosis
, facial blushing
, Raynaud's disease and reflex sympathetic dystrophy. By far the most common complaint treated with ETS is palmar hyperhidrosis, or "sweaty palms". In this disorder, the palms may constantly shed so much sweat that the affected person is unable to handle paper, sign documents, keep clothes dry, or shake hands. The result is often social phobia
so severe as to be disabling.
Sympathectomy physically destroys some tissue anywhere in either of the two sympathetic trunks, which are long chains of nerve ganglia
lying along either side of the spine. Each nerve trunk is broadly divided into three regions: cervical (neck
), thoracic (chest), and lumbar
(lower back). The most common area targeted in sympathectomy is the upper thoracic region, that part of the sympathetic chain lying between the first and fifth thoracic vertebrae.
In addition to the normal risks of surgery, such as bleeding and infection, sympathectomy has several specific risks, such as adverse changes in how nerves function.
.
There are reports of ETS being used to achieve cerebral revascularization for patients with moyamoya disease, and to treat headaches, hyperactive bronchial tubes, long QT syndrome
and other conditions.
Thoracic sympathectomy can alter many bodily functions, including sweating
, vascular responses, heart rate
, heart stroke volume
, thyroid
, baroreflex
,lung volume, pupil dilation, skin temperature, goose bumps
and other aspects of the autonomic nervous system
, like the fight-or-flight response
. It may diminish the body's physical reaction to exercise.
in the upper thoracic region of the sympathetic nervous system
, thus interrupting neural messages that ordinarily would travel to many different organs, glands and muscles. It is via these nerves of the autonomic nervous system that the brain is able to make adjustments in the body in response to changing conditions in the environment, changing emotional states, level of exercise, and other factors to maintain the body's homeostasis
.
When performed endoscopically, the surgeon penetrates the chest cavity, making holes about the diameter of a straw between ribs. This allows the surgeon to insert the video camera in one hole and a surgical instrument in another.
Sympathectomy is accomplished by dissecting the nerve tissue of the main sympathetic chain. The clamping method, also referred to as endoscopic sympathetic blockade (ESB) employs titanium clamps around the nerve tissue, and was developed in an attempt to make the procedure reversible. However, reversal of the clamping procedure must be performed within a short time after clamping (a few days or weeks at most), and recovery may not be complete.
Swedish National Board of Health and Welfare statement on treatment results says: "A large amount of international studies shows that an incision on the sympatikotomi nerve gives a very positive result when it comes to hand perspiration and also that the side effects are rare." Critics have raised serious questions about the methodology of such studies.
Sympathectomy works by disabling part of the autonomic nervous system, by surgically destroying it, and disrupting the signals to the brain. Many non-ETS doctors find this to be disturbing, as symptoms of the ANS dysfunction go further than the disabled thermoregulation. Sympathectomy prevents the occurrence of a variety of bodily changes, and hence, prevents sensory feedback of those changes.
Exact results of ETS are impossible to predict, because of considerable anatomic variations in sympathetic nerve function from one patient to the next, and also because of variations in surgical technique. The autonomic nervous system is not anatomically exact and connections might exist with different parts of the body. This theory has been proven by the fact that a significant number of patients who have had sympathectomy for hand sweating might notice a reduction or elimination of feet sweating. No reliable operation exists for foot sweating per se except lumber sympathectomy.
Lumbar sympathectomy is largely of historical interest today, being reserved for cases of severe sympathetic dystrophy or selected cases of rest pain, where is it usually done by percutaneous ablation of the lumbar sympathetic chain by phenol injection under imaging guidance. Its original use as an operation for lower limb ischaemia has been superseded by direct revascularisation operations or endovascular revacularisation procedures such as angioplasty or angioplasty with stenting of occuded arteries with reasonable runoff i.e. endovascular surgery.
Studies by ETS surgeons have claimed an initial satisfaction rate around 85-95% with at least 2%-19% regretting the surgery and up to 51% of the patients complaining about decreased quality of life. One study shows a satisfaction rate as low as 28.6. Most patients report various adverse reactions as a result of the surgery. However, ETS surgeon Samuel S. Ahn of UCLA claims "100% success with no negative side effects".
A large study of psychiatric patients treated with this surgery showed significant reductions in fear
, alertness
and arousal
. (Teleranta, Pohjavaara, et al. 2003, 2004). Arousal is essential to consciousness, in regulating attention and information processing, memory and emotion.
This study also proves what many patients have claimed, that the surgery caused psychological changes. You cannot reduce 'bad' emotional responses, like fear or anxiety. If you reduce emotional responses, they will affect the whole range of emotions and their intensity. With the elimination of the heart rate variability, emotions are also 'capped'.
ETS patients are being studied using the autonomic failure protocol headed by David Goldstein, M.D. Ph.D., senior investigator at the U.S National Institute of Neurological Disorders and Stroke. He has documented loss of thermoregulatory function, cardiac denervation, and loss of vasoconstriction
.
Recurrence of the original symptoms due to nerve regeneration or nerve sprouting can occur within the first year post surgery, but regeneration can start years after sympathectomy. Nerve sprouting, or abnormal nerve growth after damage or injury to the nerves can cause other further damage. Sprouting sympathtetic nerves can form connections with sensory nerves, and lead to pain conditions that are mediated by the SNS. Every time the system is activated, it is translated into pain.
This sprouting and its action can lead to Frey's syndrome
, a well recognized after effect of sympathectomy, when the growing sympathetic nerves innervate salivary glands. This leads to excessive sweating when eating. For patients different tastes can trigger this abnormal facial sweating (curiously this happens in the area where people who have undergone this procedure can not sweat any more normally). For some it only occurs with hot food, for others, with hot, sour - even by eating an apple, or sweet. Smelling can also cause abnormal reactions, as the signals get mixed up.
Nerve regeneration and subsequent abnormal synapses is a well-documented phenomena.
Some patients have required an artificial pacemaker
after developing bradycardia
(slow heart beat) as a side effect of the surgery.
(collapsed lung) can occur (2% of patients).
Compensatory hyperhidrosis
(sweating) is common over the long term, causing 1-2 percent of patients in one review to regret having had the surgery. The rates of severe compensatory sweating vary widely between studies, ranging from as low as 1.2% and as high as 30.9% of patients. Of those patients that develop this side effect, about a quarter said it was major and disabling.
ETS can cause corposcindosis, in which the patient feels like he or she is living in two separate bodies: one half of the body is numb or "dead," and the other half has hyperactive sympathetic nerve function.
The Finnish Office for Health Care Technology Assessment concluded in a 40 page systematic review that Endoscopic Thoracic Sympathectomy is associated with significant immediate and long-term adverse effects.
Quoting the aforementioned (see Results) Swedish National Board of Health and Welfare statement: "The method can give permanent side effects that in some cases first will become obvious after some time. One of the side effects might be increased perspiration on different places on your body. Why and how this happens is still unknown. According to the research available about 25-75% of all patients can expect more or less serious perspiration on different places on their body, such as the trunk and groin area, this is Compensatory sweating.
However, it is also mentioned in the research that 0-10% regret having the surgery done for this reason. Other documented side effects are the inability to raise the heart rate when working out physically. This has in some cases led to decreased ability to perform your work and daily activities. Some patients also complained of not being able to control their body temperature and it is experienced from being very uncomfortable to disabling. However description of a changing sweating pattern does not give a comprehensive picture of the permanently disabled thermoregulation
. Consequences of this go far beyond some discomfort wearing damp, in some cases dripping clothes and showing up in public.
A reduced efficiency in maintaining normal body temperature in warm environments is consistent with the reduced ability or complete inability to sweat above the nipple line, a common ETS outcome first shown by Dr. Kotzareff. For a fully clothed person, only the hands, cranial region and neck are typically exposed. In a hot environment, a normal person's body is cooled primarily by evaporation of water vapor through the warmest areas of exposed skin
. These areas are associated with the head and neck, which under very warm circumstances or vigorous exercise, visibly show moisture (sweat) accumulating as part of the cooling process. For an ETS patient that has lost ability to sweat from cranium, neck, and arms, an increased amount of body heat must be rejected via transpiration
/sweating
involving skin of the lower body. Unfortunately, this skin is generally at a lower temperature and usually covered by clothing - both factors that reduce the cooling efficiency and result in poor thermoregulation
. An uncomfortably warm sensation and accumulation of sweat on large areas of skin underneath clothing can result. This is one theory on the aetiology of the increased sweating phenomenon after sympathectomy. However one of the pioneers of the procedure, Dr Lin, who performed over 7000 procedures, disputes the compensatory nature of the so called Compensatory Sweating. According to him this is a result of the dysregulated thermoregulation and hypothalamus. He objects to using the "Compensatory" term, he sees as misleading. Postoperative sweating phenomenon is a reflex response between sympathetic system and Hypothalamus. "It is absolutely not a compensatory mechanism. The term of “Reflex sweating” instead of compensatory sweating is used. Hypothalamus is the center of Autonomic Nervous System, which influences human mind, mentality and endocrine system. For this sake, Dr. Lin emphasized, “Endoscopic Sympathetic Surgery helps us open a gate to Autonomic Nervous System”.
There is much disagreement among ETS surgeons about the best surgical method, optimal location for nerve dissection, and as to the nature and extent of the consequent primary effects and side effects. The internet now features many websites run by surgeons extolling the benefits of ETS backed by patient testimonials. However, there are also many websites run by disabled ETS victims who complain of severe adverse reactions and lack of adequate informed consent. Several online discussion forums are dedicated to the subject of ETS surgery, where both positive and negative patient testimonials abound, but considering that this is an elective surgery for a benign condition, even a small number of badly affected number of patients is a high number.
In 2003, ETS was banned in its birthplace, Sweden, due to overwhelming complaints by disabled patients. In 2004, Taiwanese health authorities banned the procedure on patients under 20 years of age. In other countries it is highly unregulated procedure. Although it was never evaluated for safety and adverse effects, sympathectomy is listed on Medical Benefits Scheme, and is freely available to public patients.
In 2006, the FinOHTA group, the Finnish Office for Health Technology Assessment, showed in a review that there were strong indications of side effects as a result of this surgery.
• No systematic reviews, meta-analyses, or clinical trials that evaluated the
effectiveness of endoscopic thoracic sympathectomy for treating facial
blushing were identified. However, we have identified four case series
related to the request (Drott et al. 1998, Rex et al. 1998, Telaranta 1998,
Yilmaz et al. 1996). These studies were conducted in three countries
(Sweden, Finland and the Netherlands).
• 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. (Omar Ahmed PhD Centre for Clinical Effectiveness Monash Medical Centre Australia)
Other long term adverse effects:
Ultrastructural Changes in the Cerebral Artery Wall Induced by Long-Term Sympathetic Denervation
Sympathectomy eliminates the psychogalvanic reflex
Cervical sympathectomy reduces the heterogeneity of oxygen saturation in small cerebrocortical veins
Sympathetic denervation is one of the causes of Mönckeberg's sclerosis
T2-3 sympathectomy suppressed baroreflex control of heart rate in the patients with palmar hyperhidrosis. We should note that baroreflex response for maintaining cardiovascular stability is suppressed in the patients who received the ETS.
ETS patients should be warned that these mechanisms may play a role in the development of exertional heat stroke.
Morphofunctional changes in the myocardium following sympathectomy.
In none of the limbs studied after sympathectomy could an increase in blood flow be produced reflexly by warming; in the majority of instances the opposite response, a decrease in blood flow was observed. One patient with documented transection of the spinal cord above T5 behaved like subjects after surgical sympathectomy.
Retarded adaptation of hemodynamics to a sudden start of exercise after sympathectomy. The significant fall in left circumflex coronary flow was proportional to the decline in external heart work due to sympathectomy both at rest and under exercise.
Chemical sympathectomy is associated with increased pulmonary metastases.
runs to almost every organ, gland and muscle system in the body. It was surmised that these nerves play a role in how the body regulates many different body functions in response to changes in the environment, exercise and emotion.
The first sympathectomy was performed by Alexander in 1889. Since the sympathetic nervous system
was well known to affect many body systems, the surgery was performed in attempts to treat many conditions, including idiocy, goitre
, epilepsy
, glaucoma
, and angina pectoris. Thoracic sympathectomy has been indicated for hyperhidrosis
(excessive sweating) since 1920, when Kotzareff showed it would cause anhidrosis
(total inability to sweat) from the nipple
line upwards.
A lumbar sympathectomy was also developed and used to treat excessive sweating of the feet and other ailments, and typically resulted in impotence in men. Lumbar sympathectomy is still being offered as a treatment for plantar hyperhidrosis, or as a treatment for patients who have a bad outcome (extreme 'compensatory sweating') after thoracic sympathectomy for palmar hyperhidrosis or blushing; extensive sympathectomy risks hypotension
.
Sympathectomy itself is relatively easy to perform; however, accessing the nerve tissue in the chest cavity by conventional surgical methods was difficult, painful, and spawned several different approaches. The posterior approach was developed in 1908, and required resection
(sawing off) of ribs. A supraclavical (above the collar-bone) approach was developed in 1935, which was less painful than the posterior, but was more prone to damaging important nerves and blood vessels.
Because of these difficulties, and because of disabling sequelae associated with sympathetic denervation, conventional or "open" sympathectomy was never a very popular procedure, although it continued to be practiced for hyperhidrosis, Raynaud's disease, and various psychiatric disorders. With the popularization of lobotomy
in the 1940s, sympathectomy fell out of favor as a form of psychosurgery
.
The endoscopic version of thoracic sympathectomy was pioneered by Goren Claes and Christer Drott in Sweden
in the late 1980s. The development of endoscopic "minimally invasive" surgical techniques have decreased the recovery time from the surgery and increased its popularity. Today, ETS surgery is practiced in many countries throughout the world.
In the late 1990s a group of Swedish ETS patients complaining of disabling side effects formed the organization FFSO (people disabled by sympathectomy). The group grew to over 300 members and their work led to the procedure being banned in Sweden. The two surgeons who pioneered the technique, Drott and Claes, moved their practice from Sweden. They still perform the surgery.
Pro-surgery websites
Hyperhidrosis
Hyperhidrosis is the condition characterized by abnormally increased perspiration, in excess of that required for regulation of body temperature.-Classification:Hyperhidrosis can either be generalized or localized to specific parts of the body...
, facial blushing
Blushing
Blushing refers to the involuntary reddening of a person's face due to embarrassment or emotional stress, though it has been known to come from being lovestruck, or from some kind of romantic stimulation. It is thought that blushing is the result of an overactive sympathetic nervous system...
, Raynaud's disease and reflex sympathetic dystrophy. By far the most common complaint treated with ETS is palmar hyperhidrosis, or "sweaty palms". In this disorder, the palms may constantly shed so much sweat that the affected person is unable to handle paper, sign documents, keep clothes dry, or shake hands. The result is often social phobia
Social anxiety disorder
Social anxiety disorder , also known as social phobia, is an anxiety disorder characterized by intense fear in social situations causing considerable distress and impaired ability to function in at least some parts of daily life...
so severe as to be disabling.
Sympathectomy physically destroys some tissue anywhere in either of the two sympathetic trunks, which are long chains of nerve ganglia
Ganglion
In anatomy, a ganglion is a biological tissue mass, most commonly a mass of nerve cell bodies. Cells found in a ganglion are called ganglion cells, though this term is also sometimes used to refer specifically to retinal ganglion cells....
lying along either side of the spine. Each nerve trunk is broadly divided into three regions: cervical (neck
Neck
The neck is the part of the body, on many terrestrial or secondarily aquatic vertebrates, that distinguishes the head from the torso or trunk. The adjective signifying "of the neck" is cervical .-Boner anatomy: The cervical spine:The cervical portion of the human spine comprises seven boney...
), thoracic (chest), and lumbar
Lumbar
In tetrapod anatomy, lumbar is an adjective that means of or pertaining to the abdominal segment of the torso, between the diaphragm and the sacrum ...
(lower back). The most common area targeted in sympathectomy is the upper thoracic region, that part of the sympathetic chain lying between the first and fifth thoracic vertebrae.
In addition to the normal risks of surgery, such as bleeding and infection, sympathectomy has several specific risks, such as adverse changes in how nerves function.
Indications
ETS is most commonly used to treat severe hyperhidrosis of the upper body, Raynaud's phenomenon, and facial blushingBlushing
Blushing refers to the involuntary reddening of a person's face due to embarrassment or emotional stress, though it has been known to come from being lovestruck, or from some kind of romantic stimulation. It is thought that blushing is the result of an overactive sympathetic nervous system...
.
There are reports of ETS being used to achieve cerebral revascularization for patients with moyamoya disease, and to treat headaches, hyperactive bronchial tubes, long QT syndrome
Long QT syndrome
The long QT syndrome is a rare inborn heart condition in which delayed repolarization of the heart following a heartbeat increases the risk of episodes of torsade de pointes . These episodes may lead to palpitations, fainting and sudden death due to ventricular fibrillation...
and other conditions.
Thoracic sympathectomy can alter many bodily functions, including sweating
Sweating
Perspiration is the production of a fluid consisting primarily of water as well as various dissolved solids , that is excreted by the sweat glands in the skin of mammals...
, vascular responses, heart rate
Heart rate
Heart rate is the number of heartbeats per unit of time, typically expressed as beats per minute . Heart rate can vary as the body's need to absorb oxygen and excrete carbon dioxide changes, such as during exercise or sleep....
, heart stroke volume
Stroke volume
In cardiovascular physiology, stroke volume is the volume of blood pumped from one ventricle of the heart with each beat. SV is calculated using measurements of ventricle volumes from an echocardiogram and subtracting the volume of the blood in the ventricle at the end of a beat from the volume...
, thyroid
Thyroid
The thyroid gland or simply, the thyroid , in vertebrate anatomy, is one of the largest endocrine glands. The thyroid gland is found in the neck, below the thyroid cartilage...
, baroreflex
Baroreflex
The baroreflex or baroreceptor reflex is one of the body's homeostatic mechanisms for maintaining blood pressure. It provides a negative feedback loop in which an elevated blood pressure reflexively causes heart rate to decrease therefore causing blood pressure to decrease; likewise, decreased...
,lung volume, pupil dilation, skin temperature, goose bumps
Goose bumps
Goose bumps, also called goose flesh, goose pimples, chill bumps, chicken skin, funky spots, Dasler Bumps, chicken bumps or the medical term cutis anserina, are the bumps on a person's skin at the base of body hairs which may involuntarily develop when a person is cold or experiences strong...
and other aspects of the autonomic nervous system
Autonomic nervous system
The autonomic nervous system is the part of the peripheral nervous system that acts as a control system functioning largely below the level of consciousness, and controls visceral functions. The ANS affects heart rate, digestion, respiration rate, salivation, perspiration, diameter of the pupils,...
, like the fight-or-flight response
Fight-or-flight response
The fight-or-flight response was first described by Walter Bradford Cannon....
. It may diminish the body's physical reaction to exercise.
Procedure
Sympathectomy involves division of adrenergic, cholinergic and sensory fibers which elaborate adrenergic substances during the process of regulating visceral function. It involves dissection of the main Sympathetic trunkSympathetic trunk
The sympathetic trunks are a paired bundle of nerve fibers that run from the base of the skull to the coccyx.-Structure:...
in the upper thoracic region of the sympathetic nervous system
Sympathetic nervous system
The sympathetic nervous system is one of the three parts of the autonomic nervous system, along with the enteric and parasympathetic systems. Its general action is to mobilize the body's nervous system fight-or-flight response...
, thus interrupting neural messages that ordinarily would travel to many different organs, glands and muscles. It is via these nerves of the autonomic nervous system that the brain is able to make adjustments in the body in response to changing conditions in the environment, changing emotional states, level of exercise, and other factors to maintain the body's homeostasis
Homeostasis
Homeostasis is the property of a system that regulates its internal environment and tends to maintain a stable, constant condition of properties like temperature or pH...
.
When performed endoscopically, the surgeon penetrates the chest cavity, making holes about the diameter of a straw between ribs. This allows the surgeon to insert the video camera in one hole and a surgical instrument in another.
Sympathectomy is accomplished by dissecting the nerve tissue of the main sympathetic chain. The clamping method, also referred to as endoscopic sympathetic blockade (ESB) employs titanium clamps around the nerve tissue, and was developed in an attempt to make the procedure reversible. However, reversal of the clamping procedure must be performed within a short time after clamping (a few days or weeks at most), and recovery may not be complete.
Results
The most common indication for ETS surgery is hyperhidrosis, or excessive sweating. However, one study on sweating before and one month after ETS demonstrated that the procedure increases total sweat production in a hot sauna.Swedish National Board of Health and Welfare statement on treatment results says: "A large amount of international studies shows that an incision on the sympatikotomi nerve gives a very positive result when it comes to hand perspiration and also that the side effects are rare." Critics have raised serious questions about the methodology of such studies.
Sympathectomy works by disabling part of the autonomic nervous system, by surgically destroying it, and disrupting the signals to the brain. Many non-ETS doctors find this to be disturbing, as symptoms of the ANS dysfunction go further than the disabled thermoregulation. Sympathectomy prevents the occurrence of a variety of bodily changes, and hence, prevents sensory feedback of those changes.
Exact results of ETS are impossible to predict, because of considerable anatomic variations in sympathetic nerve function from one patient to the next, and also because of variations in surgical technique. The autonomic nervous system is not anatomically exact and connections might exist with different parts of the body. This theory has been proven by the fact that a significant number of patients who have had sympathectomy for hand sweating might notice a reduction or elimination of feet sweating. No reliable operation exists for foot sweating per se except lumber sympathectomy.
Lumbar sympathectomy is largely of historical interest today, being reserved for cases of severe sympathetic dystrophy or selected cases of rest pain, where is it usually done by percutaneous ablation of the lumbar sympathetic chain by phenol injection under imaging guidance. Its original use as an operation for lower limb ischaemia has been superseded by direct revascularisation operations or endovascular revacularisation procedures such as angioplasty or angioplasty with stenting of occuded arteries with reasonable runoff i.e. endovascular surgery.
Studies by ETS surgeons have claimed an initial satisfaction rate around 85-95% with at least 2%-19% regretting the surgery and up to 51% of the patients complaining about decreased quality of life. One study shows a satisfaction rate as low as 28.6. Most patients report various adverse reactions as a result of the surgery. However, ETS surgeon Samuel S. Ahn of UCLA claims "100% success with no negative side effects".
A large study of psychiatric patients treated with this surgery showed significant reductions in fear
Fear
Fear is a distressing negative sensation induced by a perceived threat. It is a basic survival mechanism occurring in response to a specific stimulus, such as pain or the threat of danger...
, alertness
Alertness
Alertness is the state of paying close and continuous attention, being watchful and prompt to meet danger or emergency, or being quick to perceive and act. It is related to psychology as well as to physiology...
and arousal
Arousal
Arousal is a physiological and psychological state of being awake or reactive to stimuli. It involves the activation of the reticular activating system in the brain stem, the autonomic nervous system and the endocrine system, leading to increased heart rate and blood pressure and a condition of...
. (Teleranta, Pohjavaara, et al. 2003, 2004). Arousal is essential to consciousness, in regulating attention and information processing, memory and emotion.
This study also proves what many patients have claimed, that the surgery caused psychological changes. You cannot reduce 'bad' emotional responses, like fear or anxiety. If you reduce emotional responses, they will affect the whole range of emotions and their intensity. With the elimination of the heart rate variability, emotions are also 'capped'.
ETS patients are being studied using the autonomic failure protocol headed by David Goldstein, M.D. Ph.D., senior investigator at the U.S National Institute of Neurological Disorders and Stroke. He has documented loss of thermoregulatory function, cardiac denervation, and loss of vasoconstriction
Vasoconstriction
Vasoconstriction is the narrowing of the blood vessels resulting from contraction of the muscular wall of the vessels, particularly the large arteries, small arterioles and veins. The process is the opposite of vasodilation, the widening of blood vessels. The process is particularly important in...
.
Recurrence of the original symptoms due to nerve regeneration or nerve sprouting can occur within the first year post surgery, but regeneration can start years after sympathectomy. Nerve sprouting, or abnormal nerve growth after damage or injury to the nerves can cause other further damage. Sprouting sympathtetic nerves can form connections with sensory nerves, and lead to pain conditions that are mediated by the SNS. Every time the system is activated, it is translated into pain.
This sprouting and its action can lead to Frey's syndrome
Frey's syndrome
Frey's syndrome is a food related syndrome which can be congenital or acquired specially after parotid surgery and can persist for life.The symptoms of Frey's syndrome are redness and sweating on the cheek area adjacent to the ear...
, a well recognized after effect of sympathectomy, when the growing sympathetic nerves innervate salivary glands. This leads to excessive sweating when eating. For patients different tastes can trigger this abnormal facial sweating (curiously this happens in the area where people who have undergone this procedure can not sweat any more normally). For some it only occurs with hot food, for others, with hot, sour - even by eating an apple, or sweet. Smelling can also cause abnormal reactions, as the signals get mixed up.
Nerve regeneration and subsequent abnormal synapses is a well-documented phenomena.
Some patients have required an artificial pacemaker
Artificial pacemaker
A pacemaker is a medical device that uses electrical impulses, delivered by electrodes contacting the heart muscles, to regulate the beating of the heart...
after developing bradycardia
Bradycardia
Bradycardia , in the context of adult medicine, is the resting heart rate of under 60 beats per minute, though it is seldom symptomatic until the rate drops below 50 beat/min. It may cause cardiac arrest in some patients, because those with bradycardia may not be pumping enough oxygen to their heart...
(slow heart beat) as a side effect of the surgery.
Risks and controversy
No surgery is risk-free, and ETS has both the normal risks of surgery, such as bleeding and infection, and several specific risks, such as changes in how nerves function. Bleeding during and following the operation may be significant in up to 5% of patients. PneumothoraxPneumothorax
Pneumothorax is a collection of air or gas in the pleural cavity of the chest between the lung and the chest wall. It may occur spontaneously in people without chronic lung conditions as well as in those with lung disease , and many pneumothoraces occur after physical trauma to the chest, blast...
(collapsed lung) can occur (2% of patients).
Compensatory hyperhidrosis
Compensatory hyperhidrosis
Compensatory hyperhidrosis is a form of neuropathy. It is encountered in patients with myelopathy, thoracic disease, cerebrovascular disease, nerve trauma or after surgeries. The exact mechanism of the phenomenon is poorly understood. It is attributed to the perception in the hypothalamus that the...
(sweating) is common over the long term, causing 1-2 percent of patients in one review to regret having had the surgery. The rates of severe compensatory sweating vary widely between studies, ranging from as low as 1.2% and as high as 30.9% of patients. Of those patients that develop this side effect, about a quarter said it was major and disabling.
ETS can cause corposcindosis, in which the patient feels like he or she is living in two separate bodies: one half of the body is numb or "dead," and the other half has hyperactive sympathetic nerve function.
The Finnish Office for Health Care Technology Assessment concluded in a 40 page systematic review that Endoscopic Thoracic Sympathectomy is associated with significant immediate and long-term adverse effects.
Quoting the aforementioned (see Results) Swedish National Board of Health and Welfare statement: "The method can give permanent side effects that in some cases first will become obvious after some time. One of the side effects might be increased perspiration on different places on your body. Why and how this happens is still unknown. According to the research available about 25-75% of all patients can expect more or less serious perspiration on different places on their body, such as the trunk and groin area, this is Compensatory sweating.
However, it is also mentioned in the research that 0-10% regret having the surgery done for this reason. Other documented side effects are the inability to raise the heart rate when working out physically. This has in some cases led to decreased ability to perform your work and daily activities. Some patients also complained of not being able to control their body temperature and it is experienced from being very uncomfortable to disabling. However description of a changing sweating pattern does not give a comprehensive picture of the permanently disabled thermoregulation
Thermoregulation
Thermoregulation is the ability of an organism to keep its body temperature within certain boundaries, even when the surrounding temperature is very different...
. Consequences of this go far beyond some discomfort wearing damp, in some cases dripping clothes and showing up in public.
A reduced efficiency in maintaining normal body temperature in warm environments is consistent with the reduced ability or complete inability to sweat above the nipple line, a common ETS outcome first shown by Dr. Kotzareff. For a fully clothed person, only the hands, cranial region and neck are typically exposed. In a hot environment, a normal person's body is cooled primarily by evaporation of water vapor through the warmest areas of exposed skin
Skin
-Dermis:The dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many Mechanoreceptors that provide the sense of touch and heat...
. These areas are associated with the head and neck, which under very warm circumstances or vigorous exercise, visibly show moisture (sweat) accumulating as part of the cooling process. For an ETS patient that has lost ability to sweat from cranium, neck, and arms, an increased amount of body heat must be rejected via transpiration
Transpiration
Transpiration is a process similar to evaporation. It is a part of the water cycle, and it is the loss of water vapor from parts of plants , especially in leaves but also in stems, flowers and roots. Leaf surfaces are dotted with openings which are collectively called stomata, and in most plants...
/sweating
Sweating
Perspiration is the production of a fluid consisting primarily of water as well as various dissolved solids , that is excreted by the sweat glands in the skin of mammals...
involving skin of the lower body. Unfortunately, this skin is generally at a lower temperature and usually covered by clothing - both factors that reduce the cooling efficiency and result in poor thermoregulation
Thermoregulation
Thermoregulation is the ability of an organism to keep its body temperature within certain boundaries, even when the surrounding temperature is very different...
. An uncomfortably warm sensation and accumulation of sweat on large areas of skin underneath clothing can result. This is one theory on the aetiology of the increased sweating phenomenon after sympathectomy. However one of the pioneers of the procedure, Dr Lin, who performed over 7000 procedures, disputes the compensatory nature of the so called Compensatory Sweating. According to him this is a result of the dysregulated thermoregulation and hypothalamus. He objects to using the "Compensatory" term, he sees as misleading. Postoperative sweating phenomenon is a reflex response between sympathetic system and Hypothalamus. "It is absolutely not a compensatory mechanism. The term of “Reflex sweating” instead of compensatory sweating is used. Hypothalamus is the center of Autonomic Nervous System, which influences human mind, mentality and endocrine system. For this sake, Dr. Lin emphasized, “Endoscopic Sympathetic Surgery helps us open a gate to Autonomic Nervous System”.
There is much disagreement among ETS surgeons about the best surgical method, optimal location for nerve dissection, and as to the nature and extent of the consequent primary effects and side effects. The internet now features many websites run by surgeons extolling the benefits of ETS backed by patient testimonials. However, there are also many websites run by disabled ETS victims who complain of severe adverse reactions and lack of adequate informed consent. Several online discussion forums are dedicated to the subject of ETS surgery, where both positive and negative patient testimonials abound, but considering that this is an elective surgery for a benign condition, even a small number of badly affected number of patients is a high number.
In 2003, ETS was banned in its birthplace, Sweden, due to overwhelming complaints by disabled patients. In 2004, Taiwanese health authorities banned the procedure on patients under 20 years of age. In other countries it is highly unregulated procedure. Although it was never evaluated for safety and adverse effects, sympathectomy is listed on Medical Benefits Scheme, and is freely available to public patients.
In 2006, the FinOHTA group, the Finnish Office for Health Technology Assessment, showed in a review that there were strong indications of side effects as a result of this surgery.
• No systematic reviews, meta-analyses, or clinical trials that evaluated the
effectiveness of endoscopic thoracic sympathectomy for treating facial
blushing were identified. However, we have identified four case series
related to the request (Drott et al. 1998, Rex et al. 1998, Telaranta 1998,
Yilmaz et al. 1996). These studies were conducted in three countries
(Sweden, Finland and the Netherlands).
• 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. (Omar Ahmed PhD Centre for Clinical Effectiveness Monash Medical Centre Australia)
Other long term adverse effects:
Ultrastructural Changes in the Cerebral Artery Wall Induced by Long-Term Sympathetic Denervation
Sympathectomy eliminates the psychogalvanic reflex
Cervical sympathectomy reduces the heterogeneity of oxygen saturation in small cerebrocortical veins
Sympathetic denervation is one of the causes of Mönckeberg's sclerosis
T2-3 sympathectomy suppressed baroreflex control of heart rate in the patients with palmar hyperhidrosis. We should note that baroreflex response for maintaining cardiovascular stability is suppressed in the patients who received the ETS.
ETS patients should be warned that these mechanisms may play a role in the development of exertional heat stroke.
Morphofunctional changes in the myocardium following sympathectomy.
In none of the limbs studied after sympathectomy could an increase in blood flow be produced reflexly by warming; in the majority of instances the opposite response, a decrease in blood flow was observed. One patient with documented transection of the spinal cord above T5 behaved like subjects after surgical sympathectomy.
Retarded adaptation of hemodynamics to a sudden start of exercise after sympathectomy. The significant fall in left circumflex coronary flow was proportional to the decline in external heart work due to sympathectomy both at rest and under exercise.
Chemical sympathectomy is associated with increased pulmonary metastases.
History
Sympathectomy developed in the mid-19th century, when it was learned that the autonomic nervous systemAutonomic nervous system
The autonomic nervous system is the part of the peripheral nervous system that acts as a control system functioning largely below the level of consciousness, and controls visceral functions. The ANS affects heart rate, digestion, respiration rate, salivation, perspiration, diameter of the pupils,...
runs to almost every organ, gland and muscle system in the body. It was surmised that these nerves play a role in how the body regulates many different body functions in response to changes in the environment, exercise and emotion.
The first sympathectomy was performed by Alexander in 1889. Since the sympathetic nervous system
Sympathetic nervous system
The sympathetic nervous system is one of the three parts of the autonomic nervous system, along with the enteric and parasympathetic systems. Its general action is to mobilize the body's nervous system fight-or-flight response...
was well known to affect many body systems, the surgery was performed in attempts to treat many conditions, including idiocy, goitre
Goitre
A goitre or goiter , is a swelling in the thyroid gland, which can lead to a swelling of the neck or larynx...
, epilepsy
Epilepsy
Epilepsy is a common chronic neurological disorder characterized by seizures. These seizures are transient signs and/or symptoms of abnormal, excessive or hypersynchronous neuronal activity in the brain.About 50 million people worldwide have epilepsy, and nearly two out of every three new cases...
, glaucoma
Glaucoma
Glaucoma is an eye disorder in which the optic nerve suffers damage, permanently damaging vision in the affected eye and progressing to complete blindness if untreated. It is often, but not always, associated with increased pressure of the fluid in the eye...
, and angina pectoris. Thoracic sympathectomy has been indicated for hyperhidrosis
Hyperhidrosis
Hyperhidrosis is the condition characterized by abnormally increased perspiration, in excess of that required for regulation of body temperature.-Classification:Hyperhidrosis can either be generalized or localized to specific parts of the body...
(excessive sweating) since 1920, when Kotzareff showed it would cause anhidrosis
Anhidrosis
Anhidrosis means lack of sweating. It is also known by a number of other names including Adiaphoresis, Ischidrosis, Hypohidrosis, Oligidria, Oligohidrosis and Sweating deficiency.-Causes:...
(total inability to sweat) from the nipple
Nipple
In its most general form, a nipple is a structure from which a fluid emanates. More specifically, it is the projection on the breasts or udder of a mammal by which breast milk is delivered to a mother's young. In this sense, it is often called a teat, especially when referring to non-humans, and...
line upwards.
A lumbar sympathectomy was also developed and used to treat excessive sweating of the feet and other ailments, and typically resulted in impotence in men. Lumbar sympathectomy is still being offered as a treatment for plantar hyperhidrosis, or as a treatment for patients who have a bad outcome (extreme 'compensatory sweating') after thoracic sympathectomy for palmar hyperhidrosis or blushing; extensive sympathectomy risks hypotension
Hypotension
In physiology and medicine, hypotension is abnormally low blood pressure, especially in the arteries of the systemic circulation. It is best understood as a physiologic state, rather than a disease. It is often associated with shock, though not necessarily indicative of it. Hypotension is the...
.
Sympathectomy itself is relatively easy to perform; however, accessing the nerve tissue in the chest cavity by conventional surgical methods was difficult, painful, and spawned several different approaches. The posterior approach was developed in 1908, and required resection
Segmental resection
Segmental resection is a surgical procedure to remove part of an organ or gland. It may also be used to remove a tumor and normal tissue around it. In lung cancer surgery, segmental resection refers to removing a section of a lobe of the lung.- External links :* entry in the public domain NCI...
(sawing off) of ribs. A supraclavical (above the collar-bone) approach was developed in 1935, which was less painful than the posterior, but was more prone to damaging important nerves and blood vessels.
Because of these difficulties, and because of disabling sequelae associated with sympathetic denervation, conventional or "open" sympathectomy was never a very popular procedure, although it continued to be practiced for hyperhidrosis, Raynaud's disease, and various psychiatric disorders. With the popularization of lobotomy
Lobotomy
Lobotomy "; τομή – tomē: "cut/slice") is a neurosurgical procedure, a form of psychosurgery, also known as a leukotomy or leucotomy . It consists of cutting the connections to and from the prefrontal cortex, the anterior part of the frontal lobes of the brain...
in the 1940s, sympathectomy fell out of favor as a form of psychosurgery
Psychosurgery
Psychosurgery, also called neurosurgery for mental disorder , is the neurosurgical treatment of mental disorder. Psychosurgery has always been a controversial medical field. The modern history of psychosurgery begins in the 1880s under the Swiss psychiatrist Gottlieb Burckhardt...
.
The endoscopic version of thoracic sympathectomy was pioneered by Goren Claes and Christer Drott in Sweden
Sweden
Sweden , officially the Kingdom of Sweden , is a Nordic country on the Scandinavian Peninsula in Northern Europe. Sweden borders with Norway and Finland and is connected to Denmark by a bridge-tunnel across the Öresund....
in the late 1980s. The development of endoscopic "minimally invasive" surgical techniques have decreased the recovery time from the surgery and increased its popularity. Today, ETS surgery is practiced in many countries throughout the world.
In the late 1990s a group of Swedish ETS patients complaining of disabling side effects formed the organization FFSO (people disabled by sympathectomy). The group grew to over 300 members and their work led to the procedure being banned in Sweden. The two surgeons who pioneered the technique, Drott and Claes, moved their practice from Sweden. They still perform the surgery.
Popular culture
- The American TV show Grey's AnatomyGrey's AnatomyGrey's Anatomy is an American medical drama television series created by Shonda Rhimes. The series premiered on March 27, 2005 on ABC; since then, seven seasons have aired. The series follows the lives of interns, residents and their mentors in the fictional Seattle Grace Mercy West Hospital in...
featured ETS surgery for facial blushing in an episode titled "Make Me Lose Control".
External links
Anti-surgery websites- Corposcindosis (a treatise on the effects of ETS surgery)
- Truth About ETS
- FfSo - People disabled by sympathectomies
- Patients Against Sympathetic Surgery
Pro-surgery websites