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.

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.

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

Thursday, January 27, 2011

Informed consent - from the ETS forum

Physicians are required to gain informed consent prior to administering a treatment. Informed consent is gained by providing patients with a full accounting of the risks of the treatment as documented in peer-reviewed, published medical/scientific literature.

Your scenario of surgeons being flummoxed by unhappy patients complaining after surgery doesn't hold water. The rules of professional medical ethics require that the treating physician be well versed in the published literature on the treatments he delivers.

There is a mountain of published research (spanning nearly a century) documenting the adverse effects of sympathectomy. There are numerous studies, for example, showing very high rates of severe side effects and studies showing that satisfaction diminishes substantially over the long term.

It is a doctors job to know this stuff and it is their ethical duty to disclose that information to patients.

So, I see the blame thing as pretty cut and dry. Surgeons perfoming sympathectomies routinely withhold information vital to informed consent. Anyone who does objective comparison between what is documented in medical/scientific literature and what is typically disclosed to prospective ETS patients has no choice but reach this conclusion.

And, to make matters worse, many surgeons use testimonials from a hand-selected group of their happiest patients to advocate the surgery. That practice is considered unethical by all medical professional organizations.

Wednesday, January 26, 2011

82.9% Were Disturbed Because CS Was More Than Expected

Endoscopic thoracic sympathectomy (ETS) for palmar hyperhidrosis was performed using a 3-mm small endoscope at our hospital, and we conducted a questionnaire for the purpose of studying the conditions and satisfaction after surgery. The subjects were comprised of 50 patients, of which 35 patients (75%) answered the survey. The average age of the respondents was 27 years old (range: 12?62 years old) including 13 males and 22 females and the average postoperative observation period was 33 months (1?114 months). The results showed the good effects of surgery in all of the patients for palmar sweating while patient satisfaction was 79.4 points, which concluded that ETS was sufficiently accepted as treatment for palmar hyperhidrosis. However, compensatory sweating (CS) developed in 97.1% of the patients, and 82.9% answered that they were disturbed because it was more than they had expected. This result makes us realize further the importance of preoperative informed consent for CS. The problem of palmar hyperhidrosis is very serious for patients, and hence it is important to give treatment with a thorough understanding of the effectiveness and problems of ETS for palmar hyperhidrosis according to the analytical results of this questionnaire.

American Institute for Hyperhidrosis claims to cure anxiety and palpitations with ETS

"Palpitations caused by anxiety can be significantly reduced."

"Migraine occurrence and trembling of the hands may improve."

(They also claim, that Copensatory Hyperhidorsis is) "tolerable by most patients and only 5% describe it as troublesome. Some patients say it improves with time."

Question: what is the scientific definition for troublesome? Some patients say it improves with time? Surely that is not a statement worthy of a website such as this.
There has been no clinical evaluation of the severity of the so called CS to this day. Surgeons who perform the surgery and profit from it claim it to be close to insignificant..that even improves with time. Other sources will state 90% of severe CS, and 25% disabling CS. Surely it can not be just a question of semantics when you have a 25% chance of being disabled after an elective surgery!
Doctors are unable to support their claims about the positive outcomes of the surgery. There has been no controlled trial to support their positive advertising, and it is left solely to the discretion of the surgeon to admit or deny the incidence and severity of the side-effects.

Tuesday, January 25, 2011

The many reviews came up with similar conclusions:

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

Australian Review of ETS surgery

"A lack of high quality randomized 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 input, 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)

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

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

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.
University of Ouluand
Finnish Office for HealthTechnology Assessment
University of Helsinki
Finnish Office for Health Technology Assessment
University of Copenhagen

For a small group of patients sympathectomy can have devastating effects

ETS is a very effective way to treat hyperhidrosis and FB in the vast majority of the cases, but a small group of patients have devastating effects. Unfortunately, we do not know who these patients are before we operate.

Dr. Giudiceandrea Alberto, general and vascular surgeon

Possible side effects, ranging from trivial to devastating, are of even greater importance with these more permanent procedures.

G D Schott Consultant neurologist
Interrupting the sympathetic outflow in causalgia and reflex sympathetic dystrophy - A futile procedure for many patients
The National Hospital for Neurology and Neurosurgery, London
1998;316;789-790 BMJ