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

Saturday, May 21, 2011

Patient feedback often differs from how the surgeons describe sympathectomy and the impact it can have

I read absolutely all of the comments and Im frankly disappointed nobody has found a feasible cure for CS, which is absolutely destroying my life. I figure I shared with some of you pre-ops and post-ops the side effects I have experienced. I am 22 years old and had surgery exactly 1 year ago. I had cauterization of the Sympathethic nerve bilaterally at the T2 level for facial blushing.
1. CS concentrated in the thorax and groin area
2. Lack of sweat from the nipple up.
3. EXTREMLY dry hands that have turned me completely USELESS when handling objects (even paper)
4. Arthritis in the hands.
5. Neuralgia in the site of cauterization
6. Goosebumps feelings when eating sweet things.
7. ALLERGIC REACTION in forehead when eating highly condimented food
8. EXTREMELY ALLERGIC REACTION in forehead when eating spicy food.
9. Hypersensitivity to cold weather leading to goosebumps
10. Phantom sweating
11. Reduced workout output
Essentially, Ive had ALL the possible side effects :/ except for the pneumothorax, collapsed lung, and raynauds. My immune system was not able to cope with the surgery and absolutely when ape sh1t. I wake up everyday thinking how am gonna be able to live through the rest of years I have on me with the hell ETS has caused in me. Our bodies is the only tool we are given in this life, and we should PROTECT IT at all instances to be able to cope with life. For those considering ETS, (specially males), I truly recommend you to restrain from ETS surgery if you value the most magnificent tool ever invented: the human body.

My doctor also told me that it is usully the people who do not have severe hyperhidrosis and do not need the ETS surgery in the first place that have the severe compensatory sweating

Density of calcitonin gene-related peptide immunoreactive fibers in sympathectomy side of the lumbar dura mater decreased to 45.5%

Results: In the hot-plate analgesia test, sympathectomized rats increased their hot-plate latency time compared with that of sham-operated rats. Density of calcitonin gene-related peptide immunoreactive fibers in sympathectomy side of the lumbar dura mater decreased to 45.5% compared with the contralateral side. The number and size of calcitonin gene-related peptide immunoreactive cells in dorsal root ganglia showed no difference between sympathectomized and contralateral side.
Conclusion: Sympathectomy increased the pain threshold and made the sympathectomized rats hypesthetic.

An Anatomic Study of Neuropeptide Immunoreactivities in the Lumbar Dura Mater After Lumbar Sympathectomy.

Spine. 21(8):925-930, April 15, 1996.
Sekiguchi, Yasufumi MD *+; Konnai, Yasunobu MD *+; Kikuchi, Shinichi MD, PhD *; Sugiura, Yasuo MD, PhD +

Limited sympathectomy does not reduce postoperative compensatory sweating

Journal of Vascular Surgery
Volume 37, Issue 1, January 2003, Pages 124-128

Sympathectomy has a beta-blocker effect on the healthy patient

Cardiovascular changes after bilateral upper dorsal sympathectomy.

Papa MZ, Bass A, Schneiderman J, Drori Y, Tucker E, Adar R.
"The effect of bilateral upper dorsal sympathectomy (UDS) on cardiac function was investigated in two groups of young healthy patients who underwent bilateral excision of T2 and T3 ganglia for palmar hyperhidrosis.
The mean pulse rate decreased significantly in patients after they underwent bilateral UDS.
Pulse rates taken at rest and after effort were significantly lower than those taken after operation, and the blood pressure response to exercise was blunted. ECG tracings showed a significant change in the electrical frontal plane axis and shortening of
the QTc interval. These changes were evident 30 days after operation and persisted for 2 years. In conclusion, bilateral UDS has no overt arrhythmogenic effect in the young, healthy heart and its beta-blocker-like effect persists for at least 2 years." (the time of the tests performed)
Beta blockers block the action of endogenous catecholamines (epinephrine (adrenaline) and norepinephrine (noradrenaline) in particular), on β-adrenergic receptors, part of the sympathetic nervous system which mediates the fight or flight response.

The increase in heart rate in response to HUT (head-up tilt) was significantly reduced after surgery in the ETS group (from 34 ± 18 to 14 ± 11 beats·min−1). Orthostatic hypertension disappeared completely after ETS , whereas the prevalence of orthostatic hypotension increased significantly after ETS (from 3 of 11 to 9 of 11 patients).

NIH Clinical Studies book includes Sympahtectomy among Neurocardiologic disorders

Perhaps everyone considering ETS surgery should see this: the National Institute of Health (NIH) Clinical Studies book, where sympathectomy is listed as a "Neurocardiologic Disorder", right along side Parkinson's Disease, etc.

I think it is fair to assume that of the thousands of people who have undergone sympathectomy for excessive sweating or facial blushing, few if any of them understood they were consigning themselves to a permanent autonomic system disorder.

sympathectomy caused a shift of sympathovagal balance toward parasympathetic tone

Endoscopic transthoracic sympathicotomy is a recently developed technique to reduce pain and ischemia in patients with severe angina pectoris.
ETS caused a shift of sympathovagal balance toward parasympathetic tone.
The American Journal of Cardiology
Volume 79, Issue 11, 1 June 1997, Pages 1447-1452

cerebral autoregulation was impaired

CBF increased significantly after the elevation of systemic blood pressure compared with that in the control group, and cerebral autoregulation was impaired. After a 1-hour study, the specific gravity of the cerebral tissue in the treated group significantly decreased; electron microscopic studies at that time revealed brain edema. It is suggested that depletion of brain noradrenaline levels causes a disturbance in cerebral microvascular tone and renders the cerebral blood vessels more vulnerable to hypertension.
J Neurosurg. 1991 Dec;75(6):906-10.

Supersensitivity to noradrenaline and chronic neuropathic pain conditions

Supersensitivity to noradrenaline contributes to certain vascular disorders (e.g., hypertension) and chronic neuropathic pain conditions (e.g., complex regional pain syndrome). We aimed to develop a procedure for inducing adrenergic supersensitivity that could be used to investigate the role of catecholamines in these clinical conditions.
These observations indicate that prolonged depletion of adrenergic stores by guanethidine induces adrenergic supersensitivity in cutaneous vessels, and that adrenergic supersensitivity enhances thermal hyperalgesia in the presence of noradrenaline.
Autonomic Neuroscience
Volume 88, Issues 1-2, 12 April 2001, Pages 86-93

Darren M. Lipnicki and Peter D. DrummondCorresponding Author Contact Information, E-mail The Corresponding Author

School of Psychology, Murdoch University, Murdoch, Western Australia 6150, Australia

90 % of patients experienced severe compensatory sweating

Postsurgery, severe compensatory sweating was experienced in 90% of patients (P < 0.0001). The sites of
compensatory sweating were the back (75%), abdomen (51%), feet (23%), groin and thigh (13%), chest (13%), andaxillae (8%). Transient whole-body sweating for no apparent reason was experienced in 30% of patients.

Thirty-seven patients (11%) regretted having undergone the surgical procedure.

Main outcome measures included the incidence of dry hands, compensatory sweating, chest pain, upper-limb muscle weakness, shortness of breath, and gustatory phenomena;

Surg Laparosc Endosc Percutan Tech. 2000 Aug;10(4):226-9.

The rates of compensatory sweating and gustatory sweating were 93.5% and 49.4%, respectively

Surgical Endoscopy
Volume 23, Number 7 / July, 2009

Compensatory sweating occurred in 87% of the patients - serious in 36% and incapacitating in 6%

Ann Thorac Surg. 2004 Nov;78(5):1801-7.

collateral effects of thoracic sympathectomy not disclosed to patients

Several reports also demonstrate significantly lower heart rate increases during exercise in subjects who have undergone bilateral ISS [9–12] compared to pre-surgical levels. In spite of this high occurrence, recent reviews on the usual collateral effects of thoracic sympathectomy still do not include these possible cardiac consequences [6].
Eur J Cardiothorac Surg 2001;20:1095-1100

36% intense 'compensatory sweating'

The results and complication rates have not necessarily been similar in reports worldwide. This can be explained in part due to the lack of clear-cut definitions for the indications, success, complications, side effects, and short- and long-term follow-up data of the procedures. It is well known that sympathectomy is often complicated by CH; the reported incidence rates vary greatly from 30% to 84% [15]. In our series it has been noted in 62.5% of the patients (26.5% moderate and 36% intense).

Although VATS sympathectomy is a simple and quick procedure, unusual complications such as chylothorax may occur [16]. However, lethal or potentially serious complications have also been reported [8, 17, 18], such as subclavian artery injury, damage to brachial plexus, large hemothorax, cerebral edema, neurologic sequelae, sinus bradycardia, and cardiac arrest.
Ann Thorac Surg 2003;76:886-891

73% of patients suffered form 'gustatory sweating' and variety of phenomena

In a series of 100 bilateral upper dorsal sympathectomies performed for palmar hyperhidrosis,
gustatory sweating and other gustatory phenomena were reported by 68 of 93 patients (73%),
followed up for an average of 11/2 years. These gustatory phenomena were quite different from
physiologic gustatory sweating: a wide range of gustatory stimuli caused a variety of phenomena in
varied locations. There was a negative correlation between the incidence of these phenomena and the
occurrence of Horner's syndrome after sympathectomy. Analysis of our observations, and of clinical
and experimental work of others, leads to the conclusion that gustatory phenomena after upper
dorsal sympathectomy are the result of preganglionic sympathetic regeneration or collateral sprouting
with aberrant synapses in the superior cervical ganglion.

Arch Neurol. 1977;34(10):619-623.

Patient describes waking up "feeling very detached" after sympathectomy

Thursday, May 19, 2011

most of the existing literature is geared towards assessing only the effectiveness of the surgical sympathectomy

Given the fact that most of the existing literature is geared towards a) assessing only the effectiveness of the surgical sympathectomy procedures, and b) publishing only studies with positive results, adverse effects and complications are not systematically reported but rather as a secondary outcome. It seems, therefore, highly likely that the complications as reported here, are truly underestimated.

The study indicates that surgical sympathectomy, irrespective of operative approach and indication, may be associated with many and potentially serious complications.

Are We Paying a High Price for Surgical Sympathectomy? A Systematic Literature Review of Late Complications

Collagen types I and III mRNA were decreased respectively by 53% and 22% after sympathectomy

In the present study, we tested the hypothesis of the indirect (via the sympathetic nervous system (SNS)) and direct (via AT1 receptors) contributions of Angiotensin II (Ang II) on the synthesis of collagen types I and III in the left ventricle (LV) in vivo. Sympathectomy and blockade of the Ang II receptor AT1 were performed alone or in combination in normotensive rats. The mRNA and protein synthesis of collagen types I and III were examined by Q-RT-PCR and immunoblotting in the LV.
Collagen types I and III mRNA were decreased respectively by 53% and 22% after sympathectomy and only collagen type I mRNA was increased by 52% after AT1 receptor blockade. mRNA was not changed for collagen type I but was decreased by 25% for collagen type III after double treatment. Only collagen protein type III was decreased after sympathectomy by 12%, but collagen proteins were increased respectively for types I and III by 145% and 52% after AT1 receptor blockade and by 45% and 60% after double treatment. Deducted interpretations from our experimental approach suggest that Ang II stimulates indirectly (via SNS) and inhibits directly (via AT1 receptors) the collagen type I at transcriptional and protein levels. For collagen type III, it stimulates indirectly the transcription and inhibited directly the protein level. Therefore, the Ang II regulates collagen synthesis differently through indirect and direct pathways.

we conclude that the sympathetic nervous system influences the metabolic activity of the aorta

The effect of chemical sympathectomy with 6-hydroxydopamine (6-OH-DA) on collagen formation in the aortic wall was investigated in rabbits and rats. Eight weeks after 6-OH-DA treatment of rabbits, there was a significant increase an collagen content in aortas and histologic changes in the elastic elements within the media. The possibility of a direct effect of 6-OH-DA on connective tissue formation was investigated in a subsequent experiment in rats. The rates of collagen synthesis and prolyl hydroxylase activity (PHA) were determined in aortas and in the fibrotic granuloma around subcutaneously implanted polyvinylalcohol sponges. Rates of collagen synthesis and PHA were significantly increased in the aortas of 6-OH-DA treated rats, but not in fibrotic granuloma, confirming the changes seen in the aorta of rabbits and suggesting that 6-OH-DA does not directly affect collagen synthesis. We conclude that the sympathetic nervous system influences the metabolic activity of the aorta. Our data indicate that when the aortic wall is deprived of adrenergic nervous stimulation, changes occur which resemble those seen in natural aging of the aorta. It is plausible to assume that such a metabolic derangement in the vessel wall will make these vessels more vulnerable to additional stresses.

Monday, May 16, 2011

Conditions arising after Sympathectomy

After stellate ganglion blockade: HORNER'S SYNDROME
  • Drooping eyelid
  • Constricted pupil (impaired vision in low light)
  • Absent/reduced sweating one side of the face and head
  • Redness of eyes
  • Facial flushing
After regional sympathectomy: DUMPING SYNDROME:
  • Rapid emptying of the stomach: lower end of small intestine fills too quickly
  • Early dumping: nausea/vomiting/bloating/diarrhoea/shortness of breath
  • Late dumping: 1-3 hours after eating: weakness/sweating/dizziness
  • Both types may co-exist.