Anthem medical policy for ETS surgery

Position statement:

Iontophoresis is considered medically necessary in the treatment of primary or secondary hyperhidrosis only for individuals who have tried prescription strength antiperspirants without success and meet any ONE of the following criteria:

• Presence of medical complications or skin maceration with secondary infection; or
• Significant functional impairment, as documented in the medical record.

Botulinum toxin is considered medically necessary in the treatment of primary hyperhidrosis only for those individuals who have failed a 6 month trial of any one or more types of nonsurgical treatment (i.e., topical dermatologics such as aluminum chloride, tannic acid, glutaraldehyde, anticholinergics; systemic anticholinergics, tranquilizers or non steroid anti-inflammatory drugs) and meet any ONE of the following criteria:

• Presence of medical complications or skin maceration with secondary infection; or
• Significant functional impairment, as documented in the medical record.

Botulinum toxin is considered medically necessary in the treatment of secondary hyperhidrosis when the condition is related to surgical complications and both of the following criteria are met:

• Presence of medical complications or skin maceration with secondary infection; and
• Significant functional impairment, as documented in the medical record.

Treatment of primary axillary or palmar hyperhidrosis with endoscopic thoracic sympathectomy is consideredmedically necessary in the small subset of individuals with hyperhidrosis where both of the following criteria (1 and 2) have been met:

1. It has been adequately documented that all efforts at nonsurgical therapy have failed; and
2. Either of the following:
• Presence of medical complications or skin maceration with secondary infection; or
• Significant functional impairment, as documented in the medical records;

http://www.anthem.com/medicalpolicies/policies/mp_pw_a050005.htm

Correlating Dermatomal Level to Surface Landmarks

Table 3. Correlating Dermatomal Level to Surface Landmarks
Dermatomal Level	Surface Landmark	Comments
C8	Little finger	Cardioaccelerator fibers blocked (T1 to T4)
T1, T2	Inner aspect of the arm	Above fibers blocked but to lesser degree
T4	Nipple line, root of scapula	Cesarean section, Appendectomy, upper abdominal surgery
T7	Inferior border of scapula; Tip of xiphoid	Splanchnic (T5 to L1) blockage; lower abdominal surgery; T5 to T7 for thoracotomy or fractured ribs (at relevant interspace)
T10	Umbilicus	Usual level for LE procedures, hip surgery, TURP, vaginal delivery
L2 to L3	Anterior thigh	Appropriate for knee, foot surgery
S1	Heel of foot	Part of sacral plexus, difficult to block

http://www.nysora.com/test2/regional_anesthesia/neuraxial_techniques/3026-epidural-blockade.html

"sympathectomy of one side of the body leads to an increase in the development of tumors on the denervated side"

Coujard R, Heitz F. Cancerologic: Production de tumeurs malignes consecutives a des lesions des fibres sympathiques du nerf sciatique chez le Cobaye. C R Acad Sci 1957; 244: 409­411.


This suggest that interference with the sympathetic nervous system (SNS) can lead to a compromise of the body's immune system [81–82]. Conversely, an immunological response can alter the response pattern of the sympathetic nervous system. [83]
http://www.chiro.org/LINKS/FULL/VERTEBRAL_SUBLUXATION_2.shtml 

Management of reflex sweating in spinal cord injured patients

Reflex sweating can be a problem for cervical spinal cord injured patients. Patient comfort and skin breakdown have been the major concerns. Five patients were studied prospectively, using a patch containing 1.5mg of scopolamine. Patches were changed every third day. Each patient was carefully monitored before and after application of the patch for signs and symptoms of anticholinergic side effects such as dizziness, blurred vision and dry mouth. Patients were also monitored for changes in patch signs before and after use, including residual urine volumes, blood pressure, heart rate, and mental status. Our study indicates that topical scopolamine successfully controlled reflex sweating in 5 patients without anticholinergic side effects.

PMID:

2742472

[PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/2742472

"Caesar judging Caesar" - utterly dysfunctional medical boards

In the end, the state's medical board, two-thirds of which are doctors, allowed the doctor to retain his registration to practise with one condition: he stop working in intensive care.

Ms Barber, who revealed a series of concerns to 7.30 in April about malpractice in Queensland hospitals, says it is a case of "Caesar judging Caesar".
She says the review of such cases should be handled by a panel of people who are "legally minded", with the assistance of medical administrators.
"It's completely and utterly dysfunctional and if you were to look in the last 10 years, those [doctors] that actually had been struck off or completely gotten rid of as a result of their incompetence would be - you could count them on one hand. Maybe five or six," she said.
The allegations have been referred to Queensland's Crime and Misconduct Commission (CMC).
The CMC has appointed a former Supreme Court judge to examine what it calls a series of allegations and has referred material to the homicide squad.
Former MP Rob Messenger, who was instrumental in revealing the deeds of Dr Jayant Patel, says the case needs to go to a commission of inquiry "right now".
"It needs to go from an assessment stage to a full-blown investigation stage, but that investigation won't be effective unless witnesses are given protection," he said.
"And it's only a commission of inquiry that will be able to give potential witnesses the protection and confidence for them to come forward and tell the truth, tell their story."
The medical board declined 7:30's request for interview, but released a statement saying its role is to protect the public but that it must also be fair, lawful and provide natural justice to practitioners.
http://www.abc.net.au/news/2012-07-10/doctor-accused-of-ended-patients-lives-prematurely/4122522

Heart rate significantly decreased after bilateral but not after unilateral right sympathectomy

http://www.ncbi.nlm.nih.gov/pubmed/12643398

Sympathectomy or doxazosin, but not propranolol, blunt myocardial interstitial fibrosis

http://www.ncbi.nlm.nih.gov/pubmed/16216989

surgical and chemical sympathectomy can both modulate bone cell function

It is known that surgical and chemical sympathectomy can both modulate bone cell function.  However, the sympathetic
nervous system (SNS) can give rise to both anabolic and catabolic effects [28-31] and its role in regulating bone remodeling is, therefore, controversial. For example, some researches reported that if bone is deprived of its sympathetic innervation, bone
deposition and mineralization is reduced and bone resorption increases [31], while in some other reports a sympathectomy impairs bone resorption [28].
Wei Fan BSc, MSc
Institute of Health and Biomedical Innovation
Faculty of Built Environment & Engineering
Queensland University of Technology

eprints.qut.edu.au/35722/7/35722b.pdf

Sustained Benefit (sic!) Lasting One Year from T4 Instead of T3-T4 Sympathectomy

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2664277/

No statistically significant association between the CS with age, family history, type of HH and extent of TS

http://ejcts.oxfordjournals.org/content/34/3/514.full

Sympathectomy exacerbated the inflammation and osteopathic destruction of arthritic joints

http://www.ncbi.nlm.nih.gov/pubmed/8632052

results of sympathectomy deteriorate with time

results of sympathectomy deteriorate with time (T.S. Lin & Fang, 1999; Walles et al., 2008). This recurrent postoperative sweating may be due to local nerve regeneration but has not yet been proven (Lee et al., 1999).
http://www.intechopen.com/books/topics-in-thoracic-surgery/surgical-management-of-primary-upper-limb-hyperhidrosis-a-review

Pain in the form of intercostal neuralgia with dysesthesia at the site of trocar insertion is rarely documented but more frequent than generally recognized

Pain in the form of intercostal neuralgia with dysesthesia at the site of trocar insertion is rarely documented but more frequent than generally recognized. Many centres perform short-stay surgery that may lead to underestimation of pain results. In most series pain resolves within months, but Walles and colleagues could detect a persistence for years (Walles et al., 2008).
http://www.intechopen.com/books/topics-in-thoracic-surgery/surgical-management-of-primary-upper-limb-hyperhidrosis-a-review

compensatory sweating is extremely common and often worse than the original problem

Endoscopic thoracic sympathectomy is useful only when all other treatments fail and then should be considered only with caution as compensatory sweating is extremely common and often worse than the original problem.

BMJ 2009;338:b1166    doi:10.1136/bmj.b1166

left thoracic sympathectomy to prevent electrical storms in CPVT - Department of Cardiology, Sydney Children's Hospital

Catecholaminergic Polymorphic Ventricular Tachycardia (CPVT), a life threatening arrhythmia induced by sympathetic stimulation in susceptible individuals is often refractory to antiarrhythmic agents. First line of treatment, beta-blockers can be ineffective in up to 50% with implantable cardioverter-defibrillator (ICD) placement for refractory cases. Paradoxically ICD can be arryhthmogenic from shock-associated sympathetic stimulation, initiating more shocks and "electrical storms". This has led to the use of more effective beta blockade offered by left sympathectomy, now performed by minimally invasive video assisted thoracoscopic surgery (VATS).
To our knowledge this is first such reported case.
Heart Lung Circ. 2011 Nov;20(11):731-3. Epub 2011 Apr 7.

 http://www.ncbi.nlm.nih.gov/pubmed/21478052

Sympathectomy for the treatment of polymorphic ventricular tachycardia

Bilateral thoracoscopic cervical sympathectomy for the treatment of recurrent polymorphic ventricular tachycardia.

Turley AJ, Thambyrajah J, Harcombe AA.
Despite potassium and magnesium supplements, beta blockade, implantation of a single then dual chamber implantable cardioverter defibrillator (ICD), amiodarone, nicorandil, and mexiletine, the patient continued to experience arrhythmia storms, receiving more than 700 ICD discharges over seven months. She was ultimately treated successfully with bilateral thoracoscopic cervicothoracic sympathectomies. This is the first reported bilateral thoracoscopic treatment of a patient with LQTS and symptomatic life threatening ventricular tachyarrhythmias refractory to current pharmacological and pacing techniques.

Cardiothoracic Division, The James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, UK. andrew.turley@stees.nhs.uk

Heart. 2005 Jan;91(1):15-7.
http://www.ncbi.nlm.nih.gov/pubmed/15604323

Loss of impulse control as a side-effect of surgery for blushing and sweaty hands

http://www.sympatix.fi/blog/?lang=en_

Severity of the so-called 'compensatory sweating'

http://www.sympatix.fi/blog/?p=706

Informed consent: it’s not a reality for too many patients

http://ehln.org/?p=25222

'Fit and healthy' woman died after operation in Bupa hospital to cure heavy sweating

http://www.dailymail.co.uk/news/article-1193315/Woman-died-operation-stop-sweating-much.html

The Dangers of ETS Surgery for Excessive Sweating

If you have an excessive sweating problem, you may have heard of endoscopic sympathectomy (ETS) surgery. If you are considering this option - Don't!
This surgery can have severe complications and, in spite of the promises, could leave you in a worse situation than you currently face. Some people have experienced more sweating after the operation than before.
That's right - more sweating. Doesn't sound like a good solution to the problem of excessive sweating, does it? Okay, you have problems with excessive sweating, which can be embarrassing and uncomfortable. You want a solution. That's fair enough. However, ETS Surgery is NOT the solution.
http://howardboon.hubpages.com/hub/The-Dangers-of-ETS-Surgery-for-Excessive-Sweating

dynamic cerebral autoregulation is altered by ganglion blockade

We measured arterial pressure and cerebral blood flow (CBF) velocity in 12 healthy subjects (aged 29+/-6 years) before and after ganglion blockade with trimethaphan. CBF velocity was measured in the middle cerebral artery using transcranial Doppler. The magnitude of spontaneous changes in mean blood pressure and CBF velocity were quantified by spectral analysis. The transfer function gain, phase, and coherence between these variables were estimated to quantify dynamic cerebral autoregulation. After ganglion blockade, systolic and pulse pressure decreased significantly by 13% and 26%, respectively. CBF velocity decreased by 6% (P <0.05). In the very low frequency range (0.02 to 0.07 Hz), mean blood pressure variability decreased significantly (by 82%), while CBF velocity variability persisted. Thus, transfer function gain increased by 81%. In addition, the phase lead of CBF velocity to arterial pressure diminished. These changes in transfer function gain and phase persisted despite restoration of arterial pressure by infusion of phenylephrine and normalization of mean blood pressure variability by oscillatory lower body negative pressure.
Conclusions-: These data suggest that dynamic cerebral autoregulation is altered by ganglion blockade. We speculate that autonomic neural control of the cerebral circulation is tonically active and likely plays a significant role in the regulation of beat-to-beat CBF in humans.
Circulation. 106(14):1814-1820, October 1, 2002.
http://www.problemsinanes.com/pt/re/dyslipidaemia/abstract.00003017-200210010-00017.htm;jsessionid=PX6phQHYFG5PD1p2DMS1cJLvG1TbtLLLH0bfJT6vKJgLLx1zn0Xf!1816077220!181195629!8091!-1?nav=reference

Effects of cervical sympathectomy, stage of the estrous cycle and estradiol treatment.

C A CA Nagle, D P DP Cardinali and J M JM Rosner Life Sci 13(8):1089-103 (1973) PMID 4357690

Horner syndrome, pneumothorax, hemothorax, asymmetry of results, intercostal neuralgia, causalgia, hypoesthesia, incomplete results, paresthesia in the anterolateral abdominal wall, dyspareunia

The complications and side effects are very significant, such as irreversible compensatory sweating (20% to 50%), low satisfaction with results, Claude-Bernard-Horner syndrome, pneumothorax, hemothorax, asymmetry of results, intercostal neuralgia, causalgia, incomplete results, and anesthetic complications^11-13.

Retroperitoneoscopic lumbar sympathectomy (video-assisted): this technique is effective in the treatment of isolated or persistent plantar hyperhidrosis (compensatory after thoracic sympathectomy). The treatment consists of removing the nerves of the sympathetic chain located in the abdomen, in the anterolateral portion of the lumbar vertebrae. It requires hospitalization and is carried out under general anesthesia. It may lead to complications such as lesions of structures adjacent to the sympathetic chain, light abdominal distension, neuralgia, and causalgia as well as hypoesthesia in the thighs and groin, limitation of leg movement,
paresthesia in the anterolateral abdominal wall, change in libido, dyspareunia, pulmonary thromboembolism, hemorrhages, arrhythmias, and cardiac decompensation, amongst others. It definitively eliminates plantar hyperhidrosis14,15.  
http://www.scielo.br/scielo.php?pid=S1983-51752011000400008&script=sci_arttext&tlng=en#end

SADS - sympathectomy and CPVT

SADS - sympathectomy and CPVT

limited understanding of the role of the sympathetic nervous system in mediating pain

The role of sympathetic blocks in herpes zoster (HZ) and postherpetic neuralgia (PHN) remains controversial due to methodologic shortcomings in published studies and limited understanding of the role of the sympathetic nervous system in
mediating pain.


Information for Health Professionals          Hunter Integrated Pain Service         Updated January 2010

Procedural Intervention Guideline 

Vasodilation; Vasomotor Disturbances

Complex regional pain syndromes (CRPS) are characterized by vascular disturbances primary affecting the microcirculation in the distal part of the involved extremity. In the acute stage inhibited sympathetic vasoconstriction and exaggerated neurogenic inflammation driven by central and peripheral mechanisms, respectively, seem to be the major pathophysiological mechanisms inducing vasodilation. During the chronic course of the disease as well as early in some patients vasoconstriction dominates the clinical picture induced by changes in the microcirculation itself such as endothelial dysfunction or vascular hyperreactivity, whereas sympathetic vasoconstrictor activity returns and neurogenic inflammation is less severe. It can be suggested that the interaction between different mechanisms underlying vasomotor disturbances as well as the severity of each single mechanism in the individual patient have a great impact on the variety of the overall clinical picture in CRPS. Irrespective of the underlying pathophysiology, measurements of skin temperature differences between the affected and the contralateral extremity can serve as a diagnostic tool in CRPS, in particular when sensitivity and specificity is increased by considering dynamic alterations in skin temperature asymmetries.
http://onlinelibrary.wiley.com/doi/10.1111/j.1526-4637.2010.00914.x/abstract

Epidemiology /Etiology

CRPS is found to result:^[1]
- After traumatic injury (65%)

• 1-2% of all fractures result in CRPS
• Largest risk of CRPS for fractures of the wrist

- After surgical intervention (19%)
- Infection (4%)
- Prior inflammation (2%)
- No clear cause (10%)
A review stated that women are predominantly affected, by a factor of 3,5 and a genetic predisposition has also been theorized.
The disease affects all ages, though most cases are between 50 and 70 years old, and it is generally believed to occur mainly in caucasian and Japanese people.^[4]

Characteristics/Clinical Presentation

The following symptoms have been found in literature:^[5]
- Autonomic and trophic disorders:

• Distal Edema in 80% of the patients
• Skin temperature changes at the affected body part in 80% of the patients, initially warmer and in 40% of patients gradually cools down until colder in comparison to the rest of the body as the disease progresses. Another review mentioned that 30% of the patients start off from the primarily cold stage.3
• In 40% of the patients skin at the affected body part starts showing redness, but becomes pale or livid in later stages
• In 55% altered sweating takes place, with hyperhydrosis being more common than hypohydrosis.
• Hair and nail growth possibly increase in early stages
• Atrophy of skin and muscles in later stages, as well as contractures may severely restrict movement

- Sensory disturbances (90%) typically in a glove or stocking-like distribution

• Spontaneous pain occurs in 75%, usually burning dragging or stinging

• 68% felt in deep structures
• 32% felt in skin
• In 77% pain shows fluctuating intensity, lesser proportion shows shooting pain
• Pain can be increased by orthostasis, anxiety, exercise or temperature changes.
• In many cases, pain is more pronounced at night

• Sensory gain (Mechanical hyperalgesia, allodynia, ...) or sensory loss (hypaesthesia, hypalgesia, …) may be present.

- Motor dysfunction

• Motor weakness
• Severe impairment of complex movements
• Impairment of range of motion, initially by concomitant edema, later by contractures and fibroses
• Neglect like symptoms have been found in some patiënts, described as the body part in question feeling foreign.
• Enhanced physiological tremor in around 50%
• Myoclonus or dystonia, especially in type II CRPS

http://www.physio-pedia.com/Complex_Regional_Pain_Syndrome

Sympathectomy involves division of adrenergic, cholinergic and sensory fibers which elaborate adrenergic substances during the process of regulating viscera

http://pharmrev.aspetjournals.org/content/18/1/611.full.pdf+html

effect of bilateral cervical sympathetic ganglionectomy on the architecture of pial arteries

The influence of the cranial sympathetic nerves on the architecture of pial arteries in normo- and hypertension was examined. For this purpose the effect of bilateral superior cervical ganglionectomy was evaluated in normotensive rats (WKY) and stroke-prone spontaneously hypertensive rats (SHRSP). The operations were performed at the age of 1 wk, which is just prior to the onset of ganglionic transmission. The length of the inner media contour was measured and the media cross-sectional area was determined planimetrically, with computerized digitalization of projected photographic images of transversely sectioned pial arteries. Four wk after sympathectomy there was a 20% reduction in media cross-sectional area and a consequent reduction in the ratio between media area and calculated luminal radius in the major pial arteries at the base of the brain in WKY but not in SHRSP. Conversely, in small pial arteries linear regression analysis showed that in WKY subjected to ganglionectomy the relationship between media cross-sectional area and luminal radius was significantly larger in arteries with a radius less than 21 microns compared to untreated WKY. No such effect was seen in the corresponding SHRSP vessels. In addition, the cross-sectional area of the internal elastic membrane (IEM) in the basilar arteries of WKY was measured by means of a computerized image-analysing system. Mean cross-sectional area of the IEM was approximately 45% larger following SE than in control animals. The present findings propose a 'trophic' role for the sympathetic perivascular nerves in large pial arteries of the rat. The increased media-radius ratio in the small pial arteries of the WKY following sympathectomy might reflect a compensatory hypertrophy due to reduced protection from the larger arteries against the pressure load. The inability to detect any morphometrically measurable effect of the sympathectomy in the cerebral arteries of SHRSP is probably explained by a marked growth-stimulating effect of the high pressure load in these animals.
http://www.ncbi.nlm.nih.gov/pubmed/7701941

Postural Hypotension and Postural Dizziness

The subjects were 204 consecutive non–insulin-dependent patients with diabetes and 408 age- and sex-matched nondiabetic control subjects who underwent physical examinations for preventive reasons at the National Cheng Kung University Hospital between October 1992 and September 1994. Subjects were excluded from the study for sympathectomy, anemia, thyroid disorder, pregnancy, chronic alcohol use, and/or use of anti-Parkinson drugs, narcotics, sedatives, antipsychotic agents, or antidepressants within 2 weeks of the study. The subjects with diabetes included 114 men and 90 women with a mean age ± SD of 57.9 ± 10.5 years. The nondiabetic control subjects were 228 men and 180 women with a mean age ± SD of 57.1 ± 9.5 years.
Postural Hypotension and Postural Dizziness in Patients With Non–Insulin-Dependent Diabetes
Jin-Shang Wu, MD; Feng-Hwa Lu, MD; Yi-Ching Yang, MD; Chih-Jen Chang, MD
[+] Author Affiliations
Arch Intern Med. 1999;159(12):1350-1356. doi:10-1001/pubs.Arch Intern Med.-ISSN-0003-9926-159-12-ioi80679

Bilateral lumbar sympathectomies carry a risk of impotence

           Contraindications. Prior contralateral sympathectomy, significant cardiovascular disease, or autonomic nervous system insufficiency.
           Post-operative course. Mild-moderate post-operative pain, usually lasting less than 2 weeks.
           Results. Sympathetic blocks and sympathectomies may provide significant relief in 60% of patients who undergo them (19-23). The mechanism on which this relief is based is open to question. There may be a significant placebo effect influencing the response to sympathetic blocks (18, 19). Mean time to pain recurrence following sympathectomy is six months (23).
           Benefits. Several months of sympatholysis from a safe, repeatable, outpatient procedure, which doesn't cause local fibrosis, rendering subsequent retroperitoneal surgery difficult.
           Risks. There are various risks associated with sympathectomy. These risks are minimized through the use of CT imaging, careful needle placement, and utilizing RF instead of chemical neurolysis.
           The major risks of radiologically guided sympathectomies include pnemothorax, inadvertent damage to the genitofemoral nerve in the lumbar area, and inadvertent root trauma. Transient hypotension may follow sympathetic blocks and sympathectomies. Bilateral cervical sympathectomies should be avoided because of the destruction of cardioaccelerator tone. Bilateral lumbar sympathectomies carry a risk of impotence.
http://www.hiesiger.com/physicians/physicianrfl.html

Causes of orthostatic hypotension - surgical sympathectomy

Causes of orthostatic hypotension (modified from Simon et al9).
Hypovolemia or hemorrhage Addison’s disease Drug-induced hypotension • Antidepressants • Antihypertensives • Bromocriptine • Diuretics • Levodopa • Monoamine oxidase (MOA) inhibitors • Nitroglycerin • Phenothiazines Polyneuropathies • Myeloid neuropathy • Diabetic neuropathy • Guillain-Barre syndrome • Porphyric neuropathy • Vincristine neuropathy Other neurologic disorders • Idiopathic orthostatic hypotension • Multiple sclerosis • Parkinsonism • Posterior fossa tumor • Shy-Drager syndrome • Spinal cord injury with paraplegia • Surgical sympathectomy • Syringomyelia • Syringobulbia • Tabes dorsales (syphilis) • Wernicke’s encephalopathy Cardiovascular disorders Prolonged bed rest or immobilization
http://www.scribd.com/doc/15030687/Dizziness-Classification-and-Pathophysiology

significant fall in left circumflex coronary flow was proportional to the decline in external heart work due to sympathectomy

http://www.springerlink.com/content/k2n6j4555g16x773/

sympathectomy affects the heart, sweating, and circulation

heart rate was significantly reduced at rest (14%), at sub-maximal exercise (12.3%), and at peak exercise (5.7%), together with a significant increase in oxygen pulse (11.8, 12.7, and 7.8%, respectively). The rate pressure product (RPP) was also significantly reduced following the surgical procedure at all three study stages, while all other physiological variables measured remained unchanged. It is suggested that thoracic-sympathetic denervation affects the heart, sweating, and circulation of the respective denervated region

Eur J Appl Physiol. 2008 Sep;104(1):79-86. Epub 2008 Jun 10.

Post-sympathectomy neuralgia is a severe complication since pain can be permanent, severe, and incapacitating

http://www.springerlink.com/content/q04711t06j164206/

"ETS has proved moderately successful in treating hyperhidrosis, although the operation does carry a high risk of complications. "

Other complications of ETS include:

• sweating on the face and neck after eating food (gustatory sweating),
• inflammation of the nose (rhinitis), and
• air becoming trapped between the layers of the lung (pneumothorax) which can cause chest pain and breathing difficulties (although this usually resolves itself without the need for treatment).

Rarer complications of ETS include:

• Horner's syndrome, a condition that causes drooping of the eyelids, and
• damage to the phrentic nerve (a nerve that is used to help in breathing).

Phrentic nerve damage can lead to shortness of breath, though it may be possible to repair the nerve during surgery.

http://www.knowsley.nhs.uk/health-a-to-z/h/hyperhidrosis-excessive-sweating/

75% pneumothorax expected after sympathectomy

A small insignificant pneumothorax can be expected after ETS in about 75% of cases [15], which gets spontaneously absorbed, usually within 24 h.

Comparing T2 and T2–T3 ablation in thoracoscopic sympathectomy for palmar hyperhidrosis: a randomized control trial
A. N. Katara, J. P. Domino, W.-K. Cheah, J. B. So, C. Ning, D. Lomanto
Minimally Invasive Surgical Centre, Department of General Surgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074
Received: 13 October 2006/Accepted: 2 November 2006
http://medicine.nus.edu.sg/medsur/research_publications_2007.html


Permanent side effects included compensatory sweating in 67.4%, gustatory sweating in 50.7% and Horner's trias in 2.5%. However, patient satisfaction declined over time, although only 1.5% recurred. This left only 66.7% satisfied, and a 26.7% partially satisfied. Compensatory and gustatory sweating were the most frequently stated reasons for dissatisfaction. Individuals operated for axillary hyperhidrosis without palmar involvement were significantly less satisfied (33.3% and 46.2%, respectively).
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1234291/

sympathectomy improves skin blood flow at the thermoregulatory but not the nutritive level of skin microcirculation

sympathectomy improves skin blood flow at the thermoregulatory but not the nutritive level of skin microcirculation. This may be related to the fact that the thermoregulatory vessels are mainly sympathetically controlled, whereas the nutritive capillaries are mainly controlled by local (nonneural) factors.
http://www.springerlink.com/content/ukwtrn2y72age93t/

Depending on the series and the duration of follow-up, the success rate of sympathectomy varies from 12% to 97%

http://www.ispub.com/journal/the-internet-journal-of-pain-symptom-control-and-palliative-care/volume-2-number-1/complex-regional-pain-syndrome-a-clinical-review.html

typical CRPS changes also occur following sympathectomy, which has traditionally been considered curative of CRPS

 (p.557) 

Handbook of Neurosurgery

Mark S. Greenberg

Thieme, 22/02/2010 - 1352 pages

For two decades, Handbook of Neurosurgery -- now in a fully updated seventh edition -- has been an invaluable companion for every neurosurgery resident and nurse, as well as neurologists and others involved in the care of patients with brain and spine disorders.

Sympathectomy has been discredited in this condition

Vasospastic conditions

Raynaud’s syndrome

http://surgeryonline.wordpress.com/category/arterial-disorders/

Drug warning - Karvezide, AVAPRO HCT - 'you must tell your doctor if you have had sympathectomy'

Tell your doctor if:

* you have had a sympathectomy

* you have been taking diuretics

*you have a history of allergy or asthma


www.racgp.org.au/cmi/swckarvz.pdf

2. Before you start to take AVAPRO HCT

Tell your doctor if:

• you suffer from any medical conditions especially-
  - kidney problems, or have had a kidney transplant or dialysis
  - heart problems
  - liver problems, or have had liver problems in the past
  - diabetes
  - gout or have had gout in the past
  - lupus erythematosus
  - high or low levels of potassium or sodium or other electrolytes in your blood
  - primary aldosteronism
• you are strictly restricting your salt intake
• you are lactose intolerant or have had any allergies to any other medicine or any other substances, such as foods, preservatives or dyes.
• have had a sympathectomy
• you have been taking diuretics
• you have a history of allergy or asthma

http://www.mydr.com.au/medicines/cmis/avapro-hct-300-25-tablets

Published by MIMS/myDr March 2011

UBM Medica Australia uses its best endeavours to ensure that at the time of publishing, as indicated on the publishing date for each resource (e.g. Published by MIMS/myDr January 2007), the CMI provided was complete to the best of UBM Medica Australia's knowledge.  

Use of stellate ganglion block for the treatment of psychiatric and behavioral disorders

The present invention is directed to a method for the treatment of a patient suffering from psychiatric and behavioral disorders, including post partum depression, post traumatic stress disorder, compulsive smoking, attention deficit hyperactivity disorder, gambling addiction, comprising the step of administering a stellate ganglion block to the patient to alleviate the symptoms. The stellate ganglion block may be followed by a sympathectomy to provide permanent relief.

United States Patent 20070135871

Kind Code: A1

http://www.freepatentsonline.com/y2007/0135871.html

Number of sympathectomies is on the increase in Australia - the power of medical advertising

years 2000 - 2001:
Total: 1034

years 2001-2002:
Total: 1575

years 2002 - 2003
Total: 1228

years 2003 - 2004
Total: 1193

years 2004 - 2005
Total: 1483

years 2005 - 2006
Total:1358

years 2006 - 2007
Total: 972

years  2007 - 2008
Total: 850

years 2008 - 2009
Total: 891

years  2009 - 2010
Total: 1083

source: aihw.gov.au

Iatrogenic harlequin syndrome resulting from sympathectomy

Postgrad Med J 2003;79:278 doi:10.1136/pmj.79.931.278

A 29 year old man with severe facial hyperhidrosis underwent an uncomplicated right thoracoscopic sympathectomy. Before operating on his left side, a starch-iodine preparation was applied to his face in order to demarcate residual sudomotor function. The preparation becomes blue on exposure to moisture, thereby representing residual sweat gland activity.

Figure 1 demonstrates that sympathetic innervation to the face is strictly unilateral, and nerve fibres do not appear to cross the midline. This is essentially an iatrogenic variation of the harlequin syndrome,² which usually results from interruption of post-ganglionic sympathetic fibres secondary to malignant invasion.

His facial hyperhidrosis was completely treated once the contralateral sympathectomy was performed.

T3 sympathectomy leads to subclinical pupillary dysfunction with a tendency for miosis

We found statistically significant differences (P < 0.001) between the preoperative P/I ratio [0.40 mm (standard deviation, SD 0.07 mm)] and the postoperative basal ratio [0.33 (SD 0.05)] at 24 h. The P/I ratio at 24 h increased from 0.33 to 0.36 (SD 0.09), a nonsignificant increase (P = 0.45), after instillation of medicated eye drops. No differences were observed between the preoperative [0.40 (SD 0.07)] and 1-month basal values [0.38 (SD 0.07)], and instillation of apraclonidine no longer induced a hypersensitivity response.

CONCLUSIONS:

T3 sympathectomy leads to subclinical pupillary dysfunction with a tendency for miosis, even though this impairment is not generally evident on standard physical examination or reported by patients. This subclinical dysfunction may be caused by injury to an undefined group of presympathetic nerve cell axons in caudocranial direction that communicate with the cervical sympathetic ganglia and whose function is mydriatic pupillary innervation.
http://www.ncbi.nlm.nih.gov/pubmed/22044979

medical students need to realise how vulnerable they are to being seduced by the special privileges of their profession

More than 7% of all German physicians became members of the Nazi SS during World War II, compared with less than 1% of the general population. In so doing, these doctors willingly participated in genocide, something that should have been antithetical to the values of their chosen profession. The participation of physicians in torture and murder both before and after World War II is a disturbing legacy seldom discussed in medical school, and underrecognised in contemporary medicine. Is there something inherent in being a physician that promotes a transition from healer to murderer? With this historical background in mind, the author, a medical student, defines and reflects upon moral vulnerabilities still endemic to contemporary medical culture.
http://jme.bmj.com/content/early/2012/05/02/medethics-2011-100372.abstract

Alessandra Colaianni, of Johns Hopkins Medical School, asks the unsettling question: "Is there something inherent in being a physician that promotes a transition from healer to murderer?" Some recent situations in the United States suggest that this is possible: allegations of euthanasia in the wake of Hurricane Katrina, torture of Guantanamo detainees, and the participation of doctors in capital punishment. Colaianni suggests that there are illuminating parallels between medical training and the work of doctors in Auschwitz.
Socialisation and hierarchy: doctors are pressured to conform to group norms, often with techniques like "Sleep deprivation, heightened stress levels and fear of failure". Ambition: just as Nazi doctors participated in the T4 euthanasia program to advance their careers, today's doctors are pressured to succeed even at the risk of losing their integrity. Doctors have a "licence to sin" which can easily be perverted: some "actions are allowed when they are performed by physicians, but are the stuff of horror films and criminal cases when non-licensed personnel attempt them."
Detachment was also a characteristic of Nazi doctors. They could select prisoners by day and dine with their colleagues by night: "the medical profession requires unflappability in the face of things that others would consider disgusting, horrific, or otherwise overwhelming".
Colaianni concludes that medical students need to realise how vulnerable they are to being seduced by the special privileges of their profession. "It is for this reason that a solid grounding in principles of ethics, individualism and human rights is so crucial for physicians and others in positions of power or trust."
http://www.bioedge.org/index.php/bioethics/bioethics_article/10042

nerves that sent blood-pressure-raising flight-or-fight signals to the brain were cut

page 187:
It was a grueling operation called sympathectomy, in which the nerves that sent blood-pressure-raising flight-or-fight signals to the brain were cut...The nerve cutting scrambled signals to her circulatory system. She was cold on one side of her body and warm on the other.

The Happy Bottom Riding Club: The Life and Times of Pancho Barnes (Paperback)

by Lauren Kessler (Author)

The second thoracic sympathetic ganglion was most commonly located (50%) in the second intercostal space

Presence of the stellate ganglion was noted in 56 (84.8%) sides, and 6 (9.1%) sides showed a single large ganglion formed by the stellate and the second thoracic sympathetic ganglia. The second thoracic sympathetic ganglion was most commonly located (50%) in the second intercostal space. CONCLUSION: The anatomic variations of the intrathoracic nerve of Kuntz and the second thoracic

sympathetic ganglion were characterized in human cadavers.

J Thorac Cardiovasc Surg  2002 Mar;123(3):498-501

Chung IH, Oh CS, Koh KS, Kim HJ, Paik HC, Lee DY.

Sympathectomy increased the pain threshold and made the sympathectomized rats hypesthetic

Normal adult rats were sympathectomized at L2-L3. The threshold for thermal noxious pain by hot-plate analgesia test and changes in neuropeptides in the lumbar dura mater and dorsal root ganglia using light microscopic immunohistochemistry were assessed and compared with control rats.

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. A large numbers of sensory fibers innervated the lumbar dura mater via L2-L3 sympathetic nerve in rats. Sympathectomy reduced the number of these nerve fibers in the lumbar dura mater. Sympathetic nerves may play an important role for low back pain involving the lumbar dura mater.

http://journals.lww.com/spinejournal/Abstract/1996/04150/An_Anatomic_Study_of_Neuropeptide.4.aspx

Long-term sympathectomy induces sensory and parasympathetic fibres sprouting, and mast cell activation in the rat dura mater

http://discovery.ucl.ac.uk/1330488/

There are similarities between the delayed onset of the human pain state and the delayed rise in sensory peptides after sympathectomy

The effect of sympathectomy on the calcitonin gene-related peptide (CGRP) level in the rat primary trigeminal sensory neurone was investigated. Six weeks after bilateral removal of the superior cervical ganglion there was a 70% rise in the CGRP content of the iris and the pial arteries, a 34% rise in the concentration in the trigeminal ganglion but no change in the brainstem. The CGRP rise in both end organs suggests that this phenomenon may be common to all peripheral organs receiving combined sensory and sympathetic innervations. The lack of any rise in the brainstem CGRP content raises the possibility that this process spares central terminations. In contrast, the level of neuropeptide Y, a peptide mainly contained in sympathetic terminals, fell to 35% of control values in the iris and pial arteries whilst the trigeminal ganglion and brainstem concentrations remained unchanged. The possible relevance of these observations to the clinical syndrome of postsympathectomy pain (sympathalgia) is discussed. There are similarities between the delayed onset of the human pain state and the delayed rise in sensory peptides after sympathectomy.
http://www.ncbi.nlm.nih.gov/pubmed/3877546

huge percentages of people who give their informed consent to treatment do not really understand what they have chosen

Informed consent is one of the foundations of bioethical discourse. Bureaucrats have forced doctors and researchers to fill out endless forms in the belief that informed consent will enhance patients’ autonomy.
However, questions are being asked about whether this business of informed consent is really working. In an early online article in the Journal of Medical Ethics, Neil Levy, the Australian editor of another journal, Neuroethics, argues that bioethicists need to rethink informed consent.
Why? Because the lesson of all of modern psychology and of post-modern philosophy is that our rationality is terribly flawed. We are blind to the future consequences of our actions; we are not objective in assessing claims that touch us personally;  we overestimate the effects of setbacks on our well-being; we are unreliable in estimating how bad or how good events made us feel. In short, human reasoning is subject to many fallibilities. it seems utterly naïve to think that Yes always means Yes and No always means No. So Levy declares that doctors need to return to paternalism, to some extent:

“patient autonomy is best promoted by constraining the informed consent procedure. By limiting the degree of freedom patients have to choose, the good that informed consent is supposed to protect can be promoted…

Somewhat surprisingly, Arthur Caplan, of the University of Pennsylvania, probably the best-known bioethicist in the US, agrees with Levy. In a companion article, he says:

“autonomy is fundamentally inadequate in healthcare settings and requires supplementation by experience-based paternalism on the part of doctors and healthcare providers…

“A large number of studies have shown that huge percentages of people who give their informed consent to treatment or to their involvement in research do not really understand what they have chosen. Autonomy lives with hope and hope, in the form of the therapeutic misconception, often trumps autonomy.”

Questioning informed consent shakes a pillar of modern bioethics and the call for more benevolent paternalism is sure to face stiff opposition.
http://www.bioedge.org/index.php/bioethics/bioethics_article/9979#comments

Digital infrared thermal image after T2 sympathicotomy or T3 ramicotomy

(A) Clear cut change of skin temperature after a T2 sympathicotomy. (B) An even distribution of skin temperature after ramicotomy.

Gossot and colleagues [8] analyzed a group of T2, T3, T4 sympathectomy patients in comparison with a group of patients undergoing a T2, T3, T4 ramicotomy and they reported no statistical difference regarding the incidence of CS between the two groups studied (72.2% and 70.9%). However in terms of the severity of CS (embarrassing, disabling) causing inconveniences to daily life, they reported 27% and 13% incidences in these two groups, respectively. These findings suggest that by preserving the sympathetic trunk, it was possible to reduce the severity of CS.

The preganglionic fibers of the sympathetic nerve to the arm originate mostly from the spinal segments T3–T6 and the postganglionic fibers of the sympathetic nerve to the arm originate from T2 and, to a lesser extent, the T3 ganglia [9]. This implies that the division of preganglionic fibers (rami communicantes) reduces the extent of denervation of the sympathetic nerve as compared with the division of postganglionic fibers (sympathetic trunk) in the treatment of palmar hyperhidrosis.
Sympathectomy or sympathicotomy is one of the procedures used to divide the sympathetic trunk. Sympathicotomy distinctively changes sympathetic nerve distribution in comparison with a ramicotomy. Figure 4A illustrates the clear-cut changes of skin temperature after a T2 sympathicotomy. However the overall sympathetic nerve distribution to the body is not markedly changed after a T3 ramicotomy because a T3 ramicotomy is a procedure that is used to divide one of the preganglionic fibers and to preserve the sympathetic trunk. Figure 4B illustrates an even distribution of skin temperature after T3 ramicotomy.

 http://ats.ctsnetjournals.org/cgi/content/full/78/3/1052#FIG4

Drionic effectively "...reduced sweating for up to 6 weeks..."

Clinical Studies

The following comments are from clinical studies which demonstrated the safety and effectiveness of Drionic:

1. Efficacy of the Drionic unit in the treatment of hyperhidrosis. J Am Acad Dermatol 1987;16:828-832. "...the Drionic unit appears to have a definite place in the treatment of hyperhidrosis." Daniel L. Akins, M.D. John L. Meisenheimer, M.D. Richard L. Dobson, M.D., Professor & Chairman, Dept. of Dermatology From the Department of Dermatology, Medical University of South Carolina, Charleston, South Carolina
   
2. A new device in the treatment of hyperhidrosis by iontophoresis. Cutis 1982;29:82-89. Drionic effectively "...reduced sweating for up to 6 weeks..." Further, the study concluded that "Because of its design, it has great potential for home use." CPT John L. Peterson, M.D. MAJ Sandra I. Read, M.D. COL Orlando G. Rodman, M.D. Chief, Dermatology Service From the Dermatology Service, Dept. of Medicine, Walter Reed Army Medical Center, Washington, DC
3. Tap water iontophoresis in the treatment of hyperhidrosis. Int J Dermatol 26;1987:194-197. "Tap water iontophoresis is a recognized method of reducing sweat in various parts of the body. The Drionic device is a battery-operated method of inducing tap water iontophoresis. This simple device may be used at home and is effective in reducing hyperhidrosis for as long as 6 weeks." Mervyn L. Elgart, M.D., Professor & Chairman, Dept. of Dermatology Glenn Fuchs, M.D. From the Department of Dermatology, George Washington Univ. Medical Center, Washington, DC.
4. Efficacy of the Drionic unit in the treatment of hyperhidrosis. JAm Acad Dermatol 16:828-832, Apr. 1987. Elgart ML, Fuchs G: Tap water iontophoresis in the treatment of hyperhidrosis. Int J Dermatol 26: 194-197, Apr. 1987. (old model)

Informing the patient of the seriousness of the consequences before this operation is absolutely necessary

http://ats.ctsnetjournals.org/cgi/content/full/80/3/1160-a

the surgical 'cure' for hyperhidrosis can make he condition worse

First, we object to the classification of excessive sweating and facial blushing as diseases. While it is true that these conditions can be very embarrassing, causing the afflicted to dislike or avoid social situations, and this can indeed have a negative impact on the quality of life, from a physiological point of view they are entirely harmless. We believe that the recent “official” classification of these conditions as diseases is borne not of medical accuracy, but rather out of a desire to legitimize and justify the surgery in the eyes of both prospective patients and their insurance carriers.

Second, and more importantly, we object to the procedure itself. Interrupting the sympathetic chain in the thoracic region (by whatever means) is proven to cause a litany of permanent physical and mental disabilities, including anhidrosis, lowered heart function, lowered mental function, diminished lung volume, loss of baroreflex, paralyzed blood vessels, dysfunctional thermoregulation, chronic pain, paresthesia, lowered alertness, decreased exercise capacity, lowered response to fear, thrills, and other strong emotions. Thousands of unsuspecting patients are having psychiatric surgery without consent, forever robbed of their strongest feelings.

And, infamously, ETS surgery can cause uncontrollable, clothes-drenching sweating from the nipple-line down. In other words, the “cure” for hyperhidrosis can actually cause WORSE hyperhidrosis. Some cure.
http://forums.randi.org/archive/index.php/t-77170.html

pathological pain, such as occurs in response to peripheral nerve injury

It is recently become clear that activated immune cells and immune-like glial cells can dramatically alter neuronal function. By increasing neuronal excitability, these non-neuronal cells are now implicated in the creation and maintenance of pathological pain, such as occurs in response to peripheral nerve injury. Such effects are exerted at multiple sites along the pain pathway, including at peripheral nerves, dorsal root ganglia, and spinal cord. In addition, activated glial cells are now recognized as disrupting the pain suppressive effects of opioid drugs and contributing to opioid tolerance and opioid dependence/withdrawal. While this review focuses on regulation of pain and opioid actions, such immune-neuronal interactions are broad in their implications. Such changes in neuronal function would be expected to occur wherever immune-derived substances come in close contact with neurons.
http://www.ncbi.nlm.nih.gov/pubmed/17706291

most surgeons do not have a clear understanding of their short-term outcomes for the majority of procedures they perform

The public would probably be surprised to know that most surgeons do not have a clear understanding of their short-term outcomes for the majority of procedures they perform.

Of even greater concern is the lack of data on long-term outcomes associated with surgical interventions.

Many surgeons argue that they are too busy and do not have the time and resources to conduct this sort of follow-up. This is not entirely without foundation, but it does seem difficult to defend a stance that says “I will continue to work feverishly at the operations I do but not assess how successful my results are”.

Guy Maddern (ASERNIP-s): No excuse for poor surgical outcomes

MJA INSIGHT, 8 August 2011

Disorders of sweating - Iatrogenic causes: Surgical sympathectomy/sympathotomy

(p. 558)

Primer on the Autonomic Nervous System

 edited by David Robertson, Italo Biaggioni, Geoffrey Burnstock, Phillip A. Low, Julian F.R. Paton

CS is referred to as perilesional hyperhidrosis - the shifting narrative

Perilesional/Compensatory Hyperhidrosis
Central and/or peripheral denervation of large numbers of sweat glands produces increased sweat output in innervated glands, maximal in contiguous dermatomal regions, occurs in PAF, Ross syndrome, SCI and post-surgical sympathectomy. (p.555)

Primer on the Autonomic Nervous System

David Robertson, Italo Biaggioni, Geoffrey Burnstock, Phillip A. Low, Julian F.R. Paton

Academic Press, 01/11/2011 - 730 pages

Sympathectomy, ganglionopathies and myelopathies produce such pattern

Segmental Anhidrosis

This pattern occurs when a large, contiguous body area of sweat loss with sharply demarcated borders conforming to sympathetic or somatic dermatomes are present.
Sympathectomy, ganglionopathies and myelopathies produces such pattern. When borders are not well defined and anhidrosis not contiguous, a regional pattern is said to exist. Both postganglionic and preganglionic lesions may produce these distributions. (p.557)

Primer on the Autonomic Nervous System

 edited by David Robertson, Italo Biaggioni, Geoffrey Burnstock, Phillip A. Low, Julian F.R. Paton

sympathectomy cannot by direct effect on the muscle vessels either abolish or lessen claudication

http://pmj.bmj.com/content/29/335/459

Sympathectomy useless, even detrimental

A number of surgical procedures have been developed, which, although well-intentioned, are found unfortunately by further study to prove useless, or even detrimental. It is believed at present that lumbar sympathetic ganglionectomy in the treatment of the post-thrombotic type of ulceration of the lower extremity should be placed in this category.
http://archsurg.ama-assn.org/cgi/content/summary/67/1/2

reductions in heart rate variability are a predictor of sudden cardiac death, even in individuals without a prior history of cardiovascular disease

Research indicates that a highly variable heart rate increases your capacity to respond and adapt to life’s challenges.
In a sense, it makes your cardiovascular system more flexible. If you’re less able to switch to the rest system, you’re more likely to feel stressed because your body is indicating that there’s danger in the environment – even if there isn’t.
Research has shown that reductions in heart rate variability are a predictor of sudden cardiac death, even in individuals without a prior history of cardiovascular disease.

1. Daniel Quintana

   PhD candidate and researcher at University of Sydney
   

2. Andrew Kemp

   NHMRC Career Development Fellow at University of Sydney
   

http://theconversation.edu.au/depression-can-break-your-heart-literally-1102

the medical profession is so trusted that its activities are rarely questioned

By Paul Komesaroff, Monash University; Ian Kerridge, University of Sydney, and Wendy Lipworth, University of New South Waleshttps://theconversation.edu.au/big-debts-in-small-packages-the-dangers-of-pens-and-post-it-notes-4949

'Fit and healthy' woman died after operation to cure heavy sweating

http://www.dailymail.co.uk/news/article-1193315/Woman-died-operation-stop-sweating-much.html

compensatory sweating was perceived in 56% of the adults and all of the children, or CS was lower in children - illustrations of typical contradictions about effects of ETS

compensatory sweating was perceived in 56% of the adults and all of the children. With the compensatory sweating, the effect on the life was severe in children and the patient's satisfaction was 50-60%, showing a large difference from the satisfaction of the adult patients at nearly 100%. As for other complications, neuralgia was recognized in 9% of the adults, but not in the children, and the crisis of perceptual disorder, hemorrhage and Horner's syndrome did not occur in both the adults and children. The compensatory sweating in the child patients was more remarkable than in the adult patients and the postoperative satisfaction was low, and it seems better to perform thoracoscopic sympathic blockade after the adolescence.
http://sciencelinks.jp/j-east/article/200513/000020051305A0251361.php

Do children tolerate thoracoscopic sympathectomy better than adults? CS appeared within 6 months postoperatively in 81.8% of all the patients but significantly less in children
(69.8%) compared to the others (88.5%; P < 0.001). CS increased with time in 12% of the participants, but decreased in 20.8% of the children versus 10.5% of the others (P = 0.034), usually within the first two postoperative years. The severity of the CS was also lower in children: it was absent or mild in 54.3% of the children versus 38.0% of the others, and moderate or severe in 45.7 versus 62%, respectively (P = 0.004). Fifty-one percent of the participants claimed that their quality of life decreased moderately or severely as a result of CS, but only one-third of them (7.9% children vs. 22.4% others, P = 0.001) would not have undergone the operation in retrospect.
http://www.ncbi.nlm.nih.gov/pubmed/17999068

hypoaesthesia in the bilateral axillar region after endoscopic thoracic sympathectomy for palmar hyperhidrosis

http://sciencelinks.jp/j-east/article/199920/000019992099A0655152.php

Heart Rate Variability before and after the Endoscopic Transthoracic Sympathectomy in Hyperhidrosis

The etiology of primary hyperhidrosis has been speculated as "unknown" hyperactivity of the sympathetic nervous system. In our clinic, we performed endoscopic transthoracic sympathectomy(ETS) for the treatment of hyperhidrosis. In this study, we studied the cardiac autonomic nervous function using heart rate variability(HRV) before and after ETS in 70 patients with hyperhidrosis, and compared with normal control. Before ETS, high frequency(HF) power was lower in hyperhidrosis than control group, however, there was no significant difference in LF/HF. After ETS, LF/HF decreased by 31%, and lower than control. No Severe cpomplications were occurred by ETS. In conclusion, on the cardiac autonomic nervous tone, hyperhidrosis patients had the relative dominance of the sympathetic nervous tone by suppression of the parasympathetic nervous tone. After ETS, the sympathetic nervous tone was suppressed. Clinical symptoms in hyperhidrosis patients were impoved by ETS. Although ETS affected the cardiac autonomic nervous tone, it was useful and safety method for hyperhidrosis.
http://sciencelinks.jp/j-east/article/200002/000020000299A0930354.php

Persistent blushing as a side-effect of the surgery for blushing...

http://www.hyperhidrosis-usa.com/facial_blushing.html

Botulinum Toxin: A Treatment for Compensatory Hyperhidrosis in the Trunk

Severe compensatory hyperhidrosis (CH) in the trunk occurs after sympathectomy in some patients. Limited treatment options for these cases have been proposed, and the overall results have been disappointing, but injection of botulinum toxin-A (BTX-A) is an emerging, reliable treatment method for focal hyperhidrosis.

http://onlinelibrary.wiley.com/doi/10.1111/j.1524-4725.2009.01140.x/abstract?userIsAuthenticated=false&deniedAccessCustomisedMessage=

Being female or male is a predisposing factor for severe 'compensatory' sweating

Compensatory sweating (CS) appeared in 55% and was not related to the extension of the TS. Being female was a predisposing factor of CS (p<0.004). Excessive dryness appeared at 9% and was associated with extensive TS (P<0.001). Plantar hyperhidrosis improved at 33.6%, worsened at 10% and remained stable during the follow-up. Satisfaction degree decreased with the passage of time and was associated with recurrence.
http://lib.bioinfo.pl/pmid:18599303

He also asserts that with experience he has become better at predicting which patients are more likely to get it (uptight, overweight men).
John van Tiggelen, interviewing Dr Roger Bell in Melbourne. Article published on the 10h of March, 2012 in the Good Weekend Magazine

It’s not unusual to hear people who have undergone sympathectomies describe themselves as feeling emotionally “colder” than before

It’s not unusual to hear people who have undergone sympathectomies describe themselves as feeling emotionally “colder” than before. Among psychologists and neurologists alike there is concern, but no evidence, that the procedure limits alertness and arousal as well as fear, and might affect memory, empathy and mental performance. Professor Ronald Rapee, the director of the Centre of Emotional Health at Sydney’s Macquarie University, says he’s counselled several people who complain of feeling “robot-like” in the long-term wake of the operation. “They’re happy they no longer blush, but they miss the highs and lows they used to feel.”
(John van Tiggelen, Good Weekend Magazine, The Age and the Sydney Morning Herald, 10th March 2012)

Full text of the article available here:

http://etsandreversals.yuku.com/topic/5083/Article-about-the-surgery-in-the-mainstream-media-RED-ALERT#.T2KiyiNLU1g

our advice to patients must reflect the true potential outcomes

Dear Editor,

I refer to the article on palmar hyperhidrosis by Dr Sanjay Sharma (Managing palmar hyperhidrosis, March). I feel that the adverse effects [of thoracoscopic sympathectomy] are understated by my colleague. For example, compensatory hyperhidrosis is common, and can be disabling, leading to regret about the procedure in some patients (up to 51% in one review). Reversal of the procedure is difficult and requires sural nerve transplant if the sympathetic chain is removed.

The procedure can be effective and worthwhile, but our advice to patients must reflect the true potential outcomes.

Dr Ian Gilfillan, Cardiothoracic Surgeon


http://www.medicalhub.com.au/wa-news/letters/3217-palmar-hyperhidrosis-revisited

post-sympathectomy neuralgia is frequent

Surgical sympathectomy has a long heritage for the treatment of peripheral vascular disease and various chronic pain problems.

Despite concerns expressed as long ago as 1942 about the efficacy of surgical sympathectomy for the management of non-cancer pain, the procedure was enthusiastically pursued for the management of reflex sympathetic dystrophy or complex regional pain syndrome (CRPS), migraine, dysmenorrhea, epilepsy, chronic pancreatitis, postherpetic neuralgia of the trigeminal nerve, postdiscectomy syndrome, and phantom limb pain. However, systematic reviews have found no tangible evidence supportive of sympathectomy for the management of neuropathic pain. Furthermore, postsympathectomy neuralgia is a common complaint with a reported incidence between 15% to 50%.

As surgery is often mentioned as a cause of CRPS, it is somewhat illogical to consider surgery as an effective treatment. Nonetheless, surgical sympathectomy has a long anecdotal history in the treatment of RSD, and more recently endoscopic and radiofrequency sympathectomy has been tried.

Bonica's Management of Pain,

Lippincott Williams & Wilkins, 2009 - 2064 pages

Permanent pain following sympathectomy

The mean inpatient pain scores were significantly higher in the biportal group (1.2±0.6) than that in the uniportal group (0.8±0.5, P=0.025). For the first three weeks after operation, four out of 20 (20%) patients in the uniportal group constantly suffered from mild or moderate residual pain while eight out of 25 (32%) cases in the biportal group (P=0.366). Among them, two cases in the uniportal group and five cases in the biportal group need to take analgesics.
Chinese Medical Journal, 2009, Vol. 122 No. 13 : 1525-1528

impairment of the CBF autoregulation after unilateral cervical sympathectomy

Although these findings argued against a neurogenic mechanism, James at al. (1969) reported impairment of autoregulation after unilateral cervical sympathectomy in the babbon. Gotoh et al. (1971/1972) observed impairment of autoregulation in patients with the Shy-Drager syndrome.
It was concluded that the autonomic nervous system plays an important role in the mechanism of autoregulation of CBF and that his mechanism is independent of the chemical control of the cerebral vessels. This was confirmed by direct observation of the pial vessels in cats, where separate sites of action in the vascular tree for autoregulation and chemical control were demonstrated; the autoregulatory reaction was located in pial arteries with a diameter larger than 50 μ, and the reaction to carbon dioxide in pial arteries of smaller diameter (Gotoh et al. 1975).
They concluded that the arteries operating in autoregulation were the larger ones with the dense innervation, while the smaller arteries with sparse innervation were involved in chemical control.
Coronna and Plum (1973) demonstrated the absence of CBF autoregulation in a patient with a Shy-Drager syndrome who had a postganglionic denervation.

Gotoh et al (1979) subsequently showed that autoregulation in patients with this syndrome was impaired irrespective of the localization of the damage to the cervical sympathetic nervous system (preganglionic, central, postganglionic) as judged by the eye instillation test.
Handbook of Clinical Neurology,

Vascular Diseases, Part I by P. J. Vinken, G. W. Bruyn, H. L. Klawans, and J. F. Toole

, Volume 53, Part 1

Elsevier Health Sciences, 1988