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

reduced oxygen saturation and shallow respiration after a thoracoscopic sympathectomy

1. D. J. Canty1,2,3,* and  C. F. Royse4,5

¹Department of Anaesthesia, Royal Hobart Hospital, 48 Liverpool Street, Hobart, Tasmania 7000, Australia

1. ²Medical School of The University of Tasmania, Tasmania, Australia
2. ³Department of Pharmacology, The University of Melbourne, Melbourne, Australia
3. ⁴Anaesthesia and Pain Management Unit, Department of Pharmacology, University of Melbourne, Melbourne, Australia
4. ⁵Royal Melbourne Hospital, Victoria, Australia

1. *Corresponding author. E-mail: david.canty@dhhs.tas.gov.au 
2.     http://bja.oxfordjournals.org/content/103/3/352.full

Although bilateral sympathectomy almost totally depleted the NA from the right atrium (by 98%), the NPY-ir levels were only reduced by 50%

Unilateral and bilateral sympathectomy produced similar reductions in the concentrations of NPY-ir and NA in the ventricular tissue.
Maccarrone C, Jarrott B.

Source

University of Melbourne, Department of Medicine, Austin Hospital, Heidelberg, Vic., Australia.
http://www.ncbi.nlm.nih.gov/pubmed/3450689

St Vincent’s Hospital in Melbourne does not perform sympathectomies

http://www.svhm.org.au/gp/clinics/Pages/Hepatobiliary.aspx

Occurrence and multiple recurrence of severe vasospasm of the upper extremity following thorascopic sympathectomy for hyperhidrosis

http://www.ncbi.nlm.nih.gov/pubmed/21130009

CAUSES AND MANAGEMENT OF ORTHODEOXIA - The Australian Short Course on Intensive Care Medicine, 2005

DEFINE AND LIST THE CAUSES AND MANAGEMENT OF PLATYPNOEA AND
ORTHODEOXIA

p. 79:
Autonomic
o Parkinson disease (Hussain 2004)
o Bilateral thoracic sympathectomy (van Heerdon 2004)

Published in 2005 by
The Australasian Academy of Critical Care Medicine
“Ulimaroa”
630 St Kilda Rd, Melbourne,
Victoria 3004

ISSN 1327-4759

A POTENTIAL DANGER DURING ENDOSCOPIC THORACIC SYMPATHECTOMY

1.  *Department of Vascular Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
2. †Department of Surgery, University of Sydney, Sydney, New South Wales, Australia

Australian and New Zealand Journal of Surgery

Volume 67, Issue 8, pages 578–579, August 1997

A report of a patient with an azygos lobe and an associated anomalous azygos vein covering the upper thoracic sympathetic chain. This anomaly poses a significant risk during the procedure of endoscopic thoracic sympathectomy. A chest X-ray is useful in detecting this anomaly and alerting the surgeon to potential problems.

a reduction of the muscular tone and to a secondary neurovascular disorder at the edge of the sympathetic denervation zone

Surgical sympathectomies and chemical sympatholyses bring about a true sympathetic deafferentation. This leads to central retrograde degenerescence reactions of the pre-ganglionic neurons, to a reduction of the muscular tone and to a secondary neurovascular disorder at the edge of the sympathetic denervation zone.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Retrieve&list_uids=2256535&dopt=abstractplus

HAZARDS ASSOCIATED WITH CERVICO-THORACIC SYMPATHECTOMY

The following is a case report of a healthy 18-year-old woman who had bilateral Cervico- Thoracic sympathectomy done in two stages for severe hyperhidrosis in the palms of her hands.
Two episodes of asystolic arrest occurred during the 2nd stage left Cervico-Thoracic sympathec- tomy.

Thirty-five minutes after starting the operation, as the surgeon was retracting and dissecting the upper thoracic chain,
the cardiac monitor showed sudden onset of sinus bradycardia. The pulse rate was 50 beats per minute. Atropine 1·2 mg was given intravenously but cardiac asystole occurred.

External cardiac compression was started and another dose of atropine 1· 2 mg was given, followed by adrenaline 1·0 mg but there was no response. Following a second dose of adrenaline 1·0 mg and sodium bicarbonate 100 mEq, the
heart restarted with a marked sinus tachycardia.

The cause of hyperhidrosis apparently originates from some poorly understood stimulation of the sympathetic nervous system (Cloward 1969), and in sensitive patients this may possibly lead to excessive vagal stimulation to counteract it, as illustrated by the bradycardia and asystolic reaction to the sudden removal of the sympathetic control, and by the high doses of sympathomimetic drugs necessary to recommence cardiac activity. Anatomically the heart is innervated by the cardiac plexus which consists of the cardiac nerves derived from the cervical and upper thoracic ganglia of the sympathetic trunk and branches of the vagus.The pacemaker of the heart, the sino-atrial node, is innervated by both the parasympathetic and sympathetic nerves (King and Coakley 1958). The ventricular muscle of the heart is supplied solely by the sympathetic nerves, and the larger branches of the coronary arteries are also predominantly innervated by sympathetics (Woollard 1926). These factors may also have a bearing on the hazard of a bilateral cervico- thoracic sympathectomy, which leaves the heart solely under vagal control. Usually, following
denervation, the heart will initiate its own impulse, without recourse to external agencies, but there may be a place for transvenous electrode cardiac pacing, if spontaneous initiationof impulse is delayed, or bradycardia is severe.


R. F. Y. ZEE*
Royal Perth Hospital, Perth
Anaesthesia and Intensive Care, Vol. V, No. 1, February, 1977, Australia

Cervical sympathetic chain injury is a rare complication of surgery for thyroid and parathyroid conditions

ANZ Journal of Surgery. 74(6):442-445, June 2004.
HARDING, JANE L. MB BS; SYWAK, MARK S. MB BS, FRACS; SIDHU, STAN MB BS, PhD, FRACS; DELBRIDGE, LEIGH W. MD, FRACS

Many patients come initially to the surgeon and they want a permanent effective cure

http://www.southernvascular.com.au/html/procedures_sympathectomy.html

A statistically significant drop in the level of norepinephrine occurred in all assessed patients after sympathectomy - the 'lobotomy' effect

http://icvts.oxfordjournals.org/content/5/4/464.full

 As a stress hormone, norepinephrine affects parts of the brain where attention and responding actions are controlled.
Along with epinephrine, norepinephrine also underlies the fight-or-flight response, directly increasing heart rate,
triggering the release of glucose from energy stores, and increasing blood flow to skeletal muscle.

Norepinephrine is also released from postganglionic neurons of the sympathetic nervous system, to transmit the
fight-or-flight response in each tissue respectively. The adrenal medulla can also be counted to such postganglionic
nerve cells, although they release norepinephrine into the blood.
Norepinephrine system
The noradrenergic neurons in the brain form a neurotransmitter system, that, when activated, exerts effects on large
areas of the brain. The effects are alertness and arousal, and influences on the reward system.

www.caam.rice.edu/~cox/wrap/norepinephrine.pdf

"I think the surgeons may not be aware of the long term consequences of denervation"

Email response from Dr. Ahmet Hoke of  John Hopkins School of Medicine,  School of Neurology - Specifically I asked him his opinion on three things:

1. What was his opinion of ETS in terms of risks vs benefits
2. His opinion on why Thoracic surgeons would advertise a surgical reversal approach when, as he sees it, it would  have a very low probability of success
3. His opinion on the Davinci Robot Reversal article regarding surgical reattachment of the sympathetic nerves

1. It all depends on the risk benefit analysis, for some patients yes it may make sense as not everyone develops as severe side effects.
2. I think the surgeons may not be aware of the long term consequences of denervation.

The paper you refer to is not a good model of what happens to the patients because they cut the nerve and immediately repaired it. In such immediate repairs, the ganglia does not loose it's neurons and can regenerate. A better model would be to cut the nerves, wait 6 months and then do the repair; I suspect the recovery would be a lot less.
Ahmet Hoke M.D., Ph.D. FRCPC
Professor of Neurology and Neuroscience
Director, Neuromuscular Division
Johns Hopkins School of Medicine
Department of Neurology
855 N. Wolfe St., Neurology 248
Baltimore, MD, 21205
USA

diabetic autonomic neuropathy has already sympathectomized the patient

This diabetic syndrome has been attributed to a lesion of the sympathetic nerve fibres which control sweat secretion [11] and follow the course of the peripheral nerves [12]. This affects the efferent branch of the reflex arch and is identical to that occurring distal to a surgical sympathectomy [13].

There was no difference found between the histological changes in the nerves of the spontaneous anhidrotic patients
(Fig. 1) and those of the two previously sympathectomized patients.

A number of papers have been published which stressed [22-24] the high failure rate of sympathectomy operations in diabetics. We believe that the failure of the operation is due to the fact that diabetic autonomic neuropathy has already sympathectomized the patient. The results of the present study are compatible with this idea.
http://www.springerlink.com/content/v21h52461037653k/

A dysesthetic syndrome can occur after sympathectomy

A dysesthetic syndrome can occur after sympathectomy; it usually is transient but sometimes can be persistent.

Eugenia-Daniela Hord, MD, Instructor, Departments of Anesthesia and Neurology, Massachusetts General Hospital Pain Center, Harvard Medical School

Dysesthethic pain is a common complaint of patients with syringomyelia, traumatic paraplegia, and various myelopathic conditions. Because cavitary lesions of the spinal cord can be defined with good resolution by magnetic resonance imaging, syringomyelia provides a potential model for examining anatomic correlates of central pain. In this study, a syndrome of segmental dysesthesias, characterized by burning pain, hyperesthesia, and a variable incidence of trophic changes, was described by 51 of 137 patients (37%) with syringomyelia at the time of clinical presentation. Complete magnetic resonance scans, including axial images, demonstrated extension of the syrinx into the dorsolateral quadrant of the spinal cord on the same side and at the level of pain in 43 of 51 patients (84%). Surgical treatment of syringomyelia resulted in the relief or improvement of dysesthetic pain in 22 of 37 patients (59%), but 15 patients (41%) reported no improvement or an intensification of pain despite collapse of the syrinx. Postoperative dysesthetic pain was often a disabling complaint that responded poorly to medical therapy, including analgesics, sedatives, antiepileptics, antispasmodics, and anti-inflammatory agents. In most cases, there was a gradual improvement of symptoms, although six patients continued to complain of pain 24 to 74 months postoperatively.

We conclude that painful dysesthesias can be caused by a disturbance of pain-modulating centers in the dorsolateral quadrant of the spinal cord and have certain causalgia-like features that respond in an unpredictable way to surgical collapse of the syrinx.
http://www.ncbi.nlm.nih.gov/pubmed/8727819

Surgical procedure advertised as 'reversible' is not reversible

a recent consensus statement by the Society of Thoracic Surgeons recommended that the clipping method should be considered irreversible as the clipped nerve might not be able to recover after the removal of clips [6].
Ann Thorac Surg 2011;91:1642-8.

extreme case of compensatory truncal hyperhidrosis and anhidrosis over the head and neck region which led to a heatstroke

Thoracic sympathectomy is a commonly performed surgical procedure for the treatment of palmar hyperhidrosis. However, one major complication of such a procedure is compensatory truncal hyperhidrosis. We describe an extreme case of compensatory truncal hyperhidrosis and anhidrosis over the head and neck region which led to a heatstroke.

http://icvts.oxfordjournals.org/content/early/2011/12/20/icvts.ivr121.abstract?sid=89a2ce71-1ea3-4573-9e63-17329e7c09cd

Presence of intense dyschromia in the region corresponding to anhidrosis after sympathectomy

http://ats.ctsnetjournals.org/cgi/content/full/88/4/e42

distinct patterns of peripheral physiological activity are associated with different emotion

The existence of specific somatic states associated with different emotions remains controversial. In this study, we investigated the profile of cardiorespiratory activity during the experience of fear, anger, sadness and happiness. ECG and respiratory activity was recorded in 43 healthy volunteers during the recall and experiential reliving of one or two potent emotional autobiographical episodes and a neutral episode. Univariate statistics indicated that the four emotions differed from each other and from the neutral control condition on several linear and spectral indices of cardiorespiratory activity. Dependent variables were further reduced to five physiologically meaningful factors using an exploratory principal component analysis (PCA). Multivariate analyses of variance and effect size estimates calculated on those factors confirmed the differences between the four emotion conditions. A stepwise discriminant analyses predicting emotions using the PCA factors led to a classification rate of 65.3% for the four emotions (chance=25%; p=0.001) and of 72.0-83.3% for pair-wise discrimination (chance=50%; p's<0.05). These findings may be considered preliminary in view of the small sample on which the multivariate approach has been applied. However, this study emphasizes the need to better characterize the multidimensional factors involved in cardio-respiratory regulation during emotion. These results are consistent with the notion that distinct patterns of peripheral physiological activity are associated with different emotions.

http://www.ncbi.nlm.nih.gov/pubmed/16439033

As you ought not to attempt to cure eyes without head, or head without body, so you ought not to treat body without mind.

Socrates, Ca. 400 B.C.

sympathicotomy may cause a temporary impairment of the caudal-to-rostral hierarchy of thermoregulatory control and changes in microcirculation

Patients with palmar hyperhidrosis have been reported to have a much
more complex dysfunction of autonomic nervous system, involving compensatory high parasympathetic
activity as well as sympathetic overactivity (13, 14), suggesting that sympathicotomy initially induces a
sympathovagal imbalance with a parasympathetic predominance, and that this is restored on a
long-term basis (14). Therefore, thoracic sympathicotomy may cause a temporary impairment of the
caudal-to-rostral hierarchy of thermoregulatory control and changes in microcirculation. The reduction
of finger skin temperature on the non-denervated side may be due to either a decrease in the cross-
inhibitory effect or the abnormal control of the inhibitory fibers by the sudomotor center (6).
Vasoconstrictor neurons have been found to be largely under the inhibitory control of various afferent
input systems from the body surface, whereas sudomotor neurons are predominantly under excitatory
control (15). The basic neuronal network for this reciprocal organization is probably located in the spinal
level (15). Therefore, the reduction in the contralateral skin temperature may be explained by cross-
inhibitory control of various afferent in the spinal cord.
In particular, our study showed that, following bilateral T3 sympathicotomy, the skin temperatures on
the hands increased whereas the skin temperatures on the feet decreased. These findings suggest a
cross-inhibitory control between the upper and lower extremities. However, the pattern of skin
temperature reduction on the feet differed from that on the contralateral hand. The skin temperature on
the feet did not decrease after right T3 sympathicotomy but decreased significantly after bilateral T3
sympathicotomy.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2722005/

significant impairment of the heart rate to workload relationship was consistently observed following sympathectomy

The aim of the present prospective study was to confirm that a significant impairment of the heart rate to workload relationship was consistently observed following unilateral and/or bilateral (sympathectomy) surgery. Eur J Cardiothorac Surg 2001;20:1095-1100 http://ejcts.ctsnetjourna...i/content/full/20/6/1095

a correlation of the findings of cytoarchitectonics and sympathectomy with fibre degeneration following dorsal rhizotomy

Autonomic neurons in the spinal cord of the rhesus monkey: a correlation of the findings of cytoarchitectonics and
sympathectomy with fibre degeneration following dorsal rhizotomy.
J Comp Neurol 146:189 –218.
http://onlinelibrary.wiley.com/doi/10.1002/cne.901460205/abstract


Cytoarchitecture or Cytoarchitectonics is the study of the cellular composition of the body's tissues under the microscope.

Bradicardia, hypotension and hypoxia are frequently observed during thoracic sympathicotomy

Clinical Autonomic Research

Volume 13, Number 2, 147-161, DOI: 10.1007/s102860300008

ISSS-ABSTRACTS

5^th International Symposium on Sympathetic Surgery 29^th–31^th May 2003

sympathectomy results in a pronounced increase of cerebrospinal fluid production

Electrical stimulation of the sympathetic nerves, which originate in the superior cervical ganglia, induces as much as 30% reduction in the net rate of cerebrospinal fluid (CSF) production, while sympathectomy results in a pronounced increase, about 30% above control, in the CSF formation. There is strong reason to believe that the choroid plexus is under the influence of a considerable sympathetic inhibitory tone under steady-state conditions.

http://ukpmc.ac.uk/abstract/MED/6276421

"Lumbar sympathectomy/Sympathectomy and Hydrocephalus sharing one common finding"

http://en.diagnosispro.com/disease_comparison-for/lumbar-sympathectomy-versus-hydrocephalus/16143-22570.html


DiagnosisPro is a medical expert system.^[1] It provides exhaustive diagnostic possibilities for 11,000 diseases and 30,000 findings.^[2] It is supposed to give the most appropriate differential however this is not always the case.^[3] Between Oct 2008 and Oct 2009 the site averaged 61,000 visits per month. ^[4]
http://en.diagnosispro.com/disease_comparison-for/lumbar-sympathectomy-versus-hydrocephalus/16143-22570.html


Hydrocephalus also known as "water in the brain," is a medical condition in which there is an abnormal accumulation of cerebrospinal fluid (CSF) 

http://en.wikipedia.org/wiki/Hydrocephalus

Effect of ganglion blockade on cerebrospinal fluid norepinephrine

Prevention of ganglion blockade-induced hypotension using phenylephrine did not prevent the decrease in CSF NE caused by trimethaphan, and when phenylephrine was discontinued, the resulting hypotension was not associated with increases in CSF NE. The similar decreases in plasma NE and CSF NE during ganglionic blockade, and the abolition of reflexive increases in CSF NE during hypotension in ganglion-blocked subjects, cast doubt on the hypothesis that CSF NE indicates central noradrenergic tone and are consistent instead with at least partial derivation of CSF NE from postganglionic sympathetic nerve endings.

 http://www.mendeley.com/research/effect-of-ganglion-blockade-on-cerebrospinal-fluid-norepinephrine/

Ischemic spinal cord injury has been reported after sympathectomy

Toole's Cerebrovascular Disorders

E. Steve Roach, James F. Toole, Kerstin Bettermann, José Biller

Cambridge University Press, 31/01/2010 - Medical - 408 pages

Severe Bronchospasm Following Bilateral T2-T5 Sympathectomy

http://www.ispub.com/journal/the-internet-journal-of-anesthesiology/volume-12-number-2/severe-bronchospasm-following-bilateral-t2-t5-sympathectomy.html

isolated failure of sympathetic sudomotor activity

The main clinical features include symptoms of heat intolerance: feeling hot, flushed, dyspneic, light-headed, and weak when the ambient temperature is high or when exercising. Recent accounts of acquired idiopathic anhidrosis, however, have emphasized the heterogeneous features and sub-types of this condition.
Fitzpatrick's Dermatology In General Medicine, Seventh Edition: Two Volumes
Pub Date: NOV-07

The practice of sympathectomy for treating neuropathic pain is based on very weak evidence. Furthermore, complications of the procedure may be significant.

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

http://summaries.cochrane.org/CD002918/cervico-thoracic-or-lumbar-sympathectomy-for-neuropathic-pain

Post sympathectomy syndrome is a poorly understood condition

Post sympathectomy syndrome is a poorly understood condition, which occurs in up to 50% of patients undergoing sympathectomy. This is proposed to be a complex neuropathic and central deafferentation and reafferentation sydnrome. This can occur anywhere from few days to weeks following chemical or surgical sympathectomy. This is characterized by deep, aching pain with superficial burning and hyperesthesia, which may or may not respond to narcotic analgesics. Tricyclic antidepressants may help to reduce the incidence of postsympathoctomy neuralgia. Phenytoin, Carbamazepine or Gabapentin may be useful to reduce spontaneous pain and allodynia. Mexiletine and I.V. lignocaine may help some patients. Occasionally invasive therapies like sympatheic block or more complete sympathectomy can also help.

Stellate ganglion block is one of the most frequently performed procedures in he practice of chronic pain. It can provide good diagnostic, therapeutic and prognostic value.
It can produce complete sympathectomy to the head and neck structures but only a partial sympathetic block of the upper extremity in some patients with variation in anatomy.

Interventional Pain Management

DK. Baheti, Bombay Hospital

Jaypee Brothers Publishers, 2009

There is a fairly extensive literature on pain after lumbar sympathectomy

bja.oxfordjournals.org/content/87/1/88.full

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

Spinal Ischemic Stroke from complications of abdominal surgery, esp. sympathectomy

B. Arterial feeders (e.g. thoracic, intercostal, or cervical branch from subclavian or vertebral artery)
1) thromboembolic disease!
2) complications of abdominal surgery (esp. sympathectomy)
3) dural AV fistulas (between radicular arteries and veins outside dura mater) – cause venous
hypertension → characteristic dilated veins that course on spinal cord surface.

Viktor’s Notes℠ for the Neurosurgery Resident
Please visit website at www.NeurosurgeryResident.net
Updated: April 17, 2010

"Sympathectomy frequently interferes with ejaculation"

Kaplan & Sadock's synopsis of psychiatry:

behavioral sciences/clinical psychiatry

Benjamin J. Sadock, Harold I. Kaplan, Virginia A. Sadock

Lippincott Williams & Wilkins, 2007 - 1470 pages

After peripheral nerve section the amount of GAL produced and present in sensory fibers proximal to the section is dramatically upregulated

Front Neuroendocrinol. 1992 Oct;13(4):319-43.

Galanin in sensory neurons in the spinal cord.

Department of Clinical Physiology, Karolinska Institute, Huddinge University Hospital, Sweden.

The distribution and physiological effects of the neuropeptide galanin (GAL) have been examined in the somatosensory system. GAL is normally present in a few sensory neurons that terminate in the dorsal horn of the spinal cord and it is colocalized with substance P and calcitonin gene-related peptide. After peripheral nerve section, but not dorsal root section, the amount of GAL produced and present in sensory fibers proximal to the section is dramatically upregulated. In parallel functional studies, we could demonstrate that exogenous GAL has a complex effect on the spinal cord reflex excitability, facilitatory at low doses and inhibitory at high doses. Furthermore, GAL inhibits the effect of excitatory neuropeptides physiologically released at the peripheral and central terminals of small diameter afferents that subserve a nociceptive function. After axotomy, the inhibitory effect of GAL is increased. We conclude that GAL may have an important role in the control of nervous impulses that underlie pain states that can occur after peripheral nerve injury.

http://www.ncbi.nlm.nih.gov/pubmed/1281124

Increased expression of galanin in the rat superior cervical ganglion after pre- and postganglionic nerve lesions

http://www.ncbi.nlm.nih.gov/pubmed/7515354

Galanin is a neuropeptide encoded by the GAL gene,^[1] that is widely expressed in the brain, spinal cord, and gut of humans as well as other mammals. Galanin signaling occurs through three G protein-coupled receptors.^[2]
The functional role of galanin remains largely unknown; however, galanin is predominately involved in the modulation and inhibition of action potentials in neurons. Galanin has been implicated in many biologically diverse functions, including: nociception, waking and sleep regulation, cognition, feeding, regulation of mood, regulation of blood pressure, it also has roles in development as well as acting as a trophic factor.^[3] Galanin is linked to a number of diseases including Alzheimer’s disease, epilepsy as well as depression, eating disorders and cancer.^[4][5] Galanin appears to have neuroprotective activity as its biosynthesis is increased 2-10 fold upon axotomy in the peripheral nervous system as well as when seizure activity occurs in the brain. It may also promote neurogenesis.^[2]
http://en.wikipedia.org/wiki/Galanin

Compensatory changes in contralateral sympathetic neurons of the superior cervical ganglion and in their terminals in the pineal gland following unilateral ganglionectomy

The sympathetic noradrenergic neurons of the rat superior cervical ganglia (SCGs) provide the major source of innervation to the pineal gland. The present study sought to determine if this sympathetic innervation can undergo collateral sprouting following partial denervation of the pineal by unilateral removal of the SCG (ganglionectomy), and whether such growth of axon terminals is associated with biochemical changes in the contralateral SCG. In the pineal gland following partial denervation, residual noradrenergic terminals underwent compensatory changes indicative of collateral sprouting, as evidenced by: a rapid reduction in tyrosine hydroxylase (TH) activity and in [3H]norepinephrine (NE) uptake, to about 50% of control by 2 days, which was followed by a gradual but sustained increase to levels of approximately 80% of control by 10 days and a reduction in the intensity and density but not in the distribution of fibers containing NE-induced fluorescence by 2 days, which was followed by a sustained increase. In the contralateral SCG, choline acetyltransferase (CAT) activity, a marker of cholinergic preganglionic terminals, was transiently increased to about 115% of control by 4 days and returned to control levels by 14 days after unilateral ganglionectomy; later, TH activity in noradrenergic cell bodies was gradually increased to about 140% of control by 10 days where it remained for up to 52 days. Unilteral ganglionectomy combined with decentralization of the contralateral SCG by preganglionic nerve cut prevented the compensatory changes in noradrenergic nerve terminals within the pineal.
http://www.ncbi.nlm.nih.gov/pubmed/2861259

Hypertrophy and neuron loss: structural changes in sheep SCG induced by unilateral sympathectomy

Interaction effects between time and ganglionectomy-induced changes were significant for SCG volume and mean perikaryal volume. These findings show that unilateral superior cervical ganglionectomy has profound effects on the contralateral ganglion. For future investigations, it would be interesting to examine the interaction between SCGs and their innervation targets after ganglionectomy. Is the ganglionectomy-induced imbalance between the sizes of innervation territories the milieu in which morphoquantitative changes, particularly changes in perikaryal volume and neuron number, occur? Mechanistically, how would those changes arise? Are there any grounds for believing in a ganglionectomy-triggered SCG cross-innervation and neuroplasticity?
http://www.ncbi.nlm.nih.gov/pubmed/21334426

SYMPATHECTOMY ON THE FATTY DEPOSIT IN CONNECTIVE TISSUE

The effect of unilateral extirpation of the stellate and the superior cervical ganglia on the amount of the pericardial fat and the effect of unilateral extirpation of the lumbar and sacral ganglia on the abdominal and subcutaneous fat on the denervated side make it likely that the effects of the splanchnic nerves on the perirenal fat may be extended to describe the relation between fat storage in and sympathetic innervation of connective tissue in general.
http://ep.physoc.org/content/27/1/1

Retrograde Changes in the Nervous System Following Unilateral Sympathectomy

In consequence of right-sided smpathectomy at the level of C5 it was found that in the sheep the cervical sympathetic trunk contains nerve fibres which proceed from cells situated in the first four segments of the thoracic part of the spinal cord and in the stellate ganglion. These fibres are about 85 per cent of all fibres of the sympathetic trunk. The remaining 15 per cent proceed from nerve cells situated nasally of the anterior cervical ganglion.
http://onlinelibrary.wiley.com/doi/10.1111/j.1439-0442.1967.tb00255.x/abstract

Telaranta's patient commits suicide after elective surgery for sweaty hands

One of Dr. Telaranta’s patients who had made a complaint began to experience strong reactions of anxiety which did not go away even after corrective surgery. Later the patient committed suicide. 

Surgery involving the clamping of sympathetic nerve trunks to prevent excessive perspiration and blushing appears to be of questionable value.
      Complications have been reported, ranging from phantom perspiration to blood clots in the brain.
      The Finnish Office for Health Care Technology Assessment (FinOHTA), which is part of the National Research and Development Centre for Welfare and Health (STAKES) recently conducted a survey on the various effects of hyperhidrosis surgery at the request of the Finnish Medical Association.
      Finnish surgeon Timo Telaranta has performed about 2,000 such operations at private clinics in Helsinki and Oulu in the past ten years.
     
The National Authority for Medicolegal Affairs has issued three warnings to Telaranta and the Provincial Government of Southern Finland has issued one. 

Many doctors have serious reservations about the idea of treating complaints such as excessive perspiration, blushing, and performance anxiety by severing people’s nerves. 
http://www.hs.fi/english/article/1101979734791   

Patients with sympathectomy are not suitable controls for sleep study. Why?

Exclusions:
Patients with permanent pacemaker, non-sinus cardiac arrhythmias, peripheral vasculopathy or neuropathy, severe lung disease, status postbilateral cervical or thoracic sympathectomy, finger deformity that precludes adequate sensor application, using a-adrenergic receptor blockers, or alcohol or drug abuse during the last 3 years.

Evaluation of a Portable Device Based on Peripheral Arterial Tone for Unattended Home Sleep Studies

 The clinic sleep laboratory of the Technion Sleep Medicine Centre, Israel
http://chestjournal.chestpubs.org/content/123/3/695.long
CHEST March 2003 vol. 123 no. 3 695-703

MSAC Application no 1130, Assessment Report

The amount of compensatory sweating depends the amount of cell body reorganization in the spinal cord after surgery

The amount of compensatory sweating depends on the patient, the damage that the white rami communicans incurs, and the amount of cell body reorganization in the spinal cord after surgery.

Other potential complications include inadequate resection of the ganglia, gustatory sweating, pneumothorax, cardiac dysfunction, post-operative pain, and finally Horner’s syndrome secondary to resection of the stellate ganglion.
www.ubcmj.com/pdf/ubcmj_2_1_2010_24-29.pdf

ETS considered psychiatric surgery - says Dr Nagy

"ETS can alter many bodily functions, including sweating , heart rate , heart stroke volume , blood pressure , thyroid , baroreflex , lung volume , pupil dilation, skin temperature, goose bumps and other aspects of the autonomic nervous system . It can diminish the body's physical reaction to exercise and/or strong emotion, and thus is considered psychiatric surgery. In rare cases sexual function or digestion may be modified as well. "
http://www.lvhyperhidrosis.com/treatment.html

MD admits stellate ganglion block impacts on the insular cortex of the brain and alters emotions

Dr. Lipov says, "What really intrigued me about Dr, DeWall's study was he showed Tylenol exerted this emotional effect by acting on the insular cortex of the brain. That's exactly the same area that's affected by a Stellate Ganglion Block.[4]" The specialist is also Director of Chronic Pain Research at Northwest Community Hospital in Arlington Heights.
http://www.medicalnewstoday.com/releases/227298.php

Individual cardiovascular response to different levels of sympathetic blockade varies widely, depending on the degree of sympathetic tone before the block

The cardiovascular responses to epidural anaesthesia are almost entirely due to the fact that the local anaesthetic injected into the epidural space not only blocks somatic, sensory and motor fibres, but also produces preganglionic sympathetic denervation.

Postganglionic sympathetic nerves play an important role in controlling cardiac function and vascular tone. The most important of the cardiovascular effects are related to blockade of vasoconstrictor fibres (below T4) with resulting dilatation of resistance and capacitance vessels and/or cardiac sympathetic fibres with loss of chronotropic and inotropic drive to the myocardium (T1-5) (Figure 1).

The cardiac sympathetic outflow emerges from C5 to T5 levels, with the main supply to the ventricles from T1 to T43. A significant part of the chronotropic and inotropic control of the heart is mediated through the upper four thoracic spinal segments.
Denervation of preganglionic cardiac accelerator fibres leaving the cord at T1-T5 results in minimal vasodilatory consequences. Changes however in heart rate, left ventricular function and myocardial oxygen demand may occur due to high thoracic epidural blockade and are discussed below.

The major determinant of heart rate is the balance between sympathetic and parasympathetic systems with the latter predominating. A high thoracic epidural anaesthesia (TEA) covering the cardiac segments (T1-T4) produces small but significant reductions in heart rate4-8. During cardiac sympathetic denervation, parasympathetic cardiovascular responses, including those involved in baroreflexes, may dominate.


It was suggested that the sympathetic control of heart rate modified the dominating parasympathetic tone, rather than functioning as an active cardiac accelerator. In this study there was no compensation for changes in preload;
therefore cardiopulmonary baroreceptors affected by changes in central volume secondary to peripheral vasodilatation or vasoconstriction might have altered arterial baroreceptor heart rate reflex as well.



High TEA added to general anaesthesia significantly decreased the cardiac acceleration in response to decreasing blood pressure, suggesting that baroreflex-mediated heart rate response to a decrease in arterial blood pressure depends on the integrity of the sympathetic nervous system. However general anaesthesia, in addition to high levels of epidural anaesthesia, may have modified the balance between sympathetic and parasympathetic tone as well.
By applying power spectral analysis, i.e., frequency analysis of electrocardiographic R-R interval, the individual components of the autonomic nervous system can be discerned and can be used as a sensitive indicator of sympathovagal interaction.


Individual cardiovascular response to different levels of sympathetic blockade varies widely, depending on the degree of sympathetic tone before the block.
Anaesth Intensive Care 2000; 28: 620-635
B. T. VEERING*, M. J. COUSINS†
Department of Anesthesiology, Leiden University Medical Center, Leiden, The Netherlands and Department of Anaesthesia and
Pain Management, University of Sydney, Royal North Shore Hospital, Sydney, New South Wales

diabetic autonomic neuropathy has already sympathectomized the patient

Although not specific, the symptoms suffered by diabetics from sweating disturbances are fairly typical [5]. Initially there is heat intolerance accompanied by hyperhidrosis of the upper half of the body, particularly affecting the face, neck, axillae and hands. It is of interest that these patients rarely perspire excessively below the umbilicus. This diabetic syndrome has been attributed to a lesion of the sympathetic nerve fibres which control sweat secretion [11] and follow the course of the peripheral nerves [12]. This affects the efferent branch of the reflex arch and is identical to that occurring distal to a surgical sympathectomy [13].

There was no difference found between the histological changes in the nerves of the spontaneous anhidrotic patients
(Fig. 1) and those of the two previously sympathectomized patients.

A number of papers have been published which stressed [22-24] the high failure rate of sympathectomy operations in diabetics. We believe that the failure of the operation is due to the fact that diabetic autonomic neuropathy has already sympathectomized the patient. The results of the present study are compatible with this idea.
http://www.springerlink.com/content/v21h52461037653k

Sympathectomy decreased CD4+ T-cells in lymph nodes

Alterations in lymphocyte activity does not always correlate with changes in the proportions of T- or B-lymphocyte subsets. Sympathetic denervation leads to loss of an important regulatory mechanism in immune system physiology. This is apparently site specific in that both lymph node and spleen T-cell proliferative responses are reduced.
Article by Dr. Brian A. Smith
http://home.earthlink.net/~doctorsmith/hivandchiro.htm

ETS story

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.

http://etsandreversals.yuku.com/reply/22927/Would-you-do-it-again#reply-22927

'Improved sympathectomy' - is it an oxymoron?

"also it seems like the more bad and negative affects were from 10 to 12 years ago when they had just started performing the surgery.. they must have improved it a lot by now.?"

This procedure has been performed since the 1920's. Yes, the 1920's. In the 1980's they started to do it using "keyhole" surgery which means they don't have to make a big incision. But, the surgery is no different than what they've been doing for the last 70+ years. It's a nerve injury. You can't "improve" they way you inflict a nerve injury. You can't injure the nerve in some "special" way such that the injury suddenly has a different effect on the body.

The functional name for the this surgery is "sympathetic denervation". It's not some super-advanced, modern cure based on recent discoveries in neurophysiology. It's a primitive, destructive procedure. It's a method used on animals for research. It's brute force method...destroy the pathways to the sweat glands over a large region. Unfortunately, it destroys pathways to and from many other organs including the heart and lungs and causes a large number of neuropathological dysfunction. That hasn't changed in the last ten years. It will not and cannot change in the next 1000 years because it will still be a nerve injury 1000 years from now. I'm not making this up. It's a simple fact. Don't let some doctor take advantage of your ignorance
http://etsandreversals.yuku.com/topic/4919/Should-i-have-ETS-surgery#.Tok-TE8YAyk

sympathectomy will block the chronotropic response

Around 50% of patients have bradycardia in the following minutes of a bilateral surgery with mean and diastolic blood pressure significant reduction. Since the sympathectomy will block the chronotropic response, a significant increase of the ejection volume is observed when the patient moves in the erect position from dorsal decubitus [6]. Two cardiovascular complications were reported in the literature. First, an asystolic cardiac arrest in an 18-year-old woman during the second side (left) of bilateral sympathectomy for severe hyperhidrosis, requiring resuscitation maneuvers, with no chronic sequelae [7]. The second case was reported in a 23-year-old woman in whom a bilateral T₂ sympathectomy was performed for facial hyperhidrosis. Two years later, following electrophysiologic studies confirming unopposed vagotonic stimulation, she underwent permanent pacemaker insertion for symptomatic bradycardia [8].
http://icvts.ctsnetjournals.org/cgi/content/full/8/2/238

many claims in Australia do not result in payments to plaintiffs

However, as with the US research, many claims in Australia do not result in payments to plaintiffs. This fact often comes as a surprise to medical practitioners as it is not well publicised.


It is not a simple matter for a plaintiff to succeed in a claim for compensation based in medical negligence. And it certainly is an expensive exercise especially when there can be no guarantee of success.


For doctors involved in a claim that is successfully defended there is usually no direct financial cost.

Ms Cheryl McDonald is claims department manager with MIGA (Medical Insurance Group Australia).

MJA InSight, Issue 38 - 10 Oct, 2011

HAZARDS ASSOCIATED WITH CERVICO-THORACIC SYMPATHECTOMY

The need for a realistic appraisal of the potentialities for harm in Cervico-Thoracic sympathectomy is apparent on anatomic grounds alone (Orkin et al. ] 950). Fatalities occur from time to time, but only a few reports of such fatalities find their way into the literature (Adriani et al. 1952). Reported complications associated with Ccrvico-Thoracic sympathectomy, which is, in effect a permanent Stellate
Ganglion block (Moore 1954), include pneumothorax, Horner's syndrome, phrenic and recurrent laryngeal nerve damage, infection from oesophageal puncture, cardiac arrhythmias (Tochinai 1974), and very infrequently cardiac arrest (Moore 1954).
The following is a case report of a healthy 18-year-old woman who had bilateral Cervico-Thoracic sympathectomy done in two stages for severe hyperhidrosis in the palms of her hands.
Two episodes of asystolic arrest occurred during the 2nd stage left Cervico-Thoracic sympathectomy.
The
cause of hyperhidrosis apparently originates
from some poorly understood stimulation of the
sympathetic nervous system (Cloward 1969),
and in sensitive patients this may possibly lead
to excessive vagal stimulation to counteract it,
as illustrated by the bradycardia and asystolic
reaction to the sudden removal of the
sympathetic control, and by the high doses of
sympathomimetic drugs necessary to
recommence cardiac activity. Anatomically the
heart is innervated by the cardiac plexus which
consists of the cardiac nerves derived from the
cervical and upper thoracic ganglia of the
sympathetic trunk and branches of the vagus.
The pacemaker of the heart, the sino-atrial
node, is innervated by both the parasympathetic
and sympathetic nerves (King and Coakley
1958). The ventricular muscle of the heart is
supplied solely by the sympathetic nerves, and
the larger branches of the coronary arteries are
also predominantly innervated by sympathetics
(Woollard 1926). These factors may also have a
bearing on the hazard of a bilateral cervico-
thoracic sympathectomy, which leaves the heart
solely under vagal control. Usually, following
denervation, the heart will initiate its own
impulse, without recourse to external agencies,
but there may be a place for transvenous
electrode cardiac pacing, if spontaneous initiation
of impulse is delayed, or bradycardia is severe.
Anaesthesia and Intensive Care, Vol. V, No. 1, February, 1977

R. F. Y. ZEE
Royal Perth Hospital, Perth