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{{ClinPsy}}
'''Endoscopic thoracic sympathectomy''' (ETS) is a surgical procedure where certain portions of the [[sympathetic nerves|sympathetic nerve]] trunk are destroyed. ETS is used to treat [[hyperhidrosis]], facial [[blushing]], [[Raynaud's disease]] and [[Reflex Sympathetic Dystrophy]]. By far the most common complaint treated with ETS is [[palmar hyperhidrosis]], or "sweaty palms". In this disorder, the palms may constantly shed so much sweat that the affected person is unable to handle paper, sign documents, keep clothes dry, or shake hands. The result is often [[social phobia]] so severe as to be disabling.
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{{Interventions infobox |
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Name = Endoscopic thoracic sympathectomy |
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Image = |
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ICD10 = |
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ICD9 = {{ICD9proc|05.2}} |
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MedlinePlus = 007291 |
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OtherCodes = |
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}}
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'''Endoscopic thoracic sympathectomy''' (ETS) is a surgical procedure in which a portion of the [[sympathetic nerves|sympathetic nerve]] trunk in the [[thoracic]] region is destroyed.<ref name="STS2011">{{cite journal|last1=Cerfolio|first1=Robert J.|last2=De Campos|first2=Jose Ribas Milanez|last3=Bryant|first3=Ayesha S.|last4=Connery|first4=Cliff P.|last5=Miller|first5=Daniel L.|last6=DeCamp|first6=Malcolm M.|last7=McKenna|first7=Robert J.|last8=Krasna|first8=Mark J.|title=The Society of Thoracic Surgeons Expert Consensus for the Surgical Treatment of Hyperhidrosis|journal=The Annals of Thoracic Surgery|volume=91|issue=5|year=2011|pages=1642–1648|issn=00034975|doi=10.1016/j.athoracsur.2011.01.105|url=http://www.sts.org/sites/default/files/documents/pdf/expertconsensus/Surgical_Treatment_of_Hyperhidrosis.pdf}}</ref> ETS is used to treat [[hyperhidrosis]], facial [[blushing]], [[Raynaud's disease]] and [[reflex sympathetic dystrophy]]. By far the most common complaint treated with ETS is [[palmar hyperhidrosis]], or colloquially known as "sweaty palms".
   
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Sympathectomy physically destroys relevant nerves anywhere in either of the two [[sympathetic trunks]], which are long chains of nerve [[Ganglion|ganglia]] located bilaterally along the vertebral column (situated to reduce the potential for injury) responsible for various important aspects of the peripheral nervous system (PNS). Each nerve trunk is broadly divided into three regions: cervical ([[neck]]), [[human thorax|thoracic]] (chest), and [[lumbar]] (lower back). The most common area targeted in sympathectomy is the upper thoracic region, that part of the sympathetic chain lying between the first and fifth thoracic vertebrae.
   
==Overview==
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==Indications==
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ETS is most commonly used to treat Localized Hyperhidrosis (that specifically affects the palms, soles, armpits and face), severe hyperhidrosis of the upper body, Raynaud's phenomenon, and facial [[blushing]].
   
ETS surgery works by dissection [[nerve]] tissue in the upper thoracic region of the [[sympathetic nervous system]], thus interrupting neural messages that ordinarily would travel to many different organs, glands and muscles. It is via these nerves of the autonomic nervous system that the brain is able to make adjustments in the body in response to changing conditions in the environment, changing emotional states, level of exercise, and other factors.
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There are reports of ETS being used to achieve cerebral revascularization for patients with [[moyamoya disease]],<ref>{{cite journal |author=Suzuki J, Takaku A, Kodama N, Sato S |title=An attempt to treat cerebrovascular 'Moyamoya' disease in children |journal=Childs Brain |volume=1 |issue=4 |pages=193–206 |year=1975 |pmid=1183260 |doi=10.1159/000119568 }}</ref> and to treat headaches, hyperactive bronchial tubes,<ref>{{cite journal |author=Sung SW, Kim JS |title=Thoracoscopic procedures for intrathoracic and pulmonary diseases |journal=Respirology |volume=4 |issue=1 |pages=19–29 |year=1999 |month=March |pmid=10339727 |doi=10.1046/j.1440-1843.1999.00146.x |url=http://www3.interscience.wiley.com/journal/119085923/abstract}}</ref> [[long QT syndrome]]<ref>{{cite journal |author=Telaranta T |title=Psychoneurological applications of endoscopic sympathetic blocks (ESB) |journal=Clin Auton Res. |volume=13 |issue=Suppl 1 |pages=I20–1; discussion I21 |year=2003 |month= December|pmid=14673667 |doi=10.1007/s10286-003-1107-1 }}</ref><ref>[http://www.londonarrhythmiacentre.co.uk/diagnosis-ventricular-ventricular-tachycardia.html Ventricular Arrhythmia/ Tachycardia]</ref><ref>{{cite journal |author=Khan IA |title=Long QT syndrome: diagnosis and management |journal=Am Heart J. |volume=143 |issue=1 |pages=7–14 |year=2002 |month= January|pmid=11773906 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002870302249595 |doi=10.1067/mhj.2002.120295}}</ref> and other conditions.
   
When performed endoscopically, the surgeon penetrates the chest cavity, making holes about the diameter of a soda straw between ribs. This allows the surgeon to insert a tiny video camera in one hole and a surgical instrument in another.
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==Surgical Procedure==
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ETS involves dissection of the main [[Sympathetic trunk]] in the upper thoracic region of the [[sympathetic nervous system]], thus interrupting neural messages that ordinarily would travel to many different organs, glands and muscles. It is via these nerves of the autonomic nervous system that the brain is able to make adjustments in the body in response to changing conditions in the environment, changing emotional states, level of exercise, and other factors to maintain the body's [[homeostasis]]. This normative function is disabled or impaired by sympathectomy, because the functions these physiological mechanisms perform also regulate conditions like blushing or sweating, that the procedure is designed to eliminate.
   
Sympathectomy is accomplished by dissecting the nerve tissue. The clamping method, also referred to as ESB (Endoscopic Sympathetic Blockade) employs titanium clamps around the nerve tissue, and was developed in an attempt to make the procedure reversible. However, reversal of the clamping procedure has a short time window (a few days or weeks at most) and may be incomplete. In a study by [http://www.sweaty-palms.com Dr. Rafael Reisfeld], it was concluded that the clamping method at the T3-T4 level is as effective as the coagulation or the excisional method done at the T2-T3 level.<ref>Reisfeld, Rafael. "Sympathectomy for hyperhidrosis: should we place the clamps at T2-T3 or T3-T4?" Clinical Autonomic Research, December 2006, Volume 16, Number 6. </ref>
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There is much disagreement among ETS surgeons about the best surgical method, optimal location for nerve dissection, and the nature and extent of the consequent primary effects and side effects. When performed endoscopically as is usually the case, the surgeon penetrates the chest cavity, making incisions about the diameter of a straw between ribs. This allows the surgeon to insert the video camera (endoscope) in one hole and a surgical instrument in another. The operation is accomplished by dissecting the nerve tissue of the main sympathetic chain. The clamping method, also referred to as '''endoscopic sympathetic blockade''' (ESB) employs titanium clamps around the nerve tissue, and was developed in an unsuccessful attempt to make the procedure reversible. However, technical reversal of the clamping procedure must be performed within a short time after clamping (a few days or weeks at most), and a recovery, evidence suggests, will not be complete.
   
It has been proposed and anecdotal, that 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 has been proposed, but generally scientifically unproven, that it can also diminish the body's physical reaction to exercise and possibly reactions to strong emotion.
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==Physical, Mental and Emotional Effects==
   
==Results==
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Sympathectomy works by disabling part of the autonomic nervous system (and thereby disrupting its signals from the brain), through surgical intervention, in the expectation of removing or alleviating the problem. Many non-ETS doctors have found this practice questionable chiefly because its purpose is to destroy anatomically normal, but [[functional disorder|functionally disordered]], nerves.<ref>{{cite book |author=McNaughton, Neil |title=Biology and emotion |publisher=Cambridge University Press |location=Cambridge, UK |year=1989 |pages=67 |isbn=0-521-31938-2 |url=http://books.google.com/?id=-5KpUqb058oC&pg=PA67&lpg=PA67&dq=viscera+sympathectomy}}</ref>
The most common indication for ETS surgery is hyperhidrosis, or excessive sweating. However, the only empirical study on sweat before and after ETS demonstrated that the procedure increases total body sweating. <ref name="pmid11193740">{{cite journal |author=Kopelman D, Assalia A, Ehrenreich M, Ben-Amnon Y, Bahous H, Hashmonai M |title=The effect of upper dorsal thoracoscopic sympathectomy on the total amount of body perspiration |journal=Surg. Today |volume=30 |issue=12 |pages=1089–92 |year=2000 |pmid=11193740 |doi=10.1007/s005950070006}}</ref>
 
   
Swedish National Board of Health and Welfare statement on treatment results says (English translation is available at: [http://home.swipnet.se/sympatiska/news.htm], the original Swedish text can be found at [http://www.socialstyrelsen.se]): "A large amount of international studies shows that an incision on the sympatikotomi nerve gives a very positive result when it come to hand perspiration and also that the side effects are rare.". Critics have raised serious questions about the methodology of such studies.
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Exact results of ETS are impossible to predict, because of considerable anatomic variations in nerve function from one patient to the next, and also because of variations in surgical technique. The autonomic nervous system is not anatomically exact and connections might exist with different parts of the body. This theory has been proven by the fact that a significant number of patients who have had sympathectomy for hand sweating might notice a reduction or elimination of feet sweating, in contrast to others who do not. No reliable operation exists for foot sweating per se except lumbar sympathectomy, at the opposite end of the SNS chain.
   
Exact results of ETS are impossible to predict, because of considerable anatomic variations in sympathetic nerve function from one patient to the next, and also because of variations in surgical technique.
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Thoracic sympathectomy can alter many bodily functions, including [[sweating]],<ref name=Sihoe07/> vascular responses,<ref name=Redisch57>{{cite journal |author=Redisch W, Tangco FT, Wertheimer L, Lewis AJ, Steele JM |title=Vasomotor responses in the extremities of subjects with various neurologic lesions. I. Reflex responses to warming |journal=Circulation |volume=15 |issue=4 |pages=518–24 |date=1 April 1957|pmid=13414070 |url=http://circ.ahajournals.org/cgi/content/abstract/15/4/518 }}</ref> [[heart rate]],<ref name=Abraham>{{cite journal |author=Abraham P, Berthelot J, Victor J, Saumet JL, Picquet J, Enon B |title=Holter changes resulting from right-sided and bilateral infrastellate upper thoracic sympathectomy |journal=Ann Thorac Surg. |volume=74 |issue=6 |pages=2076–81 |year=2002 |month= December|pmid=12643398 |url=http://ats.ctsnetjournals.org/cgi/content/full/74/6/2076 |doi=10.1016/S0003-4975(02)04080-8}}</ref><ref>[http://ats.ctsnetjournals.org/cgi/content/full/74/6/2076/FIG1 Abraham P 2002: Fig 1. Histogram (mean ± SEM) of the heart rate before , after right-side, and after bilateral infrastellate sympathectomy.]</ref> heart [[stroke volume]],<ref>{{cite journal |author=Chess-Williams RG, Grassby PF, Culling W, Penny W, Broadley KJ, Sheridan DJ |title=Cardiac postjunctional supersensitivity to beta-agonists after chronic chemical sympathectomy with 6-hydroxydopamine |journal=Naunyn Schmiedebergs Arch. Pharmacol. |volume=329 |issue=2 |pages=162–6 |year=1985 |month= April|pmid=2861571 |doi=10.1007/BF00501207 }}</ref><ref name=Hashmonai>{{cite journal |author=Hashmonai M, Kopelman D |title=The pathophysiology of cervical and upper thoracic sympathetic surgery |journal=Clin. Auton. Res. |volume=13 |issue=Suppl 1 |pages=I40–4 |year=2003 |month= December|pmid=14673672 |doi=10.1007/s10286-003-1105-3 |url=http://www.springerlink.com/content/jrcm3h5k8pye9yyu/}}</ref> [[thyroid]], [[baroreflex]],<ref name=Kawamata>{{cite journal |author=Kawamata YT, Homma E, Kawamata T, Omote K, Namiki A |title=Influence of Endoscopic Thoracic Sympathectomy on Baroreflex Control of Heart Rate in Patients with Palmar Hyperhidrosis |journal=Anesthesiology |volume=95 |pages=A160 |year=2001 |doi= |url=http://www.asaabstracts.com/strands/asaabstracts/abstract.htm;jsessionid=300DD0D5F41DDA41B7A3AF0625A0CD97?year=2001&index=3&absnum=1370}}</ref>[[lung volume]],<ref name=Hashmonai/><ref>{{cite book |author=Milner P, Lincoln J, Burnstock G |chapter=The neurochemical organization of the autonomic nervous system |editor=Appenzeller O, Vinken PJ, Bruyn GW |title=The autonomic nervous system |publisher=Elsevier Science Publishers |location=[Amsterdam, Netherlands] |year=1998 |pages=110 |isbn=0-444-82812-5}}</ref> pupil dilation, skin temperature, [[goose bumps]] and other aspects of the [[autonomic nervous system]], like the [[fight-or-flight response]]. It reduces the physiological responses to strong emotion, and may diminish the body's physical reaction to exercise.<ref name=Sihoe07/><ref name=Hashmonai/><ref name=Bassenge>{{cite journal |author=Bassenge E, Holtz J, Restorff W Von, Oversohl K |title=Effect of chemical sympathectomy on coronary flow and cardiovascular adjustment to exercise in dogs |journal=Pflugers Arch. |volume=341 |issue=4 |pages=285–96 |year=1973 |month=July |pmid=4798744 |doi=10.1007/BF01023670 |url=http://www.springerlink.com/content/k2n6j4555g16x773/}}</ref>
   
Studies by ETS surgeons have claimed a satisfaction rate around 85-95% with at least 2% regretting the surgery.<ref name="pmid14673674">{{cite journal |author=Choi BC, Lee YC, Sim SB |title=Treatment of palmar hyperhidrosis by endoscopic clipping of the upper part of the T4 sympathetic ganglion. Preliminary results |journal=Clin. Auton. Res. |volume=13 Suppl 1 |issue= |pages=I48–51 |year=2003 |pmid=14673674 |doi=10.1007/s10286-003-1112-4}}</ref><ref name="pmid11788259">{{cite journal |author=Lardinois D, Ris HB |title=Minimally invasive video-endoscopic sympathectomy by use of a transaxillary single port approach |journal=Eur J Cardiothorac Surg |volume=21 |issue=1 |pages=67–70 |year=2002 |pmid=11788259 |doi=10.1016/S1010-7940(01)01042-9}}</ref><ref name="pmid9640370">{{cite journal |author=Drott C, Claes G, Olsson-Rex L, Dalman P, Fahlén T, Göthberg G |title=Successful treatment of facial blushing by endoscopic transthoracic sympathicotomy |journal=Br. J. Dermatol. |volume=138 |issue=4 |pages=639–43 |year=1998 |pmid=9640370 |doi=10.1046/j.1365-2133.1998.02176.x|url=http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0007-0963&date=1998&volume=138&issue=4&spage=639}}</ref> One surgeon study shows a satisfaction rate as low as 28.6.<ref name="titleKoreaMed - Basic Search">{{cite web |url=http://www.koreamed.org/SearchBasic.php?RID=257346&DT=1&QY=hyperhidrosis+%5BALL%5D |title=KoreaMed - Basic Search |accessdate=2007-12-02 |format= |work=}}</ref> Most patients report various adverse reactions as a result of the surgery. However, ETS surgeon Samuel S. Ahn of UCLA claims "100% success with no negative side effects". <ref name="titleSweaty Palms Hereditary">{{cite web |url=http://www.webmd.com/content/article/18/1685_52932.htm?lastselectedguid=%7B5FE84E90-BC77-4056-A91C-9531713CA348%7D |title=Sweaty Palms Hereditary |accessdate=2007-12-02 |format= |work=}}</ref>
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A large study of psychiatric patients treated with this surgery showed significant reductions in [[fear]], [[alertness]] and [[arousal]]. (Teleranta, Pohjavaara, et al. 2003, 2004. Online link unavailable). Arousal is essential to consciousness, in regulating attention and information processing, memory and emotion.<ref>[http://herkules.oulu.fi/isbn9514274571/isbn9514274571.pdf Social phobia: aetiology, course and treatment with endoscopic sympathetic block (ESB). A qualitative study of the development of social phobia and its meaning in people's lives and a quantitative study of ESB as its treatment<!-- Bot generated title -->]</ref>
   
A large study of psychiatric patients treated with this surgery showed significant reductions in [[fear]] and alertness, among other emotional changes (Teleranta, Pohjavaara, et al 2003, 2004). <ref>[http://herkules.oulu.fi/isbn9514274571/isbn9514274571.pdf Social phobia: aetiology, course and treatment with endoscopic sympathetic block (ESB). A qualitative study of the development of social phobia and its meaning in people's lives and a quantitative study of ESB as its treatment<!-- Bot generated title -->]</ref>
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ETS patients are being studied using the autonomic failure protocol headed by David Goldstein, M.D. Ph.D., senior investigator at the U.S National Institute of Neurological Disorders and Stroke. He has documented loss of thermoregulatory function, cardiac denervation, and loss of [[vasoconstriction]].<ref>{{cite journal |author=Moak JP, Eldadah B, Holmes C, Pechnik S, Goldstein DS |title=Partial cardiac sympathetic denervation after bilateral thoracic sympathectomy in humans |journal=Heart Rhythm |volume=2 |issue=6 |pages=602–9 |year=2005 |month=June |pmid=15922266 |doi=10.1016/j.hrthm.2005.03.003 }}</ref>
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Recurrence of the original symptoms due to nerve regeneration or nerve sprouting can occur within the first year post surgery. Nerve sprouting, or abnormal nerve growth after damage or injury to the nerves can cause other further damage. Sprouting sympathtetic nerves can form connections with sensory nerves, and lead to pain conditions that are mediated by the SNS. Every time the system is activated, it is translated into pain.
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This sprouting and its action can lead to [[Frey's syndrome]], a recognized after effect of sympathectomy, when the growing sympathetic nerves innervate salivary glands, leading to excessive sweating regardless of environmental temperature through olfactory or gustatory stimulation.
   
ETS patients are being studied using the autonomic failure protocol headed by David Goldstein, M.D. Ph.D., senior investigator at the U.S National Institute of Neurological Disorders and Stroke. He has documented loss of thermoregulatory function, cardiac denervation, and loss of [[vasoconstriction]].
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== Risks ==
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No surgery is risk-free, and ETS has both the normal risks of surgery, such as bleeding and infection, and several specific risks, including permanent and unavoidable changes in nerve function. A number of patients, mostly young women, have died during this procedure. Bleeding during and following the operation may be significant in up to 5% of patients.<ref name="ojimba04">{{cite journal|last=Ojimba|first=TA|coauthors=Cameron, AEP|title=Drawbacks of endoscopic thoracic sympathectomy|journal=British Journal of Surgery|publisher=John Wiley & Sons|volume=91|issue=3|pages=264–269|doi=10.1002/bjs.4511|accessdate=2009-01-19|pmid=14991624|year=2004}}</ref> [[Pneumothorax]] (collapsed lung) can occur (2% of patients).<ref name=ojimba04 />
   
==Risks and controversy==
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[[Compensatory hyperhidrosis]] (sweating) is common over the long term, causing 1% to 2% patients in one review to regret having had the surgery.<ref name=ojimba04 /> The rates of severe compensatory sweating vary widely between studies, ranging from as low as 1.2% and as high as 30.9% of patients.<ref name="pmid18557592">{{cite journal |author=Dumont P |title=Side effects and complications of surgery for hyperhidrosis |journal=Thorac Surg Clin |volume=18 |issue=2 |pages=193–207 |year=2008 |month=May |pmid=18557592 |doi= 10.1016/j.thorsurg.2008.01.007|url=http://www.truthaboutets.com/Studies/ETS-Complication-PascalDumont.pdf |format=PDF}}</ref> Of those patients that develop this side effect, about a quarter said it was major and disabling.<ref name="pmid14622605">{{cite journal |author=Furlan AD, Mailis A, Papagapiou M |title=Are we paying a high price for surgical sympathectomy? A systematic literature review of late complications |journal=J Pain |volume=1 |issue=4 |pages=245–57 |year=2000 |pmid=14622605 |doi=10.1054/jpai.2000.19408 |url=}}</ref>
   
The Finnish Office for Health Care Technology Assessment concluded in a 40 page systamatic review that Endoscopic Thoracic Sympathectomy is associated with significant immediate and long-term adverse effects.<ref>Centre for Reviews and Dissemination - http://www.crd.york.ac.uk/crdweb/ShowRecord.asp?View=Full&ID=32005000254</ref>
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A severe possible consequence of thoracic sympathectomy is [[corposcindosis]] (split-body syndrome), in which the patient feels that he or she is living in two separate bodies, because sympathetic nerve function has been divided into two distinct regions, one dead, and the other hyperactive.<ref name="pmid18557592">{{cite journal |author=Dumont P |title=Side effects and complications of surgery for hyperhidrosis |journal=Thorac Surg Clin |volume=18 |issue=2 |pages=199 |year=2008 |month=May |pmid=18557592 |doi= 10.1016/j.thorsurg.2008.01.007|url=http://www.truthaboutets.com/Studies/ETS-Complication-PascalDumont.pdf |format=PDF}}</ref>
   
Quoting the aforementioned (see Results) Swedish National Board of Health and Welfare statement: "The method can give permanent side effects that in some cases first will become obvious after some time. One of the side effects might be increased perspiration on different places on your body. Why and how this happens is still unknown. According to the research available about 25-75% of all patients can expect more or less serious perspiration on different places on their body, such as the trunk and groin area, this is ''Compensatory sweating''. However, it is also mentioned in the research that 0-10% regrets having the surgery done for this reason. Other documented side effects are the inability to raise the heart rate when working out physically. This has in some cases led to decreased ability to perform your work and daily activities. Some patients also complained of not being able to control their body temperature and it is experienced as very uncomfortable."
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Additionally, the following side effects have all been reported by patients: Chronic muscular pain, numbness and weakness of the limbs, Horner Syndrome, anhidrosis, neuralgia, paraesthesia, fatigue and amotivationality, breathing difficulties, substantially diminished physiological/chemical reaction to internal and environmental experience (e.g. pleasure and pain/ perceptual stimuli), somatosensory malfunction, aberrant physiological reaction to stress and exertion etc., Reynaud’s disease caused by cold weather etc. (ironically a possible indication for surgery), reflex hyperhidrosis (or compensatory sweating as above), systemic thermoregulatory dysfunction (hyperthermia), altered/erratic blood pressure and circulation, defective fight or flight response system, loss of adrenaline, eczema and other skin conditions resulting from exceptionally dry skin, rhinitis, gustatory sweating (or Frey's syndrome, see above).<ref name="STS2011" />
   
A reduced efficiency in maintaining normal body temperature in warm environments is consistent with the reduced ability or complete inability to sweat above the nipple line, a common ETS outcome first shown by Dr. Kotzareff. For a fully clothed person, only the hands, cranial region and neck are typically exposed. In a hot environment, a normal person's body is cooled primarily by evaporation of water vapor through the warmest areas of exposed [[skin]]. These areas are associated with the head and neck, which under very warm circumstances or vigorous exercise, visibly show moisture (sweat) accumulating as part of the cooling process. For an ETS patient that has lost ability to sweat from [[cranium]], neck, and arms, an increased amount of body heat must be rejected via [[transpiration]]/[[sweating]] involving skin of the lower body. Unfortunately, this skin is generally at a lower temperature and usually covered by clothing - both factors that reduce the cooling efficiency and result in poor [[thermoregulation]]. An uncomfortably warm sensation and accumulation of sweat on large areas of skin underneath clothing can result.
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[[File:Songboythermal.jpg|thumb|300px|A thermal image of an ETS patient 2 years after surgery, showing corposcindosis (split-body syndrome)]]
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Some long-term adverse effects include:
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* Ultrastructural Changes in the Cerebral Artery Wall Induced by Long-Term Sympathetic Denervation<ref name=Dimitriadou/>
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* Sympathectomy eliminates the psychogalvanic reflex<ref>{{cite journal |author=Verghese A |title=Some observations on the psychogalvanic reflex |journal=Br J Psychiatry |volume=114 |issue=510 |pages=639–42 |year=1968 |month=May |pmid=5654139 |doi=10.1192/bjp.114.510.639 |url=http://bjp.rcpsych.org/cgi/content/abstract/114/510/639}}</ref>
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* Cervical sympathectomy reduces the heterogeneity of oxygen saturation in small cerebrocortical veins<ref>{{cite journal |author=Wei HM, Sinha AK, Weiss HR |title=Cervical sympathectomy reduces the heterogeneity of oxygen saturation in small cerebrocortical veins |journal=J. Appl. Physiol. |volume=74 |issue=4 |pages=1911–5 |date=1 April 1993|pmid=8514710 |url=http://jap.physiology.org/cgi/content/abstract/74/4/1911 }}</ref>
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* Sympathetic denervation is one of the causes of Mönckeberg's sclerosis<ref>{{cite journal |author=Goebel FD, Füessl HS |title=Mönckeberg's sclerosis after sympathetic denervation in diabetic and non-diabetic subjects |journal=Diabetologia |volume=24 |issue=5 |pages=347–50 |year=1983 |month=May |pmid=6873514 |doi=10.1007/BF00251822 |url=http://www.springerlink.com/content/u8412488401j7762/}}</ref>
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* T2-3 sympathectomy suppressed baroreflex control of heart rate in the patients with palmar hyperhidrosis. We should note that baroreflex response for maintaining cardiovascular stability is suppressed in the patients who received the ETS.<ref name=Kawamata/>
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* Exertional heat stroke.<ref name=Sihoe07/>
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* Morphofunctional changes in the myocardium following sympathectomy.<ref>{{cite journal |author=Beskrovnova NN, Makarychev VA, Kiseleva ZM, Legon'kaia, Zhuchkova NI |title=[Morphofunctional changes in the myocardium following sympathectomy and their role in the development of sudden death from ventricular fibrillation] |language=Russian |journal=Vestn. Akad. Med. Nauk SSSR |issue=2 |pages=80–5 |year=1984 |pmid=6711115 }}</ref>
   
There is much disagreement among ETS surgeons about the best surgical method, optimal location for nerve dissection, and as to the nature and extent of the consequent primary effects and side effects. The internet now features many websites run by surgeons extolling the benefits of ETS backed by patient testimonials. However, there are also many websites run by disabled ETS victims who complain of severe adverse reactions and lack of adequate informed consent. Several online discussion forums are dedicated to the subject of ETS surgery, where both positive and negative patient testimonials abound.
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Other side effects are the inability to raise the heart rate sufficiently during exercise with instances requiring an [[artificial pacemaker]] after developing [[bradycardia]] being reported as a consequence of the surgery.<ref name=Dimitriadou>{{cite journal |author=Dimitriadou V, Aubineau P, Taxi J, Seylaz J |title=Ultrastructural changes in the cerebral artery wall induced by long-term sympathetic denervation |journal=Blood Vessels |volume=25 |issue=3 |pages=122–43 |year=1988 |pmid=3359052 |doi=10.1159/000158727 |url=http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowPDF&ArtikelNr=000158727&Ausgabe=239141&ProduktNr=224160&filename=000158727.pdf}}</ref><ref>{{cite journal |author=Lai CL, Chen WJ, Liu YB, Lee YT |title=Bradycardia and permanent pacing after bilateral thoracoscopic T2-sympathectomy for primary hyperhidrosis |journal=Pacing Clin Electrophysiol |volume=24 |issue=4 Pt 1 |pages=524–5 |year=2001 |month= April|pmid=11341096 |doi=10.1046/j.1460-9592.2001.00524.x |url=http://www3.interscience.wiley.com/journal/119020027/abstract?CRETRY=1&SRETRY=0}}</ref><ref>{{cite journal |author=de Souza Faleiros AT, de Abreu Maffei FH, de Lima Resende LA |title=Effects of cervical sympathectomy on vasospasm induced by meningeal haemorrhage in rabbits |journal=Arq. Neuro-Psiquiatr. |volume=64 |issue=3a |pages= |year=2006 |doi=10.1590/S0004-282X2006000400006 |url=http://www.scielo.br/scielo.php?pid=S0004-282X2006000400006&script=sci_arttext&tlng=}}</ref>
   
In 2003, ETS was banned in its birthplace, Sweden, due to overwhelming complaints by disabled patients (0.3% of the total world-wide number of patients). In 2004, Taiwanese health authorities banned the procedure on patients under 20 years of age.
+
The Finnish Office for Health Care Technology Assessment concluded in a 400 page systematic review that Endoscopic Thoracic Sympathectomy is associated with an unusually high number of significant immediate and long-term adverse effects.<ref>{{cite web |url=http://www.crd.york.ac.uk/crdweb/ShowRecord.asp?View=Full&ID=32005000254 |title=Effectiveness and safety of endoscopic thoracic sympathectomy |work=Health Technology Assessment (HTA) Database |publisher=Centre for Reviews and Dissemination}}</ref>
   
In 2006, the FinOHTA group, the Finnish Office for Health Technology Assessment, showed in a review that there were strong indications of side effects as a result of this surgery.<ref name="titleReports - Publications - Finohta">{{cite web |url=http://finohta.stakes.fi/EN/publications/reports/index.htm |title=Reports - Publications - Finohta |accessdate=2007-12-02 |format= |work=}}</ref>
+
Quoting the Swedish National Board of Health and Welfare statement: "The method can give permanent side effects that in some cases will first become obvious only after some time. One of the side effects might be increased perspiration on different places on your body. Why and how this happens is still unknown. According to the research available about 25-75% of all patients can expect more or less serious perspiration on different places on their body, such as the trunk and groin area, this is ''Compensatory sweating''".<ref>{{cite journal |author= Roberto de Menezes Lyra, Campos JR, Kang DW, Loureiro Mde P, Furian MB, Costa MG, Coelho Mde S; Sociedade Brasileira de Cirurgia Torácica. |title=Guidelines for the prevention, diagnosis and treatment of compensatory hyperhidrosis. |journal=J Bras Pneumol. |volume=34 |issue=11 |pages=967–77 |year=2008 Nov |pmid=19099105 |url=http://www.jornaldepneumologia.com.br/detalhe_artigo.asp?id=740}}</ref>
   
According to Dr. Reisfeld some of the reasons why ETS is banned in certain countries is because of the unjustified performance of ETS on patients with facial blushing and or facial sweating and or armpit sweating . Dr. Reisfeld believes that ETS should only be performed on patients with severe palmar hyperhidrosis. <ref name="titleThe Center for Hyperhidrosis. Dr. Reisfeld, world renowned expert and pioneer, can help!">{{cite web |url=http://www.sweaty-palms.com/faq8.html |title=The Center for Hyperhidrosis. Dr. Reisfeld, world renowned expert and pioneer, can help! |accessdate=2007-12-02 |format= |work=}}</ref>
+
==Controversy==
   
==Popular culture==
+
In 2003, ETS was banned in its birthplace, Sweden, due to overwhelming complaints by disabled patients. In 2004, Taiwanese health authorities banned the procedure on patients under 20 years of age. In other countries it is a notoriously unregulated procedure.
In the movie ''[[Sublime (film)|Sublime]]'' the character George Grieves (played by [[Tom Cavanagh]]) accidentally undergoes the procedure. The American TV show "Grey's Anatomy" featured ETS surgery for facial blushing in an episode titled "Make Me Lose Control". <ref name="titleIntroduction - Corposcindosis">{{cite web |url=http://www.editthis.info/corposcindosis/Introduction#Grey.27s_Anatomy |title=Introduction - Corposcindosis |accessdate=2007-12-02 |format= |work=}}</ref>
+
  +
The internet now features many websites run by surgeons extolling the benefits of ETS. However, there are also many websites run by disabled ETS victims who complain of severe adverse reactions leading to decreased ability to perform ones occupation and daily activities and a perceived lack of adequate informed consent. Several online discussion forums are dedicated to the subject of ETS surgery, where patient testimonials abound.
  +
  +
==History==
  +
Sympathectomy developed in the mid-19th century, when it was learned that the [[autonomic nervous system]] runs to almost every organ, gland and muscle system in the body. It was surmised that these nerves play a role in how the body regulates many different body functions in response to changes in the environment, exercise, emotion and pleasure.
  +
  +
The first sympathectomy was performed by Alexander in 1889.<ref>http://www.springerlink.com/content/d58vv03v5vx6g2q6/</ref> Since the [[sympathetic nervous system]] was well known to affect many body systems, the surgery was performed in attempts to treat many conditions, including idiocy, [[goitre]], [[epilepsy]], [[glaucoma]], and [[angina pectoris]]. Thoracic sympathectomy has been indicated for [[hyperhidrosis]] (excessive sweating) since 1920, when Kotzareff showed it would cause [[anhidrosis]] (total inability to sweat) from the [[nipple]] line upwards.<ref name=Sihoe07>{{cite journal |author=Sihoe AD, Liu RW, Lee AK, Lam CW, Cheng LC |title=Is previous thoracic sympathectomy a risk factor for exertional heat stroke? |journal=Ann Thorac Surg. |volume=84 |issue=3 |pages=1025–7 |year=2007 |month= September|pmid=17720429 |doi=10.1016/j.athoracsur.2007.04.066 |url=http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025}}</ref>
  +
  +
A lumbar sympathectomy was also developed and used to treat excessive sweating of the feet and other ailments, and typically resulted in [[impotence]] in men. Lumbar sympathectomy is still being offered as a treatment for plantar hyperhidrosis, or as a treatment for patients who have a bad outcome (extreme 'compensatory sweating') after thoracic sympathectomy for palmar hyperhidrosis or blushing; extensive sympathectomy risks [[hypotension]].
  +
  +
Sympathectomy itself is relatively easy to perform; however, accessing the nerve tissue in the chest cavity by conventional surgical methods was difficult, painful, and spawned several different approaches. The [[Posterior (anatomy)|posterior]] approach was developed in 1908, and required [[Segmental resection|resection]] (sawing off) of ribs. A supraclavical (above the collar-bone) approach was developed in 1935, which was less painful than the posterior, but was more prone to damaging important [[nerves]] and [[blood vessels]]. Because of these difficulties, and because of disabling [[sequelae]] associated with sympathetic denervation, conventional or "open" sympathectomy was never a very popular procedure, although it continued to be practiced for hyperhidrosis, [[Raynaud's disease]], and various psychiatric disorders. With the popularization of [[lobotomy]] in the 1940s, sympathectomy fell out of favor as a form of [[psychosurgery]].
  +
  +
The endoscopic version of thoracic sympathectomy was pioneered by Goren Claes and Christer Drott in [[Sweden]] in the late 1980s. The development of [[endoscopic]] "minimally invasive" surgical techniques have decreased the recovery time from the surgery and increased its popularity. Today, ETS surgery is practiced in many countries throughout the world.
   
 
==See also==
 
==See also==
*[[Sympathectomy]]
+
* [[Harlequin syndrome]]
  +
* [[Sympathectomy]]
   
 
==References==
 
==References==
Line 51: Line 52:
   
 
==External links==
 
==External links==
  +
*[http://corposcindosis.blogspot.com/] Corposcindosis (Split-Body Syndrome) The Effects of Thoracic Sympathectomy in Humans
 
*[http://www.editthis.info/corposcindosis/Corposcindosis Corposcindosis] A medical treatise on the effects of ETS surgery
 
*[http://www.editthis.info/corposcindosis/Corposcindosis Corposcindosis] A medical treatise on the effects of ETS surgery
 
*[http://www.truthaboutets.com Truth About ETS] Covering all aspects of the sympathectomy industry since 2004
 
*[http://www.truthaboutets.com Truth About ETS] Covering all aspects of the sympathectomy industry since 2004
Line 58: Line 60:
 
*[http://home.swipnet.se/sympatiska/index3.htm FfSo] - People disabled by sympathectomies
 
*[http://home.swipnet.se/sympatiska/index3.htm FfSo] - People disabled by sympathectomies
 
*[http://www.ets-sideeffects.netfirms.com/ P.A.S.S.] - Patients Against Sympathetic Surgery
 
*[http://www.ets-sideeffects.netfirms.com/ P.A.S.S.] - Patients Against Sympathetic Surgery
  +
  +
 
{{Neurosurgical procedures}}
 
{{Neurosurgical procedures}}
   

Latest revision as of 21:40, September 7, 2013

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Endoscopic thoracic sympathectomy
Intervention
Script error
ICD-9-CM Template:ICD9proc
MedlinePlus 007291

Endoscopic thoracic sympathectomy (ETS) is a surgical procedure in which a portion of the sympathetic nerve trunk in the thoracic region is destroyed.[1] ETS is used to treat hyperhidrosis, facial blushing, Raynaud's disease and reflex sympathetic dystrophy. By far the most common complaint treated with ETS is palmar hyperhidrosis, or colloquially known as "sweaty palms".

Sympathectomy physically destroys relevant nerves anywhere in either of the two sympathetic trunks, which are long chains of nerve ganglia located bilaterally along the vertebral column (situated to reduce the potential for injury) responsible for various important aspects of the peripheral nervous system (PNS). Each nerve trunk is broadly divided into three regions: cervical (neck), thoracic (chest), and lumbar (lower back). The most common area targeted in sympathectomy is the upper thoracic region, that part of the sympathetic chain lying between the first and fifth thoracic vertebrae.

IndicationsEdit

ETS is most commonly used to treat Localized Hyperhidrosis (that specifically affects the palms, soles, armpits and face), severe hyperhidrosis of the upper body, Raynaud's phenomenon, and facial blushing.

There are reports of ETS being used to achieve cerebral revascularization for patients with moyamoya disease,[2] and to treat headaches, hyperactive bronchial tubes,[3] long QT syndrome[4][5][6] and other conditions.

Surgical ProcedureEdit

ETS involves dissection of the main Sympathetic trunk in the upper thoracic region of the sympathetic nervous system, thus interrupting neural messages that ordinarily would travel to many different organs, glands and muscles. It is via these nerves of the autonomic nervous system that the brain is able to make adjustments in the body in response to changing conditions in the environment, changing emotional states, level of exercise, and other factors to maintain the body's homeostasis. This normative function is disabled or impaired by sympathectomy, because the functions these physiological mechanisms perform also regulate conditions like blushing or sweating, that the procedure is designed to eliminate.

There is much disagreement among ETS surgeons about the best surgical method, optimal location for nerve dissection, and the nature and extent of the consequent primary effects and side effects. When performed endoscopically as is usually the case, the surgeon penetrates the chest cavity, making incisions about the diameter of a straw between ribs. This allows the surgeon to insert the video camera (endoscope) in one hole and a surgical instrument in another. The operation is accomplished by dissecting the nerve tissue of the main sympathetic chain. The clamping method, also referred to as endoscopic sympathetic blockade (ESB) employs titanium clamps around the nerve tissue, and was developed in an unsuccessful attempt to make the procedure reversible. However, technical reversal of the clamping procedure must be performed within a short time after clamping (a few days or weeks at most), and a recovery, evidence suggests, will not be complete.

Physical, Mental and Emotional EffectsEdit

Sympathectomy works by disabling part of the autonomic nervous system (and thereby disrupting its signals from the brain), through surgical intervention, in the expectation of removing or alleviating the problem. Many non-ETS doctors have found this practice questionable chiefly because its purpose is to destroy anatomically normal, but functionally disordered, nerves.[7]

Exact results of ETS are impossible to predict, because of considerable anatomic variations in nerve function from one patient to the next, and also because of variations in surgical technique. The autonomic nervous system is not anatomically exact and connections might exist with different parts of the body. This theory has been proven by the fact that a significant number of patients who have had sympathectomy for hand sweating might notice a reduction or elimination of feet sweating, in contrast to others who do not. No reliable operation exists for foot sweating per se except lumbar sympathectomy, at the opposite end of the SNS chain.

Thoracic sympathectomy can alter many bodily functions, including sweating,[8] vascular responses,[9] heart rate,[10][11] heart stroke volume,[12][13] thyroid, baroreflex,[14]lung volume,[13][15] pupil dilation, skin temperature, goose bumps and other aspects of the autonomic nervous system, like the fight-or-flight response. It reduces the physiological responses to strong emotion, and may diminish the body's physical reaction to exercise.[8][13][16]

A large study of psychiatric patients treated with this surgery showed significant reductions in fear, alertness and arousal. (Teleranta, Pohjavaara, et al. 2003, 2004. Online link unavailable). Arousal is essential to consciousness, in regulating attention and information processing, memory and emotion.[17]

ETS patients are being studied using the autonomic failure protocol headed by David Goldstein, M.D. Ph.D., senior investigator at the U.S National Institute of Neurological Disorders and Stroke. He has documented loss of thermoregulatory function, cardiac denervation, and loss of vasoconstriction.[18] Recurrence of the original symptoms due to nerve regeneration or nerve sprouting can occur within the first year post surgery. Nerve sprouting, or abnormal nerve growth after damage or injury to the nerves can cause other further damage. Sprouting sympathtetic nerves can form connections with sensory nerves, and lead to pain conditions that are mediated by the SNS. Every time the system is activated, it is translated into pain. This sprouting and its action can lead to Frey's syndrome, a recognized after effect of sympathectomy, when the growing sympathetic nerves innervate salivary glands, leading to excessive sweating regardless of environmental temperature through olfactory or gustatory stimulation.

Risks Edit

No surgery is risk-free, and ETS has both the normal risks of surgery, such as bleeding and infection, and several specific risks, including permanent and unavoidable changes in nerve function. A number of patients, mostly young women, have died during this procedure. Bleeding during and following the operation may be significant in up to 5% of patients.[19] Pneumothorax (collapsed lung) can occur (2% of patients).[19]

Compensatory hyperhidrosis (sweating) is common over the long term, causing 1% to 2% patients in one review to regret having had the surgery.[19] The rates of severe compensatory sweating vary widely between studies, ranging from as low as 1.2% and as high as 30.9% of patients.[20] Of those patients that develop this side effect, about a quarter said it was major and disabling.[21]

A severe possible consequence of thoracic sympathectomy is corposcindosis (split-body syndrome), in which the patient feels that he or she is living in two separate bodies, because sympathetic nerve function has been divided into two distinct regions, one dead, and the other hyperactive.[20]

Additionally, the following side effects have all been reported by patients: Chronic muscular pain, numbness and weakness of the limbs, Horner Syndrome, anhidrosis, neuralgia, paraesthesia, fatigue and amotivationality, breathing difficulties, substantially diminished physiological/chemical reaction to internal and environmental experience (e.g. pleasure and pain/ perceptual stimuli), somatosensory malfunction, aberrant physiological reaction to stress and exertion etc., Reynaud’s disease caused by cold weather etc. (ironically a possible indication for surgery), reflex hyperhidrosis (or compensatory sweating as above), systemic thermoregulatory dysfunction (hyperthermia), altered/erratic blood pressure and circulation, defective fight or flight response system, loss of adrenaline, eczema and other skin conditions resulting from exceptionally dry skin, rhinitis, gustatory sweating (or Frey's syndrome, see above).[1]

File:Songboythermal.jpg

Some long-term adverse effects include:

  • Ultrastructural Changes in the Cerebral Artery Wall Induced by Long-Term Sympathetic Denervation[22]
  • Sympathectomy eliminates the psychogalvanic reflex[23]
  • Cervical sympathectomy reduces the heterogeneity of oxygen saturation in small cerebrocortical veins[24]
  • Sympathetic denervation is one of the causes of Mönckeberg's sclerosis[25]
  • T2-3 sympathectomy suppressed baroreflex control of heart rate in the patients with palmar hyperhidrosis. We should note that baroreflex response for maintaining cardiovascular stability is suppressed in the patients who received the ETS.[14]
  • Exertional heat stroke.[8]
  • Morphofunctional changes in the myocardium following sympathectomy.[26]

Other side effects are the inability to raise the heart rate sufficiently during exercise with instances requiring an artificial pacemaker after developing bradycardia being reported as a consequence of the surgery.[22][27][28]

The Finnish Office for Health Care Technology Assessment concluded in a 400 page systematic review that Endoscopic Thoracic Sympathectomy is associated with an unusually high number of significant immediate and long-term adverse effects.[29]

Quoting the Swedish National Board of Health and Welfare statement: "The method can give permanent side effects that in some cases will first become obvious only after some time. One of the side effects might be increased perspiration on different places on your body. Why and how this happens is still unknown. According to the research available about 25-75% of all patients can expect more or less serious perspiration on different places on their body, such as the trunk and groin area, this is Compensatory sweating".[30]

ControversyEdit

In 2003, ETS was banned in its birthplace, Sweden, due to overwhelming complaints by disabled patients. In 2004, Taiwanese health authorities banned the procedure on patients under 20 years of age. In other countries it is a notoriously unregulated procedure.

The internet now features many websites run by surgeons extolling the benefits of ETS. However, there are also many websites run by disabled ETS victims who complain of severe adverse reactions leading to decreased ability to perform ones occupation and daily activities and a perceived lack of adequate informed consent. Several online discussion forums are dedicated to the subject of ETS surgery, where patient testimonials abound.

HistoryEdit

Sympathectomy developed in the mid-19th century, when it was learned that the autonomic nervous system runs to almost every organ, gland and muscle system in the body. It was surmised that these nerves play a role in how the body regulates many different body functions in response to changes in the environment, exercise, emotion and pleasure.

The first sympathectomy was performed by Alexander in 1889.[31] Since the sympathetic nervous system was well known to affect many body systems, the surgery was performed in attempts to treat many conditions, including idiocy, goitre, epilepsy, glaucoma, and angina pectoris. Thoracic sympathectomy has been indicated for hyperhidrosis (excessive sweating) since 1920, when Kotzareff showed it would cause anhidrosis (total inability to sweat) from the nipple line upwards.[8]

A lumbar sympathectomy was also developed and used to treat excessive sweating of the feet and other ailments, and typically resulted in impotence in men. Lumbar sympathectomy is still being offered as a treatment for plantar hyperhidrosis, or as a treatment for patients who have a bad outcome (extreme 'compensatory sweating') after thoracic sympathectomy for palmar hyperhidrosis or blushing; extensive sympathectomy risks hypotension.

Sympathectomy itself is relatively easy to perform; however, accessing the nerve tissue in the chest cavity by conventional surgical methods was difficult, painful, and spawned several different approaches. The posterior approach was developed in 1908, and required resection (sawing off) of ribs. A supraclavical (above the collar-bone) approach was developed in 1935, which was less painful than the posterior, but was more prone to damaging important nerves and blood vessels. Because of these difficulties, and because of disabling sequelae associated with sympathetic denervation, conventional or "open" sympathectomy was never a very popular procedure, although it continued to be practiced for hyperhidrosis, Raynaud's disease, and various psychiatric disorders. With the popularization of lobotomy in the 1940s, sympathectomy fell out of favor as a form of psychosurgery.

The endoscopic version of thoracic sympathectomy was pioneered by Goren Claes and Christer Drott in Sweden in the late 1980s. The development of endoscopic "minimally invasive" surgical techniques have decreased the recovery time from the surgery and increased its popularity. Today, ETS surgery is practiced in many countries throughout the world.

See alsoEdit

ReferencesEdit

  1. 1.0 1.1 (2011). The Society of Thoracic Surgeons Expert Consensus for the Surgical Treatment of Hyperhidrosis. The Annals of Thoracic Surgery 91 (5): 1642–1648.
  2. Suzuki J, Takaku A, Kodama N, Sato S (1975). An attempt to treat cerebrovascular 'Moyamoya' disease in children. Childs Brain 1 (4): 193–206.
  3. Sung SW, Kim JS (March 1999). Thoracoscopic procedures for intrathoracic and pulmonary diseases. Respirology 4 (1): 19–29.
  4. Telaranta T (December 2003). Psychoneurological applications of endoscopic sympathetic blocks (ESB). Clin Auton Res. 13 (Suppl 1): I20–1; discussion I21.
  5. Ventricular Arrhythmia/ Tachycardia
  6. Khan IA (January 2002). Long QT syndrome: diagnosis and management. Am Heart J. 143 (1): 7–14.
  7. McNaughton, Neil (1989). Biology and emotion, 67, Cambridge, UK: Cambridge University Press.
  8. 8.0 8.1 8.2 8.3 Sihoe AD, Liu RW, Lee AK, Lam CW, Cheng LC (September 2007). Is previous thoracic sympathectomy a risk factor for exertional heat stroke?. Ann Thorac Surg. 84 (3): 1025–7.
  9. Redisch W, Tangco FT, Wertheimer L, Lewis AJ, Steele JM (1 April 1957). Vasomotor responses in the extremities of subjects with various neurologic lesions. I. Reflex responses to warming. Circulation 15 (4): 518–24.
  10. Abraham P, Berthelot J, Victor J, Saumet JL, Picquet J, Enon B (December 2002). Holter changes resulting from right-sided and bilateral infrastellate upper thoracic sympathectomy. Ann Thorac Surg. 74 (6): 2076–81.
  11. Abraham P 2002: Fig 1. Histogram (mean ± SEM) of the heart rate before , after right-side, and after bilateral infrastellate sympathectomy.
  12. Chess-Williams RG, Grassby PF, Culling W, Penny W, Broadley KJ, Sheridan DJ (April 1985). Cardiac postjunctional supersensitivity to beta-agonists after chronic chemical sympathectomy with 6-hydroxydopamine. Naunyn Schmiedebergs Arch. Pharmacol. 329 (2): 162–6.
  13. 13.0 13.1 13.2 Hashmonai M, Kopelman D (December 2003). The pathophysiology of cervical and upper thoracic sympathetic surgery. Clin. Auton. Res. 13 (Suppl 1): I40–4.
  14. 14.0 14.1 Kawamata YT, Homma E, Kawamata T, Omote K, Namiki A (2001). Influence of Endoscopic Thoracic Sympathectomy on Baroreflex Control of Heart Rate in Patients with Palmar Hyperhidrosis. Anesthesiology 95: A160.
  15. Milner P, Lincoln J, Burnstock G (1998). "The neurochemical organization of the autonomic nervous system" Appenzeller O, Vinken PJ, Bruyn GW The autonomic nervous system, 110, [Amsterdam, Netherlands]: Elsevier Science Publishers.
  16. Bassenge E, Holtz J, Restorff W Von, Oversohl K (July 1973). Effect of chemical sympathectomy on coronary flow and cardiovascular adjustment to exercise in dogs. Pflugers Arch. 341 (4): 285–96.
  17. Social phobia: aetiology, course and treatment with endoscopic sympathetic block (ESB). A qualitative study of the development of social phobia and its meaning in people's lives and a quantitative study of ESB as its treatment
  18. Moak JP, Eldadah B, Holmes C, Pechnik S, Goldstein DS (June 2005). Partial cardiac sympathetic denervation after bilateral thoracic sympathectomy in humans. Heart Rhythm 2 (6): 602–9.
  19. 19.0 19.1 19.2 Ojimba, TA, Cameron, AEP (2004). Drawbacks of endoscopic thoracic sympathectomy. British Journal of Surgery 91 (3): 264–269.
  20. 20.0 20.1 Dumont P (May 2008). Side effects and complications of surgery for hyperhidrosis. Thorac Surg Clin 18 (2): 193–207.
  21. Furlan AD, Mailis A, Papagapiou M (2000). Are we paying a high price for surgical sympathectomy? A systematic literature review of late complications. J Pain 1 (4): 245–57.
  22. 22.0 22.1 Dimitriadou V, Aubineau P, Taxi J, Seylaz J (1988). Ultrastructural changes in the cerebral artery wall induced by long-term sympathetic denervation. Blood Vessels 25 (3): 122–43.
  23. Verghese A (May 1968). Some observations on the psychogalvanic reflex. Br J Psychiatry 114 (510): 639–42.
  24. Wei HM, Sinha AK, Weiss HR (1 April 1993). Cervical sympathectomy reduces the heterogeneity of oxygen saturation in small cerebrocortical veins. J. Appl. Physiol. 74 (4): 1911–5.
  25. Goebel FD, Füessl HS (May 1983). Mönckeberg's sclerosis after sympathetic denervation in diabetic and non-diabetic subjects. Diabetologia 24 (5): 347–50.
  26. Beskrovnova NN, Makarychev VA, Kiseleva ZM, Legon'kaia, Zhuchkova NI (1984). [Morphofunctional changes in the myocardium following sympathectomy and their role in the development of sudden death from ventricular fibrillation]. Vestn. Akad. Med. Nauk SSSR (2): 80–5.
  27. Lai CL, Chen WJ, Liu YB, Lee YT (April 2001). Bradycardia and permanent pacing after bilateral thoracoscopic T2-sympathectomy for primary hyperhidrosis. Pacing Clin Electrophysiol 24 (4 Pt 1): 524–5.
  28. de Souza Faleiros AT, de Abreu Maffei FH, de Lima Resende LA (2006). Effects of cervical sympathectomy on vasospasm induced by meningeal haemorrhage in rabbits. Arq. Neuro-Psiquiatr. 64 (3a).
  29. Effectiveness and safety of endoscopic thoracic sympathectomy. Health Technology Assessment (HTA) Database. Centre for Reviews and Dissemination.
  30. Roberto de Menezes Lyra, Campos JR, Kang DW, Loureiro Mde P, Furian MB, Costa MG, Coelho Mde S; Sociedade Brasileira de Cirurgia Torácica. (2008 Nov). Guidelines for the prevention, diagnosis and treatment of compensatory hyperhidrosis.. J Bras Pneumol. 34 (11): 967–77.
  31. http://www.springerlink.com/content/d58vv03v5vx6g2q6/

External linksEdit

  • [1] Corposcindosis (Split-Body Syndrome) The Effects of Thoracic Sympathectomy in Humans
  • Corposcindosis A medical treatise on the effects of ETS surgery
  • Truth About ETS Covering all aspects of the sympathectomy industry since 2004
  • [2] Total number of ETS surgeries performed worldwide
  • [3] Social phobia world hyperhidrosis forum
  • ESFB Channel - Discussion about excessive sweating, facial blushing, rosacea and social phobia
  • FfSo - People disabled by sympathectomies
  • P.A.S.S. - Patients Against Sympathetic Surgery


|}


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