A scientific society has been created for surgery of the sympathetic nervous system, the International Society of Sympathetic Surgery (ISSS); and in the most recent thoracic surgery and related specialities congresses it fills up a considerable percentage of the programme.
On the other hand, this surgery, especially for hyperhidrosis and facial reddening, is the one that on a percentage basis generates more demands and complaints from the patients, even with medico-legal connotations.7 Despite that the majority of the patients show a very high degree of satisfaction, the presence of a patient operated for hyperhidrosis with important compensatory sweating that repeatedly manifest their dissatisfaction to the surgeon is a very annoying situation with an intractable solution. There are even forums on the Internet that constantly manifest their discomfort with this type of surgery in a violent and insulting tone, for example, the World Against Sympathectomy Website.
In summary, we are faced with a new disorder that is being attended massively in our hospitals and needs a moment of contemplation. What are we doing? Are we doing it properly? What are the future implications in these patients of dorsal sympathetic denervation? For the first 2 questions, we could find the answer in the new clinical guidelines and scientific society norms and with the publication of linger series, randomised systematic studies, reviews and meta-analyses. However, it is perhaps the latter of these that implies greater consideration. To date, sufficient importance has not been placed on the long term effects that could cause dorsal sympathectomy, and the effects on lung function, heart function, skin colouring and psychological state are being studies, among others;10 the most important being the first 2. secondary consequences of the operation.
The consequences of sympathetic denervation after a dorsal sympathectomy on lung function have been studied on several occasions11 and reductions in forced vital capacity, forced expiratory flow in the first second and maximum mesoexpiratory flow have been found, but with no clinical significance. It therefore seems that, despite sympathetic innervation being scarce, it directly influences motor tone, especially of the fine respiratory tracts, which cause a light obstructive pattern after the operation and favours bronchial hyperreactivity.12 It is of great interest to know the results of the research being carried out to recognise the long term effects.
Something similar occurs with heart function, the sympathectomy in the short term causes bradycardia due to a lack of sympathetic stimulation to the heart. Several cases of myocardial infarction13 and
chronotropic heart failure requiring the insertion of a pacemaker14 have been reported. In the long term, dorsal sympathetic interruption causes an effect similar to beta blockers on the heart, and produced a decrease in average heart rate, but with no significant changes in the electrocardiogram (normal Q-T).15 It may be good to know through long term prospective studies which effects it truly has on heart function and what it could mean for the daily lives of the operated patients. For the time being, those individuals who practice aerobic sports (for example, long distance runners and cyclists)
should be informed that with sympathectomy their heart rate may be reduced in situations of maximum effort and lower their performance.16
M. Congregado / Arch Bronconeumol. 2010;46(1):1-2
Tuesday, August 23, 2011
Monday, August 8, 2011
significant change after sympathectomy: reduced sympathetic and increased vagal tone
The HRV analysis showed a significant change of indices reflecting sympatho-vagal balance indicating significantly reduced sympathetic (LF) and increased vagal (HF, rMSSD) tone. These changes still persisted after 2 years. Global HRV increased over time with significant elevation of SDANN after 2 years. QT dispersion was significantly reduced 1 month after surgery and the dispersion was further diminished 2 years later.
http://www.sciencedirect.com/science/article/pii/S0167527399001011
http://www.sciencedirect.com/science/article/pii/S0167527399001011
Wednesday, August 3, 2011
Serious complications reported after sympathectomy
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.
There are currently no complaints pending against Telaranta, and the authority has not considered restricting his rights to practice medicine.
The Finnish Patient Insurance Centre has processed 20 complaints concerning Telarantas Privatex clinic. The complaints resulted in 14 decisions to pay compensation. All except two of the surgeries were conducted by Telaranta himself.
Telaranta says that he treats patients suffering from difficult social anxiety with endoscopic surgery in which an incision is made into the upper part of the chest cavity, and the sympathetic nerve trunk is severed or clamped.
Most patients are satisfied with the treatment. However, FinOHTA found that there were many negative side-effects, some of which were very serious.
With most patients, heavy perspiration of the palms has moved to other parts of the body, below the breasts. As many as 15% of those who have undergone the surgery said that the surge in body perspiration forces them to change underwear several times a day.
Other side-effects have included drying of the skin on the face and hands, as well as perspiration triggered by eating spicy food. There are also reports of phantom perspiration - the feeling of perspiration when none takes place - as well as a weakened tolerance for cold.
More serious effects include collapsing of a lung, breathing difficulties, and blood clots in the brain. Some patients got a hanging eyelid, while others reported a sudden raspiness of their voice.
One of Dr. Telarantas 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.
Dr. Telaranta himself says that the side-effects are regrettable. However, he says that he has developed a procedure which does not cause any such side effects.
He also says that it is important to examine patients carefully, and to perform surgery only on those who are suited for the procedure.
Many doctors have serious reservations about the idea of treating complaints such as excessive perspiration, blushing, and performance anxiety by severing peoples nerves.
Helsingin Sanomat
http://www.hs.fi/english/article/1101979734791
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.
There are currently no complaints pending against Telaranta, and the authority has not considered restricting his rights to practice medicine.
The Finnish Patient Insurance Centre has processed 20 complaints concerning Telarantas Privatex clinic. The complaints resulted in 14 decisions to pay compensation. All except two of the surgeries were conducted by Telaranta himself.
Telaranta says that he treats patients suffering from difficult social anxiety with endoscopic surgery in which an incision is made into the upper part of the chest cavity, and the sympathetic nerve trunk is severed or clamped.
Most patients are satisfied with the treatment. However, FinOHTA found that there were many negative side-effects, some of which were very serious.
With most patients, heavy perspiration of the palms has moved to other parts of the body, below the breasts. As many as 15% of those who have undergone the surgery said that the surge in body perspiration forces them to change underwear several times a day.
Other side-effects have included drying of the skin on the face and hands, as well as perspiration triggered by eating spicy food. There are also reports of phantom perspiration - the feeling of perspiration when none takes place - as well as a weakened tolerance for cold.
More serious effects include collapsing of a lung, breathing difficulties, and blood clots in the brain. Some patients got a hanging eyelid, while others reported a sudden raspiness of their voice.
One of Dr. Telarantas 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.
Dr. Telaranta himself says that the side-effects are regrettable. However, he says that he has developed a procedure which does not cause any such side effects.
He also says that it is important to examine patients carefully, and to perform surgery only on those who are suited for the procedure.
Many doctors have serious reservations about the idea of treating complaints such as excessive perspiration, blushing, and performance anxiety by severing peoples nerves.
Helsingin Sanomat
http://www.hs.fi/english/article/1101979734791
Tuesday, August 2, 2011
Sympathecomy - a treatment for chronic refractory angina
Despite all the therapeutic measures discussed above many patients will remain severely incapacitated by their chest pain. In such cases, other therapeutic options, such as transcutaneous electric nerve stimulation (TENS), spinal cord stimulation (SCS), left stellate ganglion blockade (LSGB), endoscopic thoraco- scopic sympathectomy (ETS), transmyocardial laser revascularization (TMR) and angiogenesis have to be considered.
Endoscopic transthoracic sympathicotomy was developed by Go¨ ran Claes in the mid 1980s[114].
Initially it was used to treat palmar hyperhidrosis. In the late 1980s, Claes, Wettervik et al. started to use high transthoracic endoscopic sympathicotomy to treat refractory angina pectoris.
The procedure is performed under general anaesthesia. The pleural cavity is entered through the second or third intercostal space anteriorally. Carbon dioxide is then insufflated and the lung collapsed. Sympathetic ganglia are electrocoagulated using an electroresectoscope. Transsection of the thoracic ganglia T1–T5 is usually performed. The procedure is normally performed on the left side. If the effect is unsatisfactory the operation is done bilaterally. Note that the procedure should not be performed on the right side only as this carries a risk of inducing ventricular arrhythmia. (Mannheimer et al.)
European Heart Journal (2002) 23, 355–370
Endoscopic transthoracic sympathicotomy was developed by Go¨ ran Claes in the mid 1980s[114].
Initially it was used to treat palmar hyperhidrosis. In the late 1980s, Claes, Wettervik et al. started to use high transthoracic endoscopic sympathicotomy to treat refractory angina pectoris.
The procedure is performed under general anaesthesia. The pleural cavity is entered through the second or third intercostal space anteriorally. Carbon dioxide is then insufflated and the lung collapsed. Sympathetic ganglia are electrocoagulated using an electroresectoscope. Transsection of the thoracic ganglia T1–T5 is usually performed. The procedure is normally performed on the left side. If the effect is unsatisfactory the operation is done bilaterally. Note that the procedure should not be performed on the right side only as this carries a risk of inducing ventricular arrhythmia. (Mannheimer et al.)
European Heart Journal (2002) 23, 355–370
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