The Society of Thoracic Surgeons Expert Consensus for the Surgical Treatment of Hyperhidrosis -- Cerfolio et al. 91 (5): 1642 -- The Annals of Thoracic Surgery

The Society of Thoracic Surgeons Expert Consensus for the Surgical Treatment of Hyperhidrosis -- Cerfolio et al. 91 (5): 1642 -- The Annals of Thoracic Surgery: "Because the goal of this procedure is to improve quality of life, complications should be minimal and essentially eliminated. The primary side effects of hyperhidrosis surgery include CH, bradycardia, and Horner's syndrome. It is important for patients to be aware, however, of all of the possible complications that can occur. In general, "the higher the level of blockade on the chain, the higher is the expected regret rate" [26]."

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Thoracoscopic Sympathectomy for Isolated Facial Blushing -- Licht et al. 81 (5): 1863 -- The Annals of Thoracic Surgery

Thoracoscopic Sympathectomy for Isolated Facial Blushing -- Licht et al. 81 (5): 1863 -- The Annals of Thoracic Surgery: "Criticism has been raised about surgical treatment for facial blushing because there is very little evidence that the patients most likely to pursue surgical treatment for facial blushing actually blush more readily and intensely than other people [21]. It has been pointed out that facial blood flow during acute embarrassment seems to be unrelated to ratings of the self-reported frequency of blushing [22]. On the other hand, self-consciousness and fear of blushing correlate well with subjective estimates of blushing frequency and intensity [22]. It has therefore been suggested that if the source of the patient's problem is anxiety about blushing rather than blushing per se, anxiety would be a more appropriate target for treatment than permanently eliminating the normal regulation of facial blood flow and sweating [21]."

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The vasodilating effect of spinal dorsal column stimulation is mediated by sympathetic nerves - Springer

The vasodilating effect of spinal dorsal column stimulation is mediated by sympathetic nerves - Springer: "Immediately after sympathectomy, the contralateral right arm became increasingly cold and cyanotic and the patient complained of chronic painful coldness and severe cold-intolerance in the right arm. Attempts to pharmacologically vasodilate the arm with felodipine did not affect the local vasoconstriction and pain. Dorsal column stimulation (associated with symmetrical paraesthesia in both arms) induced an immediate and marked (ten-fold) increase in skin blood flow in the right arm (and in the leg), whereas skin blood flow in the left arm remained unaffected. The lack of vasomotor response in the left arm was not due to maximal vasodilatation at rest, since skin blood flow in the left arm showed a normal capacity for axon reflex vasodilatation following antidromic activation of sensory afferents. The results suggest that the marked vasodilatation induced by dorsal column stimulation is mediated by sympathetic vasomotor fibres, via modulation of central neuronal circuits involved in the regulation of skin sympathetic discharge."

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Medical Board Disciplines ETS surgeon Dr Nielson

Nielson,  David  Hugh,  M.D.,  Lic.  #K0962,  San  Antonio  TX
On  February  5,  2010,  the  Board  and  Dr.  Nielson  entered  into  an  agreed  order  requiring  Dr. Nielson  to  complete  15  hours  of  CME  in  medical  record-­keeping,  risk  management  and  ethics within  one  year;;  and  pay  an  administrative  penalty  of  $4,000  within  60  days.  The  action  was based  on  the  Board’s  finding  that  Dr.  Nielson  failed  to  keep  adequate  medical  records,  failed to  use  proper  diligence  in  his  professional  practice,  and  failed  to  adequately  supervise  the activities  of  those  acting  under  his  supervision.  The  Board  found  that  digital  photos  that  were part  of  patient  records  were  inadvertently  deleted  and  that  Dr.  Nielson  authorized  a  person  to represent  his  clinic  and  that  person  misrepresented  risks  and  procedures  for  Dr.  Nielson’s treatment  of  rosacea. 
http://www.tmb.state.tx.us/news/press/2010/021710.php

Transection below T8-T10 is not accompanied by reflex sweating

Reflex sweating in patients with spina... [Arch Phys Med Rehabil. 1977] - PubMed - NCBI: "Sweat glands derive their innervation from the sympathetic nervous system. The spinal sympathetic structures that are located in the intermediolateral areas extend from T1-L2 segments and are under the control of hypothalamic centers. Cord transection abolishes the supraspinal control of sudorimotor function. Since sympathetic innervation does not follow a clear segmental distribution, normal sweating may be preserved at a higher or lower level than skin sensation. Nonthermoregulatory reflex sweating is an indication of unchecked spinal cord facilitation and is precipitated by afferent stimuli from bladder, rectum, and various other sources. It is usually a manifestation of mass reflex or autonomic crisis and occurs particularly in cervical or high thoracic lesions. Transection below T8-T10 is not accompanied by reflex sweating. The phenomenon of thermal relfex sweating is controversial. Although some aspects of nonthermoregulatory reflex sweating are still unclear, proper immediate and continuing preventive management will reduce the incidence of this and other autonomic manifestations. "

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Hemodynamic changes in vertebral and carotid arteries were observed after sympathicotomy

T3 sympathicotomy segment was the most frequent transection done (95.83%), as only ablation (25%) or in association with T4 (62.50%) or with T2 (8.33%). It was observed increase in RI and PI of the common carotid artery (p < 0.05). The DPV of internal carotid artery decreased in both sides (p < 0.05). The SPV and the DPV of the right and left vertebral arteries also increased (p < 0.05). Asymmetric findings were observed so that, arteries of the right side were the most frequently affected.
CONCLUSIONS: Hemodynamic changes in vertebral and carotid arteries were observed after sympathicotomy for PH. SPV was the most often altered parameter, mostly in the right side arteries, meaning significant asymmetric changes in carotid and vertebral vessels. Therefore, the research findings deserve further investigations to observe if they have clinical inferences.
http://www.ncbi.nlm.nih.gov/pubmed/16186983 

Gustatory sweating, flushing and other responses after sympathectomy

Gustatory sweating on the head, neck and arms, often occurs after cervico-thoracic sympathectomy. Haxton (1948) reported an incidence of 36 percent, the same as in the present series. It was thought that some information about regeneration in the cervical sympathetic might be revealed by investigation of this surgical curiosity.

Although sweating is the common gustatory response after cervical sympathectomy, other changes are experienced. Haxton (1948) described associated paresthesia and flushing, gooseflesh may occur (Herxheimer, 1958) and vaso-constriction is reported in this paper. These occur together or separately and occasionally sweating might be absent. The subject has been confused by comparison with post-parotidectomy gustatory sweating which has a different mechanism (Glaister et al.,1958; Bloor, 1958).

Sweating is produced by cholinergic sympathetic fibres. In normal individuals both vasocontriction and gooseflesh are adrenergic. This also holds in gustatory responses.  Figure 2 shows blocking of sweating by atropine, whilst gooseflesh continues unchanged.
   The tingling sensations were described as being unlike normal sensation, and likened to plucking out of hair. In one patient in was so unpleasant that she refused to take a test stimulus. Flushing usually occurs on the upper chest and neck, and is an erythema with sharp demarcation, not associated with a rise in skin temperature.
   Of the patients, 29 were found to have gustatory responses, and 24 were studied in detail. Of 22 patients with sweating who could be studied, 11 had gooseflesh, 10 tingling, 6 flushing, and 4 vasoconstriction. Four patients, however, had no sweating and their gustator responses consisted of gooseflesh and tingling in one, tingling alone, and flushing in two. None of these four showed vasoconstriction.
   The stimulus for testing used was usually Worcester sauce, but specificity of the response was sometimes great, and one patient reacted only to boiled sweets made by one particular firm.

http://brain.oxfordjournals.org/content/92/1/137.extract   &
http://ang.sagepub.com/content/17/3/143.extract

not exposing patients to the risk of experiencing the side effects of sympathectomy

The use of oxybutynin for treating ... [An Bras Dermatol. 2011 May-Jun] - PubMed - NCBI: "not exposing patients to the risk of experiencing the side effects of sympathectomy"

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rates and characteristics of the paresthesia following needlescopic VATS are similar to those observed after conventional VATS

Incidence of chest wall paresthesia ... [Eur J Cardiothorac Surg. 2005] - PubMed - NCBI: "Paresthetic discomfort distinguishable from wound pain was described by 17 patients (50.0%). The most common descriptions were of 'bloating' (41.2%), 'pins and needles' (35.3%), or 'numbness' (23.5%) in the chest wall. The paresthesia resolved in less than two months in 12 patients (70.6%), but was still felt for over 12 months in three patients (17.6%). Post-operative paresthesia and pain did not impact on patient satisfaction with the surgery, whereas compensatory hyperhidrosis in 24 patients (70.6%) did (P=0.001). The rates and characteristics of the paresthesia following needlescopic VATS are similar to those observed after conventional VATS."

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Stellate ganglion block may relieve hot flashes by interrupting the sympathetic nervous system

Stellate ganglion block may relieve hot flash... [Med Hypotheses. 2007] - PubMed - NCBI: "the wide range of conditions that have been reported to respond favorably to stellate ganglion block suggest that its effectiveness may not be solely the result of increased blood flow nor restricted just to its sphere of innervation. We have found that stellate ganglion block is effective in the treatment of hot flashes in postmenopausal women, as well as those with estrogen depletion resulting from breast cancer treatment. Based on evidence that hot flashes may be centrally mediated and that the stellate ganglion has links with the central nervous system nuclei that modulate body temperature, we hypothesize that the stellate ganglion block provides relief of hot flashes by interrupting the central nervous system connections with the sympathetic nervous system, allowing the body's temperature-regulating mechanisms to reset. If this mechanism can be confirmed, this would provide women with intractable hot flashes with an effective, potentially long-lasting means of relieving their symptoms, and potentially widen the range of indications for stellate ganglion block to include other centrally mediated syndromes."

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These observations further emphasize our ignorance of the mechanisms responsible for primary hyperhidrosis and of the effect of sympathetic ablation

"These observations further emphasize our ignorance of the mechanisms responsible for primary hyperhidrosis and of the effect of sympathetic ablation on the function of the remaining sympathetic system."  

"Only investigators who deviate from accepted standards innovate and thus advance science. Obviously, such deviations may also result in disasters;"  

Statement made by the former President of the International Society of Sympathetic Surgery,  and ETS surgeon, Moshe Hashmonai (Invited Commentary)   Endoscopic Lumbar Sympathectomy Following Thoracic Sympathectomy in Patients with Palmoplantar Hyperhidrosis    

World J Surg (2011) 35:54–55 DOI 10.1007/s00268-010-0809-5

Sympathectomy results in a substantial interference in regulatory processes of the body

"ESB  (whether as ETS as ETSC or ELS) generally represents a substantial interference in regulatory processes of the body.  Therefore decision for this operation requires that previously conservative treatments were made. An ESB is therefore at the end of a treatment history, and never at the beginning." 

Dr. Christoph H. Schick, ETS surgeon, President of the International Society of Sympathetic Surgery (ISSS)  

text has been  translated by google from German

http://www.dhhz.de/index.php?page=8&subPage=&section=32

Post-sympathectomy pain

Postsympathectomy limb pain, postsympathectomy parotid pain, and Raeder's paratrigeminal syndrome are pain states associated with the loss of sympathetic fibres and in particular with postganglionic sympathetic lesions. There is a characteristic interval of about 10 days between surgical sympathectomy and onset of pain. It is proposed that this pain in man is correlated with the delayed rise in sensory neuropeptides seen in rodents after sympathectomy. These chemical changes probably reflect the sprouting of sensory fibres and may result from the greater availability of nerve growth factor after sympathectomy. The balance between the sensory and sympathetic innervations of a peripheral organ may be determined by competition for a limited supply of nerve growth factor.

Lancet. 1985 Nov 23;2(8465):1158-60

http://www.ncbi.nlm.nih.gov/pubmed/2414615?dopt=Abstract

Sympathectomy to treat the urge to smoke

Lipov, Eugene (Chicago, IL, US)  treating addiction with disruption of the sympathetic chain.

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

Complications of surgical (Thoracic and Lumbar) Sympathectomy

Post-sympathectomy neuralgia - pain overlying the scapula

Compensatory sweating - involving the lover back or face

Pneumothorax

Bleeding due to azygos vein or intercostal artery injury

Winged scapula due to long thoracic nerve injury (p. 517)

Mastery of Vascular and Endovascular Surgery

Gerald B. Zelenock, Thomas S. Huber, Louis M. Messina, Alan B. Lumsden, Gregory L. Moneta

Lippincott Williams & Wilkins, 15/12/2005 - 900 pages

The custom of a majority is no guarantee of safety and is seldom a guide to best medical practice.

Cameron`s claim that there has been only one death attributable to synchronous bilateral thoracoscopic sympathectomy is implausible. Surgeons and anaesthetists are reticent in publicizing such events and Civil Law Reports of settled cases are an inadequate measure of the current running total. The custom of a majority is no guarantee of safety and is seldom a guide to best medical practice.

Jack Collin,

Consultant Surgeon

Oxford

http://www.bmj.com/content/320/7244/1221?tab=responses

reduction in all proline-richproteins (PRP) in the saliva following sympathectomy

The protein constituents in parasympathetically evoked saliva from normal and short-term sympathectomized parotid gland swere compared. There was a reduction in all proline-richproteins (PRP) in the saliva following sympathectomy. The decrease was quantified for acidic PRP by high- performance ion-exchange chromatography, which showed an increase in the ratio of amylase to other proteins. These results suggest that sympathetic impulses influence the synthesis of PRP and amylase in opposite directions. 

Quarterly Journal ofExperimental Physiology (1988) 73, 139-142

No compensatory sweating after botulinum toxin... [Br J Dermatol. 2005] - PubMed - NCBI

No compensatory sweating after botulinum toxin... [Br J Dermatol. 2005] - PubMed - NCBI: "No compensatory sweating after botulinum toxin treatment of palmar hyperhidrosis"

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patient information must include the long-term substantial risk for sever CS and regret of the procedure.

http://www.ncbi.nlm.nih.gov/pubmed/22191130

Another case of disabled thermoregulation and heatstroke following sympathectomy

We describe an extreme case of compensatory truncal hyper- hidrosis and anhidrosis over the head and neck region which led to a heatstroke. 

Six months after the initial operation, he had an episode of heatstroke while perform- ing outdoor duties which required running for around 5 km. The temperature on the day was between 30–32°C, and the relative humidity was between 75 and 85%. At that time, he complained of light-headedness, ‘feeling’ that heat could not dissipate from his head and neck region and muscle cramp in his legs. He was transferred to a hospital and was found to have a body tem- perature of 40°C and shock. His presentation was similar to a previous report by Sihoe et al. [1] on a patient with post- sympathectomy heatstroke. He was subsequently successfully treated with fluid and electrolyte resuscitation and supportive care.
  

Interactive CardioVascular and Thoracic Surgery 14 (2012) 350–352

no chance for nerve regeneration as early as 10 days after clipping

*Study presented at the 9th Biannual International Society for Sympathetic Surgery Conference in Odense, Denmark in May 2011. 

www.tswj.com/aip/134547.pdf

69% of patients continued to have relief after ETS, patient satisfaction rate was 56%

There were no operative mortalities, minor complications occurred in 22%. Initial success rate was 88%. Median follow up was 93 (24-168) months, response rate to the questionnaire was 85%. Sixty-nine per cent of patients continued to have relief of initial symptoms, whereas patient satisfaction rate was 56%. CS was present in 42 patients (68%). Long-term satisfaction rates per initial indication group were 42% for facial blushing and 65% for hyperhidrosis (n.s.), and CS was present in 79% vs 61%, respectively.

CONCLUSION:

ETS appears a safe treatment for upper limb hyperhydrosis with acceptable long-term results. For excessive blushing, however, long-term satifaction rates of ETS are severely hampered by a high incidence of disturbing compensatory sweating. ETS should only be indicated in patients with unbearable symptoms refractory to non-surgical treatment. The patient information must include the long-term substantial risk for sever CS and regret of the procedure.

http://www.ncbi.nlm.nih.gov/pubmed/22191130

"sympathectomy highlighted the disparity between what is known in practice and what appears in the literature"

The March 2004 edition was quite outstanding, with an excellent editorial reminding the reader that only good results are published. The review on thoracoscopic sympathectomy highlighted the disparity between what is known in practice and what appears in the literature. 

‘Know Your Results’, the topic of the ASGBI Annual Scientific Meeting, is of outstanding importance; what is more, the surgeon has to go on knowing his/her results to ensure standards of practice do not slip.

The Journal appreciates comments and criticism and the correspondence column remains a crucial part of the BJS in its interaction between editors and reader. It is also part of the scientific process.

A more robust and incisive criticism of articles known to be flawed would prevent the retractions that have recently been published in the Lancet.

Christopher Russell, Chairman, BJS Society

Association of Surgeons of Great Britain and Ireland, ANNUAL REPORT 2004

The effect of bilateral sympathectomy was significantly greater than that of unilateral sympathectomy

The effect of bilateral sympathectomy was significantly greater than that of unilateral sympathectomy. Unilateral and bilateral sympathectomy produced similar reductions in the concentrations of NPY-ir and NA in the ventricular tissue. In contrast dissimilar changes were produced in the atrium. Although bilateral sympathectomy almost totally depleted the NA from the right atrium (by 98%), the NPY-ir levels were only reduced by 50%. These results indicate that approximately half the content of NPY in the right atrium is not present in sympathetic noradrenergic neurones. 

Maccarrone C, Jarrott B.

Source

University of Melbourne, Department of Medicine, Austin Hospital, Heidelberg, Vic., Australia.

J Auton Nerv Syst. 1987 Dec;21(2-3):101-7.

http://www.ncbi.nlm.nih.gov/pubmed/3450689

sympathectomy induced morphological alterations in the masseter muscles

Sympathectomized animals showed varying degrees of metabolic and morphological alterations, especially 18 months after sympathectomy. The first five groups showed a higher frequency of type I fibres, whilst the oldest group showed a higher frequency of type IIb fibres. In the oldest group, a significant variation in fibre diameter was observed. Many fibres showed small diameter, atrophy, hypertrophy, splitting, and necrosis. Areas with fibrosis were observed. Thus cervical sympathectomy induced morphological alterations in the masseter muscles. These alterations were, in part, similar to both denervation and myopathy. These findings indicate that sympathetic innervation contributes to the maintenance of the morphological and metabolic features of masseter muscle fibres.

http://www.ncbi.nlm.nih.gov/pubmed/11454103

Bilateral cervical sympathectomies should be avoided because of the destruction of cardioaccelerator tone

http://www.hiesiger.com/physicians/physicianrfl.html

Chylothorax as complication of sympathectomy

Chylothorax has been reported as a complication of wide range of other operations, including esophagoscopy, stellate ganglion blockade, thoracic sympathectomy, high translumbar aortography, lung resection, thyroid surgery, and spinal surgery.
http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-1-4160-4710-0..00074-2--s0250&isbn=978-1-4160-4710-0&type=bookPage&from=content&uniqId=350894912-2

SURGICAL SYMPATHECTOMY ON THE SENSITIVITY TO EPINEPHRINE OF THE BLOOD VESSELS OF MUSCULAR SEGMENTS OF THE LIMBS

Pursuing this study of the effect of epinephrine on muscle blood flow, Duff and Swan (10) reported that during intravenous epinephrine infusions the initial marked dilatation was succeeded by a second phase of moderate dilatation in normal but not in sympathectomized limbs. Because of its absence in chronically sympathectomized limbs this secondary vasodilatation was at that time thought to be an indirect vasomotor effect mediated by the sympathetic nerves. Re-examination of their data in the light of some subsequent critical experiments now reveals that the difference which they found between normal and sympathectomized limbs may be ascribed largely to vascular hypersensitivity in the later.

In the present paper these additional data are reported, and are incorporated with those of Duff and Swan(10); the whole material being interpreted to provide evidence that hypersensitivity of the vessels of skeletal muscle in the upper and lower limbs may result from pre- and postganglionic sympathectomy in man.

EFFECT OF SURGICAL SYMPATHECTOMY ON THE SENSITIVITY TO EPINEPHRINE OF THE BLOOD VESSELS OF MUSCULAR SEGMENTS OF THE LIMBS, ROBERT S. DUFF

J Clin Invest. 1953 September; 32(9): 851–857.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC438413/

Sympathetic nerves protect against blood-brain barrier disruption

http://www.ncbi.nlm.nih.gov/pubmed/7064183

It is well recognized that preganglionic sympathectomy involves division of cholinergic elements ad sensory fibers

Pharmacological Reviews, 1966 Vol. 18, No. 1. Part I

When sympathectomized rats were injected with the same carcinogen, 24 out of 38 developed tumors

"Lesions od the sympathetic nervous system have been shown to increase the incidence, induction, and take and growth, of tumors. In neurally intact rats which were infected with a known carcinogen, only 1 out of 30 developed a tumor. When sympathectomized (intentional sympathetic nerve interference) rats were injected with the same carcinogen, 24 out of 38 developed tumors. These results confirm that sympathetic block enhances tumor implantation."

"Clearly the autonomic nervous system in exquisitely sensitive to information from all parts of the nervous system and may affect many aspects of the immune response."

"Since immune response is initiated by the nervous system, this appears to be a likely place to look for the cause of disease."

Edward E. Cremata, Neural control of immunity, January/February, 1982 The Digest of Chiropractic Economics

1. Couhard, R. and P. Hein, Cancers de types divers provoqucs par lesion du sympathique, CR. Acad. Sci,  2434-2437, 1957.

2. Couhard, R. and F. Heitz, Production de tumeurs malìgncs consecutivas a des lesions des fibres sympaxhiqucs du neri sciatique chez le cobaye. CR. Amd. Scl", 244: 4-09-411, 1957. 

3. Nayar, KK., Arthur, E. and Ballís,  M4, Th: transmission of tumours induced in cockroaches by nerve severance, Experienria, 27: 183, 1971. 

4. Champy, C.. Lesions neum-sympathìques precedam la canccrixation dans Patlaque de Porganìsmc par les substances cancerîgenes, C.R. Acad. Sci, 248: 3665-1666; 1959. 

 www.usapr.org/paperpdfs/75.pdf

blockade of sympathetic nerves - Trigeminal Substance P Neurons in Cluster Headache

A comparison is made with the present opinion on activation of parasympathetic and blockade of sympathetic nerves to explain the various symptoms of a cluster attack.

The Involvement of Trigeminal Substance P Neurons in Cluster Headache. An Hypothesis

Jan Erik Hardebo , M.D.

From the Department of Neurology and Department of Histology, University of Lund, Lund, Sweden.

Headache: The Journal of Head and Face Pain

Volume 24 Issue 6, Pages 294 - 304

Published Online: 22 Jun 2005

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

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


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

Management of reflex sweating in spinal cord injured patients

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

PMID:

2742472

[PubMed - indexed for MEDLINE]

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

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

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

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

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

Sympathectomy exacerbated the inflammation and osteopathic destruction of arthritic joints

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

results of sympathectomy deteriorate with time

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

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

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

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

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

left thoracic sympathectomy to prevent electrical storms in CPVT patients

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

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

Sympathectomy for the treatment of polymorphic ventricular tachycardia

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

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

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

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

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

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

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

This is how "compensatory" sweating looks like

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

The Dangers of ETS Surgery for Excessive Sweating and blushing

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

dynamic cerebral autoregulation is altered by ganglion blockade

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

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

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

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

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

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

Vasodilation; Vasomotor Disturbances

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

Epidemiology /Etiology

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

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

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

Characteristics/Clinical Presentation

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

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

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

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

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

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

- Motor dysfunction

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

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

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

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

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

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

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

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

sympathectomy affects the heart, sweating, and circulation

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

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

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

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

Possible surgical complications of sympathectomy may include

• Horner's syndrome
• Infection
• Hematoma
• Bleeding
• Postsympathectomy neuralgia
• Pleurotomy
• Pleural effusion
• Phrenic nerve injury
• Subclavian artery injury
• Adverse reaction to anesthesia
• Collapsed lung 

http://www.malonie.com/surgeries/upper-extremity-sympathectomy.htm

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

Other complications of ETS include:

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

Rarer complications of ETS include:

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

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

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

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

75% pneumothorax expected after sympathectomy

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

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


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

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

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

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

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

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

Tell your doctor if:

* you have had a sympathectomy

* you have been taking diuretics

*you have a history of allergy or asthma


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

2. Before you start to take AVAPRO HCT

Tell your doctor if:

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

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

Published by MIMS/myDr March 2011

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

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

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

United States Patent 20070135871

Kind Code: A1

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

Variations in dynamic lung compliance during endoscopic thoracic sympathectomy with CO2 insufflation

The current study examined the effects of capnothorax on dynamic lung compliance (DLC) of the ventilated lung during ETS.
One way analysis of variance (ANOVA) was used for analysis of data before, during and after OLCV. P<0.05 was considered significant. The mean values of the DLC were 52 +/- 6, 30 +/- 3, 39 +/- 5 and 53 +/- 9 ml/cmH(2)O before, during (at 10 and 5 mmHg IPP) and after OLCV respectively with significant differences before and at 10 and 5mmHg IPP. In conclusions, during OLCV and capnothorax for ETS, DLC tends to decrease with increasing of intrapleural CO(2) insufflation pressure. However, in short procedures it has no deleterious postoperative effect. To the best of our knowledge this is the first study performed to investigate DLC changes during OLCV with capnothorax.
Clin Auton Res. 2003 Dec;13 Suppl 1:I94-7.

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

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.

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

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

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

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

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

Neuropathic pain is caused by damage to, or dysfunction of, the nervous system

http://www.mydr.com.au/pain/neuropathic-pain

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

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

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

facial anhidrosis and disturbed cardiovascular responses to temperature

"Although thoracic sympathectomy is commonly used to reduce upper limb sweating, it may also lead to facial anhidrosis and disturbed cardiovascular responses to temperature. The resultant effect on overall body heat loss has not been documented. We present a case of a young patient with previous thoracic sympathectomy who suffered severe heat stroke after heavy exercise.
http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

sympathectomy can impair the autonomic nervous system’s increase of the heart rate in response to exercise

it has been shown that thoracic sympathectomy can impair the autonomic nervous system’s increase of the heart rate in response to exercise [6]. Although absolute tachycardia is not eliminated, given the endocrine and paracrine stimuli during exercise, the maximum heart rate reached during exercise has been shown to be significantly reduced after sympathectomy. Thus for a given workload during exercise, there will be a relative bradycardia. This may possibly affect the circulatory system’s ability to convey heat from the body core to the extremities for heat loss.
http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

abnormal sympathetic skin response may lead to peripheral vascular failure or the reduced cardiac chronotropic response may impair the body

An already impaired cardiovascular system is recognized to be a significant risk factor for development of heat stroke. In the post-sympathectomy patient, the abnormal sympathetic skin response may lead to peripheral vascular failure or the reduced cardiac chronotropic response may impair the body’s capacity to compensate for shock. These may have contributed to the rapid development of shock and severe multiple organ dysfunction syndrome in this patient.
He had multiple organ dysfunction syndrome develop, with severe renal and hepatic failure, grade II hepatic encephalopathy, and disseminated intravascular coagulation. He responded remarkably well to aggressive supportive measures including forced alkaline diuresis, and he was eventually discharged home after 1 month. The patient was previously a healthy, physically fit, nonsmoker. He worked as a body building trainer and led an active, sporty lifestyle. The only significant medical history was that he had received thoracic sympathectomy for axillary hyperhidrosis 4 years ago at another hospital.

http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

abnormal peripheral vascular responses to temperature

thoracic sympathectomy has been demonstrated to abolish or alter sympathetic vasoconstrictive responses in the skin, and this may contribute to abnormal peripheral vascular responses to temperature [4]. Paradoxically it has been suggested that in some cases there may be abnormal vasoconstriction rather than the expected vasodilatation after sympathectomy [5]. It is not impossible that such atypical peripheral vascular responses to rising body temperature may have contributed to impaired heat loss during exercise or to an inappropriate response to shock on the development of the heat stroke.
http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

sympathectomy can impair the autonomic nervous system’s increase of the heart rate in response to exercise

it has been shown that thoracic sympathectomy can impair the autonomic nervous system’s increase of the heart rate in response to exercise [6]. Although absolute tachycardia is not eliminated, given the endocrine and paracrine stimuli during exercise, the maximum heart rate reached during exercise has been shown to be significantly reduced after sympathectomy. Thus for a given workload during exercise, there will be a relative bradycardia. This may possibly affect the circulatory system’s ability to convey heat from the body core to the extremities for heat loss.
http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

Gustatory sweating is a frequent side effect after thoracoscopic sympathectomy (32%)

Overall, gustatory sweating occurred in 32% of patients, and the incidence was significantly associated with extent of sympathectomy (p = 0.04). However, because the extent of sympathectomy was always decided by the location of primary hyperhidrosis, the latter may also explain the risk of gustatory sweating. CONCLUSIONS: Gustatory sweating is a frequent side effect after thoracoscopic sympathectomy. This is the first study to report that its incidence is significantly related to the extent of sympathectomy or the location of primary hyperhidrosis. Although there is no pathophysiologic explanation of gustatory sweating, these findings should be considered before planning thoracoscopic sympathectomy and patients should be thoroughly informed.
The Annals of thoracic surgery (Ann Thorac Surg), 2006-Mar; vol 81 (issue 3) : pp 1043-7

GUSTATORY SWEATING AND OTHER RESPONSES AFTER SYMPATHECTOMY

Gustatory sweating on the head, neck and arms, often occurs after cervico-thoracic sympathectomy. Haxton (1948) reported an incidence of 36 percent, the same as in the present series. It was thought that some information about regeneration in the cervical sympathetic might be revealed by investigation of this surgical curiosity.

Although sweating is the common gustatory response after cervical sympathectomy, other changes are experienced. Haxton (1948) described associated paresthesia and flushing, gooseflesh may occur (Herxheimer, 1958) and vaso-constriction is reported in this paper. These occur together or separately and occasionally sweating might be absent. The subject has been confused by comparison with post-parotidectomy gustatory sweating which has a different mechanism (Glaister et al.,1958; Bloor, 1958).

Sweating is produced by cholinergic sympathetic fibres. In normal individuals both vasocontriction and gooseflesh are adrenergic. This also holds in gustatory responses.  Figure 2 shows blocking of sweating by atropine, whilst gooseflesh continues unchanged.
   The tingling sensations were described as being unlike normal sensation, and likened to plucking out of hair. In one patient in was so unpleasant that she refused to take a test stimulus. Flushing usually occurs on the upper chest and neck, and is an erythema with sharp demarcation, not associated with a rise in skin temperature.
   Of the patients, 29 were found to have gustatory responses, and 24 were studied in detail. Of 22 patients with sweating who could be studied, 11 had gooseflesh, 10 tingling, 6 flushing, and 4 vasoconstriction. Four patients, however, had no sweating and their gustator responses consisted of gooseflesh and tingling in one, tingling alone, and flushing in two. None of these four showed vasoconstriction.
   The stimulus for testing used was usually Worcester sauce, but specificity of the response was sometimes great, and one patient reacted only to boiled sweets made by one particular firm.

http://brain.oxfordjournals.org/content/92/1/137.extract   &
http://ang.sagepub.com/content/17/3/143.extract

The development of gustatory sweating after cervical sympathectomy can only be explained if one is to admit that the primary event of gustatory sweating is a degeneration of the cervical sympathetic neurons. The initial event is the loss of postganglionic sympathetic neurons and the resulting denervation of the corresponding facial sweat glands. Regeneration of parasympathetic fibers, within the degenerating sympathetic neurilemmal sheets, is a secondary event although it accounts for the observed symptoms.

Salivary gland disorders

Eugene N. Myers, Robert L. Ferris

 0 Reviews

Springer, 2007 - Medical - 517 pages

profound decrease of arterial oxygen partial pressure during sympathectomy

Left-lung ventilation and right-chest operation caused profound decrease of arterial oxygen partial pressure (PaO2), compared with two-lung ventilation before surgery (70.7%, P > 0.0003) and compared with PaO2 at two-lung ventilation during and after surgery (decrease of 80.1% and 75.3%, respectively; P > 0.001 and < 0.005, respectively). Right-lung ventilation and left-chest operation did not cause hypoxemia.

Pulse oximetry and repeated blood gas measurements are needed during endoscopic transthoracic sympathectomy in order to detect and treat hypoxemic events, which may jeopardize the patient's life.
Journal of Cardiothoracic and Vascular Anesthesia
Volume 10, Issue 2, February 1996, Pages 207-209

hypoxic pulmonary vasoconstriction may be impaired after Sympathectomy

It is well known that hypoxic pulmonary vasoconstriction(HPV) plays an important role to protect hypoxemia during the atelectasis induced by one-lung ventilation. Thoracic sympathectomy may have effects on pulmonary vasculature(HPV) and hemodynamics during one-lung anesthesia.

Mean arterial blood pressure was decreased from 81.9+/-2.89 to 73.2+/-2.49 mmHg after thoracic sympathectomy and heart rate was decreased from 104.4+/-3.12 to 88.2+/-2.31beats/min. Arterial oxygen tension was decressed from 570.5+/-17.9 to 521.4+/-23.2mmHg after position change, and decreased to 271.1+/-28.1 mmHg under one-lung ventilation, and finally decreased to 217.0+/-18.3 mmHg after thoracic sympathectomy. With the above results, we can conclude that patients for TES should be carefully observed during and after the procedure, and hypoxic pulmonary vasoconstriction may be impaired after TES.
Korean J Anesthesiol. 1993 Aug;26(4):695-699.

sympathectomy causes autonomic dysfunction

The finger wrinkling response is abolished by upper thoracic sympathectomy. The test is also abnormal in some patients with diabetic autonomic dysfunction, the Guillan-Barre syndrome and other peripheral sympathetic dysfunction in limbs. (p.46)
Other causes of autonomic dysfunction without neurological signs include medications, acute autonomic failure, endocrine disease, surgical sympathectomy . (p.100)

Disorders of the Autonomic Nervous System

By David Robertson, Italo Biaggioni

Edition: illustrated

Published by Informa Health Care, 1995

ISBN 3718651467, 9783718651467

sensory abnormalities, abnormal body sweating, pathologic gustatory sweating after sympathectomy

The present study does not allow for conclusions about the effectiveness of surgical sympathectomy for neuropathic pain.
However, our findings indicate that if the pain persists after the procedure, the complications may be quite serious and at times worse than the problem for which the surgery was originally performed.
The Clinical Journal of Pain
2003, vol. 19, n^o3, pp. 192-199

sympathectomy produces complex alterations of vascular reactivity

In conclusion, we showed that sympathectomy produces complex alterations of vascular reactivity both in vivo and in isolated vessels, which shift the balance of the sensitivity of the vessel between vasoconstrictor and vasodilating agents towards an increased constriction. These results are unlikely to simply reflect denervation supersensitivity; their underlying receptor, post-receptor and/or contractile mechanisms are yet to be identified. Journal of Hypertension. 18(8):1041-1049, August 2000.

benefits or side effects associated with sympathectomy for treating facial blushing have not been properly evaluated and reported

Reported success stories on ETS are "prone to bias and have significant methodological problems"

Australian Review of ETS surgery - 2001
The four case series were not critically appraised because they are prone to bias and have significant methodological problems. These studies represent level IV evidence according to the NHMRC criteria and one should not draw firm conclusions from their findings.

To date, the benefits or side effects associated with endoscopic thoracic sympathectomy for treating facial blushing have not been properly evaluated and reported.

Further research using a well-designed controlled trial is warranted to assess the efficacy of endoscopic thoracic sympathectomy for treating facial blushing.

Centre for Clinical Effectiveness - Monash, Melbourne Australia

Patients should be clearly warned that sympathectomy is not as minor a procedure as usually asserted

Ann Thorac Surg 2001;71:1116-1119