Unsubstantiated statements by ETS surgeon can be misleading

"The incidence of compensatory hyperhidrosis is
proportional to
the surface
area rendered anhidrotic."


"The statement is based on my own observations.  It is
original and does not refer to any other article.
You have already discovered the
original source.

It is a clinical observation.  I have done no
measurements that is/yet to be subjected to
scientific study.
You can quote it as a clinical
hypothesis that I have postulated."

Jack Collin,
consultant surgeon
Oxford

Mia: the only study done (and posted on this blog)
so far, states that 
Sympathectomy will INCREASE the total
amount of body sweat.
http://www.ncbi.nlm.nih.gov/pubmed/11193740

Sympathectomy - division of adrenergic, cholinergic and sensory fibres

In general sympathectomy has been used for one or more of the following purposes:
1) to eliminate tonic or engendered responses which depend upon impulses in adrenergic nerves;
2) to eliminate visceral stores or adrenergic substances which depend upon the integrity of the postganglionic sympathetic innervation;
3) to eliminate postganglionic sympathetic tissue as a locus for the synthesis, uptake, binding, release and metabolism of adrenergic substances;
4) to eliminate visceral afferent fibers which are frequently distributed in common with autonomic nerves. The extent to which the surgical procedure is adjudged successful is usually related to the anatomical extent of the denervation and the time after operation at which the result is evaluated.
It is clear that "sympathectomy" is not a selective excision of adrenergic elements only. It is well recognized that preganglionic sympathectomy involves division of cholinergic elements ad sensory fibers.
Pharmacological Reviews, 1966 Vol. 18, No. 1. Part I

Bilateral surgical sympathectomy provides a valuable tool for future investigations of the cellular basis of supersensitivity in the myocardium.

K Goto, PA Longhurst, LA Cassis, RJ Head, DA Taylor, PJ Rice and WW Fleming

Volume 234, Issue 1, pp. 280-287, 07/01/1985
Copyright © 1985 by American Society for Pharmacology and Experimental Therapeutics

Autonomic dysreflexia

Autonomic dysreflexia is a potentially life-threatening complication in these patients. This disorder represents an autonomic response, which is primarily sympathetic, to specific visceral stimuli in patients with spinal cord injury above the level of T6. An incomplete compensatory parasympathetic outflow will occur above the level of injury. This phenomena is more common in patients with cervical injuries, and common triggers include bowel and bladder distention. Symptoms may involve piloerection, diaphoresis, pounding headache, flushing above the level of the injury, and may be associated with sudden and severe hypertension accompanied by reflex bradycardia. Although bradycardia is most common, tachycardia and arrhythmias may be present. Hypertension may be of varying severity from causing a mild headache to a seixure or life-threatening cerebral hemorrhage.

Voiding Dysfunction

By Rodney A. Appell
Published by Humana Press, 2000

Hypotension

Orthostatic hypotension is commonly associated with prolonged bed rest (24 hours or longer). It may also result from sympathectomy, which disrupts normal vasoconstrictive mechanisms.

READ BOOK EXCERPT ONLINE »

Orthostatic hypotension [Postural hypotension]: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

reduction of catecholamines by more than 90%

Sympathectomy has been used to study the role of the sympathetic nervous system in the control of gastric acid secretion. Conflicting results may reflect differences in the sympathectomy procedures used. In a previous study we showed a reduction of catecholamines by more than 90% in the gut wall of the rat after surgical upper abdominal sympathectomy.

Total denervation, including combined surgical and chemical sympathectomy plus vagotomy, did not reduce noradrenaline levels more than surgical sympathectomy alone, suggesting that the proportion of adrenergic fibers that derive from the vagus is quantitatively insignificant but that the vagus exerts a local control of the sympathetic stores of gastric catecholamines. Thus, surgical upper abdominal sympathectomy is the method of choice in studies of the role of the sympathetic nervous system in regulating gastric functions. Adrenaline and dopamine levels were much lower than the noradrenaline levels but showed roughly the same trends of changes after the denervations (except that chemical sympathectomy did not affect dopamine).
Scandinavian Journal of Gastroenterology, Volume 20, Issue 10 December 1985 , pages 1276 - 1280
H. Graffner ^a; M. Ekelund ^a; R. Hkanson ^a; E. Rosengren ^a

Affiliation:

a Depts. of Surgery and Pharmacology, University of Lund, Lund, Sweden

Serum Dopamine-β -Hydroxylase: Decrease after Chemical Sympathectomy

Dopamine-β -hydroxylase is an enzyme that is localized to catecholamine-containing vesicles in sympathetic nerves and the adrenal medulla, and is also found in the serum. Treatment of rats with 6-hydroxydopamine, a drug which destroys sympathetic nerve terminals, leads to a decrease in serum dopamine-β -hydroxylase activity.

		Weinshilboum, Richard; Axelrod, Julius
Publication:		Science, Volume 173, Issue 4000, pp. 931-934
Publication Date:		09/1971
Origin:		JSTOR

Absence of the localized Schwartzman reaction

This investigation was undertaken to determine whether the presence of catechol amines was necessary for endotoxin to be operative in the production of a localized Schwartzman reaction. Seven rabbits were pretreated with 6–OH dopamine to produce a generalized chemical sympathectomy. An attempt was made to induce a localized Schwartzman reaction in these rabbits as well as in a control group. The rabbits in the experimental group did not develop the classical localized Schwartzman reaction, while those in the control group developed the localized Schwartzman reaction both clinically and histologically.
L. Shapiro ¹ , P. Cuevas ¹ , R. E. Stallard ¹ , M. P. Ruben ¹

¹ Clinical Research Center, Boston University Medical Center, School of Graduate Dentistry, Boston, Massachusetts, USA.

Journal of Periodontal Research, Volume 9 Issue 4, Pages 207 - 210

Published Online: 30 Jun 2006

Sympathectomy decreased NE and DA concentrations of muscles to approximately 10% of control values

We studied the effect of unilateral sympathectomy on rat quadriceps and gastrocnemius muscle concentrations of endogenous dihydroxyphenylalanine (DOPA), dopamine (DA), and norepinephrine (NE) and assessed the relationships between these catecholamines in several rat tissues. Catecholamines were measured by reverse-phase high-performance liquid chromatography with electrochemical detection. Sympathectomy decreased NE and DA concentrations of muscles to approximately 10% of control values, whereas the DOPA concentration tended to increase. Relatively high concentrations of DOPA were found in the gastrointestinal tract, kidney, and spleen. No correlations were obtained between the tissue concentration of DOPA and NE. A DA-to-NE ratio approximately 1% was observed in liver, muscle, pancreas, spleen, and heart, whereas we found exponentially increasing DA values with increasing NE concentration in tissues obtained from stomach, small and large intestine, kidney, and lung. In conclusion, endogenous DOPA in muscle tissue is not located in sympathetic nerve terminals but probably in muscle cells. DA concentrations in the gastrointestinal tract and in the kidneys were greater than could be ascribed to its role as a precursor in the biosynthesis of NE.

E. Eldrup, E. A. Richter and N. J. Christensen
Department of Internal Medicine and Endocrinology, Herlev University Hospital, Denmark.

Am J Physiol Endocrinol Metab 256: E284-E287, 1989;

sympathectomy abolished the differences in body fat accumulation

There is evidence to suggest that obese individuals,
and those predisposed to obesity, may have a defective
thermogenic response to meal ingestion when compared
with lean individuals (Raben et al. 1994; Napoli &
Horton, 1996; Matsumoto et al. 2001). De Jonge & Bray
(1997) concluded that DIT was lower in obesity, an out-
come demonstrated in twenty-two of twenty-nine studies
The role of the sympathetic nervous system may be
important to the results documented here (Fagius &
Berne, 1994). There is evidence for a reduced sympathetic
nervous system activity in the aetiology of obesity in ani-
mals and man (Bray, 1990; Matsumoto et al. 2001).
While all macronutrients stimulate the sympathetic nervous
system (Fagius & Berne, 1994), the type of dietary fat has
important influences as well (Young & Walgren, 1994).
Takeuchi et al. (1995) and Matsuo et al. (1995) have
demonstrated a lower sympathetic activity and low DIT,
but a higher carcass fat content in rats fed beef tallow
(saturated fat) as compared with safflower oil (unsaturated
fat). Importantly, sympathectomy abolished the differences
in body fat accumulation and DIT between the two dietary
fat groups.
M. J. Soares*, S. J. Cummings, J. C. L. Mamo, M. Kenrickand L. S. Piers1
Department of Nutrition, Dietetics and Food Science, School of Public Health, Curtin University of Technology,
Department of Human Movement and Exercise Science, University of Western Australia,
British Journal of Nutrition (2004), 91, 245–252

Influence of vagatomy and sympathectomy on thermogenesis

P. L. Andrews, N. J. Rothwell and M. J. Stock

Infusion of rats with insulin (8 U/day via implanted minipump) for 7 days caused a 22% rise in resting oxygen consumption, which was inhibited by acute injection of the beta-adrenergic antagonist propranolol. Insulin treatment produced significant increases in brown fat mass, protein content, and total thermogenic activity (assessed from binding of guanosine diphosphate to isolated brown fat mitochondria), but these responses were inhibited by prior surgical sympathectomy of the tissue. Animals subjected to subdiaphragmatic vagotomy gained more weight than pair-fed, sham-operated controls and showed reductions in total energy expenditure, the acute thermogenic response to a meal and brown adipose tissue activity. Daily injections of insulin (1 U/day) prevented all of these effects of vagotomy. These data demonstrate that the changes in brown fat activity induced by exogenous insulin are mediated by the sympathetic nervous system and that the depressed thermogenesis and brown fat activity associated with vagotomy appear to be due to a relative insulin deficiency and can be reversed by treatment with the hormone.

Am J Physiol Endocrinol Metab 249: E239-E243, 1985;

Brown adipose tissue - thermogenesis

The sympathetic nervous system (SNS) plays a critical role in the regulation of mammalian thermogenic responses to cold exposure and dietary intake. Catecholamine-stimulated thermogenesis is mediated by the beta-adrenergic receptor. In the rat brown adipose tissue is the major site of metabolic heat production in response to both cold (nonshivering thermogenesis) and diet (diet-induced thermogenesis). Measurements of norepinephrine turnover rate in interscapular brown adipose tissue of the rat demonstrate increased sympathetic activity in response to both cold exposure and overfeeding. In adult humans, a physiologically significant role for brown adipose tissue has not been established but cannot be excluded.
http://www.ncbi.nlm.nih.gov/pubmed/6380306?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=4&log$=relatedreviews&logdbfrom=pubmed
Landsberg L, Saville ME, Young JB.
Am J Physiol. 1984 Aug;247(2 Pt 1):E181-9.

sympathectomy induces a disappearance of diurnal fluctuation in the sensitivity to injected noradrenaline

In sympathectomized animals a depletion of noradrenaline from interscapular brown adipose tissue and the heart was observed. Besides, a change in adrenaline/noradrenaline ratio was found in the adrenals.
Petrović VM, Maksimović K, Davidović V.
Arch Int Physiol Biochim. 1980 Aug;88(3):273-6.
http://www.ncbi.nlm.nih.gov/pubmed/6159854

Surgical aspects of chronic post-thoracotomy pain

Chronic post-thoracotomy pain is a continuous dysaesthetic burning and aching in the general area of the incision that persists at least 2 months after thoracotomy. It occurs in approximately 50% of patients after thoracotomy and is usually mild or moderate. However, in 5% the pain is severe and disabling. No one technique of thoracotomy has been shown to reduce the incidence of chronic postthoracotomy pain. The most likely cause is intercostal nerve damage, although the precise mechanism for this is not known. Future work needs to examine surgical technique in detail. Until then, patients need to be adequately warned of this sequela of thoracotomy.
Mark L. Rogers, John P. Duffy

Department of Cardiothoracic Surgery, Nottingham City Hospital, Hucknall Road, Nottingham NG5 1PB, UK
Received 16 May 2000;

Autonomic neuropathy in the skin following sympathectomy

In diabetics with the anhidrotic syndrome, autonomic nerve fibres were studied in skin biopsies using argentic techniques and light microscopy. The Minor test was used to differentiate normal from anhidrotic skin areas. In the anhidrotic areas, histology of the nerve fibres showed beading, spindle-shaped thickening and fragmentation adjacent to the sweat glands. These changes were similar to those observed in two patients who had previously undergone lumbar sympathectomy. No abnormalities of the sympathetic nerve endings could be found in biopsies taken from normal areas of the forearm of the same patients. We conclude that the diabetic anhidrotic syndrome, a form of diabetic autonomic neuropathy, is due to a lesion of the sympathetic nerve supply to the skin.
I. Faerman¹, E. Faccio³, I. Calb², J. Razumny¹, N. Franco², A. Dominguez² and H. A. Podestá¹
Diabetologia
Volume 22, Number 2 / February, 1982

relevant to the pathogenesis of human dysautonomias

Systemic injection of monoclonal antibodies to neural acetylcholinesterase in adult rats caused a syndrome with permanent, complement-mediated destruction of presynaptic fibers in sympathetic ganglia and adrenal medulla. Ptosis, hypotension, bradycardia, and postural syncope ensued. In sympathetic ganglia, acetylcholinesterase activity disappeared from neuropil but not from nerve cell bodies. Choline acetyltransferase activity and ultrastructurally defined synapses were also lost. Electrical stimulation of presynaptic fibers to the superior cervical ganglion ceased to evoke end-organ responses.
This model of selective cholinergic autoimmunity represents another tool for autonomic physiology and may be relevant to the pathogenesis of human dysautonomias.
S Brimijoin and V A Lennon

Department of Pharmacology, Mayo Clinic, Rochester, MN 55905.

Proc Natl Acad Sci U S A. 1990 December; 87(24): 9630–9634.

James-Lang Theory of Emotion

We have experiences, and as a result, our autonomic nervous system creates physiological events such as muscular tension, heart rate increases, perspiration, dryness of the mouth, etc. This theory proposes that emotions happen as a result of these, rather than being the cause of them.

The sequence thus is as follows:

Event ==> arousal ==> interpretation ==> emotion

The bodily sensation prepares us for action, as in the Fight-or-Flight reaction. Emotions grab our attention and at least attenuate slower cognitive processing.

http://changingminds.org/explanations/theories/james_lange_emotion.htm

DURATION OF VASODILATATION AFTER LUMBAR SYMPATHECTOMY

A. Mcpherson M.B. Lpool, M.R.C.P, LAMING EVANS RESEARCH FELLOW, and A. W. L. Kessel M.B.E., M.C., F.R.C.S, CLINICAL RESEARCH ASSISTANT, INSTITUTE OF ORTHOPÆDICS, LONDON

ROYAL COLLEGE OF SURGEONS OF ENGLAND., United Kingdom

Copyright © 1956 Published by Elsevier Science Ltd.
Available online 5 September 2003.

STERILITY AND PSYCHONEUROSES FOLLOWING LUMBAR SYMPATHECTOMY

ArthurF. Hurst M.D. Oxon., F.R.C.P. Lond., SENIOR PHYSICIAN TO GUY'S HOSPITAL

Copyright © 1935 Published by Elsevier Science Ltd.
Available online 22 September 2003.

LACK OF RETURN OF VASCULAR TONE IN THE FEET AFTER SYMPATHECTOMY

R. B. Lynn M.D. Queen's Univ., Ont., F.R.C.S., F.R.C.S.E., ASSISTANT LECTURER IN SURGERY and Peter Martin V.R.D., M.Chir. Camb., F.R.C.S.E., ASSISTANT SURGEON AND LECTURER IN SURGERY POSTGRADUATE MEDICAL SCHOOL OF LONDON

Copyright © 1950 Published by Elsevier Science Ltd.
Available online 20 September 2003.

Postsympathectomy pain and changes in sensory neuropeptides

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.
Schon F.
Lancet. 1985 Nov 23;2(8465):1158-60.

Pain after sympathectomy

Surgical sympathectomies and chemical sympatholyses bring about a true sympathetic deafferentation. This leads to central retrograde degenerescence reactions of the pre-ganglionic neurons, to a reduction of the muscular tone and to a secondary neurovascular disorder at the edge of the sympathetic denervation zone.
Farcot JM, Grasser C, Muller JF.
Clinique de la Toussaint, Strasbourg.
Agressologie. 1990 Apr;31(4):191-7.

M.D.s Knock Surgery for Hyperhidrosis & Huge Insurance Scam includes ETS

(March 2005) The Canadian news magazine "Macleans" reaches nearly 3 million readers every week. In early March, this publication ran a story about the risks of severe compensatory sweating after endoscopic thoracic sympathectomy (ETS) surgery for the treatment of hyperhidrosis. The story's headline read, "Doctors knock controversial sweating treatment; Surgical procedure leaves many people dripping wet on other parts of the body." (Editor's note: As of July 2007, this article was no longer available free online. You may, however, purchase the March 2005 edition of Macleans by visiting
this link.)
According to the article, the most common problem following ETS is increased and profuse sweating on other parts of the body, most often the back, legs, groin, and abdomen. This compensatory sweating, reports Macleans, can be mild to severe and occurs in 80 to 90 percent of patients. In one study of people who had surgery for excessive underarm sweating, 90 percent of the patients reported compensatory sweating and half of them were forced to change their clothes during the day because of it.

In related news, major news outlets (including "The New York Times") have reported this week on a massive insurance scam in the US in which thousands of patients from 40 states had been transported to California to undergo unnecessary surgical and diagnostic procedures. Insurers and employers have lost US $350 million in claims paid to date due to the illegal operations.

As part of the scheme, patients traveled to outpatient surgery clinics in California to receive three or more procedures in a single week. Among the procedures unnecessarily performed on these patients, according to The New York Times, was "...a highly unusual procedure to treat 'sweaty palms.'" The paper quoted an expert who said this particular surgery "posed potential risks to the patient because it involved collapsing the patient's lungs and deactiviating a nerve near the spine."

In return for undergoing unnecessary colonoscopies, endoscopies, and surgeries for "sweaty palms", participating patients were paid anywhere from $200 to $2,000 each and may have received discounts on cosmetic surgery.
http://www.sweatsolutions.org/sweatsolutions/Article.asp?ArticleCode=19570137&EditionCode=95129982

Cervical sympathectomy affects gonadotropin-releasing hormone, luteinizing hormone and testosterone in male rats

	Journal of Anesthesia
Publisher	Springer Japan
ISSN	0913-8668 (Print) 1438-8359 (Online)
Issue	Volume 9, Number 2 / June, 1995

Hiroshi Iwama¹ , Choichiro Tase¹, Yoshikazu Tonosaki² and Yasuo Sugiura²

(1)	Department of Anesthesiology, Fukushima Medical College, 1 Hikarigaoka, 960-12 Fukushima, Japan

(2)	Department of Anatomy, Fukushima Medical College, 1 Hikarigaoka, 960-12 Fukushima, Japan

Received: 24 August 1994 Accepted: 16 December 1994

http://www.springerlink.com/content/t2v222700m284612/

a defect at the adrenoceptor level in patients with sympathectomy

Intradermal injection of 0.5 ug histamine produced equal skin reactions in normal individuals and in diabetic patients with or without evidence of autonomic neuropathy as well as in patients after lumbar sympathectomy. Addition of noradrenaline (0.1 µg) resulted in a significantly smaller skin reaction (mean ± SEM) in normals and in diabetic patients without autonomic neuropathy, but remained unchanged in diabetic patients with autonomic neuropathy and after lumbar sympathectomy when compared with the reaction to histamine alone. Addition of terbutaline produced similar results as observed with noradrenaline. These findings suggest a defect at the adrenoceptor level in diabetic patients with autonomic neuropathy and in patients with lumbar sympathectomy. Thus, the combined intradermal injection of histamine and the adrenoceptor agonists noradrenaline or terbutaline represents a simple and useful test for identifying patients with impaired adrenergic function.

A Skin Test for Autonomic Neuropathy
A. Hoffmann, D. Conen, U. Leibundgut, W. Berger

Copyright © 1982 S. Karger AG, BaselMedizinische Universitäts-Poliklinik, Departement für Innere Medizin, Kantonsspital, Basel, Schweiz

Eur Neurol 1982;21:29-33
http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowAbstract&ArtikelNr=115450&Ausgabe=234380&ProduktNr=223840

The global recurrence rate was 8.8%

The global recurrence rate was 8.8%: 6.6% for palmar hyperhidrosis and 65% for axillary hyperhidrosis. Compensatory sweating was observed in 86.4% of the patients.

Dominique Gossot, MD^a*, Domenico Galetta, MD^a, Antoine Pascal, MD^a, Denis Debrosse, MD^a, Raffaele Caliandro, MD^a, Philippe Girard, MD^a, Jean-Baptiste Stern, MD^a, Dominique Grunenwald, MDa

Thoracic Department, Institut Mutualiste Montsouris, Paris, France

Ann Thorac Surg 2003;75:1075-1079

symptoms subsequently deteriorated

We describe a patient who underwent upper thoracic sympathectomy for palmar hyperhidrosis, and whose symptoms subsequently deteriorated, becoming worse than those on initial presentation.

---

Recurrence of hyperhidrosis after endoscopic transthoracic sympathectomy—case report and review of the literature

C.H. ORTEU ¹ , J.M. MCGREGOR ¹ , J.R. ALMEYDA ¹ M.H.A. RUSTIN ¹

¹ Dermatology Departments, The Royal Free Hospital, Pond Street, London NW3 2QG and The North Middlesex Hospital, London N18 1QX, UK

Copyright 1995 Blackwell Science Ltd

Accepted for publication 6 January 1995

The results of endoscopic sympathectomy deteriorate progressively from the immediate outcome

Intermediate-term results of endoscopic transaxillary T2 sympathectomy for primary palmar hyperhidrosis
The results of endoscopic sympathectomy deteriorate progressively from the immediate outcome.
Dr T. S.-M. Chiou ^{1 *}, S.-C. Chen ²¹Department of Neurosurgery, Chung Shan Medical and Dental College Hospital, 23, Section 1, Taichung Kang Road, Taichung, Taiwan, Republic of China
British journal of surgery
ISSN 0007-1323 CODEN BJSUAM

1999, vol. 86, n^o1, pp. 45-47 (12 ref.)

ROLE OF THE SYMPATHETIC NERVOUS SYSTEM IN THE ONSET OF HYPERTENSION IN THE RAT: THE EFFECT OF 6-OH-DOPAMINE

The magnitude of the blood pressure rise on ACTH was greater in 6-OHDA-treated rats than in intact control rats. Metabolic changes were similar.

Ming Li 1 Judith A. Whitworth 1 , 2
1 Department of Nephrology, Royal Melbourne Hospital and Howard Florey Institute of Experimental Physiology and Medicine, University of Melbourne, Victoria, Australia
Correspondence to 2 Professor J. A. Whitworth, School of Medicine, St George's Hospital, Kogarah, NSW 2217, Australia.
Clinical and Experimental Pharmacology and Physiology
Volume 18 Issue 4, Pages 197 - 204
Published Online: 28 Jun 2007
12 October 1990 7 December 1990

ETS for severe cases of LQT

Left cervical sympathectomy:

Selective left cervical sympathectomy
may be considered for:
1. Those with severe disease and in
whom beta blockers are contra-
indicated or AICD cannot be placed or
is not wanted. 2. Controlling VT
storms in those with an AICD, 3.
LQT3 or a personal or family history
of events during rest or sleep.


From the publication by the Cardiac Society of Australia and New Zealand,
Volume XVIII, No. 1, March 2006
This document represents the views of the Cardiac Society of Australia and New Zealand. The guidelines were approved by the Council of the CSANZ on 25th November, 2005.