Endoscopic thoracic sympathectomy (ETS) is a surgical procedure where certain portions of the sympathetic nerve trunk are burned, severed, removed or clamped. ETS is used to treat hyperhidrosis, facial blushing, social phobia, Raynaud's disease and Reflex Sympathetic Dystrophy. By far the most common complaint treated with ETS is palmar hyperhidrosis, or "sweaty palms". The sympathetic nervous system (SNS) is one half of the autonomic nervous system; the parasympathetic nervous system (PNS) is the other. ... Primary hyperhidrosis is the condition characterized by abnormally increased perspiration, in excess of that required for regulation of body temperature. ... To blush is to display a marked redness of ones face; the term is seldom applied except when the redness is construed as a result of embarrassment, shame, or modesty. ... Social anxiety, sometimes known as social phobia or social anxiety disorder (SAD), is a common form of anxiety disorder that causes sufferers to experience intense anxiety in some or all of the social interactions and public events of everyday life. ... Raynauds disease (RAY-noz) is a condition that affects blood flow to the extremities which include the fingers, toes, nose and ears when exposed to temperature changes or stress. ... Reflex Sympathetic Dystrophy Syndrome (RSD) - also known as Complex Regional Pain Syndrome (CRPS) - is a chronic neurological syndrome characterized by: * severe burning pain * pathological changes in bone and skin * excessive sweating * tissue swelling * extreme sensitivity to touch This syndrome occurs after 1 to 2 % of various fractures, after 2 to... Primary hyperhidrosis is the condition characterized by abnormally increased perspiration, in excess of that required for regulation of body temperature. ...

Sympathectomy refers to the intentional destruction of tissue anywhere in either of the two sympathetic trunks, long chains of nerve ganglia lying along either side of the spine. Each trunk is broadly divided into three regions: cervical (up by the neck), thoracic (in the chest) and lumbar (in the lower back). The most common area targeted in sympathectomy is the upper thoracic region, that part of the sympathetic chain lying between the first and fifth thoracic ribs. The sympathetic trunks (sympathetic chain, paravertebral ganglia, gangliated cord) extend from the base of the skull to the coccyx. ... This is a dorsal root ganglion (DRG) from a chicken embryo (around stage of day 7) after incubation overnight in NGF growth medium stained with anti-neurofilament antibody. ... In anatomy, cervical is an adjective that has two meanings: of or pertaining to the neck. ... Diagram of a tsetse fly, showing the head, thorax and abdomen The thorax is a division of an animals body, that lies between the head and the abdomen. ... In anatomy, lumbar is an adjective that means of or pertaining to the abdominal segment of the torso, between the diaphragm and the sacrum (pelvis). ...

History

Scientists became fascinated with the idea of sympathectomy in the mid-19th century when it was learned that the autonomic nervous system runs to almost every organ, gland and muscle system in the body, and it was surmised that somehow these nerves must play a role in how the body is able to automatically adjust levels on many different body functions in response to changes in the environment, exercise and emotion. They wondered how exactly it was that the autonomic nervous system was able to do all that, and they wondered what might change if various parts of it were cut out.

The first sympathectomy was performed by Dr. Alexander in 1889. Since the sympathetic nervous system was well known to affect many body systems, the surgery was performed in attempts to treat many conditions, including idiocy, goiter, epilepsy, glaucoma, and angina pectoris. Thoracic sympathectomy has been indicated for hyperhidrosis (excessive sweating) since 1920, when Dr. A. Kotzareff showed it would cause anhidrosis (total inability to sweat) from the nipple line upwards. 1889 (MDCCCLXXXIX) was a common year starting on Tuesday (see link for calendar). ... Grays FIG. 838– The right sympathetic chain and its connections with the thoracic, abdominal, and pelvic plexuses. ... A goitre (or goiter) (Latin struma) is a swelling in the neck (just below adams apple or larynx) due to an enlarged thyroid gland. ... Primary hyperhidrosis is the condition characterized by abnormally increased perspiration, in excess of that required for regulation of body temperature. ... 1920 (MCMXX) was a leap year starting on Thursday (link will take you to calendar) // Events January January 3 - Babe Ruth is traded by the Boston Red Sox to the New York Yankees for $125,000, the largest sum ever paid for a player at that time. ... Anhidrosis means lack of sweating. ... Typical human female nipple and areola. ...

A lumbar sympathectomy was also developed and used to treat excessive sweating of the feet and other ailments, and typically resulted in impotence in men. Impotence or, more clinically, erectile dysfunction is the inability to develop or maintain an erection of the penis for satisfactory sexual intercourse regardless of the capability of ejaculation. ...

Sympathectomy itself is relatively easy to perform; however, accessing the nerve tissue in the chest cavity by conventional surgical methods was difficult, painful, and spawned several different approaches. The posterior approach was developed by Dr. A.W. Adson in 1908, and required resection (sawing off) of ribs. Sales of the procedure were slow. Dr. E.D. Telford came up with a supraclavical (above the collar-bone) approach in 1935, which was less painful than the posterior, but was more prone to damaging important nerves and blood vessels, also not a good selling point. The English word POSTERIOR is identical to the original Latin adjective, and has two different uses : as an ADJECTIVE, it indicates that someone or something is behind another, either spatially or chronologically it also became a SUBSTANTIVE, indicating the rear-end, especially of a person, i. ... 1908 (MCMVIII) was a leap year starting on Wednesday (link will take you to calendar). ... Resection is a method of orientation (direction or position finding) using a compass and topographic map. ... 1935 (MCMXXXV) was a common year starting on Tuesday (link will take you to calendar). ... A nerve is an enclosed, cable-like bundle of nerve fibers or axons, which includes the glia that ensheath the axons in myelin. ... The blood vessels are part of the circulatory system and function to transport blood throughout the body. ...

Because of these difficulties, and because of disabling sequelae associated with sympathetic denervation, conventional or "open" sympathectomy was never a very popular procedure, although it continued to be practiced for hyperhidrosis, Raynaud's disease, and various psychiatric disorders. With the popularization of lobotomy in the 1940s, sympathectomy fell out of favor as psychosurgery. A sequela (plural sequelae) is a pathological condition resulting from a disease. ... Raynauds disease (RAY-noz) is a condition that affects blood flow to the extremities which include the fingers, toes, nose and ears when exposed to temperature changes or stress. ... A human brain that had undergone lobotomy. ... // Events and trends World War II was a truly global conflict with many facets: immense human suffering, fierce indoctrination, and the use of new, extremely devastating weapons such as the atomic bomb. ... Psychosurgery is a term for surgeries of the brain involving procedures that modulate the performance of the brain, and thus effect changes in cognition, with the intent to treat or alleviate severe mental illness. ...

The endoscopic version of thoracic sympathectomy was pioneered by Drs. Goren Claes and Christer Drott at the Boras hospital in Sweden in the late 1980s. The development of endoscopic "minimally invasive" surgical techniques have made possible the mass-marketing of sympathectomy, and today ETS surgery is practiced in many countries throughout the industrial world. The total number of ETS surgeries performed worldwide to date numbers well over 100,000. The examples and perspective in this article or section may not represent a worldwide view. ... Endoscopy means looking inside and refers to looking inside the human body for medical reasons. ...

In addition to hyperhidrosis and Raynaud's, the indications for ETS have expanded to include facial blushing, and, once again, psychiatric disorders such as social phobia and agoraphobia. There are reports of ETS being used to treat headaches and hyperactive bronchial tubes. To blush is to display a marked redness of ones face; the term is seldom applied except when the redness is construed as a result of embarrassment, shame, or modesty. ... Social anxiety, sometimes known as social phobia or social anxiety disorder (SAD), is a common form of anxiety disorder that causes sufferers to experience intense anxiety in some or all of the social interactions and public events of everyday life. ... Agoraphobia is a form of anxiety disorder. ...

In the mid 1990s a group of Swedish ETS patients complaining of disabling side effects formed the organization FFSO (people disabled by sympathectomy). The group grew to over 300 members. See also 1990s, the band The 1990s decade refers to the years from 1990 to 1999, inclusive, sometimes informally including popular culture from the late 1980s and shortly after the year 2000. ...

Overview

ETS surgery works by destroying healthy nerve tissue in the upper thoracic region of the sympathetic nervous system, thus interrupting brain messages that ordinarily would travel to many different organs, glands and muscles. It is via these nerves of the autonomic nervous system that the brain is able to make adjustments in the body in response to changing conditions in the environment, changing emotional states, level of exercise, and other factors. Nerves (yellow) Nerves redirects here. ...

The surgeon penetrates the chest cavity, making holes about the diameter of a soda straw between ribs. This allows the surgeon to insert a tiny video camera in one hole and a surgical instrument in another.

Sympathectomy is accomplished by burning, cutting, or clamping the nerve tissue. The clamping method, aka ESB (endoscopic sympathetic blockade) employs titanium clamps around the nerve tissue, and was developed in an attempt to make the procedure reversible. However, reversal of the clamping procedure has a short time window (a few days or weeks at most) and may be incomplete.

ETS can alter many bodily functions, including sweating, heart rate, heart stroke volume, blood pressure, thyroid, baroreflex, lung volume, pupil dilation, skin temperature, goose bumps and other aspects of the autonomic nervous system. It can diminish the body's physical reaction to exercise and/or strong emotion, and thus is considered psychiatric surgery. In rare cases sexual function or digestion may be modified as well. Sweating (also called perspiration or sometimes transpiration) is the loss of a watery fluid, consisting mainly of sodium chloride (commonly known as salt) and urea in solution, that is secreted by the sweat glands in the skin of mammals. ... Heart rate is a term used to describe the frequency of the cardiac cycle. ... In cardiovascular physiology, stroke volume (SV) is the amount of blood pumped by the left ventricle into the aorta. ... A sphygmomanometer, a device used for measuring blood pressure. ... Special nerve cells called baroreceptors are located in the wall of the heart auricles, vena cava, aortic arch and carotid sinuses, and are specialized to monitor changes in blood pressure. ... The average pair of human lungs can hold about 6 litres of air, but only a small amount is used during normal breathing. ... Goose bumps on a human Goose bumps (AE), also called goose pimples, goose flesh (BE), chicken skin (Hawaiian Pidgin), or cutis anserina, are the bumps on a persons skin at the base of body hairs which involuntarily develop when a person is cold or experiences strong emotions like fear. ... This article or section is in need of attention from an expert on the subject. ... Please wikify (format) this article as suggested in the Guide to layout and the Manual of Style. ...

Results

Swedish National Board of Health and Welfare statement on treatment results says (english translation is available at: [1], the original Swedish text can be found at [2]): "A large amount of international studies shows that an incision on the sympatikotomi nerve gives a very positive result when it come to hand perspiration and also that the side effects are rare.". Critics have raised serious questions about the methodology of such studies.

Exact results of ETS are impossible to predict, because of considerable anatomic variations in sympathetic nerve function from one patient to the next, and also because of variations in surgical technique.

Studies by ETS surgeons have claimed a satisfaction rate around 85-95% with at least 2% regretting the surgery [3] [4] [5]. One surgeon study shows a satisfaction rate as low as 28.6 [6]. Most patients report various complications as a result of the surgery.

A large study of psychiatric patients treated with this surgery showed significant reductions in fear and alertness, among other emotional changes (Teleranta, Pohjavaara, et al 2003, 2004). [7] Fear is a basic emotional sensation and response system (feeling) initiated by an aversion to some perceived risk or threat. ...

ETS patients are studied in the autonomic failure protocol headed by David Goldstein, M.D. Ph.D., senior investigator at the U.S National Institute of Neurological Disorders and Stroke. He has documented loss of thermoregulatory function, cardiac denervation, and loss of vasoconstriction The blood vessels are part of the circulatory system and function to transport blood throughout the body. ...

Risks and controversy

Quoting the above-mentioned Swedish National Board of Health and Welfare statement: "The method can give permanent side effects that in some cases first will become obvious after some time. One of the side effects might be increased perspiration on different places on your body. Why and how this happens is still unknown. According to the research available about 25-75% of all patients can expect more or less serious perspiration on different places on their body, However, it is also mentioned in the research that 0-10% regrets having the surgery done for this reason. Other documented side effects are the inability to raise the heart rate when working out physically. This has in some cases led to decreased ability to perform your work and daily activities. Some patients also complained of not being able to control their body temperature and it is experienced as very uncomfortable.".

There is much disagreement among ETS surgeons about the best surgical method, opitimal location for nerve destruction, and as to the nature and extent of the consequent primary effects and side effects. The internet now features many websites run by surgeons extolling the benefits of ETS backed by happy patient testimonials. However, there are also many websites run by disabled ETS victims who complain of severe complications and lack of adequate informed consent. Several online discussion forums are dedicated to the subject of ETS surgery, where both positive and negative patient testimonials abound.

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

In 2006, the FinOHTA group, the Finnish Office for Health Technology Assesment, showed in a review that there were strong indications of side effects as a result of this surgery - http://finohta.stakes.fi/EN/publications/reports/index.htm

External links

• [8] Total number of ETS surgeries performed worldwide
• [9] Social phobia world hyperhidrosis forum
• ESFB Channel - Discussion about excessive sweating, facial blushing, rosacea and social phobia
• Truth About ETS - ETS education, editorials, and testimonials. Extensive documentation of sympathectomy side effects.
• ETS & Reversals - Discussion about ETS, the side effects, the surgeons, and the ongoing search for a working reversal
• FfSo - People disabled by sympathectomies
• P.A.S.S. - Patients Against Sympathetic Surgery
• Presentations at the 4th International Symposium on Sympathetic Surgery
• [10] - Treatment and cure for excessive sweating