Endoscopic Thoracic Sympathectomy

PROCEDURE OF THE DAY

Endoscopic Thoracic Sympathectomy

Endoscopic thoracic sympathectomy (ETS) is a surgical procedure where certain portions of the sympathetic nerve trunk are destroyed. ETS is used to treat hyperhidrosis, facial blushing, Raynaud's disease and Reflex Sympathetic Dystrophy. By far the most common complaint treated with ETS is palmar hyperhidrosis, or "sweaty palms". In this disorder, the palms may constantly shed so much sweat that the affected person is unable to handle paper, sign documents, keep clothes dry, or shake hands. The result is often social phobia so severe as to be disabling.

Sympathectomy refers to the 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 vertebrae.


History

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

The first sympathectomy was performed by Alexander in 1889.[citation needed] Since the sympathetic nervous system was well known to affect many body systems, the surgery was performed in attempts to treat many conditions, including idiocy, goitre, epilepsy, glaucoma, and angina pectoris. Thoracic sympathectomy has been indicated for hyperhidrosis (excessive sweating) since 1920, when Kotzareff showed it would cause anhidrosis (total inability to sweat) from the nipple line upwards.[1][not in citation given]

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

Sympathectomy itself is relatively easy to perform; however, accessing the nerve tissue in the chest cavity by conventional surgical methods was difficult, painful, and spawned several different approaches. The posterior approach was developed in 1908, and required resection (sawing off) of ribs.[citation needed] A supraclavical (above the collar-bone) approach was developed in 1935, which was less painful than the posterior, but was more prone to damaging important nerves and blood vessels.[citation needed]

Because of these difficulties, and because of disabling sequelae associated with sympathetic denervation, conventional or "open" sympathectomy was never a very popular procedure, although it continued to be practiced for hyperhidrosis, Raynaud's disease, and various psychiatric disorders. With the popularization of lobotomy in the 1940s, sympathectomy fell out of favor as a form of psychosurgery.

The endoscopic version of thoracic sympathectomy was pioneered by Goren Claes and Christer Drott in Sweden in the late 1980s. The development of endoscopic "minimally invasive" surgical techniques have 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. This minimally invasive approach has its own dangers. During the surgery carbon-dioxide insufflation allows the collapse of the lung and access to the sympathetic chain. The use of carbon-dioxide has been associated with cardiovascular collapse.[2] Left, but not right, one-lung ventilation causes hypoxemia during endoscopic transthoracic sympathectomy,[3] and can have significant adverse effects on cardiopulmonary physiology,[4] and cause reduced perioperative arterial oxygen saturation.[5]

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 achieve cerebral revascularization for patients with moyamoya disease [6] to treat headaches, - although there are reports of headache after cervical sympathectomy[7][8] - hyperactive bronchial tubes,[9] Long QT syndrome[10][11][12] Arrythmias and other symptathetic disorders. The surgery also has a Beta blocker effect on the heart,[1][2] and can suppress baroreflex control of the heart rate in patients with essential hyperhidrosis.[3]

From Dr Lin's website: A certain percentage of Angina, Reflex sympathetic dystrophy and pain, Raynaud’s syndrome, Asthma, Schizophrenia, Social phobia, Rhinitis, Migraine, Tremor disorders, Parkinsonism … can be treated by sympathetic surgery.

Dr Lin also treats addiction and alcoholism with this procedure.[13]

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 and their work led to the procedure being banned. The two surgeons who pioneered the technique, Drott and Claes, moved their practice from Sweden. They still perform the surgery.

Overview

Sympathectomy involves division of adrenergic, cholinergic and sensory fibers which elaborate adrenergic substances during the process of regulating visceral function.[14] It involves dissection of the main Sympathetic trunk in the upper thoracic region of the sympathetic nervous system, thus interrupting neural messages that ordinarily would travel to many different organs, glands and muscles. It is via these nerves of the autonomic nervous system that the brain is able to make adjustments in the body in response to changing conditions in the environment, changing emotional states, level of exercise, and other factors to maintain the body's homeostasis.

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

Sympathectomy is accomplished by dissecting the nerve tissue of the main sympathetic chain. The clamping method, also referred to as ESB (Endoscopic Sympathetic Blockade) employs titanium clamps around the nerve tissue, and was developed in an attempt to make the procedure reversible. However, reversal of the clamping procedure has a short time window (a few days or weeks at most) and may be incomplete. There has been no independent study done into the reversibility of the procedure and many doctors maintain that the clamping method causes the same damage to the nerve, as the nerve tissue dies under the clamps within 24 hours, making it as irreversible as the cutting method.

It has been proposed that ETS can alter many bodily functions, including vascular responses [15] sweating,[1] heart rate,[16][17] heart stroke volume, [18][19] thyroid, baroreflex,[20]lung volume,[21][19] pupil dilation, skin temperature, goose bumps and other aspects of the autonomic nervous system, like the fight-or-flight response. It has been proposed, that it can also diminish the body's physical reaction to exercise [22][1][19] and possibly reactions to strong emotion by reducing sympathetic input to the heart (and thus is considered psychiatric surgery). In rare cases sexual function or digestion may be modified as well. [4][23][unreliable source?]

Some patients have required an artificial pacemaker after developing bradycardia as a side effect of the surgery.[24][25][26]

Results

The most common indication for ETS surgery is hyperhidrosis, or excessive sweating. However, the only empirical study on sweat before and after ETS demonstrated that the procedure increases total body sweating. [27]

Swedish National Board of Health and Welfare statement on treatment results says (English translation here, the original Swedish text here): "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. It is interesting to note, that there has been no independent study into the effectiveness of safety of the ETS procedure. The systematic reviews that have been done only included articles published by the surgeons who perform the surgery, although a large number of articles has been published in the medical journals that investigate different effects and the changes following sympathectomy.

A news release published by John Wiley & Sons on the 5th of February 2004: "Lifestyle' Surgical Procedure Carries Unrecognized Risk of Complications".[5]

Sympathectomy works by disabling part of the autonomic nervous system, by surgically destroying it, and disrupting the signals to the brain. Many non-ETS doctors find this to be disturbing, as symptoms of the ANS dysfunction go further than the disabled thermoregulation. Sympathectomy prevents the occurrence of a variety of bodily changes, and hence, prevents sensory feedback of those changes (see Cervero & Sharkley, 1985).[28]

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. The autonomic nervous system is not anatomically exact and connections might exist with different parts of the body. This theory has been proven by the fact that a significant number of patients who have had sympathectomy for hand sweating might notice a reduction or elimination of feet sweating.

Studies by ETS surgeons have claimed an initial satisfaction rate around 85-95% with at least 2%-19% regretting the surgery and up to 51% of the patients complaining about decreased quality of life.[29][30][31][32] One study shows a satisfaction rate as low as 28.6.[33] Most patients report various adverse reactions as a result of the surgery. However, ETS surgeon Samuel S. Ahn of UCLA claims "100% success with no negative side effects". [34]

A large study of psychiatric patients treated with this surgery showed significant reductions in fear,alertness and arousal. (Teleranta, Pohjavaara, et al 2003, 2004). Arousal is essential to consciousness, in regulating attention and information processing, memory and emotion. [35] This study also proves what many patients have claimed, that the surgery caused psychological changes. You can not reduce 'bad' emotional responses, like fear or anxiety. If you reduce emotional responses, they will affect the whole range of emotions and their intensity. With the elimination of the heart rate variability, emotions are also 'capped'.[36] visceral and autonomic functions and were the key to understanding emotional processes. Paul D. MacLean believed that emotional experience could be most accurately described as a response to the composite of stimuli the brain receives from the external environment, as a result of ongoing perceptions of the outside world, and internal sensations or feedback transmitted to the brain from bodily organs and systems.

Galen, James..., [and] Cannon...are all saved; visceral [bodily] processes are the basis of emotion; and an identifiable part of the brain is responsible for emotional control and experience because of its selective relations with viscera...The path from the “emotions in the vascular system” to “emotions in the forebrain” had finally been completed, and each step along the way freed us from preconceptions popularly current when the step was taken.(Pribram KH. Emotions: A neurobehavioral analysis, p. 16)

ETS patients are being studied using the autonomic failure protocol headed by David Goldstein, M.D. Ph.D., senior investigator at the U.S National Institute of Neurological Disorders and Stroke. He has documented loss of thermoregulatory function, cardiac denervation, and loss of vasoconstriction.[37] Recurrence of the original symptoms due to nerve regeneration or nerve sprouting can occur within the first year post surgery, but regeneration can start years after sympathectomy. Nerve sprouting, or abnormal nerve growth after damage or injury to the nerves can cause other further damage. Sprouting sympathtetic nerves can form connections with sensory nerves, and lead to pain conditions that are mediated by the SNS. Every time the system is activated, it is translated into pain. This sprouting and it's action can lead to Frey's syndrome, a well recognized after effect of sympathectomy, when the growing sympathetic nerves innervate salivary glands. This leads to excessive sweating when eating. For patients different tastes can trigger this abnormal facial sweating (curiously this happens in the area where people who have undergone this procedure can not sweat any more normally). For some it only occurs with hot food, for others, with hot, sour - even by eating an apple, or sweet. Smelling can also cause abnormal reactions, as the signals get mixed up. Nerve regeneration and subsequent abnormal synapses is a well-documented phenomena.

Risks and controversy

Bleeding during and following the operation may be significant in up to 5% of patients.[38] Pneumothorax (collapsed lung) can occur (2% of patients).[38] Compensatory hyperhidrosis (sweating) is common over the long term, causing 1-2 percent of patients in one review to regret having had the surgery.[38]

A systematic review of the literature by Andrea D. Furlan, Angela Mailis, and Marios Papagapiou concluded: In these studies, 26.3% of patients with compensatory hyperhidrosis considered the complication major and disabling.[6]

The Finnish Office for Health Care Technology Assessment concluded in a 40 page systematic review that Endoscopic Thoracic Sympathectomy is associated with significant immediate and long-term adverse effects.[39]

Quoting the aforementioned (see Results) Swedish National Board of Health and Welfare statement: "The method can give permanent side effects that in some cases first will become obvious after some time. One of the side effects might be increased perspiration on different places on your body. Why and how this happens is still unknown. According to the research available about 25-75% of all patients can expect more or less serious perspiration on different places on their body, such as the trunk and groin area, this is Compensatory sweating. However, it is also mentioned in the research that 0-10% regrets having the surgery done for this reason. Other documented side effects are the inability to raise the heart rate when working out physically. This has in some cases led to decreased ability to perform your work and daily activities. Some patients also complained of not being able to control their body temperature and it is experienced from being very uncomfortable to disabling. However description of a changing sweating pattern does not give a comprehensive picture of the permanently disabled thermoregulation. Consequences of this go far beyond some discomfort wearing damp, in some cases dripping clothes and showing up in public.

A reduced efficiency in maintaining normal body temperature in warm environments is consistent with the reduced ability or complete inability to sweat above the nipple line, a common ETS outcome first shown by Dr. Kotzareff. For a fully clothed person, only the hands, cranial region and neck are typically exposed. In a hot environment, a normal person's body is cooled primarily by evaporation of water vapor through the warmest areas of exposed skin. These areas are associated with the head and neck, which under very warm circumstances or vigorous exercise, visibly show moisture (sweat) accumulating as part of the cooling process. For an ETS patient that has lost ability to sweat from cranium, neck, and arms, an increased amount of body heat must be rejected via transpiration/sweating involving skin of the lower body. Unfortunately, this skin is generally at a lower temperature and usually covered by clothing - both factors that reduce the cooling efficiency and result in poor thermoregulation. An uncomfortably warm sensation and accumulation of sweat on large areas of skin underneath clothing can result. This is one theory on the aetiology of the increased sweating phenomenon after sympathectomy. However one of the pioneers of the procedure, Dr Lin, who performed over 7000 procedures, disputes the compensatory nature of the so called Compensatory Sweating. According to him this is a result of the dysregulated thermoregulation and hypothalamus. He objects to using the "Compensatory" term, he sees as misleading. Postoperative sweating phenomenon is a reflex response between sympathetic system and Hypothalamus. "It is absolutely not a compensatory mechanism. The term of “Reflex sweating” instead of compensatory sweating is used. Hypothalamus is the center of Autonomic Nervous System, which influences human mind, mentality and endocrine system. For this sake, Dr. Lin emphasized, “Endoscopic Sympathetic Surgery helps us open a gate to Autonomic Nervous System”.

There is much disagreement among ETS surgeons about the best surgical method, optimal location for nerve dissection, and as to the nature and extent of the consequent primary effects and side effects. The internet now features many websites run by surgeons extolling the benefits of ETS backed by patient testimonials. However, there are also many websites run by disabled ETS victims who complain of severe adverse reactions and lack of adequate informed consent. Several online discussion forums are dedicated to the subject of ETS surgery, where both positive and negative patient testimonials abound, but considering that this is an elective surgery for a benign condition, even a small number of badly affected number of patients is a high number.

In 2003, ETS was banned in its birthplace, Sweden, due to overwhelming complaints by disabled patients. In 2004, Taiwanese health authorities banned the procedure on patients under 20 years of age. In other countries it is highly unregulated procedure. Although it was never evaluated for safety and adverse effects, sympathectomy is listed on Medical Benefits Scheme, and is freely available to public patients.

In 2006, the FinOHTA group, the Finnish Office for Health Technology Assessment, showed in a review that there were strong indications of side effects as a result of this surgery.[40]

• No systematic reviews, meta-analyses, or clinical trials that evaluated the effectiveness of endoscopic thoracic sympathectomy for treating facial blushing were identified. However, we have identified four case series related to the request (Drott et al. 1998, Rex et al. 1998, Telaranta 1998, Yilmaz et al. 1996). These studies were conducted in three countries (Sweden, Finland and the Netherlands).

• 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. (Omar Ahmed PhD Centre for Clinical Effectiveness Monash Medical Centre Australia)

Other long term adverse effects: Ultrastructural Changes in the Cerebral Artery Wall Induced by Long-Term Sympathetic Denervation[26] Sympathectomy eliminates the psychogalvanic reflex[41] Cervical sympathectomy reduces the heterogeneity of oxygen saturation in small cerebrocortical veins[42] Sympathetic denervation is one of the causes of Mönckeberg's sclerosis[43] T2-3 sympathectomy suppressed baroreflex control of heart rate in the patients with palmar hyperhidrosis. We should note that baroreflex response for maintaining cardiovascular stability is suppressed in the patients who received the ETS.[20] ETS patients should be warned that these mechanisms may play a role in the development of exertional heat stroke.[1] Morphofunctional changes in the myocardium following sympathectomy.[44]

In none of the limbs studied after sympathectomy could an increase in blood flow be produced reflexly by warming; in the majority of instances the opposite response, a decrease in blood flow was observed. One patient with documented transection of the spinal cord above T5 behaved like subjects after surgical sympathectomy.[15] Retarded adaptation of hemodynamics to a sudden start of exercise after sympathectomy. The significant fall in left circumflex coronary flow was proportional to the decline in external heart work due to sympathectomy both at rest and under exercise.[22] Chemical sympathectomy is associated with increased pulmonary metastases.[45]

Popular culture

In the movie Sublime the character George Grieves (played by Tom Cavanagh) accidentally undergoes the procedure. The American TV show "Grey's Anatomy" featured ETS surgery for facial blushing in an episode titled "Make Me Lose Control". [46] In 'House' - Episode 3, Season 5 - A cardiac sympathectomy (a surgery that reduces the effect of the sympathetic nervous system on the heart) is ordered. The patient is told that the drawback might be that he actually will not FEEL it when he is having a heart attack.




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