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REFINED REVERSAL SURGERY OF ETS
updated 1.9.2008

Timo Telaranta, MD, PhD, Ass. Prof. of Clinical Surgery, Rome, Italy

Introduction

Endoscopic Thoracic Sympathectomy (ETS) has been a widespread surgery for handsweating and facial blushing all over the world. There are, however, some side effects even in the normal train of the surgery. The lower body sweating, so called Compensatory Sweating (CS) or Reflex Sweating (RS) is known to happen in some degree to nearly everyone (1). More recently, as the volume of the operated persons grow, there have also been occasional cases of fatigue, and other nonspecific dystonia-like symptoms. When the side effects surprise the patient, she may demand the reversal of the surgery due to the regrets of the side effects. To better cope with this demand, I have developed and further refined an endoscopic method, with the aim to 1. Remove the scar tissue from around the destroyed nerves and ganglia 2. Restore the continuity of the sympathetic chain with a living vascularized intercostal nerve graft (ICNG), and 3. Add CS-inhibition with an intercostal nerve transposition (ICNT) to T1.

METHODS

Surgical procedure

Since most of the original surgeries are performed with electrocautery, there usually is scarring and adhesions between the lung and the chest wall, present in three of four patients. These have to be removed with either electrocautery or harmonic scalpel, depending on the amount of the scar, plenty of scar calling for the harmonic scalpel.

The lowest sympathetic ganglia viable as recipients for donor nerve are then evaluated, usually beginning from the right side due to the difference in cardiac sympathetic effects. The ganglion is then prepared on its upper pole to a fresh nerve end. All the subsequent higher ganglia are analogously prepared for a possible multistaged grafting. Usually one other, notably the 2nd thoracal sympathetic ganglion is prepared at its upper pole for this purpose. Lastly, the stellate ganglion is identified and carefully freed from the surrounding scar tissue, and its nether pole sectioned for fresh nerve tissue.

The graft material needed is measured, and the amount needed is harvested from the second intercostal nerve. The distal end of thenerve is then transposed to T1 and glued in place with fibrin glue (Tisseel, Immuno AG). Then another graft needed to interconnect the T1 and T2 or eventually T3 is harvested as a vascularized nerve graft from the third intercostal nerve and interposed between the freshened nerve ends of the sympathetic chain.

All the endoscopies are performed with single lumen anesthesia. If there has been a dense scar tissue between the lung and the chest wall, drainage tubes may be left under suction for added security.

Patient evaluation

I have now operated on more than 250 patients, the majority of which with this new method. Thus far, only the patients with the earlier method using sural nerve grafting (n=51) have been followed up long enough to permit an analysis of their results, which are presented underneath. The patients with the new method can earliest be evaluated after one more year to get a picture of their final recovery. The first signs, however, show that the recovery is more rapid beginning already after some weeks, though even with this method the recovery continues for a long period, even years after the surgery.

Mean age at the reconstruction was 35 years (19 to 69). Mean interval between the first surgery and reconstruction was 2 years 10 months (2 months to 23 years).

The symptoms were evaluated by the patients themselves, and many also measured with a sweat meter before the surgery. The sweat meter used was a Delphin vapometer based on the evaporation chamber measurement of humidity, and then converted to the same scale 1 to 5 as all the other evaluations. In the scoring 1 to 5 the meanings of the scores are clarified in the Table 2.

Results

Table 2. shows the global results estimated by the patients themselves. The final scoring is estimated according to the measured and told changes, score 4-5 can be taken as good to excellent.

It is to be noted, that the patients themselves estimated their own compensatory (or reflex sweating) to be 4,9 before the surgery, i.e. nearly maximum unbearability, whereas objectively this could not be verified on the measurements, not in the resting level, nor in hot water swallowing stress test. There were also 9 fatigue patients, they all reported better stamina after the surgery. There were two heavily psychotic and very suicidal patients, who both recovered extraordinarily well, both mentally and physically with far better sweating pattern than before the surgery.

Despite of the difficult scarred conditions, there were only three complications, two due to bleeding, necessitating new surgery for the bleeder. One patient, who had an anomalous azygos vein lobe prolonging the duration of the surgery to 6 hours, developed a brachial plexus palsy related to the long angel position of the arms, the palsy recovered in 4 weeks time. In addition to them, there were occasional small pneumothorax cavities, necessitating secondary draining by suction. No patient deaths or infections were present. The patients tolerated well the harvesting of the donor nerve.

One patient had a heavy blow to the chest 4 months after the reconstruction. Till that time he had noticed a clear reduction of the compensatory sweating, but after the blow had it recurred. He urged to have the situation checked at a new surgery, and in it the grafts were seen very well incorporated and having some new blood vessels and every aspect in the grafts seemed viably. This was also verified photographically. Also the anastomosis lines seemed still well adapted and had no visible neuroma formation. Nothing else than a gentle external neurolysis was performed.

Discussion

The investigation has been especially difficult, since the patients are from all over the world (Table 1). Reliable sweat measurements or even estimates are incommensurable and thus a crude evaluation has had to be performed, based on the reported new areas of sweating, and the decreased areas and amounts of reflex sweating. In 20 patients it has been possible to measure the sweating pattern both pre and postoperatively, but only right after the surgery within the 2 po-days. These all have shown a clear initial drop in reflex sweating.

Only 3 Swedish patients thus far have come to the requested follow-up 2 years after the surgery, they all had practically normal sweating patterns.

Based on the discrepancy between the measured reflex sweating and the experienced reflex sweating (Table 2), it seems, that the sweating feeling is something different from sweating, but rather like imminent sweating and uncomfortable feeling all over, kind of tingling or ant crawling under the skin. The patients were not stressed with any psychological tests, but the author dares doubt that the psychological vulnerability of these patients is increased compared to general surgical population. However, to support this there only is my opinion as an experienced surgeon, who’s also trained in psychotherapy.

One resurgery proved that the grafts remain in place with just fibrin glue, and thus macroscopically the anastomosis lines remained congruent and the grafted nerves filled with normal looking tissue and having some blood vessels indicating their viability.

Conclusion

29 % benefited greatly from the procedure and 81 % had at least useful recovery with a marked relief in the reflex sweating. Only 19 % denied all benefit, but none of these claimed any worsening of the situation. Even these patients may have had some benefit, but because of the pending lawsuits and compensation requests it is understandable, that willingness to evaluate positively the end result is not at the highest level.

These results clearly demonstrate the possibility with this reconstructive surgery to increase the quality of life of the patients disappointed with the side effects of their previous ETS-surgery.

The method should be noted officially as one that merits all the insurance benefits that a corrective reconstructive surgery in any other disease indications has. The International Society for Sympathetic Surgery (ISSS) should also recognize it as an important adjuvant to the sympathetic ablations.

TABLES

Table 1. Patient information

Table 2. Results of the reconstruction surgeries

All values represent mathematical means.

Scoring in side effects 1 to 5:
1 = normal, 2 = mild side effects, 3 = uncomfortable, 4 = bad, 5 = unbearable

Acquired benefit:
1 = no improvement, 2 = some relief in CS, 3 = major relief in CS, some new sweating, 4 = practically no CS, nearly normal sweating, 5 = no CS, normal sweating pattern