Psychiatrist treating patients with cardiac problems ?

"The guidelines for the block in individual cases:
Sweating of the underarms and hands - T4 or T5
Sweating of the face and blushing - T3 or T4
Blushing of the face alone - T2
Social anxiety with blushing - T2
Social anxiety without FB - T3 and T4 on the left side only
Heart racing and rhythm disorders - T3, T4, and T5 on the left side only "

Telaranta also claims that  after clamping/crushing the nerve  and subsequent removal of the titanium clips, the sympathetic chain will regain full function. Sadly, this is an unproven and unsubstantiated claim.

He also claims that his procedure is "more gentle". Nerve injury - no matter how acquired - remains a nerve injury with it's complications.  
http://www.privatix.fi/index.shtml?&a=0&s=navig_03&l=en&d=01_details

Sympathectomy results in isolated failure of sympathetic sudomotor activity

The main clinical features include symptoms of heat intolerance: feeling hot, flushed, dyspneic, light-headed, and weak when the ambient temperature is high or when exercising. Recent accounts of acquired idiopathic anhidrosis, however, have emphasized the heterogeneous features and sub-types of this condition.
Fitzpatrick's Dermatology In General Medicine, Seventh Edition: Two Volumes
Pub Date: NOV-07

Sympathectomy useless, even detrimental

A number of surgical procedures have been developed, which, although well-intentioned, are found unfortunately by further study to prove useless, or even detrimental. It is believed at present that lumbar sympathetic ganglionectomy in the treatment of the post-thrombotic type of ulceration of the lower extremity should be placed in this category.
http://archsurg.ama-assn.org/cgi/content/summary/67/1/2

It has to push us to publish our works, to inform the medical corps, relentlessly and without restraint

7th International Symposium on Sympathetic Surgery 20th-22nd March 2007 Muro Alto (PE), Brazil
Clinical Autonomic Research. New York:Apr 2007. Vol. 17, Iss. 2, p. 126-44 (19 pp.)

Pity colleagues, pity for these poor patients!
Gross Michel* Institution: Private Cabinet*; Grone - Switzerland
A desperate 22-year-old man comes to consult and tells me about his idea of committing suicide. Since the age of 9, he suffers from a severe cephalic ephidrosis, with blushing face, intensifying with years, to such an extent that it became unbearable over the last year:
''It is a real Calvary''. His family GP assures him that his troubles are going to disappear as he will get older and ''ut aliquid fieri'' he prescribes sage drops and anxiolytic. As these prescriptions do not improve his situation, his GP sends him to an endocrinologist who performs many exams to exclude an hyperthyreosis, a carcinoıd tumor or a pheochromocytoma. Among the considerable number of blood exams, one appears to be out of normal ranges. The patient goes therefore to an haematologist, who does not find anything
abnormal. A neurologist, then consulted, does not suspect anything in particular, but asks however for some radiology exams, including a brain MRI, as well as a Pet-scan, to exclude an adrenal gland tumor. All these exams being normal, the patient is sent to a behaviour therapist to begin a psychotherapy. Exhausted by the
weight of these useless consultations here and there, our young patient, always seeking for the solution to his problems, decides to turn to an acupuncturist, an osteopath, a healer and a radiesthesist, in vain. He then decides to consult a dermatologist and shares with him a summary of information gathered on Internet, including information from my site. Finally, the patient was referred to me.
Aware of that, the GP warns his colleagues by sending a letter indicating that any therapeutic measure other than psychotherapy is not recommended, considering the surgical alternative as irresponsible. I did by the way, not get any call from any of my colleagues. The patient had successful surgery 2 weeks later
(sympathicotomy T2-3-4-5) This recent history redraws, once again, iatrogenic caricatural wandering to which our patients are too often subjected. It has to push us to publish our works, to inform the medical corps, relentlessly and without restraint. The information could also, throughout the public, reach our colleagues. It is at the end an interesting paradox to note that physicians, whose primary role is to relieve patients, are also the primary actors of a film where patients are maintained in a ''medical jail''.

Patients with sympathectomy are not suitable controls for sleep study. Why?

Exclusions:
Patients with permanent pacemaker, non-sinus cardiac arrhythmias, peripheral vasculopathy or neuropathy, severe lung disease, status postbilateral cervical or thoracic sympathectomy, finger deformity that precludes adequate sensor application, using a-adrenergic receptor blockers, or alcohol or drug abuse during the last 3 years.



The clinic sleep laboratory of the Technion Sleep Medicine Centre, Israel
http://chestjournal.chestpubs.org/content/123/3/695.long
CHEST March 2003 vol. 123 no. 3 695-703


MSAC Application no 1130, Assessment Report

The amount of compensatory sweating depends the amount of cell body reorganization in the spinal cord after surgery

The amount of compensatory sweating depends on the patient, the damage that the white rami communicans incurs, and the amount of cell body reorganization in the spinal cord after surgery.

Other potential complications include inadequate resection of the ganglia, gustatory sweating, pneumothorax, cardiac dysfunction, post-operative pain, and finally Horner’s syndrome secondary to resection of the stellate ganglion.
www.ubcmj.com/pdf/ubcmj_2_1_2010_24-29.pdf

ETS considered psychiatric surgery - says Dr Nagy

"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. "
http://www.lvhyperhidrosis.com/treatment.html

MD admits stellate ganglion block impacts on the insular cortex of the brain and alters emotions

Dr. Lipov says, "What really intrigued me about Dr, DeWall's study was he showed Tylenol exerted this emotional effect by acting on the insular cortex of the brain. That's exactly the same area that's affected by a Stellate Ganglion Block.[4]" The specialist is also Director of Chronic Pain Research at Northwest Community Hospital in Arlington Heights.
http://www.medicalnewstoday.com/releases/227298.php

Deceit and fraud in medical research

Deceit and fraud in medical research is a serious problem for the credibility of published literature. Although estimating its prevalence is difficult, reported incidences are alarming. The spectrum of the problem ranges from what may seem as rather innocuous gift authorship to wholesale fabrication of data. Potential factors which may have promoted fraud and deceit include financial gain, personal fame, the competitive scientific environment and scientific hubris. Fraud and deceit are difficult to detect and are generally brought to the fore by whistleblowers.
International Journal of Surgery
Volume 4, Issue 2, 2006, Pages 122-126
Usman Jaffer, and Alan E.P. Cameron

ETS story

Physicians are required to gain informed consent prior to administering a treatment. Informed consent is gained by providing patients with a full accounting of the risks of the treatment as documented in peer-reviewed, published medical/scientific literature.

Your scenario of surgeons being flummoxed by unhappy patients complaining after surgery doesn't hold water. The rules of professional medical ethics require that the treating physician be well versed in the published literature on the treatments he delivers.

There is a mountain of published research (spanning nearly a century) documenting the adverse effects of sympathectomy. There are numerous studies, for example, showing very high rates of severe side effects and studies showing that satisfaction diminishes substantially over the long term.
It is a doctors job to know this stuff and it is their ethical duty to disclose that information to patients.
So, I see the blame thing as pretty cut and dry. Surgeons perfoming sympathectomies routinely withhold information vital to informed consent. Anyone who does objective comparison between what is documented in medical/scientific literature and what is typically disclosed to prospective ETS patients has no choice but reach this conclusion.

And, to make matters worse, many surgeons use testimonials from a hand-selected group of their happiest patients to advocate the surgery. That practice is considered unethical by all medical professional organizations.

http://etsandreversals.yuku.com/reply/22927/Would-you-do-it-again#reply-22927

'Improved sympathectomy' - is it an oxymoron?

"also it seems like the more bad and negative affects were from 10 to 12 years ago when they had just started performing the surgery.. they must have improved it a lot by now.?"

This procedure has been performed since the 1920's. Yes, the 1920's. In the 1980's they started to do it using "keyhole" surgery which means they don't have to make a big incision. But, the surgery is no different than what they've been doing for the last 70+ years. It's a nerve injury. You can't "improve" they way you inflict a nerve injury. You can't injure the nerve in some "special" way such that the injury suddenly has a different effect on the body.

The functional name for the this surgery is "sympathetic denervation". It's not some super-advanced, modern cure based on recent discoveries in neurophysiology. It's a primitive, destructive procedure. It's a method used on animals for research. It's brute force method...destroy the pathways to the sweat glands over a large region. Unfortunately, it destroys pathways to and from many other organs including the heart and lungs and causes a large number of neuropathological dysfunction. That hasn't changed in the last ten years. It will not and cannot change in the next 1000 years because it will still be a nerve injury 1000 years from now. I'm not making this up. It's a simple fact. Don't let some doctor take advantage of your ignorance
http://etsandreversals.yuku.com/topic/4919/Should-i-have-ETS-surgery#.Tok-TE8YAyk

'Improved sympathectomy' - is it an oxymoron?

"also it seems like the more bad and negative affects were from 10 to 12 years ago when they had just started performing the surgery.. they must have inproved it alot by now.?"

I'd like to echo what some others have said just so you are completely clear on this issue. This procedure has been performed since the 1920's. Yes, the 1920's. In the 1980's they started to do it using "keyhole" surgery which means they don't have to make a big incision. But, the surgery is no different than what they've been doing for the last 70+ years. It's a nerve injury. You can't "improve" they way you inflict a nerve injury. You can't injure the nerve in some "special" way such that the injury suddenly has a different effect on the body.

The functional name for the this surgery is "sympathetic denervation". It's not some super-advanced, modern cure based on recent discoveries in neurophysiology. It's a primitive, destructive procedure. It's a method used on animals for research. It's brute force method...destroy the pathways to the sweat glands over a large region. Unfortunately, it destroys pathways to and from many other organs including the heart and lungs and causes a large number of neuropathological dysfunction. That hasn't changed in the last ten years. It will not and cannot change in the next 1000 years because it will still be a nerve injury 1000 years from now. I'm not making this up. It's a simple fact. Don't let some doctor take advantage of your ignorance
http://etsandreversals.yuku.com/topic/4919/Should-i-have-ETS-surgery#.Tok-TE8YAyk

There is no evidence whatsoever that the sympathetic ganglia have any regulatory function on sweating

There is no "signal that tells the body to sweat excessively". The nervous system doesn't work like that. Worse, it implies that there is some separate signal that tells the body to sweat "normally" which, again, is implied to be unaffected by the surgery. It's nonsense and an affront to all that is known about neuroanatomy and neurophysiology.

Of all the lies and distortions, this is the one that pisses me off the most. Not only is it demonstrably false, it is criminally misleading in terms of what it leads the patient to expect. There no evidence whatsoever that the sympathetic ganglia have any regulatory function. Regulation if sympathetic activity occurs in the brain, not the sympathetic ganglia.

Why the hell don't they call it what it is?: sympathetic denervation surgery (which is a fancy name for a particular type of nerve injury). It eliminates excessive sweating by eliminating the ability to sweat at all (anhidrosis) over a large area. It achieves this end in the most brutal way possible: by permanently destroying the neural pathways. Any statement or implication that sympathectomy reduces sweating to normal levels or improves the regulation of sweating in any way is a boldfaced lie.

So numerous are the possible variations that the outcome of a sympathectomy is unpredictable

The sympathetic pathways to the heart are extremely variable in their topography, and the diversity of arrangements encountered accounts for the morphological contradictions in the literature. So numerous are the possible variations that the outcome of a sympathectomy is unpredictable. Where denervation is incomplete, collateral sprouting and regeneration of nerves could even lead to hyperstimulation via the sympathetic pathways.
http://onlinelibrary.wiley.com/doi/10.1002/aja.1001240203/abstract

sympathectomy created imbalance of autonomic activity and functional changes of the intrathoracic organs - yet it is heavily advertised on the internet as the best elective procedure for sweaty hands or blushing

Surgical thoracic sympathectomy such as ESD (endoscopic thoracic sympathectic denervation) or heart transplantation can result in an imbalance between the sympathetic and parasympathetic activities and result in functional changes in the intrathoracic organs.
Therefore, the procedures affecting sympathetic nerve functions, such as epidural anesthesia, ESD, and heart transplantation, may cause an imbalance between sympathetic and parasympathetic activities (1, 6, 16, 17). Recently, it has been reported that ESD results in functional changes of the intrathoracic organs.


In conclusion, our study demonstrated that ESD adversely affected lung function early after surgery and the BHR was affected by an imbalance of autonomic activity created by bilateral ESD in patients with primary focal hyperhidrosis.
Journal of Asthma, 46:276–279, 2009
http://informahealthcare.com/doi/abs/10.1080/02770900802660949

important relationship among cognitive performance, HRV, and prefrontal neural function

These findings in total suggest an important relationship among cognitive performance, HRV, and prefrontal neural function that has important implications for both physical and mental health. Future studies are needed to determine exactly which executive functions are associated with individual differences in HRV in a wider range of situations and populations.
http://www.ncbi.nlm.nih.gov/pubmed/19424767

Low HRV is a risk factor for pathophysiology and psychopathology

The intimate connection between the brain and the heart was enunciated by Claude Bernard over 150 years ago. In our neurovisceral integration model we have tried to build on this pioneering work. In the present paper we further elaborate our model. Specifically we review recent neuroanatomical studies that implicate inhibitory GABAergic pathways from the prefrontal cortex to the amygdala and additional inhibitory pathways between the amygdala and the sympathetic and parasympathetic medullary output neurons that modulate heart rate and thus heart rate variability. We propose that the default response to uncertainty is the threat response and may be related to the well known negativity bias. We next review the evidence on the role of vagally mediated heart rate variability (HRV) in the regulation of physiological, affective, and cognitive processes. Low HRV is a risk factor for pathophysiology and psychopathology. Finally we review recent work on the genetics of HRV and suggest that low HRV may be an endophenotype for a broad range of dysfunctions.
http://www.ncbi.nlm.nih.gov/pubmed/18771686

Surgical sympathectomy is the gold standard of treatment for this disease, by which all other treatments must be judged

http://www.fortishospitals.com/heart-care/treatments-and-procedures/vats-sympathetectomy.html

acute response to surgical denervation and abrupt release of sympathetic tone

Intraoperative predictability of successful outcome depends on monitoring of the acute response to surgical denervation and abrupt release of sympathetic tone.

Information on the long-term physiological sequelae is emerging rapidly. Preoperatively, in addition to abnormal sudomotor control, sympathetic cardiovascular regulation may be affected mildly in severe cases of hyperhidrosis. A blunted reflex bradycardia response to parasympathomimetic maneuvers such as Valsalva maneuver or cold water face immersion, as well as an increased heart rate response
to orthostatic stress, suggests a hyperfunctioning sympathetic discharge that is reversed after ETS.25,69 Because sympathetic cardiac accelerator fibers exit the spinal cord from segments T1 to T4, ETS is believed to simulate a mild physiological !-adrenergic blockade.70 This is because the heart rate at rest and during maximal exercise is lower 6 weeks postoperatively

DIAGNOSIS AND TREATMENT OF HYPERHIDROSIS,  CONCISE REVIEW FOR CLINICIANS
Mayo Clin Proc.     •     May 2005;80(5):657-666 

Several autonomic reflexes were dramatically affected after sympathectomy for hyperhidrosis

major effects on local blood flow and temperature are elicited by TES. Complex autonomic reflexes are also affected. The patient should be completely informed before surgery of the side effects elicited by transthoracic endoscopic sympathicotomy (TES).
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0404.2008.01046.x/abstract

To date, sufficient importance has not been placed on the long term effects that could cause dorsal sympathectomy

A scientific society has been created for surgery of the sympathetic nervous system, the International Society of Sympathetic Surgery (ISSS); and in the most recent thoracic surgery and related specialities congresses it fills up a considerable percentage of the programme.
On the other hand, this surgery, especially for hyperhidrosis and facial reddening, is the one that on a percentage basis generates more demands and complaints from the patients, even with medico-legal connotations.7 Despite that the majority of the patients show a very high degree of satisfaction, the presence of a patient operated for hyperhidrosis with important compensatory sweating that repeatedly manifest their dissatisfaction to the surgeon is a very annoying situation with an intractable solution. There are even forums on the Internet that constantly manifest their discomfort with this type of surgery in a violent and insulting tone, for example, the World Against Sympathectomy Website.

In summary, we are faced with a new disorder that is being attended massively in our hospitals and needs a moment of contemplation. What are we doing? Are we doing it properly? What are the future implications in these patients of dorsal sympathetic denervation? For the first 2 questions, we could find the answer in the new clinical guidelines and scientific society norms and with the publication of linger series, randomised systematic studies, reviews and meta-analyses. However, it is perhaps the latter of these that implies greater consideration. To date, sufficient importance has not been placed on the long term effects that could cause dorsal sympathectomy, and the effects on lung function, heart function, skin colouring and psychological state are being studies, among others;10 the most important being the first 2. secondary consequences of the operation.

The consequences of sympathetic denervation after a dorsal sympathectomy on lung function have been studied on several occasions11 and reductions in forced vital capacity, forced expiratory flow in the first second and maximum mesoexpiratory flow have been found, but with no clinical significance. It therefore seems that, despite sympathetic innervation being scarce, it directly influences motor tone, especially of the fine respiratory tracts, which cause a light obstructive pattern after the operation and favours bronchial hyperreactivity.12 It is of great interest to know the results of the research being carried out to recognise the long term effects.
Something similar occurs with heart function, the sympathectomy in the short term causes bradycardia due to a lack of sympathetic stimulation to the heart. Several cases of myocardial infarction13 and
chronotropic heart failure requiring the insertion of a pacemaker14 have been reported. In the long term, dorsal sympathetic interruption causes an effect similar to beta blockers on the heart, and produced a decrease in average heart rate, but with no significant changes in the electrocardiogram (normal Q-T).15 It may be good to know through long term prospective studies which effects it truly has on heart function and what it could mean for the daily lives of the operated patients. For the time being, those individuals who practice aerobic sports (for example, long distance runners and cyclists)
should be informed that with sympathectomy their heart rate may be reduced in situations of maximum effort and lower their performance.16


M. Congregado / Arch Bronconeumol. 2010;46(1):1-2

ETS story

I had ETS surgery (cutting of T2) about 10 years ago for facial HH. The surgery worked very well and I had virtually no immediate complications from the surgery (infection, nerve damage, etc). I now experience severe CS on my trunk (worse on my back) that is pretty debilitating. At this point I'm considering reversal surgery (and am very open to any insight).

I had the surgery done in San Francisco, CA by a now-retired thoracic surgeon (I live in the Portland, OR area). He did mention CS as a possible side effect but didn't present it as a huge risk. To be fair, I was so desperate that I probably wouldn't have listened anyway. That's why it is incumbent on doctors to save us from ourselves. Any surgeon that performs invasive, irreversible surgery to treat conditions where patients are despondent and vulnerable should overemphaasize the risks and minimize the possible benefits (under-promise and over-deliver).

The surgery was uneventful and recovery was quick and I had no immediate complications. In terms of efficacy, the surgery was tremendously successful. My facial HH was immediately and completely resolved, as was my hand-sweating (which wasn't a huge problem, but they are 100% dry now). I still experience gustatory sweating occasionally with very rich or spicy foods but it's not a problem at all. I also still experience blushing but I believe it may be better than it was.

That's the good part. Like many others, I now have severe CS on my trunk (worse on my back). I don't have any of the other dry scalp or pain syndromes that others have though, so maybe I'm one of the lucky ones.

Interestingly, having no moisture on your hands does cause some problems. It's hard to count out money (seriously) or pick things up and it's almost impossible to deal cards (and I used to be a BJ dealer in Las Vegas in college!). It's also hard to play basketball as you really need a little moisture on your hands to properly grip and put spin on the ball.

I've tried hyoscyamine and Robinul and find that Robinul seems to work better but really only reduces the CS about 20-30% most of the time. Often, it doesn't matter what I take. 
http://www.no-ets.com/forums/viewtopic.php?p=1489&sid=6ff9da7866e646365a7b8ba9bfcbd845

Surgical Sympathectomy should be first line treatment according to 'Center for the Cure of Sweaty Palms™' surgeon

Given the clear superiority of BTS (bilateral thoracoscopic sympathectomy) for severe palmoplantar hyperhidrosis, deliberately using medical treatments that are known with near certainty to be eneffective and at times considerably noxious simply as a requisite to surgery may not be in the best interest of such patients, nor is such an approach ultimately cost-effective. There is no evidence that surgical intervention should be considered a "last resort" for this form of hyperhidrosis. BTS can safely and confidently be recommended as first-line treatment for the typical, severe form of palmoplantar hyperhidrosis.

(no conflict of interest has been declared by the authors)


Fritz J. Baumgartner^{, a,} , Shana Bertin^a and Jiri Konecny^a

Annals of Vascular Surgery
Volume 23, Issue 1, January-February 2009, Pages 1-7
http://www.sciencedirect.com/science/article/pii/S0890509608001854

This injures all the neurons at this level of the spinal cord, some of which may die, and may predispose the patient to spinal cord reorganization and severe compensatory hyperhidrosis

Sympathectomy vs sympathotomy. Sympathectomy, with use of ganglionectomy and by definition, must sever the primary axon from the neuron in the intermediolateral cell column of the spinal cord (red) before primary or collateral synapse in the T2 ganglion. This injures all the neurons at this level of the spinal cord, some of which may die, and may predispose the patient to spinal cord reorganization and severe compensatory hyperhidrosis. Sympathotomy interrupts only axons after potential T2 ganglion synapses, a less injurious effect on the neuron, and is the least destructive procedure possible with successful treatment
of palmar hyperhidrosis.
Mayo Clin Proc 2003;78:167-172.   http://www.mayoclinic.org/medicalprofs/enlargeimage5096.html

the requirement to practise according to widely accepted professional standards implies the need to be abreast of contemporary clinical practice

http://www.mja.com.au/public/issues/194_05_070311/choice_070311_fm.html

Intentional misrepresentation of the elective surgical sympathectomy is common practice

"Sweating is one form of regulating the body's temperature. If the operation prevents sweating in one area, it is possible that patients will notice a greater amount of sweating elsewhere in their body in order to compensate. This is called "compensatory sweating" and can occur on the face, abdomen, back, buttocks, thighs, or feet. While this is a mild nuisance for most patients, occasionally (5-10% of the time) it can be severe and interfere with the patient's lifestyle. If it occurs, it usually improves within 6 months."
http://thoracic.surgery.virginia.edu/general-thoracic/general-thoracic-conditions-treatment/hyperhidrosis/


Mia: None of the 'facts' listed in the above text can be supported by scientific evidence. The information illustrates the myths spread on the internet by those who have a financial interest in offering ETS, - an interest that overrides the medical and ethical obligations of the medical profession. 
The so called "compensatory sweating" is NOT compensatory, and the only study looking into  this concluded that patients did sweat more after ETS. 
If this side-effect  of the elective surgery (intentional neurological injury/lesion) would be "compensatory" in order to maintain thermoregulation, it would be observed after botox or ionthoporesis treatment as well. Hyperhidrosis (reflex hyperhidrosis)  is an usual finding in people after spinal cord injuries (especially above T6) and in diabetics due to damage to the SNS. It is a pathological response to injury.

 No evidence can support - and there is clear contrary evidence -   that if this compensatory sweating would occur, it would diminish in 6 months. It is all part of the intentional misrepresentation of elective surgeries to make them appear more appealing and safer than they are.

Extreme caution is called for when considering surgical sympathectomy

Surgical sympathectomy is carried out on the basis of poor quality evidence, studies without
control groups, and personal experience. Though it would appear logical (and has been
suggested) that surgical sympathectomy is indicated primarily for patients with confirmed
'sympathetic-dependent pain, other authors take the view that the treatment results are
not correlated to this. Eighteen percent of patients undergoing sympathectomy for
neuropathic pain experience compensatory hyperhidrosis and 25% experience neuropathic
complications.
Extreme caution is called for when considering surgical sympathectomy for pain control in
CRPS-I. The procedure should be conducted in the context of a trial in order to ascertain
the efficacy and potential risks.
Guideline

INITIATIVE:
Netherlands Society of Rehabilitation Specialists
Netherlands Society of Anaesthesiologists

WITH THE SUPPORT OF:
Institute for Healthcare Improvement CBO
www.cbo.nl/Downloads/341/rl_crps_eng_07.pdf

Informed consent - sympathectomy

Physicians are required to gain informed consent prior to administering a treatment. Informed consent is gained by providing patients with a full accounting of the risks of the treatment as documented in peer-reviewed, published medical/scientific literature.

Your scenario of surgeons being flummoxed by unhappy patients complaining after surgery doesn't hold water. The rules of professional medical ethics require that the treating physician be well versed in the published literature on the treatments he delivers.

There is a mountain of published research (spanning nearly a century) documenting the adverse effects of sympathectomy. There are numerous studies, for example, showing very high rates of severe side effects and studies showing that satisfaction diminishes substantially over the long term.
It is a doctors job to know this stuff and it is their ethical duty to disclose that information to patients.
So, I see the blame thing as pretty cut and dry. Surgeons perfoming sympathectomies routinely withhold information vital to informed consent. Anyone who does objective comparison between what is documented in medical/scientific literature and what is typically disclosed to prospective ETS patients has no choice but reach this conclusion.

And, to make matters worse, many surgeons use testimonials from a hand-selected group of their happiest patients to advocate the surgery. That practice is considered unethical by all medical professional organizations.

http://etsandreversals.yuku.com/reply/22927/Would-you-do-it-again#reply-22927

Segmental myoclonus was associated with thoracic sympathectomy

Spinal myoclonus was associated with laminectomy, remote effect of cancer, spinal cord injury, post-operative pseudomeningocele, laparotomy, thoracic sympathectomy, poliomyelitis, herpes myelitis, lumbosacral radiculopathy, spinal extradural block, and myelopathy due to demyelination, electrical injury, acquired immunodeficiency syndrome, and cervical spondylosis.
http://www.ncbi.nlm.nih.gov/pubmed/3753263

Spinal myoclonus is typically associated with a localized area of damaged tissue (focal lesion). The injured area may include direct damage of the spinal cord or may cause abnormal changes in the function of the spinal cord.
http://www.wemove.org/myo/myo_pc.html

Spinal myoclonus following a peripheral nerve injury: a case report
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2526081/

90% can experience gustatory sweating after sympathectomy

Some individuals (up to 90%) may experience another type of sweating that is increased while eating or smelling certain foods (gustatory sweating) (Hornberger).

Source: Medical Disability Advisor

http://www.mdguidelines.com/sympathectomy

sympathectomy can cause postsympathectomy pain called sympathalgia in up to 44% of patients

The sympathalgia secondary to sympathectomy usually starts around the first 2 weeks of the surgical procedure. It is a dull and cramping pain and occasionally can be a sharp pain. Although it is temporary in some patients, in others it can persist for several months or years.

H. Hooshmand, M.D.
Chronic Pain, page 156

83% of patients who underwent T2 sympathectomy reported severe compensatory sweating

one year after surgery and the majority of those reported they regretted the decision to have the surgery.
Heather Ennis. Medical Post. Toronto: Feb 15, 2005. Vol. 41, Iss. 7; pg. 17, 2 pgs

Serious complications reported after sympathectomy

Surgery involving the clamping of sympathetic nerve trunks to prevent excessive perspiration and blushing appears to be of questionable value.

Complications have been reported, ranging from phantom perspiration to blood clots in the brain.

The Finnish Office for Health Care Technology Assessment (FinOHTA), which is part of the National Research and Development Centre for Welfare and Health (STAKES) recently conducted a survey on the various effects of hyperhidrosis surgery at the request of the Finnish Medical Association.

Finnish surgeon Timo Telaranta has performed about 2,000 such operations at private clinics in Helsinki and Oulu in the past ten years.
The National Authority for Medicolegal Affairs has issued three warnings to Telaranta and the Provincial Government of Southern Finland has issued one.
There are currently no complaints pending against Telaranta, and the authority has not considered restricting his rights to practice medicine.

The Finnish Patient Insurance Centre has processed 20 complaints concerning Telarantas Privatex clinic. The complaints resulted in 14 decisions to pay compensation. All except two of the surgeries were conducted by Telaranta himself.
Telaranta says that he treats patients suffering from difficult social anxiety with endoscopic surgery in which an incision is made into the upper part of the chest cavity, and the sympathetic nerve trunk is severed or clamped.
Most patients are satisfied with the treatment. However, FinOHTA found that there were many negative side-effects, some of which were very serious.
With most patients, heavy perspiration of the palms has moved to other parts of the body, below the breasts. As many as 15% of those who have undergone the surgery said that the surge in body perspiration forces them to change underwear several times a day.
Other side-effects have included drying of the skin on the face and hands, as well as perspiration triggered by eating spicy food. There are also reports of phantom perspiration - the feeling of perspiration when none takes place - as well as a weakened tolerance for cold.

More serious effects include collapsing of a lung, breathing difficulties, and blood clots in the brain. Some patients got a hanging eyelid, while others reported a sudden raspiness of their voice.
One of Dr. Telarantas patients who had made a complaint began to experience strong reactions of anxiety which did not go away even after corrective surgery. Later the patient committed suicide.

Dr. Telaranta himself says that the side-effects are regrettable. However, he says that he has developed a procedure which does not cause any such side effects.
He also says that it is important to examine patients carefully, and to perform surgery only on those who are suited for the procedure.
Many doctors have serious reservations about the idea of treating complaints such as excessive perspiration, blushing, and performance anxiety by severing peoples nerves.
Helsingin Sanomat
http://www.hs.fi/english/article/1101979734791

decreased conditioning-related activity in insula and amygdala in patients with autonomic denervation

The degree to which perceptual awareness of threat stimuli and bodily states of arousal modulates neural activity associated with fear conditioning is unknown. We used functional magnetic neuroimaging (fMRI) to study healthy subjects and patients with peripheral autonomic denervation to examine how the expression of conditioning-related activity is modulated by stimulus awareness and autonomic arousal. In controls, enhanced amygdala activity was evident during conditioning to both "seen" (unmasked) and "unseen" (backward masked) stimuli, whereas insula activity was modulated by perceptual awareness of a threat stimulus. Absent peripheral autonomic arousal, in patients with autonomic denervation, was associated with decreased conditioning-related activity in insula and amygdala. The findings indicate that the expression of conditioning-related neural activity is modulated by both awareness and representations of bodily states of autonomic arousal.

http://www.ncbi.nlm.nih.gov/pubmed/11856537

Sympathectomy - a surgically induced neuropathy

"Vascular and neural diseases are closely related and intertwined. Blood vessels depend on normal nerve function, and nerves depend on adequate blood flow. The first pathological change in the microvasculature is vasoconstriction. As the disease progresses, neuronal dysfunction correlates closely with the development of vascular abnormalities, such as capillary basement membrane thickening and endothelial hyperplasia, which contribute to diminished oxygen tension and hypoxia."

http://en.wikipedia.org/wiki/Diabetic_neuropathy

Sympathectomy results in vascular abnormalities, loss of vasoconstriction, capillary basement thickening and endothelial hyperplasia...

cervical sympathectomy works systemically through hypothalamus endocrine system

Background: To investigate the general action of stellate ganglion block (SGB), we examined the effects of heat stimulation and cold stress on the behavior and stress hormone of the bilateral cervical sympathectomy rats as a long-term and repeated SGB model. Methods: Wistar's male rats were divided into three groups: control (C), sham operation (S) and sympathectomy (Sx) groups. After 2 weeks, two experiments were done. One was measurement of escape response time from the heat stimulus and the other was hormone measurement. Serum adreno-corticotropic hormone (ACTH), .ALPHA.-melanocyte stimulating hormone (.ALPHA.-MSH) and .BETA.-endorphine (.BETA.-END) levels were measured assigning 3 groups to 2 subgroups with and without cold stress. Results: Escape response time was significantly extended in the Sx group. ACTH in the Sx group was significantly higher than in other groups, but changes of ACTH by cold stress were similar in 3 groups. In the Sx group .ALPHA.-MSH was hardly changed by cold stress while .ALPHA.-MSH was significantly decreased in the S group. Changes of .BETA.-END by cold stress were similar in the S and Sx groups. Conclusions: These results suggest that SGB works systemically through hypothalamus endocrine system and affects stress hormone differently. (author abst.)

http://sciencelinks.jp/j-east/article/200402/000020040204A0020288.php

We disagree that surgery and botulinum toxin are treatments of choice in severe cases of hyperhidrosis

The truth is exactly the opposite. Surgery is only rarely necessary, and the editorial quite properly warns of numerous surgical pitfalls, which include recurrence of hyperhidrosis, almost certain impotence, compensatory sweating, permanent neurological damage from anoxia, and death (their words). Botulinum toxin, which they recommend for axillary or plantar hyperhidrosis, requires 12 injections per axilla and 24-36 injections per foot. Even this horrendous procedure gives only 11 months' relief, and antibody formation may reduce long term efficiency.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1118569/

Iontophoresis should be tried before other treatments

Iontophoresis should be tried before other treatments

Iontophoresis is easy to perform, effective in about 90% of patients in two studies with 54 and 30 participants, free of hazardous side effects, and well accepted by almost all patients.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1118569/

the Kuntz nerve played no part in the success or failure of ETS surgery

If you research the topic of ETS, you will come across various claims and counter-claims
about the importance or otherwise of the Kuntz nerve. The Kuntz nerve is a small nerve
fibre sometimes seen on the second rib not far from the main sympathetic chain. Its
function is not known in humans. Some web-sites on ETS claim success rates of up to
100% for facial blushing because they search for and destroy the Kuntz nerve(s). These
same people also claim to be able to correct failed ETS operations by reoperating and
destroying the Kuntz nerve.
At the meeting of the International Society for Sympathetic Surgery in Germany, May
2003, attended by a majority of the world’s experts in ETS surgery (including us), all but
one of the surgeons present were of the opinion that the Kuntz nerve played no part in the
success or failure of ETS surgery for facial blushing. We share this majority opinion.
www.lapsurgeryaustralia.com.au

"Sympathectomy is a technique about which we have limited knowledge, applied to disorders about which we have little understanding."

http://www.pfizer.no/templates/Page____886.aspx

Fake websites in the service of the ETS industry - who protects the patients?

Mia:
Many surgeons compete with each other for the attention of the 'costumer' in the saturated market of the www. Adaptations to a business model raises ethical questions that should have been explored long ago and should have raised the ire of the medical community. The occasional whimper of discord is silenced by the cacophony of (ignorant) enthusiasm. Not quite the scientific behavior one would expect.

How does the entrepreneurial aspect of medicine impact on the information patients are given? In the area of elective procedures, is it in the interest of the service provider to provide full disclosure? Does self-interest influence and modify how the information is conveyed? How information morphs into little facts and more emoting. to appeal to the irrational in all of us. To be seduced.

Fake websites that pretend to be independent,  informative, with the sole raison d'etre to praise the surgeon's skill, expertise and experience, - and to hook the patient into reading more on the surgeons' website, with many obvious links to the surgeon on every page.
Why are predatory practices of medical professionals tolerated?

ETS surgeons claim that their procedure is extremely safe and effective,

- even  'almost miraculous' -, so why is there a need to devise a modified procedure, if the results are as unprecedented as they all claim in their articles/websites?


Why is there a need to devise a procedure where the "rate of embarrassing and disabling compensatory sweating was significantly less..."?! Disabling? After an elective surgery? These terms did not enter the vocabulary of the previous ads of the ETS industry. 
The surgeon claiming great success with his new "SUPER SELECTIVE ETS'  also claimed excellent results with his old, non-super selective procedure... He did NOT mention his patients being disabled by his elective procedure or the need to devise a better procedure previously. His results were excellent then but they are not excellent in hindsight? How is that possible that unprecedented successes morph into disability?



"In this method, the main trunk of the sympathetic nerve are left intact, however, the rami communicanes which connect the sympathetic ganglia to the peripheral nerves are cut. In one study that compared the conventional ETS to the super-selective ETS, the overall rate of compensatory sweating was similar in both groups; however, the rate of embarrassing and disabling compensatory sweating was significantly less in the super-selective ETS. This further illustrates that the more selective the surgery is, the less chance of disabling compensatory sweating."

In 70 % compensatory sweating severe, recurrence rates were 15% and 19% at 1 and 2 years after surgery

They will not tell you this:

In T2 and T3 resection, all patients experienced Compensatory Sweating and over 70% of the patients felt it was severe. Even in T2 resection, 90% of patients experienced CS and in 50% of these it was severe. High rates of CS are reported in Asian countries with hot and humid climates.

In T2 resection, recurrence rates were 15% and 19% at 1 and 2 years after surgery.It was not rare for a patient to experience recurrence more than 3 years after surgery.
Motoki Yano, MD, PhD and Yoshitaka Fujii, MD, PhD

Volume 138, Issue 1, Pages 40-45 (July 2005)

bradycardia and other cardiac complications are common side effects?

The most common side effects of sympathectomy are compensatory sweating, gustatory sweating and cardiac changes including decreasing heart rate, systolic-diastolic and mean arterial pressure. The mechanism of bradycardia and other cardiac complications that develop after thoracic sympathectomy are still unclear.

http://tipbilimleri.turkiyeklinikleri.com/abstract_54802.html

very severe discomfort and hyperhidrosis in the neighboring non-sympathectomized regions occurred with alarming frequency

and what he will not tell you:

After thoracoscopic sympathectomy for hyperhidrosis, very severe discomfort and hyperhidrosis in the neighboring non-sympathectomized regions occurred with alarming frequency and intensity.
(p.879)

Cousins and Bridenbaugh's Neural Blockade in Clinical Anesthesia and Pain Medicine by Michael J Cousins, Phillip O Bridenbaugh, Daniel B Carr, and Terese T Horlocker

Wolters Kluwer Health
Edition: 4 - 2008

Cautiously worded, yet it still means the same: ETS = Lobotomy

Knowledge of the elimination of embarrassing physical symptoms in social situations helps the patient to expose himself to formerly impossible situations, and success in them also causes psychological symptoms to subside. But the relief of psychological symptoms may also be due to direct a biological effect of the operation on the anxiety-mediating areas in the nervous system. The only meaningful side effect is compensatory sweating of the trunk, but not even that is significant when modern surgical method are used. (sic!)

http://informahealthcare....0.1080/08039480310000266

Lack of disclosure to ETS patients is unethical and would be criminal in a just society

It is the doctor's moral and ethical duty to provide you with full and honest disclosure of the facts prior to surgery. The whole doctrine of informed consent is to prevent patients from having to realize they made a mistake in hindsight. You shouldn't have had to find out from a former patient's wife that the surgery would cause drenching sweating on your back. It was Garza's job to do that. He completely lied to you regarding the supposed reversibility. Anyone who goes through medical school knows that can't crush a nerve with a metal clamp, remove it later and have the nerve return to normal functioning.

Although it is not possible to predict exactly what will occur in each individual case, there is nearly 100 years of published scientific and medical research available on the effects of sympathectomy. That research paints a very different picture of the effects of this surgery than the one presented to patients considering this surgery. That's the issue. Generally, they lie and tell patients that CS is inconsequential in all but a tiny fraction of cases and simply fail to disclose a huge number of verified adverse effects of the surgery. They take advantage of the patient's ignorance on medical matter. It's unethical and would be criminal in a just society.

In short, you do have a way of knowing what will likely occur as a result of the surgery before you have it done. All the information necessary to make an informed decision exists. It's just not getting to patients.

http://etsandreversals.yuku.com/reply/22927/Would-you-do-it-again#reply-22927

Pathophysiology of cervical and upper thoracic sympathetic surgery

What your ETS or ESB surgeon will not tell you during the consultation:

T(2)-T(3) ganglionectomy significantly decreases pulse rate and systolic blood pressure, reduces myocardial oxygen demand, increases left ventricular ejection fraction and prolongs Q-T interval. A certain loss of lung volume and decrease of pulmonary diffusion capacity for CO result from sympathectomy. Histomorphological muscle changes and neuro-histochemical and biochemical effects have also been observed.

Clin Auton Res. 2003 Dec;13 Suppl 1:I40-4.

Instead, you will be told:

"Usually the surgery is used to treat sweating in the palms or face. The surgery stops or turns off the nerve signals that tell the part of the body to sweat too much."
http://www.nlm.nih.gov/medlineplus/ency/article/007291.htm

or this:

"The procedure turns off the signal that tells the body to sweat excessively. It is usually done on patients whose palms sweat much more heavily than normal."

or this:

"This method does not involve the cutting of the sympathetic nerves. Instead, the surgeon interrupts their activity by applying a titanium clamp to the nerve, thus stopping their activity. The clamp exerts pressure on the nerve and the signals the nerve produces don’t reach the sympathetic nerve endings. This is method that has a positive effect in the sense that the sympathetic ganglia are not destroyed. This leaves the patient with the possibility of having the nerves reconstructed in the future by simply removing the titanium clamp."
http://www.hyperhidrosis.us/ets.php

All the above statements are carefully crafted to make the surgery appear harmless, easy and safe. Yet, ETS and ESB procedures disrupt the nerve signals not only to the sweat glands but other structures and systems in the body, most notably the heart, resulting in Bradycardia in patients, who are unaware that they are signing up for a surgery that potentially will impact on their neurocardiology.

The response of the heart to stress is much attenuated by upper thoracic sympathectomy

What your ETS or ESB surgeon will not tell you:

“The response of the heart to stress is much attenuated by upper thoracic sympathectomy.”
European Journal of Surgery See Also: British Journal of Surgery Volume 164 Issue S1, Pages 37 - 38 Published Online: 2 Dec 2003

prevents them from responding to reflex or emotional changes in the central nervous system

Your ETS or ESB surgeon will not tell you:

“...cervical sympathectomy or some pathological condition, isolates all these sympathetic ganglion cells from the central nervous system and prevents them from responding to reflex or emotional changes in the central nervous system.
Cunningham's Manual of Practical Anatomy: Volume III: Head, Neck and Brain (Oxford Medical Publications) 1986

Parallels between Lobotomy and Sympathectomy

Both surgeries were obscure and unpopular until a "minimally invasive" version led to mass-marketing.

Both surgeries featured positive stories in the media. Walter Freeman had several glowing write-ups in the New York Times and Life Magazine.

Both surgeries featured dubious published studies touting the safety and effectiveness. One very large 1962 study said that 28% had been cured by lobotomy, another 25% significantly improved, 20% showed no change (from lobotomy!!) 4% died, and only 2% were made worse off.

In both instances medical professionals were reluctant to openly criticize their colleagues or speak up about undisclosed harmful effects of the procedure.

http://etsandreversals.yuku.com/reply/9783/Lobotomy-Barbaric-surgery#reply-9783