Endoscopic thoracic sympathectomy is prohibited for patients under 20 years in Taiwan
Patients with severe compensatory sweating after ETS must change clothes several times a day (some patients complained that they change as often as 10 times a day), resulting in serious impact on work and social interaction. Patients suffering from such serious side effects in Taiwan have formed a support group based on an Internet discussion forum to request the government to take this problem seriously. Starting in October 2004, The Department of Health, Executive Yuan, Taiwan, has prohibited surgeons from performing this operation on patients under 20 years old. To our knowledge, this type of support group also exists in United States, England, Sweden, Spain and Japan (Table 1).
ETS is a relatively safe and simple procedure. However the side effects are possibly devastating All physicians providing this service and all peoples preparing to undergo this treatment should know this well.
Min-Huei Hsu (10 January 2005)
http://www.cmaj.ca/content/172/1/69.abstract/reply
ETS is a relatively safe and simple procedure. However the side effects are possibly devastating All physicians providing this service and all peoples preparing to undergo this treatment should know this well.
Min-Huei Hsu (10 January 2005)
http://www.cmaj.ca/content/172/1/69.abstract/reply
Hyperhidrosis is not due to sympathetic overactivity.
Our overall findings suggest that essential hyperhidrosis is a complex autonomic dysfunction rather than sympathetic overactivity, and parasympathetic system seems to be involved in pathogenesis of this disorder.
Dayimi Kaya, M.D.*, Semsettin Karaca, M.D.†, Irfan Barutcu, M.D.‡, Ali Metin Esen, M.D.‡, Mustafa Kulac, M.D.†, and Ozlem Esen, M.D.
Annals of Noninvasive Electrocardiology,
Dayimi Kaya, M.D.*, Semsettin Karaca, M.D.†, Irfan Barutcu, M.D.‡, Ali Metin Esen, M.D.‡, Mustafa Kulac, M.D.†, and Ozlem Esen, M.D.
Annals of Noninvasive Electrocardiology,
Volume 10 Issue 1, Pages 1 - 6
Published Online: 13 Jan 2005
ANS provides physiological stability
The autonomic nervous system dynamically controls the response of the body to a range of external and internal stimuli, providing physiological stability in the individual. With the progress of information technology, it is now possible to explore the functioning of this system reliably and non-invasively using comprehensive and functional analysis of heart rate variability. This method is already an established tool in cardiology research, and is increasingly being used for a range of clinical applications. This review describes the theoretical basis and practical applications for this emerging technique.
- Functional assessment of heart rate variability: physiological basis and practical applications .
- International Journal of Cardiology , Volume 84 , Issue 1 , Page 1
- J . Pumprla
Copyright © 2003 Elsevier Inc
hyperhidrosis is based on a much more complex autonomic dysfunction than generalised sympathetic overactivity
Our highly interesting findings indicate that primary focal hyperhidrosis is based on a much more complex autonomic dysfunction than generalised sympathetic overactivity and seems to involve the parasympathetic nervous system as well.
Cardiac Autonomic Function in Patients Suffering from Primary Focal Hyperhidrosis
Peter Birnera, Harald Heinzlb, Monika Schindlc, Jiri Pumprlad, Peter Schnidera
Eur Neurol 2000;44:112-116
Cardiac Autonomic Function in Patients Suffering from Primary Focal Hyperhidrosis
Peter Birnera, Harald Heinzlb, Monika Schindlc, Jiri Pumprlad, Peter Schnidera
Eur Neurol 2000;44:112-116
Sympathectomy Suppresses Baroreflex Control of Heart Rate
Endoscopic Thoracic Sympathectomy Suppresses Baroreflex Control of Heart Rate in Patients with Essential Hyperhidrosis
Yurie T. Kawamata, MD*, Tomoyuki Kawamata, MD†, Keiichi Omote, MD†, Eiji Homma, MD*,
Tatsuo Hanzawa, MD*, Toshifumi Kaneko, MD‡, and Akiyoshi Namiki, MD†
(Anesth Analg 2004;98:37–9)
In this study, baroreflex control of HR was completely inhibited in 9 of 21 patients in the depressor test but in only 1 of 19 patients in the pressor test. All patients who showed complete inhibition had received bilateral T2-3 sympathectomy. Responses to decreased blood pressure are mediated by the sympathetic nervous system, whereas responses to increased blood pressure predominantly involve vagal compensation (13). Therefore, it seems that the effects of sympathetic denervation were most prominent in the de-
pressor test after ETS.
The suppression of baroreflex function can be detrimental during anesthetic management. In particular, a poorly preserved baroreflex response to decreasing blood pressure may exaggerate hemodynamic perturbation after a sudden loss of circulating blood volume.
In addition, it is possible that patients who have received ETS will show unexpected HR responses after the administration of a vasopressor or vasodilator. We conclude that baroreflex response as a compensatory function for hemodynamic changes is suppressed in patients who receive ETS.
Yurie T. Kawamata, MD*, Tomoyuki Kawamata, MD†, Keiichi Omote, MD†, Eiji Homma, MD*,
Tatsuo Hanzawa, MD*, Toshifumi Kaneko, MD‡, and Akiyoshi Namiki, MD†
(Anesth Analg 2004;98:37–9)
In this study, baroreflex control of HR was completely inhibited in 9 of 21 patients in the depressor test but in only 1 of 19 patients in the pressor test. All patients who showed complete inhibition had received bilateral T2-3 sympathectomy. Responses to decreased blood pressure are mediated by the sympathetic nervous system, whereas responses to increased blood pressure predominantly involve vagal compensation (13). Therefore, it seems that the effects of sympathetic denervation were most prominent in the de-
pressor test after ETS.
The suppression of baroreflex function can be detrimental during anesthetic management. In particular, a poorly preserved baroreflex response to decreasing blood pressure may exaggerate hemodynamic perturbation after a sudden loss of circulating blood volume.
In addition, it is possible that patients who have received ETS will show unexpected HR responses after the administration of a vasopressor or vasodilator. We conclude that baroreflex response as a compensatory function for hemodynamic changes is suppressed in patients who receive ETS.
Increased Lipid Deposits in the Iris following Sympathectomy
• Much interest has focused recently on the important role played by the smooth muscle
cell in the pathogenesis of atherosclerosis. This is because it is the smooth muscle cell of
the intimal and subintimal region which is involved early and to a marked degree by the
lipid deposits.
The eye provides a model system with three unique advantages: (1) the iris is rich in smooth
muscle cells which are well localized; (2) lipid deposits in the eye can be easily seen and their
progression can be followed visually; (3) certain experimental modifications can be readily
introduced into the model system during life. For example, the eye can be sympathetically
denervated. This deprives smooth muscle cells of the levator and iris dilator muscles of locally
released norepinephrine. It is increasingly recognized that norepinephrine exerts a regula-
tory effect on lipid metabolism.
1971;2;23-34 Stroke (Stroke is published by the American Heart Association)
ARMSTRONG JAMES AUSTIN, WILLIAM ROBERTS, HANS NEVILLE and DONALD
cell in the pathogenesis of atherosclerosis. This is because it is the smooth muscle cell of
the intimal and subintimal region which is involved early and to a marked degree by the
lipid deposits.
The eye provides a model system with three unique advantages: (1) the iris is rich in smooth
muscle cells which are well localized; (2) lipid deposits in the eye can be easily seen and their
progression can be followed visually; (3) certain experimental modifications can be readily
introduced into the model system during life. For example, the eye can be sympathetically
denervated. This deprives smooth muscle cells of the levator and iris dilator muscles of locally
released norepinephrine. It is increasingly recognized that norepinephrine exerts a regula-
tory effect on lipid metabolism.
1971;2;23-34 Stroke (Stroke is published by the American Heart Association)
ARMSTRONG JAMES AUSTIN, WILLIAM ROBERTS, HANS NEVILLE and DONALD
Autonomic dysequilibrium leading to obesity
Total chemical sympathectomy in experimental animals results in loss of shivering and nonshivering thermogenesis, and death within a few hours.
Further evidence suggesting that abnormal sympathetic activity may cause pain comes from reports of pain following sympathectomy. This has occurred after stellate ganglion block and lumbar sympathectomy.
A similar reduction of fat mobilization from fat depots occurs after VMH lesions, as after local sympathectomy, suggesting that the sympathetic pathway to the adipose tissue runs through the VMH.
Bray and York hypothesize that the change in energy balance in animals after VMH lesions is a result of autonomic dysequilibrium. The sympathetic outflow is reduced and the parasympathetic outflow increased. This shift in balance results in hyperinsulinemia and altered metabolic pathways leading to obesity. During the digestion and metabolism of a meal, the autonomic nervous system provides important (but not sole) feedback control on satiety.
The Nervous System and Adipose Tissue, By Katharine Dalziel, MD, MBBS, MRCP
Clinics in Dermatology
October-December 1989, Volume 7, Number 4, pages 62-77
Further evidence suggesting that abnormal sympathetic activity may cause pain comes from reports of pain following sympathectomy. This has occurred after stellate ganglion block and lumbar sympathectomy.
A similar reduction of fat mobilization from fat depots occurs after VMH lesions, as after local sympathectomy, suggesting that the sympathetic pathway to the adipose tissue runs through the VMH.
Bray and York hypothesize that the change in energy balance in animals after VMH lesions is a result of autonomic dysequilibrium. The sympathetic outflow is reduced and the parasympathetic outflow increased. This shift in balance results in hyperinsulinemia and altered metabolic pathways leading to obesity. During the digestion and metabolism of a meal, the autonomic nervous system provides important (but not sole) feedback control on satiety.
The Nervous System and Adipose Tissue, By Katharine Dalziel, MD, MBBS, MRCP
Clinics in Dermatology
October-December 1989, Volume 7, Number 4, pages 62-77
Neuroma following Sympathectomy
The authors conclude recomemnding the application of clips and if the syndrome nevertheless appears novocaine infiltration of the upper end of the sympathetic chain. The authors are convinced that the theory of Hermann and Cooley about neuroma formation at the ends of the sympathetic chain after resection of a segment is true.
http://www.revangiol.com/sec/resumen.php?or=web&i=e&id=227082.
Traumatic neuroma follows different forms of nerve injury (often as a result of surgery). They occur at the end of injured nerve fibres as a form of ineffective, unregulated nerve regeneration; it occurs most commonly near a scar, either superficially (skin, subcutaneous fat) or deep (e.g., after a cholecystectomy). They are often very painful. It is also known as "pseudoneuroma".
http://www.revangiol.com/sec/resumen.php?or=web&i=e&id=227082.
Traumatic neuroma follows different forms of nerve injury (often as a result of surgery). They occur at the end of injured nerve fibres as a form of ineffective, unregulated nerve regeneration; it occurs most commonly near a scar, either superficially (skin, subcutaneous fat) or deep (e.g., after a cholecystectomy). They are often very painful. It is also known as "pseudoneuroma".
postsympathectomy syndrome
In both groups two cases of postsympathectomy syndrome were seen, with one leg being colder and dryer than the other.
Clinical Orthopaedics & Related Research. 360:122-126, March 1999.
Clinical Orthopaedics & Related Research. 360:122-126, March 1999.
neuropathic and central deafferentation/reafferentation syndrome
Post-sympathectomy neuralgia is proposed here to be a complex neuropathic and central deafferentation/reafferentation syndrome dependent on: (a) the transection, during sympathectomy, of paraspinal somatic and visceral afferent axons within the sympathetic trunk; (b) the subsequent cell death of many of the axotomized afferent neurons, resulting in central deafferentation; and (c) the persistent sensitization of spinal nociceptive neurons by painful conditions present prior to sympathectomy. Viscerosomatic convergence, collateral sprouting of afferents, and mechanisms associated with sympathetically maintained pain are all proposed to be important to the development of the syndrome.
Pain. 1996 Jan;64(1):1-9
http://www.ncbi.nlm.nih.gov/pubmed/8867242?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
Pain. 1996 Jan;64(1):1-9
http://www.ncbi.nlm.nih.gov/pubmed/8867242?ordinalpos=2&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
Postsympathectomy pain and changes in sensory neuropeptides
Postsympathectomy limb pain, postsympathectomy parotid pain, and Raeder's paratrigeminal syndrome are pain states associated with the loss of sympathetic fibres and in particular with postganglionic sympathetic lesions. There is a characteristic interval of about 10 days between surgical sympathectomy and onset of pain. It is proposed that this pain in man is correlated with the delayed rise in sensory neuropeptides seen in rodents after sympathectomy. These chemical changes probably reflect the sprouting of sensory fibres and may result from the greater availability of nerve growth factor after sympathectomy. The balance between the sensory and sympathetic innervations of a peripheral organ may be determined by competition for a limited supply of nerve growth factor.
Lancet. 1985 Nov 23;2(8465):1158-60
http://www.ncbi.nlm.nih.gov/pubmed/2414615?dopt=Abstract
Lancet. 1985 Nov 23;2(8465):1158-60
http://www.ncbi.nlm.nih.gov/pubmed/2414615?dopt=Abstract
sensory abnormalities, abnormal body sweating, and pathologic gustatory sweating
The aim of this study is to describe the incidence and characteristics of pain, sensory abnormalities, abnormal body sweating, and pathologic gustatory sweating in pain patients with persistent post-sympathectomy pain.
Results: Seventeen adults (13 females and 4 males) with a mean age of 37 years (range 25-52) at the time of sympathectomy met the inclusion criteria. Five of the 17 patients experienced temporary pain relief for an average of 4 months (range 2-12 months), 3/17 retained the same pain as before the surgery, 1 patient was cured of her original pain but experienced a new debilitating pain, and 8/17 patients continued to have the same or worse pain in addition to a new or expanded pain. Pathologic gustatory sweating was present in 7/11 patients asked, and abnormal sweating (known as compensatory hyperhidrosis) in 11/13 patients asked. Discussion: The present study does not allow for conclusions about the effectiveness of surgical sympathectomy for neuropathic pain. However, our findings indicate that if the pain persists after the procedure, the complications may be quite serious and at times worse than the problem for which the surgery was originally performed.
The Clinical journal of pain
2003, vol. 19, no3, pp. 192-199
http://cat.inist.fr/?aModele=afficheN&cpsidt=14775091
Results: Seventeen adults (13 females and 4 males) with a mean age of 37 years (range 25-52) at the time of sympathectomy met the inclusion criteria. Five of the 17 patients experienced temporary pain relief for an average of 4 months (range 2-12 months), 3/17 retained the same pain as before the surgery, 1 patient was cured of her original pain but experienced a new debilitating pain, and 8/17 patients continued to have the same or worse pain in addition to a new or expanded pain. Pathologic gustatory sweating was present in 7/11 patients asked, and abnormal sweating (known as compensatory hyperhidrosis) in 11/13 patients asked. Discussion: The present study does not allow for conclusions about the effectiveness of surgical sympathectomy for neuropathic pain. However, our findings indicate that if the pain persists after the procedure, the complications may be quite serious and at times worse than the problem for which the surgery was originally performed.
The Clinical journal of pain
2003, vol. 19, no3, pp. 192-199
http://cat.inist.fr/?aModele=afficheN&cpsidt=14775091
Recurrent sweating occurred in 17.6% of patients
J Neurosurg Spine. 2005 Feb;2(2):151-4.
http://www.ncbi.nlm.nih.gov/pubmed/15739526
http://www.ncbi.nlm.nih.gov/pubmed/15739526
Post-sympathectomy the peripheral vascular failure or the reduced cardiac chronotropic response can impair the body’s capacity to compensate for shock
First, the abolition of sweating from the upper body as well as the axillae and both upper limbs may have significantly reduced the capacity of the patient to lose heat through sweating during exercise. Anhidrosis in the head and neck after sympathectomy affects a proportion of patients, but is often neglected in most reports of post-sympathectomy complications [3]. The loss of head and neck sweating in this patient may have further impaired overall heat loss. However we would also note that the degree of heat loss impairment after sympathectomy has never been quantified, and its effect on body temperature during exercise remains to be established.
Second, thoracic sympathectomy has been demonstrated to abolish or alter sympathetic vasoconstrictive responses in the skin, and this may contribute to abnormal peripheral vascular responses to temperature [4]. Paradoxically it has been suggested that in some cases there may be abnormal vasoconstriction rather than the expected vasodilatation after sympathectomy [5]. It is not impossible that such atypical peripheral vascular responses to rising body temperature may have contributed to impaired heat loss during exercise or to an inappropriate response to shock on the development of the heat stroke.
Third, it has been shown that thoracic sympathectomy can impair the autonomic nervous system’s increase of the heart rate in response to exercise [6]. Although absolute tachycardia is not eliminated, given the endocrine and paracrine stimuli during exercise, the maximum heart rate reached during exercise has been shown to be significantly reduced after sympathectomy. Thus for a given workload during exercise, there will be a relative bradycardia. This may possibly affect the circulatory system’s ability to convey heat from the body core to the extremities for heat loss.
Alan D.L. Sihoe, FRCSEd(CTh)a,* , Raymond W.T. Liu, MRCPb , Alex K.L. Lee, MRCPb , Chak-Wah Lam, FHKAMb , Lik-Cheung Cheng, FRCSa
http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025
Second, thoracic sympathectomy has been demonstrated to abolish or alter sympathetic vasoconstrictive responses in the skin, and this may contribute to abnormal peripheral vascular responses to temperature [4]. Paradoxically it has been suggested that in some cases there may be abnormal vasoconstriction rather than the expected vasodilatation after sympathectomy [5]. It is not impossible that such atypical peripheral vascular responses to rising body temperature may have contributed to impaired heat loss during exercise or to an inappropriate response to shock on the development of the heat stroke.
In the post-sympathectomy patient, the abnormal sympathetic skin response may lead to peripheral vascular failure or the reduced cardiac chronotropic response may impair the body’s capacity to compensate for shock. These may have contributed to the rapid development of shock and severe multiple organ dysfunction syndrome in this patient.
Third, it has been shown that thoracic sympathectomy can impair the autonomic nervous system’s increase of the heart rate in response to exercise [6]. Although absolute tachycardia is not eliminated, given the endocrine and paracrine stimuli during exercise, the maximum heart rate reached during exercise has been shown to be significantly reduced after sympathectomy. Thus for a given workload during exercise, there will be a relative bradycardia. This may possibly affect the circulatory system’s ability to convey heat from the body core to the extremities for heat loss.
Is Previous Thoracic Sympathectomy a Risk Factor for Exertional Heat Stroke?
Atrial Fibrillation chemically induced
Pituitary adenylate cyclase-activating polypeptide-27 causes a biphasic chronotropic effect and atrial fibrillation in autonomically decentralized, anesthetized dogs.
Author: Hirose, M : Furukawa, Y : Nagashima, Y : Lakhe, M : Chiba, S
J-Pharmacol-Exp-Ther. 1997 Nov; 283(2): 478-87
Author: Hirose, M : Furukawa, Y : Nagashima, Y : Lakhe, M : Chiba, S
J-Pharmacol-Exp-Ther. 1997 Nov; 283(2): 478-87
Effect of local autonomic denervation on in vitro responsiveness of lymphocytes
The results further indicate that an appropriate sympathetic and parasympathetic local environment may be needed for immunomodulation, as well as for cyclosporine activity in lymphoid tissue.
Journal of the Autonomic Nervous System
Volume 62, Issue 3, 17 February 1997, Pages 155-162
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T05-3PKTG6C-6&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=da81efda6c250763623b89537aed8109
Journal of the Autonomic Nervous System
Volume 62, Issue 3, 17 February 1997, Pages 155-162
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T05-3PKTG6C-6&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=da81efda6c250763623b89537aed8109
Origins of the sympathetic projections to rat thyroid and parathyroid glands
These results indicate that postganglionic sympathetic perikarya innervating the thyroid-parathyroid territory are located in the middle and/or inferior cervical ganglia and send their axons through the SCG and the external carotid nerve to these glands.
http://lib.bioinfo.pl/pmid:3772028
http://lib.bioinfo.pl/pmid:3772028
stress responses and adrenal sensitivity to ACTH.
Walker CD.
Chemical sympathectomy and maternal separation affect neonatal stress responses and adrenal sensitivity to ACTH.
Am J Physiol Regul Integr Comp Physiol 268: R1281–R1288, 1995.
Chemical sympathectomy and maternal separation affect neonatal stress responses and adrenal sensitivity to ACTH.
Am J Physiol Regul Integr Comp Physiol 268: R1281–R1288, 1995.
Decrease in neuronal uptake of noradrenaline
Shibata K, Takei S, Kawai T, Imaizumi Y, and Watanabe M.
Decrease in neuronal uptake of noradrenaline simply explains the supersensitivity
after sympathectomy in the rat iris dilator.
Jpn J Pharmacol 50: 19 –29, 1989.D
Decrease in neuronal uptake of noradrenaline simply explains the supersensitivity
after sympathectomy in the rat iris dilator.
Jpn J Pharmacol 50: 19 –29, 1989.D
Sympathetic nervous system activity in rat thyroid: potential role in goitrogenesis
Unilateral superior cervical ganglion decentralization led to a reduction in thyroid weight, in 125I uptake by thyroid tissue, and in TSH-induced stimulation of 125I uptake in decentralized hemithyroids. These results suggest that sympathetic activity in thyroid contributes to gland enlargement and may modulate tissue responsiveness to TSH.
Am J Physiol Endocrinol Metab 288: E861-E867, 2005. First published December 7, 2004
http://ajpendo.physiology.org/cgi/content/full/288/5/E861
Am J Physiol Endocrinol Metab 288: E861-E867, 2005. First published December 7, 2004
http://ajpendo.physiology.org/cgi/content/full/288/5/E861
