"Sympathectomy is a technique about which we have limited knowledge, applied to disorders about which we have little understanding." Associate Professor Robert Boas, Faculty of Pain Medicine of the Australasian College of Anaesthetists and the Royal College of Anaesthetists

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

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

stellate ganglion block in the treatment of panic/anxiety symptoms

Both patients experienced immediate, significant and durable relief as measured by the PCL (score minimum 17, maximum 85). In both instances, the pre-treatment score suggested a PTSD diagnosis whereas the post-treatment scores did not. One patient requested repeat treatment after 3 months, and the post-treatment score remained below the PTSD cutoff after 7 additional months of follow-up. Both patients discontinued all antidepressant and antipsychotic medications while maintaining their improved PCL score.

CONCLUSION:

Selective blockade of the right stellate ganglion at C6 level is a safe and minimally invasive procedure that may provide durable relief from PTSD symptoms, allowing the safe discontinuation of psychiatric medications.
http://www.ncbi.nlm.nih.gov/pubmed/20412504

Stellate ganglion block "reboots" the insular cortex

The following is a summary from our publications in Lancet Oncology and Medical Hypothesis

34   The picture demonstrates the connections from the stellate ganglion to other neural structures.  This was demonstrated using retro rabies virus techniques and functional MRI.  Both are objective data demonstrating the effect on the insula by the stellate ganglion.  Stellate ganglion block effectively "reboots" the insular cortex, allowing for a reduction in hot flashes


The stellate ganglion refers to the ganglion formed by the fusion of the inferior cervical and the first thoracic ganglion as they meet anterior to the vertebral body of C7. It is present in 80% of subjects. It usually lies on or above the neck of the first rib.
http://dardipainclinic.com/stellate_ganglion_block.php 

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

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 

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. BaumgartnerCorresponding Author Contact Information, a, E-mail The Corresponding Author, Shana Bertina and Jiri Konecnya

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

denervation supersensitivity of alpha receptors after sympathectomy

There is, however, considerable risk of developing a post-sympathectomy pain syndrome that may be the result of a denervation supersensitivity of alpha receptors.
www.mc.vanderbilt.edu/.../Complex%20Regional%20Pain%20Syndrome-1. 

 Paradoxically it has been suggested that in some cases there may be abnormal vasoconstriction rather than the expected vasodilatation after sympathectomy.
ats.ctsnetjournals.org/cgi/content/full/84/3/1025  

compensatory disease may not be immediate after sympahectomy

Newer techniques include the use of clips instead of complete transsection of the nerve but reversal is not always possible as nerve destruction can be quick and compensatory disease may not be immediate.

The main complications with sympathectomy include compensatory sweating, phantom sweating, gustatory sweating, Horner syndrome, and neuralgia.

Management of Hyperhidrosis

Aamir Haider, Nowell Solish and Nicholas J. Lowe
www.sweatclinicsofcanada.com/Book.pdf

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

reduction in hypothalamic dopamine after sympathecomy, which leads to an increase in serum prolactin level

At this point, it is particularly interesting to recall the earlier reports of middle ear bone remodeling in the gerbil after chemical sympathectomy by guanethidine sulfate (86) or hydroxydopamine (85). Although these neurotoxins do eliminate sympathetic activity, there are, in parallel, major central consequences. In particular, both treatments reduce hypothalamic dopamine, which leads to an increase in serum prolactin levels.
http://ajpendo.physiology.org/content/293/5/E1224.full

"Again, patients admitted with any malignancy, cholecystectomy, thyroidectomy, renal disease, cardiac disease, sympathectomy, or vascular graft were eliminated as controls."
This article reviews the evidence that neuroleptics may increase the risk of breast cancer via their effects on prolactin secretion.
Paul M. Schyve; Francine Smithline; Herbert Y. Meltzer
Neuroleptic-induced Prolactin Level Elevation and Breast Cancer: An Emerging Clinical Issue
Arch Gen Psychiatry, Nov 1978; 35: 1291 - 1301.

Body temperature is highly correlated with plasma prolactin in thermally stressed men
(78), suggesting that normal heat defense is associated with decreased central dopamine, and
intraventricular haloperidol produces a coordinated heat-defense response (79). These reports refute a
unique or essential role for central dopamine antagonism in neuroleptic malignant syndrome hyperthermia and provide additional evidence that state-dependent factors are important mediators of dopamine antagonist effects.

There is substantial evidence to support the hypothesis that dysregulated sympathetic nervous system hyperactivity is responsible for most, if not all, features of neuroleptic malignant syndrome. A predisposition to more extreme sympathetic nervous system activation and/or dysfunction in response to emotional or psychological stress may constitute a trait vulnerability for neuroleptic malignant syndrome, which, when coupled with state variables such as acute psychic distress or dopamine receptor antagonism, produces the clinical syndrome of neuroleptic malignant syndrome. This hypothesis provides a more comprehensive explanation for existing clinical data than do the current alternatives.

http://ajp.psychiatryonline.org/cgi/content/full/156/2/169

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

lumbar sympathectomy results in loss of ejaculation

Sympathectomy for the long term management of such patients has been carried out (Abel et al., 1974) and success reported. Loss of ejaculation does follow sympathectomy but his is a minor problem in patients who have an already destroyed sacral cord. (p. 410)

During fever pyrogen is released from leucocytes and his agent causes the disturbed thermoregulation (Atkinson, 1960). For his response to occur, an intact efferent sympathetic system is requred because fever can be markedly reduced by bilateral sympathectomy in he cat (Pinkston, 1935). (p.193)
The autonomic nervous system: an introduction to basic and clinical concepts By Otto Appenzeller, Emilio Oribe, Elsevier Health Sciences, 1997 - Medical

significant change after sympathectomy: reduced sympathetic and increased vagal tone

The HRV analysis showed a significant change of indices reflecting sympatho-vagal balance indicating significantly reduced sympathetic (LF) and increased vagal (HF, rMSSD) tone. These changes still persisted after 2 years. Global HRV increased over time with significant elevation of SDANN after 2 years. QT dispersion was significantly reduced 1 month after surgery and the dispersion was further diminished 2 years later.
http://www.sciencedirect.com/science/article/pii/S0167527399001011

Surgical and chemical sympathectomy can alter cellular proliferation

Surgical denervation and chemical sympathectomy can alter cellular proliferation, B- and T-cell responsiveness and lymphocyte migration in lymphoid organs [17]. In vitro studies have shown that neuropeptides can have numerous effects, either inhibiting or stimulating the proliferation, differentiation
and functions of immune cells [19]*
Development of systemic lupus erythematosus in mice is associated with alteration of neuropeptide concentrations in inflamed kidneys and immunoregulatory organs
Neuroscience Letters 248 (1998) 97– 100

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

relevant to post-sympathectomy pain

These data suggest that induction of a prolonged state of mechanical hyperalgesia causes time-dependent alterations in the sympathetic control of peripheral nociceptive mechanisms such that sympathectomy can lead to enhanced hyperalgesic response. These findings may be relevant to post-sympathectomy pain, a clinical entity for which there has been no available animal models.
http://www.sciencedirect.com/science/article/pii/0306452295005307

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

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).
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