Bagolie Friedman (lawyer)'s warning about ETS:

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Tuesday, October 25, 2005

Endoscopic Thoracic Sympathectomy (ETS) Surgery & Hyperhidrosis

ETS surgery works by deliberately destroying part of the sympathetic nervous system. ETS stands for Endoscopic Thoracic Sympathectomy. We use the term ETS to include all its variations, including "ESB" (Endoscopic Sympathetic Blockade) a.k.a. "ETS clamping method", and "VAT Sympathectomy" (Video Assisted Thoracotomy). All of these methods work by destroying some part of the thoracic sympathetic nerves trunk.

ETS is performed to treat hyperhidrosis (excessive sweating), facial blushing, and psychiatric conditions such as social phobia. Although sympathectomy has been performed since 1920, the video-assisted "minimally invasive" technique was developed in Sweden in the late 1980's, and is currently being heavily marketed in the U.S. and around the world, except in Sweden, because ETS was banned there in 2003 due to overwhelming complaints by disabled patients.

The most common body areas treated for hyperhidrosis are the hands, face and scalp, the armpits, and the feet. Using miniature endoscopic, video-assisted technology, the surgeon enters the chest cavity and destroys part of the sympathetic nerve chain by burning, cutting, resecting or clamping.

The sympathetic trunk is two chains of nerve ganglia running down along either side of the spine. These chains go through three body regions - the cervical (by the neck), the thoracic (in the chest), and the lower back (lumbar). The pairs of ganglia are referred to with a letter and a number; the letter being either C (cervical), T (thoracic) or L (lumber); and the number referring to which vertebrae the ganglia is near. So T2 would be the ganglion at the level of the 2nd thoracic vertebrae. It has been known for many decades that interupting the sympathetic chain in the area of T2-T5 would cause an inability to sweat from the nipple line up. This is also known to cause a host of other changes, including reduction in heart rate.

The sympathetic nervous system is part of the autonomic nervous system, which controls many bodily functions outside the conscious will of the mind. The sympathetic and parasympathetic systems work in opposition to one another. In general, the sympathetic nerves speed up or strengthen a function, while the parasympathetic nerves slow down or weaken the function. For instance, the sympathetic nerves are responsible for speeding up the heart rate, the parasympathetic nerves are responsible for slowing it back down again. When the sympathetic nerves are destroyed, an imbalance between the two systems is created. We can call this imbalance "parasympathetic dominance".

There are quite a few variations on the surgery. Origianlly, the nerve ganglia were resected (removed). This was permanent and left no possibility for reversal, should the patient experience bad side-effects. This led to merely cutting the sympathetic chain at a particular level, while leaving the ganglia intact. Eventually, surgeons developed the technique of blocking the nerve impulses with titanium clamps, on the theory that they could be removed to restore at least partial function.

Also among the surgical variants are the specific T-level(s) targeted. Dr. Chien-Chih Lin of Taiwan and Dr. Timo Telaranta of Finland have created the Lin-Telaranta classification system, which attempts to categorize patients according to their specific patterns of sweating and blushing, and then recommend targeted sympathetic surgery. The "magic bullets" have proved elusive, and all ETS surgeries cause widespread denervation. Here are Dr. Telaranta's current (2004) general guidelines for clamping:

Sweating of the hands - T4
Sweating and Facial Blushing - T3
Blushing of the face alone - T2
Social anxiety with Facial Blushing - T2
Social anxiety without Facial Blushing - T3 and T4 on the left side only
Heart racing and rhythm disorders - T3, T4, and T5 on the left side only

A few surgeons take a much more aggressive approach, removing the entire T2 and T3 ganglia, and sometimes T4 (known as ganglia resection or ganglionectomy).

Due to extremely high dissatisfaction rates and severe side effects, especially among facial sweaters, surgeons have explored methods to reverse the surgery. As mentioned, many ETS surgeons are now using titanium clamps to interrupt the sympathetic nerve. Unfortunately, unless the clamps are removed within a few days, or at most a few weeks after surgery, the crushed nerve tissue will mostly fail to revive.

Another attempted method of reversal is the nerve graft, of which two variations have been developed. One involves taking a piece of the sural nerve from the left calf and bridging the damaged area of the sympathetic chain. The grafted nerve is supposed to act as a "bridge" or "shield" to allow regeneration of the severed axons. It has proven very difficult to create a viable blood supply for the grafted nerve, and also leaves the patient with a numb left foot. The sural nerve graft appears mostly ineffective.

The other nerve graft is called ICNG, for intercostal nerve graft. In this one, pieces of intercostal nerves, along with blood vessels, are disconneted from under the ribs, flopped over and grafted into the damaged sympathetic chain. This method has the advantage of an already functioning blood supply, but can cause severe chest pain.This method has also seen very limited success.

The theoretical possiblity of regenerating nerves in the sympathetic trunk does exist, with some importatnt considerations. It is crucial to distinguish between "nerve" and "nerve ganglia". A nerve is a long series of axons covered by a sheath. Axons can regenerate themselves over time in certain circumstances, expecially if the patient is young. A nerve ganglion is made of neurons, that is nerve cell bodies. They are like little brains. Nerve ganglia do not regenrate under any circumstances. You are born with all the neurons you will ever have.

The sympathetic trunk is not "a nerve". It is a long chain of nerve ganglia connected by nerves. A sympathectomy which only involved the destruction of the nerves in between ganglia would offer at least a theoretical chance of useful regenration. Sympathectomy involving destruction to the ganglia themselves is absolutely permanent unless and until cloning of body parts becomes viable.

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