This page has been set up to allow ETS patients, unhappy with side effects, to have access to skeleton letters, review recommendations and addresses of Surgical Review Societies. In Australia, a group of us have written to the Australian Medical Boards and ASERNIPs, a surgical review group, and have since been in regular contact with them. Together we will work together in Australia to create awareness. We, in Australia, like the other support groups around the world, are sick and tired of having to research and find answers. The responsibility should NOT be on the patient, but on the Medical Community. It is also a joke that controlled trials are being written and published by the Doctors who perform these operations. This is totally partisan and against the objective scientific approach the scientific community should take when investigating any operation. For this reason, it would be a waste of time to publish the ETS surgeons papers/studies who find NO incidence of side-effects or no significance. We aim to publish only papers/studies/reviews written objectively. As many members of P.A.S.S and other ETS groups are academics, it is also our aim to be respectful and only publish full articles we have been given permission to present on this site. Otherwise, we have just published the publically available Abstracts.
This a letter to an editor, written by Dr Teleranta and Dr Lin, in response to Dr Reisfeld. The reason i've posted it is because it's an excellent indicator that side effects do exist. It is also a reflection of Dr Teleranta's changing tone over the years about ETS surgery. He no longer performs the ETS operation, but only does the Reversal operation. He sent me a personal email in around 2004 expressing his decision to stop performing ETS surgery, based on the large amount of unhappy patients.
This article is a poemic letter with the results of Dr Reisfeld. It was written by Tomasz J. Stefaniak, MD, PhD. I have full permission by him to publish this letter on our website. The original article, which the latter letter was a response to, will be posted after I get permission. This letter basically is a recognition by Dr Reisfeld that there is a need for objective trials and more frequent follow-ups.
This is a paper which reflects that there are severe side-effects.
This is a systematic objective review, which shows AGAIN that there are side-effects.
This is a paper which shows that Compensatory Sweating is a side-effect.
This was the first objective study to show that there are Gustatory sweating side-effects as a direct result of ETS surgery.
This letter was written to Meg in Australia from ASERNIP-s (surgical ethical review society) in 2003 after she requested that the surgery be investigated. It STILL has not had an objective trial done on the surgery.
The attached ETS review recommendations were sent by 'Madonna' (an Australian woman who successfully sued for the ETS operation she had and has moved on with her life) to the Medical Board VIC, AUSTRALIA.
Endoscopic Thoracic Sympathectomy -
Endoscopic Thoracic Sympathectomy (ETS) is being marketed and routinely performed in Australia for facial blushing and hyperhidrosis, seemingly without adequate patient screening, follow up, disclosure of side effects or surgeon expertise.
ETS Marketing -
In 1998 the surgical procedure Endoscopic Thoracic Sympathectomy (ETS) was featured on Channel Nine’s Good Medicine Program as an effective treatment for palmar or generalized hyperhidrosis and facial blushing. A follow up fact sheet entitled “Blushing” was posted on the ninemsn.com web site of Good Medicine and contained patient testimonials. Hundreds of Australians subsequently contacted the two surgeons featured on the program or sought a local doctor performing ETS.
Patient Pre-Screening -
In brochures, doctor emails and verbal advice patients are commonly given the following information from surgeons performing ETS:
Many patients are not advised about non-surgical treatments nor requested to rule out other physical causes in blushing and sweating.
Evidence of patient Dissatisfaction -
Good Medicine removed the “Blushing” fact sheet from their web site in April 2002.
The Melbourne Centre for Hyperhidrosis and Facial Blushing have recently updated their web site now acknowledging that side effects do occur for radical underarm sweating surgeries and have changed from the cutting to the clamping method.
Satisfaction with the side effects of ETS diminishes over time, predominantly due to the persistence of compensatory sweating.
Facial Blushing -
Non-surgical remedies such as Cognitive Behavioural Therapy (CBT) and/or medication should be a pre-requisite as the cognitive processing involved in social phobias such as fear of blushing cannot be cured by ETS. Possible underlying conditions such as Body Dismorphic Disorder need to be ruled out as such blushing may not be as noticeable to others as some patients imagine. Anti-anxiety medications should also be mandatory. Given a blushers hypersensitivity about physical appearance, the impact of side effects of dry facial skin, noticeable compensatory hyperhidrosis, facial swelling and increased facial flushing have not been considered by ETS surgeons.
Patients should be fully informed that:
Hyperhidrosis -
Medical testing to rule out all possible causes of sweating (eg thyroid disorders) should be mandatory. Those we seek ETS for palmar HH only may be extremely dissatisfied with ETS due to CS. The T2 ganglia is also cut for palmar hyperhidrosis.
ETS Side Effects are not adequately disclosed or are often downplayed by doctors:
Doctors do not adequately explain or disclose all ETS side effects: It is misleading to inform patients that only 2% will develop severe compensatory sweating since:
It is misleading to inform patients that should they develop compensatory sweating, it usually diminishes over time, since:
In a study by Fredman B, Zohar E, Shachor D, Bendahan J, Jedeikin R.. Surg Laparosc Endosc Percutan Tech 2000 Aug;10(4):226-9 results showed:
Postsurgery, severe compensatory sweating was experienced in 90% of patients (P < 0.0001). The sites of compensatory sweating were the back (75%), abdomen (51%), feet (23%), groin and thigh (13%), chest (13%), and axillae (8%). Transient whole-body sweating for no apparent reason was experienced in 30% of patients. Thirty-seven patients (11%) regretted having undergone the surgical procedure
It is misleading to tell patients ETS is effective for FB when no studies have shown this to be the case. The Centre for Clinical Effectiveness, Monash Institute of Health Services Research, Monash University, conduct a study into the effectiveness of ETS for Facial Blushing. 6 In response to the question: Is endoscopic thoracic sympathectomy (ETS) an effective treatment option for facial blushing? they concluded: Facial blushing has returned in some Australian patients post ETS. Some doctors now believe that the T1 ganglia, not the T2 which is routinely cut/clamped for FB, is responsible for FB.
Many doctors have changed to the ESB clamping method which is considered to be theoretically reversible in the first 3-6 months only.
Patient Follow Up -
To date no Australian doctors performing ETS do regular comprehensive patient follow ups. They continue to quote positive results, dismiss side effects as unrelated and isolated incidences or refer those with side effects post ETS elsewhere. One doctor even referred a patient to a psychologist when she reported facial burning and flushing, yet never conducted any psychological pre-screening before performing the surgery. Some patients have reported feelings of isolation, depression and thoughts of suicide due to post ETS side effects.
Based on a literature review and survey of Australians and Australian neurosurgeons who have received many requests for ETS nerve graft reversal surgery an urgent review of ETS needs to be conducted so that: ETS is viewed as a drastic last resort measure in treating conditions such as hyperhidrosis. Physical examinations to rule out other causes and non surgical treatments should be tried first, not merely a first option via GP referral.
The practice and long term effectiveness of ETS in treating Facial Blushing needs to be investigated. Cognitive Behavioral Therapy should be a mandatory prerequisite given the socio-psychological basis of facial blushing and other equally embarrassing side effects of the surgery such as compensatory sweating (CS) which patients cannot comprehend pre-surgery.
Doctors and patients need to be fully educated about the side effect of compensatory sweating and its incidence. Lower body Compensatory Sweating (CS) and upper body anhidrosis will occur in all patients to some degree and has never been quantified. There is no evidence or physiological reason why CS should diminish over time and it is misleading that many Australian doctors inform patients pre-ETS that CS settles down over time . CS needs to be fully explained and graphic images shown so that patients can adequately assess the permanent impact of CS on their quality of life. No studies or known cases of post ETS pregnancies or implications for menopause have been reported.
Doctors should be asked to back up their statistical claims with patient follow up data. While they frequently report success rates, patient satisfaction rates (ie with the side effects) are thus not reflected. This is misleading.
Patient follow-ups should be regularly conducted by an independent body to assess patient satisfaction over time. Timing of studies to allow patients to experience CS over summer should be considered. The trade off in developing side effects for the original (FB/HH) condition should be factored in. As most patients are told CS diminishes over time, initial satisfaction rates with the surgery may not factor in its permanence. There appear to be a significant number of Australian patients who are dissatisfied with the surgery and are seeking legal action.
ETS should not be performed on young children or teenagers where blushing and sweating may be common hormonal /developmental stages they will outgrow.
1
http://www.med.monash.edu.au/healthservices/cce/evidence/pdf/c/541.pdf
2
http://camelot.hiwd.net/customers/hcu/complications.html#effect1 3
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&
list_uids=11727092&dopt=Abstract : . Riet M, Smet AA, Kuiken H, Kazemier
G, Bonjer HJ , Surg Endosc 2001 Oct;15(10):1159-62 Prevention of
compensatory hyperhidrosis after thoracoscopic sympathectomy for
hyperhidrosis.
4 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&
list_uids=10961751&dopt=Abstract ? Fredman B, Zohar E, Shachor D,
Bendahan J, Jedeikin R.. Surg Laparosc Endosc Percutan Tech 2000
Aug;10(4):226-9 Video-assisted transthoracic sympathectomy in the
treatment of primary hyperhidrosis: friend or foe Department of
Anesthesiology and Critical Care, Meir Hospital, Kfar Saba, Israel.
5 http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&
list_uids=10961751&dopt=Abstract ? Fredman B, Zohar E, Shachor D,
Bendahan J, Jedeikin R.. Surg Laparosc Endosc Percutan Tech 2000
Aug;10(4):226-9 Video-assisted transthoracic sympathectomy in the
treatment of primary hyperhidrosis: friend or foe Department of
Anesthesiology and Critical Care, Meir Hospital, Kfar Saba, Israel.
http://www.med.monash.edu.au/healthservices/cce/evidence/pdf/c/541.pdf
Centre for Clinical Effectiveness, Monash Institute of Health
Services Research Feb 2001
Department of Surgery, Erasmus University Medical
Center, Rotterdam, The Netherlands.
Centre for Clinical Effectiveness, Monash Institute of Health Ser
vices Research Feb 2001
Dr Peter Drummond has always questioned the efficiency of ETS surgery for blushing. He also has been a supporter of Australian ETS patients who've complained about the side-effects. We have received permission by Blackwell Publishing to publish the following letter.
LETTER TO THE EDITOR OF BRITISH MEDICAL JOURNAL BY DR PETER DRUMMOND
* to be added later with PDF.
This is a letter/article published in the British Journal of Dermatology on ETS and its side-effects. He basically cautions people to not choose ETS for sweating and blushing, due to CS.
The title of the paper is:
Drummond PD. A caution about surgical treatment for facial blushing. British Journal of Dermatology 2000; volume 142: pages 194-195.
A caution about surgical treatment for facial blushing
SIR, The fear of blushing can become so problematic that it limits the range of activities in which the blusher is willing to participate, and occasionally develops into full-blown social phobia. Recently endoscopic transthoracic sympathicotomy has been publicized in this Journal(1) and elsewhere(2,3) as a solution for chronic blushing. Short-term results from this procedure were positive,(1-3) and few distressing side-effects were encountered. However, the benefits of surgery must be balanced against the risk of developing post-surgical complications, primarily compensatory sweating and pathological gustatory sweating and flushing. These conditions seem almost to be the rule rather than the exception. For example, gustatory sweating was reported by 47% of 352 patients who were followed up by questionnaire or clinical examination a median period of 16 years after endoscopic transthoracic sympathectomy for palmar hyperhidrosis.(4,5) In this series, patient satisfaction declined from 95.5% initially to 66.7% when patients were questioned many years after the operation.(5) In fact, compensatory and gustatory sweating were the most frequently stated reasons for dissatisfaction with the surgical outcome. The incidence of gustatory sweating was lower (12 of 72 patients) in another series,(6) but all patients except one suffered from compensatory sweating elsewhere in the body. Physiological assessment of gustatory sweating would probably have revealed a higher incidence than self-report in this study. Gustatory sweating takes time to develop; a patient who initially is satisfied with the surgical outcome may later regret having the operation when autonomic disturbances appear.
Pathological gustatory sweating and flushing can develop after injury to preganglionic cervico-thoracic sympathetic fibres, an unavoidable consequence of resecting that part of the sympathetic chain. The mechanism of this abnormal response is uncertain; conceivably, though, regeneration of injured salivatory fibres or collateral sprouting from nearby intact fibres creates aberrant connections between salivatory fibres and denervated vasomotor and sudomotor neurons in the superior cervical ganglion.(7) Commands to salivate would then be translated into commands to sweat and flush in the distribution of sympathetic denervation. Cross-innervation lower down in the stellate ganglion can also produce unusual and potentially distressing autonomic disturbances in the sympathetically-denervated arm (e.g., piloerection while eating).(8)
Interrupting the sympathetic pathway to the face destroys the neural circuitry which controls flushing to heat and blushing to emotional events,(9) and may therefore alleviate anxiety about blushing. However, since inappropriate facial sweating and flushing while eating can be just as distressing as anxiety about blushing, most patients who opt for the surgical procedure may be little better off in the long term. At present there is very little evidence to show that those most likely to pursue surgical treatment for blushing actually blush more readily or intensely than other people. In fact, changes in facial blood flow during acute embarrassment seem to be unrelated to ratings of the self-reported frequency of blushing.(10,11) On the other hand, self-consciousness and fear of blushing correlate well with subjective estimates of blushing frequency and intensity.(10,11) In this respect blushing differs from palmar hyperhidrosis, the usual indication for endoscopic transthoracic sympathectomy; sweaty palms are far easier for the patient to detect than blushing, which often is just a worrying suspicion not substantiated by fact.
If the source of the patient's problem is anxiety about blushing rather than blushing per se, anxiety would be a more appropriate target for treatment than permanently eliminating the normal regulation of facial blood flow and sweating. Cognitive-behavioural and drug therapies help patients with social phobia to control anxiety,12 and should thus be considered the treatments of choice for patients with a fear of blushing.
Peter D. Drummond, School of Psychology, Murdoch University, 6150 Perth, Western Australia
References (1) Drott C, Claes G, Olsson-Rex L, Dalman P, Fahlén T, Göthberg G. Successful treatment of facial blushing by endoscopic transthoracic sympathicotomy. Br J Dermatol 1998; 138: 639-643. (2) Telaranta T. Treatment of social phobia by endoscopic thoracic sympathicotomy. Eur J Surg 1998; 164 (Suppl. 580): 27-32. (3) Yilmaz EN, Dur AHM, Cuesta MA, Rauwerda JA. Endoscopic versus transaxillary thoracic sympathectomy for primary axillary and palmar hyperhidrosis and/or facial blushing: 5-year experience. Eur J Cardio-Thorac Surg 1996; 10: 168-172. (4) Zacherl J, Huber ER, Imhof M, Plas EG, Herbst F, Fugger R. Long-term results of 630 thoracoscopic sympathicotomies for primary hyperhidrosis: the Vienna experience. Eur J Surg 1998; 164 (Suppl 580): 43-46. (5) Herbst F, Plas EG, Fugger R, Fritsch A. Endoscopic thoracic sympathectomy for primary hyperhidrosis of the upper limbs: a critical analysis and long-term results of 480 operations. Ann Surg 1994; 220: 86-90. (6) Lai YT, Yang LH, Chio CC, Chen HH. Complications in patients with palmar hyperhidrosis treated with transthoracic endoscopic sympathectomy. Neurosurg 1997; 41: 110-113. (7) Drummond PD, Lance JW. Mechanisms of normal and abnormal facial flushing and sweating. In PA Low (Ed.) Clinical autonomic disorders. (2nd edition). Philadelphia: Lippincott-Raven. 1997; 715-726. (8) Herxheimer A. Gustatory sweating and pilomotion. Br Med J 1958; 1: 688-689. (9) Drummond PD, Lance JW. Facial flushing and sweating mediated by the sympathetic nervous system. Brain 1987; 110: 793-803. (10) Mulkens S, de Jong PJ, Bögels SM. High blushing propensity: fearful preoccupation or facial coloration? Pers Indiv Diff 1997; 22: 817-824. (11) Drummond PD. The effect of adrenergic blockade on blushing and facial flushing. Psychophysiol 1997; 34: 163-168. (12) Stravynski A, Greenberg D. The treatment of social phobia - a critical assessment. Acta Psychiat Scand 1998; 98: 171-181.
A note that this material provided if used is subject to the
approval of Blackwell Publishing. The contact details are: Lindsay
Doyle
E: lindsay.doyle@blacksci.co.uk
A link to the Synergy website is http://www.blackwell-synergy.com/servlet/useragent?func=showHome< /FONT>
ENDOSCOPIC THORACIC SYMPATHECTOMY FOR TREATMENT OF FACIAL BLUSHING
This is a report written by Omar Ahmed Phd of Monash Medical Centre pointing out bias in four case series related to ETS and a need for a well controlled trial. This is an excellent report pointing out the need for a Surgical Review Society to perform an unbiased controlled trial. This CCE reports was freely available to publish as a whole document, including authorship and disclaimers. I must be noted that this review was done in 2001 and is now 7 years old. The findings are unlikely to be consistent with current information, but I see it was as a worth while paper to have on our site.
