Sunday, July 29, 2012

"The literature does not support the claims that a lowered level of sympathetic ablation results in less compensatory hyperhidrosis"

Some ETS surgeons, particularly in the United States, claim that their version of ETS results in fewer side effects because they operate only at T4 (thoracic vertebrae level 4) on the Sympathetic Nervous System.

These ETS surgeons typically claim that sympathectomies for hyperhidrosis or facial blushing performed at the T2, T3 or T2 and T3 levels are more likely to result in side effects, in particular the common ETS side effect of compensatory sweating, aka compensatory hyperhidrosis.

Many ETS patients experience compensatory hyperhidrosis to varying degrees that affects mainly the trunk (back, chest, stomach) and sometimes the groin and legs. A significant number of ETS patients report that their compensatory sweating is so severe that the excessive sweating on their trunk (and often groin and legs) soaks through their clothing every day, leaving them professionaly and socially disabled, fatigued, and with much worse quality of life compared with their pre-surgery, localised hyperhidrosis condition.

Naturally, compensatory sweating is a much-feared side effect of ETS among prospective patients - unsurprisingly, none of us want to swap sweaty hands, a sweaty face/head, sweaty underarms or a blushing face for a dripping wet torso, groin and legs.

Aware of this fear among prospective patients, some ETS surgeons have been claiming for several years now, with no scientific basis, that by performing ETS at the T4 level only, the chance of compensatory sweating developing as a side effect is greatly reduced.

Well, researchers Kopelman and Hashmonai at Ha'emek Hospital in Afula, Israel, reviewed much of the published literature on ETS surgery to evaluate the validity of the claim that a lower level of sympathectomy, and other techniques such as limiting the extent of nerve ablation (aka limiting the number of nerve levels cut, cauterised or clamped), reduces the occurrence of compensatory sweating.

Their paper was published in the World Journal of Surgery in Nov. 2008, and their conclusion was that there was no validity for the claim. Their conclusion stated:

"The compiled results published so far in the literature do not support the claims that lowering the level of sympathetic ablation, using a method of ablation other than resection, or restricting the extent of sympathetic ablation for primary palmar hyperhidrosis result in less compensatory hyperhidrosis. In the future, standardization of the methods of retrieving and reporting data are necessary to allow such a comparison of data."

Link to the abstract of this study:

So what does this mean if you are considering ETS surgery and worried about the side effect of compensatory sweating?

If any surgeon tries to claim that their version of the surgery is less likely to cause side effects such as compensatory sweating, I encourage you to be wary of what is effectively marketing spin with no scientific basis. It is your (only) body and your health. Do your research: read about the Sympathetic Nervous System, talk to others who have had the surgery, and read the online testimonials of ETS patients. Note the wide range of levels (T2, T3, or T4, or combinations of) that patients who did and did not develop compensatory sweating (and other side effects) were operated on. In addition, note the different types of surgical method used for different patients when you read their testimonials - were their nerves cut, clamped or cauterised?

Do testimonials from different patients operated at different levels, using different methods, often mention side effects - sometimes severe, life-changing side effects?

Do patient testimonials support the claim of some ETS surgeons that one method of surgery is safer than another and guarantees specific results?

For example, I was cauterised at T2 only - a level that some ETS surgeons claim is associated with much greater risk of compensatory sweating if operated on. Yet I have never experienced any compensatory sweating in the 11 years since I had my surgery, but I know of others cut or cauterised at T2 only who have experienced everything from mild to severe compensatory sweating (and other adverse side effects). And I have read testimonials of at least two ETS patients clamped at T4 who experienced severe compensatory sweating.

Images of severe compensatory sweating, courtesy of an Italian ETS patient:

Sunday, July 22, 2012

Tuesday, April 17, 2012

Article on ETS published in The Press, Christchurch's daily paper

A shorter (but still substantial) version of the article on ETS surgery that was published in Australia (see details in the previous blog dated April 2, 2012) was recently published in the New Zealand mainstream print media. It appeared in the Saturday April 7 weekend edition of The Press in the magazine supplement called 'Your Weekend'.

The NZ version of the article included some brief comment, in a separate section at the end of the article, from NZ ETS surgeon David Ferrar (based in Hamilton).

The article does not appear to have been published online so I will scan it at some stage and link to it here.

In the mean time, here is a copy of the mini interview with Hamilton-based ETS surgeon David Ferrar that appeared in The Press' version of John Van Tiggelen's article.

Sugrery may do more than spare blushes
By Beck Eleven

Hamilton surgeon Mr David Ferrar says there are fewer than 20 vascular surgeons in New Zealand and of those, only about six perform endoscopic throacic sympathectiomies.

The vast majority relate to severe sweating conditions and he would perform about 10 of these surgeries a year. However, people who come to Ferrar solely for problem blushing are rare. In the past five or six years, he's seen ten blushers, with six choosing to go through with the operation after being advised of potential side-effects.

"Most people would be sweating so profusely from their hands they find it hard to use a keyboard or hold a piece of paper. The blushing is part of the procedure, but the best results are for people who sweat as well."

He knows the procedure is controversial because of the unpredicatability of side-effects.

"If blushing is the only problem, you can expect to come away with very, very dry hands. Also, 30 to 40 percent of people get compensatory sweating on the front or back of their trunk.

"So if you sweat profusely from your hands and that's been cured, the patient doesn't mind too much if their hands are dry and they sweat a bit more on their trunk. However, if blushing is the only problem, people are more likely to complain."

People who consult Ferrar about severe blushing are usually at the end of the line, having already exhausted other methods such as therapy.

"They worry about things like public speaking or embarrassment in the office.

"Imagine you're a lawyer and the first thing you do when you meet a client is shake their hand but you are sweating and going bright red. You can see why that would be upsetting."

Ferrar believes much of the controversy lies in surgeons, mainly in the United States, who perform the surgery on anyone who asks for it, rather than the severe end of the spectrum.

"In America, there are so many that have been operated on when it hasn't been necessary, or the surgeon has given the patient false expectations, that there are support groups for people who've had complications or adverse effects. The people that come to me are almost self-selecting; they've tried everything else."

The youngest patient he has performed an endoscopic thoracic sympathectomy on was 8-years-old, with most being in puberty (when the condition tends to arise). Or they are in their 20s when they are beginning relationships and jobs.

He sasys older people tend to have lived with the condition and grown used to it.

Monday, April 2, 2012

Article about ETS surgery published in Sydney Morning Herald's 'Good Weekend' magazine

The article, published on March 10 2012, was written by journalist John Van Tiggelen and looks at the social and professional impacts of facial blushing, why people would seek surgery for this misunderstood condition, and some of the controversy around the surgery offered for facial blushing (and hyperhidrosis) - ETS.

Here is a link to the full text and scans of the article that were shared by an Australian ETS patient on the US-based support forum for those living with adverse side effects of ETS:

The article was not published online, only in print.

The Australian ETS surgeon interviewed for the article is Dr Roger Bell, a Melbourne vascular surgeon who specialises in ETS. In the last two years, since he advertised on the radio, he has done 100-150 sympathectomies a year. He claims he has a patient dissatisfaction rate of around 10%, though the journalist points out that he does not follow up his patients beyond one week post-surgery.

From the article:

Bell fell into his specialty almost by accident. “For years I knew there was a big need out there and that if someone just marketed this, you’d make a killing. People with facial blushing or sweaty hands suffer in silence. They hide it and their GPs don’t generally know anything about it. But I didn’t have an entrepreneurial streak in me. Then a couple of years ago I became friendly with a plastic surgeon and he said, ‘Why don’t you set up a website?’ So I did. One of the first guys who came to see me was from [Melbourne’s] Fox FM and he said, ‘Why don’t you put ads on the radio?’ I did, and things just took off. Until two years ago I was doing about five or 10 sympathectomies a year. Now I’m doing well over 100 a year, maybe 150.”

Tuesday, March 20, 2012

"Surgeon failed to give adequate information on the procedure before asking for the patient's consent"

This news is not related to an ETS surgery but I am copying it here because I believe there are similarities between this complaint and those made about Auckland ETS surgeon Murray MacCormick.

In addition, although the HDC found the surgeon to be seriously at fault in this case, having breached two sections of the Code of Health and Disability Services Consumers' Rights, the disciplinary action ordered of him is, in my opinion, pathetic.

Facelift leaves woman 'humiliated'

A plastic surgeon has been ordered to apologise to a patient after a facelift left her feeling "inadequate, humiliated and insignificant".

The names of the patient, surgeon and clinic have all been suppressed, but a decision released today by Health and Disabilities Commissioner Anthony Hill found the surgeon failed to give adequate information on the procedure before asking for the patient's consent.

The 49-year-old woman, known as Mrs A, visited the surgeon, Dr B, in July 2008, after seeking help for premature aging.

In a 45-minute consultation the surgeon examined the woman, talked of the risks and recommended she be a candidate for a facelift.

No medical records were made of the consultation aside from a letter written by the surgeon to Mrs A on the same day, summarising their meeting.

After asking a number of questions via email, Mrs A signed consent for the surgery on August 26.

On September 9, Dr B performed the $31,000 surgery, which included an endoscopic brow lift, limited incision facelift, neck lift, pinch lower blepharoplasty and upper eyelid blepharoplasty at a private hospital.

In the months after her surgery, Mrs A said she was satisfied with the results, but by January 2009, her appearance began to deteriorate when the skin on her cheek bones started to sag.

Dr B reassured his patient the final result would not be visible until up to 12 months after the surgery.

However, in the commissioner's report, it said a follow-up consultation held with the surgeon in September "was conducted in a treatment room, [and] made her feel inadequate, humiliated and insignificant".

The findings said Dr B gave no reason as to why the surgery was a failure, but recommended corrective surgery at a further cost of $19,000.

Mrs A did have further surgery, carried out by a different surgeon, to fix the sagging.

In his findings, Dr Hill said the patient was not given enough information to be able to give informed consent.

"Dr B did not, either at the consultation or in subsequent emails, give Mrs A an adequate explanation of the options available regarding facial rejuvenation surgery, including an assessment of the expected risks, side effects, benefits and costs of each option."

Dr Hill also said a follow-up consultation one year after the surgery was far too long to wait.

"By three months, in my opinion, a stable state has been reached. Scars may still be immature, but swelling will have resolved, and any asymmetries at that stage are unlikely to resolve spontaneously."

Dr B was found to have breached two sections of the Code of Health and Disability Services Consumers' Rights: firstly when he failed to provide Mrs A with adequate information regarding the possible outcome of the surgery; and secondly when he performed the surgery on a patient who was not in a position to make an informed choice.

He was ordered to give a written apology to Mrs A.