ETS Reversal Information
Dr.Reisfeld does perform the reversal operation. The type of reversal is dependent on the type of surgery initially performed (the cutting of the nerve versus the clamping of it).
Over the last decade, more and more ETS surgeries have been performed. Before about 1990, all of the sympathectomies were done in an open fashion that turned away physicians as well patients from having this procedure done. The endoscopic approach made it easier for patients and surgeons alike to accept the operation for problems such as sweaty hands, facial blushing, and facial sweating. The term hypersympathetic activity is being used to describe this entity as a physiological manifestation of the hyperactive sympathetic system.
Another reason why more ETS procedures have been done over the last decade is due to the recent increase and quality of information available on the internet. The dramatic increase in the number of cases being done also brought with it a certain amount of patients (about 3% to 5%) who are unhappy with the results.
What can be done about those patients who are unhappy with the results of the surgery? In the past, the only method that was done endoscopically was the cutting method. For those cases an attempt was made with some medications but when that failed then the reversal operations with the nerve graft was the only other option. More recently, the clamping method has also been used making the reversal operation easier (simply removing the clips) if needed. Below, both types of reversals that Dr. Reisfeld has performed are reviewed.
With this method a nerve graft is taken from the ankle region (the sural nerve) and is connected to the divided edges of the sympathetic chain with a spacial biological glue. The operation has two components:
The mechanical part is composed of an endoscopic approach to the prior sympathectomy site (the location where the operation was previously done) at which point the surgeon refreshes the edges of the previously cut nerve. This can be done with an ultrasound scalpel or with scissors not connected to electricity. This part is not always possible due to severe scar tissue built up during the first operation. In cases where there is severe scar tissue the operation may be aborted. Also any other technical difficulty can terminate the attempt, although this is not common.
Once the area of the previous sympathectomy is freshened up, the intercostal nerve graft or any other nerve graft is sutured or glued to the missing segment and the procedure is finished. The same procedure is performed on the other side of the chest cavity.
Physiological (Time it takes for the nerve itself to resume conduction)
In this part, the resumption of nerve conduction and return to normal sympathetic regulation is a matter that is different from one patient to another and the amount of information that we have about it is very minimal. The process can take a long time and initial symptoms of recovery will not always show before 6 to 9 months after the reversal. So far, those cases done by Dr. Reisfeld show some improvements. The improvements can be seen in lessening of compensatory sweating, better ability to perform exercises, returning of sweat to the facial area and upper body, and hence better cooling of the upper body regions. These results are similar to those reported by Dr. Telaranta who also does the reversal.
At a meeting in Germany (2003) the results of nerve graft reversal were presented by Dr. Reisfeld and Dr. Telerantra. Both surgeons reported similar results, however there is a long way to go in order to get definite statistical data. In order to get meaningful data we will need to perform many more cases with longer followup.
Similar work for nerve graft reversal is being done by urological – plastic surgeons when they use the sural nerve to repair damage done to the sympathetic chain within the pelvic cavity. Also here the sural nerve graft is used as a tube similar to what is being done in our reversal procedure. The difference is that they do it immediately at the time of the initial operation; also, it’s being done in an open fashion with very fine sutures. Their results also are not yet etched in stone and in a recent verbal communication with the leading plastic surgeon who performs these operations the need for more cases and longer followup is emphasized. One clear fact is that the shorter the segment that is cut, the better the chances are for reversibility with the nerve graft. There are too few cases to really say anything more than this at this time.
Intercostal Nerve Graft
With regard to the intercostals nerve graft method please refer to the picture below and try to understand the complex and unique method that can be tried to bridge the segment that was taken off in the original ETS surgery.
- The difficulties that a surgeon might encounter when performing the intercostals nerve graft procedure are few. Amongst them are the length of the segment that was taken and the amount of scar tissue that might be found during the initial exploration.
- In the picture (open diagram) one can see a harvested intercostal nerve at the third rib level which was harvested and freed from the surrounding tissues, ready to be cut and flipped over to the site of the previous divided sympathetic nerve. The theoretical benefit of this intercostal nerve graft is the blood supply is maintained to the harvested nerve. The intercostal nerve also contains some sympathetic and sensory fibers which might add to the physiological response. Again, with this method more cases have to be done and more follow-up with regard to the results is needed. As equipment and technical dexterities are improving it is now possible to perform the intercostal grafting procedure not with the glue to adhere both ends of the nerves but now with very fine sutures to connect the end of the graft as well as the previously cut sympathetic chain. With this technique a better chance is given to get partial or full recovery from the side effects of previously done sympathectomies with the old method of cutting. Both methods that are now used are the robotic equipment or modern refined endoscopic equipment.
- As said in the previous paragraph the incorporation of suturing in order to bring the nerve ends together is much more effective and promising but one should put a word or caution into this statement by saying again that more follow-up and cases are needed to come with a definite statement. The question of numbness in the chest wall in the segment where the nerve was used is now better answered with the fact that there is numbness but not to a severe degree. Again this question was answered only with the ability to follow patients with a very long term follow-up.
Reversal for the clamping method
Since about 1999, the clamping method became the method of choice for Dr. Reisfeld. Dr. Reisfeld only does the clamping method. If a patient is unhappy with the results, the clamps can be taken out, giving the patient an easier potential for reversal and recovery. So far, Dr. Reisfeld has performed several clamp removal reversals; those cases have shown improvement in compensatory sweating (compensatory hydrosis or reflex sweating) and performance ability. The healing process and improvement of the symptoms can take from a few months up to a year.
Dr. Reisfeld wishes to emphasize that the clamping method does not provide for guaranteed complete reversal, he simply believes that the clamping method gives a much greater opportunity for reversal.
As time goes by, more cases will be done and more information will be gathered. Those results and experiences will be posted as soon as they are available. For the time being, about 37 reversal cases have been done on patients who previously had the clamping method and about half of them show improvement. The improvement presents itself with reduction of compensatory sweating, return of sweat to the facial region, and minimal to mild hand sweating. As more time has passed since the introduction of clamp removal to alleviate severe side effects such as compensatory sweating we are getting more and more patients who indeed testify that the clamp removal reduced or eliminated their side effects. In some of those cases it took 2 to 3 years to see the benefits from clamp removal. This fact is in line with the knowledge that nerve growth and recovery of the autonomous nervous system is a very slow process. Recently an unpublished medical paper described the experience of European surgeons that described the experience stretched over a few years about the fate of clamp removal over 10 years. Basically it reflects the opinion of Dr. Reisfeld that the clamp removal does have positive results over time. One should bear in mind that it is a very complicated matter and not all the facts are yet known. The sympathetic chain is still a very unknown entity in neurological science and a lot has to be explored. We know that it has some sort of regeneration process but to what degree it happens is still a mystery. We can draw clinical experience some statements but again those are not always consistent. The fact is that some cases showed recovery after clip removal which was primarily a factor of time but not always. Also one should bear in mind that compensatory sweating is something that changes with time even without clip removal. To have a definite answer to this issue is not simple but if a patient wants to have their clips removed then more information should be obtained from the involved surgeon.
Do you have any questions that were not answered here? Would you like to speak with Dr. Reisfeld to answer those questions? To learn more about what we can do for you, contact The Center for Hyperhidrosis by contacting our office.