The second thoracic sympathetic ganglion was most commonly located (50%) in the second intercostal space

Presence of the stellate ganglion was noted in 56 (84.8%) sides, and 6 (9.1%) sides showed a single large ganglion formed by the stellate and the second thoracic sympathetic ganglia. The second thoracic sympathetic ganglion was most commonlylocated (50%) in the second intercostal space. CONCLUSION: The anatomic variations of the intrathoracic nerve of Kuntz and the second thoracic

sympathetic ganglion were characterized in human cadavers.

J Thorac Cardiovasc Surg  2002 Mar;123(3):498-501

Chung IH, Oh CS, Koh KS, Kim HJ, Paik HC, Lee DY.

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

"sympathectomy is a form of sensory neurectomy" (p.1500)

Bonica's Management of Pain Scott Fishman, Jane Ballantyne, James P. Rathmell Lippincott Williams & Wilkins, 2010 - Medical - 1661 pages

more than 75% of the patients evolved with an improvement in facial hyperhidrosis - nonsurgical treatment works, just don't ask the surgeons

http://www.ncbi.nlm.nih.gov/pubmed/21738960

sympathectomized arteries become more susceptible to lipid accumulation

Combined effect of cholesterol feeding and sympathectomy on the lipid content in rabbit aortas

Atherosclerosis

Volume 37, Issue 4, December 1980, Pages 521–528

Decreased HRV is predictive of adverse cardiovascular outcomes in a variety of disease states

Water immersion-induced skin wrinkling (WISW) is dependent on intact peripheral sympathetic function. WISW was hypothesized to reflect autonomic function in subjects with- out peripheral neuropathy. We prospectively studied 70 healthy subjects (aged 31 88 years, 63% females) without cardiovascular risk factors or neurological disease. All sub- jects underwent short-term heart rate variability (HRV) stud- ies. Time and frequency domain variables were derived in- cluding the HRV index. WISW was graded using a previously validated scale of 1–4 of which 18.6% of subjects exhibited grade 1 (minimal) WISW and 35.7% had grade 2 WISW. On multivariate analysis using the HRV index, WISW was inde- pendently related to height and the HRV index. We conclude that WISW is related to central autonomic function.

Although the mechanism is not fully understood, WISW is felt to be caused by passive diffusion of water across the stratum corneum into the sweat ducts, which in turn alters electrolyte balance, decreases membrane stabilization, increases sympathetic neural firing and stimulates vasoconstriction [1–3, 8].WISW is decreased in diabetic patients and in patients after cervical sympathectomy [4, 9].

Heart rate variability (HRV) is the beat-to-beat variation in cardiac cycle length due to autonomic influence on the sinus node. Decreased HRV is predictive of adverse cardiovascular outcomes in a variety of disease states[5]. The influence of the central nervous system activity on autonomic function suggests that HRV may be a useful prognostic indicator in patients with cerebrovascular events [6].

Cardiology 2010;116:247–250 DOI: 10.1159/000316043

Received: May 10, 2010

Accepted after revision: May 28, 2010 Published online: August 18, 2010

Removal of the clips from the sympathetic trunk does not provide resolution of compensatory sweating

Removal of the clips from the sympathetic trunk does not provide resolution of compensatory sweating in 1 year of observation. T6-9 block does not provide remedy for compensatory hyperhidrosis. Regional abdomino-lumbar iontophoresis seems to be very promising, but further research and followup are mandatory.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3458267/

Natural bodily functioning does not include “purely autonomic” or “purely somatic” responses, just as it does not include ‘purely sympathetic” or “purely parasympathetic” responses

Langley initially expected to find afferent cell bodies in autonomic ganglia, with projections to other ganglia. He believed that activation of these “autonomic afferents” should lead to purely autonomic responses. However Langley’s own careful work demonstrated that there were no such neurons.

The fundamentally important point is that integrative processes responsible for the organization of visceral function occur principally within the central nervous system (brain and/or spinal cord). Both somatic and visceral afferents result in complex, brain mediated, responses that include somatic and visceral function. Autonomic motor activity can be generated by both somatic and visceral inputs to the CNS, and visceral inputs to the CNS initiate responses that are both somatic and autonomic. Natural bodily functioning does not include “purely autonomic” or “purely somatic” responses, just as it does not include ‘purely sympathetic” or “purely parasympathetic” responses.

Bill Blessing and Ian Gibbins (2008), Scholarpedia, 3(7):2787.

revision #46085 [link to/cite this article]

Curator: Dr. Bill Blessing, Centre for Neuroscience, Flinders University, Adelaide, AUSTRALIA

there are three main conditions which could impair the autonomy of a patient's medical decision: insufficient information, irrational beliefs/desires, and influence of different framing effects

http://onlinelibrary.wiley.com/doi/10.1111/j.1467-8519.2012.01973.x/abstract

Topical ibuprofen inhibits blushing during embarrassment and facial flushing during aerobic exercise in people with a fear of blushing

The flush that develops during whole-body heat stress depends partly on prostaglandins production in the skin. Variations in the strength of this local mechanism may contribute to individual differences in susceptibility to blushing and associated anxiety. To investigate this in the present study, the anti-inflammatory agent ibuprofen (which blocks prostaglandins formation) was applied topically to a small area of the cheek in 16 participants with a fear of blushing and in another 14 without this fear. Changes in skin blood flow were monitored at the ibuprofen-treated site and at a mirror image control site while participants sang (to induce embarrassment and blushing) and during aerobic exercise (to induce flushing). The topical ibuprofen treatment inhibited increases in cheek blood flow in both groups during both of these tasks. However, increases in cheek blood flow were greater in participants with high than low fear of blushing immediately after exercise. These findings suggest that prostaglandins contribute to dilatation of facial blood vessels both during emotional arousal (embarrassment) and aerobic exercise. Furthermore, fear of blushing may be associated with mechanisms that delay the resumption of normal vascular tone after a period of vasodilatation. Whether topical ibuprofen gel is suitable for intermittent or long-term use as an aid for blushing control requires further investigation.

• Peter D. Drummond^, , 
 
• Kate Minosora, 
 
• Gretta Little, 
 
• Wendy Keay

• School of Psychology and Exercise Science, Murdoch University, Perth, 6150 Western Australia, Australia

http://www.sciencedirect.com/science/article/pii/S0924977X13002137

Drionic effectively "...reduced sweating for up to 6 weeks..."

Clinical Studies

The following comments are from clinical studies which demonstrated the safety and effectiveness of Drionic:

1. Efficacy of the Drionic unit in the treatment of hyperhidrosis. J Am Acad Dermatol 1987;16:828-832. "...the Drionic unit appears to have a definite place in the treatment of hyperhidrosis." Daniel L. Akins, M.D. John L. Meisenheimer, M.D. Richard L. Dobson, M.D., Professor & Chairman, Dept. of Dermatology From the Department of Dermatology, Medical University of South Carolina, Charleston, South Carolina 
2. A new device in the treatment of hyperhidrosis by iontophoresis. Cutis 1982;29:82-89. Drionic effectively "...reduced sweating for up to 6 weeks..." Further, the study concluded that "Because of its design, it has great potential for home use." CPT John L. Peterson, M.D. MAJ Sandra I. Read, M.D. COL Orlando G. Rodman, M.D. Chief, Dermatology Service From the Dermatology Service, Dept. of Medicine, Walter Reed Army Medical Center, Washington, DC
3. Tap water iontophoresis in the treatment of hyperhidrosis. Int J Dermatol 26;1987:194-197. "Tap water iontophoresis is a recognized method of reducing sweat in various parts of the body. The Drionic device is a battery-operated method of inducing tap water iontophoresis. This simple device may be used at home and is effective in reducing hyperhidrosis for as long as 6 weeks." Mervyn L. Elgart, M.D., Professor & Chairman, Dept. of Dermatology Glenn Fuchs, M.D. From the Department of Dermatology, George Washington Univ. Medical Center, Washington, DC.
4. Efficacy of the Drionic unit in the treatment of hyperhidrosis. JAm Acad Dermatol 16:828-832, Apr. 1987. Elgart ML, Fuchs G: Tap water iontophoresis in the treatment of hyperhidrosis. Int J Dermatol 26: 194-197, Apr. 1987. (old model)

Systemic therapy with glycopyrrolate or clonidine can be effective for HH. Nearly two-thirds responded to therapy, and less than a quarter had treatment-limiting adverse effects, all of which were self-limited and nonserious

J Am Acad Dermatol. 2012 Mar;66(3):387-92. doi: 10.1016/j.jaad.2011.01.023. Epub 2011 Aug 4.
http://www.ncbi.nlm.nih.gov/pubmed/21820204

Only 56% would recommend thoracoscopic sympathectomy to others with hyperhydrosis

http://www.ncbi.nlm.nih.gov/pubmed/21539945

sympathectomy interrupts neural messages to many different organs, glands and muscles

Sympathectomy involves dissection of the main sympathetic trunk in the upper thoracic region thus interrupting neural messages that ordinarily would travel to many different organs, glands and muscles. It involves division of adrenergic, cholinergic and sensory fibers which elaborate adrenergic substances during the process of regulating visceral function.

Journal of Applied Sciences Research, 6(6): 659-664, 2010

Sympathectomy involves division of adrenergic, cholinergic and sensory fibers

Sympathectomy involves division of adrenergic, cholinergic and sensory fibers which elaborate adrenergic substances during the process of regulating viscera

http://pharmrev.aspetjournals.org/content/18/1/611.full.pdf+html

Post-sympathectomy neuralgia is proposed here to be a complex neuropathic and central deafferentation/reafferentation syndrome

http://www.ncbi.nlm.nih.gov/pubmed/8867242

Long-term efficiency? 40% affirmed they would ask for the operation if it were to be redone, 53% recurrence

At an average 12 years after surgery, 47% of patients were satisfied with the treatment results, 40% were disappointed. 
53% complaining about a decent to moderate recurrence of hand sweating and compensatory and gustatory sweating were observed in 9 (60%) and 5 (33%) patients, respectively. 
Interact CardioVasc Thorac Surg(2009) 8 (1): 54-57.

the medical profession is so trusted that its activities are rarely questioned

By Paul Komesaroff, Monash University; Ian Kerridge, University of Sydney, andWendy Lipworth, University of New South Wales
https://theconversation.edu.au/big-debts-in-small-packages-the-dangers-of-pens-and-post-it-notes-4949

A randomized placebo-controlled trial of oxybutynin for the initial treatment of palmar and axillary hyperhidrosis

Palmar and axillary hyperhidrosis improved in >70% of the patients, and 47.8% of those presented great improvement. Plantar hyperhidrosis improved in >90% of the patients. Most patients (65.2%) showed improvements in their quality of life. The side effects were minor, with dry mouth being the most frequent (47.8%).

Journal of Vascular Surgery, Volume 55, Issue 6, June 2012, Pages 1696-1700

"return of sweating in the hands is common occurrence in patients followed up for sufficient length of time"

Annals of the Royal College of Surgeons of England (1989) vol. 7.1

limited understanding of the role of the sympathetic nervous system in mediating pain - NSW HEALTH

limited understanding of the role of the sympathetic nervous system in mediating pain

The role of sympathetic blocks in herpes zoster (HZ) and postherpetic neuralgia (PHN) remains controversial due to methodologic shortcomings in published studies and limited understanding of the role of the sympathetic nervous system in
mediating pain.


Information for Health Professionals          Hunter Integrated Pain Service         Updated January 2010

Procedural Intervention Guideline 

significant number of primary hyperhidrosis patients (more than 70%) were so pleased with the results that they decided to forgo the surgery

At the beginning of our study, thoracic sympathectomy was indicated indiscriminately to all primary hyperhidrosis patients. The authors observed a number of patients who were dissatisfied with the results obtained from this technique, particularly due to the undesirable but frequent side effect of compensatory hyperhidrosis. Hyperhidrosis is a condition that deeply affects the individual's emotional component, and many of them, despite being warned previously, are not psychologically prepared to address this new situation. The authors then included a psychologist in the study and directed the patients for routine psychological evaluations to prepare and better select them for surgery. In addition, the authors began to study a pharmacological formula to medicate these patients for the same purpose. Oxybutynin is an anticholinergic drug that has been used safely at high doses (up to 15 mg/day) to treat micturition disorders, and a side effect observed in these patients has been diminished sudoresis. Studies conducted by our group have documented the clinical benefits of a low dose of oxybutynin (10 mg/day). The authors found that a significant number of primary hyperhidrosis patients (more than 70%) were so pleased with the results that they decided to forgo the surgery [50-53].

Expert Review of Dermatology7.6 (Dec 2012): 529-538.

Neuralgia due to sympathectomy

Depending on the skill of the surgeon and difficulty encountered performing various intraoperative maneuvers, the incidence of complications following sympathectomy should be the same as that following any other extraperitoneal or extrapleural operation. However, a frequent complication following sympathectomy, and one which is apparently unrelated to operative technique, is that of postsympathectomy neuralgia.

This neuralgia is characterized by aching thigh pain after lumbar sympathectomy or aching shoulder and arm pain after cervical sympathectomy. The pain is intense in severity, sudden in onset and disappearance, and not related to any major neurologic manifestations.

Recently we have reviewed the files of the Vascular Surgical Service at the West Roxbury Veteran's Hospital and the literature on this condition. This report is a presentation of our findings.

Incidence  Pain following sympathectomy has been described as "an all too common complaint."⁸ Reports have varied in incidence from 2.1% to "practically every case."

http://archsurg.jamanetwork.com/article.aspx?articleid=560162

This is how 'Australia’s leading source for trustworthy medical information' describes sympathectomy

"Sympathectomy is a procedure that is used to treat neuropathic pain. It interrupts the sympathetic nervous system either temporarily or permanently."

http://www.virtualmedicalcentre.com/medical-dictionary/alpha/s

Australia’s leading source for trustworthy medical information written by health professionals. Please be aware that we do not give advice on your individual medical condition, if you want advice please see your treating physician. Virtual Medical Centre © 2002 - 2013 | Privacy Policy Last updated 8 Aug 2013

Sympathectomy is not minimally invasive

The term ‘‘minimally invasive surgery’’ was initially applied to coelioscopic procedures such as laparoscopic cholecystectomy and hernia repair, thoracoscopic sympathectomy, and arthroscopy, but has since been abandoned, because doing the same operation through a smaller incision is not necessarily less invasive. The term ‘‘minimally invasive parathyroidectomy’’ does not fully convey the nature of the techniques, and, as previously debated in the wider field of minimal-access surgery, carries connotations of increased safety that are not necessarily supported by the existing data [12].

Surg Clin N Am 84 (2004) 717–734

F. Fausto Palazzo, MS, FRCS(Gen),
Leigh W. Delbridge, MD, FACS*

Department of Surgery, Royal North Shore Hospital, Sydney 2065, NSW, Australia

Limited sympathectomy does not reduce postoperative compensatory sweating

Endoscopic transthoracic for upper limb hyperhidrosis: Limited does not reduce postoperative compensatory sweating:

sympathectomy led to significant decrements in escape and avoidance responding

PsycNET - Option to Buy: "Chemical sympathectomy and avoidance learning in the rat.
By Di Giusto, E. L.; King, M. G.
Journal of Comparative and Physiological Psychology, Vol 81(3), Dec 1972, 491-500.
Abstract
Reports results of 5 experiments with male Wistar rats (N = 108). Depletion of peripheral sympathetic noradrenaline induced by administration of 6-hydroxydopamine, ip, led to significant decrements in escape and avoidance responding when the required response was difficult, but not when it was relatively easy to acquire. Results are similar to previous findings obtained with adrenal-demedullated Ss. Findings clarify the role of the sympathetic nervous system in the motivation of behavior elicited by aversive stimulation. Implications for 2-process theory and the "Kamin effect," or "learned helplessness," are discussed. (40 ref.) (PsycINFO Database Record (c) 2012 APA, all rights reserved)"

Medical mistakes: A silent epidemic in Australian hospitals

ABC Radio “The World Today” 10 June 2013

http://www.abc.net.au/worldtoday/content/2013/s3778256.htm

Patients complain of emotional blunting following endoscopic thoracic sympathectomy for hyperhidrosis and blushing

Hohmann, G.W. : The effect of dysfunction of the autonomic nervous system on experienced feelings and emotions

Paper read at Conference on Emotions and Feelings at New School for Social Research, New York, Oct 1962.

Sherrington, C.S.: Experiments on the value of vascular and visceral factors for the genesis of emotion 

Proc. Roy.Soc., 1900, 66, 390-403

Wenger, M.A.: Emotion as visceral action: an extension of Lange's theory. In Reymert, M.L., Feelings and emotions: the Moosehart ymposium, New York: McGraw-Hill, 1950. Pp.3-10.

Wynne, L.C., and Solomon, R.L.: Traumatic avoidance learning: acquisition and extinction in dogs deprived of normal peripheral autonomic function. 

Genet. psychol. Monogr., 1955, 52, 241-84

Landis, C., and Hunt, W. A. Adrenalin and emotion. 

Psychol. Rev., 1932, 39, 467-85.

Schachter, S., and Wheeler, L.: Epinephrine, chlorpromazine, and amusement. 

J. of abnorm. soc. Psychol., 1962, 65, 121-28.

Recurrent hyperhidrosis is another potential side effect from hyperhidrosis surgery

The Society of Thoracic Surgeons Expert Consensus for the Surgical Treatment of Hyperhidrosis -- Cerfolio et al. 91 (5): 1642 -- The Annals of Thoracic Surgery: "Recurrent hyperhidrosis is another potential side effect from hyperhidrosis surgery. Incidence rates vary considerably and have been described as 0% to 65%"

'via Blog this'

BioEdge: Leveson Inquiry recommends reform of science reporting

BioEdge: Leveson Inquiry recommends reform of science reporting: "Remember patients: don't call something a "cure" that is not a cure."

'via Blog this'

Limited heart rate variability, autonomic nervous system imbalance implicated in Chronic Fatigue Syndrome

The Conversation: "The stress-response neural systems of chronic fatigue syndrome (CFS) patients remain on high alert even when they sleep, signalling that it’s not safe to relax, researchers have found.

Researchers also discovered that reduced heart rate variability, or changes in heart beat timing, are the best predictors of cognitive disturbances, such as concentration difficulties commonly reported by CFS sufferers. This adds to the growing body of evidence linking autonomic nervous system imbalance to this disorder.

The findings could lead to new ways to improve cognitive difficulties in people with CFS, which remains a poorly understood condition."

http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0049518  

ETS result in limited (reduced) heart rate variability and alters the ANS (sympathetic and parasympathetic balance). This article might provide some insight into the cases where ETS resulted in a variety of unwelcome and detrimental side-effects, including fatigue, altered cognitive function ('brain fog'), etc.

No compensatory sweating after botulinum toxin treatment of palmar hyperhidrosis

No compensatory sweating after botulinum toxin... [Br J Dermatol. 2005] - PubMed - NCBI: "Recordings were made at 16 skin areas and compared with subjective estimates of sweating.
RESULTS:
Following treatment, palmar evaporation decreased markedly and then returned slowly towards pretreatment values, but was still significantly reduced 6 months after treatment. No significant increase of sweating was found after treatment in any nontreated skin area.
CONCLUSIONS:
Successful treatment of palmar hyperhidrosis with botulinum toxin does not evoke compensatory hyperhidrosis in nontreated skin territories."

'via Blog this'

Botulinum toxin type A should be PBS listed for treatment of palmar hyperhidrosis | Medical Journal of Australia

Botulinum toxin type A should be PBS listed for treatment of palmar hyperhidrosis | Medical Journal of Australia:

'via Blog this'

A randomized placebo-controlled trial of oxybuty... [J Vasc Surg. 2012] - PubMed - NCBI

"Palmar and axillary hyperhidrosis improved in >70% of the patients, and 47.8% of those presented great improvement. Plantar hyperhidrosis improved in >90% of the patients. Most patients (65.2%) showed improvements in their quality of life. The side effects were minor, with dry mouth being the most frequent (47.8%).
CONCLUSIONS:
Treatment of palmar and axillary hyperhidrosis with oxybutynin is a good initial alternative for treatment given that it presents good results and improves quality of life."

http://www.ncbi.nlm.nih.gov/pubmed/22341836

Petition never received - claims the Office of the Health Minister

Our previous Petition on this matter, sent on the 30th of March 2012, (and confirmation received on that day) to the Office of the Health Minister went unanswered. Following our inquiry we were told that the office never received the signed Petition.
Sending the Petition (this time) to the Senate will ensure transparency and accountability.

The revised text of the Petition (in compliance with the rules) can be read and signed here:


Text of the updated Petition to the Senate


Thank you for your support.

Drug warning - Karvezide, AVAPRO HCT - you must tell your doctor if you have had sympathectomy

Tell your doctor if:

* you have had a sympathectomy

* you have been taking diuretics

*you have a history of allergy or asthma


www.racgp.org.au/cmi/swckarvz.pdf

2. Before you start to take AVAPRO HCT

Tell your doctor if:

• you suffer from any medical conditions especially-
  - kidney problems, or have had a kidney transplant or dialysis
  - heart problems
  - liver problems, or have had liver problems in the past
  - diabetes
  - gout or have had gout in the past
  - lupus erythematosus
  - high or low levels of potassium or sodium or other electrolytes in your blood
  - primary aldosteronism
• you are strictly restricting your salt intake
• you are lactose intolerant or have had any allergies to any other medicine or any other substances, such as foods, preservatives or dyes.
• have had a sympathectomy
• you have been taking diuretics
• you have a history of allergy or asthma

http://www.mydr.com.au/medicines/cmis/avapro-hct-300-25-tablets

Published by MIMS/myDr March 2011

UBM Medica Australia uses its best endeavours to ensure that at the time of publishing, as indicated on the publishing date for each resource (e.g. Published by MIMS/myDr January 2007), the CMI provided was complete to the best of UBM Medica Australia's knowledge.  

Number of sympathectomies is on the increase in Australia

Number of ETS procedures performed in Australia between 2000 - 2010

years 2000 - 2001:
Total: 1034

years 2001-2002:
Total: 1575

years 2002 - 2003
Total: 1228

years 2003 - 2004
Total: 1193

years 2004 - 2005
Total: 1483

years 2005 - 2006
Total:1358

years 2006 - 2007
Total: 972

years  2007 - 2008
Total: 850

years 2008 - 2009
Total: 891

years  2009 - 2010
Total: 1083
 
source: aihw.gov.au

most surgeons do not have a clear understanding of their short-term outcomes for the majority of procedures they perform

The public would probably be surprised to know that most surgeons do not have a clear understanding of their short-term outcomes for the majority of procedures they perform.

Of even greater concern is the lack of data on long-term outcomes associated with surgical interventions.

Many surgeons argue that they are too busy and do not have the time and resources to conduct this sort of follow-up. This is not entirely without foundation, but it does seem difficult to defend a stance that says “I will continue to work feverishly at the operations I do but not assess how successful my results are”.

Guy Maddern (ASERNIP-s): No excuse for poor surgical outcomes

MJA INSIGHT, 8 August 2011

Petition to the Health Minister - Australia, February 2012

The Hon Tanya Plibersek MP, Minister for Health
House of Representatives
Parliament House
Canberra ACT 2600

Dear Minister,

In response to the recent decision by the Health Minister to fund Botox treatment for axillary hyperhidrosis we have been prompted to submit this petition.

We would like to bring to your attention that palmar, facial, pedal and severe compensatory hyperhidrosis can have a negative social effect on a person’s life. Due to its high cost, Botox treatment is not accessible to many patients in Australia. We would like to petition for extended funding for Botox treatment for these conditions, rather than the current surgical treatments such as Endoscopic Thoracic Sympathectomy (ETS).

ETS has many common and undisclosed side-effects,  including severe compensatory hyperhidrosis as found in reviews by FinOHTA [1] and 'ASERNIP-S'  [2] . We wish to argue that the Medical Benefit Scheme (MBS) listing for ETS should be immediately suspended and urgently reviewed according to the strict guidelines set out by the Medical Services Advisory Committee (MSAC).

The level of endorsement (MBS listing) might impact on how the procedure is perceived by the public.
The recent MBS listing for Botox for axillary hyperhidrosis treatment sets out clear conditions and restrictions on its availability. There are no such conditions set out for the availability of the irreversible neurosurgical procedure, ETS.

We trust that decisions regarding funding are based on best available evidence regarding safety, effectiveness and cost effectiveness - and in this order. Available evidence however, cannot, and does not support the use of ETS as a safe procedure, and MSAC has never evaluated it.


In consideration of the provided supporting evidence, we hereby ask the Health Minister to:

Remove funding for Endoscopic Thoracic Sympathectomy and review the availability of this procedure, and the public’s exposure to it (including advertising, and infomercials), due to lack of reliable supporting evidence, and reports of adverse effects from the literature.

Extend funding for less harmful procedures (Botox and Ionthoporesis) for people with palmar, facial, pedal and severe compensatory hyperhidrosis. Patients with hyperhidrosis (and blushing) are evaluated by thoracic, vascular, general surgeons, with no training in treating or evaluating these conditions, nor in the field of Autonomic Nervous System (ANS). Patients should be evaluated and treated by specialists who are qualified to assess and treat these conditions (psychologists, dermatologists, neurologists).

Specify the alternative treatments patients have to trial before being able to undergo ETS  - with sufficient funding, and time for these treatments to prove effectiveness.

Provide comprehensive and uniform information to all patients (including the internet) that describe the nature and consequences of this procedure, the foreseeability of complications, and recurrence, all based on high level evidence.

  
Clinical decision making can be tainted by bias, especially in the context of entrepreneurial medicine and elective procedures. Information provided to patients, especially in this setting can fall short of accepted standards of  ‘informed consent’.

We look forward to your assistance in ensuring all Australians have a right to a fair medical system, where all surgical procedures have an objective trial, supporting evidence regarding safety, and alternative treatments are offered at a reasonable cost.


Sincerely yours,






[1] http://finohta.stakes.fi/NR/rdonlyres/A4F5CFC3-A6B4-43F5-8E2A-49689F3B7980/0/r026f.pdf
[2] http://www.surgeons.org/media/17412/RPT_2009-09-10_Evidence_essential_ETS.pdf


T(2)-T(3) ganglionectomy significantly decreases pulse rate and systolic blood pressure, reduces myocardial oxygen demand, increases left ventricular ejection fraction and prolongs Q-T interval. A certain loss of lung volume and decrease of pulmonary diffusion capacity for CO result from sympathectomy.
Histomorphological muscle changes and neuro-histochemical and biochemical effects have also been observed.
Clin Auton Res. 2003 Dec;13 Suppl 1:I40-4.
http://www.ncbi.nlm.nih.gov/pubmed/14673672


Several reports also demonstrate significantly lower heart rate increases during exercise in subjects who have undergone bilateral ISS [9–12] compared to pre-surgical levels. In spite of this high occurrence, recent reviews on the usual collateral effects of thoracic sympathectomy still do not include these possible cardiac consequences [6].
Eur J Cardiothorac Surg 2001;20:1095-1100
http://www.sciencedirect.com/science/article/pii/S1010794001010028

The results of endoscopic sympathectomy deteriorate progressively from the immediate outcome 

British Journal of Surgery ISSN 0007-1323  1999, vol. 86, no1, pp. 45-47 (12 ref.)

Australian Review of ETS surgery, 2009

"A lack of high quality randomised trial evidence on ETS means that it is difficult to make a judgment on the safety and effectiveness of this technique. There is potentially a number of safety issues associated with this procedure. ASERNIP-s suggests that a full systematic review including all available comparative and case series information, together with clinical inpuut, should be undertaken to provide up-to-date and comprehensive assessment of the safety and effectiveness of ETS." (ASERNIP-s Report No. 71, August 2009)

Australian Review of ETS surgery, 2001

The four case series were not critically appraised because they are prone to bias and have significant methodological problems. These studies represent level IV evidence according to the NHMRC criteria and one should not draw firm conclusions from their findings.

To date, the benefits or side effects associated with endoscopic thoracic sympathectomy for treating facial blushing have not been properly evaluated and reported.

Further research using a well-designed controlled trial is warranted to assess the efficacy of endoscopic thoracic sympathectomy for treating facial blushing.
Centre for Clinical Effectiveness - Monash

Swedish Review, 1999, 2002

The findings by SBU Alert show that poor* evidence is available about ETS as regards side effects, risks, and short-term effects. There is no* scientific evidence demonstrating the long-term results of the method or its cost effectiveness in relation to other methods.
(Swedish Council on Technology Assessment in Health Care (SBU), the Medical Products Agency, the National Board of Health and Welfare, and the Federation of Swedish County Councils.
Published: 1999-08-30 Revised: 2002-09-30

Finnish Review, 2005

Conclusions: The evidence of the effectiveness of ETS is weak due to a lack of randomized trials. The intervention leads to severe immediate complications in some of the patients, and to persistent side-effects for many of the patients.
UniversityofOuluand FinnishOfficeforHealthTechnologyAssessment
FinnishOfficeforHealthTechnologyAssessment
UniversityofHelsinki and FinnishOfficeforHealthTechnologyAssessment
UniversityofCopenhagenand FinnishOfficeforHealthTechnologyAssessment

Cochrane Database Syst. Review, 2003

”The practice of surgical and chemical sympathectomy is based on poor quality evidence, uncontrolled studies and personal experience.“ 

Cochrane Database Syst Rev. 2003;(2):CD002918.

UK Review of ETS surgery, 2003

We did not identify any controlled trials or cohort studies. The evidence about effectiveness, based on three case series, was therefore very limited. The main weakness of these studies was their lack of a comparison group and their resulting inability to exclude a placebo response to surgery. In addition, the methods of assessing outcome were poorly described and not validated, and the range of outcomes assessed was limited. The studies provided very limited evidence that sympathectomy improves blushing. Side effects were common.
London: Bazian Ltd (Editors), Wessex Institute for Health Research and Development, University of Southampton 2003: 11

 Wiley & Sons, Inc, news release, 2004

"Lifestyle" surgical procedure carries unrecognized risk of complications.”
Hoboken, NJ: John Wiley & Sons, Inc, British Journal of Surgery, Feb 5, 2004

"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

"This is a field in which the unknown is still substantial and some of the known - controversial." M. Hashmonai, ISSS President at the 6th International Symposium on Sympathetic Surgery (ISSS) 4th -6th May 2005, Vienna Medical Academy,  Austria