
 [1]  http://www.handsdry.com/treatment-possible-side-ef.html
              2004, aparece en el 100% de los operados. DrGarza
TREATMENT - Possible Side Effects
As with all surgical procedure, there are certain associated side effects and risks. However when performed by a skilled endoscopic surgeon who has had an extensive experience with this procedure, the incidence of complications are low. 


Compensatory Hyperhidrosis: Compensatory Sweating (CS) is the most common and significant side effect of ETS. This is reported to occur in 100% of patients who undergo sympathectomy for hyperhidrosis. It occurs regardless of whether the procedure is an open or Endoscopic procedure. The severity of the condition is dependent upon the levels on the sympathetic chain that are interrupted. Compensatory hyperhidrosis is a condition where the heat loss or sweating is shifted from the hands, armpits, face and scalp to the upper and lower back, lower chest, abdomen, buttocks, groin and the backs of the thighs. The brain does this is order to get rid excess body heat. It has been theorized that the CS would only happen if more than one level (T2) were clamped, but it is well known that severe CS may occur when only T2 is clamped, cut or removed. It has been discovered that the T2 or nerve trunk is responsible for the most severe forms of CS. The reason for this is because T2 or T3 nerve trunks are also responsible for eliminating sweating and heat loss from the top of the head, neck, shoulders, chest to under the breast, hand and underarms. The head alone is responsible for elimination of 44% of all body heat. This excess body heat has to be released elsewhere and will be released on the trunk, groin, buttocks and legs. Recent findings have led to a modification of the traditional technique, and it is believed that this new technique will lead to elimination of reduction of CS in patients with certain types of Hyperhidrosis. The main goal of the technique is to spare the T2 and T3 nerve trunks. The new technique spares the T2 and T3 nerve trunks and applies clamps on to the 4th nerve trunk. The new technique is applicable to those with hand or underarm sweating. Unfortunately, clamping of the T2 nerve trunk is essential for those with facial sweating or blushing. Clamping of the T4 nerve trunk will not help those with facial sweating or blushing. 

Mild to moderate sweating occurs in all cases it is and is usually tolerable. The symptoms of CS may occur intermittently or even be constant throughout the day. What matters is the severity of the syndrome. Mild CS creates moisture on the trunk, buttocks, groin or legs but does not show through their clothes. Moderate CS involves moisture on the same areas but does show through their clothes. Most people tolerate it or may use some medications so that it diminishes. Most patients express the feeling, "I can tolerate it as long as my hands and underarms no longer pour with sweat."

Severe CS causes profuse sweating between the breast, below the breasts to the lower chest, abdomen, upper and lower back, groin, buttocks and the backs of the thighs and knees. Patients may feel cold or hot and just plain uncomfortable. Those who develop severe CS may feel that this side effect is worse than their previous symptoms and express regret regarding their sympathectomy.

There is currently no method of determining who will get the severe form of compensatory hyperhidrosis, but there are some clues as to who will develop the severe form of Compensatory Sweating after the operation. The sweating pattern prior to a sympathectomy will usually determine the sweating pattern after the operation.

Those who sweat only on the hands, feet and underarms, but do not sweat on the trunk, groin or legs will usually develop mild compensatory sweating after a T4 sympathectomy. Those who have sweating on the hands, feet and underarms but also sweat on the back, chest, abdomen, groin or legs prior to the operation will most likely develop severe postoperative Compensatory Sweating after the operation.

Those who undergo a T2 or T2 + T3 sympathectomy usually will develop severe compensatory sweating after the operation.

The compensatory hyperhidrosis may occur soon after the operation or many years later. Again, most people can tolerate mild or moderate compensatory hyperhidrosis as long as their hands or underarms are no longer dripping with sweat. It is the 5% of all patients who develop the severe form of compensatory hyperhidrosis who wish they had never had the procedure.

For those in which the compensatory sweating is severe and unmanageable, the new technique of clamping the sympathetic nerve with a Titanium clip is the best option currently available. The technique for early reversal is the same Endoscopic technique as the original ETB, except that the nerve clip is removed instead of applied. While early removal of the clamps will not always reverse the operation, this has the highest rate of reversal. Once the nerve is cut, the effect is permanent and rarely reversible.

There is a new technique for those who developed Severe Compensatory Sweating after a sympathectomy in which the nerve was cut or removed. It involves transplanting a small skin nerve in the lower leg (Sural Nerve) into the site where the nerve was cut or removed. This is a complicated procedure and is reserved for those with the severe form of Compensatory Sweating. Again, it should be stressed that the sympathetic nerve trunk should be clamped and not cut or removed. It is far easier to remove a Titanium clamp than it is to transplant a new nerve. Not all patients with the nerve transplant will recover fully from the effects of Severe Compensatory Sweating.

Medications do exist that may lessen the effects of CS. They are not always effective in reducing the compensatory sweating. 
The most useful medications for compensatory hyperhidrosis are Robinul Forte and Ditropan.

Robinul Forte is the first line of medical treatment of this condition. It causes generalized body dryness; because of this, it should be used only when necessary and should be avoided heavy physical exercise. Side effects can include dryness of the mouth (cottonmouth), headaches or constipation. The most effective dosage is by taking the medication 3 hours prior to meals.

Ditropan used in low doses has recently been found to be very effective in the treatment of severe CS.

Gustatory Sweating: This condition causes facial sweating after eating or smelling foods. People describe it as similar to facial sweating that follows after eating hot spicy foods such as chili. The condition occurs in about 10% of all patients who undergo a T2 sympathectomy but not a T4 sympathectomy. If it does occur, it happens years after the ETS or ETB. Treatment of this condition is with a Robinul Forte topical suspension in a cream solution. 

Decreased Heart Rate: In those who undergo a T2 sympathectomy, 10% experience a 10% decrease in resting heart rate. This does not occur after a T4 sympathectomy. Dr. Garza recommends against performing a T2 sympathectomy on athletes. A T2 sympathectomy may impair an athlete's performance. 

Dry Facial Skin: Dry facial skin and improvement of complexion problems may occur following ETS or ETB. The dryness is rarely severe and patients rarely quire a facial skin moisturizer. An unexpected benefit from the sympathectomy is that any acne complexion problems usually resolve within the first week after the operation. Most patients can stop taking their Accutane after the procedure. Some patients may develop dandruff after the procedure. This side effect occurs after a T2 or T3 sympathectomy but not a T4 sympathectomy. 


Post Surgical Considerations: 

Phantom sweating: Before surgery, most patients report that prior to the onset of their sweating, feeling a tingling sensation in their hands. After the operation, many remain conscious of the same sensation that preceded their abnormal sweating. A typical echo voiced after surgery is to sense "that feeling" in their hands or face, and fear the operation didn't work, only to find that no sweating recurs. After awhile, the awareness of any "tingling" or "pre-sweating sensation" fades. 

Pleuritis and Neuritis : Pleuritis is a condition where the chest wall lining (pleura) is inflamed. It may cause a stabbing-like pain one to two weeks after the operation. Neuritis is a condition where there is inflammation involving the underlying nerves. Either of these conditions may occur after surgery. Medications are given to help prevent or reduce the discomfort of these symptoms should they occur. Since the introduction of the Radio Frequency Probe, these symptoms have decreased.

Dry Hands: After surgery, the hands will be very dry. Frequently, the use of hand lotion is necessary to keep the skin soft. Because dry skin has never been a problem for most people with hyperhidrosis, this can be a surprising result. It is important for patients to learn to keep hands moist with lotion. Carrying lotion in your car and keeping a bottle in a desk is often helpful.

Emotional Relief: After surgery, the burden and embarrassment of severe sweating vanishes. Most patients note a profound emotional experience as soon as they rouse from the anesthesia. About half of all patients wake up crying in the recovery room. Only one afflicted with the symptoms of hyperhidrosis can truly understand this reaction. 
It usually takes about one to two weeks for patients to develop confidence that they will no longer sweat or blush.

Many have related a common dream occurring within the first month after the operation. One patient described this dream to Dr. Garza. His dream was extreme and may give those who dont have the syndrome a better understanding of what it is like to have hyperhidrosis. He dreamt that the sweating had recurred and those around him were laughing about his condition. He felt embarrassed and shamed. It upset him so much that he woke up and looked in the mirror. After confirming that he was OK, he returned to sleep.

There is an immediate apprehension to doing things that most of the non-hyperhidrosis-world takes for granted. Actions like touching objects or people, holding hands, reading the Sunday Newspaper without having to fret about ink smudge, opening door knobs, turning a steering wheel without soaking it, inserting contact lenses without contaminating them with sweaty salt that irritates the eyes, shifting gears in a car, or applying makeup or finger nail polish become new experiences. It improves the quality of life.

Former patients have reported they found themselves "unburdened" and wanted to "come out."

If the patient has been in therapy, resumption is highly recommended. 

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http://www.handsdry.com/treatment-post-surgical.html

TREATMENT - Post-Surgery

Following an ETS procedure, most patients leave the surgical center about an hour after the operation. Patients who are accompanied by a friend or a family member may leave the hospital after the operation. Patients who came alone are asked to stay overnight in the hospital.

On the day following surgery, the Band-Aids may be removed and the patient can shower. Since there are no stitches to be removed, Steri Strips (small tapes) may be removed five to seven days after the procedure.


Returning to work is up to each individual patient. Light duty work may be resumed four or five days after the procedure. However, heavy-duty work should be delayed until ten days following the operation. In the meantime, patients are encouraged to walk and climb stairs on the day after the operation and can usually drive by the second day after surgery. 
It has been Dr. Garza's observations that women tend to tolerate chest wall discomfort better than men. Enough said! 


Possible Side Effects 

As with all surgical procedures, there are certain side effects and risks associated with an ETS. However, when this procedure is performed by a skilled endoscopic surgeon with extensive experience with this treatment, the incidence of complications is low.

Compensatory Hyperhidrosis 
Compensatory sweating (CS) is the most common, expected and significant side effect of an ETS. CS is reported to occur in 100% of patients who undergo sympathectomy for hyperhidrosis. It occurs regardless of whether the procedure is an open or endoscopic procedure. 

The severity of the CS depends upon the levels of the sympathetic chain that are interrupted. Compensatory hyperhidrosis is a condition where the heat loss or sweating is shifted from the hands, armpits, face and scalp to the upper and lower back, lower chest, abdomen, buttocks, groin and backs of the thighs. The brain transfers the sweat to a different location in order to get rid excess body heat.

It has been theorized that the CS would only happen if more than one level (T2) were clamped. However, it is now understood that severe CS may occur when only the T2 is clamped, cut or removed. In addition, it has been discovered that the T2 or nerve trunk is responsible for the most severe forms of CS. The reason for this is because T2 or T3 nerve trunks are also responsible for eliminating sweating and heat loss from the top of the head, neck, shoulders, chest, under the breasts, hands and underarms. The head alone is responsible for eliminating 44% of all body heat. This excess body heat has to be released elsewhere and will be distributed on the trunk, groin, buttocks and legs.

Recent findings have led to a modification of the traditional technique. It is believed that this new technique will lead to the reduction of CS in patients with certain types of hyperhidrosis. The main goal of the technique is to spare the T2 and T3 nerve trunks. In this new technique, small clamps are applied to the 4th nerve trunk, thus sparing the T2 and T3 nerve trunks. The new technique is appropriate for people with hand or underarm sweating. Unfortunately, clamping of the T2 nerve trunk is essential for those with facial sweating or blushing. Clamping of the T4 nerve trunk will not help those with facial sweating or blushing.

Some mild to moderate sweating occurs in all cases following an ETS procedure and is usually tolerable. The symptoms of CS may occur intermittently or even be constant throughout the day. What matters is the severity of the syndrome. Mild CS creates moisture on the trunk, buttocks, groin or legs, but does not penetrate through clothing. Moderate CS involves moisture in the same areas, but does show through clothes. Most people tolerate it or may use some medications so that the CS diminishes.

Patients have frequently told Dr. Garza, "I can tolerate it as long as my hands and underarms no longer pour with sweat." 

Severe CS causes profuse sweating between the breast, below the breasts to the lower chest, abdomen, upper and lower back, groin, buttocks and the backs of the thighs and knees. Patients may feel cold or hot and just plain uncomfortable. Those who develop severe CS may feel that this side effect is worse than their previous symptoms and express regret regarding their sympathectomy.

Currently, it is not possible to accurately determine who will develop the severe form of compensatory hyperhidrosis after an ETS procedure. However, there are some clues regarding who might develop the severe form of CS after the operation. The sweating pattern prior to a sympathectomy will usually determine the sweating pattern after the operation.

Persons who sweat only on the hands, feet and underarms, but not on the trunk, groin or legs will usually develop mild CS after a T4 sympathectomy. Those who have sweating on the hands, feet and underarms as well as the back, chest, abdomen, groin or legs prior to the operation will most likely develop severe CS after the operation. 

Patients who undergo a T2 or T2 + T3 sympathectomy usually will develop severe CS after the operation.

The compensatory hyperhidrosis may occur soon after the operation or many years later. Again, most people can tolerate mild or moderate compensatory hyperhidrosis as long as their hands or underarms no longer drip with sweat. It is the 5% of all patients who develop the severe form of compensatory hyperhidrosis who express regret in having the procedure performed. For those persons who experience severe and unmanageable CS, the new technique of clamping the sympathetic nerve with a small titanium clip is the best option currently available. The technique for early reversal involves the same endoscopic technique as the original ETB, except that the nerve clip is removed instead of applied. While early removal of the clamps will not always reverse the operation, this has the highest rate of reversal. However, once the nerve is cut, the effect is permanent and rarely reversible. 

There is a new treatment for those persons who developed severe CS after a sympathectomy in which the nerve was cut or removed. This new treatment involves transplanting a small skin nerve from the lower leg (the Sural nerve) into the site where the nerve was cut or removed. This is a complicated procedure and is reserved only for those with severe CS. Again, it should be stressed that the sympathetic nerve trunk should be clamped and not cut or removed. It is far easier to remove a titanium clamp than to transplant a new nerve. And it should be noted that not all patients with the nerve transplant will recover fully from the effects of severe CS.

There are some medications that may lessen the effects of CS, although they are not always effective in reducing the CS. The most useful medications for treating CS are Robinul Forte and Ditropan. Robinul Forte is the first line of medical treatment of this condition. Since this medicine can cause generalized body dryness, it should be used only when necessary and should be avoided during heavy physical exercise. Side effects can include dryness of the mouth (cottonmouth), headaches or constipation. The most effective dosage is taking the medication 3 hours prior to meals. 

Used in low doses, Ditropan has recently been found to be very effective in the treatment of severe CS. 

Gustatory Sweating 
This condition causes facial sweating after eating or smelling foods. People describe it as similar to facial sweating that follows after eating hot spicy foods such as chili. This condition occurs in about 10% of all patients who undergo a T2 sympathectomy, but not a T4 sympathectomy. If it does occur, it happens years after the ETS or ETB. Persons who develop gustatory sweating can be treated with a Robinul Forte topical suspension in a cream solution. 

Decreased Heart Rate 
Among patients who undergo a T2 sympathectomy, approximately 1 of 10 will experience a 10% decrease in their resting heart rate. This does not occur after a T4 sympathectomy. Dr. Garza recommends against performing a T2 sympathectomy on athletes as a T2 sympathectomy may impair his or her performance.

Dry Facial Skin 
Dry facial skin and an improved complexion may occur following an ETS or ETB. The dryness is rarely severe and patients seldom require a facial skin moisturizer. An unexpected benefit from the sympathectomy is that any acne complexion problems usually clear up within the first week after the operation. Most patients who had previous complexion problems are able to stop taking their Accutane after the procedure.

In some cases, patients may develop dandruff after the procedure. This side effect can occur after a T2 or T3 sympathectomy, but not a T4 sympathectomy.


Post Surgical Considerations 

Phantom sweating 
Before surgery, most patients report that prior to the onset of their sweating, they feel a tingling sensation in their hands. After the operation, many remain conscious of this same sensation that preceded their abnormal sweating. After the operation, many patients have commented that they still sense that tingling sensation in their hands or face and fear the operation was not successful. However, they gladly discover that no sweating recurs. After awhile, the awareness of any phantom "tingling" or "pre-sweating sensation" fades.

Pleuritis and Neuritis 
Pleuritis is a condition where the chest wall lining (pleura) is inflamed. It may cause a stabbing-like pain one to two weeks after an ETS or ETB. Neuritis is a condition where there is inflammation involving the underlying nerves. Either condition may occur after surgery. Medications are given to help prevent or reduce the discomfort of these symptoms should they occur. With the introduction of the radio frequency probe during the procedure, these symptoms have decreased.

Dry Hands 
After surgery, the hands will be very dry. Frequently, hand lotion is necessary to keep the skin soft. Since most people with hyperhidrosis have not had problems with dry skin, this can be a surprising result. It is important for patients to keep their hands moist with lotion. It is recommended that you keep a bottle of lotion at your desk and in your car.

Emotional Relief 
Following the surgery, the burden and embarrassment of severe sweating vanishes. Most patients feel a profound emotional experience as soon as they wake up from the anesthesia. Nearly half of all patients wake up crying with joy in the recovery room. Only someone who has suffered from the physical and emotional symptoms of hyperhidrosis can truly understand this reaction.

It usually takes about one to two weeks for patients to develop confidence that they will no longer sweat or blush.

Many patients have experienced a common dream within the first month after the operation. One patient described this dream to Dr. Garza. Although his dream was extreme, it can help those who do not have hyperhidrosis to better understand what it is like to have this condition. In this patient's dream, he dreamt that the sweating had recurred and those around him were laughing about his condition. He felt embarrassed and ashamed. The dream upset him so much that he woke up and looked in the mirror. After confirming that he was alright and that his hands were indeed dry and smooth, he returned to sleep.

Even after the procedure, there may be an immediate apprehension to do activities that most of the non-hyperhidrosis-world takes for granted. For example, simple daily actions become new experiences, such touching objects or people, holding hands, reading the newspaper without having to fret about ink smudge, opening door knobs, turning a steering wheel without soaking it, inserting contact lenses without contaminating them with sweaty salt that irritates the eyes, shifting gears in a car, or applying makeup or finger nail polish. Suddenly, patients who had suffered with hyperhidrosis find that their quality of life has greatly improved. 

Former patients have reported they found themselves "unburdened" and wanted to "come out." 

For patients who had been in therapy prior to the operation, it is highly recommended that they continue with their therapy sessions after the procedure. 


Possible Complications 

Horner's Syndrome 
Horner's Syndrome is Ptosis (a droopy eyelid), meiosis (a constricted pupil) and anhydrosis (absence of sweating). The patient may also develop nasal congestion. Horner's Syndrome results from the disruption of the Stellate ganglion, or first thoracic (T1) sympathetic nerve. This condition may occur following an ETS or ETB and may be temporary or permanent. It can temporary if after an ETB (with clamping), the clip is quickly removed. The nerve can then regenerate. It is definitely permanent if the nerve is destroyed or removed. Injury to the Stellate ganglion usually occurs when the procedure is performed by an inexperienced surgeon who is just learning how to do the operation. 
Dr. Garza has performed over 4,000 sympathectomies and has never had a patient who developed Horner's Syndrome. 

Brachial Plexus Injury 
The Brachial Plexus is a maze of nerves that radiates from the neck spine and travels down the shoulder to the arms. Injury to the spinal nerve roots may cause pain, muscle weakness or paralysis in the arm and hand. Treatment of this syndrome is extremely difficult. Fortunately, this is a very rare condition and Dr. Garza has never had a patient who experienced this complication. Occasionally, some discomfort in the inner arm for a brief period is felt in a small number of patients. 

Hemothorax 
This is a condition where bleeding occurs in the chest cavity. This is generally due to bleeding from a small artery that runs underneath the ribs. It is treated by chest tube drainage. This condition happens in less than 1% among all patients. It is rare for Dr. Garza to insert chest tubes after the operation. 
The only exception to this is if Dr. Garza has to cut across old scars from previous pneumonias or from a prior operation. A chest tube is usually inserted as a precautionary procedure. 

Pneumothorax 
This is a condition in which the lung does not fully expand. This happens in about 1% of all patients and may become an issue if the patient has severe lung problems such as emphysema. Chest tube insertions may be required if Dr. Garza has to cut across old scars in the chest from previous pneumonias or from a prior operation. A chest tube is usually inserted as a precautionary procedure. 

Neuritis 
Neuritis, which is pain between the shoulder blades, may develop in a small percentage of patients. This discomfort is due to inflammation of the underlying nerves. In rare cases, it may be severe and possibly last two to three weeks. Treatment consists of steroids and non-steroidal anti-inflammatory agents. 

Post Operative Rib Pain 
Occasionally, there is pain between the ribs at the site where the endoscope was inserted. A sensory nerve runs below each rib. Compression of this sensory nerve by the endoscope may cause this problem. This usually resolves on its own in a short time. Rarely is this is a continuing problem. About 20% of patients may develop a feeling of strong pressure-like sensation on their breastbone immediately after the operation. This is due to bruising of the intercostal (under the ribs) nerve when the endoscope was introduced between the ribs. Patients report that it "feels like someone is standing on my chest and I can't breathe." If one does develop this sensation, it usually abates after the first hour and rapidly fades away.
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