http://www.pain.com/sections/painresources/library/article.cfm?ID=3589&Current_Page=1&start=1&RecordDisplays=10&Search_phrase=furlan&orderdir=DESC&sort=online_date&records=2

What price success? Ask the patient.
Boas RA

 
This commentary evaluates the article by Furlan et al regarding the acceptable treatment outcome of surgical sympathectomy for hyperhidrosis. He also states Furlan questions: (1) whether transthoracic sympathectomy represents an advance in the treatment of palmar hyperhidrosis; (2) what constitutes an acceptable therapeutic outcome to this or other symptomatic interventions; and (3) if the price is high, what is the cost of other treatment options. The final question of Furlans review is what degree of sympathetic ablation is needed to achieve a satisfactory outcome. 
The more precise thoracoscopic sympathectomy technique is less costly, less invasive, and allows bilateral therapy, which was unacceptable in most patients undergoing open surgery. This review of the literature is a timely reassessment of sympathectomy as a treatment modality. 

The present commentary is directed to the issue of outcome measures that are appropriate to assess symptomatic therapies. Currently the emphasis is on the use of multiple clinical measures of treatment outcomes, including that of asking the patients how satisfied they are with their treatment. Retrospective audits may be deficient in these areas as it is with hindsight that the important issues are recognized. 

At the heart of the issue is the manner in which clinicians make assessments. These assessments are operator focused, limited in scope and quantifica-tion, nonobjective, and usually short term. Controlled, randomized clinical trials are not appropriate for day-to-day audits of surgical treatments. Inclusion of simple, predetermined and accepted outcome measures would add immensely to progress in patient care. The measures would include (1) criteria for diagnosis, (2) symptomatic and objective measures of the disorder, (3) functional and behavioral limitations imposed by the disorder, (4) standardization of treatment, (5) patients goals and expectations, (6) objective measures of outcome responses, (7) patient satisfaction measures to balance untoward responses and benefits, and (8) repeat evaluations of outcome over time. 

These clinical requirements for any practitioner seem needed, but are virtually unattainable in individualized everyday practice. Thus, as Furlan states, controlled multicenter trials with critical standards of assessment in all areas are needed. 

Dr Boas agrees with Furlans concerns regarding the appropriateness of permanent sympathectomy for pain therapy, but this gives rise to the question of how well the sympathectomy was done. Is it a more appropriate procedure in the hands of some than others? 

Boas concludes that sympathectomy is a procedure about which there is limited knowledge, applied to conditions about which there is little understanding. What remains clear is that clinical audits and wider collaboration in obtaining data are needed. Patients and membership could be well served by such organizations as the American Pain Society were they to promote and initiate clinical outcome studies for scientific presentation. 


Journal: J Pain, 1(4):258-260, 2000. 11 References
Reprint: Dept of Anaesthesia, Auckland Hospital, Auckland, New Zealand (RA Boas, MB, CHB)
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http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14622606
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http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14622608
1: J Pain. 2000 Winter;1(4):265-7.  Related Articles, Links  


Comment on: 
J Pain. 2000 Winter;1(4):258-60. 
J Pain. 2000 Winter;1(4):261-4. 

Reviewing critically noncontrolled literature on surgical sympathectomy: valuable lessons for treating physicians and our patients.

Mailis A, Furlan AD.

Comprehensive Pain Program, Toronto Western Hospital, University Health Network, Ontario, Canada.

Publication Types: 
Comment

PMID: 14622608 [PubMed] 
