- Afirma que esta operacion comun que da beneficia a los que sufren de sudor excesivo va a ser DEBATE controvertido, como 2 informes publicados que varian los grados de conformidad con los sintomas post-operatorios y llegan a conclusiones diferentes en cmo y cundo la operacion debe de ser realizada.
- Afirma que se siguen realizando varios metodos para operar, y cada uno de ellos, ha ofrecido resultados distintos en la literatura medica.
- Afirma que se contradicen los estudios sobre la satisfacion de los pacientes con la cirujia. Por ejemplo muestra como cirujanos de America afirman que depende del ganglio cortado y por el contrario muestra como cirujanos de Dinamarca han observado que tanto cortando un ganglio u otro la mitad de sus operados han tenido sudor compensatorio disabilitador.
- Afirma que los cirujanos claman por la necesidad de mayores estudios clinicos aleatorios para determinar el mejor tratamiento al sudor excesivo

http://www.medicalpost.com/mpcontent/article.jsp%3fcontent=20050213_122420_4408

Compensatory sweating affects most patients who undergo cutting of sympathetic ganglia 
By Heather Ennis

February 12, 2005 Volume 41 Issue 07
TAMPA, FLA.

A common procedure to bring relief to patients who suffer from excess sweating became the subject of heated debate here as two contradictory papers reported varying degrees of postoperative symptoms and arrived at conflicting conclusions on how and when the surgery should be performed.

Sympathectomy is often the last resort for patients who experience excessive sweating on their palms, face, scalp and underarms. The procedure involves interrupting the nerve signal that causes sweating in the affected area by selectively cutting, clipping or excising part of the sympathetic ganglia. Several methods are commonly performed, and each has drawn mixed results in the literature.

A study involving 121 patients reported here by surgeons from Dallas showed the success of the surgery after one year was dependent on the type of sympathectomy performed. Researchers follow a protocol that involves excising a small part of the T2 ganglia for facial sweating or blushing, the T3 ganglia for hand sweating and T4 ganglia for armpit sweating. In patients with mixed symptoms, multiple excisions were performed.

Palm sweating treatable

"The patients who were most satisfied were those whose sympathectomies were performed for isolated palmar sweating," said Dr. Todd Dewey of the Medical City Dallas Hospital. "Our most dissatisfied patients were those who had sympathectomy for isolated face sweating, face and axillary sweating, and face, palms and axillary sweating."

The most common postoperative symptom following sympathectomy is increased sweating on other parts of the body, most often the back, legs, groin and abdomen. This compensatory sweating can be mild or severe, and occurred in 82% of the Dallas patients. 

Dissatisfied patients seemed to have something in common, said Dr. Dewey, who noted people who underwent surgery involving the T2 ganglia were more likely to experience disabling compensatory sweating after the procedure.

"We would recommend limiting the level of resection to one level if possible or detailed patient counselling for all multi-level or T2 resections regarding the possibility of severe compensatory symptoms," he said.

Fully 83% of patients who underwent T2 sympathectomy reported severe compensatory sweating one year after surgery and the majority of those reported they regretted the decision to have the surgery.

"Patients with T2 resections strongly report they would not have the surgery again except if T3 was part of the excision," said Dr. Dewey. "This is probably because palmar symptoms are more socially stigmatizing and that overrode their severe compensatory sweating."

In contrast, a second research team from Denmark reported a series of 100 patients who underwent surgery for underarm sweating. Surgeons there routinely cut the T2 ganglia, and the study compared two groups who had either T2-T4 or T2-T3 resections. Approximately 90% of patients reported compensatory sweating, half of whom were forced to change their clothes during the day because of it. There was no difference between the two groups, leading investigators to conclude compensatory sweating is determined by the original site of sweating rather than the extent or site of the surgery.

"We speculate that the risk of side-effects following sympathectomy in general depends more on the primary location of hyperhidrosis rather than the extent of sympathectomy," said Dr. Peter Licht of Aarhus University Hospital. "It's been claimed to relate to the extent of sympathectomy, but our results fail to confirm this."

The frequency of compensatory sweating in the Danish study is more likely associated with their decision to cut the T2 ganglia in all patients, according to a Canadian surgeon who has performed more than 640 sympathectomies and has abandoned the T2 procedure because of unacceptable side-effects.

"I had to do a number of reversals in that group," said Dr. Ernie Spratt of St. Joseph's Health Centre in Toronto. "I'm highly selective about who I will do now, and I won't do any type of cutting or cautery procedure."

Dr. Spratt uses a clipping technique that can be reversed within six months of the procedure if severe compensatory sweating develops. He operates on only 35% of the patients referred to his officemost often on people with isolated hand, or hand and underarm sweating. The results in that patient group have been excellent, he said, and the key to his success is careful patient selection. For isolated underarm sweating he recommends sweat gland removal, but admits there are no good options for people with facial or scalp sweating.

"All I can say at this point is I don't think sympathectomy is the answer for that," he said. "They're very depressed when I see them, and I tell them I cannot recommend this procedure."

Other complicating factors may include the type of procedure performedcutting, excising or clippingand the heterogeneity of the patient population. Little is known about the relationship between preoperative sweating and the success of sympathectomy. Both presenters in Tampa stressed the need for a large randomized clinical trial to determine best practices in sympathectomy for excessive sweating.
 