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Repeat ETS Surgery for Recurrent Sweating Symptoms



Introduction
VIEW CASE HISTORIES & RESULTS
Missed Kuntz nerves are an important factor in recurrence of symptoms prompting many of the 142 redo ETS surgeries Dr. Nielson has performed. Intact Kuntz nerves is the most common reason Dr. Nielson finds for persistent symptoms after a patient has undergone bilateral sympathectomy.

Partial nerve regeneration has also been found in many redo surgeriesby Dr. Nielson on patients who had a sympathectomy by another doctor.

Much less commonly, persistent symptoms is due to mis-identifying the T3 as the T2 level and therefore leaving the T2 level completely untouched and free to carry sympathetic nerve signal to the fingers and face.

 
 
Before - Severe Raynaud's After - Micro ETS Symptoms Resolve  

December 2012  Successful Redo ETS R2 caused warming of cold 3/4/5 fingers of both hands!
37 year old man developed recurrent Raynaud's (episodes of cold fingers) of the 3rd, 4th, and 5th finger and Blushing 8 months following T2/3/4 sympathectomy.  Prior to the redo ETS, touching objects that were slightly cool would trigger cold 3rd, 4th, and 5th fingers - right hand worse than the left hand and sparing his 1/2 (thumb and index) fingers of both hands. His first and second fingers of both hands would remain warm when the 3rd, 4th, and 5th finger would become very cold and numb.
Successful redo ETS caused immediate warming of his 3rd, 4th, and 5th finger of both hands after the scar tissue overlying the 2nd rib head (location of previous sympathectomy) was precisely divided using a micro scissor. The divided ends were cauterized to lessen the chance of some of the neurons being able to reconnect. He was discharged the same day a few hours after the redo ETS with warm and dry hands (all 5 fingers per hand).

 

April  2008  CT guided Thermal (RFA) Sympathectomy of T2. Redo surgery of patient who was not a candidate for traditional ETS due to adhesions of the left lung covering the 2nd and 3rd rib heads.  (Click to See)

April  2008  Only the second patient to have CT guided Thermal (RFA) Sympathectomy of T2. Redo surgery of patient who was not a candidate for traditional ETS.  (Click to See)

Previous surgeries by another doctor unsuccessful, Dr. Nielson performs successful repeat surgery:

T3 T4 clamping attempt to resolve facial sweating and blushing fails by another surgeon.  Patient comes to Dr. Nielson for REDO.  After Micro ETS is performed by Dr. Nielson, the patient's symptoms resolve.  (Click Here to See Video)

12 Clamps placed by another surgeon caused severe irritation of the nerve (neuroma) making the patient's symptoms worse than before the clamps were placed.  Dr. Nielson removed the clamps, cut the nerves, and the patient's symptoms improved.  (Click Here to See Video)              

MIS-FIRED CLAMPS BY A DIFFERENT SURGEON REMOVED, NERVES CUT, PATIENT'S SYMPTOMS RESOLVE. clamping removal

View Video of Clamp Removal

Why have people come to you to have redo Micro ETS surgery?

Some individuals have come to me with persistent symptoms (sweating for example) after having had ETS surgery performed by someone else. I have treated them with redo Micro ETS successfully and discharged them the same day despite undergoing a redo procedure.I have found the cause(s) to be hidden sympathetic nerve/ganglia under thick tissue making it easy to have been missed the first time, intact Kuntz sympathetic nerves crossing the second and/or third rib(s), and dislodged clamps that are no longer in contact with the nerves and cannot interrupt the nerve signal!

Other doctors do a partial pleurectomy, cutting out a window of pleura so they can see the sympathetic nerve. This is quite traumatic and causes scar tissue that sticks like glue to the chest wall. Probably part of the reason re-do patients tell us their post op pain and recovery is much less with the Micro single incision ETS re-do than their original surgery.

T2 Sympathetic Innervation to The Sweat Glands of the Face

Over several years of experience in treating patients with recurrent and/or persistent sweating of the face after undergoing T2 sympathectomy, I have found that persistence of any sympathetic nerve innervation across the second rib level, just above the T2 ganglion, plays a significant role in persistent sweating conditions of the face after undergoing a T2. T3, or T4 sympathectomy.

It is apparent in some patients that there are neuronal contributions from lower levels such as the T3 that pass up over the second rib level on their way to the face that participate in the sweating symptoms of the face. Some physicians misunderstand the sympathetic nerve innervation of the face and believe in order to treat facial sweating it is important to cut the sympathetic nerve at the T1 level or above, thereby causing the dreaded Horner’s Syndrome. This, in my experience, I’ve found not to be the case.

In summary, for successful treatment of facial sweating, it is imperative that all sympathetic nerve innervation crossing the second rib level be divided as opposed to clamped or having lower levels cut or clamped. Also, accessory nerve branch pathways bypassing the T2 ganglion can or may contribute to persistent facial symptoms.

Case Histories and Results

Patient had a Dorsal Sympathectomy who then developed regeneration of the sympathetic nerve 6 years later. She had had a dorsal (posterior approach 6 yrs ago with clamps and excision).Dr Nielson found tremendous lung adhesions from the previous surgery (Lung adhesions are possible negative effects of more invasive surgical approaches by other techniques).
Click to see image of clamps from a previous, highly invasive dorsal sympathectomy

Patient had four previous clampings by another surgeon for facial blushing/hyperpyrexia.   Blushing persisted of his face after all four clamping attempts.  After Micro ETS, facial blushing/hyperpyrexia resolved completely on both sides.
   Click to see surgery video of redo for facial blushing / hyperpyrexia

 

Patient is a male who had two previous clampings by another surgeon for facial sweating.   Sweating persisted on one side of his face after both clamping attempts. After Micro ETS, his facial sweating resolved completely on both sides.
 Click to see surgery video of redo for facial sweating

 

Patient is a 49 year old female who had ETS five years ago with a different surgeon and technique.  Her facial blushing persisted after the surgery.  She had Micro ETS of T2 (above) to improve blushing. She feels much less anxious now with NO post op pain or CS.  She is "very satisfied" with the results.
Click to see surgery video of redo for facial blushing

 

Sweating on hands returned one and a half years after clamps had been placed at the T2 level on both sides.  After micro ETS patient's hands have remained dry.
Click to see surgery pictures showing dislodged clamps

 

Patient had persistent facial sweating after clamping/cutting of the T2.  Dr. Nielson performs a redo on him and finds that the clamps have fallen off the nerve where they had beenplaced just above the T2 ganglion on both sides. By precisely cutting the sympathetic nerve at the upper border of the 2nd rib the patient was successfully treated for his facial sweating.
  Click to see clamps

Patient had persistent facial sweating after clamping/cutting of the T2. Dr. Nielson did a redo on him and found that the clamps had fallen off the nerve where they had been placed just above the T2 ganglion on both sides. Dr. Nielson reduced patient's facial sweating (forehead) by cutting the nerve at the 2nd rib level. His previous surgeon had told him that his persistent forehead sweating after T2 clamping/cutting was due to T1 innervation to his eye which if cut to reduce his forehead sweating would also cause Horner's syndrome. This wasn't the case and Dr. Nielson successfully treated his persistent forehead sweating by precisely cutting the sympathetic nerve at the upper border of the 2nd rib.

Patient has previous surgeries with clamps at 2nd, 3rd, and 4th ribs. Patient's facial blushing does not resolve with either surgery and he developes severe CS and facial sweating. Twelve days after surgery with Dr. Nielson, patient reports facial blushing is getting better everyday.

Patient had two previous surgeries with clamps at 2nd, 3rd, and 4th ribs. His facial blushing was not resolved with either surgery, he developed severe CS and facial sweating. Twelve days after surgery patient reports facial blushing seems to be getting a little bit better everyday. Rates his facial blushing as a 1 (on a scale of 1 to 3, being the most severe), but says he hasn't really been in a situation that would trigger the most severe episode of facial blushing.
CS of the back and trunk are much improved. Started using the Oxytrol transdermal patch, but discontinued. CS still seems improved after stopping.

Patient has bilateral T2 in Sweden. Four years after surgery, severe Blushing and moderate facial sweating and moderate cold hands (but hands still dry) developed. Dr. Nielson performs micro ETS of T2(above) and blushing resolves along with facial sweating.

Professional prior to  first ETS was terrible. After has been great, however recurring symptoms are beginning to effect again. Social and personal have been better since first ETS as a whole. Since nearly every social activity involves eating, however, the gustatory sweating has made life miserable from that standpoint. The Levsin takes an hour to kick in and you can't do anything spontaneously that way. Gustatory sweating began 6 mo post op, hands are still warm and dry after first ETS, all other symptoms started about 4 years post op (facial blushing and sweating). CS  of the chest is moderate, worse with heat and humidity. Patient thinks the surgeon cauterized T2 bilaterally. Gustatory sweating started one month after surgery.

3/20/98

Patient has bilateral T2 in Sweden. Bilateral cautery distruction of the T2 ganglia. Palmar sweating ceased. 6 months later gustatory sweating developed. 4 years after surgery, severe Blushing and moderate facial sweating and moderate cold hands (but hands still dry) developed.

8/20/03

Dr. Nielson performs micro ETS of T2(above) (5 years after  patient had undergone ETS) and Blushing resolved along with facial sweating.

22 year old white male underwent ETS-C (clamping) of T2 for severe Blushing and mild palmar hyperhidrosis that was unsuccessful. After bilateral Micro ETS of T2(above) complete resolution of Blushing and palmar hyperhidrosis occurred.
  Click to see dislodged clamps

22 year old white male underwent ETS-C (clamping) of T2 for severe Blushing and mild palmar hyperhidrosis. Four months later he presented with persistent severe cranio-facial erythema (blushing) and mild hyperhidrosis of the palms despite ETS-C of T2. Micro ETS of T2(above) was then performed (by me) with precise division of the sympathetic nerve at the 2nd rib bilaterally. The titanium clamp was across the nerve 4 mm below the 2nd rib on the right and had become dislodged from the nerve and was lying 5 mm away from the nerve on the left side. Complete resolution of Blushing and palmar hyperhidrosis occurred after bilateral Micro ETS of T2(above).

Redo at T2 level for blushing & hyperpyrexia (burning) is successful. Two previous surgeries were performed at the T3/T4 and later at the T2 level by other surgeon with clamping.
  Click to see surgery pictures

29 year old asian male with severe Blushing, facial sweating and mild palmar sweating who underwent ETS-clamping of T3/T4 without improvement in his facial symptoms and developed cs (compensatory sweating). His hands had become mostly dry but were still slightly cool. One month later he elected to have ETS-clamping of T2 without any improvement in his facial blushing or sweating and no change in his cs.

He then presented to me 20 months later to haveMicro ETS of T2 (above) with division (cutting) of the nerve where it crossed the 2nd rib. Dense lung adhesions to the 2nd and 3rd rib heads made it too invasive to remove the clamps. The nerve was divided where it crossed the 2nd rib head using the tips of micro endoshears. Immediate significant decrease in both Blushing and facial Hyperpyrexia (burning) symptoms occurred as well as facial sweating. His fingers became warm too. No change in the degree of cs that he had preoperatively.

Redo at T2 level for blushing & hand sweat is successful. A previous surgery was performed at the T3 level by other surgeon.

(Click Icon to view surgery)

Persistent facial blushing after sympathectomy can occur if any kuntz nerve that crosses the second thoracic rib is left intact, and can therefore continue to carry nerve signals to the face.
In the many redo's Dr. Nielson has performed for persistent facial blushing, he has found that the most common reason for persistent blushing has been missed Kuntz nerves crossing the second thoracic rib and less commonly dividing the sympathetic nerve at the T3 level by mistake rather than the T2 level.

Kuntz nerves that arise from T4 can actually cross the second rib several inches lateral to the main sympathetic nerve trunk, making them easily missed especially if not examined from an optimized angle and if the surgeon's technique is one where only very large Kuntz nerves can be seen. In instances such as these, the incidence of finding Kuntz nerves is reportedly as low as 5 to 20%.

Redo surgery at T2 level shows scar tissue resulting from clamping. Missed kuntz nerves are divided & symptoms resolve.

(Click Icon to view surgery)

Re-do patients tell us their post op pain and recovery is much less with re-do than their original surgery.

Redo surgery for facial blushing at T2 level. Symptoms resolve.

(Click Icon to view surgery)

A 24 year old white male sufferred from severe blushing with severe facial hyperpyrexia (face/head heat) and moderate palmar hyperhidrosis for 14 years. These symptoms were refractory to Ativan, Valium, Effexor and Prozac. He elected to undergo bilateral ETS of T2 by clamping technique three months ago. At that time, two clamps were placed above and two clamps below the the T2 ganglion bilaterally. Postop pain the following day he described was significant when raising his arms but gradually diminished over time. His hands had become warm and dry immediately after that surgerybut he had only noticed a 40% decrease in his blushing and no improvement at all in his facial hyperpyrexia.

He elected to have me perform Micro ETS of T2 todivide any missed Kuntz nerve branches present crossing the second rib and to divide the main sympathetic nerve by my micro cutting technique precisely at the upper border of the 2nd rib on each side.

The patient underwent Micro ETS of T2 by me and I found a large Kuntz nerve 2mm under the pleural surface crossing the second rib approximately 2.5 cm lateral to the main sympathetic nerve trunk on the right side and 3.0 cm lateral to the main nerve on the left side. There were two metal clamps across the main sympathetic nerve at the second rib level and two at the third rib level (above and below the T2 ganglion).

By my Micro ETS technique, precise division of these Kuntz nerves was done without having to remove a pleural window of tissue just to see the nerves. After both sides had been precisely divided by my Micro ETS technique, the patient's blushing completely resolved as did his severe hyperpyrexia.
The next day after Micro ETS redo surgery, he was in no pain but just a slight amount of soreness of the inner chest wall lining (pleura) on deep breaths. He has been enjoying complete cessation of his facial blushing and hyperpyrexia ever since then.

 

I find that the most common reason for recurrence of symptoms or failure to resolve them is missed Kuntz nerves crossing the second rib. The second most common reason for recurrence is mis-identified T2 where T3 is mistaken for T2 and the clamps or cutting is at the T3 level rather than the T2.

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