Timo Telaranta Chairman of the Symposium

The 4^th International Symposium on Sympathetic Surgery was held in Finland in June 2001, and was attended by the world’s most renowned ETS surgeons, including its Chairman, Dr. Timo Telaranta. Louis Stein of Surgical Team was there to listen to the experts.

·        International Society for Sympathetic Surgery founded
International Society for Sympathetic Surgery was founded during the Symposium. It has a council of five members:

- Dr. Christer Drott from Sweden - The Society’s first Chairman
- Dr. Christoph Schick from Germany
- Dr. Timo Telaranta from Finland
- Dr. Chien-Chih Lin from Taiwan
- Dr. Moshe Hashmonai from Israel

Dr. Alan Cameron from England joined as an English language expert, especially for the revision of the by-laws.

·        Several interesting topics were discussed:

-         Cauterization - Clamping, T2 - T3 - T4
No uniform strategies for one and only method could be taken. There are still those participants who want to resect at least from T2 to T4 for any treatment, those who either cut or cauterize at T2 level only, those who clamp at T2 level only, and then those who adopted the new selective Lin-Telaranta classification and clamp only the needed levels, be them T4, T3, or T2. (see Abstracts)

There was an unofficial vote about the favorite method, cutting or clamping, and cutting was still favored, though the trend seems to be going towards clamping.

-         The role of the Kuntz nerve
Presentations were made on whether the Kuntz nerves have any importance with regards to compensatory sweating. The conclusion was that, at the moment, the question remains unanswered and doubts were raised. (see Abstracts)

The next symposium, the 5th International Symposium on Sympathetic Surgery, will be organized and chaired by Dr. Christoph Schick in Erlangen, Germany in 2003.

Selected Abstracts:

Experiences of T4-sympathetic block by clamping (ESB4) in treatment of hyperhidrosis palmaris et axillaris

Chien-Chih Lin, M.D., Hsing-Hsien Wu, M.D., Department of Surgery, Tainan Municipal Hospital, Tainan, Taiwan

Conclusion:  The ESB4 is by far the only method that can stop hand and axillary sweating without interrupting the sympathetic tone to head, thus reflex (compensatory) sweating can be avoided after sympathetic surgery.

Many surgeons try to find out a method that can treat Hyperhidrosis without inducing reflex (compensatory) sweating when sympathetic surgical technique becomes well developed in treating Hyperhidrosis. Evidence suggests that reflex sweating can be avoided only when the sympathetic tone to human brain is preserved in sympathetic surgery. Incidentally, we found that T4-sympathetic block by clamping (ESB4) is a method that can treat Hyperhidrosis without interrupting the sympathetic tone to human brain. The mechanism and how to avoid reflex sweating are discussed. We applied ESB4 to treat 165 cases (84 males and 81 females) of Hyperhidrosis palmaris et axillaris from August 1, 2000 to February 28, 2001. Operative procedures were performed as conventional ETS method by two-port approach except that the sympathetic nervous trunk is clamped with 5 mm Auto Suture clips at the upper borders of 4th and 5th ribs. It takes less than 10 minutes to finish ESB4 bilaterally. Patients were followed up after operation. Hand and axillary sweating were stopped immediately after ESB4 except in one patient who regretted the operative result for no cessation of her face and body sweating; another one got no change of hand sweating, the other three ones were satisfied with minor hand sweating preserved. Most of them are without reflex sweating after ESB4, or reflex sweating happens only mild or ignorant degree in popliteal areas in hot environment. Reflex sweating after sympathetic procedures for Hyperhidrosis is controlled by Hypothalamus. It can be avoided when the sympathetic tone to head is preserved in sympathetic operation. The ESB4 is by far the only method that can stop hand and axillary sweating without interrupting the sympathetic tone to head, thus reflex sweating can be avoided after sympathetic surgery.

Kuntz's Fiber: The scapegoat of surgical failure in sympathetic surgery

Chien-Chih Lin, MD, Hsing-Hsien Wu, MD, *Lim-Shen Lee, MD. Departments of Surgery and Anesthesiology, Tainan Municipal Hospital, Tainan, Taiwan

Conclusion: We consider that Kuntz's fiber is only a scapegoat of surgical failure in ETS; its re-definition is necessary especially in this era of endoscopic surgery.

The incidences of surgical failure rate less than 2.0% are acceptable in Endoscopic Thoracic Sympathetic Surgery (ETS). The cause of surgical failure is investigated. The presence of Kuntz's fiber is once considered the fetal reason of surgical failure. However, our clinical cases prove that Kuntz's fiber plays no role in surgical failure of sympathetic operation but does in anatomic role at our series of study. Re-definition of Kuntz's fiber is necessary in this era of Endoscopic Surgery.

Kuntz's fiber was described routinely on 1085 consecutive cases when ETS was performed between 1992 and 1994. The incidence of Kuntz's fiber is around 60% in general population in our study. Kuntz's fiber is preserved when Endoscopic Thoracic Sympathetic Block by clamping (ESB) was invented and used in 1996, while our surgical failure rates were around 1.5% in our 785 cases of ESB between 1996 and 1998. There is significant difference between the incidence of Kuntz's fiber and surgical failure rate after Kuntz's fiber preservation procedures. Navarro's animal experiment proved that the amount of hand sweating is positively related to the number of sympathetic nervous fibers to sweat glands. Our surgical failure rate is about 1.5% in our ETS patients with Kuntz's fibers preservation, while the incidence of Kuntz's fibers is about 60%, which was also supported by Japanese and Korean studies. So far, difference between surgical failure rate and the incidence of Kuntz's fiber was found in our study. Inappropriate application of clips was the main cause of our surgical failure. Surgical results follow "all or none" rule in sympathetic surgery .Sweating disorder is cured or not in ETS, but there's no intermediate condition of hand sweating after ETS. If Kuntz's fibers are composed a portion of sympathetic fibers, decreased hand sweating amount is predicted on the case of ETS with Kuntz's fibers preserved. We consider that Kuntz's fiber is only a scapegoat of surgical failure in ETS; its re-definition is necessary especially in this era of endoscopic surgery.

Lin- Telaranta Classifications:
The Base of Designing New Procedures for Different Indications in Sympathetic Surgery

Chien-Chih Lin, M.D., *Timo Telaranta, M. D. Surgical Departments, Tainan Municipal Hospital Tainan, Taiwan; *Privatix Clinic, Tampere, Finland

Conclusion: The patients are individuals with individual symptom complexes. There does not seem to exist any clear-cut Hyperhidrosis disease, Blushing disease, nor necessarily any social phobia disease, or schizophrenia disease. All these states are symptom complexes of multiple origin, and should be treated individually along the proposed guidelines.

Endoscopic Thoracic Sympathetic Surgery (ETS) has become a worldwide standard procedure in the treatment of Hyperhidrosis and many other sympathetic disorders. Reflex sweating (compensatory is an incorrect term) is probably the most common complication in sympathetic surgery .Whereas around 5.0% of patients undergoing sympathetic surgery suffer from postoperative reflex sweating, many modified sympathetic procedures, including the sympathetic block by clamping method (ESB) first proposed by Lin in 1996, have been designed to avoid postoperative complications. Despite the reversibility granted by this method, the patients must be satisfied with their original condition after the removal of the clamps. They have no option of both: dry hands and no reflex sweating. Is there any sympathetic procedure that can treat hyperhidrosis without inducing reflex sweating? Fortunately, there now seems to be such a procedure. The new method was designed through clarifying the mechanism of reflex sweating and the nervous tracts of sympathetic innervation.

Surgeons usually consider that the other portions of the body naturally take over the sweating "job" of hands after a sympathetic operation. However, some discrepancies exist. Many studies have shown that there's no relationship between the sweating amount of hands and compensatory areas. In addition, reflex sweating is not found on lumbar sympathectomy for pure Hyperhidrosis plantaris. Why are there different postoperative responses between thoracic and lumbar sympathetic surgeries? Is traditional consideration of sympathetic innervation wrong? New concepts and classifications of sympathetic disorders proposed can explain all post-operative phenomena in sympathetic surgery. We believe that they will become standard rules in sympathetic surgery.

Sweating after sympathetic surgery is a reflex cycle between the sympathetic system and the anterior portion of the hypothalamus according to our investigations. Reflex sweating will not happen if hand sweating can be stopped without interrupting sympathetic tone to the human brain. We proved clinically from nervous mapping that neither T2 nor T3, but T4 and lower ganglia provide the major sympathetic innervation to hands. Major sympathetic fibers at the levels of T3 and above innervate head and neck. Few or none from T2 and T3 innervate the hands while the fibers from T4 must definitely pass through T2 and T3 to innervate hands. This is the reason why T2-sympathetic procedures can treat hyperhidrosis but with higher incidence and degree of reflex sweating. Thus, we know that ESB4 can treat hyperhidrosis palmaris without interrupting sympathetic tone to the head and neck, therefore no reflex sweating is predicted on ESB4 cases. We have performed ESB4 to treat more than 160 hyperhidrotic patients with incredibly good results from August 1, 2000 to February 28, 2001.

The blushing and social phobic patients form a special group in ESB surgery. While it seems clear that T2 is the ganglion mostly responsible for flushing as well as blushing, it has become more and more evident that T3 and even T4 participate in blushing control. The role of the different ganglia is not yet entirely clear, but the surgeries thus far performed at T3 level for blushing seem to be sufficient for those having also sweating of the face as part of the problem. Those having only blushing and intense flushing seem to need a T2 clamping, and even so that one clamp should be put on the upper border of the second rib, or just underneath the Stellate ganglion, should this be lower. Moreover , the medical branches of the lowest stellate ganglia and T2 are better also included in the procedure in intense flushing and blushing.

The social phobia patients having no problems with either blushing or sweating have in our studies had equally good results statistically by unilateral left sided clamping. Left side is selected whenever possible due to lesser risk of ectopic heart beats or arrhythmias. In unilateral blocks the levels can be selected on a wider basis, e.g. T2 to T 4 without almost any fear of reflex sweating.

After having mapped these new concepts on sympathetic nervous tracts, we classified the sympathetic disorders into three groups. We name this new classification "Lin-Telaranta classifications of sympathetic disorders". A totally new concept has emerged with that classification. "Different procedures for different sympathetic disorders" is emphasized too. 95% of post-operative complications can be avoided with our classification.

Here are the basics of our new classifications:
ESB2 (clamp upper end of T2 only): 2.5%, (in Europe 15%)
Facial blushing, Craniofacial sweating, Some psychic disorders, Rosacea, Vibration disorder (?), Parkinsonism (?)...
ESB3: 2.5%, (in Europe 50%)
Hyperhidrosis Palmaris with Craniofacial sweating, blushing, or any other craniofacial sympathetic disorders
ESB4: 95%, (in Europe 20%)
Hyperhidrosis Palmaris with or without axillary hyperhidrosis (Bromidrosis)
Unilateral ESB: (in Europe 15%)
Social phobia, schizophrenia, sleep disorders, addiction, cardiac arrhythmias

Conclusion: The patients are individuals with individual symptom complexes. There does not seem to exist any clear-cut Hyperhidrosis disease, Blushing disease, nor necessarily any social phobia disease, or schizophrenia disease. All these states are symptom complexes of multiple origin, and should be treated individually along the proposed guidelines.

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