ETS Reversal, reversal operation up to date information

Dr.Reisfeld does perform the reversal operation. The type of reversal is dependent on the type of surgery initially performed (the cutting of the nerve versus the clamping of it).

Over the last decade, more and more ETS surgeries have been performed. Before the last decade, all of the sypathectomies were done in an open fashion that turned away physicians as well patients from having this procedure done. The endoscopic approach made it easier for patients and surgeons alike to accept the operation for problems such as sweaty hands, facial blushing, and facial sweating. The term hypersympathetic activity is being used to describe this entity as a physiological manifestation of the hyperactive sympathetic system.

Another reason why more ETS procedures have been done over the last decade is due to the recent increase and quality of information available on the internet. The dramatic increase in the number of cases being done also brought with it a certain amount of patients (about 3% to 5%) who are unhappy with the results.

What can be done about those patients who are unhappy with the results of the surgery? In the past, the only method that was done endoscopically was the cutting method. For those cases an attempt was made with some medications but when that failed then the reversal operations with the nerve graft was the only other option. More recently, the clamping method has also been used making the reversal operation easier (simply removing the clips) if needed. Below, both types of reversals that Dr. Reisfeld has performed are reviewed.

2009 Nerve Graft Update:
Recent developments in the production and preparation of allograft nerves has opened a window for a possible new approach to nerve graft reversal. In this method a human cadaver is used to harvest a nerve segment for possible connecting of the missing segment of the nerve that was destroyed. This harvested nerve is very carefully washed, and gama radiated to ensure no immune response or any other unwanted reaction.

What does this mean?
This new development provides a decellularized graft which retains naturally occurring neurotropic support and the three dimensional nerve structure is maintained. This eliminates the need to harvest a donor nerve (current process) and it also provides pathways for guided regeneration. The question as to whether impregnation with nerve growth factor or stem cell is still an open possibility but will require many more years of research and development. Dr. Reisfeld is looking into the potential of this approach and hopefully soon enough this can be offered to the patients who previously had the cutting method done with undesirable side effects. Please call or contact our office for more information.

Nerve Graft
With this method a nerve graft is taken from the ankle region (the sural nerve) and is connected to the divided edges of the sympathetic chain with a spacial biological glue. The operation has two components:

Mechanical (Surgery)
The mechanical part is composed of an endoscopic approach to the prior sympathectomy site (the location where the operation was previously done) at which point the surgeon refreshes the edges of the previously cut nerve. This can be done with an ultrasound scalpel or with scissors not connected to electricity. This part is not always possible due to severe scar tissue built up during the first operation. In cases where there is severe scar tissue the operation may be aborted. Also any other technical difficulty can terminate the attempt, although this is not common.

Once the area of the previous sympathectomy was freshened up, the nerve graft is glued to the missing segment and the procedure is finished. The same procedure is performed on the other side of the chest cavity.

Physiological (Time it takes for the nerve itself to resume conduction)

In this part, the resumption of nerve conduction and return to normal sympathetic regulation is a matter that is different from one patient to another and the amount of information that we have about it is very minimal. The process can take a long time and initial symptoms of recovery will not always show before 6 to 9 months after the reversal. So far, those cases done by Dr. Reisfeld show some improvements. The improvements can be seen in lessening of compensatory sweating, better ability to perform exercises, returning of sweat to the facial area and upper body, and hence better cooling of the upper body regions. These results are similar to those reported by Dr. Telaranta who also does the reversal.

At a recent meeting in Germany (2003) the results of nerve graft reversal were presented by Dr. Reisfeld and Dr. Telerantra. Both surgeons reported similar results, however there is a long way to go in order to get definite statistical data. In order to get meaningful data we will need to perform many more cases with longer followup.

Similar work for nerve graft reversal is being done by urological - plastic surgeons when they use the sural nerve to repair damage done to the sympathetic chain within the pelvic cavity. Also here the sural nerve graft is used as a tube similar to what is being done in our reversal procedure. The difference is that they do it immediately at the time of the initial operation; also, it's being done in an open fashion with very fine sutures. Their results also are not yet etched in stone and in a recent verbal communication with the leading plastic surgeon who performs these operations the need for more cases and longer followup is emphasized. One clear fact is that the shorter the segment that is cut, the better the chances are for reversibility with the nerve graft. There are too few cases to really say anything more than this at this time.

Reversal for the clamping method
Over the last 4 years, the clamping method became the method of choice for Dr. Reisfeld. Dr. Reisfeld only does the clamping method. If a patient is unhappy with the results, the clamps can be taken out, giving the patient an easier potential for reversal and recovery. So far, Dr. Reisfeld has performed several clamp removal reversals; those cases have shown improvement in compensatory sweating (compensatory hydrosis or reflex sweating) and performance ability. The healing process and improvement of the symptoms can take from a few months up to a year.

Dr. Reisfeld wishes to emphasize that the clamping method does not provide for guaranteed complete reversal, he simply believes that the clamping method gives a much greater opportunity for reversal.

As time goes by, more cases will be done and more information will be gathered. Those results and experiences will be posted as soon as they are available. For the time being, 36+ reversal cases have been done on patients who previously had the clamping method and about half of them show improvement. The improvement presents itself with reduction of compensatory sweating, return of sweat to the facial region, and minimal to mild hand sweating. As more time has passed since the introduction of clamp removal to alleviate severe side effects such as compensatory sweating we are getting more and more patients who indeed testify that the clamp removal reduced or eliminated their side effects. In some of those cases it took 2 to 3 years to see the benefits from clamp removal. This fact is in line with the knowledge that nerve growth and recovery of the autonomous nervous system is a very slow process.

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ETS Reversal Information