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출처 : http://www.hyperhidrosisclinicusa.com/postsurgery.html
Post Surgery
After about three hours, the patient may elect to leave or to stay in the
hospital. (Those who came accompanied by a friend or a family
member may elect to leave the hospital after the operation. Patients
who came alone are required to stay overnight in the hospital.) Most are
ready to leave the hospital on the day of the procedure. Others stay
overnight and leave the next morning.
On the day following surgery, the Band-Aids?? may be removed and the
patient may take a shower. Since there are no stitches to be removed,
Steri?? Strips (small tapes) may be removed on the fifth or seventh day.
Return to work is up to each individual patient. Light duty work may be
started on day four or five, but heavy-duty work should be delayed until
the tenth postoperative day. In the meantime, patients are encouraged
to walk and climb stairs on the day after the operation, with driving
probable by the second day after surgery.
It has been Dr. Garza’s observations that women tolerate chest wall
discomfort better than men do. No more need be stated.
Side Effects:
As with any surgical procedure, there are certain associated risks.
However when performed by a skilled endoscopic surgeon who has
had an extensive experience with this procedure, the risks of ETS are
low and complications are rare
Compensatory Hyperhidrosis:
Compensatory Sweating (CS) is the most common side effect of ETS.
This is reported to occur in 100% of patients who undergo
sympathectomy for hyperhidrosis. It occurs regardless of whether
the procedure is an open or Endoscopic procedure. The severity of
the condition is mainly dependent upon the levels on the
sympathetic chain that are interrupted. Compensatory
hyperhidrosis is a condition where the sweating is shifted from the
hands, armpits, face and scalp to the upper and lower back,
lower chest, abdomen, buttocks, groin and the backs of the
thighs. The brain does this is order to get rid excess body heat. It has
been theorized that the CS would only happen if more than one level
(T2) were clamped, but it is well known that severe CS may occur
when only T2, T3 or T2+3 is cut or clamped. It has been discovered
that the T2 or T3 nerve trunk is responsible for the most severe
forms of CS. The reason for this is because T2 or T3 is also
responsible for eliminating sweating and heat loss from the neck
to the top of the head. This will eliminate 44% of all body heat. This
excess body heat has to be released elsewhere and will be released on
the trunk, groin, buttocks and legs. Recent findings have led to a
modification of the traditional technique, and it is believed that this new
technique will lead to elimination of reduction of CS in patients with
certain types of Hyperhidrosis. The main goal of the technique is to
spare the T2 nerve trunk. The new technique spares the T2 nerve
trunk and applies clamps on to the 4th or the 4th plus the 5th
nerve trunks. The new technique is applicable to those with hand
or underarm sweating. Clamping of the T2 and T3 nerve trunk is
essential for those with facial sweating or blushing. Clamping of the
T4 and T5 nerve trunks will not help those with facial sweating or
blushing. While clamping of the 4th or the 4+ 5th nerve trunks
usually leads to mild compensatory sweating, one out of 20 may
develop severe compensatory sweating.
Mild to moderate sweating occurs in most cases it is and is usually
tolerable.
The symptoms of CS may occur intermittently or even be constant
throughout the day. What matters is the severity of the syndrome. Mild
CS creates moisture on the trunk, buttocks, groin or legs but does not
show through their clothes. Moderate CS involves moisture on the same
areas but does show through their clothes. Most people tolerate it or
may use some medications so that it diminishes. Most patients express
the feeling, "I can tolerate it as long as my hands don't sweat or my face
doesn't blush".
Severe CS causes profuse sweating between the breast, below the
breasts to the lower chest, abdomen, upper and lower back, groin,
buttocks and the backs of the thighs and knees. Patients may feel cold
or hot and just plain uncomfortable. Those who develop severe CS may
feel that this side effect is worse than their previous symptoms and
express regret regarding their sympathectomy. Severe CS occurs in 2
out of 5 who undergo a T2+T3 sympathectomy. While removal of the
clamps will not always reverse the operation, this has the highest
possible rate of reversal. Once the nerve is cut, the effect is permanent
and rarely reversible.
There is currently no method of determining who will get the severe form
of compensatory hyperhidrosis, but it was recently discovered that
sympathectomy of the T2 or the T3 nerve trunk is responsible for the
severe forms of CS. The compensatory hyperhidrosis may occur soon
after the operation or many years later. Again, most people can tolerate
mild or moderate compensatory hyperhidrosis as long as my hands,
underarms or face are not sweating or blushing. There are some who
develop severe Compensatory Sweating who wish they had never
undergone the operation.
It is impossible to determine in advance who is prone to develop
severe Compensatory Sweating. Dr. Garza has observed that
those who present with excessive sweating of the back, under
the breast, abdomen or groin, prior to any type of
sympathectomy, are the ones who will later develop the severe
form of Compensatory Sweating.
For those in which the compensatory sweating is severe and
unmanageable, the new technique of clamping the sympathetic nerve
with a Titanium clip is the best option currently available. The technique
for reversal is the same Endoscopic technique as the original ETB,
except that the nerve clip is removed instead of applied.
There is a new technique for those who developed Severe
Compensatory Sweating after a sympathectomy in which the nerve was
cut or removed. It involves transplanting a small skin nerve in the lower
leg (Sural Nerve) into the site where the nerve was cut or removed. This
is a complicated procedure and is reserved for those with the Severe
form of Compensatory Sweating. Again, it should be stressed that the
sympathetic nerve trunk should be clamped and not cut or removed. It is
far easier to remove a Titanium clamp than it is to transplant a new
nerve. Not all patients with the nerve transplant will recover fully from the
effects of Severe Compensatory Sweating.
Medications do exist that may lessen the effects of CS.
The most useful medications for compensatory hyperhidrosis
are Robinul Forte?? and Ditropan??.
Robinul Forte?? is the first line of medical treatment of this
condition. It causes generalized body dryness; because of this, it
should be used only when necessary and should be avoided
heavy physical exercise. Side effects can include dryness of the
mouth (cottonmouth), headaches or constipation. The most
effective dosage is by taking the medication 3 hours prior to
meals.
Ditropan?? used in low doses has recently been found to be very
effective in the treatment of severe CS.
Another medication that may be helpful is called Probantheline
Bromide.
Horner's Syndrome:
Horner's Syndrome is ptosis (a droopy eyelid), meiosis (a constricted
pupil) and anhydrosis (absence of sweating). The patient may also
develop nasal congestion. This is due to disruption of the Stellate
ganglion, or first thoracic (T1) sympathetic nerve. This condition may
occur following ETS or ETB and may be temporary or permanent. It can
temporary if after an ETB (with clamping), the clip is quickly removed.
The nerve can then regenerate. It is definitely permanent if the nerve is
destroyed or removed. A temporary Horner's Syndrome is not
uncommon following ETS. These symptoms are rarely permanent. The
permanent Horner's can be treated by a skilled facial plastic surgeon
that will tighten the eyelid muscle and relieve the droopy eye. The major
goal is, however, not to injure the nerve. An experienced surgeon
usually avoids this complication.
Brachial Plexus Injury:
Injury to the spinal nerve roots may cause pain, muscle weakness or
paralysis in the arm and hand. Treatment of this syndrome is extremely
difficult. Fortunately, this is a very rare condition and Dr. Garza has not
encountered this problem. Occasionally, a brief period of inner arm
discomfort is felt in a small number of patients.
Hemothorax:
This is a condition where there is bleeding into the chest cavity. This is
most commonly due to bleeding from a small artery that runs
underneath the ribs. It is treated by chest tube drainage. The frequency
of this is less than 1%.
Pneumothorax:
This is a condition in which the lung does not fully expand. This happens
in about 1% of all patients and may become an issue if the patient has
severe lung problems such as Emphysema.
Gustatory Sweating:
This condition causes facial sweating after eating or smelling foods.
People describe it as similar to facial sweating that follows after eating
hot spicy foods such as chili. The condition occurs in about 10% of all
patients. If it does occur, it happens years after the ETS or ETB.
Treatment of this condition is with a Robinul Forte?? topical suspension
in a cream solution.
Neuritis:
Neuritis or pain between the shoulder blades may develop in a small
percentage of patients. This discomfort is due to inflammation of the
underlying nerves. In rare cases, it may be severe and possibly last two
to three weeks. Treatment consists of steroids and non-steroidal
anti-inflammatory agents.
Post Operative Rib Pain:
Occasionally, there is pain between the ribs at the site where the
endoscope was inserted. A sensory nerve runs below each rib.
Compression of this sensory nerve by the endoscope may cause this
problem. This usually resolves on its own in a short time. Rarely is this is
a continuing problem. About 20% of Dr. Garza's patients may develop a
strong pressure-like sensation on their breastbone immediately after
the operation. This is due to bruising of the intercostal (under the ribs)
nerve when the endoscope was introduced between the ribs. Patients
report it "feels like someone is standing on my chest and I can't
breathe." If one does develop this sensation, it usually abates after the
first hour and rapidly fades away.
Post Operative Back Pain:
This occurs between the shoulder blades and typically develops one
week after the operation. It is due to and inflammation of the ribs under
the nerve trunk where it was teased out of the overlying tissue to expose
it. The pain is characterized by a dull ache and tends to be most
bothersome at night time. It usually responds to anti-inflammatory
medications.
Decreased Heart Rate:
In those who undergo a T2 sympathectomy, 10% experience a 10%
decrease in resting heart rate. This does not occur after a T4-5
sympathectomy. Studies have shown that the level of exercise
tolerance, strength and endurance are not diminished. While the heart
rate may slow down, the heart makes up for this by increasing the total
amount of blood volume (increasing the stroke volume) that is pumped
per beat. Elite class athletes should avoid this procedure.
Dry Facial Skin:
Dry facial skin and improvement of complexion problems may occur
following ETS or ETB. The dryness is rarely severe and patients rarely
quire a facial skin moisturizer. An unexpected benefit from the
sympathectomy is that any acne complexion problems usually resolve
within the first week after the operation. Most patients can stop taking
their Accutane?? after the procedure. Some patients may develop
dandruff after the procedure.
Post Surgical Considerations:
Phantom sweating: Before surgery, most patients report that prior to
the onset of their sweating, feeling a tingling sensation in their hands.
After the operation, many remain conscious of the same sensation that
preceded their abnormal sweating. A typical echo voiced after surgery
is to sense "that feeling" in their hands or face, and fear the operation
didn't work, only to find that no sweating recurs. After awhile, the
awareness of any "tingling" or "pre-sweating sensation" fades.
Pleuritis and Neuritis: Pleuritis is a condition where the chest wall
lining (pleura) is inflamed. It may cause a stabbing-like pain one to two
weeks after the operation. Neuritis is a condition where there is
inflammation involving the underlying nerves. Either of these conditions
may occur after surgery. Medications are given to help prevent or
reduce the discomfort of these symptoms should they occur. Since the
introduction of the Radio Frequency Probe, these symptoms have
decreased.
Dry Hands: After surgery, the hands will be very dry. Frequently, the
use of hand lotion is necessary to keep the skin soft. Because dry skin
has never been a problem for most people with hyperhidrosis, this can
be a surprising result. It is important for patients to learn to keep hands
moist with lotion. Carrying lotion in your car and keeping a bottle in a
desk is often helpful.
Emotional Relief: After surgery, the burden and embarrassment of
severe sweating vanishes. Most patients note a profound emotional
experience as soon as they rouse from the anesthesia. About half of all
patients wake up crying in the recovery room. Only one afflicted with the
symptoms of hyperhidrosis can truly understand this reaction.
It usually takes about one to two weeks for patients to develop
confidence that they will no longer sweat or blush.
Many have related a common dream occuring within the first month
after the operation. One patient described this dream to Dr. Garza. His
dream was extreme and may give those who don’t have the syndrome
a better understanding of what it is like to have hyperhidrosis. He
dreamt that the sweating had recurred and those around him were
laughing about his condition. He felt embarrassed and shamed. It upset
him so much that he woke up and looked in the mirror. After confirming
that he was OK, he returned to sleep.
There is an immediate apprehension to doing things that most of the
non-hyperhidrosis-world takes for granted. Actions like touching objects
or people, holding hands, reading the Sunday Newspaper without
having to fret about ink smudge, opening door knobs, turning a steering
wheel without soaking it, inserting contact lenses without contaminating
them with sweaty salt that irritates the eyes, shifting gears in a car, or
applying makeup or finger nail polish become new experiences. It
improves the quality of life.
Former patients have reported they found themselves "unburdened"
and wanted to "come out."
If the patient has been in therapy, resumption is highly recommended.