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ETS REVERSAL METHODS Any advertising above for ETS is NOT accepted by us as we are AGAINST ETS because of the side effects

REVERSALS

IS THERE A REVERSAL AVAILABLE?

Yes. There are two reversal procedures available. If the nerve is clamped, then this a simple procedure of having it removed, but if scarring has occured and the clamp has been on the nerve for even a small period of time then the nerve might be destoryed. If the nerve is cauterised or destroyed, then a reversal method involving a nerve regraft must be employed. This involves taking a nerve graft from the ankle site (the sural nerve) or a nerve from the chest site,intercostal nerve,and by using microsurgical nerve reconstruction uniting the T1 and T2, possibly T3 and T4 ganglia, or connecting to the next most available nerve site. These two nerve sites will have to grow back together, which could take six months or longer. Also, the surgeon will transpose the intercostal nerve to the stellate (T1) ganglion. This latter method was first employed by Dr Lin and is now also being used by Dr Teleranta. At this point there is no solid evidence that this procedure works. The effects are purely subjective. The most experienced surgeon with this procedure in the world is Dr Telaranta. Dr Reisfeld and Dr Lin also perform this procedure, but is not as experienced.

HOW IS THIS SURGERY DIFFERENT FROM ETS?

It is major surgery. In a conventional ETS surgery just one port is used, through which both an optic and burning electrode are used simultaneously to cauterise the T2 nerve. However, in the reversal one port is needed for the optics tube, and two for different instruments (forceps, scissors, harmonic scalpel etc). Also, because the reversal is major surgery there is a longer recovery time. Due to a nerve being removed and grafted onto the Sympathetic Nervous Chain there can be more complications.

WHAT ARE THE COMPLICATIONS?

There is a possibility of bleeding in the lung as a result of the scarring being removed from the Sympathetic Nervous Chain. Any blood loss will have to be removed by a drainage tube (please make sure you ask Dr Telaranta to anaesthetise the drainage entry area very well, as his method was particularly painful). The draining of any blood, fluid or air pockets could take a few days. These complications might be very rare, but I was glad I was with Dr Teleranta as I was covered for any complications and I was able to stay in the day hospital for a few days longer. This is the prime reason I insist you choose Dr Telaranta if you are from Australia, as complications aren't covered if you go to the States. Please make sure that you stay in Italy or the States 10 days after the operation. You must discuss this with the surgeon, as this is the amount of time recommended by my G.P in Australia to recover after an operation before travelling overseas. I also recommend that you wear special stockings on the flight back home, take half an aspirin (speak to your surgeon about this, as aspirin can increase bleeding), and walk continually around the plane. Also, you must have an x-ray as soon as you get home if you have any concerns at all in regard to your breathing. When I returned to Australia I suffered pneumothorax (air pockets), and I had a haematothorax (blood clot) that had travelled to my lung. A Haemothorax is the collection of blood that may result from bleeding after scar tissue is removed. The Haemothorax is found between the chest wall and the lung. It is not the same as the Pulmonary Embolus, which is the blood clot commonly caused by Deep Vein Thrombosis and is much more serious. The symptoms I had were an inability to breathe properly and persistant coughing. After having an x-ray done, I immediatelly went to the emergency section of a major hospital where the blood and fluid were drained (the registrar did an excellent job of anaesthetising the area so there was absolutely no pain). The blood clots were removed by surgery a few days later. This was a successful surgery, but even three months on I still have some minor pleural thickening or fluid present in the left costophrenic angle (causing a minor pain when I sneeze or yawn). However, as far as my specialist is concerned i'm on a full road to recovery. You might ask would I go through this again with these complications - with my returned energy, i'd do it in a heart-beat.
WHAT IS THE THEORY OF THE REVERSAL?
According to Dr Telaranta, once the T2 has been cut it can not repaired. However, the functions from the lower ganglia also control sweating at the hand and face level. If a transplanted nerve can be attached from the T1 to the lowest available ganglian it may allow moisture in dry hands or a dry face. Also body perspiration will become less and energy levels may increase. This will allow the control of the heart to become more normal, and energy control of the midbrain structures as well as temperature control systems (thermoregulation) will thus normalize. To do the transplant the surgeon will need to remove any adhesions or scarring that has built up between the parietal and visceral pleurae (scars develop at the end of any nerves that have tried to grow back). To try and explain this basically - it's like removing blocks that have blocked the passage of a new telephone line (the nerve graft). The adhesions are removed by sectioning them with an harmonic scalpel. The operation is performed on your right side first. A long sural nerve graft (approximately 7 cms long) or the intercostal nerve, which is found in the chest, is anastomosed between the freshly prepared sympathetic nerve ends - between the lower pole of the stellate ganglian and the upper pole of the next available ganglian (for me it was the 3rd)(by-pass). He also may be able to (if there is not much scarring) place the fascicular graft between the stellate and T2, and another between the stellate and the next available ganglian. This apparently has a better result for the patient. He then will take the end of the cut intercostal nerve and reroute it to meet the T1 ganglia.

Dr Lin's Reversal methodology employs, as far as i'm aware, the same procedure. Lin studies the scene of the original surgery and evaluates if T2 is healthy and viable. He will then cut the 2nd intercostal nerve in one place, which is connected to the sympathetic chain at T2, and then reroute the end of the nerve to an area close to the sympathetic chains T1 ganglia, but not attached to the previously cut nerve coming from T1 ganglia. The end of the newly grafted intercostal nerve is then supposed to sprout into the sympathetic chain's T1 ganglia and in this way form connections allowing neurotransmission.

As far as we know Dr Lin will use this technique even if T2, T2-T3-T4-T5 have been cautorised. It is believed a graft on one side is enough to allow neurotransmission.

WHAT IF THERE IS ALOT OF SCARRING AT THE NERVE SITE?
If there is scar tissue at the nerve site the surgeon will either remove it, or if there is too much scarring, leave it. Sometimes it is too dangerous to remove scar tissue, due to the possiblity of bleeding. The surgeon will then have to by-pass and connect the graft from the T1 to the next nerve site. If, however, there is no scar tissue then it is possible to connect all the remaining ganglian to each other instead of doing a total bypass. For example, in my reversal operation I had no scar tissue on the right side so Dr Telaranta was able to bridge the graft from T1 to T2 in addition to T1 to T3. On my left side there was slight adhesions, so adecent nerve bridging between T1 and T2 was not possible. Some patients may have been cut very high near the stellate ganglian in the original ETS operation, so the surgeon would need to anastomose very high near the stellate, with a definate risk of Horner's sign.

WILL ANY NERVES BE DAMAGED DURING THE REVERSAL PROCESS?
Dr Telaranta also explains that not a single living ganglion needs to be touched in the reconstruction. The nerve trunk between the destroyed T2 ganglion and the live T3 ganglion is cut and then the nerve graft is glued to the fresh nerve end, leaving T3 untouched and functioning. The trunk itself are only nerve axons, without connection to any living end organ on the other end, so there will be no function lost at all when this nerve structrure is cut. Moreover, it can then again connect via the graft to the other living nerve structure in the T1 ganglion and also in the peripheral end organs like sweat glands.

The nerve trunk is the cable between two ganglia - there are no whole nerve cells in it, but only connective tissue cells like Schwann cells forming a tube for axons, which are like fibers or threads from the cells in the ganglia towards the nearest other ganglion and new nerve cells within it. These axons and nerve fiber threads then communicate with synapses and the other nerve cell bodies, and carry on the information. See www.privatix.fi for more detailed information, or www.sweaty-palms.com/reversal_ets.html

HOW LONG WILL THE REVERSAL TAKE TO WORK?
It may take some time for the reversal to work. The nerve grafted between the two ends is not able to transmit information, but can only function as a conduit for the new nerve growth from both ends. This new growth can maximally proceed at a speed of 1 mm/day, and even then the beginning function is always very difficult to notice. The very small changes are so hard to notice on a daily basis, that you only notice after a longer time period 'Hey, I'm not sweating as much as I did last summer'. I was told by Timo Telaranta that it could take anywhere from six months to 3 years to notice changes. All these changes need time and a successful surgery.

CAN WE SCIENTIFICALLY DETERMINE IF THE REVERSAL WORKS OVER TIME?
"Finding out about nerve regeneration is usually most reliably achieved through demonstrated return of function. In the case of something like the nerves to a muscle, or to skin sense receptors, the return of function is usually easy to quantify. It is also possible to record electrical signs of active nerves, and those in the limbs are amenable to such recording with minimal invasion.

Assessment of sympathetic activity is difficult at best, but to demonstrate regenerated function would be quite difficult I think. (I say I think as I have no experience in trying to so this.) Recording electrical signals (or lack thereof) is theoretically possible, but only through quite invasive techniques in the case of something like the sympathetic chain. Electron microscopy could give some indication of anatomical outcomes, but this would be extremely invasive, as part of the graft would have to be removed for histological processing - the electron microscope cannot be used to observe living tissue, not even tissue removed from the body. So you might consider arranging for a post-mortem microscropic study of your grafts (or those of other interested people), but I don't think you should think about it until then.

A further complication of microscopic studies is that the presence of anatomically normal neuron processes within the graft could not be taken as evidence that those processes were functional. Many studies have shown that peripheral nerve grafts, such as the sural nerve, implanted into the central nervous system will cause sprouting of central neurons leading to "normal" peripheral nerve structure. But the same sorts of studies have shown little evidence for functional connections of the processes which grown through the grafts with other neurons. Use of these peripheral nerve implants as bridges to bypass injured parts of the spinal cord remain of considerable interest, because of the "innervation" of the bridges that occurs, but there is little evidence that any restoration of function results from the neuron processes reaching the other end of the graft. The problem of provoking functional connections remains the big challenge.

So overall I think the most valuable answer to your question about whether there has been regeneration is one that you can answer: whether the negative side-effects of the orginal surgery have been alleviated by the grafting." (Honorary Associate Professor David F. Davey, Department of Physiology/ University of Sydney)

WILL FLUSHING RETURN AFTER THE REVERSAL?
Some flushing may exist (not the burgendy colour). Nobody is totally pale.
IS THERE SCARRING?
Yes. Dr Telaranta removes a nerve from the ankle site leaving 5 wounds (which are very ugly, but apparently fade very well in time). Since this time I have actually decided to have the scars revised, with a recognised plastic/cosmetic surgeon, as the scars turned out to be quite ugly and raised. I did the wrong thing however, by walking around Helsinki and not giving my scars a chance to heal properly. Dr Reisfeld leaves one small longitudinal scar, which is about 4 inches over the ankle site (which can be hidden by a sock). There are two reasons why Dr Telaranta does separate wounds:

  • The wounds heal better when transverse in the calf area giving a superb cosmetic result compared to one longer wound (I don't agree with this one, by the sounds of it Dr Reisfield gives a better cosmetic result)
  • You get longer nerve graft (up to 40 cm) without any need to damage the nerve by manipulation or tension
  • If you take the nerve from one wound, the wound either has to be very long and longitudinal leaving an ugly scar, or you have to take the nerve blindly by tearing and stripping it, which damages the nerve very easily and then does not give as good a transplant.

    DOES THE GRAFT NERVE SURVIVE?
    Not alot of information is known on this topic. Apparently the Sural nerve, when used as a donor nerve, dies relatively fast and the nerve merely funtions as a "tube" for the axons to grow along.

    The sural nerve can act as a live nerve, actually allowing nerve signals to pass through it, for a few days and up to a few weeks. Then it dies and functions as a tube for the axons in the new nerve regrowth ( Schwann cells in this "tube"). This is why some see amazing improvements in their condition during the first days to weeks after a reversal, but only last this mentioned period. Hereafter, the slow slow process of nerves regrowing starts, and the waiting time begins.

    This is quoted from Dr T.T from the BFS forum:

    There are several reasons for different outcomes:

    1) All the cases are individual, what count to the prognosis are:

  • age of the patient
  • type of the original surgery
  • the extent of ganglia destroyed or just plain cut
  • tissue damage caused in the original surgery due to fat under the pleura, bleeding during the surgery, big veins intimately situated beside or under the nerves
  • time interval between the two surgeries, the longer time interval, the less recovery is to be expected

    2) The original good result comes from the scar tissue removal from around the cut nerve ends, also immediately after the nerve graft has been put into its place, it can serve as an action potential bridge (=functioning nerve) for a couple of days to a couple of weeks. Then the nerve itself disintegrates and can no longer mediate nerve impulses.

    3) The nerve regrowth proceeds along the Schwann cell tubes in the nerve graft, from where the nerve has died away and this regrowth can maximally happen at a speed of 1 mm/day. Every scar and narrowing in the tubes slow this process.

    4) When the nerve graft needs to be long in long nerve defects, like in T2-T4 resections or destructions, then there is a race between the narrowing by fibrosis of the tube and the regrowth of the nerve. The longer the graft, the less recovery is to be expected.

    5) The best results come when there is no scar in the chest cavity, clean cuts of the nerves, only T2 performed, and less than 2 to 4 months interval between the two surgeries.

    6) Because the nerves are living in the ganglia T1 and the first ganglion not touched in the orginal surgery (T3, 4, 5), there always remains potential for some recovery. The biggest time interval in my patients has been 31 years and still the result was very good, indeed!

    Recently Dr Telaranta re-opened a patient that had a "heavy blow to the chest" and showed his previously placed sural nerve had achieved somewhat of a blood supply: "One patient succumbed a heavy blow on the chest 4 months after the reconstruction. Till that time he had noticed clear reduction of the compensatory sweating, but after the blow had it recurred. He urged to have the situation checked at a new surgery, and in it the grafts were seen very well incorporated and having some new blood vessels and every aspect in the grafts seemed viably. This was also verified photographically. Also the anastomosis lines seemed still well adapted and had no visible neuroma formation. Nothing else than a gentle external neurolysis was performed." "One resurgery proved that the grafts remain in place with just fibrin glue, and thus macroscopically the anastomosis lines remained congruent and the grafted nerves filled with normal looking tissue and having some blood vessels indicating their viability."

    There is strong debate about whether the sural or intercostal nerve is a better donar candidate. Dr T.T and Dr R prefer sural, Dr Lin uses intercostal because of the ability to better able preserve blood supply and it's similarity to the sympathetic nerves. It would be best if Dr Lin could allow his patients to communicate with us to hear about their thoughts.

    WHAT ARE THE COSTS AND TREATMENT DETAILS WITH DR TELARANTA?

    This procedure is very expensive (ridiculously expensive for the suffering people out there). The clinical base for Dr T.T is Clinic St. Anna, 58 via Cavour, 39012 Merano, Italy. Dr Telaranta works with Dr. Ivo Tarfusser in Meran, and does the reversals in team work with Dr. Tarfusser and Dr. Schick, who takes the responsibility of the preoperative and postoperative sweat measurements in University of Erlangen, Germany. In Italy the costs are (as of November 2002) 14,500 USD (it's getting cheaper guy's!) - including all the costs of the operating theatre and anaesthesia fees. Other fees are: hospital stay 285 EUR / per night and admin costs 800 or 1500 EUR

    (option packages are available). Option 1: Basic admin package fee is 800 EUR and includes administrative fee (patients make all the travel arrangements themselves).

    Option 2: Full admin package is 1500 EUR and includes administrative fee, help with the travel arrangements, meeting at the airport, accompanyment to the hotel from the airport, arrival information, 2 nights at the hotel, and post-operative kit (remember, all costs need to be confirmed with Kati).

    You can get a 10% discount if you are a student (remember you only have to ask - Dr Telaranta is reasonable and takes this into consideration). You will be expected to stay in Italy for atleast a week. This is an operation so you will need to rest. Due to the sural nerve being removed, you will no longer have any sensation from your ankle to below your knee on the side of your leg. Australian citizens are unable to claim this back, but US citizens can according to some patients. As far as I know it can also be claimed in Norway and maybe in Sweden in the future. Flight costs will have to be covered by you. To date Dr Telaranta has performed 80 + reversals, using the nerve regraft method. He is the most experienced reversal surgeon in the world and introduced Dr Reisfeld to this procedure at his symposium. Dr Telaranta also works closely with Dr Lin and developed the Lin-Telaranta classification for clamping. Apparently he has a new method (as of 2005) which is meant to be better than his other technique by employing a couple of different techniques, but that is all I know.

    WHAT ARE THE COSTS AND TREATMENT DETAILS WITH DR REISFELD?

    As he is based in LA it may be more convenient to see him if you are a US citizen. It will also be easier to claim back on your insurance if you are a US citizen. He is very experienced with ETS surgery. His fees can be discussed with him. He does not perform the procedure in a major hospital, but a day surgery. If there are any complications you are in hot water if you do not have insurance (this is why I really think you should only see him if you are covered by insurance in the U.S). See the doctors page for more information. This may be discussed with Dr Reisfeld in more detail. His is an outpatient procedure only. None of his patients so far have stayed overnight for any complications. They all go home straight after the operation, but this seems a little unusual to me as I needed to convaless after the operation for atleast two days - I was on pethidine and a drip. Dr Reisfeld explains that indeed all the patients that were operated on by himself with nerve graft reversals went home the same day with very minimal to moderate amount of pain. He uses just two ports of entry and makes one long incision in the ankle region. The results for his cases, he explains, are pretty much inline with those of Dr.Telaranta and those show better heat tolerance, reduction in compensatory sweating, and return of upper body sweat. He also performs the operation with only two incisions each side (compared to three used by Dr Telaranta). The scar left from the nerve graft is a vertical line up the back of the ankle.

    He is very experienced with ETS clamping and reversing clamping, but not as experienced as Dr Telaranta with conventional reversals and there are currently no objective studies under way. He has performed the nerve graft reversal on eleven patients. This needs to be verified, as it could be alot more.

    WHAT ARE THE COSTS AND TREATMENT DETAILS WITH DR LIN?

    Dr Lin is based in Taiwan. He performs the Sympathetic reconstruction with intercostal nervous graft. He believes the blood supply found in this nerve is guarantee of it's graft survival, compared to the sural nerve. However, one of the negative effects is chest pain. Neuralgia or paresthesia sensation (a strange sensation) usually happens after the nerve has been cut. It happens due to regeneration process of nervous fibers. (Incidentally I had Sympathetic Neuralgia after a nerve was accidentally scraped on my left side after ETS. I had a numb and heavy sensation in my left arm for about six weeks. The surgeon said it would go on it's own. If Dr Lin is saying that this is a temporary effect after having the intercostal nerve removed I can imagine it would be painful and annoying...it felt like pins and needles when you lie on your foot too long). His method is different from the other surgeon's as the cuts the intercostal nerve at one end and reroutes it to join up with the stellate ganglian .

    Dr Lin states that it takes about two hours to complete the whole sympathetic reconstructive procedures of his method. Except temporary chest pain, no neuralgia or numbness of chest wall is found in his experiences. Numbness of small toes cannot be avoided if sural nerve is used as nervous graft to reconstruct the sympathetic nerve.

    The price he currently quotes (December 2002) is US$10,000 which includes anesthesia and operation fee and a three-night hospital stay.

    Here is a report of the Advantages and disadvantages of Intercostal nervous graft comparing with sural nervous graft in sympathetic nervous reconstruction written by Dr Lin:

    (I) Advantages:

    From the viewpoint of human anatomy:

    1) There are 12 intercostal nerves in each thoracic cavity neighboring to sympathetic nerves and ganglions. In addition, the caliber of intercostal nerve, without exception, is the same as sympathetic nervous trunk. Its location and nervous size play the best role of nervous graft in reconstruction of sympathetic nerve.

    On the contrary, there is only one sural nerve in either ankle area. Its location is so far from thoracic cavity. The caliber of sural nerve is variable, which usually cannot correspond to the size of sympathetic nervous trunk. For this sake, I usually emphasize that Intercostal nerves are the Gift of God and the first choice to reconstruct sympathetic nerve.

    2) Limitation of the length of nervous graft: The length of intercostal nervous graft can be taken as long as clinical necessity without the problem of graft survival. On the other hand, length limitation of sural nervous graft is anticipated for the sake of difficulty in preservation of its survival.

    3) Factors influencing graft survival: Intercostal nervous graft can be taken as a rotation flap for reconstruction of sympathetic nervous trunk, which can preserve its micro-vascular circulation intact. Blood supply is guarantee of graft survival. It is difficult to preserve blood supply of sural nervous graft when it is completely removed from ankle area to reconstruct thoracic sympathetic nervous trunk in thoracic cavity. Tissue fluid effusion is the only, but unreliable, way to maintain survival of sural nervous graft.

    From the viewpoint of human physiology:

    Neuro-transmitters are the same among different nervous fibers, but different nervous fibers express different functions. The role of nervous graft is to bridge the gap between cut nerves and return normal transmission of neuro-transmitters. Only nervous graft survival can guarantee normal transmission of neuro-transmitters. We can understand that intercostal nervous graft is much better than sural nervous graft.

    Surgical technique: Sympathetic reconstruction with intercostal nervous graft can be performed completely under endoscopic method. But two-stage operation is necessary to reconstruct sympathetic nerve with sural nervous graft. Endoscopic preparation of surgical field is performed before sural nerve is taken by open method from ankle area for a nervous graft. It takes less than three hours to complete the reconstructive procedures with intercostal nervous graft, but more than 6 hours for reconstruction with a sural nervous graft.

    (II) Disadvantages of Intercostal nervous graft:

    There are possible disadvantages of intercostal nervous graft in reconstructive sympathetic surgery. 1) Mild degree of tense chest pain or chest tight is the common complaint after intercostal nervous grafting. 2) A small area of numbness in armpits or anterior chest wall is not uncommon, but usually acceptable by patient.

    Permanent numbness of bilateral small toes is encountered on the case of sural nervous grafting, though neuralgia is uncommon. From medical point of view, there's no difference between paresthesia or tense chest pain on the case of intercostal nervous grafting and numbness of small toes on the case of sural nervous grafting.

    written by Dr Lin.

    So far I have spoken via an interpreter to three men who've had a Reversal with Dr Lin. Two were happy with the outcome, the other wasn't. There are also three other ETS paitents who've had a Reversal, but are waiting for changes. Simon's testimonial is in the Reversal Testimonial's section. Lars wishes not to provide a testimonial until he is at the six month point, but has still provided an update at the Ezyboard in the Reversal section. At this point they are unable to give a proper evalutation of the outcome. Dr Lin is working on an objective study on the results of his reversals. Apparently he's done 3 reversals using the sural nerve, and several using the intercostal nerve. I've put up these details for anyone out there to make their own decision on whether they should contact him about his reversal procedure. The side-effect of chest pain should be seriously considered. Even though Dr Lin states that it is temporary, I think it would be wise to speak to his prior Reversal patients to see how they feel. It would also be wise to ask about the care and treatment given at the hospital in Taiwan. Western patients may find a problem with the lack of English spoken in the hospital, and the different cultural approach to patient care - including pain management, nursing assistance and diet. It may be wise to take a friend or partner to the hospital to assist you. Dr Lin also doesn't have the experience in reversals that Dr Telaranta does. After speaking to Dr Lin though, he does say that he invented and used the clamping method more than 6 years ago. I believe that Dr Lin has alot of experience in clamping and removing clamps to reverse the procedure.

    Dr Lin still performs ESB on a regular basis and he is performing more Reversals now due to patient dissatisfaction. Hopefully he will see soon that patient selection should be narrowed significantly for this barbaric operation. See Reversal Testimonial for Marie to see that clamping is not necessarily reversable.

    Dr Lin's web-site address is www.sweathand.com

    FOR THE PHOTO OF THE CUTTING METHOD REVERSAL PLEASE GO TO:
    www.sweaty-palms image of reversal

    Unfortunately it has been requested that the technical drawing of the Sural Reversal method be removed. I apologise to anyone who was interested in seeing a picture of this method.


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