David Nielson, M.D., FACS, a minimally-invasive thoracic surgeon in San Antonio, Texas, talks about a solution for people suffering through excessive sweating.
Interview conducted by Ivanhoe Broadcast News in September 2016.
Thoracic surgery, what does that mean?
Dr. Nielson: What thoracic surgery means is I specialize in the area of the body which is the chest as far as surgical procedures to improve different pathologic conditions.
What is this called this particular technique that you do?
Dr. Nielson: Well endoscopic thoracic sympathectomy is cutting a sympathetic nerve in the upper chest cavity, behind the lungs through a small incision using an endoscope usually requires two to three incisions per side. Incision size is usually a quarter of an inch to about an inch, even now days they can vary that much and typically two to three incisions per side. The micro ETS procedure which I developed several years ago uses only one incision per side and that one tiny incision is only a twelfth of an inch in size. It’s about that big or two millimeters, a twelfth of an inch that’s made high up in the underarm without collapsing the lung either. This is very important, without having to dig out the nerve from the tissue of the chest wall to find the nerve. Which means the chances of bleeding, pain, Horner Syndrome or drooping of the upper eyelid and other things is much, much reduced. The recovery is faster as well.
Those are good points and that’s all the points that make this different from other surgeons who do just the typical surgery for this, is that correct?
Dr. Nielson: That’s correct.
Where is the nerve, it surprised me to hear that the nerve for sweating of the palms, sweating of the hands and feet, or just hands?
Dr. Nielson: Well it’s actually hands and feet, and it could be even the face, it could be the scalp and the underarms. Really it’s actually responsible for triggering sweating in almost all areas of the body.
This is the same nerve?
Dr. Nielson: Yes except just imagine like a guitar string or a piano string. You know it’s very long for instance, and imagine my fingers representing say the second rib, the third rib, the fourth rib or the fifth rib and the nerve, the sympathetic nerve, crosses over the rib heads like a guitar string for instance. At each one of these specific and precise levels, branches come off of the sympathetic nerve that go to various parts of the body. For instance the T2 area, say this is the second rib that goes to the face, scalp, palms. The T3 goes to a little bit lower, say to the underarms and part of the chest and so on up and down this sympathetic nerve chain. We call it a chain because it’s a very long nerve that goes actually from the cervical all the way down to the sacral area, for instance.
These are the ribs in the front of my body or in the back?
Dr. Nielson: No, it’s in the back. Imagine say my knuckles here represent the spine and each of my fingers are representing the rib as it comes around to the front. This is actually at the back behind the lung. The lung is say a structure that’s in front of where the nerve crosses over the rib head at the back. But inside, that’s precisely where they sympathetic nerve runs.
You go in and you clip where the issues are very specifically?
Dr. Nielson. Yes I do but it’s usually precisely at the second rib head. There’s a ganglion, a nerve junction in between each of the ribs where it sits. That nerve junction I don’t touch, I don’t disturb in any way. Just imagine it’s like say you have a bunch of roads from a city that all connect to a mountain pass road. Like the Grand Tetons, there’s one road that goes up over that mountain pass at the Grand Teton. If you can block the traffic from going over that mountain pass at that only road that goes over you’re going to block a hundred percent of the traffic. It’s the same principle with the nerve signals. If you therefore can stop the nerve transmission right at the second rib head and not disturb any of the nerve tissue below then therefore the chances of achieving a hundred percent cessation of nerve transmission is really, really high. Because that’s where all of these connections have to join as they cross and go up to say like the hands or the face. That’s where the success of achieving complete dryness and warmth of the hands approaches ninety nine percent, ninety nine point nine percent actually if done that way. If you cut lower down or put clamps on the nerve the problem with putting clamps on the nerve is it’s just squeezing the nerve and the nerve may start to function over a period of time, like a year or two or three. Then if it does, then the symptoms come back.
Are there other things that this affects when you cut a nerve?
Dr. Nielson: Yes it does. It immediately will stop excessive sweating or sweating of the palms. If done at that second rib head level it also will stop all of the cranial facial of the face, scalp, upper lip sweating. If you have burning blushing episodes, like let’s say you’re at work and you’re talking, or you’re out socially and someone taps you on the back and you turn to see who it is it kind of startles you’re un-expecting that, and then if you do have this tendency to blush your face turns bright red and feels warm or even very hot, it stops that too. Also if you have very cool or cold fingers or fingertips in some cases you don’t have say excessive sweating of the palms you just have cold hands, cold fingertips. Like severe Raynaud’s is the condition. If you have that condition then you can have non-healing ulcers develop or wounds of the fingertips that either don’t heal or take a very long time to heal and it improves that as well.
Are there any other side effects that something could happen? Are there bad side effects of these nerves being clipped?
Dr. Nielson: The most likely side effect of the way I do the ETS or the micro ETS procedure is what we call increased sweating of say the abdomen and the lower back. It can even occur behind the legs as well. But most of my patients experience mild to moderate, but in some it’s definitely severe. But that’s the most likely side effect done the way I perform the sympathectomy.
Do you feel like it’s a risky surgery?
Dr. Nielson: No, the risk is very, very, very small. As a matter of fact since it’s minimally invasive in such a way that it’s only one incision high up in the underarm on each side and the incisions are that big the chances of having, for instance, chronic numbness of breast or the chest wall or pain from having injured one of the nerves, intercostal nerves that runs in between each of the ribs, the chance of that is minimal. The chance of a Horner syndrome or dropping of upper eyelid that would occur if you injured the sympathetic higher than the T1 level because of having dug out the nerve and putting nerve hooks or having pulling on the nerve to find the nerve. That’s another aspect of my micro technique I don’t have to dig the tissue out to find the nerve. But those risks are minimized by just being less invasive; hardly touching any tissue by the nerve let alone to precisely divide the nerve. Like a little wire cutter, just imagine taking the sheet rock out of the wall to find the wire. You’re able to know exactly where the nerve is and then you just precisely cut the nerve without disturbing any of the surrounding tissue.
How is it that this technique allows you to find that nerve so differently than other doctors?
Dr. Nielson: It’s the way I use a lightly pressurized carbon dioxide and the way I approach my technique is very high up in the underarm, it’s not lower down. I’m able to see and visualize where the nerve crosses precisely the second rib head again without having touched anything. I routinely, like this morning, I preformed this micro ETS procedure on a patient where as I zoom in with the little micro endoscope and I could identify the right nerve where it precisely crosses over the second rib without having touched anything. I shoot a picture and give it to the patient afterwards. The point is this is really actually a big improvement for patients post-op for the chest pain and recovery time is really shortened. Without having to dig out the tissue to find it, the pain is much, much less, recovery time is much faster. If you don’t touch or disturb tissue it doesn’t bleed, it doesn’t hurt and so on.
Why is it that other doctors apparently have to dig to see the nerve, what are you doing that’s different that allows you to see it without having to dig and other doctors do?
Dr. Nielson: Well it’s the way I use the carbon dioxide pressurization. You can’t just pressurize the inside cavity where the lung is very much because if you do it tends to affect the heart as far as blood flow to the heart, impairing blood return to the heart. You don’t want to impair or impede that. It’s the way I use this carbon dioxide. Keep in mind it’s also that it’s done through one incision that’s very, very tiny.
How do you even manipulate your instrumentation.
Dr. Nielson: That is a learned technique I developed over several years. It’s kind of like dancing with a partner and you’re feeding off the movements of your partner to know to go this way or that way. That’s what I use with my fingers specifically to be able to control and operate the instrumentation all through one little incision.
What is the carbon dioxide?
Dr. Nielson: What the carbon dioxide does is imagine a potential space where say these are the ribs and the nerve like a guitar string or a piano string crosses right over the rib head and the lung is inflated and its right up against it. There is no space in there to work. What the carbon dioxide does is as it does in the abdominal cavity if you’re ever having laparoscopic abdominal surgery, is it fills a space or creates a space that’s void of any tissue, meaning its carbon dioxide. It lifts gently the lung or pushes the lung away from this precise area. Then I take advantage of that temporary cavity to work in. That’s why I then quickly will slip my instrumentation through that same single tiny incision in the underarm in to that space where the carbon dioxide temporarily is. It allows me to work and have access to where that nerve is right at that level of the second rib. Then I will, as I identify where that nerve is without other instrumentation through other incisions, have to collapse the lung or retract the lung out of the way or any of that. Because I’ve identified where the nerve crosses precisely the second rib then that’s when I like the analogy of micro scissor or wire cutter cutting the wire precisely at this location. I then take advantage of that short time frame that I have in this temporary working cavity. I divide the nerve, cut it with a little micro scissor and then I evacuate the carbon dioxide so that potential space or that space then disappears. The carbon dioxide is evacuated with a tiny little needle up the top of the chest here. Then I do the same thing on the other side.
You have to do both sides?
Dr. Nielson: You do have to do both sides because can you imagine if you only did one side? What you would experience is continuous sweating on the opposite hand or the opposite side of the face.
You’re going to hit both the ribs on each side?
Dr. Nielson: Yeah. Where that is, is right between the shoulder blades. That’s the anatomical area where that second rib head is. It’s high up, the thoracic, the chest cavity here it’s typically right between the shoulder blades.
Sweating of the hands it’s more than just minor inconvenience isn’t it?
Dr. Nielson: Well I don’t want to use it just for minor inconvenience but in treating and seeing and communicating with patients over the last twenty years that have had various aspects of degrees of severities and impairment and stuff it actually impairs almost all of one’s activities you do of the day. Whether it’s greeting somebody, focused attention on like an instrument, video games, typing, using your hands to work with, sewing and driving. Holding the steering wheel and to have it wet, holding a gun, just a doorknob. To have that stopped it is like, the patients describe it to me as lifting this huge burden off of them. They always usually say this kind of a term or phrase is, ‘I can just be myself.’ I don’t have to always be hiding or thinking how I’m going to deal with this or that. They can just not think about that and just be there where they’re at and just act like they say, normal.
You think about how often during the day we shake someone’s hand and they don’t like to do that.
Dr. Nielson: They don’t like to or they will do this, it’s a learned behavior where they’ll just dry their hand right before. Or they’ll have a cold drink in their hand or they’ll have books that they’re holding, it’s for a prop of sorts where they’d have an excuse and easy out to not have to shake someone’s hand. Or they’ll excuse themselves, or presence they may not go to church. Let’s say they’re church going and you know it’s common to greet other church members shaking their hands or giving them a hug. They don’t like that. Some will even quit going to church because of it.
I’m sure there are a lot of things that they don’t do because of that, it’s a big deal. How long have you been doing this?
Dr. Nielson: I’ve been doing micro ETS since the October of 1997. It’s approaching twenty years.
You do it so uniquely that others don’t do this.
Dr. Nielson: Yes. Others across the world don’t use the single twelfth of an inch incision with also not collapsing the lungs and this is really important, without having to dig out the tissue to find where the nerve is. Because that in and of itself adds a whole lot more let’s say risks of bleeding, pain, scarring.
If they’re collapsing the lungs don’t they have the space to work?
Dr. Nielson: Well they do have to space but they can’t see where the nerve is. Because the nerve is underneath of the lining of the chest wall, the pleura are behind it. They can’t see necessarily where the nerve is.
Putting CO2 allows you to see it?
Dr. Nielson: The way I do it, it does. But then keep in mind I’m in there all the time. As opposed to a surgeon who may be doing let’s say and endoscopic sympathectomy once every month, or once every year or once every several months. If you’re in there it’s with any kind of surgical procedure. If you’re doing whatever it is frequently, meaning you’re in that part of the anatomy of the body you’re going to over time not only have seen various changes or variations between patient to patient to patient but you’re definitely more familiar with and therefore it can be a big difference or improvement for the patient’s chance of success. Be able to be there preciously as opposed to a little lower missing some branches that may occur, it lessens that chance too.
It can cause depression too or anxiety?
Dr. Nielson: Yes, anxiety is actually very common with patients that suffer from either severe blushing of the face or severe Hyperhidrosis of face or hands, where it’s actually commonly misdiagnosed. In other words when a patient with Hyperhidrosis goes to their physician and tries to explain they have this condition of the frequent cold wet hands impair a lot of their aspects of their day, their activities commonly physicians will actually make the diagnosis or determination that the reason or the etiology of their sweating is because they’re anxious, too nervous or depressed. It’s very common therefore for them to be put on an antianxiety medication and it doesn’t help much at all because that’s not the cause. Actually the condition of the wetness of the hand causes the anxiety to skyrocket.
It’s just sort of like a circle, this to this to back.
Dr. Nielson: It intensifies; it’s like throwing fuel on a fire. It really intensifies the severity of the condition.
END OF INTERVIEW
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