AhnTalk
From Corposcindosis
IHHS Conference
Transcript of Q&A with Dr. Samuel Ahn.
Ahn: All my patients had complete resolution of their hyperhidrosis. In that sense it’s a hundred percent effective. We had no mortality, minimal blood loss, no one needed a blood transfusion, we had a very low complication rate, um, and uh, and we had good outcome. 98.3% of the patients said that they had “sustained reduction of symptoms to a tolerable level” and on a scale of 1 to 10, 10 being “completely satisfied” the average e score in these patients was 8.7. So by and large, we’ve had a very good outcome.
If you look at the hospitalization rate, it sort of shakes out of here. Now, I divided . . . these were the differences . . . and these were the problems – Horner’s syndrome and compensatory truncal hyperhidrosis and hospital stays. Those are the main areas of problems with this surgery.
And it turns out that if we separate out my early experience and my late experience, there’s a difference. And my techniques were different in my early phase versus the late phase. And it turns out that probably around 1998 I finally stabilized my procedure. I finally . . .
The first several years I sort of experimented around trying to figure out what’s the best. Do I take just 2? Do I take 2 and 3? Do I take 1 and 4? Do I use clips or do I use electrocautery? Et cetera et cetera. So . . .uh. . . so in the first . . .uh. uh . . .first part, before I stabilized the procedure, there were 34 patients and we can see that the . . .50% of patients went home on the same day. But, uh, we had patients stay, they lingered around the hospital. Half the patients stayed in the hospital one, two, three days. Now after I stabilized my procedure, most of the patients went home. 88% of the patients went home on the same day. And only 11% stayed over night, and no one stayed after that.
The Horner’s rate, all my Horner’s . . .were in the early patients, uh, and I have not had a Horner’s since 1998.
Intercostal Neuralgia [inaudible] that’s usually not mentioned in the literature.
Compensatory truncal Hyperhidrosis is, uh, in the early group, 60% of the patients had no truncal hyperhidrosis, but, ah, but we did have some people who had severe, intolerable hyperhidrosis. And so in that early group we had 12% of the patients, uh, and actually 25% overall who had severe or intolerable truncal hyperhidrosis.
But after I stabilized my procedure, I have it now down to about 5, 6% of patients who have severe, intolerable . . .by that I mean they had to change their shirts on a daily basis, and they, and, and they complained about it, and they didn’t like it. Of these patients, of all these patients, the ones who did have severe truncal hyperhidrosis or intolerable, most of them said they were still OK with it, they prefer to have sweaty trunks rather than sweaty palms. But one patient, one of my patients did say that he wished he had never had the operation.
Uh, now, what changed? What changed? And let me tell you what changed in my techniques. I don’t use electrocautery, I don’t. Because I believe that if you use electrocautery or any heat, you get a lot of thermal damage, and you can damage the nerve, surrounding nerve. You can irritate the nerve and make those nerves angry. Also, if you, uh, get too close to T1, uh then you get the Horner’s, especially if you get collateral damage from the heat. I also now take just 2 and 3, ‘cause if I take 2, I know I can get a hundred percent on the hands, but I don’t always get the axillae. If I get 2 and 3, I will get the hand, and I’ll get most of the axillae.
The reason I’ve, I’ve. . .I’ve, I’ve, I’ve. . .I believe that’s because out of this whole group, I’ve had one patient who have had a recurrence of their hyperhidrosis partially, after 46 months. And that was an attorney, uh, who I, uh, did only 2, I did only 2 . . .I did 2 . . .I did 2 on the right, I did 2 and 3 on the left. And the reason I did only 2 on the right was because there was a big, uh, intercostal [inaudible] vein sitting right on top of T3, and because he was an attorney I said “I better leave that alone”. And I backed out, I chickened out. Anyway . . .the right side’s fine, but the left side she has, she had a small area of axillary hyperhidrosis, that recurred in 46 months. And that’s the side, I was wrong, the right side, and that’s the side that I did only, only 2 instead of 2 and 3.
So . . .and I had some other [pamphlets?] too. So, uh, the um, uh . . .also now I, I use very, very precise cuts. Uh, I don’t use, and, and uh, everything’s magnified, and I, I very individually, carefully dissect out the ganglia, cut all the rami to it, and take out with great precision just the T2 andT3 ganglia. And I have very little collateral damage with [inaudible].
Now, uh, this was sort of interesting. Uh, I just saw this recently.
[Shows slide depicting newspaper articles about ETS in Sweden, Telaranta’s disciplinary actions, and Taiwan’s ETS ban on patients under 20]
And if you look at the literature, the, the Chinese, the Taiwanese, and also there’s a Finnish group and also a Swedish group that have reported thousands of cases in the literature. And now they are all under investigation, uh, they’re, and, and now they’re under, uh, they report devastating complications, uh, and uh, they talk about all the negative effects. Also, a lot of, uh, a lot of these, uh, the, the literature, from the, from the, from the, uh, from the patient literature, uh, uh describe using mostly thermal ablation, rather than actual precise, uh, uh sharp dissection. And I think they’re getting a lot of, lot of, uh, collateral damage. Now I don’t know that, of course, for a fact, but that’s my opinion.
So anyway, just to show you what I’m talking about, how I do it. [to helper] Does this video want to play, or . . .how do we get this video to work?
So anyway, you have to watch out for all these things. So even though this operation may look like it’s very minimally invasive, uh, and certainly on the outside it’s minimally invasive, what goes on on the inside is still very major.
So anyway, uh, uh, it’s . . . the operation, if done properly, can be very effective, and uh, it also can be quite good. But, you can also get in all kinds of trouble, and it has happened. So it’s a major operation on the inside. You’re still in the chest, and this is still the chest open. We put a chest tube in, this chest tube comes out in the recovery room, and the patient goes home the same day.
And these scars, uh, heal up really, really well!
Are you miserable enough that you want to undergo an operation, where the possible complications are bleeding, infection, death, injury of all those nerves I mentioned, stroke, injury of the esophagus, trachea, lungs, etc.? Now in my hands, the risk of that is small, it’s less than 1%, but it’s not zero. Nothing in life is [inaudible]. So then I ask them, OK, so how miserable are you? Because what you have is not life threatening, it’s a purely elective operation.
Uh, and before I even get to that point, I make sure that they have tried, uh, everything, uh, all the non invasive, uh, techniques, uh, first, uh, such as the Drysol, iontophoresis, Botox you’ve heard about, to make sure that they’ve gone through that route. And the reason that I tell ‘em this, because I, I say to them, “Surgery is permanent. You can’t reverse that. But Botox is 3 to 6 months”. If they have a complication with Botox it’ll be gone in 3 to 6 months. Iontophoresis, uh is very safe, uh Drysol is very safe. If you get some irritation of the skin, well you stop using it and the irritation is gone in, in a few days. So, ah, but surgery’s permanent. And if you have any complications, or if you have any, uh, side effects from the surgery, uh, it’s permanent.
Now, for some reason I missing the slide, but in my, uh . . .
So anyway, I think you have to be very sanguine about this operation. And it really should be reserved for patients who have tried everything and who are miserable, and it really affects their life on a daily basis. And for those patients, uh, the right operation, at the right time, in the right place, by the right hands, gets a, a pretty good result.
Now I didn’t mention, oh, I know what I was going to say. About the timing issue. The timing is very important too. And that’s the slide I’m missing.
Uh, for example, I had, I has a patient who was 60 years old, he was an editor of a newspaper, and uh, and he somehow went through all his life with it, and he clearly had hyperhidrosis [inaudible], and I said, “Well I you know, given your current situation now, are you sure you really want it?” And he thought about it and he said, “Well, you know, now that I’m retiring, it really doesn’t interfere with my work, so maybe I don’t want to have it after all. Ten years ago I would have wanted it. Now I got through it, I don’t need it.”
Uh, I have kids who are, who come in, or teenagers, pre-teens even, all the time. And I tell ‘em . . .in fact just this week I had a 7 year-old girl that came in to see me. Severe hyperhidrosis. And, uh, and she had gone through various treatments. She hadn’t tried botox. And I said to the parents, I said “You know”, and I said to the girl, “Does it really, really bother you right now?” And she says, “No, it’s sort of icky, but, you know, It’s, it actually helps keep the boys away!” [audience laughs] And I said, uh, “well”, I said “Well, come back later on, when you, you know, when you get older, and if it, if it really bothers you at that time . . .” And so I told her parents, “You know, maybe, you know, when she’s close to being a teenager, and she starts worrying about boys and all that stuff, maybe that’s the time to do it. I don’t know.” But, the timing is also very, very important. So, uh, so make sure you get the timing right.
Uh, and I think that’s about it. Any questions in the audience? Yes . . .
Female Audience Member: Is there any way to predict which patients are going to get the compensatory hyperhidrosis?
Ahn: Uh, well, yes and no. Uh, I . . .All of the . . .Basically I’ve, I’ve had five patients, uh, who have had severe, severe, hyperhidrosis where they have had to change shirts all day long. All five were these sort of big, burly, muscular, men. Now, I don’t know, my denominator’s kind of small, so it’s sort of a generalization, but, knock on wood, so far, I have not had a woman, uh, or a thin person, have severe truncal hyperhidrosis. Uh, other than that I have no way of telling. In fact, when a patient asks me that question, my answer is, “No, I have no way of telling whether you’re going to get it or not, and it’s just luck of the draw”. Yes?
13:44
Szarnicki: Seeing I’m the only other surgeon in the room, that you don’t mind if I make a few comments. Uh, My technique, like yours is very [inaudible] has evolved so that I now resect just the T2, but only T2 and I’ll tell you why. Uh, I see a lot of people in my practice who had ETS by other people, and when questioned, and getting op notes from the operating surgeons, most of them have had resection of T2, 3, 4 and 5. Now I can’t . . . I personally believe, although I can’t prove it, that the incidence of compensatory sweating is indeed related to the number of ganglia you remove.
Ahn: Absolutely!
Szarnicki: I mean, even . . .but I stopped doing T3, even though it improves the axillae sweating a bit, I, I get more compensatory sweating. So I don’t operate on people with that sort of hyperhidrosis. If that’s all they have, I send ‘em for botox and they’re [inaudible]
Ahn: Yeah, you and I are in the same camp . . .
Szarnicki: Certainly. Our results are almost identical. But I want to tell you some interesting things that I’ve changed also. I noticed you’re using 5mm instruments up there.
Ahn: That’s correct.
Szarnicki: I have gone to using pediatric 3mm scopes . . .
Ahn: Right
Szarnicki: And the degree of post-operative pain is remarkably less using that. And my scars are 2mm, which I stretch to 3 and a half. Uh, and women are very happy, because I position very high in the axillae, so that you can’t see them at all!
The other comment on positioning of the patient on the operating table. I just put ‘em on the operating table with their arms out to the side, and if you use a 30 degree scope, you can see great! Anyway, that’s my . . .
Ahn: I think all those points are, uh, are uh, quite valid, and I agree with all your statements. I firmly believe too, and this again, this is my opinion, it’s from my exp . . ., there’s no prospective [inaudible] trial, the more ganglia you take, the more compensatory hyperhidrosis you get. And the only reason I still take 3, is because most of the patients I operate on have a combination of palmar and axillary. Like you, if the patient’s main complaint, even though they may still have palmar hyperhidrosis, if their main complaint is axillary hyperhidrosis, I will, uh, I will , they will get Botox. Uh, I really think Botox is the treatment of choice for axillary hyperhidrosis. And I have not operated on a patient for pure axillary hyperhidrosis, in, since early, very early in my experience.
Szarnicki: I want to make one other, one other comment. This is about the [inaudible] in the literature about the effect of sympathectomy on heart rate.
Ahn: Yes, that’s correct.
Szarnicki: And that is a 10% reduction in heart rate if you do a synmpathectomy.
Ahn: That’s correct.
Szarnicki: I was asked to appear as a legal expert witness on a case back east where someone had taken out T2, 3 and 4 in a young child, a six year old, who ended up needing a pacemaker. That scares me away from doing anything more aggressive than T2 also.
Ahn: Right. That’s certainly a well point, a point well taken. The reason, and uh, I still go ahead and take 3, and maybe in time I will go to just 2, in certain, in certain cases, for just palmar I will take just T2. But, um, um my compensatory hyperhidrosis rate has gotten better. Perhaps if I took just T2, it would get even better still. And you may be right. But then we compromise on the axillae, and then the patient’s not as happy so as a result if they have both palmar and axillae I still take both 2 and 3. And, uh, in fact, actually I have not had a severe, uh, uh, truncal hyperhidrosis uh, in about 4 years now. I’m not sure exactly why, maybe I’ve just gotten lucky.
So now, now your comments about the 3 mm ports . . .Now, I’ve, I’ve also gone that route too, I’ve tried that 3mm ports, and, uh, it was very appealing, but, but then I realized none of my patients are, have ever complained about their scar. And yet I look at them when they come back, and the scar’s actually very hard to see anyway, utilizing 5mm ports. But when I compromised with the 3mm ports, it’s that, it’s that, it’s that the visualization and the light, the light is not quite as good. And, and, and uh, I just got spoiled over the years. I like the extra light.
Szarnicki: I can’t believe we used to do it with a 10 port!
Ahn: And as far as the positioning, that’s a, that’s a really good point. I’ve thought often about it. It’s a pain in the butt . . .It’ll take me 45 minutes to do the right, it’ll take me 30 minutes to do the left, the positioning takes an hour. So, uh, so if you did it, if I did it your way, it probably would cut down on the [inaudible].
(to songboy) yes
Songboy: Just so I’m clear, the actual effect of resecting the T2 ganglia is just stop sweating on the palm of the hand?
Ahn: (showing songboy his palms) Right.
Songboy: And no other areas? It just stops sweating on the palm of the hands?
Ahn: It generally will get some axillae in some people, but not on a consistent basis. If you want to get axillae consistently you’ve got to take T3.
Songboy: O.K., so if you take T2 and T3 you’ll lose sweating on the palms of the hands . . . Ahn: And the axillae
Songboy: . . .and the armpits, and that’s it?
Ahn: Right.
Songboy: I see. OK.
Ahn: Well, uh, actually no, some people’s faces get affected, not everyone, but some people’s faces won’t sweat either.
Songboy: Oh, I see. Like, what, what percentage would you say, if it’s a T2-T3 resection?
Ahn: Or even if you just take T2. Uh, I’d say about a quarter of the patients . . .maybe 10 to percent of the. . .to 25% of patients say their face don’t sweat as much.
Songboy: As much? Or at all? Or . . .
Ahn: Well, some people they don’t sweat at all. I haven’t looked . . .I don’t have, uh, hard numbers on that, but that is a definite effect.
Songboy: Well, that’d be pretty detrimental to thermoregulation, wouldn’t it?
Ahn: Well, no, uh, actually it hasn’t been. Um, and um, so far it hasn’t been. And, and also . . .[turns back to Szarnicki] Oh, heart rate, let me get back to the heart rate. I’ve done some left side sympathectomies for prolonged Q-T syndrome with good results. Um, and then I’ve had a few patients, uh, who say that their basal heart rate is . . .is lower by 10 per minute, but when they exercise it goes back up appropriately. And I put ‘em on a treadmill, just on those patients, just to see if it does come up and it does, and it doesn’t interfere with their [inaudible].
Songboy: So maximal heart rate is not affected?
Ahn: No it’s not. It’s just the basal.
Songboy: If I could, I saw an article about you on WebMD from 2002, and the article said “One treatment, pioneered by Ahn, involves minimally invasive surgery to snip the sympathetic nerve connection to the hand. ‘So far’, says Ahn, ‘the operation has been 100% successful with no negative side effects’”. Did you say that?
Ahn: Well, first of all, I don’t know who said that on the web but I don’t have anything . . . Songboy: Article by Liza Jane Maltin, WebMD feature, review by Gary Vogin, M.D. March 6, 2002.
Ahn: I have no idea. I’ll just say that’s the first time I’ve heard of that report but, I, I do remember saying specifically that so far, uh, I’ve had a hundred percent efficacy rate in stopping the sweating. About the “no negative”, I would find that hard to believe that I would have said that.
Songboy: OK, there was actually a very similar article on Eureka Press Release. Did you see that one?
Ahn: No I missed that. [Looks to DeAnna Glaser for help] There’s a lot out on the web that I have no control over . . .
Glaser: It’s kind of hard . . . We’re not here to [inaudible]
Ahn: I have no control over any of that. I have no control over what’s out on the web. So . . .
Szarnicki: Can I make one other comment? The potential there, is, I don’t recommend operating on this as a primary problem, but secondary to doing this for sweating, particularly in women, have a blushing problem that seems to go right along with this. And I have noted a dramatic reduction in facial blushing, and you may know there used to be a web page that was “Red Mask Foundation” put up by some, uh, New York woman who was a television anchor or something, that had the operation. And she was going to lose her job or something . . .
Ahn: The blushing issue I think is important because, uh, it will, if you take 2, you will get the blushing in some of the patients, but not all. And I’ve had patients come to me specifically for facial blushing and facial sweating, and I tell them ahead of time, and in fact it [inaudible] talks ‘em out of the surgery and I tell ‘em, if I really want to make sure I get the facial blushing and sweating, I’ve got to take part of T1, and if I do that, my risk of Horner’s goes right up. Now, do you really want the surgery or not? Most of them say no.
But, anyway, let me also state for the record, that I have not personally put anything out on the web myself, on any of this stuff, and I certainly have not ever advertised for this operation. So I just wanted to make sure you were aware of that.
Immunorat: I’m wondering about the side effects and when the surveys occur after surgery. For how long after the surgery does the nervous system adjust? How long does it take for the nerves to completely remodel themselves, you know, after the insult, and does that correlate with your studies on satisfaction?
Ahn: Now that’s ah, that’s an excellent question. I don’t have a good answer and I’ve been struggling with that as well. I do know that some patients with compensatory hyperhidrosis will get better with time. Some people have had it transiently. I’ve had some Horner’s syndrome that has been transient. In fact most, I think only one was permanent. Uh, and I’ve had that one recurrence at 46 months. Most of the recurrences in the literature seem to occur somewhere around, uh, 1 to 3 years. So if that gives you any hints . . .But I think it’s a very dynamic process. It’s different in different people and different circumstances, I think it’s very hard to put a handle on it.
Immunorat: I wonder if you’re aware if there are any kinetic studies underway . . .I did attend a luncheon by Dr. Ho, he was discussing AIDS sequelae , and that HIV hides in the nervous system he figured about 3 years of treatment before it could be, he used Scatchard plots and other devices in order to show the mathematics of it. And I’m wondering, I’ve never actually run into anything in the literature that’s that accurate as far as symptoms or concerns with this operation. I wonder if you’re aware of any studies?
Ahn: I don’t, I don’t know but you do, you do remind me of another issue, about one of the reasons I don’t’ operate on, on, on uh, on pre-puberty, uh, people . . .is that theoretically, and this is all theory, I have no proof of this, theoretically, if you cut the sympathetic nerves, you could interfere with bone metabolism. Now this is really indirect, really soft. Now the reason I say that is because RSD, is an over-activity of the sympathetic nerve, right, and, ah, and, and we know that in RSD, with over-sympathetic, I mean, we get a, we get a positive bone scan, uh, you get a positive scan because the bones are more active. So reverse this, if you take away the sympathetic drive to that bone area, you will decrease that metabolic activity in bone growth. And you could, theoretically interfere with the bone metabolism and the bone strength. And that’s just pure theory, but, uh, that’s one of the reasons that, um, um, and that has been mentioned in the literature.
Immunorat: Is that purely a regional phenomenon?
Ahn: Probably, uh, I don’t really know. This is, this is, it’s purest, it’s almost pure speculation. It’s theory. But, but anyway it’s enough theory to, to keep me away from, away from, from, you know, kids.
Songboy: Dr. Telaranta has published a lot about the psychiatric effects that he achieves with sympathectomy. Is that something that needs to be discussed with hyperhirosis patients?
Ahn: Uh, in some patients, yes. Uh, as far as, wanting, you know . . . You have to look at the motivation for wanting to have the surgery. But certainly, um, uh, the psychological issue, the social issue is a very clearly component of hyperhidrosis. It, it, it clearly affects people’s lives, their psychic, uh . . .
Songboy: No, I was getting . . .
Ahn: [inaudible]
Songboy: I was getting at the psychiatric effects of the surgery.
Ahn: Oh, I see, from the surgery. I was, I don’t know of any studies that have been done on it . . .
Songboy: Telaranta’s released 2 huge ones. . .
Ahn: Yeah, but my . . .I’m not sure I believe his studies by the way.
Songboy: Oh.
Ahn: But my impression, my result is that these are some of the happiest, most grateful patients I have. I’ve seen it dramatically change their lives, their lifestyle, their careers, and by and large I would say they are very happy to have had it. Retrieved from "http://editthis.info/corposcindosis/AhnTalk"
