An Argentine patient suffering from a sympathetic block overcame all difficulties to come to Taiwan for medical treatment, while also strictly following epidemic prevention policies

This story is about Gabriela from Argentina, who was a typical patient treated with endoscopic thoracic sympathectomy (ETS). She couldn’t stand the symptoms of her plantar hyperhidrosis, which caused significant inconvenience in her daily life and social life. Therefore, in October 2019, she traveled abroad for a sympathectomy procedure on her waist. Although her sweaty feet had been successfully treated, the sympathetic nerve was completely severed, resulting in unbearable complications, such as her feet always being hot (higher than 35°C degrees), pain, excessively dryness, etc.

In addition, the ETS also induced a number of systemic side effects, including dry mouth, dry eyes, dermatitis, compensatory sweating on her hands and back, poor appetite, menstrual disorders, inattention, loss of motivation to try new things, anxiety, fatigue, insomnia, etc. These symptoms could not be relieved with any treatment. At the end of 2019, Gabriela found Chang Gung Memorial Hospital through a variety of channels. The medical team at the hospital recommended using da Vinci surgery to explore the damaged area, and to treat the sympathetic nerve damage by removing the sural nerve of the left foot and using it for microscopic reconstruction.

However, when all medical matters were fully communicated, the COVID-19 outbreak in early 2020 swept through the world, so Taiwan suspended the entry of foreign nationals for medical treatment. This meant that Gabriela's trip was also put on hold, and her hope of regaining her health was cut off. The International Medical Center, strictly abiding by Taiwan's epidemic prevention measures, continued to care for overseas patients through email or videoconferencing in order to provide psychological support to people who feel helpless due to the interruption of their treatment during the pandemic. Both the medical team and the patient were determined to not give up hope. Gabriela kept in touch with the medical team during the outbreak and waited for her opportunity to come to Taiwan for treatment.

▲Case manager Wen explained the matters needing attention to Gabriela for the treatment

In August 2020, as the pandemic in Taiwan was abating, the government conditionally removed the suspension of the entry of foreign nationals, including allowing special applications for medical treatment. However, it was not easy to come to Taiwan through a special application; in addition to a 14-day home quarantine and 7 days of self-health monitoring, foreign nationals coming to Taiwan must also submit of a wide array of documents, including a treatment deposit for a confirmed diagnosis of COVID-19.

Since Gabriela was the one of the first few patients to submit a special application to travel to Taiwan, the Ministry of Health and Welfare reviewed her application very carefully. The medical team was requested several times to provide supplementary documents demonstrating the suitability and urgency of Gabriela's treatment in Taiwan, which made Gabriela a little frustrated. "All the documents had been provided as requested, why can't I go to Taiwan?"

In addition to the special application in Taiwan, the COVID-19 pandemic also presented a challenge to Gabriela in Argentina: traveling overseas had become very difficult. Missing a flight meant waiting a long time for the next flight. Fortunately, thanks to the efforts of the medical team in producing the required documents and submitting the application, the Ministry of Health and Welfare issued a permit in time, and Gabriela, with help from the government of Argentina, finally came to Taiwan with her aunt.

For them, coming to beautiful Taiwan undoubtedly felt like a gift from God. After patiently waiting for the end of the quarantine and self-health monitoring, and after a test confirmed she did not have COVID-19, Gabriela finally met the medical team that was about to operate on her.

Sympathetic Nerve Reconstruction (SNR)

▲SNR Process / Dr. Tommy Nai-Jen Chang (left) and Dr. See-Tong Pang (right)

▲ Doctor operating the da Vinci robotic arm

Because she kept in touch with the team during the epidemic, Gabriela was able to quickly complete the pre-operation preparations and underwent the operation successfully. She could quickly feel her body recovering after the operation. In particular, problems such as an inability to focus and negative feelings almost immediately improved.

Although other physical problems still needed time to recover, the initial progress brought by the reconstruction surgery made Gabriela confident that her life could return to normal. She couldn't wait to share her thoughts about the surgery with other patients, and encouraged others who have the same problems to never give up hope and to wait for the opportunity to come to Taiwan for the treatment. She was particularly excited about having the chance to recuperate in a beautiful foreign land, and thoroughly enjoyed her time in Taiwan before returning home. Through the follow-ups conducted via quantitative online questionnaires and care from other members of the patient community, we are certain we will continue to hear good news about Gabriela's recovery.

Treatment of multiple complications caused by sympathetic block

Although local hyperhidrosis (sweaty hands, sweaty feet, sweaty head) is generally not harmful to health, it cause inconvenience in professional and social contexts. For these and other reasons, most patients will undergo a sympathectomy to overcome their problems.

However, some patients experienced side effects due to sympathetic disorders after surgery, such as compensatory sweating (mainly in the chest, abdomen, buttocks and lower body, thus requiring frequent changes of clothing when the weather is hot), impaired thermoregulation (loss of sweating function above the chest), dizziness, hot head and cold feet, frequent heat stroke and heat exhaustion, and other sympathetic nerve regulation problems, including in the salivary glands, hair follicles, pupils, cardiovascular system, respiratory system, gastrointestinal system, urinary and reproductive system, and severe emotional disorders. These symptoms usually become worse with time, and cannot be alleviated through pharmaceutical products. Currently, they are still medically incurable.

The SNR team at Chang Gung has accumulated ample experience

Although there are a few cases in the literature regarding using thoracoscopic surgery to remove the intercostal nerve or sural nerve for reconstruction in patients with severe complications, these cases occurred when the technology for microsurgical nerve repair was still being developed and explored, and therefore the effectiveness was generally poor.

In order to help patients in Taiwan and abroad suffering from the complications of sympathetic block, Chang Gung Memorial Hospital combined the teams of Director Yin-Kai Chao of the Department of Thoracic Surgery, Dr. Tommy Nai-Jen Chang of the Division of Reconstructive Microsurgery, the Department of Plastic Surgery and other professional teams at the Departments of Urology, Neurology and Psychiatry in 2017. The hospital also introduced and refined the da Vinci surgical system for sympathetic nerve reconstruction surgery, having treated more than 30 patients. Most of them achieved more than 50% improvement within 3-6 months after the surgery, and continue to show improvement. Our team is one of the few medical teams in the world that regularly performs this operation while achieving stable treatment results.

 ▲Team of Attending Physicians: Dr. Tommy Nai-Jen Chang of the Department of Plastic Surgery (left) , Director Yin-Kai Chao of the Department of Thoracic and Cardiovascular Surgery (right)

 ▲Medical team in a hybrid OR

Thanks to the efforts of the medical team in promoting the procedure in academic circles and patient communities, our hospital has gradually attracted international patients who are seeking sympathetic nerve reconstruction treatments. On the academic side, the microsurgical reconstruction team at Chang Gung Memorial Hospital has published several articles in international journals. Combined with quantitative surveys of clinical patients and scientific animal experiments, Chang Gung is trying to explore in depth the reasons why sympathetic complications are complex and difficult to treat. In terms of the social aspect, the attending physician of the medical team has personally established an online patient community for those treated for sympathetic blocks, and actively publishes articles and videos and responds to patients’ questions. Patients from North America, South America, Europe, Japan and other places have been drawn to interact with the medical team on the Internet.

▲Photo of Gabriela (center) and the attending physicians before returning home