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PubMed1994

[Distal arteritis of the legs: lumbar sympathectomy].

Among atheromatous occlusive arterial disease of the lower limbs, chronic sub-popliteal arterial occlusions refer an heterogenous group of patients. In this medical condition, lumbar sympathectomy constitutes a classical possible treatment. Actually, the beneficial effect of sympathectomy has never been confirmed by controlled randomised trials. In this particular and uncomfortable situation, it is only possible to list non indications for sympathectomy: asymptomatic patient, claudication, critical ischemia, limb salvage, and combination with vascular surgery. Lumbar sympathectomy deserves a controlled evaluation in patients with a small foot ischemic ulceration without hemodynamic critical ischemia i.e. systolic toe pressure > 30 mm Hg and/or ankle systolic pressure > 50 mm Hg.

Arterial Occlusive Diseases↗
PubMed1993

Distal thigh/arm index as a predictor of success for lumbar sympathectomy.

Data from 90 lumbar sympathectomies were reviewed to assess the role of a distal thigh/arm Doppler systolic index (DTAI) and of external magnetic flowmeter (MCBF) measurements for predicting patient outcome following lumbar sympathectomy. The presenting symptoms included impending gangrene, gangrene, rest pain, nonhealing ulcers, and disabling claudication. Of the 90 cases, clinical improvement occurred in 57% of the limbs. Major amputation was not required in 73% of the limbs. The MCBF data showed variability which masked the relationship to the effects of sympathectomy. DTAI test results were significantly related to outcome. For DTAI > 0.6 (57 patients), improvement occurred in 70% of the limbs, with major amputation not required in 86% of the limbs. For DTAI < 0.6 (33 patients), improvement occurred in only 33% of the limbs, and major amputation was not required in 52% of the limbs. The Doppler systolic index has provided a noninvasive measure that can be used in conjunction with good clinical judgment for predicting the outcome of lumbar sympathectomy.

Amputation, Surgical↗
PubMed1993

Effects of lumbar sympathectomy on canine transcutaneous oxygen tension.

Augmentation of cutaneous blood flow by postganglionic lumbar sympathectomy may not reflect an increase in nutritive vascular supply to the dermal tissues. Transcutaneous oxygen tension (TcPO2) was compared with radionuclide microsphere determination of dermal microcirculation in a hind limb sympathectomy model in 20 dogs. After 90 minutes the TcPO2 was greater in the sympathectomized limbs than in the contralateral limbs (125 mm Hg versus 114 mm Hg, p < or = 0.05). In contrast, microsphere-determined paw dermal capillary flow declined in sympathectomized limbs (4.9 ml/min/100 gm versus 11.8 ml/min/100 gm, p < or = 0.05). Decreases in the TcPO2/venous PO2 ratio correlated with sympathectomy-induced increases in total limb blood flow (r = 0.60; p < or = 0.001), reflecting less efficient oxygen extraction. These observations confirm the lack of enhancement of tissue oxygen delivery by sympathectomy because of the associated dilation of cutaneous arteriovenous shunts.

Animals↗
PubMed1977

[Present place of lumbar sympathectomy in arteritis of the lower limbs (author's transl)].

A study of 75 lumbar sympathectomy helped the authors in specifying the indications of this operation for arteritis of the lower limbs. Lumbar sympathectomy is based on precise anatomical facts : para-vertebral sympathetic chain is usual but a collateral chain must be searched if the latter appears too thin. Lumbar sympathectomy can be performed alone or in association with reconstructive procedures. It is used alone in old people for its antalgic and moderately functional effect in accordance with their level of activity. Also it is used alone in cases of gangrene localized or pending or in the absence of a runoff vasculature. It is associated to repair if one wants to improve an incompetent peripheral perfusion. The authors record 79% of favourable results of which 52% were maintained when lumbar sympathectomy was used alone. In patients where direct vascular surgery is added, favorable results account for 82% of which 78% long lasting.

Aged↗
PubMed1977

Direct measurement of arteriovenous anastomotic blood flow after lumbar sympathectomy.

Absolute blood flows through hind limb capillaries and arteriovenous anastomoses (AVA) were determined by the radioactive microsphere technique of relative shunt measurement combined with direct (electromagnetic) measurement of femoral artery flow. Hemodynamic parameters were measured before and after laparotomy, after unilateral lumbar sympathectomy, during reactive hyperemia, and during alpha adrenergic blockade in normal and sympathectomized hindlimbs of six anesthetized dogs. After sympathectomy arteriovenous (A-V) shunting increased from 3.8 to 32.1% (p less than 0.05). AVA flow increased from 4 to 54 ml/minute (p less than 0.01), while capillary flow was unchanged. Nonsympathectomized limbs did not demonstrate these changes. During reactive hyperemia, capillary flow increased more than 100% (p less than 0.03) in both normal and sympathectomized limbs, while AVA flow was unchanged. After phentolamine (5 mg, intravenously), AVA flow increased from 2 to 19 ml/minute (p less than 0.01) only in nonsympathectomized limbs. Phentolamine mimicked surgical sympathectomy effects in nonsympathectomized limbs, with paw temperature, femoral flow, A-V O2 difference, A-V shunting, AVA flow, and capillary flow equal to sympathectomized limbs after phentolamine administration. In the acute canine model, increased blood flow after sympathectomy is due to increased nonnutritive AVA flow, with no change in total hindlimb capillary flow, both at rest and during reactive hyperemia.

Animals↗
PubMed1996

Interpleural bupivacaine for pain relief after transthoracic endoscopic sympathectomy for primary hyperhidrosis.

BACKGROUND: Interpleural local anesthetic has been reported to provide good postoperative pain relief in patients receiving thoracotomy or upper abdominal surgery. However, there were few reports regarding interpleural local anesthetic for postoperative pain relief in patients receiving transthoracic endoscopic sympathectomy for palmar hyperhidrosis. The aim of the present study was to evaluate the effect of interpleural bupivacaine for postoperative pain relief in patients receiving transthoracic endoscopic sympathectomy for palmar hyperhidrosis. METHODS: Sixty adult patients undergoing bilateral transthoracic endoscopic sympathectomy were randomly divided into two groups (n = 30, each group) for study. At the end of surgery, patients in group 1 were given bilaterally an injection of 0.5% interpleural bupivacaine (10 ml) through the surgical endoscope, whereas those in the group 2 who were not given any treatment at the juncture served as control. Postoperatively, intravenous morphine 2.5 mg was given luxuriously to the patients at their request at intervals of 30 min. The intensity of postoperative pain was assessed at rest and during cough with visual analogue scale (VAS, 0-10 points). RESULTS: It was showed that at rest the pain scores were less in group 1 than in group 2 within 4 h postoperatively. During cough, group 1 also had less VAS scores than group 2 within 5 h postoperatively. Furthermore, patients in group 1 consumed less intravenous morphine than those in group 2 within 6 h postoperatively. CONCLUSIONS: Interpleural bupivacaine significantly decreased the intensity of postoperative pain and morphine consumption in patients undergoing transthoracic endoscopic sympathectomy for palmar hyperhidrosis. We are looking forward to seeing that with the addition of epinephrine to the anesthetic solution and a considerable increase of dosage and/or volume of bupivacaine may provide a better and longer pain relief, about which further studies are needed.

Adult↗
PubMed1997

[Thoracic sympathectomy using thoracoscopy].

In the years 1996-1997 9 dorsal sympathectomies (DS) were performed in the authors Department using VATS technique. There were 6 right dorsal sympathectomies and 3 left DS in the group of 7 patients. Indication for dorsal sympathectomies was idiopathic hyperhidrosis in 4 cases and vascular disorders in 3 cases. Operating time for the single procedure was 30'. Chest drain was never used. There were no major complications (Horner's syndrome-one patient, intercostal neuralgia, which disappeared in a few days-2 patients). Patients left hospital the day after operation (only those with fingers ulceration stayed longer). The results of dorsal sympathectomies in patients with hyperhydorsis were excellent, less impressive in those suffered from vasospastic and vascular disorders.

Adult↗
PubMed1978

Analysis of intestinal cell proliferation after guanethidine-induced sympathectomy. I. Stathmokinetic, labelling index, mitotic index, and cellular migration studies.

Guanethidine-induced sympathectomy in the rat during the neonatal period (injection of 20 microgram/g body weight every 48 h from day of birth until day 14) produces an absolute reduction in the number of sympathetic ganglion cells, but no significant alteration of body weight. Superior cervical ganglia show 79.8% fewer cell bodies at 15 days and 92.3% at 45 days; coeliac ganglia exhibit an 81.0% reduction at 15 days and 89.6% at 45 days in guanethidine-treated rats as compared to normal controls. The sympathetic ganglion cells that remain after treatment have an abnormal morphological appearance with distended mitochondria and depletion of endoplasmic reticulum. Sympathectomy produces a prolongation of the generation cycle time (Tc) as measured by the colchicine-induced mitotic arrest technique, and a decrease in labelling, mitotic, and migration indices. In addition, sympathectomy suppresses the amplitude of the circadian rhythm in mitotic activity. The general suppression of this activity in the intestinal epithelium is more pronounced in the jejunum and ileum than in the duodenum. Variation in the effectiveness of sympathectomy on the inhibition of intestinal cell proliferation may be related to segmental differences in cell proliferation, to segmental differences in innervation, and/or to segmental variation in the effectiveness of guanethidine.

Animals↗
PubMed1976

Modification and characterization of the permanent sympathectomy produced by the administration of guanethidine to newborn rats.

The administration of guanethidine to newborn rats has been shown to produce a permanent sympathectomy with potential advantages over immunosympathectomy and 6-hydroxydopamine-induced chemical sympathectomy. In this paper, we report on a revised treatment regimen involving initiation of treatment (50 mg/kg/day) on day 7 after birth and continuing for 3 weeks. Animals treated by this protocol have a low mortality rate (approx. 10% above saline-treated controls) and no permanent growth deficit. Analysis of tyrosine hydroxylase activity in and light microscopic examination of superior cervical ganglia of the guanethidine-treated animals indicate complete destruction of sympathetic neurons by the end of the second week of treatment. During and after treatment there are no decreases in norepinephrine in whole brain of the treated animals. Norepinephrine levels in peripheral tissues are markedly reduced at both 9 and 16 weeks of age. Stimulation of vasomotor outflow produces no increase in blood pressure in guanethidine-treated rats at 9 or 26 weeks of age, indicating a complete and permanent functional denervation of the vasculature. The adrenal glands of the guanethidine-treated animals are not destroyed, but rather respond, apparently by transsynaptic induction, with increases in tyrosine hydroxylase and epinephrine content. Interestingly, despite the continued deprivation of a peripheral sympathetic nervous system in these animals. adrenal tyrosine hydroxylase and epinephrine levels return to control levels by 10 weeks of age. These data indicate that administration of guanethidine to newborn rats produces a very complete and permanent sympathectomy with significant advantages over immunosympathectomy and 6-hydroxydopamine-induced chemical sympathectomy.

Adrenal Glands↗
PubMed1999

Video-assisted thoracoscopic sympathectomy for severe intractable angina.

OBJECTIVE: Endoscopic trans-thoracic sympathectomy is a well documented, safe and successful treatment for palmar and axillary hyperhidrosis. This may also be helpful in the management of patients with intractable angina and advanced coronary disease unsuitable for coronary artery bypass graft (CABG) or percutaneous transluminal coronary angioplasty (PTCA). We evaluated video assisted thoracoscopic sympathectomy (VATS) in such patients with the aim of improving symptoms and quality of life. METHODS: Video assisted thoracoscopic sympathectomy, a minimally invasive procedure, was performed under general anaesthesia with alternating single lung ventilation. Three stab incisions were made at the level of the fourth intercostal space in the anterior and posterior axillary lines, and at the fifth intercostal space in the mid-axillary line through which an extensive thoracic sympathectomy was performed to include second to the fourth ganglia, bilaterally. RESULTS: A total of 16 patients aged 46-76 (mean 61) years were assessed for VATS. Of these 10 patients had the procedure performed; nine with previous CABG and one with diffuse coronary disease. Six patients were excluded because of an evolving MI (n = 1), left ventricular ejection fraction (LVEF) < 30% (n = 2), and chronic stable angina with no objective evidence of ischaemia (n = 3). All 10 patients had marked symptomatic improvement with reduction of both angina frequency and intensity of attacks. Mean follow-up period 11.5 months. Exercise tolerance and time to onset of angina measured on exercise treadmill was significantly increased post-VATS (P = 0.028) and maintained 1 year post-operative. CONCLUSION: VATS was associated with both reduction in angina symptoms and an increase in exercise time to onset of angina. An improved quality of life was evident.

Aged↗
PubMed1979

Effect of neonatal sympathectomy by 6-hydroxydopamine on volume and resistance regulation in stroke-prone spontaneously hypertensive rats.

1. Neonatal sympathectomy with 6 hydroxy-dopamine (6-OHDA) was used as a tool to assess the significance of an increased sympathetic vascular tone for the development of high blood pressure in stroke-prone spontaneously hypertensive rats. After administration of 6-OHDA the rise in blood pressure was blunted for the following 9 weeks until innervation was re-established. 6-OHDA-treated rats retained more sodium and had larger plasma and blood volumes than sham-treated rats. 2. Catecholamines in plasma were increased 2-10-fold immediately after sympathectomy, but their concentrations were subnormal on day 7. Eight weeks after sympathectomy plasma noradrenaline and dopamine were not elevated, but plasma adrenaline has increased twofold. 3. The reactivity of resistance vessels to noradrenaline was markedly enhanced and the neuronal uptake and metabolism of noradrenaline were still reduced 8 weeks after neonatal sympathectomy. 4. These results confirm the significance of an intact sympathetic nervous system for the development in these rats. Sodium retention and increased plasma and blood volume may be considered as a compensatory mechanism for the vasodilatation resulting from decreased vasomotor tone.

Animals↗
PubMed1977

Blood and plasma volume changes in dogs after sympathectomy with 6-hydroxydopamine.

The effect of chemical sympathectomy with 6-hydroxydopamine (6-OHDA) on blood volume was studied in unanesthetized splenectomized and nonsplenectomized dogs. A significant increase in total blood volume essentially accounted for by a marked plasma volume expansion was found in both groups after 6-OHDA treatment (50 mg/kg). The red cell volume in the nonsplenectomized dogs was significantly reduced 3 and 7 days after sympathectomy but returned to normal after 15 days. In contrast, the red cell volume was unchanged in the splenectomized dogs after sympathectomy. The blood volume changes were accompanied in both groups by significant decreases in hematocrit in plasma sodium and potassium and in serum protein concentrations while serum calcium concentrations were only slightly increased. These results confirm that the inhibition of adrenergic tone directly influences blood volume. They also indicate that an increase in blood volume constitutes an important compensatory mechanism for the long-term maintenance of adequate blood pressure levels after chemical sympathectomy by 6-OHDA.

Animals↗
PubMed1995

A mechanism for sympathectomy-induced bone resorption in the middle ear.

BACKGROUND: Recent investigations have demonstrated a link between sympathectomy and osteoclast-mediated bone resorption. The exact nature of this link, however, is unknown. We hypothesize that substance P, a potent vasoconstrictive neuropeptide found in peripheral sensory fibers, including those innervating bone, is the mediator of this phenomenon. To test this theory, the effects of substance P on in vitro calcium release from cultured neonatal mouse calvaria were assessed. In addition, an in vivo study was conducted whereby gerbils were injected with capsaicin to eliminate substance P-containing fibers before sympathectomy with 6-hydroxydopamine. If the effects of 6-hydroxydopamine were eliminated by prior administration of capsaicin, the role of sensory nerves in sympathectomy-induced resorption would be strongly implicated. IN VITRO STUDY: Substance P at 10(-8) mol/L was incubated with eight newborn Swiss-Webster mouse hemicalvarial explants and compared with explants incubated in control media alone. The neonatal mice were euthanized at day 3, and their hemicalvaria were preincubated in 2 ml of stock media without treatment for 24 hours at 36.5 degrees C as a stabilization period. After the stabilization period, the stock media were replaced with 2 ml of fresh control media or media containing substance P at 10(-8) mol/L. A similar experiment was performed with the addition of indomethacin at 5 x 10(-7). The explants were then incubated for 72 hours with gassing every 12 hours with a mixture of O2, N2, and CO2. At the end of the 72-hour period, the media were analyzed for calcium content by atomic absorption spectrophotometry and compared by one-way analysis of variance with Bonferroni-corrected post hoc tests. IN VIVO STUDY: Forty-eight Mongolian gerbils were placed into four groups: group 1 received intraperitoneal injections of 6-hydroxydopamine at 75 micrograms/gm body weight on days 1, 2, 6, 7, and 8; group 2 received identical injections of hydroxydopamine, but 12 hours after receiving subdermal injections of capsaicin at 50 micrograms/gm body weight; group 3 received only subdermal injections of capsaicin; and group 4 received only saline injections to serve as controls. Seven days after treatment, the animals were euthanized, and the ventral wall of each animal's right bulla was resected and quantified for osteoclast number and surface with a computer-based histomorphometry system. Analysis was then made by one-way analysis of variance with Bonferroni-corrected post hoc tests. RESULTS: The results of the in vitro study revealed that substance P at 10(-8) mol/L (11.05 +/- 3.37 micrograms/ml) induced significant calcium release from cultured neonatal mouse calvaria when compared with control bone incubated in base media alone (0.92 +/- 2.85 micrograms/ml, p < 0.01). The process was completely inhibited by 5.0 x 10(-7) indomethacin. The results of the in vivo study showed 6-hydroxydopamine treatment significantly increased both the osteoclast number (NOc/TL = 3.14 +/- 1.33/mm) and the osteoclast surface (OcS/BS = 16.04% +/- 6.95%) of bone when compared with bone from saline-treated controls (NOc/TL = 1.77 +/- 0.79/mm, p < 0.01; OcS/BS = 8.88% +/- 4.15%, p < 0.01). These 6-hydroxydopamine-induced increases were eliminated, however, in animals pretreated with capsaicin before sympathectomy (NOc/TL = 1.86 +/- 0.68/mm, p > 0.05; OcS/BS = 9.92 +/- 3.73, p > 0.05), whereas treatment with capsaicin alone had no effect when compared with bone from saline-treated controls (NOc/TL = 2.02 +/- 0.50/mm, p > 0.05; OcS/BS = 10.28% +/- 2.62%, p > 0.05). Substance P has thus been shown to induce calcium release from membranous bone in vitro, whereas capsaicin, a substance P-specific sensory neurolytic chemical, eliminates the in vivo osteoclast-inductive effects of 6-hydroxydopamine when given 12 hours before treatment. The results indicate that substance P is capable of inducing resorption and that substance P-containing sensory ne

Animals↗
PubMed1993

Acute and chronic effects of unilateral cervical sympathectomy on nasal allergy-like symptoms induced by toluene diisocyanate in guinea pigs.

The role of the sympathetic nervous system in nasal allergy was examined using guinea pigs with nasal allergy sensitized by 2,4-toluene diisocyanate (TDI). Nasal allergy-like symptoms were suppressed at the first TDI provocation after cervical sympathectomy. This finding suggests that the sympathetic nervous system contributes to the development of symptoms in nasal allergy. However, the inhibitory effect of sympathectomy gradually disappeared. The animals with chronic cervical sympathectomy were more prone to manifest nasal allergy-like symptoms induced by TDI. These findings suggest that compensatory activation of the parasympathetic nervous system in reaction to sympathectomy might exacerbate nasal allergy. The findings in the present study also provide an experimental basis for stellate ganglion block treatment of nasal allergy.

Animals↗
PubMed1992

Normal blood flow but lower oxygen tension in diabetes of young rats: microenvironment and the influence of sympathectomy.

Studies of rats with experimental streptozotocin (STZ)-induced diabetes at 4 months have identified sciatic nerve trunk oligemia and hypoxia, but it is uncertain how early these abnormalities develop or which develops first. We studied young (4-week-old) rats after 6 or 16 weeks of STZ-induced diabetes (or after citrate buffer injection in controls) by recording multi-fiber conduction in three different nerve territories and by measuring sciatic endoneurial blood flow (NBF) and oxygen tension (PnO2) at end point. To evaluate the impact of sympathectomy on this diabetic model, separate animal groups were treated for 5 weeks with guanethidine monosulfate given at the onset of diabetes (group 1, end point 6 weeks) or after 6 weeks of diabetes (group 2, end point 16 weeks). Diabetes was associated with deficits in sensory and motor caudal conduction and increased resistance to ischemic conduction failure (RICF). NBF was comparable to control animals at both time points and was within the published normal range of NBF. In contrast, oxygen tensions were shifted to lower values in diabetic animals. Sympathectomy was associated with blunting of the RICF increase in group 2 but worsened caudal sensory conduction despite evidence of modest improvement in sciatic nerve oxygenation. Our findings support the concept that neuropathy occurs early in diabetes and that hypoxia develops before oligemia. Sympathectomy did not benefit this diabetic model.

Action Potentials↗
PubMed1964

THE ROLE OF SYMPATHECTOMY IN THE TREATMENT OF OBLITERATIVE PERIPHERAL VASCULAR DISEASE.

The immediate good results of endarterectomy and vascular grafting have pushed sympathectomy into the background as a form of treatment for peripheral obliterative arterial diseases. There are, however, many instances in which the nature of the arterial disease prevents performance of direct arterial surgery. In these cases an increase in circulation to the skin may not only relieve pain and heal ulcers but also, not infrequently, save the limb from amputation or permit a minor rather than a major amputation.A consecutive group of 90 lumbar and cervicodorsal sympathectomies was reviewed. The majority of patients suffered from atherosclerosis; smaller numbers had Buerger's or Raynaud's disease. The assessment of patients, selection for surgery, technique of operation, its complications and early results are discussed. There was one death in this series of patients who ranged in age from 17 to 81 years. This study indicates that, although sympathectomy is not a panacea for obliterative arterial disease, neither is it an obsolete procedure.

Amputation, Surgical↗
PubMed1977

Gustatory phenomena after upper dorsal sympathectomy.

In a series of 100 bilateral upper dorsal sympathectomies performed for palmar hyperhidrosis, gustatory sweating and other gustatory phenomena were reported by 68 of 93 patients (73%), followed up for an average of 1 1/2 years. These gustatory phenomena were quite different from physiologic gustatory sweating: a wide range of gustatory stimuli caused a variety of phenomena in varied locations. There was a negative correlation between the incidence of these phenomena and the occurrence of Horner's syndrome after sympathectomy. Analysis of our observations, and of clinical and experimental work of others, leads to the conclusion that gustatory phenomena after upper dorsal sympathectomy are the result of preganglionic sympathetic regeneration or collateral sprouting with aberrant synapses in the superior cervical ganglion.

Adult↗
PubMed1982

Sympathectomy in the treatment of chronic venous leg ulcers.

Patients with recurrent, intractable postphlebitic ulcer were treated by using sympathectomy as an adjunctive procedure. After standardized aggressive conservative therapy and 47 prior operations, including skin grafts, local excision, and various localized and extensive vein ligations and/or strippings, 23 patients continued to have ulcerations for 11 months to thirteen years. After sympathectomy, all ulcers healed within two to 6 1/2 months. During a follow-up of 2 1/2 to 11 years, 18 patients remained free of ulcers. Four had recurrent ulcerations, three promptly healing with reinstitution of elastic support, which had been discontinued. Sympathectomy is a simple and effective adjunctive method of surgical management for the occasional patient with intractable recurrent postphlebitis ulceration.

Adult↗