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Focal necrosis of the ureter was observed in our patient 7 days after CT-guided chemical sympathectomy. The injection of phenol was apparently rendered remote from the ureter and still caused ureteric necrosis. Ureteric injury may thus result following chemical sympathectomy, not from direct puncture of the ureter, but from unpredictable individual diffusion pathways.
Primary hyperhidrosis (PH) often starts in childhood and adolescence and can be a troublesome condition. In Taiwan, there is a high incidence in childhood (1.6%-2.0%) and adolescence (2.2%-2.6%). There are few reports regarding transthoracic endoscopic sympathectomy (TES) for PH in children and adolescents. From July 1994 to April 1998, a total of 438 patients underwent TES. There were 174 males and 264 females with a mean age of 14.2 years (range 5-17 years). All patients were placed in a semi-sitting position under single-lumen intubation anesthesia. We performed ablation of the T2 ganglion and any Kuntz fibers in 350 patients with palmar hyperhidrosis and a similar procedure on the T2 and T3 ganglia in 88 patients with palmar and axillary hyperhidrosis using either a 6- or 8-mm thoracoscope via one 0.8-cm incision just below each axilla. In the 438 patients, 875 sympathectomies were performed. There was 1 technical failure due to severe pleural adhesions. TES was usually accomplished within 15 min (range 7-20 min). All except 5 patients were discharged within 4 h after operation. The surgical complication rate was minimal: 1 pneumothorax (0.23%) and 2 segmental lung collapses (0.46%). There was no surgical mortality. The mean postoperative follow-up period was 25.2 months (range 4-45 months). The result was highly satisfactory in 408 patients (93.2%), although 377 (86%) developed compensatory sweating of the trunk and lower limbs, the distribution affecting the back (86%), abdomen (48%), lower limbs (78%), and soles (1.4%). The recurrence rate of palmar hyperhidrosis was 0.6% in the 1st, 1.1% in the 2nd, and 1.7% in the 3rd year. TES is thus a safe and effective method for treating palmar and axillary hyperhidrosis in children and adolescents.
Developmental studies indicate a role for GDNF in survival of motor, autonomic, and sensory neurons. However, no study attempted to demonstrate its participation in autonomic nerve regeneration. In this work, chemical sympathectomy by 6-hydroxydopamine provided the model for assessing heart GDNF expression during denervation and axonal regrowth. A glyoxylic acid-based histochemical technique evaluated the noradrenergic innervation. ELISA determined GDNF levels after concentrating heart homogenates. Light and ultrastructural in situ hybridization and immunocytochemistry were used for identifying cells expressing GDNF mRNA and protein. In control rats, the GDNF cardiac levels were significantly higher in 37-day-old animals in comparison with those aging 60 days. In sympathectomized rats, GDNF cardiac levels were significantly higher 7 days after sympathectomy and dropped to control levels at day 30. GDNF mRNA was expressed in atrial and ventricular myocytes from normal and sympathectomized rats. GDNF immunoreactivity occurred on atrial granules and quantitative analysis in electron micrographs confirmed ELISA-obtained data. In ventricular myocytes gold particles occurred sparsely. These findings constitute the first evidence for GDNF synthesis by cardiomyocytes and postulate a role for this factor soon after cardiac sympathetic denervation, probably in nerve regeneration. In atrial myocytes, GDNF is probably secreted by regulated pathway.
Renal transplantation experiments have shown that the kidney contributes to chronic sympathectomy-induced arterial pressure reduction in spontaneously hypertensive rats (SHR). The underlying mechanisms are currently unclear but may include alterations in the function of small renal arteries. Neonatal SHR were sympathectomized by intraperitoneal guanethidine injections and removal of adrenal medullary tissue. Controls were sham- or hydralazine-treated. At 12 weeks of age, distal interlobar artery segments were investigated using small-vessel wire myography. Vessels from sympathectomized animals showed increased sensitivity to noradrenaline (NE). Vasopressin- and endothelin-1-induced vasoconstriction was similar in all groups (as reflected by the pD(2), i.e. -logEC(50), where EC(50) is the molar concentration of agonist eliciting a half-maximal response). Maximum vasopressin-induced tension was similar in all groups while endothelin-1-induced maximum tension was significantly higher in sympathectomized than in sham-treated SHR. The sensitivity of NE-induced vasoconstriction to extracellular Ca(2+) did not differ between groups while sensitivity to L-type Ca(2+) channel activation was significantly higher in both sympathectomized and hydralazine-treated animals than in sham-treated animals. Endothelium-dependent and independent vasodilation were similar in all groups. Sequential blockade of NO-synthase and cyclooxygenase had similar effects in all groups. In conclusion, neonatal sympathectomy does not induce any changes in the function of isolated proximal renal resistance arteries from SHR that could explain the blood pressure lowering effect of a kidney graft from sympathectomized SHR.
BACKGROUND: Reports on intrapleural analgesia (IPA) are conflicting. The current study assessed the effect of a single-dose thoracoscopic bilateral intrapleural anesthetic administration on the immediate postoperative recovery room and 24-h pain control. METHODS: Fifty patients with primary palmar hyperhidrosis were randomly classified into two groups to receive either 20 ml of 0.5% bupivacaine and 5 mg/ml epinephrine or 0.9% NaCl in each thoracic cavity at the end of thoracoscopic T2-T3 sympathectomy. The degree of early postoperative pain was estimated by visual analog scale (VAS). The 24-h parenteral opioid analgesic requirement was recorded. RESULTS: The immediate postoperative VAS score (1.46 +/- 0.41 vs 2.0 +/- 0.61, p = 0.03), opioid consumption (0.42 +/- 0.36 vs 0.65 +/- 0.28, p = 0.0133), and 24-h opioid consumption (1.02 +/- 0.80 vs 1.48 +/- 0.84, p = 0.05) were significantly reduced following IPA compared to those of the control group. CONCLUSION: IPA is a simple and effective means for postoperative pain control following thoracoscopic upper dorsal sympathectomy.
BACKGROUND: Before the introduction of endoscopic thoracic sympathectomy (ETS) for the management of hyperhidrosis, anomalous azygos lobes of the lung were rarely encountered. When performing ETS, it is important to have knowledge of and be prepared to deal with this anatomical anomaly. METHODS: A database of 2,272 patients who underwent ETS was reviewed to determine the incidence of azygos lobe, describe the characteristics of patients with azygos lobe, and evaluate the outcomes. RESULTS: Twenty cases (0.9%) of azygos lobe were identified. Two distinctive variations were encountered, one in which proximal venous drainage was present (type 2) and one in which this downward drainage system did not exist (type 1). In type 2, the vein and veil must be retracted to obtain better exposure. All patients were treated endoscopically, without conversion to open thoracotomy. Palmar sweating was cured in all cases, and all of the patients reported satisfaction with the outcome. CONCLUSIONS: Azygos lobe occurs in 1% of the population and can make ETS more difficult. If the surgeon is prepared, there are effective techniques for performing the sympathectomy. The results are similar to those obtained in patients without this anatomical variation.
BACKGROUND: Upper thoracoscopic sympathectomy, obtained either by ablation or resection of the appropriate ganglia, is now the preferred treatment for primary palmar hyperhidrosis. Therefore, we undertook a review to compare the relative efficacy of these two techniques. METHODS: A Medline search was performed for the years 1974-99 to identify all published studies of thoracoscopic sympathectomy for hyperhidrosis. RESULTS: In all, 33 studies were identified and divided into two groups-ablation and resection. When the resection method was used, the immediate success rate was 99.76%, whereas the ablation method achieved dry hands in 95.2% of cases (p = 0.00001). Palmar sweating recurred in 0% of patients treated via resection and -4.4% treated with ablation. Ptosis was noted in 0.92% of cases after ablation and in 1.72% after resection (p = 0.017). CONCLUSIONS: Resection yields superior results, yet the majority of surgeons ablate, probably because it is easier, requires a shorter operating time, leads to fewer cases of Horner's syndrome, and because resympathectomy eventually overcomes initial failure.
We prospectively evaluated all patients with superficial foot necrosis of 1-3 cm and transcutaneous oxygen tension (TcPO2) values of <30 mmHg who received a sympathectomy as the primary treatment of their vascular occlusive disease. Preoperatively, and every 2-3 days in the postoperative period, measurement of TcPO2 of the forefoot was performed. Clinical success was defined as healing of the necrosis or healing of a toe amputation and avoidance of a major below-knee/above-knee amputation for 1 year. Ten patients were available for long-term evaluation. During the first 4-5 days, all patients increased their foot TcPO2 and the mean increase (23 mmHg) was significant (p = 0.04). Clinical improvement was marked by an average increase of 29 mmHg by postoperative day 10. In contrast, patients with clinical failure had only an average increase of 5 mmHg in TcPO2 by the same postoperative interval. Preoperative increase in TcPO2 by at least 20 mmHg in response to dependency predicted a favorable response to sympathectomy. In addition, sustained postoperative increases in tissue oxygen levels by postoperative day 10 also favored wound healing.
OBJECTIVE: Compensatory sweating (CS) is the most common adverse event and the main cause of dissatisfaction among patients undergoing a VATS sympathectomy for the treatment of primary hyperhidrosis. It has been described that obese individuals experience more sweating than thinner ones. The aim of this study is to identify the Body Mass Index (BMI) and the level of resection as predictive factors for CS and its relation to levels of patient satisfaction following the procedure. METHODS: From October 1998 to June 2003, 102 patients undergoing VATS sympathectomies (51 for palmar hyperhidrosis, PH, and 51 for axillary hyperhidrosis, AH) were prospectively surveyed. They were divided into three groups according to their BMI: Group I was composed of 19 patients with BMI<20 (9 patients with PH and 10 with AH); Group II was composed of 52 patients with 20 < or =BMI<25 (25 with PH and 27 with AH); and Group III was composed of 31 patients with BMI > or =25 (17 with PH and 14 with AH). Each procedure was simultaneously and bilaterally performed under general anesthesia using two 5.5 mm trocars and a 30 degrees optic system. RESULTS: Patients treated for PH (resection of T2-T3) had more severe CS than those with AH (resection of T3-T4) (p=0.007) and the greater the BMI, the greater the severity of the CS (p<0.001). No statistically significant difference was found between the BMI bands in relation to the degree of satisfaction (p=0.644), nor when we compared the degree of satisfaction to the degree of CS (p=0.316). CONCLUSIONS: The greater the BMI, the more severe the CS, but this did not correlate with the patients' level of satisfaction. Avoiding the resection of T2 sympathetic ganglia is also important in reducing the intensity of CS.
Lumbar sympathectomy increases total limb blood flow after aortofemoral bypass in a high percentage of cases. This was true in eleven of fourteen extremities (78.6 per cent) in our series even though no specific selection criteria for entry into the study, other than the need for aortofemoral bypass, were used: that is, patients were entered into the study irrespective of preoperative ankle/arm pressure indexes or results of hyperemia testing. Overall, flow rates after sympathectomy was added to aortofemoral bypass were 1.55 times greater than after aortofemoral bypass alone. This degree of augmentation of flow may be important, particularly in cases of limited outflow.
We carried out a retrospective review of 45 patients (50 limbs) with toe gangrene not amenable to direct arterial surgery, and thus managed by lumbar sympathectomy alone. Follow-up data regarding toe salvage, limb salvage, and limb loss were compiled. At 5 and 8 year follow-up cumulative limb salvage was 71 percent and cumulative toe salvage was 51 percent. The presence of diabetes did not significantly influence limb or toe salvage. Mortality during the immediate postoperative period was 2 percent. In the majority of patients with digital gangrene who are not amenable to arterial surgery, lumbar sympathectomy is of benefit for salvaging the limb and the toes.
Ten patients, 8 female and 2 male, with refractory episodic lower extremity vasospasm were encountered during a 15 year period in which over 600 patients with upper extremity vasospasm were studied. Seven patients had associated upper extremity vasospasm. No patient had evidence of autoimmune disease. Lower extremity reserpine Bier block produced symptomatic relief for 1 to 3 days in all patients in whom it was used. Oral medications were ineffectual. A diagnostic toe photoplethysmographic pattern was noted in these patients, consisting of a normally pulsatile tracing after warming and a flat, nonpulsatile or minimally pulsatile tracing after cooling. Each patient underwent lumbar sympathectomy. During follow-up, which averaged 4 years, each patient remained free of episodic vasospasm on the side of surgery. We conclude that lumbar sympathectomy is an effective and durable treatment for lower extremity vasospasm.
An office or bedside procedure to predict benefit from or contraindications to lumbar sympathectomy has been presented. Significant benefit and no instance of paradoxic gangrene occurred in an experience of more than 30 years with the test. This personal series of over 70 patients illustrates significant benefits, including healing of gangrenous digits, successful ray (transmetatarsal) amputation, and relief of ischemic rest pain in selected patients, even in the absence of femoral (groin) pulses. A criterion of an increase of 2 degrees or more in skin temperature of the ipsilateral great toe after lumbar sympathetic block at the approximate levels of the second, third, and fourth lumbar vertebrae has proved to be an adequate parameter or indication of subsequent benefit from surgical lumbar sympathectomy. A favorable response is predictable by the method described.
The effect of sympathectomy on the calcitonin gene-related peptide (CGRP) level in the rat primary trigeminal sensory neurone was investigated. Six weeks after bilateral removal of the superior cervical ganglion there was a 70% rise in the CGRP content of the iris and the pial arteries, a 34% rise in the concentration in the trigeminal ganglion but no change in the brainstem. The CGRP rise in both end organs suggests that this phenomenon may be common to all peripheral organs receiving combined sensory and sympathetic innervations. The lack of any rise in the brainstem CGRP content raises the possibility that this process spares central terminations. In contrast, the level of neuropeptide Y, a peptide mainly contained in sympathetic terminals, fell to 35% of control values in the iris and pial arteries whilst the trigeminal ganglion and brainstem concentrations remained unchanged. The possible relevance of these observations to the clinical syndrome of postsympathectomy pain (sympathalgia) is discussed. There are similarities between the delayed onset of the human pain state and the delayed rise in sensory peptides after sympathectomy.
The effects of vinblastine (VNB) and nerve growth factor (NGF) administrations were assessed on sympathetic nerve terminals by measuring the noradrenaline (NA) content in the heart, spleen and kidneys of developing animals. Six-day-old rats, treated with 0.15 mg/kg VNB on postnatal day 3 (P3) showed a dramatic decrease of NA content in all these organs. This reduction was prevented by daily administrations of NGF on P3, P4 and P5. The effectiveness of NGF in inhibiting the VNB-induced sympathectomy was related to the dose administered and to the time interval between the VNB administration and the first NGF injection given on P3. Dose-response curves to NGF (ranging from 0.01 to 0.5 mg/kg) were obtained in both heart and spleen of VNB-treated animals. Thus, this experimental paradigm provides a quantitative assessment of the NGF activity in vivo. The systemic administration of GM1 (30 mg/kg) on P3, P4 and P5, was able to potentiate the NGF activity in preventing the VNB-induced sympathectomy. This GM1 effect was more evident in the heart and may be, at least in part, attributed to increased NGF prevention of neuronal cell death due to VNB. These results suggest an in vivo interaction between exogenous GM1 and NGF and are consistent with the view that neuronal cell repair related to in vivo administration of this ganglioside may rely on its capability to modulate the activity of endogenously occurring neuronotrophic factors.
Chronic administration of guanethidine sulfate in the rat induces a selective adrenergic neuropathy. We studied the effects of guanethidine-induced adrenergic sympathectomy on rat sciatic nerve blood flow (NBF), microvascular resistance (MR), vessel caliber and norepinephrine (NE) content. A control group of animals was studied following chronic administration of mammalian Ringer's solution. NBF and MR were measured with an endoneurial microelectrode, using the technique of hydrogen clearance (HC). Following HC, the sciatic nerve was perfused with India Ink, removed, frozen and sectioned. Measurements were made of endoneurial microvessel numbers, diameter, circumference and area. The contralateral sciatic nerve was removed for measurements of NE content. In guanethidine-treated animals we observed elevated NBF, reduced MR and dilated microvessels. Numbers of microvessels and fascicular areas were similar to controls. NE content was markedly reduced following sympathectomy. These studies suggest that NBF, unlike cerebral blood flow (CBF), is regulated by its adrenergic input. Removal of adrenergic innervation of the vasa nervorum appears to result in a loss of tonic vasoconstrictive action.
The effect of total sympathectomy and of decentralization on interdigestive myoelectric activity of the stomach and small intestine and on cycling levels of plasma motilin were studied in conscious dogs. In controls, 98.3% +/- 7.9% of the migrating myoelectric complexes (mean +/- SD) originated in the stomach. In sympathectomized dogs, 38.17% +/- 16.7% originated in the stomach, 35.8% +/- 12.3% in the duodenum, and 26.3% +/- 4.3% in the jejunum. In decentralized dogs, 5.3% +/- 1.4% of the migrating myoelectric complexes originated in the stomach, 71.0% +/- 16.5% in the duodenum, and 23.9% +/- 17.4% in the jejunum. Cycling of plasma motilin was not affected by long-term sympathectomy but coordination of peak levels of plasma motilin and initiation of gastric migrating myoelectric complexes was disrupted in decentralized dogs. These data suggest that central nervous input is required for initiation of migrating myoelectric complexes in the stomach and that central vagal but not central sympathectic input is essential for cycling of plasma motilin.
Eighteen children (15 females, 3 males) aged 7 to 15 years underwent resection of the thoracic sympathetic chain for severe palmar hyperhidrosis. A localized section of chain immediately below the first thoracic ganglion and including the second thoracic sympathetic ganglion was removed. Patients were followed for 24 to 136 months. All patients had immediate and permanent abolition of palmar hyperhidrosis. There was no mortality, one patient developed intermittent ptosis and myosis, three patients reported compensatory hyperhidrosis and one girl was unhappy with the cosmetic results. We conclude that thoracic sympathectomy is a safe and permanent treatment for severe palmar hyperhidrosis in children. In addition, limited sympathetic resection is associated with a lower incidence of compensatory hyperhidrosis than conventional more radical sympathectomy.