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Chemical sympathectomy is an alternative to surgical sympathectomy when the patient's age or general condition precludes surgery. The indications and rationale in lower-limb arterial disease are discussed, and it is suggested that X-ray control is a valuable adjunct to the procedure.
A study has been made of the effects of chemical sympathectomy and ganglion blockade on the responses of rat jejunum in vivo to intravenous doses of angiotension and noradrenaline capable of stimulating fluid transport. Pretreatment with 6-hydroxydopamine (chemical sympathectomy) or pentolinium tartrate (ganglion blockade) abolished the stimulatory actions of angiotensin II but left the responses to noradrenaline unimpaired. Dopamine, like noradrenaline, stimulated fluid transport but this response required very high dopamine infusion rates, was refractory to the dopamine antagonist sulpiride and was inhibited by the alpha- blocker phentolamine. The possible interaction between angiotensin and the intestinal sympathetics is discussed with reference to control in extracellular fluid volume.
Percutaneous phenol sympathectomy has been performed under fluoroscopic or CT guidance in 37 patients with extremely advanced vascular disease of the lower extremities. The technique is simple and well tolerated by the patient with a remarkably low incidence of complications. Of the 37 patients, 14 (38%) showed objective improvement and none of the patients experienced worsening of their ischemia. Results to date suggest that this procedure provides a sympathetic blockade as effectively as surgical sympathectomy in these patients with advanced disease.
The purpose of this study was to examine the electrophysiologic responses to sound from guinea pig cochleas, 3--6 days after a unilateral cervical sympathectomy. After recovery from surgery the guinea pigs developed a Horner's syndrome on the sympathectomized side. Some days later their bullas were opened and electrodes were placed bilaterally on the round windows. Most of the sympathectomized cochleas showed signs of decreased sensitivity to sound. They had a smaller dynamic range for the click- and tone-burst evoked compound action potential (CAP) compared with the non-sympathectomized cochleas. The threshold sound levels for the CAPs and the sound levels to produce 1 muV of cochlear microphonic potentials were unaffected. In other animals with chronic implanted electrodes, the same electrical responses were measured with only light sedation before and after sympathectomy and showed the same results. In additional animals the crossed olivocochlear bundle (COCB) was electrically stimulated and a similar inhibition of the CAP was registered on both the intact and the sympathectomized side. The results suggest that the sympathetic nerves to the cochlea, coming from the ipsilateral cervical ganglion and ending near the habenula perforata, may be important for the sound perception as they influence the CAP.
Cutaneous blood flow in the foot was assessed by 125I iodoantipyrine clearance in patients with peripheral vascular disease. Three groups were studied: group (a) consisted of 10 controls, Group (b) of 10 patients who had arterial reconstruction, and Group (c) of 10 patients having lumbar sympathectomy. Skin blood flow remained constant in the control patients. In Group (b) arterial reconstruction increased skin blood flow from mean 4.3 ml/100g/min to a mean of 14.9 ml/100g/min (p less than 0.001). In group (c) skin blood flow did not significantly change from a mean preoperative value of 7.6 ml/100g/min to a mean postoperative value of 8.1 (ml/100g/min). These results suggest that lumbar sympathectomy does not affect nutritional blood flow.
The aim of the present study was to examine the effect of beta-adrenoceptor stimulation, alpha blockade, and elimination of the adrenergic nerve function on mucosal blood flow and acid secretion in parietal-cell-vagotomized (PCV) gastric fistula dogs. Isoprenaline inhibited pentagastrin-stimulated gastric acid secretion via the beta 1 receptors non-competitively. The effect of isoprenaline was more pronounced after vagotomy than before vagotomy and significantly more pronounced than the effect on parasympathomimetically stimulated (bethanechol) gastric acid secretion. The animals were subjected to chemical sympathectomy with 6-hydroxy-dopamine, a false neurotransmitter that selectively destroys the adrenergic nerve terminals. Chemical sympathectomy increased the pentagastrin-stimulated gastric acid secretion and stabilized the mucosal blood flow at the level before vagotomy, but with an increased ratio between blood flow and acid secretion. One may conclude that the sympathetic nerve system influences gastric function after vagotomy.
In the dog, alpha 1 adrenoceptors have been identified in the aorta, femoral mesenteric, and renal arteries. The concentration of alpha receptors may be regulated by hormones such as estrogen and progesterone and by drugs such as epinephrine. To assess whether sympathetic denervation, which is known to decrease norepinephrine output, might change the population of alpha 1 receptors in vascular smooth muscle, the femoral artery alpha 1 receptor population was examined 2 weeks after unilateral lumbar sympathectomy. [3H]Prazosin radioligand receptor assay analysis was used to measure the alpha 1 receptor populations. No statistical difference for dissociation constant and receptor density values between sympathectomy and nonsympathectomy femoral artery samples could be detected.
The effect of endoscopic thoracic sympathectomy on experimentally histamine-induced itch was studied in seven patients, all of whom were suffering from palmar hyperhidrosis; cutaneous warm, cold, and heat pain perception thresholds were also studied in five of these seven patients. Surgery was effective in abolishing palmar sweating in all patients. No significant differences were seen in itch, flare, wheal, or thermal perception thresholds following sympathectomy as compared to the preoperative period. These findings suggest that the sympathetic system may be of limited importance for somatosensory perception in healthy humans during normal conditions.
The development of hypertension was studied in rats after neonatal sympathectomy by s.c. injection of 6-hydroxydopamine HCl. Three different types of hypertension were investigated: renal hypertension in the two-kidney Goldblatt model, steroid hypertension produced by deoxycorticosterone (DOCA) implantation and saline as drinking fluid, and genetic hypertension in the spontaneous hypertensive rat (SHR). Blood pressure was measured directly in conscious animals via the iliac artery. Mean blood pressure of conscious sympathectomized (SX) normotensive rats was not significantly different from that of normotensive controls. Renal hypertension reached the same level in controls and SX rats four weeks after application of a renal artery clip. DOCA-salt hypertension developed faster and to a higher level in SX rats than in control rats. The hypertension in SX DOCA-salt hypertensive rats was accompanied by a marked tachycardia. In contrast hypertension did not develop in SX SHR. Up to 12 months of age mean blood pressure was markedly lower than that of control SHR, but slightly higher than that of SX normotensive Wistar Kyoto rats. These differential effects of neonatal sympathectomy on the development of hypertension in the rat may point to differences in the pathophysiological mechanisms. It is concluded that an intact sympathetic nervous system is essential for the development of hypertension in SHR. In DOCA-salt hypertension the intact sympathetic nervous system appears to protect against a rapid rise in blood pressure.
During the years 1967-1976, bilateral lumbar sympathectomy was performed in 241 patients with arteriosclerotic occlusions. A questionnaire was completed by 137 patients. Of the total, 68% seem to have improved in some way postoperatively. The material was analyzed with regard to age, sex, diabetes and regarding the effects on pregangrene, established gangrene, amputation, claudication and skin temperature. The operative mortality was 2.1% and postoperative complications were few. Bilateral operation in one stage does not give a higher postoperative mortality than unilateral procedures. Postoperative side-effects, such as neuritic pains, sexual and urological dysfunctions, are considered. Bilateral lumbar sympathectomy still seems to be an alternative procedure, which may be offered some patients with marginal peripheral circulation, when reconstructive arterial surgery is not feasible.
Palmar hyperhidrosis has been treated using a variety of medical and surgical techniques with varying degrees of success. The authors report their experience in 82 patients in whom they performed 164 sympathectomies using a video endoscope, a laparoscopic grasper, and microscissors. Patients were monitored by palm temperature electrodes. An intraoperative histological confirmation of the sympathetic chain and a temperature rise of at least 1 degree C after the procedure resulted in complete relief of the hyperhidrosis. All the patients were relieved of their symptoms, and 41 experienced decreased plantar hyperhidrosis as well. Compensatory hyperhidrosis in 50 patients was the only significant side effect, which improved 6 months after the surgery. Video endoscopic thoracic sympathectomy is a safe, easy, reliable, and cost-effective way to treat palmar hyperhidrosis.
OBJECT: The purpose of this study was to analyze the change in cardiac sympathetic function by performing a 123I-metaiodobenzylguanidine (MIBG) imaging study after endoscopic upper thoracic sympathectomy (EUTS) in patients with palmar hyperhidrosis before and after surgery. METHODS: Between February 1999 and February 2002, 135 patients underwent bilateral EUTS to treat palmar hyperhidrosis. Between September 2001 and February 2002, 12 of these consecutively enrolled patients were also included in a 123I-MIBG imaging study. These patients underwent cardiac 123I-MIBG imaging 1 day before and 7 days after they had undergone EUTS. The heart/mediastinum (H/M) ratio and the washout rate were calculated for both early and late phases, and single-photon emission computerized tomography (SPECT) imaging of the early phase was performed. Excessive perspiration from the palms disappeared immediately after EUTS in all patients, and they showed no symptoms of a circulatory condition following the procedure. On the 123I-MIBG imaging studies, the early H/M ratio before EUTS was 2.35 +/- 0.26 and postoperatively it was 2.29 +/- 0.23. The delayed H/M ratio before EUTS was 2.59 +/- 0.3 and after the procedure it was 2.66 +/- 0.27. There was no significant difference between the H/M ratio before and after EUTS. The washout rate after EUTS (14.27 +/- 4.71%) was significantly lower than that measured before EUTS (18.36 +/- 5.13%: p < 0.01). No apparent local defects of accumulation of MIBG were found on SPECT images obtained post-EUTS. CONCLUSIONS: Endoscopic upper thoracic sympathectomy is a minimally invasive procedure; no local denervation was found after EUTS. Findings on 123I-MIBG imaging studies indicate that EUTS suppresses the activation of the sympathetic nervous system slightly, similar to beta-blocker therapy.
We have previously reported that the feeding of a beef tallow diet gives lower lipoprotein lipase activities in the interscapuler brown adipose tissue, heart and soleus muscle compared with feeding of a safflower oil diet. We have also suggested that sympathetic activities (norepinephrine turnover rates and beta-adrenergic receptor bindings) in these peripheral tissues were lower in the beef tallow diet group. To confirm the effects of dietary fats on the lipoprotein lipase activities in these tissues related to sympathetic activities, rats were chemically sympathectomized by treatment with 6-hydroxydopamine. The sympathectomized rats and control rats were meal-fed with a beef tallow diet or a safflower oil diet for 8 weeks. Sympathectomy abolished the differences in lipoprotein lipase activities in the interscapuler brown adipose tissue, heart and soleus muscle between two dietary groups. The percentage of body fat was increased by sympathectomy, resulting in no difference between the beef tallow diet group and the safflower oil diet group. These results suggest that intake of the beef tallow diet decreased lipoprotein lipase activities by reducing the sympathetic activities.
In an active duty population charged with handling weapons and heavy equipment, hyperhidrosis is a dangerous affliction. Surgical correction of hyperhidrosis is possible by transection of the thoracic sympathetic chain. Thoracoscopic sympathectomy should yield results similar to those of a standard open thoracotomy approach but with decreased recovery times, a more rapid return to duty, and improved job performance. Three active duty patients presented to the Naval Medical Center, San Diego, for evaluation of palmar hyperhidrosis. All patients underwent bilateral thoracoscopic sympathectomy for the treatment of palmar hyperhidrosis. They tolerated the procedure well without complications and were satisfied with their outcomes. They reported no further episodes of hyperhidrosis and have returned to full duty. This procedure is especially relevant for patients in the active duty population, whose job safety is affected by hyperhidrosis. Those treated can expect to return to full duty in a timely manner.
The authors report a case of reflex sympathetic dystrophy of the lower right extremity in a 51-year-old white man. The disorder developed 3 months after an ankle fracture, and bilateral lumbar surgical sympathectomies were necessary for successful treatment. Unique to this case is the patient's history of having undergone the same treatment 10 years earlier for the same disorder, which developed after a myocardial infarction and cardiac catheterization of the right femoral artery. Incomplete sympathectomy or regeneration of sympathetic ganglions after the first surgery may explain why the second surgery was necessary in this patient.
A questionnaire survey was performed in order to investigate the current status of endoscopic thoracic sympathectomy in Japan. Four hundred and twenty-nine (429) university, national or public hospitals with a minimum of 400 beds were included. A total of 248 of these hospitals responded. Among them 63 (25%) performed this procedure. The total of the cases was 1116. The number of access port and the technique for defunctioning the sympathetic chain were broadly divided into three methods. These methods were equally carried out among the departments. The clinical results were judged as satisfactory in the great majority of patients and the frequency of complications was low. On the other hand, the overall incidence of compensatory sweating remained relatively high and accumulated as the number of cases increased. But the reported frequency differed strikingly from hospital probably for lack of an objective way of quantifying following sympathectomy. Although overall complications were infrequent, the need for conventional thoracotomy to stop bleeding occurred in some cases. Therefore even this simple endoscopic operation demands the utmost surgical care, skill and experience. A few recurrences of preoperative symptoms were seen in the follow-up suggesting that all patients must be continually monitored after the operation.
BACKGROUND: Lumbar sympathectomy (LS) is often the only alternative treatment that can be considered as a means of improving the distal circulation to such extent that major amputation is prevented. To make a retrospective study in order to know the current value of LS as isolated technique for the treatment of severe ischemia of lower limbs in the absence of the possibility for vascular reconstruction. METHODS: Between 1987 and 1992, 100 LS were performed in 93 patients (82 males and 11 females) aged 64.5+/-11.1 yrs. 63% were older than 70 years. Indication was invalidant claudication/rest pain (grade II, 57%) or trophic lesion (grade III, 43%) in patients where previous reconstructive surgery failed (18%), was not possible to do (23%) or refused revascularization (20%), or with poor surgical risk (39%). Preoperative evaluation included Doppler measures, ankle/brachial index (ABI) and arteriography in every case. Surgical sympathectomy was performed in all patients. Success was considered if rest pain was absent or trophic lesions have healed at six months, comparing results in patients diabetics and non-diabetics with ABI higher or lower 0.3. RESULTS: Postoperative stage was 6.4+/-2.3 days. Morbidity was 4% and mortality was 7% in the 30-day postoperative period, related with patients older than 70 years. Long-term mortality was 9%, for a global nortality of 16%. 12 patients needed inflow surgery after LS. There was success in 58.5% of grade II and 61.7% of grade III patients at six months, with significative difference (p=0.049) if ABI was >0.3. In diabetics with ABI >0.3, trophic lesions have worse prognostic than ABI <0.3. Pre- and postoperative ABI were correlated (R2=0.65), and the increasing of 0.1 in preoperative ABI had a positive prognostic value over lesion healing. Patency of superficial femoral artery (SFA) has correlated significantly (p=0.000021) with successful outcome after LS. CONCLUSIONS: LS could be a technique that moderately improves the ischemic limb in patients who refuse major surgery or where arterial reconstruction is not indicated. Preoperative ABI has prognostic value in postoperative outcome, with clinical improvement if it is >0.3. Diabetes has not been a negative predictive factor in our series. Patency of superficial femoral artery is related to successful outcome of the patients.
Our recent morphologic studies indicated that peripheral nervous system (PNS) adrenergic neurons synthesize, transport, and store the serene protease, tissue plasminogen activator (t-PA) in axon terminals, many of which innervate vessel walls. Sympathoadrenal stimulation induces a surge of t-PA from vessel walls into the blood. The vascular endothelium, which constitutively secretes t-PA into blood also has long been widely assumed to be the principal source of this stress-induced release, but has not been verified as such. A neurologically regulated release from adrenergic stores could thus augment the known constitutive endothelial release. To functionally test this possibility, we quantitated the effects of guanethidine-induced systemic sympathectomy on the basal and stimulated release of t-PA from isolated vessel explants in superfused organ cultures. Moment-to-moment changes in the release rate were plotted from serial assays of the t-PA free activity. The effects of endothelial and adventitial nerve plexus ablations were also tested. Sympathectomy induced 30-50% reductions in t-PA release from both arterial and microvascular explants. An acute release induced by alpha-1 adrenergic receptor stimulations was also strongly suppressed, as were basal levels of the circulating enzyme in vivo. Adventitial and endothelial ablations from normal large vessel explants produced greater reductions than small vessel endothelial ablations. Ganglion electrical stimulation also induced an acute microvascular release in vivo. These and past morphologic findings indicate a physiological infusion of t-PA into the vessel walls, blood, and other innervated matrices by sympathetic neurons.