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Idiopathic (primary) hyperhidrosis is a common and distressing condition. Excessive axillary sweating responds to local excision of the eccrine glands. In severe cases, sympathectomy may be indicated to deal with hyperhidrosis of the hands and feet. The surgical anatomy of transthoracic sympathectomy is described.
Oxygen partial pressure was measured in the endolymph area of the cat cochlea under conditions of hemorrhagic hypotension. The experiments took place after unilateral upper cervical sympathectomy and under control conditions. The pO2-measurements were carried out with the aid of polarographic micro-coaxial needle electrodes according to Baumgärtl and Lübbers (1, 2, 3). In animals which had not been sympathectomized, the cochlear pO2 decreased continuously parallely to blood pressure, with the beginning of bleeding. After sympathectomy pO2-decrease in cochlea only occurred at substantially lower aortal blood pressure. This allows the following conclusions: 1. Under conditions of hemorrhagic shock the blood flow of the inner ear is not as much included in central circulation as brain and heart. 2. The blood pressure dependence of the inner ear blood flow depends on the sympathetic innervation, it can practically be abolished up to a blood pressure of 65 mm Hg by denervation. 3. It is being discussed, which therapeutic consequences can be drawn from the evident influence of the sympathetic innervation on the inner ear blood flow.
A case of acute mesenteric ischemia and massive intestinal infarction secondary to bilateral lumbar sympathectomy and without any other apparent precipitating factors is presented. Its characteristics and findings significantly agree with those described as part of the mesenteric arterial steal syndrome. Although this syndrome was originally described as secondary to surgical revascularization of the lower extremities, experimental studies have shown that lumbar sympathectomy, by means of reducing the peripheral vascular resistance in the lower extremities, similarly causes intense hemodynamic alteration of the mesenteric circulation due to the sudeen redistribution of blood flow to the lower limbs at the expense of the mesenteric flow. When marginally compensated occlusive mesenteric arterial disease exists prior to surgery, the sudden fall in the arterial pressure gradients in this vessel can precipitate the occlusion of these arteries, resulting in mesenteric ischemia and intestinal infarction. It has also been suggested that an intense vasospamodic neurogenic reflex in the mesenteric arteries is an important factor in the pathogenesis of this syndrome.
Administration of 6-hydroxydopamine (6-OHDA) causes selective acute degeneration of the adrenergic nerve terminals--that is, a reversible chemical sympathectomy. The effect of this drug was studied on the insulin-stimulated gastric secretion. Insulin-stimulated (0.15-0.4 IU/kg) gastric acid and pepsin output and serum gastrin were measured before and after 6-OHDA treatment (40 mg/kg) in gastric fistula dogs. Chemical sympathectomy resulted in a highly significant increase in acid and pepsin secretion. However, the hypoglycemic gastrin release was unaltered except the peak response, which showed a significant reduction. These data confirm earlier observations that the sympathetic innervation of the stomach has an inhibitory effect on gastric secretion in the dog. Furthermore it seems that the adrenergic fibers in the vagus nerve might have some modulating effect on the insulin-induced gastrin release.
Administration of 6 hydroxydopamine (6 OHDA) causes selective acute degeneration of the adrenergic nerve terminals, that is a reversible chemical sympathectomy. The effect of this drug was studied on the insulin stimulated gastric secretion. Insulin stimulated (0.15-0.4 IU/kg) gastric acid and pepsin output and serum gastrin was measured before and after 6 OHDA treatment (40 mg/kg) in gastric fistula dogs. Chemical sympathectomy resulted in a highly significant increase in acid and pepsin secretion. However, the hypoglycemic gastrin release was unaltered except the peak response, which showed a significant reduction. These data confirm earlier observations, that the sympathetic innervation of the stomach has an inhibitory effect on gastric secretion in the dog. Furthermore it seems that the adrenergic fibres in the vagus nerve might have some moduling effect on the insulin induced gastrin release.
This study describes the ultrastructural changes in the sinuatrial and atrioventricular nodes of the heart of the monkey (Macaca fascicularis) after right cervical sympathectomy. Obvious changes in the nodal cells were seen one day after operation. Numerous glycogen particles grouped together to form electron-dense patches containing vacuoles in the cytoplasm. At three days after operation, intracellular organelles exhibited fragmentation and dissolution. By five and seven days after operation, the affected cells were vacuolated and some were swollen and appeared to have degenerated. Simultaneously, there was massive infiltration of macrophages were present nodal tissues. Axon profiles and terminals showing various degrees of degeneration were present in the vicinity of the nodal cells throughout the period of study. It is concluded that right cervical sympathectomy resulted in a rapid degeneration in some of the cells in the sinuatrial and atrioventricular nodes.
The author describes a new technique for performing unilateral or bilateral upper thoracic sympathectomy safely, effectively, and more easily than by any of the surgical methods now in use. The technique described is one of percutaneous radiofrequency sympathectomy, which is usually done on a day surgery or outpatient surgery basis. The technique has been effective and well tolerated in a small group of patients.
The effect of sympathectomy on the functional state of skin arteriovenous anastomoses (AVA) and on the development of trophic ulceration after sciatic nerve transection was studied in rabbits. The functional state of the AVA (their opening or occlusion) was determined on the basis of gasometric and radiological investigations. The experiments showed that sympathectomy leads to an occlusion of AVA or at least to a marked reduction in blood flow through that part of microcirculation. The improvement in nutritional flow due to the increase in capillary flow and reduction in AVA flow hampers to a certain degree the development of the ulceration and results in transient healing. A hypothesis is presented about different innervation pathways of AVA and precapillary sphincters.
Structurally based resistance and vascular reactivity of the posterior body to noradrenaline were studied in normotensive rats and rats with DOCA-salt hypertension. The hypertension was induced in rats with intact sympathetic nervous system and in rats subjected to neonatal sympathectomy with guanethidine. During the prehypertensive stage, vascular sensitivity of the smooth muscles to noradrenaline was enhanced, with structural lesions being observed only in steady hypertension. Elevation of arterial pressure was accompanied by an increased vascular response to the stimulation of the sympathetic nerves. Sympathectomy prevented arterial pressure elevation and structural alterations in the vessels.
It was demonstrated that dopamine administered into the lateral ventricle of rats with chemically induced sympathectomy of the central nervous system had an evident diuretic effect observed 4 as well as 24 hours after its injection. Noradrenaline, on the other hand, increased diuresis in control rats and in those with chemical serotoninectomy, but only in the first 4 hours of the experiment. Chemical sympathectomy of the central nervous system abolished the diuretic effect of noradrenaline. The results of the experiment confirm the role of mainly dopaminergic receptors in the central regulation of diuresis in this experimental model.
Peripheral blood circulation was studied in 72 patients (85 extremities) with obliterative arteriosclerosis of lower extremities within 7 days following lumbar sympathectomy with the help of occlusive plethysmography. The outcomes of lumbar sympathectomy were shown to be independent of the level of lesions of lower extremity arteries, changes in plethysmography indices depending on their initial level and stage of the disease.
The present experimental work was undertaken to determine some quantitative changes occurring after cervical sympathectomy applied for the treatment of Raynaud's diseases. The blood flow in the brachial artery was measured before and after sympathectomy as well as the temperature, haemoglobin concentration and oxyhaemoglobin saturation in arterial and venous blood, pH and PCO2 of the arterial blood.
The reaction to body and finger cooling was recorded in seven patients with relapse of primary Raynaud's phenomenon after sufficiently performed bilateral upper thoracic sympathectomy and for comparison in eight young women with primary Raynaud's phenomenon as well as in seven normal women. The forearm venous concentration of noradrenaline was lower and adrenaline concentration higher in the sympathectomized patients than in the other groups (p less than 0,05). Noradrenaline showed a significant increase during body cooling in normals and primary Raynaud's (p less than 0,05). There was no significant correlation between the vasoconstrictor response to cooling of a finger and the noradrenaline concentration probably due to the fact that skin vasoconstriction impeded release of noradrenaline from the skin. The relapse of Raynaud's phenomenon after surgically sufficient sympathectomy could not be treated by reserpine or alfa-adrenergic receptor blockers in two patients in whom this was tried.
Reference is made to personal experience (421 lumbar sympathectomies in 1640 vascular operations carried out over the last ten years) and the results of an enquiry addressed to more than 200 Italian surgeons are cited for the proposition that the indications for this operation are still the subject of disagreement, while its results occasionally appear to be contradictory. It is felt that the procedure is best reserved for cases in the second initial or intermediate stage, and should only be employed in advanced 2nd-stage, and 3rd and 4th stage patients whose poor general condition is a contraindication to reconstruction (indication of necessity). Other parameters to be taken into consideration include: age, site and type of the obliterating disease, ineffectiveness of drug management, and concomitant diseases (if any). Sympathectomy plus reconstructive surgery should only be used in cases where the run-off seems unsatisfactory.
Results of dorsal sympathectomy in patients (67 operations) for vasomotor disorders of the upper limbs were assessed after follow-up for between 6 months and 15 years, in order to determine the best indications for surgery. Based on clinical results, sympathectomy should be performed not only when medical treatment fails, but also in the presence of a severe clinical picture of trophic disturbances or pain of the ischemic type. Two types of investigation are essential before deciding on operative therapy:--plethysmography with a hyperemia test,--arteriography of the hand. Assessment of results as a function of etiology demonstrated that they were excellent in cases of hyperhidrosis, very satisfactory in atheromatous digital arteritis or a thoracic inlet syndrome (associated with rib resection in the latter case), but only moderately good in scleroderma or post-traumatic lesions. Finally, Raynaud's disease or thromboangiitis do not appear to be indications for this operative procedure.
The results of 93 consecutive lumbar sympathectomies performed over a five year period upon 54 patients with diabetes and 39 without diabetes were compared in terms of subsequent amputation using life table analysis methods. Cumulative success rates for avoiding amputation were significantly lower in those with diabetes as compared with rates for those without diabetes at five years and at most shorter six month intervals. Although there are a number of possible explanations for this difference, an important contributing factor may be the prior spontaneous denervation of diabetic blood vessels. The results demonstrate that better predictive indexes for lumbar sympathectomy are needed.
Experience with 22 consecutive thoracic sympathectomies is presented. Diagnoses included minor causalgia (12), mixed vasospastic and occlusive disease (4), Raynaud's disease (4), and frostbite with ulceration (2). The operation was a transaxillary resection of ganglia T2, T3, and T4. Both objective and subjective results indicate that this type of sympathectomy is as good as more extensive resections without the risk of a Horner's syndrome. Morbidity was minor but frequent and included dysesthesia, pneumothorax, and compensatory sweating. The success rate of 77%.
Doppler ultrasonic examination has been used as an indirect means of per-operative checking of sweat secretion after non surgical upper dorsal sympathectomy performed by percutaneous injection of hot saline into the upper dorsal sympathetic ganglions for the treatment of palmar hyperhydrosis. Their experience with pre, per and post-operative utilisation of Doppler effect in sixty cases has evidenced a full parallelism between the arterial vasodilation and the decrease in sweat secretion following the destruction of the sympathetic ganglions by hot saline. In the last series of thirty-five cases per-operative use of Doppler ultrasonic examination has spared them failures of the procedure. They consider Doppler ultrasonic examination as a precious help in classical open sympathectomy as well in their non surgical method.