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The authors present the use of ROMICRO set (originally developed for mini laparotomy) for thoracic and lumbar sympathectomy. They review 3 thoracic and 2 lumbar sympathectomy operations that had good effects and uneventful recoveries. The advantage of the method is that no special instruments are needed and it can be done as a conventional operation.
Primary palmar hyperhidrosis is a functionally and socially disabling condition. Upper thoracic sympathectomy is the best curative treatment. Several surgical approaches have been suggested and, recently, less invasive techniques have been communicated. To evaluate which method is the best, the short- and particularly the long-term results must be compared. A series is presented of 170 upper thoracic sympathectomies by the supraclavicular approach performed on 85 patients with palmar hyperhidrosis. Follow-up for a mean of 8.3 years was obtained on 124 operated limbs. The immediate failure rate for relief from hyperhidrosis was 2.4 per cent and hyperhidrosis recurred in another 4.1 per cent of limbs after a period of between 2 and 18 months. Thirteen per cent of patients were dissatisfied with the results of operation, one because of persisting vasomotor rhinitis, two because of Horner's syndrome and five because of persisting or recurrent hyperhidrosis. Satisfactory results in approximately 87 per cent of cases make the operation rewarding. This outcome should be compared with the long-term results of other methods, such as percutaneous phenol injection and the transthoracoscopic approach, when such data are compiled and published.
A 5-year experience of 51 endoscopic transthoracic dorsal sympathectomies for idiopathic palmar hyperhidrosis in 26 patients is presented. Fifty-two percent complained of excessive sweating over their hands, 28% of axillary sweating and 20% over both areas, with a mean duration of 10 years. The second, third and fourth thoracic ganglia and their interconnecting fibres on the affected side were ablated using diathermy cautery. Over a mean follow up time of 26 months, this procedure was successful in curing or improving intractable sweating in 92%. However, axillary sweating was less well controlled than in the palms with 20% of patients describing residual wetness in the axilla. Compensatory sweating (75%) and gustatory sweating (48%) were the commonest side effects; despite this, most patients were satisfied with the functional and cosmetic outcome. Other complications included a temporary Horner's syndrome in one patient, a pneumothorax in the immediate post-operative period in another and a unilateral non-infective reactionary pleural effusion in a third. Two patients developed recurrence of palmar hyperhidrosis within 6 months of surgery. One has been successfully treated by re-operation on the affected side. All patients complained of mild to moderate interscapular chest pain which was easily controlled by non-steroidal anti-inflammatory agents, and resolved within 7-10 days post-operatively. The technique of endoscope transthoracic sympathectomy is effective, relatively simple to perform and usually requires only an overnight stay. It is recommended as the surgical treatment of choice for upper limb hyperhidrosis unresponsive to conservative measures.
Parasympathectomy is followed by a greatly increased occurrence of microliths in the feline submandibular gland, which appears to be because of secretory inactivity. The sympathetic nerves are also important in secretory processes, and so feline submandibular, sublingual and parotid glands subjected to postganglionic sympathectomy for periods from 1 day to 1 yr have now been investigated. Microliths were detected in two out of 28 sympathectomized submandibular glands and four out of 27 untreated glands, and in 10 out of 22 sympathectomized sublingual glands and seven out of 19 untreated glands. There were no significant differences between the occurrence of microliths in sympathectomized and untreated glands. Microliths were not detected in any of 29 sympathectomized and 30 untreated parotid glands. The appearance of the sympathectomized glands was similar to that of the untreated glands. The failure of sympathectomy to affect the occurrence of microliths or the appearance of the glands is possibly because of parasympathetic nerve impulses, which produce continuing secretory activity, and also the spontaneous secretion of the sublingual gland. The results support the concept that secretory inactivity is an aetiological factor of microlithiasis.
The occurrence of unmyelinated axons was examined ultrastructurally in rat molar and incisor root pulps of normal rats, of neonatally capsaicin-treated rats, of rats subjected to neonatal capsaicin treatment followed by resection of the superior cervical ganglion and of sympathectomized but otherwise normal rats. Following capsaicin treatment the occurrence of unmyelinated pulpal axons was slightly subnormal. Sympathectomy was largely without effect on the population of unmyelinated axons in tooth pulps of capsaicin-treated rats. In normal rats the proportion of unmyelinated axons in molar pulps was not altered by sympathectomy but it caused a slight decrease in the number of unmyelinated incisor pulpal axons. These findings support the view that most of the unmyelinated axons in rat molar and incisor pulps are sensory, that the parent neurons of these axons differ from nociceptive neurons at other sites by being largely resistant to neonatal capsaicin treatment and that very few unmyelinated tooth pulp axons represent postganglionic efferents.
Neonates of male stroke-prone spontaneously hypertensive rats (SHRSP) were treated with 6-hydroxydopamine (6-OHDA) on two different schedules. Peripheral sympathectomy, which was evaluated by the pressor response to exogenous noradrenaline (NA) or by the decrease in NA content of the spleen, was more evident in the NB-8 group (treated on 8th and 15th day after birth) than in the NB-1 group (treated at 6, 24 and 72 h after birth). The reduction of the NA content in the cerebral cortex was more prominent in the NB-1 group than in the NB-8 group. The blood pressure from 7 to 23 weeks of age was lower in the treated groups: NB-8 less than NB-1 less than control. Therefore, the reduction of blood pressure in the treated groups could be related to the severity of peripheral sympathectomy. The incidence of sroke was also lower in the treated groups: 38, 11 and 0% in the control NB-1 and NB-8 groups, respectively. Loading with 1% NaCl solution from 11 weeks of age enhanced the rise in blood pressure and increased the incidence of stroke in each group of rats: 100, 20 and 40% in the control. NB-1 and NB-8 groups, respectively. However, the onset of stroke after exhibiting a severe hypertension (greater than 200 mmHg) was delayed in the treated groups. It seems that the activated tone in the peripheral sympathetic nerve is likely to participate in the development of spontaneous hypertension. In addition to the high blood pressure level, the activated tone of sympathetic nerve innervating the cerebral vasculature may be partly involved in the development of stroke in the new strain of the SHR rats, SHRSP.
Bradykinin is an endogenous peptide that is thought to be a chemical mediator of the hyperalgesia following inflammation. In rat, bradykinin has been postulated to cause hyperalgesia to mechanical stimuli by releasing prostaglandin from sympathetic post-ganglionic terminals. The aim of this study was to determine whether bradykinin-induced cutaneous hyperalgesia in humans requires post-ganglionic sympathetic terminals. In humans, intradermal injection of bradykinin produces dramatic hyperalgesia to heat but not mechanical stimuli. Therefore, we measured the magnitude and duration of pain and hyperalgesia to heat stimuli following intradermal injection of bradykinin into the leg of a woman before and 6 months after an ipsilateral, surgical, lumbar sympathectomy. The pain and hyperalgesia to heat following bradykinin was found to be unaffected by the sympathectomy. These results suggest that the algesic effects of cutaneous bradykinin in human are independent of the sympathetic nervous system.
Age-related macular degeneration is the leading cause of blindness in people over the age of 55. In addition to an increased risk of vision loss due to macular degeneration, aging results in a substantial loss of sympathetic nerve activity. We have previously shown that loss of sympathetic nerve activity to the eye causes significant remodeling of the choroidal vasculature. The hypothesis of the present study was that the choroidal remodeling noted after sympathectomy was due to alterations in key angiogenic growth factors. To test this hypothesis, female Sprague-Dawley rats underwent superior cervical ganglionectomy, which eliminates all sympathetic innervation to the eye. Six weeks after surgery, eyes were removed, and the choroidal tissue was processed for real-time PCR to measure gene expression and western blot analysis to assess protein expression. Gene and protein expression were significantly increased for vascular endothelial growth factor (VEGF) and pigment epithelial-derived growth factor (PEDF) in the sympathectomized eye, as compared to the contralateral eye (P < 0.05). Protein expression was increased 4-fold for angiopoietin1, with no change in steady-state gene expression. For both p53 and placental growth factor, steady-state mRNA levels were significantly decreased, while protein expression was significantly increased. Protein expression for Flt-1 was decreased significantly, with reduced gene expression. These results suggest that the vascular remodeling noted in the choroidal blood vessels after sympathectomy is a complex process involving numerous growth factor families. Therefore, modulation of sympathetic nerve activity may be a suitable mechanism to prevent the vascular growth associated with macular degeneration.
Thoracic sympathectomy has an established role in the management of primary palmar and axillary hyperhidrosis, Raynaud's phenomenon and occlusive vascular disease. Potential problems with traditional surgical approaches to the sympathetic chain include poor exposure, risk of damage to adjacent structures and postoperative pain. A minimally invasive endoscopic approach helps to overcome these problems. Using this technique, 45 procedures have been performed on 26 patients in two districts in the South West of England over the past five years. Follow-up information was available for 39 procedures. All 27 procedures for hyperhidrosis and both for occlusive vascular disease have produced a long-term improvement. Nine of the 10 procedures for Raynaud's phenomenon have also produced some degree of long-term improvement. Complications included four asymptomatic pneumothoraces, two patients with temporary unilateral Horner's syndrome and two instances of intercosto-brachial numbness. On the positive side, patients expressed satisfaction with the efficacy, rapid recovery and small unobtrusive scars produced by the procedure. Endoscopic transthoracic sympathectomy is effective, safe and well accepted by patients and we believe is now the method of choice for this procedure.
BACKGROUND AND OBJECTIVES: Although an increase in skin temperature of the hand implies sympathetic block after stellate ganglion block (SGB), it does not indicate complete sympathetic block unless accompanied by an absence of sweating because skin temperature may increase even with a partial sympathetic block. This study examined the efficacy of the SGB to block sweating in the hand and to determine if the magnitude of temperature change in the hand is predictive of a negative sweat test. METHODS: Fifty-nine SGBs were performed in 30 patients (15 women and 15 men) for diagnostic or therapeutic indications. Stellate ganglion block was performed via an anterior paratracheal approach at C6 using 15 mL 0.25% bupivacaine. Skin temperature was measured bilaterally on the index finger. A cobalt blue sweat test was performed bilaterally pre- and post-SGB on the middle finger. Successful sympathetic block after SGB was considered present when: (a) (change in ipsilateral temperature (postblock-preblock)] (Di)-[change in contralateral temperature] (Dc) > or = 1.5 degrees C; (b) Horner's syndrome present; and (c) sweat test changed from positive to negative. Logistical regression was applied to determine what value of Di - Dc could be used to predict a negative sweat test. RESULTS: Thirty-six percent (21/59) of blocks met all three criteria. Of the blocks where Di - Dc > or = 1.5 degrees C, 72% (21/29) had a negative sweat test post-SGB. Of the blocks where Di - Dc < 1.5 degrees C, 37% (11/30) had a negative sweat test postblock. If Di - Dc > or = 2.0 degrees C, a negative sweat test could be predicted with 69 +/- 12% sensitivity and 85 +/- 10% specificity. CONCLUSIONS: Stellate ganglion block often fails to increase skin temperature in the ipsilateral more than the contralateral hand. A value of Di - Dc > or = 2.0 degrees C was a good predictor of a sympathetic block, but was not sufficient to guarantee a complete sympathetic block of the hand after SGB in all cases. An apparently successful SGB as measured by "usual" clinical criteria may not result in a complete sympathectomy of the hand as is often assumed. Therefore, if obtaining a sympathectomy is important for diagnostic or therapeutic purposes, performing a sweat test provides important confirmatory evidence of the genuine success of the sympathetic block.
This study was carried out to determine whether sympathectomy influences the phenotypic modulation of smooth muscle cells in the peripheral and cerebral arteries of heritable hyperlipidaemic rabbits. Unilateral superior cervical ganglionectomy (common origin of innervation to the middle cerebral artery and the central ear artery) was performed on four Watanabe heritable hyperlipidaemic rabbits. Cross-sections of the ipsi- (sympathectomized) and the contralateral (intact) cerebral and ear arteries were prepared 2 months later and labelled with monoclonal antibodies against vimentin and desmin, two markers of the differentiation of smooth muscle cells, and alpha-smooth muscle actin, a marker of these cells. Sections from control and sympathectomized arteries were analysed with a confocal laser scanning microscope. Compared with contralateral intact ear arteries, the sympathectomized ear artery developed a thickened intima with dedifferentiated smooth muscle cells, expressing alpha-smooth muscle actin but no desmin, whereas the middle cerebral artery remained unchanged. These results suggest that sympathectomy may favour the progression of atherosclerosis in peripheral but not in cerebral arteries of Watanabe heritable hyperlipidaemic rabbits.
Sympathetic involvement in the lateral hypothalamic (LH) lesion syndrome was examined. Male rats were surgically or chemically sympathectomized and then given LH lesions. At 24 hr postlesion, lesion-induced hyperglycemia but not hyperthermia was attenuated by splanchnicectomy and celiac ganglionectomy. Hyperthermia but not hyperglycemia was attenuated by adrenal demedullation, adrenalectomy, and neonatal guanethidine treatment. Guanethidine-sympathectomized rats also displayed lower basal temperatures, more perilesion chromatolysis, and severer external symptoms than their controls. No form of sympathectomy affected lesion-induced gastric pathology, plasma gastrin concentrations, or body weight loss. Nor did any sympathectomy influence the recovery of ingestive behavior, daily food intake, the feeding response to 2-deoxy-D-glucose, or body weight maintenance in recovered LH-lesion subjects. These results suggest that sympathetic hyperactivity contributes to some aspects of the acute LH syndrome: Hyperglycemia results from sympathetic outflow to the abdomen, whereas hyperthermia is determined by circulating catecholamines and extraabdominal sympathetic innervation. The results fail to support the hypothesis that chronic increases in sympathetic tone are responsible for the reduced food intake and body weight of the LH-lesion rat.
BACKGROUND: This report examines the intermediate-term results of endoscopic transaxillary T2 sympathectomy for palmar hyperhidrosis. METHODS: A retrospective review was carried out of 91 consecutive patients, 38 men and 53 women, with a mean age of 23 years. Attention was focused on patient satisfaction, late complications and morbidity. RESULTS: After operation, no patient died or developed Horner's syndrome. Nine of 21 patients with craniofacial, five of 16 with axillary and 17 of 73 with plantar hyperhidrosis showed simultaneous improvement. Fifteen patients (16 per cent) developed recurrent sweating, but none required reoperation. The overall mean satisfaction rate was 78 per cent with a median 80 per cent improvement using a visual linear analogue scale from 0 (poor) to 100 per cent (excellent). Twelve patients (13 per cent) were dissatisfied with the operative results, mainly owing to compensatory hyperhidrosis, which occurred in 88 patients (97 per cent) within the first year. CONCLUSION: The results of endoscopic sympathectomy deteriorate progressively from the immediate outcome.
Denervation of the sympathetic nerve can be accomplished with much less operative trauma by using the endoscopic surgical approach. Although endoscopic thoracic sympathectomy is not new, the techniques and the extent of denervation have not been standardized. The anatomic appearances and configurations of the sympathetic chain are explained, and various procedures, including ramisections, interganglionic sympathectomy, and ganglionectomy, are reviewed. Thoracoscopic approaches, operative techniques, and potential complications are discussed.
Endoscopic thoracic sympathectomy (ETS) is a minimally invasive procedure for treating palmar hyperhidrosis (PH). Hemodynamic changes are associated with CO(2) insufflation during ETS. In the present study, we examined hemodynamic changes during general anesthesia using impedance cardiography (ICG) monitor. Seventeen adult patients (15 males) scheduled to undergo elective unilateral ETS for treatment of PH were enrolled in the study. Patients with cardiorespiratory diseases were excluded from the study. Their age and weight mean values were 26.5 +/- 5 years, 71.9 +/- 11.5 kg, respectively. Besides routine monitoring, impedance cardiography monitor was used to measure cardiac output (CO), cardiac index (CI), stroke volume (SV), thoracic fluid content (TFC), and systemic vascular resistance (SVR). Three phases were defined for data collection: A, prior to CO(2) insufflation; B during gas insufflation (at 10, 5, and 2 mm Hg intrathoracic pressures); and C, after gas deflation. Repeated-measures analysis of variance (ANOVA) was used for statistical analysis and post hoc Bonferroni test for multiple comparisons of the data obtained. For all comparisons, P < 0.05 was considered significant. Systemic vascular resistance significantly increased at stages B10 and 5 compared with stage A mean value (P < 0.05). CO, CI, and SV mean values decreased significantly at stage B compared with stage A mean values. The mean values of thoracic fluid content at stages A, B10, 5, 2, and C were 33 +/- 5, 30.6 +/- 3.5, 31 +/- 3.4, 31.6 +/- 3.3, and 32.5 +/- 6.8/kOmega, respectively with significant differences (P < 0.05). Significant reductions of cardiac parameters were reported in the present study, but they were of minimal clinical significance. Of interest was the significant reduction of thoracic fluid content during CO(2) insufflation, whether it correlates to the magnitude of compression, caused by CO(2) insufflation accompanied by high systemic vascular resistance or sympathectomy procedure, yet to be further studied.
1. The effects of chemical sympathectomy with 6-hydroxydopamine (6-OHDA) on the cardiovascular system of the rat were compared in, (a) 10-week-old rats treated during the first 14 days after birth with 150 mug/g subcutaneously, and (b) adult rats injected intravenously with 2 x 50 mg/kg on day 1 and 2 x 100 mg/kg on day 7 and the experiments performed on day 8.2. Intravenous administration of 6-OHDA to adult rats almost completely abolished the pressor responses to stimulation of the entire sympathetic outflow in the pithed rat, the contractions of the lower eyelid to stimulation of the cervical sympathetic trunk and the vasconstrictor responses produced by periarterial nerve stimulation of the isolated renal artery preparation. Pressor responses to physostigmine and to tyramine were markedly reduced or abolished in anaesthetized and pithed rat preparations, respectively.3. In corresponding experiments, 10-week-old rats treated as newborns with 6-OHDA showed a marked reduction in the stimulation-induced pressor responses and contractions of the lower eyelid, but completely normal vasoconstrictor responses to periarterial nerve stimulation of the isolated perfused renal artery were obtained. The pressor responses to physostigmine were slightly reduced but the tyramine responses were unchanged.4. Treatment with 6-OHDA at birth caused an almost complete and long-lasting noradrenaline depletion in the heart, spleen, salivary glands and ileum but only a partial depletion in the mesentery from 10-week-old rats. These low noradrenaline levels showed no recovery in rats up to an age of 4 months. The tyrosine hydroxylase activity in both the cervical and stellate ganglia from 10-week-old rats was markedly reduced by treatment with 6-OHDA after birth.5. Injections of 6-OHDA after birth produce an almost complete and permanent sympathectomy of various adrenergically innervated organs in the rat. The vascular system represents a major exception, exhibiting a surprisingly high resistance to this type of chemical adrenergic denervation.
We studied the effect of unilateral sympathectomy on rat quadriceps and gastrocnemius muscle concentrations of endogenous dihydroxyphenylalanine (DOPA), dopamine (DA), and norepinephrine (NE) and assessed the relationships between these catecholamines in several rat tissues. Catecholamines were measured by reverse-phase high-performance liquid chromatography with electrochemical detection. Sympathectomy decreased NE and DA concentrations of muscles to approximately 10% of control values, whereas the DOPA concentration tended to increase. Relatively high concentrations of DOPA were found in the gastrointestinal tract, kidney, and spleen. No correlations were obtained between the tissue concentration of DOPA and NE. A DA-to-NE ratio approximately 1% was observed in liver, muscle, pancreas, spleen, and heart, whereas we found exponentially increasing DA values with increasing NE concentration in tissues obtained from stomach, small and large intestine, kidney, and lung. In conclusion, endogenous DOPA in muscle tissue is not located in sympathetic nerve terminals but probably in muscle cells. DA concentrations in the gastrointestinal tract and in the kidneys were greater than could be ascribed to its role as a precursor in the biosynthesis of NE.
Sympathetic nerve input has been proposed to regulate cardiac growth and differentiation. In the present study, this hypothesis was tested by giving the neurotoxic adrenergic neuron blocking agent, guanethidine (50 mg/kg, s.c.), daily to rats for 21 consecutive days to produce long-term peripheral sympathectomy in neonatal rats. Ontogeny of the sympathetic nerve terminal was measured by the ablity of synaptic vesicle preparations to take up radiolabeled norepinephrine, and heart growth in the sympathectomized animals was monitored by organ weight as well as by RNA and protein synthesis. Guanethidine treatment produced a massive sympathectomy, as synaptic vesicle development was totally arrested; the functional consequence of this treatment was confirmed by the attenuation of chronotropic responses to tyramine, a drug which acts by displacement of norepinephrine from the noradrenergic terminal. Despite the clear-cut effectiveness of guanethidine to prevent formation of functional sympathetic innervation of the heart, no significant alterations in heart growth or RNA and protein synthetic capabilities were observed in the developing rats. These results suggest that the presence of sympathetic innervaton is not obligatory for normal growth of the heart to occur.