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BACKGROUND: The present paper describes the development of a one-port technique for thoracoscopic sympathectomy. METHODS: A 7-mm thorascope with a working channel for diathermy was used. CONCLUSION: A highly cosmetic, simple, safe, day-case procedure is achievable.
OBJECTIVE: To evaluate the effects of vasodilator therapies and chemical sympathectomy on ipsilateral and contralateral testicular spermatogenetic activity after unilateral testicular torsion using DNA flow cytometry and thus determine whether contralateral testicular damage occurs through a reflexively decreased blood flow. MATERIALS AND METHODS: The study comprised four groups of 20 rats each (groups 1-4) respectively receiving isotonic saline, verapamil, pentoxifylline and 6-hydroxy dopamine hydrobromide (6-OHD) intraperitoneally. Each group was further divided into two subgroups containing 10 rats which respectively underwent either a sham operation or 720 degrees clockwise torsion applied to the left testis. The testes were harvested after 24 h and the relative proportions of haploid, diploid and tetraploid cells determined by DNA flow cytometry for each testis. The proportion of haploid cells was used as an estimate of spermatogenesis. The mean proportions of haploid cells in the groups were compared using a one-way ANOVA and paired groups were compared using Student's t-test. RESULTS: The proportions of haploid cells in the ipsilateral testes of rats undergoing torsion were significantly lower than in their contralateral testes and in the ipsilateral testes of the control groups. In group 4 (6-OHD) the proportion of haploid cells in the contralateral testes was significantly higher than those in the other groups after unilateral testicular torsion, but significantly lower than those in groups 1 and 4 after a sham operation. After unilateral testicular torsion the haploid cell proportions of the contralateral tests of groups 1-3 were not significantly different from each other. CONCLUSIONS: Because the spermatogenetic activity in the contralateral testis is depressed within 24 h of ipsilateral testicular torsion, contralateral testicular damage is an acquired effect: 6-OHD offers some protection and thus the damage seems to result from the involvement of the sympathetic system.
The use of periarterial sympathectomy (PAS) to manage chronic digital ischemia caused by scleroderma remains controversial. The duration of efficacy of PAS in managing scleroderma symptoms was evaluated by examining microvascular physiology, health-related quality of life, and patient satisfaction. Twenty-two patients (29 hands) with scleroderma, chronic vascular insufficiency, and a history of nonhealing digital ulcers unresponsive to nonsurgical treatment were evaluated. Isolated cold stress testing and laser Doppler fluxmetry measurements were used to evaluate microvascular perfusion before surgery and after a mean follow-up period of 31 months (range, 7-108 months). Digital temperatures did not change after surgery, but microvascular perfusion had increased significantly at a mean of 31 months in 22 hands. Health-related quality-of-life data were collected at a mean of 46 months (range, 11-108 months) after surgery. Subjective improvement (fewer ulcers, faster ulcer healing, and decreased pain) was reported for 18 of 22 patients (24 of 29 hands) at a mean follow-up period of 46 months; 6 patients remained ulcer free. Follow-up of scleroderma patients after PAS documented improved microvascular perfusion as evaluated by laser Doppler fluxmetry and by variable clinical results.
In order to better understand the regulation of blood flow to tooth-related structures, the patterns of VIP- and NPY-ergic innervations in the rat were examined. Nerve fibers showing NPY-like immunoreactivity (NPY-LI) frequently occurred in the walls of the large main arteries, as well as in association with the arterioles, to a high degree co-existing with tyrosine hydroxylase (TH), whereas VIP-LI was mainly restricted to the walls of the large arteries. After sympathectomy, no NPY/TH-LI nerve fibers were seen in blood vessel walls. However, a NPY-immunoreactive nerve population remained in the walls of the large arteries, NPY- and VIP-LI co-existing in this nerve population. Both immunoreactions were intense. The present study suggests that a NPY/sympathetic innervation as well as a VIP innervation (large arteries) are likely to have substantial roles in the balance and maintenance of vasoregulation in tooth-related structures and that a NPY/VIP innervation becomes of particular importance when the NPY/sympathetic innervation is destroyed.
A lumbar sympathectomy was performed on 36 patients with angiographical verified arterial occlusion on the upper and lower leg. Pre- and postoperative partly the lower leg flow was registered by air plethysmography and the lower leg and bridge of foot flow simultaneously registered by the Straine gauge plethysmography. Independent of the method an increase of the arterial blood flow was noticed with 40% of the patients. In spite of this improvement the registered values after the reactive hyperemia in lower leg and bridge of foot are still clearly restricted. The remaining 60% of the patients however showed a clear worthening of the blood flow conditions.
PURPOSE: Assessment of the post-operative results of peripheral sympathectomy in Raynaud's phenomenon. METHODS: Six patients with therapy refractory Raynaud's phenomenon underwent a 4 cm long adventitial stripping of the radial and ulnar arteries proximal to the wrist. The nerve of Henle was followed up to the surface of the palmar arch and resected. The pre- and postoperative examinations were performed using the help of a questionnaire, telethermography and infra-red laser reflexion rheography. RESULTS: All but two patients (two hands) were free of complaints (four patients, six hands), the three ulcers on the finger tips healed well. According to the questionnaire there was a dramatic improvement in the quality of life of the patients. CONCLUSION: In the follow-up period of two years, there was no recurrence. Adventitial stripping of the radial and ulnar arteries and resection of the nerve of Henle proximal to the wrist have demonstrated favourable results in the treatment of therapy-resistant complaints in Raynaud's phenomenon.
Fifty-seven patients who had 72 thoracic sympathectomies have been reviewed. Twenty-five patients were preoperatively diagnosed as having primary Raynaud's phenomenon, 14 as having Raynaud's phenomenon secondary to arterial occlusion, 17 as having ischemia secondary to arterial occlusion and one as having hyperhidrosis. Twenty percent of the patients initially diagnosed as having primary Raynaud's phenomenon at the time of operation developed a collagenosis during the follow-up period. Improvement after 8 years' follow-up did not depend on the primary indication. Up to the fifth year after surgery a relapse was seen in cases of primary Raynaud's phenomenon. In secondary Raynaud's phenomenon a gradual decrease in improvement of 2% a year was seen during follow-up. In ischemia secondary to arterial occlusion, after 2 years the percentage of improved patients remained constant at a level of 70%. The mean improvement after 8 years follow-up according to the survival test of Gehan was 70 +/- 10%.
Pituitary adenylate cyclase-activating polypeptide (PACAP) is a basic 38-amino acid regulatory peptide contained in the adrenal gland and involved in the control of its secretory activity. Bilateral splanchnic-nerve section caused in the rat a significant decrease in PACAP38 adrenal content and concentration, as measured by RIA. In contrast, chemical sympathectomy, obtained by administering newborn rats with 6-hydroxydopamine, was ineffective. Our findings support the view that splanchnic nerves play an important role in the control of rat adrenal function.
Pituitary adenylate cyclase-activating polypeptide (PACAP) is a basic 38-amino acid regulatory peptide contained in the adrenal gland and involved in the control of its secretory activity. Bilateral splanchnic-nerve section caused in the rat a significant decrease in PACAP38 adrenal content and concentration, as measured by RIA. In contrast, chemical sympathectomy, obtained by administering newborn rats with 6-hydroxydopamine, was ineffective. Our findings support the view that splanchnic nerves play an important role in the control of rat adrenal function.
Palmar hyperhidrosis or excessive sweating of the hands causes, to those affected, emotional and physical disturbance and impediment in professional and social life. The cause is unknown. Sweat glands are innervated by the sympathetic chain of the autonomous nervous system. The center of sympathetic regulation of the upper extremities is located between the segments of D.2-D.9 of the spinal cord. Accepted treatment consists of surgery aimed to excise the third thoracic sympathetic ganglion. Besides the surgical procedure as such, and its complications, there are complications inherent to the excision of the ganglion. These are Horner's syndrome, compensatory sweating in other parts of the body, and recurrence of sweating. CT guided chemical percutaneous thoracic sympathectomy presents an alternative, which in the event of failure does not prevent ensuing surgery. The preliminary experience with this procedure in 50 patients is presented and discussed.
A new technique for lumbar sympathectomy is described. It consists of CT-guided trans-abdominal fine needle puncture and injection of alcohol. The technique is simple and well tolerated by the patient, and it permits accurate application of the alcohol. Complications have so far not been observed.
Six months after nephrectomy for renal-cell carcinoma and during treatment with interferon-alpha and vinblastin, a 70-year-old patient developed necrotizing Raynaud's phenomenon in both hands (at first: pain, livid skin and hyperhidrosis; later: painful acral ulcers; finally: trophic changes plus almost complete impairment of mobility and fine movements in both hands). These changes persisted even after the end of chemotherapy and despite several months on aspirin, naftidrofuryl, nitrates and glucocorticoids, so that the patient's general health was seriously affected. Because repeated sympathetic blocks were efficacious for brief periods, bilateral transthoracic endoscopic sympathectomy (TES) was performed. The patient became free of pain at once, the acral ulcers healed within a few weeks and he could again use his hands. Until his death from advanced metastases 10 months later the Raynaud's phenomenon did not recur. This case suggests that sympathetic vasoconstriction is apparently involved in the maintenance and progression of malignant neoplasm-associated Raynaud's phenomenon. TES is recommended as a reasonable palliative measure in patients with limited life expectancy, as long as preceding sympathetic blockage has indicated likely success and the procedure is performed under intraoperative monitoring of acral and facial skin temperature.
The hypothesis was tested that the sympathetic nervous system (SNS) developmentally influences circulating testosterone (T), systolic blood pressure (SBP) and cardio-renal pathology in SHR/y animals. A sympathoplegic drug, guanethidine, and an antibody to nerve growth factor were administered to WKY and borderline hypertensive SHR/y male rats (n = 20/group) for the first 3 weeks of life; control groups (n = 20/group) received saline. SBP, serum T and luteinizing hormone (LH) were measured. SBP in the WKY and SHR/y sympathectomy (sympx) groups decreased 10mmHg (p < 0.001) and 50mmHg (p < 0.001), respectively, when compared to their control groups. Serum T levels in the sympx WKY group were lower (p < 0.01) than those in controls, and the rise of T typically observed in SHR/y from weeks 6-8 was delayed in the sympx SHR/y group, similar to the pattern in WKY. Serum LH levels were increased in the sympx WKY group, but not in the SHR/y group. Sympx caused a greater reduction in renal glomerular changes (p < 0.01), coronary artery collagen deposition (p < 0.01) and myocardial fibrosis (p < 0.01) in SHR/y than WKY rats. In conclusion, the SHR Y chromosome has a locus that enhances SNS activity, which can raise SBP and result in renal and cardiovascular tissue damage.
OBJECTIVE: 48 patients underwent TSSYM. Charts of patients undergoing thoracoscopy were reviewed to assess the safety and efficacy of thoracoscopic sympathectomy (TSSYM). DESIGN: A retrospective review was undertaken at four United States medical centers. RESULTS: TSSYM was performed for reflex sympathetic dystrophy in 27 patients, hyperhydrosis palmaris in 15 patients, and Raynaud's upper extremity ischemia and splanchnic pain in 2 patients each. Anesthesia with one lung ventilation was used. 2.9 ports were used per patient and 0.8 chest tubes were placed per patient. All patients underwent resection of the sympathetic chain, usually with a clip along the bottom of the resected chain. Laser, electro-ablation and electroresection were not used by any of the surgeons in his series. The mean length of hospital stay was 1.8 days. CONCLUSIONS: TSSYM is a safe and effective technique for treatment of a variety of thoracic disorders.
Four cases are presented in which complications occurred during or after thoracic endoscopic sympathectomy (TES). In one patient inappropriate TES resulted in disabling hyperhidrosis. In one patient laceration of the subclavian artery required major surgery. In two cases intraoperative cerebral damage occurred. Training in TES is essential.
OBJECTIVE: To assess the outcome after transthoracic endoscopic sympathectomy (TES) for upper limb hyperhidrosis. DESIGN: Prospective cohort study. SETTING: District general hospital. SUBJECTS: Consecutive patients undergoing TES for upper limb hyperhidrosis over a fifteen month period. INTERVENTIONS: One-stage bilateral TES. MAIN OUTCOME MEASURES: Change in quality of life as shown by the Short Form-36 health assessment questionnaire. RESULTS: Sixteen patients (11 women and 5 men, median age 26 years) underwent operation without complications. At median follow-up of 6.2 months, symptomatic improvement was found in 26 of 32 limbs treated (82%). Truncal compensatory hyperhidrosis was reported by 13 patients but was severe in only three. There were significant improvements in social function (p = 0.01) and mental health (p = 0.025) as assessed by the SF-36. CONCLUSION: Despite a high incidence of compensatory hyperhidrosis, TES improved both the symptoms and overall quality of life in patients with upper limb hyperhidrosis.
Craniofacial hyperhidrosis as well as palmar hyperhidrosis is an abnormal state of local excessive sweating of unclear etiology. The hyperhidrosis may be isolated in the craniofacial region or associated with palmar hyperhidrosis. The patient's face is so wet with sweat that their daily activities are often seriously disturbed. To the best of our knowledge, there has been no satisfactory medical therapy, nor any effective surgical treatment reported in the literature. In 1991, we started to treat a patient with such distress using endoscopic ablation of the sympathetic T2 segment, because we mastered the technique after treating a large series of palmar hyperhidrosis patients. Furthermore, we were impressed by concomitant reduction of craniofacial sweating after T2-3 sympathectomy resulting from the relatively different domination of sympathetic supply between the eye and face. It appears possible to relieve excessive sweating of the head and face, without producing ptosis or miosis by ablation of the T2 segment. During the past 2 years, 7 patients with severe craniofacial hyperhidrosis have been successfully treated with the method and all obtained a satisfactory result. No complete Horner's syndrome has been produced except in one patient, who showed a mild and transient left eye ptosis, in whom coagulation of the sympathetic trunk higher than the T2 segment was performed. Intraoperative monitoring of forehead skin perfusion and observation of the change of pupillary size is emphasized during the lesion making. The longest postoperative follow-up was 2 years, with a mean follow-up of 12.4 months.(ABSTRACT TRUNCATED AT 250 WORDS)
Twenty-one chemical sympathectomies were assessed in this study by taking infra-red thermograms of the feet before and after the procedure. Patients with relatively high perfusion pressures were shown to have the best response, while those with a low perfusion pressure had little or no increase in mean temperature in the foot.