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PubMed1977

Phantom sweating.

Phantom sweating is a sensation in which the patient feels that sweat is about to burst out of skin pores, but in which sweating never actually occurs. In a series of 100 patients undergoing bilateral upper dorsal sympathectomy for palmar hyperihidrosis, 82 patients were specifically questioned and 48 (59%) reported phantom sweating. Phantom sweating started soon after the operation, was triggered by the same stimuli that caused hyperhidrosis preoperatively, lasted for a few seconds, and tended to diminish with time. In an average follow-up of 18 months, the phenomenon disappeared in 11 patients (23%). Phantom sweating is probably a symptom of residual sympathetic activity.

Follow-Up Studies↗
PubMed1993

Asymmetric sweating in stroke: a prospective quantitative study of patients with hemispheral brain infarction.

We performed a prospective study of sweating in 40 patients with hemispheral brain infarction and 40 healthy controls to elucidate the clinical significance and prognostic value of sweating dysfunction in conjunction with brain infarction. We measured hidrosis quantitatively at six sites on each side of the body before and after a heating stimulus in the acute phase, at 1 month, and at 6 months after infarction. Excessive evaporation on the paretic side when compared with the nonparetic side was already found at baseline, but after the heating stimulus, this asymmetry reached statistical significance on the forehead, chest, forearm, and hand during the whole 6-month follow-up. Significant asymmetry in sweating occurred in 29 of the 40 patients (73%) in the acute phase of infarction, in 18 of 32 (56%) after 1 month, and in 28 of 33 (85%) after 6 months. Hyperhidrosis correlated with the severity of paresis and the presence of pyramidal tract signs. We conclude that sweating asymmetry seems to be an essential, long-lasting consequence of autonomic failure occurring in the majority of patients with hemispheral brain infarction.

Adult↗
PubMed1994

Chylothorax after endoscopic sympathectomy: case report.

Endoscopic sympathectomy is a new trend for the treatment of hyperhidrosis palmaris. It is a simple and effective technique; however, it carries some recognized risks such as Horner's syndrome and pneumohemothorax. We recently encountered a case complicated by the development of a chylothorax. The patient was a 23-year-old healthy women with profuse palmar sweating. She developed an intractable dry cough after a transthoracic endoscopic sympathectomy. A chest x-ray revealed a left pleural effusion. A chylous effusion was found after thoracentesis and fluid analysis. The pleural effusion resolved after chest tube drainage and diet control. Although endoscopic sympathectomy is a simple and quick procedure, unusual complications, such as chylothorax, may occur. Appropriate early recognition and treatment can prevent a disastrous result.

Adult↗
PubMed2005

Effect of endoscopic transthoracic sympathicotomy on plasma natriuretic peptide concentrations in humans.

BACKGROUND: The effects of endoscopic transthoracic sympathicotomy (ETS) on plasma natriuretic peptides concentrations in humans were examined in order to elucidate the role of the sympathetic nervous system in their regulation. METHODS AND RESULTS: Thirty-seven patients with palmar hyperhidrosis underwent ETS. Cardiac functional indices were assessed by echocardiography, and plasma atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) concentrations were measured before and after ETS. ETS caused decreases in heart rate, mean arterial pressure, systemic vascular resistance, and increases in left ventricular (LV) end-diastolic volume, stroke index, ejection fraction, and left atrial diameter. LV end-systolic volume and cardiac index remained unchanged. Following ETS, ANP increased from 10.7+/-5.9 to 24.7+/-16.8 pg/ml (p < 0.01), and BNP increased from 5.1+/-4.2 to 19.7+/-21.5 pg/ml (p < 0.01). From the multivariate regression analysis, ETS, age and gender were determined to be significant predictors of changes in the ANP and BNP concentrations. None of the hemodynamic parameters were useful as independent predictors. CONCLUSION: The plasma concentrations of ANP and BNP increased after ETS, independent of hemodynamic changes, and apparently because of the release of the inhibitory effects of the cardiac sympathetic nerves on natriuretic peptide secretion.

Adult↗
PubMed2005

Sympathetic hypertensive syndrome: a possible surgically curable type of hypertension.

Poorly controlled hypertension was incidentally cured after performing an endoscopic sympathetic block (ESB) in a patient with hyperhidrosis craniofacialis (HHC). A survey of the literature indicated that 30% to 40% of essential hypertension is of sympathetic origin. Patients with facial sweating associated with hypertension were then studied to determine whether blood pressure is lowered after performing ESB. Between November 2002 and July 2003, 17 hypertensive patients (13 males and 4 females) ranging in age from 22 to 62 years underwent ESB solely for HHC at the Department of Surgery of Kaohsiung Medical University, Taiwan. Their preoperative systolic blood pressure (SBP) values ranged from 170 +/- 6 to 200.7 +/- 7.6 mmHg, and their diastolic blood pressure (DBP) values ranged from 94.7 +/- 6.1 to 120.3 +/- 5.7 mmHg. Their heart rates were between 92.67 +/- 2.28 and 119.67 +/- 5.13 beats per minute (bpm). They were refractory to aggressive medical treatment, including lifestyle modifications and antihypertensive medications. Their postoperative blood pressure, heart rate and surgical outcomes were recorded. After performing ESB, HHC was cured in all 17 patients. Based on the reductions in blood pressure and heart rate, the patients could be divided into two groups, one showing high-level reductions (Group T) and one showing low-level reductions (Group S). The blood pressure of Group T (ten patients) was reduced to the range of 120.2 +/- 6.9 to 131.6 +/- 3.5 mmHg SBP and 74.8 +/- 3.1 to 85.4 +/- 4.5 DBP, and the heart rate of this group was reduced to the range of 65.36 +/- 4.63 to 85 +/- 3.60 bpm, while the blood pressure and heart rate of Group S (seven other patients) were reduced to the ranges of 145.9 +/- 5.7 to 160.5 +/- 5.5 mmHg SBP, 90 +/- 4 to 100.7 +/- 3.2 mmHg DBP, and 80 +/- 4 to 90.83 +/- 3.53 bpm, respectively. The patients in Group S were well controlled at 119.8 +/- 5.5 to 130.6 +/- 8.0 mmHg SBP and 70.1 +/- 3.8 to 84.5 +/- 5.7 mmHg DBP with a daily low-dose of calcium channel blocker. The average follow-up periods of the two groups were 17.00 +/- 2.906 and 17.43 +/- 2.37 months, respectively. We named this surgically curable form of hypertension "Sympathetic Hypertensive Syndrome" (SHS), which we define by the presence of all three of the following: 1) stage II hypertension; 2) HHC or other sympathetic disorders; and 3) heart rate > or = 100 bpm. If the patient is male the reductions of blood pressure after the surgery will be better, which might be due to the link with Y chromosome. Finally, we recommend that ESB should be performed in patients with SHS, although the female would respond less satisfactorily in terms of the blood pressure.

Adult↗
PubMed1998

Thoracoscopic splanchnicolysis for the relief of chronic pancreatitis pain: experience of a group of pneumologists.

Intractable pain is the most invalidating symptom in patients suffering from chronic pancreatitis. Anatomical interruption of the major afferent pain nerves is indicated in severe refractory cases. Among the various techniques and sites of interruption, thoracoscopic splanchnicectomy has emerged as an efficient alternative for the more aggressive open surgical splanchnicectomy, and for the (solely temporarily efficacious) transcutaneous neural blocks, which moreover bear some serious complications. Until now, all reports on thoracoscopic splanchnicectomy were typically surgical, using video-assisted thoracoscopic surgery techniques, double-lumen intubation, and so on. In analogy with thoracoscopic upper dorsal T2-T3 sympathicolysis for essential hyperhidrosis, a simplified thoracoscopic splanchnicolysis technique used in 8 patients suffering from either severe refractory chronic pancreatitis pain (7 patients) or postsurgical epigastric pain is described. Pain control was achieved in 5 of the 7 patients with chronic pancreatitis with a short (20+/-8 min) intervention, short hospitalization (2 days), and simple (single-lumen intubation, no chest drains) procedure. Thus, this simplified thoracoscopic splanchnicolysis technique may represent a valid alternative in the often difficult treatment of refractory chronic pancreatitis pain or other upper abdominal pain.

Abdominal Pain↗
PubMed1999

A case of traumatic high thoracic myelopathy presenting dissociated impairment of rostral sympathetic innervations and isolated segmental sweating on otherwise anhidrotic trunk.

A 3 year-old boy developed flaccid paraplegia, anesthesia below T3 and impaired vesical control immediately after a car accident. Three months later, the pupils and their pharmacological reactions were normal. Thermal sweating was markedly reduced on the right side of the face, neck, and shoulder and on the bilateral upper limbs, and was absent below T3 except for band like faint sweating on T7 sensory dermatome. The left side of the face, neck and shoulder showed compensatory hyperhidrosis. Facial skin temperature was higher on the sweating left side. Cervico-thoracic MRI suggested almost complete transection of the cord at the levels of T2 and T3 segments. We discussed the pathophysiology of the dissociated impairment of rostral sympathetic innervations and isolated segmental sweating on otherwise anhidrotic trunk.

Accidents, Traffic↗
PubMed2003

Botulinum toxin A: its expanding role in dermatology and esthetics.

The use of botulinum toxin A in cosmetic dermatology has increased in popularity due to the efficacy and relative safety of the treatment. Botulinum toxin A is one of eight exotoxins produced by Clostridium botulinum, a Gram-positive, spore-forming anaerobe. Flaccid paralysis results from the denervation of muscle fibers at the neuromuscular junction after botulinum toxin A administration. While treating blepharospasm, the Carruthers incidentally found that botulinum toxin A improved glabellar frown lines. Dynamic rhytides occur in areas of dynamic motion. These types of lines may be improved with botulinum toxin A. There are two types of botulinum toxin A commercially available (BOTOX and Dysport); only BOTOX is currently available in the US. The efficacy and tolerability of BOTOX was best demonstrated with a multicenter, double-blind, randomized, placebo-controlled study of the efficacy and safety of botulinum toxin type A in the treatment of glabellar lines in 264 patients. There was a significantly greater reduction in glabellar line severity with BOTOX. The effect was maintained for the duration of the study (120 days). There was low occurrence (5.4%) of mostly mild blepharoptosis in the BOTOX group. In another prospective study, it was found that about 1% of BOTOX patients reported severe headache. Botulinum toxin A can provide an alternative treatment of palmar and axillary hyperhidrosis when options such as topical agents (aluminum chloride) and iontophoresis have failed.

Botulinum Toxins, Type A↗
PubMed1996

Sympathectomy does not influence experimental itch and cutaneous temperature perception thresholds.

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.

Adult↗
PubMed2000

Changes of bilateral palmar skin temperature in transthoracic endoscopic T-2 sympathectomy.

OBJECT: Transthoracic endoscopic T-2 sympathectomy is currently the treatment of choice for palmar hyperhidrosis (PH). Intraoperative monitoring of palmar skin temperature (PST) is often used to assess the adequacy of sympathetic ablation. The aim of this study was to investigate the time course of PST changes during the operation and to determine factors involved in the sympathetic modulation of the palmar skin blood flow. METHODS: Eighty-one patients with PH underwent bilateral transthoracic endoscopic sympathectomy of T-2 in which continuous intraoperative PST monitoring was used. Palmar skin temperature data, recorded every 30 seconds throughout the operation, were plotted against time, and a graph of two PST curves was obtained in each case. A multiphasic curve pattern of great similarity was observed in nearly 70% of cases. Specific PST readings at different operative stages were collected and averaged for all cases. The trend of PST changes in response to different procedures during the operation was analyzed. It was found that unilateral procedures caused simultaneous bilateral PST alterations. In almost all cases, bilateral PST was dramatically lowered when unilateral skin incision and intercostal muscle dissection were performed. The temperature remained low until the T-2 sympathectomy was finished on one side. In addition, unilateral T-2 sympathectomy induced synchronous elevation of bilateral PST. However, the ipsilateral response was significantly stronger than that on the contralateral side. CONCLUSIONS: Although intraoperative monitoring of PST is a reliable guide for surgeons performing endoscopic transthoracic sympathectomy, it is important to realize that PST fluctuates at different stages during the operation and that surgical procedures themselves can significantly influence PST readings. The PST data recorded at specific time points, therefore, can be misleading in terms of accuracy and the completeness of ablation of the target sympathetic ganglia, especially when the sympathetic trunk or ganglia are anatomically aberrant.

Adolescent↗
PubMed2002

Anatomical location of T2-3 sympathetic trunk and Kuntz nerve determined by transthoracic endoscopy.

OBJECT: Bilateral subaxillary transthoracic endoscopic sympathectomy (TES) is a popular procedure of upper thoracic sympathectomy. The anatomical locations of the T-2 and T-3 sympathetic trunks, as viewed under the endoscope, are varied in the rib head areas. In this study, the authors investigated the more visible anatomical locations of the T-2 and T-3 sympathetic trunks, the so-called nerves of Kuntz, and intercostal rami by performing transthoracic endoscopy. METHODS: Seventy patients with palmar hyperhidrosis undergoing bilateral TES (140 sides) via the anterior subaxillary approach were included in this study. The operative findings and video images of the T-2 and T-3 sympathetic trunks and ganglia were recorded and analyzed. The anatomical locations of the T-2 and T-3 sympathetic trunks along the horizontal axes of the rib heads were determined using a three-region system constructed by the authors. The area between the rib neck and the medial border of the rib head was equally divided into Region E (external half) and Region M (medial half). The area between the medial border of the rib head and the paravertebral ligament was defined as Region I. The incidence of the T-2 and T-3 sympathetic trunks found in Regions E, M, and I were 31.4 to 42.9%, 50 to 57.1%, and 7.1 to 11.4%, respectively, on the left side, and 24.3 to 34.3%, 57.1 to 65.7%, and 8.6 to 10%, respectively, on the right side. One right (1.4%) and six left (8.6%) Kuntz nerves originating from the T-3 sympathetic trunk were found in seven patients (10%). The intercostal ramus was found around the T-2 rib neck in 24 patients (34.3%), with 18 cases (25.7%) for each side. The intercostal ramus around the T-3 rib neck was found in 17 patients (24.3%): 12 (17.1%) on the right and nine (12.9%) on the left. CONCLUSIONS: These results indicate that approximately 90% of the T-2 or T-3 sympathetic trunks are located on the rib head. These findings may also be used to assist the surgeon in fluoroscopic guidance for locating the T-2 and T-3 sympathetic trunks during posterior percutaneous sympathectomy.

Adolescent↗
PubMed1976

[Surgical indications and results of thoracic sympathectomy].

Between the 1st of July 1971 and the 31st of December 1974, among 1,459 operations on vascular surgery, we carried out 77 thoracic sympathectomies in 46 patients. In most patients there was an oblitering angiopathie of digital type, stage II to IV, confirmed by angiography. Two patients had mixed type obstructions, two others had hyperhidrosis, one patient suffered from cleroderma, another had a thoracic outlet syndrome with digital arterial obstruction. In all cases, the transaxillary approach was that which caused the least complications and which permitted satisfactory exposure of the sympathetic nerve. The cosmetic results were good. The second and third thoracic ganglia were resected and the planes of cleavage marked with silver clips. In advanced stage III and stage IV, we noted 92 p. 100 improvements i.e. return to stages I or II. The operative mortality was nil. The most serious complication was a case of hemothorax which required later pulmonary decortication. We noted in two cases, a Horner's syndrome.

Adult↗
PubMed2000

[Clinical symptoms of and diagnostic possibilities for hypophyseal adenoma in horses].

Hirsutism was the most often observed symptom in horses with a pituitary gland tumor and was present in all 13 examined horses. Other symptoms were atrophy of muscles (n = 10), hyperhidrosis (n = 8), polyuria/polydipsia (n = 5), bulging or supraorbital fat (n = 3), polyphagia (n = 2), apathy (n = 2) and seizures (n = 2). Laminitis was the most frequently observed concurrent disease (n = 8). Hyperglycaemia (mean, 9.9 +/- 3.71 mmol/l) in 13 horses and glucosuria (median, 55 [range, 2-55] mmol/l) in 7 horses were the most important laboratory results. The dexamethasone suppression test was positive in all tested horses (n = 9) 20 h after administration of dexamethasone. The pituitary gland tumor was visible in every case underwent computed tomography (n = 7). From these results it can be concluded that a pituitary gland tumor can be suspected based on typical clinical signs. Hyperglycaemia and glucosuria support the preliminary diagnosis and a positive dexamethasone suppression test allows a final diagnosis.

Adenoma↗
PubMed2001

[Minimally-invasive endoscopic transthoracic sympathectomy of the upper limbs. A new method].

OBJECTIVE: Indications for endoscopic transthoracic upper dorsal sympathectomy are axillary and palmar hyperhidrosis, upper extremities ischemia (due to, e.g., Raynaud s disease), and upper extremities causalgia. METHODS: At present, this methodology relies on (at least) double trocar insertion (per side) and/or carbon dioxide insufflation. Thus, although this approach, compared with the traditional open sympathectomy techniques, it guarantees the smallest number of postoperative complications, it still determines a certain amount of postoperative discomfort as well as a risk of complications related to carbon dioxide insufflation, as intraoperative profound bradycardia and hypotension due to mediastinal shift, and postoperative subcutaneous emphysema. From December 1995, we are using a minimally-invasive endoscopic transthoracic sympathectomy technique, performed by a single-entry specifically modified thoracoscope and without the need for carbon dioxide insufflation, with the aim to reduce the drawbacks associated with the above-mentioned currently adopted endoscopic techniques. After general anesthesia with double-lumen endotracheal tube, with the patient placed in a half-sitting position with both arms abduced to 90 degrees, a 1 cm incision is performed, along the midclavear line (in male patients) or the anterior axillary line (in female patients), in the second or third intercostal space. RESULTS: The effects of sympathectomy are immediate, and the patients wake up with warm and dry hands and axillae. CONCLUSIONS: In personal opinion, this single-entry technique, compared with other reported approaches, should minimize any damage to the intercostal neurovascular bundle, while avoiding the complications connected with carbon dioxide insufflation.

Arm↗
PubMed2001

Endoscopic upper thoracic sympathectomy.

Thoracoscopic sympathectomy provides a superb surgical option for the many patients with incapacitating essential hyperhidrosis. Whether one thoracoscopic approach to sympathectomy is ever likely to prevail is doubtful, as the results of the various reported techniques seem to be quite similar. There are definite advantages to the single-port approaches, which are faster and usually do not require repositioning of the patient to do both sides. In the rare instances where dense apical adhesions are encountered or when significant bleeding is encountered from one of the intercostal vessels, the two- or three-port approaches definitely provide better control (see commentary in article by Kohno and Takamoto). Surgeon preference probably dictates which approach is used at the different centers. Compensatory sweating remains a frequent and sometimes serious complication of the procedure, particularly in individuals living in hot climates. An understanding of its mechanisms needs improvement, with the hope of preventing its occurrence in the future. In the meantime, patients have to be informed of its frequency, and operations could probably be tailored to the patients' needs and their local climate.

Humans↗
PubMed2001

Botulinophilia: contraindication for therapy with botulinum toxin.

Botulinum toxin inhibits neuromuscular transmission and is one of the most potent toxins. It has proven to be effective in the treatment of hyperhidrosis and is being more frequently demanded for therapy. Patients with body dysmorphic disorder also seek costly treatment with botulinum toxin. This botulinophilia is a new venenophilia. Body dysmorphic disorder is defined as a preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly exessive. The patient's preoccupation causes clinically significant distress or impairment in socially, occupational, or other important areas of functioning. The sweat test according to Minor is negative. Patients with botulinophilia are among the most difficult patients managed by the dermatologist. They are demanding and time-consuming. In our clinic, 23.1% of a series of patients seeking treatment with botulinum toxin screened positive for body dysmorphic disorder. Botulinophilia is a contraindication for therapy with botulinum toxin but is an indication for psychotherapy.

Adult↗
PubMed2001

Right vs left side thoracoscopic sympathectomy: effects of CO2 insufflation on haemodynamics.

BACKGROUND AND AIMS: Currently, few reports of the haemodynamic impact of intrapleural CO2 insufflation in the clinical setting are available. Therefore, we conducted the present study to compare the haemodynamic changes between right and left side thoracoscopic sympathectomy (TS) for treatment of palmar hyperhidrosis (PH) under general anaesthesia. MATERIALS AND METHODS: 20 adult patients (17 males) undergoing TS were randomly allocated to two groups (each 10); group A, right side and group B, left side TS procedures were performed under general anaesthesia with single-lumen endotracheal tube. Besides the routine monitoring of vital signs, non-invasive cardiac output monitor (NICO) was used to record the stroke volume (SV), cardiac output (CO) and cardiac index (CI). Intrapleural CO2 insufflation was used. Anaesthesia was maintained with 1 MAC sevoflurane in 50% nitrous oxide in oxygen with incremental doses of sufentanil and atracurium when required. Haemodynamic parameters were obtained every 3 min then averaged over the time of surgery at phases; I) after tracheal intubation, II) after CO2 insufflation and III) after CO2 deflation. RESULTS: The CO, CI and SV showed decreased trend in both groups during phase II compared to phase I with significant differences (P < 0.05). Comparing the CO and CI variables revealed lower values in group A compared to group B but with non-significant differences (P > 0.05). While the SV variable showed significant low value in group A compared to group B (P < 0.05). CONCLUSIONS: Compared to left side TS, direct compression by CO2 against the venae cava and right atrium and ventricle during right side TS caused reduction of the venous return and hence low CO, CI and SV.

Adult↗
PubMed2002

[Video-assisted thoracoscopic sympathectomy: the experience of a Spanish cooperative group].

Preliminary results from the Spanish cooperative group for the treatment of palmar hyperhidrosis by video-assisted thoracoscopic surgery are presented in this paper. We have reviewed the cases of all patients with this disease treated by the group, especially noting the technique, the early results and complications. Video-assisted thoracoscopy emerges as the treatment of choice, given the ease with which the thoracic sympathetic chain can be resected, its safety, the lack of observed complications, and the good short-term results.

Adolescent↗