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Presentations at the 4th International Symposium on Sympathetic Surgery

1. History of thoracoscopic neurotomies

2. Conservative treatment of Hyperhidrosis

3. Experiences of T4-sympathetic block by clamping (ESB4) in

treatment of hyperhidrosis palmaris et axillaris

4. Highly selective sympathectomy

5. Video - assisted thoracoscopic sympathetic ramicotomy for

hyperhidrosis - A way to reduce the complications

6. Thoracoscopic sympathectomy for palmer hyperhidrosis:

ablate or resect ?

7. Kuntz's Fiber: The scapegoat of surgical failure in sympathetic


8. Kuntz nerve

9. Kinetics of rewarming following ice water immersion - more

than a therapeutical control of ets?

10. Lin-Telaranta Classifications:

The Base of Designing New Procedures for Different Indications in

Sympathetic Surgery

11. Evaluation of the efficiency of Endoscopic Thoracic

12. Video assistance reduces complication rate of thoracoscopic

sympathicotomy for hyperhidrosis: results of 656 sympathicotomies

13. Failure to resolve flushing following ETS

14. Long term effects of ETS for hyperhidrosis and facial blushing

15. Endoscopic thoracic sympathicotomy in Japan

16. Sympathetic surgery for psychiatric problems

17. The connection between psyche and sympathetic nervous


18. ESB - a new treatment of choice for social phobia?

19. Successful spinal cord stimulation after failed thoracoscopic

sympathectomy for severe Raynaud's disease

20. Successful spinal cord stimulation after failed thoracoscopic

sympathectomy for severe Raynaud's disease

21. X- Ray screening to identify the rib & sympathetic chain

22. A novel scale for assessing quality of life following bilateral

endoscopic thoracic sympathectomy for palmer and plantar


23. Quality of life changes measured by SF-s6 for palmer

24. Quality of life evaluation following ETS for upper limb and

facial hyperhydrosis

25. Abdelazeem EI-Dawlatly, Abdullah AI-Dohayan, Walid Riyad, Ahmed

Thalaj, Bilal Delvi and Salwa Al-Saud

26. Anaesthesia for morbidly obese patients: a study of

hemodynamic changes during bariatric surgery

27. VATS cervico -thoracic sympathectomy (patient awake)

28. Various kinds of anesthesia practiced in the surgery of

thoracoscopic sympathicotomy in Taiwan

29. Follow up study of thoracoscopic sympathectomy in palmer

and plantar hyperhidrosis

30. Partial sympathicotomy using newly designed devices for

palmer hyperhidrosis

31. Quantitative sudometry as a perioperative[preoperative] evaluation method

32. Reversibility of the different sympathetic surgeries

Posters presented at ISSS

p-1. Ultrasonic energy and ETS

p-2 Upper thoracic sympathectomy for palmer hyperhydrosis: the use of harmonic scalpel versus diathermy

p-3 Thoracoscopic clipping of contralateral hand for patient with unilateral sympathectomy

p-3-2 Comparison between thoracoscopic sympathectomy and

sympathetic clipping

p-4 Needlescopic thoracic sympathicotomy with non-scar healing

p-5 ESB in the treatment of addiction

p-6 Stroke volume variation and cardiac output monitoring during

transthoracic endoscopic sympathectomy with C02


History of thoracoscopic neurotomies

Peter Kux Dr. Med., Clinica Chirurgica, Belo Horizonte, Brazil

The modern sympathicotomy and other thoracscopic neurotomies are

based on the Jacobaeus Operation in its technique and in the

physiological effects on the experience of Leriche.

The thoracoscopic access by Hughes and others in arteriopathies of the

upper leg was also used independently by E. Kux in 1940 In cases of

chest tuberculosis.

The surgical improvement lead to combine the Dragstedt Vagotomy for

duodenal ulcer therapy.

Wittmoser in the 50's made intrathoracic photos without flash and in

the 6o's first endothoracic television presentations.

In the 1965 Symposium in Vienna were gastroenteric and other

indications discussed and firstly coronariographies were demonstrated


The following causal therapy of gastroduodenal ulcers with bactericides

excluded this indication for vagosplanchnicotomies realized about

7000 by E. Kux up to 1972.

Thereafter the most frequent indications are localized hyperhidrosis.


Conservative treatment of Hyperhidrosis

Kiistala Urpo M.D., PhD., Helsinki, Finland

Localized hyperhidrosis of palmer, plantar or axially regions affects mainly

young adults. The major nonsurgical treatment modalities are as follows:

Internal anticholingergics are fairly safe in young adults and have been used

by some doctors for 25 years with success. Anticholinergics should be

reserved mostly for anticipated stressful situations because of potential

problems e.g. in vision an micturation.

Aluminum chloride hexahydrate topical treatment had its peak success

20-30 years ago. Aluminum salts are still useful for axillary hyperhidrosis

but less useful for palmer and plantar hyperhidrosis. I have seen patients

using this treatment with satisfactory results for 10-20 years.

Tap water iontophoresis is beneficial for light, moderate and severe

hyperhidrosis in palmer and plantar hyperhidrosis. The therapy can be

applied also for axillary hyperhidrosis. 10% of patients may not be responsive

to this treatment. In the long run once weekly treatment is required.

Iontophoresis should not be given to pregnant or those with mental

prosthesis. The device for home use is cheap.

Botullinum toxin A local injections are of recent success, mostly applied

for axillary hyperhidrosis. Injections are less often given to palms or soles.

Botulinum may be particularly valuable in treating excessive sweating of

the face (e.g. Gustatory sweating) and on treating restricted areas of the

trunk in compensatory hyperhidrosis. The effect is dose-related, yet

temporary. The treatment may be painful, may affect transiently small

muscles and must be repeated after 4-12 months. There are no long-term

follow-up results. The treatment is fairly expensive. Repeated or high-dose



Experiences of T4-sympathetic block by clamping (ESB4) in

treatment of hyperhidrosis palmaris et axillaris

Chien-Chih Lin, M.D., Hsing-Hsien Wu, M.D., Department of Surgery,

Tainan Municipal Hospital, Tainan, Taiwan

Many surgeons try to find out a method that can treat Hyperhidrosis

without inducing reflex sweating when sympathetic surgical technique

becomes well developed in treating Hyperhidrosis. Evidence suggests

that reflex sweating can be avoided only when the sympathetic tone to

human brain is preserved in sympathetic surgery. Incidentally, we found

that T4-sympathetic block by clamping (ESB4) is a method that can

treat Hyperhidrosis without interrupting the sympathetic tone to human

brain. The mechanism and how to avoid reflex sweating are discussed.

We applied ESB4 to treat 165 cases (84 males and 81 females) of

Hyperhidrosis palmaris et axillaris from August l, 2000 to February

28, 2001. Operative procedures were performed as conventional ETS

method by two-port approach except that the sympathetic nervous

trunk is clamped with 5 mm Auto Suture clips at the upper borders of

4th and 5th ribs. It takes less than 10 minutes to finish ESB4


Patients were followed up after operation. Hand and axillary sweating

were stopped immediately after ESB4 except in one patient who regretted

the operative result for no cessation of her face and body sweating;

another one got no change of hand sweating, the other three ones were

satisfied with minor hand sweating preserved. Most of them are without

reflex sweating after ESB4, or reflex sweating happens only mild or

ignorant degree in popliteal areas in hot environment.

Reflex sweating after sympathetic procedures for Hyperhidrosis is

controlled by Hypothalamus. It can be avoided when the sympathetic

tone to head is preserved in sympathetic operation. The ESB4 is by far

the only method that can stop hand and axillary sweating without

interrupting the sympathetic tone to head, thus reflex sweating can be

avoided after sympathetic surgery.


Highly selective sympathectomy

By A. AI-Dohayan, Amal, Abdul Karim, A Salem, A. El-Dawlatly, Al-

Ageely, KSA

The purpose of this study is to compare the efficacy and safety of

thoracoscopic cutting of postganglionic fibers and transthoracic

endoscopic sympathectomy.

The work was done after doing thorasthoracic unilateral sympathectomy

for eight patients. The patients were anesthetized using single lumen

tube, with continuous flow of carbon dioxide at pressure of 10mmHg.

We have managed 20 patients complaining of hyperhydrosis in King

Khalid University Hospital, Riyadh, Saudi Arabia.

The procedure started by diathermizing post ganglionic fibers of the

second, third and fourth sympathetic chain. Then the sympathetic chain

will be excised. The hand temperature raised by 2-3 degree c. in contrast,

the second technique rises the temperature 0.0.5 degree c more. All

patients had smooth post operative recovery and were discharged within

24 hours. Cutting post ganglionic sympathetic nerve fiber may replace

excision of the sympathetic chain. Thoracoscopic sympathectomy is

standard treatment for hyperhydrosis.

However, the complication of this procedure may limit its success.

Rebound hyperhydrosis may cause more serious problems than the

initial symptoms. All available surgical techniques for hyperhydrosis

have this problem. The need of new technique is required to avoid side

effects and highly selective sympathectomy may be a useful new



Video - assisted thoracoscopic sympathetic ramicotomy for

hyperhidrosis - A way to reduce the complications

Yu-Jen Cheng, Division of Thoracic Surgery, Department of Surgery,

Kaohsiung Medical University Hospital loo Snih-Chuan 1St Road,

Kaohsiung 80708, Taiwan, Republic of China

Endoscopic resection surgery of sympathetic nerves is now the most

acceptable method to treat palmer and axillary hyperhidrosis.

Nevertheless the resection of the sympathetic trunk and ganglia can

result in the complications of the compensatory hyperhidrosis and the

over-dryness of the denervated area. From January to October 2000

we adapted endoscopic cutting of the sympathetic rami without injury

to the ganglia and trunk in eight patients, which was a technique

modified from Wittmoser. We find that it is a good way to reduce the

complications, and, most importantly, it has a cure rate comparable

with the conventional technique. The longer operation time and the

requirement of the experienced-skill are the main faults.


Thoracoscopic sympathectomy for palmer hyperhidrosis:

ablate or resect ?

M. Hashmonai, A. Assalia & D. Kopelman*, Department of Surgery

B, Rambarn Medical Center, Department of Surgery B, Ha'emek Merncal

Center*, and The Faculty of Medicine, Technion - Israel Institute of


Presently, upper thoracoscopic sympathectomy is the preferred treatment

of primary palmer hyperhidrosis, obtained by either ablation or resection

of the appropriate ganglia. The present review was undertaken to

compare the results achieved by each of these techniques.

A Medline search was performed for ten years 1974-1999 to identify all

published studies of thoracoscopic sympathectomy for hyperhidrosis.

Thirty-four studies were identified and divided into two groups: ablation

and resection. Resection obtained immediate success rate of 99-76%,

whereas ablation achieved dry hands in 95-2% (P=O.OOOOI). The

recurrence rate of palmer sweating was o% for resection and o - 4-4%

for ablation. Ptosis was noticed in 0.92% of cases after ablation and in

1.72% after resection (p=o.oi7).

Resection yields superior results, yet the majority of surgeons ablate,

probably because it is easier, requires a shorter operating time, ensues

fewer Homer's syndrome, and because, eventually, re-sympathectomy

overcomes initial failure.


Kuntz's Fiber: The scapegoat of surgical failure in sympathetic


Chien-Chih Lin, M.D., Hsmg-Hsien Wu, M.D., *Lim-Shen Lee, M.D.,

Departments of Surgery and *Anesthesiology, Tainan Municipal Hospital,

Tainan, Taiwan

The incidences of surgical failure rate less than 2.0% are acceptable in

Endoscopic Thoracic Sympathetic Surgery (ETS). The cause of surgical

failure is investigated. The presence of Kuntz's fiber is once considered

the fetal reason of surgical failure. However, our clinical cases prove

that Kuntz's fiber plays no role in surgical failure of sympathetic


but does in anatomic role at our series of study. Re-dennition of Kuntz's

fiber is necessary in this era of Endoscopic Surgery.

Kuntz's fiber was described routinely on 1085 consecutive cases when

ETS was performed between 1992 and 1994- The incidence of Kuntz's

fiber is around 60% in general population in our study. Kuntz's fiber

is preserved when Endoscopic Thoracic Sympathetic Block by clamping

(ESB) was invented and used in 1996, while our surgical failure rates

were around 1.5% in our 785 cases of ESB between 1996 and 1998.

There is significant difference between the incidence of Kuntz's fiber

and surgical failure rate after Kuntz's fiber preservation procedures.

Navarro s animal experiment proved that the amount of hand sweating

is positively related to the number of sympathetic nervous fibers to

sweat glands. Our surgical failure rate is about 1.5% in our ETS patients

with Kuntz's fibers preservation, while the incidence of Kuntz s fibers

is about 60%, which was also supported by Japanese and Korean studies.

So far, difference between surgical failure rate and the incidence of

Kuntz's fiber was found in our study. Inappropriate application of clips

was the main cause of our surgical failure. Surgical results follow "all

or none" rule in sympathetic surgery. Sweating disorder is cured or not

in ETS, but there's no intermediate condition of hand sweating after

ETS. If Kuntz's fibers are composed a portion of sympathetic fibers,

decreased hand sweating amount is predicted on the case of ETS with

Kuntz's fibers preserved. We consider that Kuntz's fiber is only a

scapegoat of surgical failure in ETS; its re-definition is necessary

especially in this era of endoscopic surgery.


Kuntz nerve

Rafael Reisfeld, Los Angeles, USA

The rapid increase in ETS and ETS-C over the last decade brought with it

a lot of success stories as well as some failures.

Attempts to correlate failures with an elusive nerve of Kuntz is being

mentioned repeatedly in the literature (professional and laymen).

The author will try to shed some light into this name and to verify or to

cancel the myth associated with the Kuntz nerve.


Kinetics of rewarming following ice water immersion - more

than a therapeutical control of ets?

Kerstin Fronek, Martin Schmelz*, Christoph H. Schick

Dept. of Surgeiy,*Dept. Physiology, Univ. of Erlangen, Germany

Hyperhidrosis manuum has been traditionally quantified by sudometric

methods. We investigated vasoconstrictory sympathetic outflow in

hyperhidrosis patients indirectly by infrared thermography.

Infrared thermography was employed to measure skin temperature of

both hands in hyperhidrosis patients and 14 control subjects. After

a baseline of 1 minute both hands were immersed in ice water for 30

s. Immediately after the immersion the hands were dried and placed

into their original position for another 8 minutes. Infrared thermograms

were recorded at 10 s intervals (average of 32 consecutive pictures)

during the whole protocol using dedicated software (Erika, TRGV-900,

Agema. Sweden). Time course of rewarming was analyzed offline

separately for 6 circular areas (diameter 5mm) spaced by 1.5 cm from

the fingertip of the middle finger to the centre of the palm. In the

patients, the test was performed" 1-2 days before, 1-2 days after and 3

months after ETS.

Before ETS rewarming of the fingertips in the patients was significantly

slower as compared to age and gender-matched controls (ANOVA,

p<o.001). One day following ETS, time course of rewarming was

aramatically changed in the patients with a rapid initial increase of

temperature in the fingertips and a higher final temperature (Fig.). 3

months after surgery the pattern of rewarming was similar, however

final temperature no longer differed from controls.

In hyperhidrosis manuum increased sweat production is combined

with higher vasoconstrictor tone suggesting elevated sympathetic outflow

as a common underlying mechanism. Relative normalization of the

rewarming 3 months after ETS can be regarded as a sign of denervation

hypersensitivity of the peripheral adrenoreceptors. It remains to be

established whether infrared thermography rather than just quantizing

the effect of ETS may contribute to outcome prediction and patient



Lin-Telaranta Classifications:

The Base of Designing New Procedures for Different Indications in

Sympathetic Surgery

Chien-Chih Lin, M.D., *Timo Telaranta, M. D.

Surgical Departments, Tainan Municipal Hospital Tainan, Taiwan;

*Pnvatix Clinic, Tampere, Finland


Endoscopic Thoracic Sympathetic Surgery (ETS) has become a worldwide f

standard procedure in the treatment of Hyperhidrosis and many other


disorders. Reflex sweating (compensatory is an incorrect term) is probably

me most

common complication in sympathetic surgery. Whereas around 5.0% of


undergoing sympathetic surgery suffer from postoperative reflex sweating,


modified sympathetic procedures, including the sympathetic block by


method (ESB) first proposed by Lin in 1996, have been designed to avoid


complications. Despite the reversibility granted by this method, the

patients must

be satisfied with their original condition after the removal of the

clamps. They have

no option of both: dry hands and no reflex sweating. Is there any


procedure that can treat hyperhidrosis without inducing reflex sweating?


there now seems to be such a procedure. The new method was designed


clanking the mechanism of reflex sweating and the nervous tracts of



Surgeons usually consider that the other portions of the body naturally


over the sweating "job" of hands after a sympathetic operation. However,


discrepancies exist. Many studies have shown that there s no relationship


the sweating amount of hands and compensatory areas. In addition, reflex


is not found on lumbar sympathectomy for pure Hyperhidrosis plantaris. Why


there different postoperative responses between thoracic and lumbar


surgeries? Is traditional consideration of sympathetic innervation wrong?


concepts and classifications of sympathetic disorders proposed can explain

all post-

operative phenomena in sympathetic surgery. We believe that they will


standard rules in sympathetic surgery.

Sweating after sympathetic surgery is a reflex cycle between the


system and the anterior portion of the hypothalamus according to our


Reflex sweating will not happen if hand sweating can be stopped without


sympathetic tone to the human brain. We proved clinically from nervous


that neither T2 nor T3, but t4 and lower ganglia provide the major


innervation to hands. Major sympathetic fibers at the levels of T3 and

above innervate

head and neck. Few or none from T2 and TS innervate the hands while the

fibers j

from T4 must definitely pass through T2 and TS to innervate hands. This is

the '

reason why T2-sympatnetic procedures can treat hyperhidrosis but with

higher I

incidence and degree of reflex sweating. Thus, we know that ESB4 can treat

hyperhidrosis palmaris without interrupting sympathetic tone to the head

and neck,

therefore no reflex sweating is predicted on ESB4 cases. We have performed


to treat more than 160 hyperhidrotic patients with incredibly good results


August 1, 2000 to February 28, 2001.

The blushing and social phobic patients form a special group in ESB

surgery. While it seems clear, that 12 is the ganglion mostly responsible

for flushing as well as blushing, it has become more and more evident

that T3 and even T4 participate in blushing control. The role of the

different ganglia is not yet entirely clear, but the surgeries thus far

performed TS level for flushing seem to be sufficient for those having

also sweating of the face as part of the problem. Those having only

blushing and intense flushing seem to need a T2 clamping, and even so

that one clamp should be put on the upper border of the second rib, or

just underneath the Stellate ganglion, should this be lower. Moreover,

the medical branches of the lowest stellate ganglia and T2 are better

also included in the procedure in intense flushing and blushing.

The social phobia patients having no problems with either

blushing or sweating have in our studies had equally good results

statistically by unilateral left sided clamping. Left side is selected

whenever possible due to lesser risk of ectopic heart beats or arrhythmia’s.

In unilateral blocks the levels can be selected on a wider basis, e.g. T2

to 14 without almost any fear of reflex sweating.

After having mapped these new concepts on sympathetic nervous

tracts, we classified the sympathetic disorders into three groups. We

name this new classification "Lin-Telaranta classifications of sympathetic

disorders". A totally new concept has emerged with that classification.

"Different procedures for different sympathetic disorders" is emphasized

too. 95% of post-operative complications can be avoided \with our

classification. Here are the basics of our new classifications.

ESB2 (clamp upper end of T2 only): 2.5%, (in Europe 15%)

Facial blushing, Craniofacial sweating. Some psychic disorders, Rosacea,

Vibration disorder (?), Parkinsonism (?)...

ESB3: 2.5%, (in Europe 50%)

Hyperhidrosis Palmaris with Craniofacial sweating, blushing, or any

other craniofacial sympathetic disorders

ESB4: 95%. (in Europe 20%)

Hyperhidrosis Palmaris with or without axillary hyperhidrosis


Unilateral ESB: (in Europe 15%)

Social phobia, schizophrenia, sleep disorders, addiction, cardiac


Conclusion: The patients are individuals with individual symptom

complexes. There does not seem to exist any clear-cut hyperhidrosis

disease. Blushing disease, nor necessarily any social phobia disease, or

schizophrenia disease. All these states are symptom complexes of

multiple origin, and should be treated individually along the proposed



Evaluation of the efficiency of Endoscopic Thoracic

Sympathicotomy along with Severing the Kuntz Nerve in the

treatment of chronic non-infectious Rhinitis.

Joao Bosco Vieira Duarte & Peter Kux

Peter Kux Clinic, Belo Horizonte, M.G. Brazil

The etiopathogenic diagnosis of rhinitis is laborious and the clinical

treatment is unsatisfactory in a large number of cases. After endoscopic

thoracic sympathicotomy (ETS), some patients have reported

improvement of the symptoms of chronic non-infectious rhinitis (CNIR).

The aim of the present study is to evaluate the influence of ETS


with the severing of the Kuntz nerve in the follow-up of patients


from CNIR.

From October, 1993 to February, 2001, 117 patients (follow-up from 2

to 88 months; 50 males and 20 females; median age 24.9 years) were

submitted to bilateral ETS and severing of the Kuntz nerve for treatment

of hyperhidrosis and chronic non-festering rhinitis. The severing of the

sympathetic trunk was performed according to hyperhidrosis location:

palmer, plantar, axillary, and facial. In 3 cases surgery was indicated

for the treatment of rhinitis, and the sympathetic trunk severed at T2

and TS level.

Rhinitis was cured in 52 patients (44-4%)' 43 patients (36.8%) improved,

and in 22 patients (18.8%) there was no change. In 3 patients


operated on for treatment of CNIR, symptoms disappeared.

The results of the present investigation confirm the benefits of ETS

associated with severing of the Kuntz nerve in the treatment of CNIR.

We recommend this procedure for the treatment of rhinitis associated

with hyperhidrosis and also for the treatment of specific, isolated cases

of CNIR.


Video assistance reduces complication rate of thoracoscopic

sympathicotomy for hyperhidrosis: results of 656 sympathicotomies

Johannes Zacherl, Christoph Neumayer, Mardn lmhof, Raimund Jakesz,

Georg Bischof, Univ. Klinik. F. Chinirgie AKH 21.A., Klin. Abt. F.

Aligemeinchirurgie, Austria

Thoracoscopic sympathicotomy (TS) is proven to be a successful

treatment in palmer hyperhidrosis. However, up to 8% of patients

experience Homer's syndrome, about 50% show compensatory sweating

as reported in literature. This study evaluates the role of


in TS for primary hyperhidrosis of the upper limb.

656 TS were performed from below T1 to T4 in 369 patients. 558

operations were done under direct view (CTS) and 98 with video-

assistance (VATS). Perioperative data were evaluated for all patients.

Follow-up was completed in 78,3% of patients after a median observation

period of 16 years. Statistical analysis was performed by using __-test.

Dry limbs were immediately achieved in 92.4% (CTS) and 98% (VATS,

p=o,98). In the CTS group Homer's syndrome occurred in 2.2% and

rhinitis in 8,3%. No patient in the VATS group showed any symptom

of Homer's triad (p=o,03) nor rhinitis (p=o,02). Compensatory sweating

was observed in 66.8% vs. 69% (P=o,73)? gustatory sweating in 50.4

vs. 27.6% (p=o,ol). Relieve of hyperhidrosis was comparable between

the groups at follow up.

In performing TS for excessive upper limb hyperhidrosis we observed

a significant decrease in the incidence of Homer's syndrome, rhinitis

and gustatory sweating when the procedure was guided by video-

imaging. The clear view and magnification provided by VATS obviously

allowed for prevention of adverse thermal injuries to important

structures. The incidence of compensatory sweating, as expected, was

not altered by video-assistance.


Failure to resolve flushing following ETS

John Rennie, Kings College Hospital, London SEs 9RE, UK

Between May 1998 and March 2001, 220 successive patients were

reviewed within 6 months of ETS for chronic facial flushing. All

endocrine, menopausal or biochemical causes of flushing were excluded.

All ETS was performed by one surgeon and consisted of division of the

chain over the 2nd rib and diathermy ablation of the chain over the 3rd


All patients were assessed at 6 weeks by outpatient visits, telephone

calls or exchange of letters. Resolution of flushing was measured on a

subjective and objective score - using a number of stimuli known to

trigger flushing, and the patients own assessment of improvement.

10 patients showed no improvement in their flushing and a further 13

noted only partial improvement. 2 patients recurred after 2 years after

an initially favorable result. Of the 23 failures, 19 were male of whom

the mean age was 36 years compared with the whole group mean age

of 26 years.

This study confirms a failure rate of 10% and suggests that older males

are more likely to fail.


Long term effects of ETS for hyperhidrosis and facial blushing

Drott C, Claes G, Rex L. Dept of Surgery, Boras Hospital, Boras, Sweden.

We have previously reported good short term results of ETS (Endoscopic

Thoracic Sympathicotomy) for hyperhidrosis and facial blushing. The

purpose of this study was to assess the results after more than one year


A detailed questionnaire was sent to all patients operated on between 1989

and 1998 (n=2992). We received answers from 1895 (63%)- The mean

follow up was 59±o.8 months for those operated for hyperhidrosis and

29±0.3 months for those with facial blushing. An analysis of the non

responders from other contacts than the questionnaire (n=5i9) revealed

85% satisfied and 15% dissatisfied patients. We had no follow-up on 578

patients (19%)-

The effect on the main symptom was very good (94~99 ~ depending on

indication) and persistent compared to the short term follow-up. The

quality of life was considerably improved. The overall satisfaction rate

ranged between 79 and 92 % depending on indication. Compared to the

previously reported short term results, the proportion of patients who


dissatisfied was unaltered but there was a higher proportion who regretted

the procedure among the unsatisfied. The dominating cause for

dissatisfaction and regret was compensatory sweating. We were unable to

detect any previously unknown late side-effects.

We conclude that the ETS procedure is rewarding for a great majority of

patients with hyperhidrosis or facial blushing. However, due to the side-

effects, the procedure should be used only in patients with a severe


of hyperhidrosis or facial blushing. Thorough disclosure of the


and complication risks are mandatory prior to surgery.


Endoscopic thoracic sympathicotomy in Japan

Takeshi Ueyama, Osafumi Yuge, Takehisa lwai, Kanazawa National

Hospital, Hiroshima University, Department of Anesthesia and Intensive

Care and Tokyo medical and Dental University, Deportment of Surgery

The modern endoscopic thoracic sympathicotomy (ETS) procedure of

Dr. Claes was introduced to Japan in December 1992. We asked members

of the Japanese society of thoracoscopic sympathicotomy about their

activities by a questionnaire. From 1992 to the end of 2000, ETS was

performed to 7 017 cases in 50 hospitals and institutes, of which 6 620

194-3 %) were for hand sweating and/or axillary sweating.

There were no deaths related to ETS either during the hospital stay or

following discharge. Intraoperative bleeding was reported in 28 cases

(0.3%) and an open chest procedure to stop bleeding was required in

6 cases (0.08%). Short-term Homer's syndrome after the operation

was found in a few cases; however, permanent symptoms were recognized

in only 18 (0.28%). The most common postoperative complaint was

compensatory sweating on the chest, back, or abdomen. Most of these

patients countered this condition by using several methods of prevention

or protection and continued their daily life with little restriction,


83 cases (1.2%) experienced severe compensatory sweating and consulted

their doctors repeatedly for more than one year. All surgeons who

perform ETS recognize the excellent indication of hand and facial

sweating. Further, many doctors prefer this procedure as a first treatment

for arterial blood flow disturbance in upper extremities.


Sympathetic surgery for psychiatric problems

Eridd Vaisanen M.D., Ph.D., Paivi Pohjavaara MD, Timo Telaranta

M.D., Ph.D.

We need evidence based knowledge about the sympathetic surgery as

a treatment method for chronic and severe social phobia. Dr. Tela-ranta

has operated many social phobics successfully but our Social Insurance

Institution does not accept that method as it reimburses psychotherapies

and psychopharmaca. In our study design all patients were first tested

by a psychologist. Then the pre- and postoperative interviews were

made by a psychiatrist. The total sample now is over one hundred

patients. All of them have had many years of different therapies and

psychiatric drugs in vain and lost lots of money, too. The operation

results are excellent. Only one did not get any relief and in one case the

effect came after some months. All the others got immediate help. In

our presentation we shall describe some cases.


The connection between psyche and sympathetic nervous


Timo Telaranta M.D., Ph.D. and Paivi Pohjavaara M.D., Privatix Clinic,

Tampere, Finland

In the central nervous system the arousal requires the brain stem, the

thalamus and the cortex, attention is maintained in the right frontal


the formation of memories happens in the medial temporal lobe, certain

diencephalic nuclei and the basal forebrain. The amygdala rates the


of an experience. The limbic system is the centre of the human drives,

their regulation requires an intact frontal cortex. The injury in the


lobe impairs the executive functions as motivation and attention.

The sympathomedullary system and locus coerulaeus are activated in

depression, mania, panic disorder and acute phases of schizophrenia. The

autonomic nervous system is one of the most important mediators between

the mind and the body. It has two roles in this function:

the role in basic metabolic function as in energy storage and release, in


control of exocrine secretion and thus intake, in conservation, loss, and

transformation of energy the role in behaviour, where the hypothalamus

is involved in alert and defense reactions.

The sympathetic system is defined as an energy consumption system and

the parasympathetic system is an energy conserving and balancing force.

The sympathomedullary system is activated in various mental disorders.

The biopsychosocial model is clearly seen in the social phobia. The "fight

or flight - response of the sympathetic system can also be seen in the

physical signs of the social phobia when the patient is in the centre of

attention. With sympathetic overload the patient starts to fear the


situations and avoid them.

The need-adaptive approach adjusts treatment plans of socially phobic

patients who haven't had any help of medication and psychotherapy. It

seems possible to treat their symptoms and cut the vicious circle of


phobia blocking the sympathetic system in the upper thoracic level with

a surgical procedure. If a patient with the social phobia hasn't had any


of conventional treatment methods such as medication and psychotherapy,

the sympathetic block could be a treatment of choice for them.


ESB - a new treatment of choice for social phobia?

Pohjavaara P (1,2), Telaranta T(3), Vaisanen E(2); (l) Tampere City Mental

Health Care Center, (2) Oulu University Psychiatric Clinic, (3) Privatix

Clinic, Tampere, Finland

Social phobia causes in its most severe forms isolation and deteriorates

the quality of life. Its life time prevalence rate is as high as about 10

% of

the population. There are many biological and psychological theories about

the etiology of this disorder, however, at least the physical symptoms


to be mediated through sympathetic nervous system. The traditional

treatment of social phobia consists of medication and/or psychotherapy,

and helps about 50-70 % of the patients.

An open, uncontrolled prospective follow-up study of 169 patients with

the social phobia was carried out. The patients hadn't had help of

conservative treatment, they had ESB between the years 1995-2000. The

life history was recorded, and they were diagnosed according to DSM IV


The psychological insecurity in the childhood was more common than

other insecurity factors (alcoholism, physical abuse, high religious


or school torment) at highly significant level. Physical abuse was more

common in older age groups statistically.

The mean benefit in the psychic and physical symptoms was about 1,5

points. The wished for effect seemed even to increase over time when the

sweating of palms was treated. The only significant side effect, the

compensatory sweating of the trunk increased with 0,7 points. The mean

satisfaction to the operation was about 3 and it remained the same over

time. The quality of life of the operated patients improved.

ESB is useful in treatment of social phobia if traditional methods fail.


only meaningful side effect is reflex sweating, but its increase was not

statistically significant. The one-sided clamping is as effective as


sided procedure. The results remain the same over time and thus placebo

effect can be excluded. In future it is important to compare this


to placebo and traditional treatment to find out its place in the crowd of

the other, already officially approved treatment methods of the social



Successful spinal cord stimulation after failed thoracoscopic

sympathectomy for severe Raynaud's disease - A case report

P.Larcher", MD, B.Neuhauser\ MD, R.Perlanann\ MD, A.KofleI3, MD,

G.Fraedrich\ MD, Department of Vascular Surgery, University Hospital

Innsbruck', Department of Neurosurgery, University Hospital

Innsbruck~, Austria

Ischemic vascular disease of the upper extremity may represent a

challenging therapeutic problem because of frequent medical treatment

failure. We describe a case of Raynaud's disease that was treated by

epidural spinal cord stimulation (SCS) after failed thoracic


A 77-year old woman was referred to our vascular department for second

opinion. Over a period of three years the patient complained about

coldness an pain in both hands with changing finger tip ulcerations.

Medical treatment had failed to relief the symptoms. Where as physical

and laboratory tests were unremarkable, the acral oscillogramms

demonstrated a functional vascular disease at both sides. Pain rating

at this time using a visual rating scale (VRS; with a scale from o = no

to 10 = maximum pain) revealed a pain level of 7.1. After several

conservative treatment regimes, a bilateral stellate ganglion block and

later a bilateral thoracscopic sympathectomy was performed with only

temporary clinical improvement. Subsequently the patient was scheduled

for a cervical SCS procedure with two thin electrodes introduced into

the dorsal epidural space and connected to two pulse generators

implanted sudcutaneously in the upper abdomen. In VRS pain level

could be immediately reduced to 1.5. At follow-up visits had no

complaints and did not require any analgesics. The mean red blood cell

velocity and the capillary density had improved significantly and pain

rating decreased to 0.8. The patients hands and fingers were warm and

all digital ulcers had healed at the latest follow-up 18 months after


We conclude, that SCS seems to be an effective treatment option in

severe cases of Raynaud's disease even after failed thoracic




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Botulinum Toxin A injections reduce subjective sweating in

axillary hyperhidrosis

M.T.Smclair*, W.RusseU, N.Toosey, H.Manji, A.E.P.Cameron, I.S.Osman

Departments of Surgery and Neurology, Ipswich Hospital, Ipswich

Does Botulinum Toxin A (BTA) reduce sweating in patients with axillary

hyperhidrosis ?

We performed a prospective double blind randomized controlled trial

of BTA in axillary hyperhidrosis. 10 patients with severe axillary

hyperhidrosis were randomized to receive 200 mouse units of Dysport

(BiA) injected subcutaneously into one axilla and placebo (P) into the

other. Sweating was assessed quantitatively after a 30 minute period

of sweat provocation. Subjective sweating was measured using a 10

point linear analogue visual scale. Measurements were collected at

baseline, 1 week, 4 weeks, 12 weeks and 24 weeks following injection.

Mann Whitney U test was used for statistical analysis.

All figures are Median with interquartile range

P robJective icon

BTA subjective score

P Sweating (g)

There was a significant reduction in subjective sweating in axillai

injected with BTA compared with placebo at 4 weeks (* p<o.oi), ii

weeks (**p<o.ol) and 24 weeks (***p<o.02) following injection. Then

was a trend towards a reduction in measured sweating in the B17


Botulinum toxin A is effective in reducing sweating in axillar



X- Ray screening to identify the rib & sympathetic chain

Abdullah AI-Dohayan, King Khalid University Hospital, Riyadh, Saud


Identification of the number of the rib is sometimes difficult especially

in obese patient. The first rib to see in the thoracoscope is the seconc

and first rib to feel is the first rib. However these procedures are not

always easy to perform. A surgeon who is performing these procedures

for the first time may use this technique before performing

sympathectomy. The technique was performed to 10 patients & frustrated

to junior surgeons. X- Ray screening to identify the number of the rib

is essential for junior surgeon.


A novel scale for assessing quality of life following bilateral

endoscopic thoracic sympathectomy for palmer and plantar


Steven M. Keller, M.D., David Sekons, M.D., Harry Scher, R.N., Peter

Homel, Ph.D., Marilyn Bookbinder, Ph.D., Montefiore Medical Center,


The purpose of the study is to uniform the methods of measuring the


of lire (QOL) following endoscopic thoracic sympathectomy (ETS) for

palmer and plantar hyperhidrosis (PPH) is necessary in order to allow

accurate comparison of results from different investigators. Current QOL

instruments may not address issues associated with PPH. We conducted

a prospective study of a QOL scale developed specifically for patients



Prior to undergoing bilateral ETS from T2-T3 via single axillary


patients complete both our novel hyperhidrosis scale and the standard

SF-36 QOL questionnaire. The forms were completed again at 2 weeks, 6

months, and l year following surgery. The hyperhidrosis scale consisted

of 15 questions that reflected the common physical symptoms and social

stigmata associated with PPH. Responses were graded between o (mild)

and 10 (severe).

71 patients entered the study between 2/99 and 12/99- The mean

preoperative score of the hyperhidrosis scale was 6.85 which decreased to

1.79,1-53, and 1.91 at 2 weeks, 6 months and l year, respectively


student t-test). Individual analysis of the hyperhidrosis scale questions

revealed strong reliability (Cronbach's Alpha = 0.89). Mean preoperative

and postoperative scores of the SF-36 were not significantly different

(p=o.70, student t-test).

Standard QOL instruments do not accurately assess the benefits of ETS

for PPH. We have developed a novel hyperhidrosis scale that reliably and

reproducibly reflects the QOL following bilateral ETS for PPH.


Quality of life changes measured by SF-s6 for palmer

hyperhidrosis and facial blushing treated with Endoscopic

transthoracic sympathicotomy

L. Rex, C. Drott, G. Claes. Department of Surgery, Boras hospital. Boras,


Patients with palmer hyperhidrosis and facial blushing were operated

with Endoscopic Transthoracic Sympathicotomy by interganglionic

transsection of the sympathetic chain over the second and third ribs.

A questionnaire, SF-36 (short-form -36) was answered by the patients

preoperatively and was sent out 3 months postoperatively. There were

37 patients operated for palmer hyperhidrosis and 52 patients for facial

blushing, the reply was achieved from 30 (78%) and 48 (92 %),

respectively. Mean age was 28 years (15-54 )• 61 % were women and 39


For hand sweat the values were changed as follows: Physical function

preop 89,9 16 postop 94,4 11,6 n.s., Social function preop 48,1 16,1

postop 90,0 19,4 P< o,ooo1, General health preop 51,3 13,6 postop

63,9 12,2 p<o,oooi. Mental health preop 64,7 10,8 postop 62,9 8,6


For facial blushing the values changed as follows: Physical function

preop 89,8 25,5 postop 92,4 16,4 u-s-. Social function preop 66,2 29,9

postop 86,4 22,8 p<o,ooi, General health preop 78,6 18,5 postop 72,8

19,1 p<o,05, Mental health preop 68,4 19,3 postop 77,7 19,3 p<o,ooi.

ETS for palmer hyperhidrosis and facial blushing was examined by SF-

36. The operation improved the social function and markedly improved

the mental health of those patients operated for facial blushing. For

physical function there were no change.


Quality of life evaluation following ETS for upper limb and

facial hyperhydrosis

Swan M.C. and Paes T., Hillingdon Vascular Unit, Hillingdon Hospital,


Endoscopic Transthoracic Sympathectomy (ETS) is a safe, effective,

minimally invasive treatment for severe primary hyperhydrosis. In spite

of current trends towards health care rationing and the need to

demonstrate clinical effectiveness, little is known of the influence of

ETS on patient Quality of Life.

In this prospective cohort study, the outcome of bilateral ETS was

assessed using the Dermatology Life Quality Index (DLQI) questionnaire.

The DLQI is a simple means of quantitatively assessing the impact of

a dermatological disease and its treatment on patients' quality of life.

10 consecutive patients (6 male and 4 female, average age 24 years)

underwent two-stage bilateral ETS for primary hyperhydrosis (5 palmer,

3 facial and 2 axillary). Two patients had combined facial blushing and

hyperhydrosis. The technique of selective electrocautery ablation was

used to minimize the risk of compensatory sweating. The dominant

side was operated on first, with the contralateral side being completed

6 weeks later. Each patient was assessed with the DLQI questionnaire

on 3 separate occasions: at the initial outpatient consultation, prior to

the second-stage operation, and finally at six weeks post re-operation.

Symptomatic improvement was achieved in all patients. No post-

operative Homer's were observed. A single patient reported mild

compensatory sweating. Statistical analysis (one-tailed Wilcoxon rank

test) demonstrates a significant (p<o.05) step-wise improvement in

Quality of Life after each stage.

This has not previously been described for two-stage bilateral ETS and

confirms the suitability of this technique in the dennitive management

of refractory primary hyperhydrosis.

pathectomy: endobronchial anesthesia vs

nesia with intrathoracic C02 insufflation


Abdelazeem EI-Dawlatly, Abdullah AI-Dohayan, Walid Riyad, Ahmed

Thalaj, Bilal Delvi and Salwa Al-Saud, Departments of Anesthesia and

Surgery, College of Medicine, King Saud University and King Khalid

University Hospital, Riyadh, Saudi Arabia

This study compares the hemodynamic and respiratory parameters

changes during thoracoscopic sympathectomy (TS) under general

anesthesia with two different anesthetic techniques namely

endobronchial anesthesia versus endotracheal anesthesia with

intrathoracic 002 insufflation.

125 patients undergoing TS for treatment of palmer hyperhidrosis (PH)

were studied (29 ± 6 and 32 ± 3 years of age for groups A and B

respectively). The patients were randomly assigned to two groups; group

A(n:68) double lumen endobronchial tube (DLT) was used and group

B (n:57) the trachea was intubated with single-lumen tube (SLT).

Anesthesia was maintained with 1 MAC isoflurane in 50% nitrous oxide

in oxygen with incremental doses of sufentanil and atracurium when

required. Arterial blood gases were measured in 10 patients of group

B. Hemodynamic and respiratory parameters were obtained.

The mean arterial oxygen saturations (Sp02) were 95 ± 1 and 98 ± i%

for groups A and B respectively (P<o.c)5). The mean duration of

anesthesia was significantly shorter in group B, 36 ± i2min compared

to group A, 50 ± i8min. Three patients in the recovery room had

Sp02<90% where the chest tube was readjusted with no further sequelae.

Although the Sp02 was significantly low in group A, it was of no clinical


General anesthesia with SLT provided excellent operating conditions

during TS. Moreover the use 01002 insufflation at a rate of 0.5 - iL/min

with maintained intrathoracic pressure at 6mmHg provided

hemodynamic stability with no clinical significant C02 retention.


Anaesthesia for morbidly obese patients: a study of

hemodynamic changes during bariatric surgery

Abdelazeem A. EI-Dawlatly M.D and Abdullah Al-Dohayan FRCS

*Departments of Anaesthesia and Surgery, College of Medicine, King

Sana University, Riyadh, KSA

Morbid obesity is a serious disease that is responsible for several co

morbid conditions. Body mass index >40 requires surgical procedures

if diet program fails. Laparoscopic adjustable gastric oanding (LAGB)

is recently introduced as minimally invasive surgery. Anesthesia for

morbid obese patients is challenging. Morbid obesity is associated with

respiratory and cardiovascular derangements. Therefore, we conducted

the present study in order to determine the hemodynamic changes

during LAGB surgery for morbidly obese patients. METHODS: Seven

patients (4 males) with a mean age of 36.2 yr (range 25-50) and a mean

Dody mass index of 49-7 kg/ni_ (range 39-3-67-3)- Each patient was

given general anesthesia, and an adjustable LAP-BAND was implanted

laparoscopically. The technique of anaesthesia was as follows:

preanaestnesiawith lorazepam 2mg and 150 mg ranitidine orally 2

hours before surgery, induction with fentanyl o.img, propofol 0.5-

i.omg/kg, succinylcholine img/kg, orotracheal intubation, maintenance

with 02-N20 50%, sevoflurane i% to 1.5%, atracurium o.5mg/kg (dosage

refers to ideal weight) awakening and decurarization with atropine

sulphate img and prostigmine 2mg. Monitoring includes non-invasive

blood pressure, 02 saturation, ECG, ETC02, temperature and non

invasive cardiac output monitor (NICO, Novametrix, Wallingford, USA).

The average operating time was 3+/-ihr. All the hemodynamic variables

were taken at three phases, phase l, prior to positioning and gas

insufflation, phase 2, after positioning and during gas insufflation and

phase 3 at gas deflation during recovery. Student's t- test was used for

statistical analysis. RESULTS: the mean values of preoperative

pulmonary function tests were 3.85+/-0.6,3.44+/-0.37L, and 82.04+/-

0.74 for FVC, FEVi and FEVi/FVC respectively. The mean values of

the preoperative arterial blood gases were 7.39+/-0.02, 84.oi+/-i4-5?

36.7+/-1.6 mmHg and 95-5+/-i-3% for the pH, Pa02, PaC02 and 02

saturation respectively. The mean cardiac output (COP) was 7.2+/-1.1,

9.06+/-2.6 and io.4+/-3-6L/mm during phases 1,2 and 3 respectively

with significant differences between phases l and 2, l and 3, 2 and 3

(p<o.05). The mean values of the stroke volume variations were 91-1+/-

12.3, 123.2+/-42.6 and 133-5+/-49-9 ml/min for phases 1,2 and 3

respectively with statistical significant differences between all the


(p<o.05). The mean values of the cardiac index (Cl) readings auring

pnases 1,2 and 3 were 3.1+/-0.7,3.4+/-1-09 and 4-03+/-1-3 respectively

with significant differences between the readings in the three phases

(p<o.05). Neither morbidity nor mortality encountered in our series.

CONCLUSION: although stroke volume, COP and Cl variations during

our study showed significant differences during gas insufflation period

compared to the gasless periods but we believe that it has no clinical

significance. Surprisingly, morbid obese patients tolerated the procedure

with no deleterious ettects.


VATS cervico -thoracic sympathectomy (patient awake)

Milanez, J.R.C; Israel, A.P.C.; Jatene F.B.; Auler Jr. J.O.C.; Kaufmann,


Margarido, C.; Paredes, J. M. , Heart Institute (InCor), University of Sao

Paulo Medical School, Sao Paulo, SP, Brazil

Nowadays video endoscopic thoracic sympathectomy (VETS) utilized for

treatment of reflex sympathetic dystrophy or hyperhidrosis is generally

realized under general anesthesia with selective orotracheal intubation.


order to reduce the cost and hospitalization time it can be realized


general anesthesia. The video will show a patient with palmer and axillary

hyperhidrosis operated by this operated by this technique.

Analyze the viability of VETS oy VATS, with the patient awake, without

orotracheal intubation and with peridural anesthesia.

Thoracic peridural anesthesia at level T3/T4 with about io dermatomes

block (Tl to Tio) and sedation with propol (io-20mg). Chest surgical

approach was bilateral, sequential, with electrocoagulation oithe

sympathetic chain (from T2 to TS). Pleural drainage witn a fine tubular

arain was done by suction, through the orifice of the axillary tocar and

removed at the end of the operation.

The patient could evaluate the result immediately at the end of the


and was discharged after a few hours, with only mild chest pain,


by common analgesics. The control chest X-ray failed to snow significant


This is a possible method, safe, effective and of lesser total cost than


realized by VATS. The video permitted its realization.


Various kinds of anesthesia practiced in the surgery of

thoracoscopic sympathicotomy in Taiwan

Lim-Shen Lee, Chien-Chih Lin, Hsiao-Ti Fang, Chung-Fai Au,

Department of Anesthesiology, Tainan Municipal Hospital, Tainan City,


The discussion of the suitable anesthesia for the surgery of thoracoscopic

sympathicotomy in the first international symposium for thoracoscopic

sympathicotomy held in Boras, Sweden 1993 was still fresh in my mind.

Now, it is well accepted that single-lumen endotracheal intubated

anesthesia is now playing the major role in the surgery of thoracoscopic


Thoracoscopic sympathicotomy covered by the government health

insurance is now a common surgery in Taiwan. Hundreds of operations

have been held each year from the medical centers to district hospitals

in Taiwan. We are going to introduce the various kinds of anesthesia

that were practiced some of these hospitals. The key point for the

success of theses anesthesia is based upon the full cooperation between

the surgeons and the anesthesiologists.


Follow up study of thoracoscopic sympathectomy in palmer

and plantar hyperhidrosis

Masahiro Shiotani MD. PhD, NTT EC, Kanto Medical Center, Pain

Clinic, Tokyo, Japan

We performed 1950 thoracoscopic sympathectomy on 975 patients

suffering from hyperhidrosis from Jan. 1994 to May 2000 in Kanto

Medical Center. The mean age of the patients was 30 years (range 9-

74) and 59% were females. 17% were below the age of 20 years and 56%

were below the age of 30 years. The operation time for a bilateral

procedure was 40 minutes. The patients were discharged after an

overnight stay or one more night stay.

522 patients answered the questions. Palmer hydrosis was completely

disappeared or decreased in 99%- Facial sweating was diminished in

56% and axillary sweating was diminished in 46%. Plantar hidrosis was

diminished in 34%- 90% had compensatory hyperhidrosis, that is,

increased sweating elsewhere on the body, which affected either the

back, abdomen, thigh, or foot. In some patients, the compensatory

hyperhidrosis caused some social embarrassment and was severe enough

to require regular change of clothing.

In follow up study with a questionnaire, patient satisfaction was


in 47%. good in 41%, fair in i%, 1% regretted the surgery and 10% were

unable to evaluate.

Thoracoscopic sympathectomy is a minimum invasive technique for

surgical sympathectomy. It otters the patients suffering from palmer

hyperhidrosis a safe and inexpensive operation.


Partial sympathicotomy using newly designed devices for

palmer hyperhidrosis

Hidehiro Yamamoto, MD, AMo Kanehira, MD, Masayoshi Okada, MD,

Munenori Kawamura, MD, and Yutaka Okita MD

Compensatory sweating (CS) has been known as a major side effect

after thoracic sympathicotomy for patients suffering from palmer

hyperhidrosis (PH). The aim of the present study was to decrease CS.

New devices including a needle scope guide, micro-pulse generator and

Laser Doppler microcirculation meter were used to perform thoracic

sympathicotomy. After insertion of a needle scope guide, complete or

partial thoracic sympathicotomy was carried out for 160 patients, the

value of the microcirculation meter on the finger of the operative side

at the stimulation of sympathetic trunk (T2, TS, 14) using a micro-pulse

generator. In group A (n=8o), complete resection of the thoracic

sympathetic trunk was done. In group B (n=8o), the lateral half side of

the trunk was done at the same sympathetic level. A questionnaire

inquiring about efficacy, severity score of CS (SSCS) was implemented

12 months after operation.

Between October, 1998 and November, 1999? 160 patients with PH

underwent unilateral thoracic sympathicotomy. SSCS in group B showed

significant decrease in CS in comparison with group A. Interpretation:

CS could be decreased by partial sympathicotomy. And CS could be

thought as a disorder of body sweating caused by resection of the nerve

fibers suppressing body sweating. We recommend partial

sympathicotomy to improve postoperative satisfaction.


Quantitative sudometry as a perioperative evaluation method

for compensatory sweating - is a prediction possible?

Christoph H. Schick, Tobias Siebert, Thomas Reck, Wemer Hohenberger,

Dept. of Surgery, Univ. of Eriangen, Germany

Endoscopic transthoracal sympathectomy (ETS) is a standard treatment

for primary hyperhidrosis. As an important side effect compensatory

sweating (CS) occurs in patients post ETS. Despite CS is located at the

back most commonly, up to now the intensity of CS is not predictable.

In a prospective study we investigated preoperative quantitative

sudometry as a marker for CS expected after ETS.

45 patients treated with ETS in a period of 10 months were investigated.

A quantitative sudometry was performed 1-2 days before and 3 months

after ETS. A measuring chamber was glued on hand, forehead, back,

and upper leg and a continuous nitrogen gas flow through the chamber

was established. Humidity was measured in the gas flow during

stimulation of sweating (Rotronic Messgerate, Ettlingen, Germany).

Data were recorded and processed computer-assisted (SPSS, SPSS Inc.,

Chicago, USA). Side effects after ETS were inquired in a questionnaire


Preoperatively patients achieved average maximum values of62.3%rH

(relative humidity) at the hand, 32.8%rH at the fore head, 35-i%rH at

the back and 2i.l%rH at the upper leg. After ETS average maximum

values were significantly lower at the hand (20.2%rH) and the forehead

(20.6%rH), higher at the back (50,2%rH), and unchanged at the upper

leg (27,o%rH). Sudometry correlated with the patients' statements

about CS. Patients with preoperative maximum values lower than

30%rH at the back defined their CS post ETS as irrelevant. Patients

with preoperative values higher than 4<3%rH felt impaired by CS at the

back after ETS.

Quantitative sudometric is a suitable procedure for the quality

assessment of ETS procedures. Patients with increased preoperative

values at the back must expect a relevant CS after an ETS operation.

Strongly increased values must be discussed as a contraindication for

the procedure.


Reversibility of the different sympathetic surgeries

Timo Telaranta, Privatix Clinic, Tampere, Finland

Sympathetic surgeries have become more and more common in the

treatment of Hyperhidrosis and Blushing disorders. Several thousand

procedures are performed on a yearly basis worldwide. This means that

even a rare side effect becomes quite common. If 10 % develop a negative

side effect, that already means Hundreds of unhappy patients.

The severity of the side effects seems to depend on three issues:

The extent and site of the preoperative sweating pattern

The extent and severity of the surgical trauma

The psychic condition of the patient

All three issues should be meticulously taken into consideration before

any surgery is performed.

When the side effects are already present, notably the reflex sweating,

there are three ways of treating the situation:

Anticholinergic and other pharmacotherapy

Temporary relief only

Removal of the clamps

Relief within 6 months from the removal, time between the surgeries

<6 months. Reconstruction of the destroyed sympathetic nerves.

Some relief immediately, more in within 3 years of a successful surgery.

Successful surgery is not always possible.


Ultrasonic energy and ETS

Lars Ladegaard, Soren Kruse-Andersen, Dept.Thor. Surg. OUH, Odenst


Ultrasonic energy is a new tool in surgery, it cuts and seals vessels and

nerve tissue, without damaging the surrounding tissue

Since April 1999 we have used ultrasonic energy(Ultracision.Ethicon)

as the cutting device in ETS procedures. This new device was introduced

in order to reduce the risk of complications.

142 patients have been operated since April 1999- The first 66 consecutive

patients participated in a questionnaire, all patients replied (100%)

The significance of using ultrasonic energy will be discussed, as well as

our results.


Upper thoracic sympathectomy for palmer hyperhydrosis: the use of harmonic scalpel versus diathermy

D. Kopelman*, H. Bahous, A. Assalia, M. Hashmonai, Department of

Surgery B, Ha'emek Medical Centre*, Department of Surgery B, Rambarn

Medical Centre, Faculty of Medicine, Technion - Israel Institute of

Technology, Haifa, Israel

Upper dorsal thoracoscopic sympathectomy, the treatment of choice

for primary palmer hyperhidrosis, is not devoid of long-term

complications, like Horner's syndrome and postoperative neuralgia. It

has been postulated that propagation of heat induced by diathermy

maybe responsible for some of these sequelae. To assess this hypothesis,

a study was undertaken to evaluate the use of harmonic scalpel, which

does not dissipate heat.

Sixteen patients with primary palmer hyperhidrosis underwent upper

dorsal thoracoscopic sympathectomy using the harmonic scalpel on

one side and diathermy on the other. The length of each procedure,

the occurrence of intra- and post-operative complications, and the

localization of postoperative pain were recorded. Follow-up was made

two years postoperatively.

The length of the procedure with each instrument was similar. No

operative or postoperative complications were observed. There was no

localization of postoperative pain, which could be attributed to either

device. No Homer's syndrome or postoperative neuralgia was reported.

The present study did not detect any advantage in the use of harmonic

scalpel over diathermy for upper dorsal thoracoscopic sympathectomy.


Thoracoscopic clipping of contralateral hand for patient with unilateral sympathectomy

A Aldohayan, M Alageely, A Abdulkarim, 0 Noraldin, A Aldawlatly

King Khalid University Hospital, Riyadh, Saudi-Arabia

Previously, King Khalid University Hospital's experience with unilateral

sympathectomy was reported. The procedure was done to avoid rebound

hyperhidrosis. Many patients were requesting the surgery for the

contralateral hand. However, those patients are at risk of rebound

hyperhidrosis. Thoracoscopic clipping of Ts was performed successfully

for 10 patients. Postoperatively, no rebound hyperhidrosis occurred.

Thoracoscopic clipping for contralateral side may be suitable operation

for patients who had undergone unilateral sympathectomy. Further

studies are needed for better outcome and reducing the rate of rebound



Comparison between thoracoscopic sympathectomy and

sympathetic clipping

A Aldohayan, M Alageely, A Abdulkarim, 0 Noraldin, A Aldawlatly

King Khalid University Hospital, Riyadh, Saudi-Arabia

Thoracoscopic clipping is a new procedure with limited experience.

Prospective study was carried out comparing the efficacy of T2-T4

sympathectomy versus clipping at level of Ts. Twenty patients were

enrolled in study. Sympathectomy was done for the right side (Group

A) and sympathetic clipping for the left side (Group B). Postoperative

recovery, satisfaction of patient, and pain were assessed. Thoracoscopic

sympathetic clipping is effective as thoracoscopic sympathectomy.

Thoracoscopic sympathectomy is performed using 3mm incisions. On

the other hand, thoracoscopic clipping is carried out using lcm incision.

Postoperative analgesias consumption rate is more in the

sympatnetectomy group. Thoracoscopic clipping is effective as

thoracoscopic sympathectomy. Longer follow is needed to assess the

real success.


Needlescopic thoracic sympathicotomy with non-scar healing

Hidehiro Yamamoto, MD, Akio Kanehira, MDi, Masayoshi Okada, MD,

Munenori, Kawamura MD2, and Yutaka Okita M.D., Kobe, Japan

The aim of this technique is to promote an ultimately less invasive

technique of video-assisted thoracic sympathicotomy. A newly trocar

(a needlescope guide) designed by us were used. One skin incision of

2.o-2.smm was made on each armpit. After insertion of the device,

thoracic sympathicotomy was carried out using the tip of the a

needlescope guide.

More than 1300 patients with palmer hyperhidrosis underwent this

technique. The effect of thoracic sympathicotomy was recognized in all

patients. The operative wound or 98.8% patients disappeared.

Complications including bleeding, pneumothorax, neuralgia, numbness

and Homer's syndrome were none. This technique resulted in non-scar

healing and improved patient's cosmesis and neural complaints. This

technique might be called as a needlescopic surgery.


ESB in the treatment of addiction

Pohjavaara P(l,2), Telaranta T(3), ja Vaisanen E(l); (i)0ulu University

Psychiatric Clinic, Finland (2)Tampere City Mental Health Care Centre,

Finland and (3)Privatix-Clinic,Tampere, Finland

Addiction problems are common in people with psychiatric disorders.

The addiction may be a primary or secondary problem.

The secondary addiction problems appear due to patients' attempts to

"treat" themselves with e.g. alcohol or excessive medication, especially

benzodiazepins. Social phobia is an example of a primary psychiatric

disorder, which leads to secondary addiction problems in about 20 % of

the patients.

L H-R was 46 years in the 1998 when the ESB was carried out to her. She

was born one handed and her mother despised her for that. Her first

psychiatric hospital treatment period began when she was 15 years old

after having attempted suicide. She was anxied, depressed, and she

developed a serious drug- and alcohol dependence. She isolated completely,

and even at her home she couldn't face people without taking large doses

of benzodiazepins and/or alcohol in advance. She had been on the

permanent disability pension for over ten years. In social situations she

hid herself to the back other healthy hand and avoided eye-contact, and

she got atetotic trembling symptoms in her head and hands.

After the sympathetic blockade her former benzodiazepin medications

(which she used over loo milligrams a day before the operation) and


use have diminished to the minimum. She feels she has got a new life and

thinks that she hadn't had to leave on pension if this kind of treatment


been available earlier.

Our patient had suffered from social phobia and its secondary problems

already from the childhood and she recovered from a serious alcohol and

drug addiction after successive treatment of her social phobia with ESB.

The psychiatric treatment of a patient with many comorbid disorders has

to begin by treating the primary problem, and after the primary disorder


Stroke volume variation and cardiac output monitoring during

transthoracic endoscopic sympathectomy with C02


Abdelazeem A. EI-Dawlatly M.D and Abdullah AI-Dohayan FRCS

Departments of Anesthesia and Surgery, College of Medicine, King Saud

University, Riyadh 11461, P.O.Box 2925, KSA

Transthoracic endoscopic sympathectomy (ETS) is an established

treatment for palmer hyperhidrosis. Anesthesia for ETS requires the

provision of one lung ventilation (OLV), which can be accomplished by

different anaesthetic strategies. We have established our anaesthetic

technique that comprises the use of single lumen endotracheal tube

with intrathoracic 002 insufflation at a maintained intrathoracic pressure

of 6mmHg. That provides the best operating, oxygenation and

hemodynamic stability conditions. However, in an attempt to study the

hemodynamic variations during ETS and C02 insufflation, we conducted

the present study using the non-invasive cardiac output (NICO) monitor

(Novametrix Medical System Inc, Wallingford, CT, USA). The NICO

monitor utilizes a minimally-invasive partial rebreathing method to

determine cardiac output by means of a differential form of the Pick

equation. In the present study we compare the stroke volume and

cardiac index variations between right and left sided ETS procedures

with intrathoracic C02 insufflation. The results of the study will be

discussed during the presentation.


Endoscopic thoracic sympathectomy in vascular lesions

associated with systemic sclerosis

Alberto Giudiceandrea, MD*, George Hamilton, FRCS, Alexander M.

Seifalian PhD, Vascular Haemodynamic Laboratory, University

Department of Surgery, Royal Free and University College Medical

School and The Royal Free Hospital, London, U.K., * Surgical Unit,

Clinica Valle Giulia, via de Notans, Rome, Italy

Systemic sclerosis is a hideous disease with involvement of the vascular

system causing digital gangrene and loss of the extremities. In cases

with proven microvascular disease ETS may be an option. In this

retrospective study set in a major UK referral centre for Scleroderma

we evaluated the safety and efficiency of ETS surgery

ETS was performed in 5 patients with severe systemic sclerosis and

digital gangrene. All patients were female with a median age of 35 7

and all nad pulmonary involvement Macrovascular disease was escluded

by angiograpghy and sympathectomy was performed on the major

affected side under general anaesthesia. A 10 mm optic was used with

a working channel and a T2, TS, T4 sympathectomy was performed.

Postoperative a chest tube was inserted. Healing was assessed on a

visual scale

There was no beneficial effect of sympathectomy on the healing, there

was no regression of the Ischemic changes and 2 patients required

subsequently amputations. 2 out of 5 patients had severe chest

complications, one had a persistent Pneumothorax, probably due to

pulmonary fibrosis and diuiculty in re-expansions of the lung, and one

had severe dyspnoea requiring subsequent intubation.

ETS is of limited value in patients with severe ringer ischaemia and

pulmonary fibrosis due to nigh grade of thoracic complications and

limited effect on digital perfusion. Pharmacological intervention or

digital sympathectomies is the treatment of choice in severe digital



Thoracoscopic sympathicotomy in causalgia

Saeed Kargar Dr.,

Shahid Saadoghi Medical University, General Surgery, Yazd, Iran

Causalgia, post-traumatic pain syndrome remain one of the most poorly

understood and frequently misdiagnosed entities encountered in clinical


We discuss a case of causalgia in 35 years old man with isyears duration

of symptoms (stage 2 Drucker ) in whom non-operative therapy consist

of arug therapy (phenytion, amitriptyline, carbamazepine.oeclofen,

ibuprofen and diclofenac Na), intermittent sympathectomy and

physiotherapy failed but full degree of pain relief achieved by thoracic

T2-T3 sympathicotomy without any major complication.


Esophageal peristalsis and upper and lower esophageal

sphincter function after thoracoscopic sympathectomy

S. Kruse-Andersen, C. Holton and L. Ladegaard, Dept. ofThoracic and

Cardiovascular Surgery and The Motility Laboratory, Odense University

Hospital, Odense, Denmark

During the last decades the number of thoracic sympathectomies has

increased considerably, especially in patients with disabling facial

blushing and palmer hyperhidrosis. The consequences of thoracic

sympathectomy for pulmonary, ocular, and cardiovascular function

have been examined. However, no investigations have been undertaken

in order to evaluate the possible consequences of thoracoscopic

sympathectomy on esophageal function. In the present study, 10 patients,

median age 35 yr. (range 18-63 yr.), were subjected to stationary

perfusion manometry of the esophagus before and after thoracoscopic

sympathectomy. At the same two occasions sweat production on the

right hand was measured quantitatively. All patients were operated by

the same surgeon and by the same technique, where the sympathetic

chain was transected bilaterally on the levels of the second and third

sympathetic ganglia. The following parameters/responses were

evaluated/registered: The gastro - oeso - phageal sphincter pressure,

the sufficiency of sphincter relaxation in response to swallowing, the

number of propagating, simultaneous, reverse, and segmentary

contractions occurring during 15 minutes of rest, distal wave amplitude,

distal wave duration, and propagation velocity following swallows of 5

ml of water and of a solid bolus, swallowing response, presence of

spontaneous contractions, and pain response to a series of provocation

tests, upper esophageal sphincter relaxation and its co-ordination to

pharyngeal contractions. Results: using paired comparison methods,

we found no significant changes in esophageal function after