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?
The Base of Designing New Procedures for Different Indications in
Sympathetic Surgery11. 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
system18. 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
hyperhidrosis23. Quality of life changes measured by SF-s6 for palmer
24.Quality of life evaluation following ETS for upper limb and
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 surgery27. VATS cervico -thoracic sympathectomy (patient awake)
28.Various kinds of anesthesia practiced in the surgery of
thoracoscopic sympathicotomy in Taiwan29. Follow up study of thoracoscopic sympathectomy in palmer
and plantar hyperhidrosis30. Partial sympathicotomy using newly designed devices for
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-2Upper thoracic sympathectomy for palmer hyperhydrosis: the use of harmonic scalpel versus diathermy
p-3Thoracoscopic clipping of contralateral hand for patient with unilateral sympathectomy
p-3-2Comparison between thoracoscopic sympathectomy and
sympathetic clippingp-4 Needlescopic thoracic sympathicotomy with non-scar healing
p-5ESB in the treatment of addiction
p-6Stroke 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
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-
The purpose of this study is to compare the efficacy and safety of
thoracoscopic cutting of postganglionic fibers and transthoracic
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,
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.
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
The Base of Designing New Procedures for Different Indications in
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
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
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
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
head and neck. Few or none from T2 and TS innervate the hands while the
from T4 must definitely pass through T2 and TS to innervate hands. This is
reason why T2-sympatnetic procedures can treat hyperhidrosis but with
incidence and degree of reflex sweating. Thus, we know that ESB4 can treat
hyperhidrosis palmaris without interrupting sympathetic tone to the head
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 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
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.
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
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
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,
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
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
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
Botulinum Toxin A injections reduce subjective sweating in
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
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
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
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
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
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
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
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
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
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
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
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