MICRONEUROGRAPHIC EVALUATION OF SYMPATHETIC
NERVE ACTIVITY IN HUMANS
De artment of Autonomic Neuroscience,
Rescarch Institute of Environmental Medicine,
Na-oya University, Na-oya, Japan
Sympathetic nerve activity (SNA) in humans has been -enerally evaluated by rather indirect measurement of effeetor organ functions or by measurin- plasma level of noradrenarine. Meanwhile, microneuro-raphy has enabled us to evaluate more directly the SNA in humans. Using this technique we can record postganglionic sympathetic nerve traffic leading to muscle (muscle sympathetic nerve activity; MSNA) and skin (skin sympathetic nerve activity; SSNA) from human peripheral
MSNA is mainly composed of muscle vasoconstrietor activity which plays an important role for blood pressure regulation. Through baroreflex mechanisms, MSNA is enhanced when blood pressure falls, while being suppressed when blood pressure rises. Stellate ganglion block was associated with increased MSNA in the tibial nerve. Lumbar sympathectomy at the level of L2 and L3 for the treatment of thromboan<yitis obliteranee abolished MSNA in the ipsilateral tibial nerve, but not completely with residual activity presumably originated from eross communicating fibers.
SSNA is mainly composed of skin vasoconstrictor and sudomotor activities which are important for thermoreculation. SSNA changes depending on ambient temperature, being minimal in thermoneutral condition. Simultaneous recordings of SSNA from peroneal and tibial nerves revealed that SSNA leading to hairy skin discharged differently from that leadin- to glabrous skin. Vasodilator activity works only in SSNA leading to hairy skin, btit not to glabrous skin, concomitantly with sudomotor activity.
Sudomotor activity was high in primary palmoplantar hyper-hidrosis. Stellate -an-lion radiation of near-lnfrared ray in a case of palmar hyperhidrosis reduced SSNA in the isilateral median nerve with marked improvement of liyperhidrosis in the ipsilateral palm.
Microneurographlc evaluation of SNA in hiimans can be a powerful tool to elucidate chan-es in sympathetic nerve traffic underlylng dysfunctions of biood vesseis and sweat or-ans.
TRANSAXILLARY THORACOSCOPIC SYMPATHECTOMY EXPERIENCE IN HOT CLIMATE: MANAGEMENT OF THE DOMINANT HAND
AI Dohayan AD' and AI Tuwaijri AS2, Depart:ment of Surgeryl, Physiology2, King Khalid Uråversity Hospital, Riyadh, Saudi Arabia
Primary palmar hyperhydrosis is functionally and socially disabling problem of unknown aetiology affecting adolescents and young adults specially in hot climate. Thoracoscopic sympathectomy is the most effective treatment for palmar hyperhydrosis. The post sympathectomy rebound hyperhydrosis @ts its success especially in hot cämate. The aim of this study is presenting the experience of thoracoscopic sympathectomy in hot c@te managing the dominant hand first and contralateral sympathectomy will be done according to the will of the patient. C)ne hundred twenty patients were operated over a 3 year period. The procedure was successfully completed in 169 operated limbs and was abandoned for one limb due to severe pleural adhesions. The procedure was done for the dominant in 70 patients and 50 patients underwent bilateral thoracoscopic sympathectomy. The mean operative time was 25 minutes. There were eighteen post-operative complicatioris. Most of the patients (95%) were discharged after oven-iight stay. The early cure rate was significantly high (97%). During the mean fohow-up period of 300 days, there was no recurrence of the original symptoms. Apparent rebound hyperhydrosis occurred in 40 patients (33%). In conclusion, transaxillary endoscopic sympathectomy is an effective treatment to patients with hyperhydrosis resulting in short hospital stay and rapid return to normal activity and can be performed as an ambulatory procedure and managing the dominant hand first.
.. . . . . . . . . . . . .
Thoracoscopie Sympathicotomy in Treatment of Rhinitis
Seok-MungNg M. D., Lim-Sim Lee M. D. *Chien-Chih Lin M. D. Departments of Anesthesiology and *Surgery, Tainan Mun.icipal Hospital, Tainan, Taiwan
Objective: The purpos@ of this report is to find an altemative operation, besides vidian nerve ablation, in treatrnent of rhinitis, and aiso diseuss the therapeutic mechanism between sympathetic and parasympathetic unbalance.
Method and Procedures: Cases of hyperhidrosis with rhinitis prevlously diagnosed by an oto-rhino-laryngologist were chosen in this study. There were 72 in 345 cases (20.9%) of hyperhidrosis with rhinitis underwent T2sympathicotomy between Jan. 1 and Dec. 31, 1996. Except 8 cases were loss of follow-up, 64 cases of hyperhidrosis (37 males and 27 females) completed the follow-up postoperatively.
Result: Subjeetive cure of rhinitis after thoracic sympathicotomy were found in 20 cases (31.8%), 18 cases (27.0%) got subsidence of symptom of rhinitis, and no improvement in 26 cases (41.2%). Persistently increased local temperature around frontai and nasal areas was found in thennography taken after thoracoscopic sympathicotomy.
Conclusion: After anesthesiologist's evaluation by stellate ganglion block pre-operatively, thoracoscopic sympathlcotomy is an altemative method in treatinent of rhinitis, especially the cases of vasomotor rhinitis.
TREATMENT OF SCHIZOPHRENIA ByETS WITH CLAMPING
TelarantaTimo MD, PhD, Privatix Clinic, Tampere, Väisänen E,
MD, PhD, Psychiatry Clinic, University of Oulu, Finland
ETS (endoscopic thoracic sympathicotomy) has been demonstrated to relieve social phobia(l). Phobic elements are also common in schizophrenia. Childhood anxiety due to bad social surroundings, ignorance of the biological father, or feeling as unwished child may lead to phobic schizophrenia.
20 schizophrenics asked ETS for their phobic symptoms. After a positive stellate block, left-sided ETS with compression clips was performed for 4, and a similar bilaterai surgery for 16 patients. ln the mean follow-up of 1 year (4 months to 2 years), 15 patients remain very satisfied, and two quite satisfied with the resuits. Three patients regretted the procedure as worthiess. They ali had left-sided surgery only; one is now happy after a complementary right-sided surgery, one is waiting for the second surgery, but the third is not interested in any further attempts. Only one patient after the bilateral surgery was unsatisfied. 6 patients remain disabled due to the disease. 4 patients are in work rehabilitation, one after 8 years of institutionalized care, 6 have returned to work. One patient with uncompleted thesis for 1 0 years has now compleied it.
Bilateral surgery was clearly more effective than the left-sided one. However, no difference with electrocautery or compression could be noted. The possibility fo reversai, on the other hand, is an invaluable advantage and an ethical prerequisite, when dealing with psychic disturbances by invasive surgery.
75 % of the patients derived great benefit from the surgery, both by selfestimated satisfaction rate, family satisfaction rate and by clinical evaluation. ETS by clamping in selected schizophrenic patients seems justified.
'Telaranta T: Treatment of social phobia by Endoscopic Thoracic Sympathicotomy. Eur J Surg 1998; 164, suppi 580: 27-32.
TREATMENT OF SOCIAL PHOBIA WITH ETS BY CLAMPING
TelarantaT, MD, PhD, Privatix Clinic, Tampere, and Väisänen
E, MD, PhD, Psychiatry Clinic, University of Oulu, Finland
260 patients had uni- or bilateral ETS during 1995-1998 for sociai phobia, 140 by electrocautery and 120 by intergangiionar clamping. Patients were selected along the DSM IV criteria. They were avaluated with Davidson's social phobia, and Liebowitz' life quality scales.
The life histories of these patients showed some clear causative elements: An often shy child is at primary school age forced by her parents, notably by the father, to the sociai skills of aduit life, towards the expectatations of the parents, good manners at the dinner table, punctuality at school, or devotedness in the sports to become an athletic hero. Lack of love, hard discipiine, and threats further create the ambience of the parental home thick and oppressive. Hard religious demands and school tormenting by teachers or schoolmates were also common. Many patients had grown up in an isolated rurai environment and moved to urban environments at an aduit age.
Both conventional ETS and ETS by clamping helped greatly in relieving the physical signs of hand or facial sweating, the blushing, and the heart racing. The facial blushing was highly significantly more reduced after ETS with clamping. Furthermore, it clearly reduced the social phobic symptoms, e.g stage fright, neurosis of eating together, and avoidant behaviour, the clamping either on one or two sides significantly more than one-sided cautery, bilateral cautery was as efficient. The side-effects in one-sided surgery were almost nonexistent. The treatment also improved the overall life quality of the patients markedly. The clamping method showed significantly better tolerable and fewer side effects than electrocautery, thus compensatory sweating was statistically in 95 % certainty level less in the clamping than in the cautery series.
The author favours bilateral clamping method because of its equal effectivity, lesser side effects as measured by compensatory sweating, and especially because of its easy reversibility within months of the original surgery.
SYMPATHECTOMY FOR DISTAL ARTERIAL DISEASE OF UPPER EXTREMITIES: RESULTS OF DIFFERENT SURGICAL PROCEDURES.
N. P. Makarova, M.D., Ph.D, A. Lobut. M.D. Yekaterinburg, Russia.
Aims: to compare results of different surgical procedures of upper-
thoracic and periarterial sympathectomy in patients with chronic upper extremities ischemia.
Materiai and methods: 74 patients with distal arterial diseas
upper extremities were prospectively studied. All patients had critical or subcritical chronic ischemia. Upper thoracic sympathectomy was performed in 32 patients. In 17 patients supraclavicular approach and in 32 patients transaxillary approach were employed. Endoscopic procedure was performed in 25 patients. In addition, periarterial sympathectomy of the digital arteries was performed in 20 patients. Patients were followed-up for 7 years with annuall physical and ultrasound examinations. Results: Complications of the procedures were Homer's syndrome in 20%, pleural tear in 34%, and neuralgic pain in the chest in 30% of the patients. Endoscopic procedure had only 2 cases (8%) of neuralgic pain as complications. The clinical status changes were markedly improved in 12% and moderately improved in 42% of the patients. 3 1 % of cases demonstrated no change and 15% became worse. Transaxillary and endoscopic approaches had significantly better results. In combination with complication rates, the endoscopic procedure had significantly better results than other techniques.
Conclusion: Endoscopic sympatectomy is effective and save procedure for treatment of distal arterial disease of upper extremities.
... . . . . . . . . . .
Rex L, Fahlen T, Drott C , Claes G
SOCIAL SKILLS AFTER ETS FOR FACIAL BLUSHING
From the Department of Surgery, Borås Hospital, BoråS, Sweden
Faciai blushing is associated with social phobia. We have previously shown that facial blushing is substantially reduced by Endoscopic Thoracic Sympathicotomy (ETS). The impact of the reduced facial blushing on social incapacitation has not
been previously studied.
Patients and methods. ETS was perforrned on 68 consecutive patients with severe facial blushing. Ali patients fulfilled the criteria for social phobia according to the Diagnostic Statistical Manual of Mental Disorders(DSM-IV). The mean age was 34+9 y. The sociai function was assessed by Sheehan Disability Scale (visual analogue scale, VAS 0-10) and Social and Occupationai Functioning Assessment Scale (SOFAS) (VAS 100-0). The patients were also evaluated by Davidsons Brief Social Phobia Scale, Fear of Negative Evaluation Scale and Blushing Propensity Scale. The blushing intensity was rated (VAS 01 0) by the patients. Ali the assessments were performed before and 3 months after surgery. The same questionnaires were given to a reference population of 65 patients operated on for minor general surgical problems. Mean +SE and paired two-tailed t-test was used.
R suits- The response rate at follow-up was 90%. Facial blushing improved from 8,98±0,18 to 2,10+0,36 p<0,001. Social and occupationai function irnproved from 7,1±0.4 to 2,2±0,5 p<0,001 (Sheehan Disability Scale) and in SOFÅS from 61,8 to 78,3 p<0,001. Davidsons Brief Social Phobia Scale, Fear of Negative Evaluation Scale and Blushing Propensity Scale showed significant difference between the study and control groups before ETS. After ETS, there was no difference between the patient and control groups. Overall 90 % were satisfied with the outcome of surgery and only one patient regretted the operation. Conelusiow. This is the first report of the impact of ETS on social function in patients suffering from severe facial blushing. The patients social function was severely impaired before surgery compared to a reference population. The social function was normalised by ETS after 3 months. These results are very encouraging and obtaining long ten-n results are important tasks for the future.
Thoracoscopic T2 Synipathicotomy under Local Anesthesia
Yong Han Yoon, MD, Doo Yun Lee,MD, , Hae Kyoon Kim, MD, Jung Shin
Department of Thoracic and Cardiovascular Surgery, Yongdong Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
Background. Hyperhidrosis of the paim, axilla and face has a strong negative impact on social and professional life. A definitive cure can he obtained by upper thoracic sympathicotomy. However, sympathicotomy has been performed under the general anesthesia by either a single lumen or double lumen endotracheal intubation. It is very tedious to perform generai anesthesia and therefore have post-operative recovery period after a short time of surgery, and we have performed thoracoseopic sympathicotomy under local anesthesia in order to avoid that.
Metliod. From April 1998 to Jui 1998, 17 cases of thoracoseopic
sympathicotomy with 2 mm video-thoracoseope were performed under the local anesthesia. The second thoracic sympathetie chain was cut on the inner side of second rib using endoscissors.
Resulis. Bilateral procedure took less than 25 minutes and the patients were discharged on same day as the operation day. There has been no mortality nor life-threatening compiieations and there were no primary failure and no recurrent hyperhidrosis. At end of postoperative follow up( median 2 months) 70.5% of the atients were satisfied with the resuit.
Compensatory sweating occurred in all 17 cases(100%) with five(29.5%) of
those classified as either embarrassing or disabling.
Conclusion. Thoracoscopic sympathicotomy under the local anesthesia is safe, minimally invasive method and it is an alternative surgical method for the treatment of palmar and craniofacial hyperbidrosis.
Clipping of T2 Sympathetie Chain Block for Essential Hyperhidrosis
Doo Yun Lee,MD, Yong Han Yoon, MD, Hyo Chae Paik, MD, Sung Soo Lee, MD.
Department of Thoracic and Cardiovascular Surgery, Yongdong Severance Hospital, Yonsei University College of Medicine, Seoul, Korea.
Background: A definitive'cure for essential hyperhidrosis can be obtained by upper thoracic sympathectomy. However, this is offset by the occurrence of compensatory hyperbidrosis as a side effects and it is irreversible. WC performed thoracoseopic sympathetie chain block using endoscopic clip in order to avoid compensatory hyperbidrosis.
Material & Method: From Aug. 1998 to Nov. 1998, 42 cases of thoracoscopie ciipping of T2 sympathetic chain were performed. The sympathetic chain was clipped instead of cutting using endoseopic clip.
Result. Bilateral procedure took less than 40 minutes and occasionally necessitated one night in the hospital. There were no mortality nor lifethreatening complications. Horner's syndrome occurred in two cases. At the end of postoperative follow-up (median 3 months), 95.0% of the patients were satisried with the results. Compensatory sweating occurred in 31 cases (77.5%) where nine of those cases were classified as either embarrassing( 6 cases -15.0%) or disabling( 3 cases-7.5%). Conclusion : Endoscopie thoracic T2 sympathetic chain block using endoscopic clippihg is an efficient, safe and minimally invasive surgieal method for the treatment of palmar and craniofacial hyperhidrosis and the results were similar to those underwent T2 sympathicotomy.
Thoracoscopic T3-sympathicotomy for palmar hyperhidrosis
Kwang Taik Kim, Song Aam Lee, Korea University, Seoul KOPEA
The purpose of this study was to evaluate the T3 sympathicotomy for treatment of palmar hyperhidrosis.
Methods: In the period from June 1998 to December 1998, 50 patients(24 women,26 men) suffering from palmar hyperhidrosis either in isolation(37) or in combination with axillary hyperhidrosis(13) were operated. The mean age of these patients was 20 years. At operation the sympathetic trunk on the 3"
rib(between 2' and 3rd gangiia) for palmar hyperhidrosis, the sympathetic trunk
on the 3" and 4" rib for palmar and axillary hyperhidrosis were divided with
electrocoagulation scissors. The sweating degree in the palms, face, trunk, and feet and patients satisfaction with surgery were assessed on a linear analogue scale(range 1-10).
Resuits: Ali the patients were relieved of palmar hyperhidrosis. Mean pahnar sweat production score after T3 sympathectomy was 1.5±0.8(11 0; 1 O=excessive sweating) Some degree of compensatory sweating has occurred in 39 patients(80 %). Compensatory sweating score was 3.4±1.6. Plantar hyperhidrosis score was 9.0+'?.8. Face sweating score was 9.0±2.8(1-1'0; 10= physiologic sweating, 1= anhidrosis). Gustatory sweating has occurred in 2 patients(4%). Satisfaction grading score of the operation was 8.5 ±1.2(1-10; 1 O=completely satisfied, 1 =regret).
Conclusions: Our results compare favorably with the T2 sympathicotomy and better in ter-ms of preserving facial sympathetic nerve function less occurrence of severe compensatory sweating and low incidence of gustatory sweating. T3 sympathicotomy is reconitnended as the surgical treatment of palmar hyperhidrosis.
ThoracoseopicT2-sympathetie Block by Clamping in
Treatment of Hyperhidrosis Palmaris --- Result of 831
Chien-Chih Lin, M. D., Hsing-Hsien Wu, M. D. Department of Surgery, Tainan Municipal Hospital, Tainan, Taiwan
Background:Endoscopic T2-sympathicotomy (ETS) is currently the most acceptable method in treatment of hyperhidrosis palmaris. Not only the irreversibility of the procedures, but postoperative compensatory sweating follows frequently. Some patients are disturbed with the sequela and regret to receive the operation. Prevention of the complication becomes more important when ETS is perforined. A new method, T2-sympathetic block by clamping (T2C), was developed for its reversible character.
Method and Material: From March 18, 1996 to August 31, 1998, there were 831 (387 males and 444 females) in 896 patients underwent thoracoscopic sympathetic block by clamping for treatment of hyperhidrosis palmaris et axillae. The remaining 65 cases underwent thoracoscopic sympathicotomy.
Result: Thoracoscopic sympathetic block by clamping was perforrned on 831 cases. The post.-operative results were effective and satisfactory except 44 cases. 30 cases (3.6%) requested reverse operation for intolerable compensatory sweating.*) Re-operation was performed on 14 cases l@70/.j f r incomplete cessation of unilateral or bilateral sweaty hands. jb@@aws@DLcomplete, cessation of sweating were incomplete clamping, inappropriate level clamped, and dislodgment of the ciips.
Conelusion: Thoracoscopic sympathetic block by clamping is a better and reversibie method than any other endoscopic sympathicotomy.
*) The reverse operation was successful in 27 cases, the period between the two operations was between 1 and 3 months. (presented in congress - note added by Timo Telaranta)
Uniportai endoscopie superior thoracic sympathectomy in the treatm,nt of palmar hyperhidrosis
Vanaciocha V.*, Panta F. Villares, G.* and Såiz-Sapena N.#
Division of Neurosurgery Fellow Division of Neurosurg@ (#) Department of
Anaesthesiology, Clinica Universitaria, University of Navarra, Pamplona, Navarra (SPAIN).
Introduction: Superior thoracic sympathectomy has been used,since long time in the treatment of palmar hyperbidrosis. Athough initially it was performed by open methods, now it is undertaken endoscopically, minimising the operative trauma and sequelae. We present overhere our technique of uniportal endoscopic thoracic sympathectomy.
Patients and methods: From Ist January 19@5 to 31st Deeember 1997 sevety-three patients (34 females/39 males, age 16-42 years, mean 26 years) were operated. They were piaced supine with
the amis abducted 901 and head 150 up. The left side was always perforrned first. Once the lung had been collapsed, an 8mm axillar incision was perforrned and the third intercostal space
perforated with a blunt trochar. A single port was always used. The endoscope (Aesculaplo) is 30cm long, with a 2mm rod lens, and three working channels. Once in place C02 insuflation was started and set at 2 litres of volume and 12mmHg of pressure. With the monopolar electrode the sympathetic chain and the ganglia from T2, T3 and T4 were coagulated. At T3 it is essential to look out for possible Kuntz nerves. Once finished the gas was aspirated from the pleural cavity and the
procedure repeated on the other side.
Resuits: Sympathectomy on both sides was accomplished within half an hour in a single stage.
Patients were discharged from the hospital after an ovemight stay. Only those requir-ing
postoperative chest tube had a longer admission. All of them obtained a complete and fully satisfactory alleviation ofpalmar hyperhidrosis.
Intraoperative bleeding happened in twenty-five cases (34.2%), most of them due to venous origin and could be controlled with the coagulating electrode. In seven cases (9.5%) the bleeding was arteiial due to the superior intercostal artery and although the bleeding was controlled with coagulation, four of them required a draining tube.
Complications included haemothorax requiring pleural tut>e insertion in four cases (5.4%) and transient Homer's syndrome in two (2.7%) and cornpensatory hyperhidrosis. There was no surgical mortality in this series. The pleural tube was inserted in the operating room through the axillary portal used for the sympathectomy. It was removed in an average of 3.1(0.7) days. The ptosis of the eyelid in the two cases of Homer's syndrome took six months to resolve cor"letely. The rnost common complication was compensatory hyperhidrosis (71.2%), that was usually mild and tolerable after reassurance. Only in five of them was the compensatory hyperhidrosis considered bothersome (6.8%), and required treatrnent with aluminium chloride in ethanol solution at 25%.
Recurrence ofpalmar hyperhidrosis has been noticed in five cases and all in the right side. All five cases were re -operated successfully. The lung showed adhesions to the previously coagulated areas but could be easily freed with the endoseopic equipment. A remaining branch of the sympathetic chain could be seen more medial than the usual side under fat (T2) or crossing veins (T3) on the
costo-vert ebrai joint.
Conclusions: On the bases on our experienee, TES performed as reported is considered a relatively rninor and safe procedure, causing minimal discomfort and almost invisible scars. The operation time and hospital stay were shortened in compan . son with other conventional sympathectomy procedures. Nevertheless attention to all details is vital to avoid unneeessary complications.
c t=ic ~t~ with a 2m
sW, k T. Y~ and K. Niiyma
af Suw,- i, @,@lt_vof Z@ ga~@ju@
Am of tlcn : @s study a rew
t,) p~ m~ly ive c
å~:@ patie!nt was usirig a sirgle--1@
and ms pi@ wlth a @ positica A 2-m stab idcisieri ias
mWe in @ ~Or axillary Iire ~ the @ lb ~ and
@cal @le ms ff~ @ @ ~le cavlty wlth 2- 2' <k trucar. @ lutx ms slowly defiated by ai-r kld tie 2-m
ms lm~ @ the c cwty A @ B=s'On Ym mde In fir ~Ilary lue @ the @ spbce a[d äm a @lar ~"
ms perf~ L 5-m 0 dia~ ~ Ms 1~ and the
@ ffl~c ~ ia thier
VW wem dlatåmed For p~ve analgesia dia~ed
tl, were by 1% Li
nally 0. 25% 3" ms ini~ @ fir c cavity-
&Mlts: @ Ms 1 in ali 88 Patients(M:F@1:47, @:12-«~tely @ s~. All had satisfi~ relief of and b~drwis"
But at two m~ n cne ca@
of ~drosis. patients @ tm~ 1 pain to
u~ in a few ffi= s dld not
Post~tive Måririg &~ ms fmffl in cm
Ccwlusian: L ~1 IY imwive
M~tive are ~ically 4. ve anal@a
RETROSTERNAL PULMONARY KISSING
Hidehiro Yamamoto, MD, Masayoshi Okada, MD, Akio
Kanehira, MD, and Munenori Kawamura, MD, Kobe,
The authors introduce an unlque technique of bilateral endoscopic thoracic sympathectomy (ETS) which reduce skin incision compared with an usual
technique employing skin incisions on the bilateral chest walls.
A skin incision (usually 6 mm) was made on the left lateral chest wall, and thoracotomy was carefully performed. A digital flexible scope and a scope guide were introduced into left pleural cavity. Left thoracic sympathectomy was carried out using electrocautery or KTP laser, then the scope guide was lead into right pleural cavity through retrosternal pulmonary kissing. Right thoracic sympathectomy was done in similar fashion. Bilateral thoracic sympatheetomy from one side was successfully for patients with palmar hyperhidrosis. There were no associated complications at 3-month follow-up. The flexible scope and scope guide enables visualization of anatomy for ETS. This technique reduced surgical trauma and improve patient's cosmesis.
Recurrent Hyperhidrosis after-open Dorsal
_RAFAEL REISFELD MD
LOS ANGELES, CA USA
The open procedures for Palmar Hyperhidrosis were replaced with Endoscopic Sympathectomy.
Many advantages were attributed to ETS such as: Painless, quick recovery, superb cosmetic results and better ability to identify the right level of T2.
Presented here are two cases done previously through the back and had . a recurrence 3-5 days later. Done Endoscopically one could see that T3 was done and not T2.
UPPER DORSAL THORÅCOSCOPIC SYMPATHECTOMY
AFFECTS THE TOTAL AMOUNT OF BODY PERSPIRATION
D. Kopelman, M. Ehrenreich, Y. Ben Amnon, H. Bahous, A. Assalia
& M. Hashmonai
Department of Surgery B, Rambam Medical Center, Haifa, Israel
BACKGROUND: Thoracoscopic upper dorsai sympathectomy is the treatment of choice for primary palmar hyperhidrosis. Compensatory hyperhidrosis is a disturbing sequela of this operation, the mechanism of which is poorly understood. It has been suggested to be a compensatory mechanism, to preserve the totai amount of perspiration. The purpose of this study was to evaluate the effect on perspiration of thoracoscopic upper dorsal sympathectomy.
METHODS: The study was performed on 17 patients with primary palmar
hyperhidrosis, who were due to undergo a bilateral upper dorsal sympathectomy.
After a regular breakfast, the patients were submitted to a heat stress by a 10 min
sauna bath (@ 70'C). After careful wiping of the sweat, the naked body weight was measured before and immediately following the sauna bath. This procedure was done one day before surgery and again one month after it.
RESULTS: Thirteen out of 17 patients showed an increase in the amount of perspiration after the operation. The remaining had a slight decrease. Thi mean amount of perspiration induced by the sauna bath was 185.29±125.80 gjr (range 60-480) before the operation, and 265.88±154.05 gr (range 60-540) after the operation; p=0.0 1 13. There was not, however, a correlation between the degree of alteration in total body sweating and the development of compensatory hyperhidrosis.
CONCLUSIONS: Thoracoscopic upper dorsal sympathectomy for primary almar hyperhidrosis affects the total body sweating response to heat, the trend being an increase in the amount of perspiration. This alteration in perspiration, however, does not correlate to the phenomenon of compensatory hyperhidrosis.
INCLUSION OF THE NER'VE OF KUNTZ IN
THORACOSCOPIC SYMPATHECTOMY MINIMIZED THE RECURRENCE OF PALMAR HYPERHYDROSIS
AI ha an AD' and AI Tuwaijri AS2, Department of Surgeryl andPhySiology2, King Khalid University Hospital, Riyadh, Saudi Arabia
Primary hyperhydrosis is a conunon problem of unknown aetiology that disrupts professional and social life. Thoracoscopic sympathectomy seems to be suitable for surgical treatment of upper limb hyperhydrosis. Recurrent sweating may occur- after apparently successful upper dorsal sympathectomy. The mechanism of recurrence is unclear but there are a number of possible explanations. The presence of nerve of Kuntz may be one of the important causes of failure
of the surgery. In this abstract we described the variations of
nerve of Kuntz. Nerve of Kuntz is another thoracic
sympathetic chain which can cause failure of thoracosc-opic
sympathectomy if not visualized and diathermized. Nerve of Kuntz was identified in six patients, it lies in the body of the rib 3-5cm lateral to the sympathetic chain. After diathern-åzing the nerve of Kuntz, the temperature incri-ased by an averaee of 0.8'C. The nerve of Kuntz should be visualized and diathern-dzed in all patients undergoing thoracoscopic sympathectomy.
Stenotie Procedure of Thoracic Sympathetie Nerve: Compensatory-sweating-free Procedure in Treatment of Hyperbidrosis - Animal Experiment
Chien-Chih Lin, Hsing-Hsien Wu, Chi-C hung Huang 'Lim-Sim
Lee, 'Seok-Mun Ng, 'Ray-Chang Tzeng, 'Chi-Yu Chou.
Departments of Surgery, 'Anaesthesiology, 'Intemal Medicine, and
'Pathology, Tainan Municipal Hospital, Tainan, Taiwan
Compensatory sweating is the major sequela after T2sympathicotomy in treatment of hyperhidrosis. Prevention of this complication becomes important for surgeons who perform T2sympathicotomy.
Animal experiments proved that the activity of sweating glands increased progressively in number in the process of successful nervous regeneration after nervous section. Artificial stenotic procedure was perfonned by clamping m-ethod to rabbit sclatic nerve which was chosen due to its diameter similar to human thoracic sympathetic trunk in this study. The rabbits were sacrificed to EMG and pathological examination. Partial degeneration and flbrosis of the nerve ftbers with retardation and decreased amplitude of nervous conductivity were achieved. In our result, we proposed that stenotic or llgating procedure to thoracic sympathetic nerve trunk is an effective method for controliing the degree of sweaty hands without compiete cessation of sweating, then compensatory sweating can be prevented.
THORACOSCOPIC SYMPATHICOTOMY IS SUPERIOR
TO SYMPATHECTOMY FOR PALMAR HYPERHIDROSIS
Tomoharu Kuda, J Oshiro, Y Kainada, A Gabya, S Nagayoshi,
N Nagamine, H Sakuda, M Tamashiro, S Ma@bara, Y Kuniyoshi
Second D ept. of Surgery, Ryukyu Univ. Okinawa, JAPAN The purpose of this study is to compare two thoracoscopic proced-ures:sympathectomy(excision) and sympathicotomy (electrocautery) for primary palmar hyperhidrosis Methods: 139 patients(pts): Sympathectomy (Group A) 18 pts. (9 M,9 F) mean age 28.7 :Sympathicotomy (Group B) 121 pts. (59 M, 62 F) mean age 28.5. For comparison of two thoracoscoplc procedures, early and long term results have been eval-uated. Results: Operation time of Group A and B was 189+/-54 and 33+/-16 min. respectively(p<0. 05). Earty result was excellent in both groups. Long term resuits are shown in Tables. Compensatory sweating is less severe in sympathicotomy. (Table 1) More pts. are satisfied after
sympathicotomy. (Table 2)
Table 1 Table 2
Compensatory Group A Group B Group A Grou-p B
swea@ Satisfied (%) 45.5 68
Tolerable 0 40 Unsatisfied (%) 9 8
-Embarrass@(%) 100 60 Neither
ofabove(%) 45.5 24
Conclusion: Sympathicotomy is superior to sympathectomy for palmar hyperhidrosis.
ENDOSCOPIC THORACIC SYMPATHECTOMY FOR PRIM-ARY HYPERHIDROSIS USING THIN TYPE
THORACOSCOPE AND ULTRASONICALLY ACTIVATED SCALPEL
H. Koshiishi*, T. Okamura*, H. Minakuchl*, N. Sugano**, and
Department of Surgery, Tokyo Metropolitan Otsuka Hospitai
First Department of Surgery, Tokyo Medical and Dental
University, Tokyo, 170-0005, Japan.
[Purpose] Cases of primary hyperhydorosis operated using thin type
thoracoscope and ultrasonocally activated scalpel from 1997 to 1999 were studied.
[Patient] Endoscoplc thoracic sympathectomy was performed in 31 cases (14 male 17 female, age 11-73 years, average 28.1 years). [Operation] After induction of general one lung anesthesia wlth a double lumen endotracheal tube, two needle type trocars are inserted into the pleural cavity at the midaxlllary line. The thin type thoracoscope that is 3 millimeters in diameter is introduced to visualize the insert'on of the trocar. The main sympathetic chain and Kuntz branches across the second to third body of n'b are carefully dissected using the electrified forceps or ultrasonically activated sealpel.
[Resultsl The average operation time was 42 minutes (range, 27 to 80 minutes) on one side. The average length of hospital stay was 4.4 days (range, 3 to 9 days). Minor postoperative complications ncluded back pain in two (6.4%), a unilaterai ptosis in two(6.4%) and atelectasis in six (19.3%). Compensatory sweating was occurred in 11 (35.4%). No chest drain had to be inserted. All operations resulted in par-tial and complete relief of symptoms.
[Comment] In five cases of usin ultrasonically activated sealpel, there were less bleeding and bum tissue at the oper-ative area, and no heat degeneration was recognlzed in surgical speclmen.This operation using thin type thoracoscope and ultrason'cally activated scalpel is effective as minimum invasive surgery.
EFFICACY OF THE UNILATERAL ENDOSCOPIC THORACIC SYMPATHECTOMY
Inoue Y. and Iwai T., Tokyo, Japan
Purpose:Compensatory sweating is the most frequently stated reasons for dissatisfaction after endoseopic thoracic sympathectomy, which is minimally invasive and effective treatment for hyperhidrosis. We report efficacy of the unilateral operation to reduce compensatory
Materials and Methods: We retrospectively investigated 96 patients operated on since November 1996. Our standard procedure was the unilateral. resection of the second thoracic sympathetic gangiion. A second stage contralaterai surgery was undertaken in 45 cases for the patients' wishes: a bilateral sympathectomy in 45 cases and a unilateral reseetion in 51 cases (right: 44, left: 7).
Resulis: Ali of the treated patients obtained a satisfactory alleviation of palmar or craniofacial hyperhidrosis. Compensatory sweating was developed 15% in unilaterai operations and 70% in cases of
Conelusion: About the half of the patients were satisfied with only a unilateral treatment. A unilateral thoracic sympathectomy was also efficient to prevent compensatory sweating.
LARYNGEAL MASK GENERAL ANESTHESIA
FOR THORACOSCOPIC SYMPATHETIC
Lim-Shen Lee, Seok-Mun Ng, Chien-Chih Lin*. Department of
Anesthesiology and Surgery*, Tainan Municipal Hospitai, Tainan,
For the past 9 years, single-lumen endotracheal intubated general anesthesia has been practiced for thoracoscopic sympathicotomy in hyperhidrotic palmaris patients (l). Ever since 1996 thoracoscopic T2-sympathetic block by clippi'ng was introduced by Dr. Lin to treat hyperhidrosis palmaris in Tainan Municipal Hospital (2), and over hundreds of patients have undergone such operation successfully. Single- lumen endotracheal intubated anesthesia was the major anesthesia.
Thoracoscopic T-2 sympathetic clipping though unique is a highly safe and
ultra-short time consumin operative procedure. Since it is a out-patient based
ambulatory surgery, a less airway invasive and irritating method by using
laryngeal mask generai anesthesia has been practiced since 1999.
We revealed the anesthetic management with laryngeal mask and the intraoperative problems that we encountered. Keeping the respiratory airway intact as well as secure for both ventilation and oxygenation is the major task of the anesthesiologist in thoracoscopic operative procedure. And laryngeal mask general anesthb'ia in our ex erience provides a secure airway, a more
intraoperative hemodynamic stability, a less post-operative sore-throat and a more economie way of anesthesia.
1. Lee LS, Ng SM, Lin CC. Single-lumen endotracheal intubated anaesthesia for thoracoscopic sympathectomy --- experience of 719 cases. Eur J Sur(Suppi) 1994;572:27-3 1.
2. Lin CC, Mo LR, Lee LS, Ng SM, Hwang MH. Thoracic T2-sympathetic block by clipping--- a better and reversible operation for treatment of hyperhidrosis palmaris: experience with 326 cases. Eur J Sur (Suppi)
REVERSAL OFETS BY ENDOSCOPIC NERVE RECONSTRUCTION
TelarantaT, MD, PhD, Privatix Ciinic, Tampere, Finland
ETS has been held traditionally a safe procedure with acceptable, mild side effects. During the last years, the procedure has become more and more popular. lt is unavoidable in today's number of surgeries also to have quite many unhappy patients with the side eff ects. Mostly the side effects are restricted to the known compensatory sweating, but many patients experience also thermoregulatory imbalance, chillblains, muscular weakness, extreme dryness of the hands and/or face, and lack of energy. ln addition nearly ali the usuai side effects familiar from vadous drug studies, most often aiso caused by placebo type effects are naturally in the list of side effects of the unhappy patients.
1 have performed 20 reversal surgeries for 10 persons in 12 separate sessions. 3 out of these have been open thoracotomies, the rest endoscopical surgeries. ln two occasions only neurolysis on one side could be performed due to scarred önvironment.
The mean duration for one-sided thoracotomy was 3,5 hours, for bilaterai endoscopic reconstruction 3,3 hours, and for bilaterai clamp removai 1 5 min.
The foilow-up is difficult, because the patients are from many countries, it stili is under way. The clamp removal patients were Finns with a good follow-up.
8 out of these 10 patients have improved markedly with loss of extensive compensatory sweating, improved moisture in formerly dry areas, and improved thermoregulation.
The 2 clamp removal patients recovered rapidly. The other noticed moisture in the face after 3 months. The other patient recovered even more quickly, in one week. For both, the interval between the original clamping and the removal of clamps was 3 months. However, this recur of the former preoperative symptoms, was so unexpected (!) to them, that both have the clamps back again, and are now satisfied.
Reversal surgery gives hope for some recovery after unhappy side effects of ETS, however, the clamping method seems superior by its clear reversibility.
A video of a reconstruction was presented.
RECOVERY OF HAND SWEATING AFTER
THORACOSCOPIC SYMPATHETIC CLIPS REMOVAL
COMPARISION OF SYMPATHETIC SKIN
RESPONSE WITH CLINICAL EVALUATION
Chien-Chih Lin*, Lim-Shen Lee, Hs'ng-Hsien Wu*. Department of 1
Anesthesiology and Surgery*, Tainan Municipal Hospital, Tainan, Taiwan
The introduction of thoracoseopic sympathetic ciipping creates a reversible operation for hyperhidrosis palmaris. The degree and the length of period of retuming of sweating function is individualized. It depends on the force appiied while clipping and the rate of nerve regeneration.
20 patients who have been undergone the procedure of thoracoscopic sympathetic clips removal were randomly chosen to evaluate the sympathetic skin response (SSR) as well as the degree of retuming of hand sweatingjudged by the patients themselves.
The appropriateness of the SSR as a tool used to evaluate the retuming of the sweating function after sympathetic clips removal will be discussed. In addition, interesting correlation of remission of compensatory sweating and SSR will be presented.
1 S THERE ANY Dl FFERENCE BETWEEN THE EFFECTS OF ETS AT T2/T3 AND T3/T4 ON PRIMARY PALMAR HYPERHIDROSIS?
T. Tate ama, M. Shiotani, Y.Naganuma, K.Ooseto,
T-Toyokawa Y.Abe Tokyo,Japan
Aim : to compare the effect of two types of operation for primary palmar hyperhidrosis. (I)bilateral electrocautery of the sympathetic trunk on the 2nd and 3rd rib.
bilateraf electrocautery of the sympathetic trunk on the 3rd and 4th rib.
Obj ective : 27 patients took (l) the f irst type of oper at i on and 1 6 pat i ent s t ook (2) t he second t ype of oper at i on. Ali the segments of electrocautery of the sympathetic trunk had been confirmed with post- operation VIDEO check. The mean foliow-up time was 247days.
Resul t s : Comparison of the effects on hyper hi dr osi s of t w o t ypes of oper at i on . Ther e i s no difference in the effects and patient satisfaction between two types of operation.
Conci usi on : lf i t i s di f f i cui t to cut the sympathetictrunk on the2nd rib, weshouid cut the sympathetic trunk on the 3rd and 4th rib.
THE MEASUREMENT OF SKIN BLOOD FLOW USING LASER DOPPLER METHOD IS USEFUL FOR MONITORING ENDOSCOPIC THORACIC SYMPATHECTOMY
y- li-v i i T. Kobata, K. Hida, S Sakamoto, J. Matstibara, IshikaNva, Japan
To coiifinii compiete denentation of synipatlietic iiene activit@, duriiig tlic eiidoseopic tlioracic sNmpathectomN,, the measurcmeiit of skiii blood f]onv of tlie finger usiiig laser Doppler method was ciiiplon,ed. The sensor of tlie laser Doppler was placed on the thumb or index finger of the patients, The data were recorded on tlie peil recorder. The skiii biood flonv decreased Nvlien tlie electrosurgical uiiit cauterized the s@.,liipatiietic gaiiglla at first. Oilcc tiie
denen,ation of sympathetie Liene actin,i@ was coiiipletcd, tue dccreasing
response of tiie blood flonv to the electrocaute@7 disappeared. Wlieii bilateral
sN mpathectomv was perfoniied, the skin biood flow increase was iiiininial
after ui-ålateral svmpathectomv although the remarkable skin blood flo@v
increase was noticed after completion of bilateral svmpatliectomv. The skiii blood flow measurement using laser Doppler method is useftil moi-åtor du@iig the endoscopic thoracic sympathectomv. Wc will show tlie video of moi@tonng endoscopic thoracic sNnipatheetoiiiN, usiiig laser Doppler iiietiiod,
Intraoperative hand and axiliary temperature monitoring during endoseopicsuperior thoracic sympathectomy in the treatment ofpalmar hyperbidrosis
Vanaclocha V.*, Panta F. *, Villares, G.* and Såiz-Sapena N. #
(*) Division ofneurosurgery; (t) Fellow Division of0 (fi). Department of Anaesthesiology, Clinica Universitaria, University ofnavarra, Pamplona, Navarra (SPAIN).
Introduction: To confirrn intraoperatively the effectiveness of a. thoracic synipathectomy some have advocated histological diagnosis of the removed sympathetic chain. Other methods can be equally useful: intraoperative temperature monitoring and increase in blood flow measured by percutaneous Doppler studies or by a laser probe. We tried to ascertain wether skin temperature monitoring might predict TES outcome.
Patients and methods: From Ist January 1995 t. 31st December 1997 bilateral thoracic endoscopic synipathectomy (TES) in the treatment of palmar hyperhidrosis was performed in 73 patients (34 females/39 males, age 16-42 years, mean 26 years). Patients were placed supine with
the arms abducted 900 in a cross-bow fashion and completely uncovered to prevent wan-ning. An
intradermal teniperature probe (Shiley(& temperature monitor) was placed on the tenar eminenee and axillae ofboth an-ns. The oesophageal temperature was measured during the whole pi-ocedure. Results: Oesophageal temperature was not affected by the syrnpathectomy. Temperature of the
hands and axillae at the begin@ng of the surgical procedure was 33.40C or Tower in 35 cases
(47.9%), 33.50C to 34.50C in 21 (28.7%), and 34.60C or higher in 17 (23.3%). Temperature of hand or axillae showed differences in almost all cases, being the palm coldcr than the an-npit by
1.2(0.6)OC. Both sides did also show differenees of 0.9(0.3)OC between them. On starting C02
insuflation it was comrnon to see a decrease in axillary temperature of 0.5(0.2). As soon as coagulation of the syrrrpathetie chain was undertaken the temperature started to rise, and in 5 to 1 0
minutes the final temperature achieved. For ihose starting with a tempemture of 33.4'C or lower the rise was 2.6(0.4)OC, for those starting with 33.50C to 34.50C the increase was 1.7(0.4)OC, while for the ones starting with 34.60C or higher only a rnodemte increase in temperature was seen -0.9(0.4)OC-. The end point was a temperature of 35.4(0.6)OC in the hand and 35.3(0.6) for the
axillae. Differenees with both sides of the same patient were 0.3(0.1)OC. In the five case; with recurrence, at the beginning of the surgical procedure the temperature of the hands was 33.6
(0.7)OC and in the axillae 33.9 (0.4)OC. Both sides did also show a difference of 0.5(0.4)OC. The tina] temperature on the left side was 35.5(0.3)OC in the hand and 35.4(0.3)OC for the axillae. On
the right side the final tempemture for the hand was 34.2(0.4)OC and for the axillae of 34.1(0.2)OC. The surgical procedure had to be hurried up in three cases due to poor tolerance to right lung collapse, precisely those that recurred at one rnonth postoperatively. On re-opemtion we revised
and coagulated thoroughly the area until temperature rose in the hand at 35.7(0.2)OC and axillae at
35.5(0.4)OC. Postoperatively none ofthese patients has had recurrenee ofthe sweating in the hands and all have continued so evet since (follow up of 32, 28, 24, 17 and 12 months).
Conclusions: Intradermal temperature monitoring is a good, quick and cost-effective rnethod to control the effectiveness of TES in the treatment of palmar hyperhidrosis. Although a hse in
temperature of IOC has signification, the most important finding is that the final temperature in the hands and axillae be above 35 OC and as elose as possible to 36 OC.
THE CENTER FOR HYPERHIDROSIS EXPERIENCE
RAFAEL REISFELD, MD LOS ANGELES, CALIFORNIA USA
OVER THE LAST THREE YEARS,
THORACOSCOPIC SYMPATHTICOTOMIES FOR
Ma,sahiro Shiotani. Kjyoshige Ooseto, Yoshikazu Nagamuma, Dept of Pain Clinic, Kanto Teishin Hospital, Tokyo 141-0022, Japan OBJ @CTIVF.: To present of our experience, over the past five years, of thoracoscopic sympathicotomy for primary palmar and or axillary hyperhidrosis. DESIGN: Retrospective clinical observation study. the Kanto Teishin Hospital and an affiliated hospital
Japan. : 1886 consecutive operations in 943 patients for
primary palmar and or axillary hyperhidrosis over a period of five years. INTFRVENTIONS: Thoracoscopie sympathicotomy from below T2 to T3 including the fibers of Kuntz using electrocautery through single site access. The patients underwent bilateral simultaneous sympathicotomy for hyperhidrosis. RESUITS: Patients with hyperhidrosis received a postal questionnaire regarding palmar, axillary and plantar sweating, compensatory and gustatory sweating, complication and satisfaction. Two patients were converted to Open surgery because of intercostal arterial bleeding and were discharged within a week. Major complication was not encountered. Ten patients required intercostal drainage because of pneumothorax or small bleeding. Other patients had an uneventful course and were discharged two days after operation. Horner's syndrome developed in five patients. Two patients were observed complete Horner's syndromes and three patients were incomplete. Postal questionnaire was sent to 435 patients and 325 patients (77.9%) responded to the questionnaire. 97.3% of patients had complete dry hands at the time of follow-up. 2%were improved than the preoperative state and reported slight sweating and 0.6%had wet palms. Compensatory and gustatory sweating was observed in 96.2% and 38.0% respectively.
82 patclltsIlliti, severe 2
ik C**, Tygescll 14**, Elli,
Di-ott C *, Claes G*,Wcttel-N
Soleiii J***, Lonisky M****,Rådberg
epii-tiiients of Siii-gery*, Mediciiic**. Boi-ås Hospitai, Boiås; departiiicnt,-,
Fi-oiii tlie d
of'Cai-diolog@,***, Ciiilieii Illiysiology****aild Tlioi-acic SLirgei-y*****, S-,iiilgi-eiiska 1 losl)il@il, Göteborg, Swc(leii
Svilipatheetoiiiy was oiice a coiiliiion treatiiient foi- aiigiiia pectoi-is. Aftei- tlie iiitrodtictioil of effective pilai-iliacological treatinent and by-pass surgei-y the syi-npatliectoiiiy option feli iilore or less into oblivion. Howcver, iiiany paticiits ai,e ilot eligable foi- by-pass sui-gery and have poor i)ain control despite optiiiial medical
11@ttients 111(1 illetiiods-. 82 coilsecutive liaticiits wei-c opei-atcd on witii ETS bet,,vceii 1 993 ,iiid 1 996. Ali llad l@ceil excluded froili by-pass siii-get-y aiid balooii aiigiopiasty. iiiclusiotl ci-iteria were: Reversible iscliciilia ,iiid iiioi-e tilan 5 ,veekly attacks of aiigiiia despite tiiaximal tolei-able medical tliei-ap@,. liivestigatioiis wei-e pei-foniied with excercise E-CG, radionucleid angiograpliy, 24 h. Ilolter-lnoiiitoring including lie,,irt i-ate variability, metaiodobenzylguanidine scintigi-aphy and a patient diat-y bcfore and 1, 12 and 24 iilotiths after surgery.
ikesuits- No niajor sui-gical coiiiplicatioii occiiri-ed. liici-eased excercise capacity i-cdticed licart i-ate aiid less ST segnient depression at iliaxiiiial coiilpai-able woi-kloacl pei-sisted duriiig follo\v-tip. F-jectioii fractioii aiid iiielaiodobeiizylguanidiiie tipiak@e wei-e not iiitlitetlced. A rcdliction of the liigii frcqlieiicy- low fi-equency ratio at tili lest Nyas obsei-ved ,ii 1 -,iiid 1 2 iiloiitlis. The fi-equency of inginai attacks aloiig ,vitii tlie coiisuiiiptioil of subliiigual nitrates were effectively t-educed.
Coiiclusion: E'FS redtices sigiis of iselieiilia itid effci-s good conti-ol of aiigiilai attacks. As tiiese effects i-einaiii at loiig tei-iii follow-tip, ETS al)peai-s aii atti-active altei-ilative tre,,ltilieiit fot- li-,itieiits ilot elilable foi coti\,eiitioilil coi-onai@, intei-\,eiltioti. WC ,il-c clii-i-eiitly coildticiiiig i raildoiiiised sttidn! coiiil)ai-iiig F-,]-S with t-edo coi-otiai-N,
THORASCOPIC SYMPATHECTOMY AND HIGHLY SELECTIVE THORASCOPIC SYMPATHECTOMY
AI Dohayan AD' and AI Tuwaijri AS2, Department of
Surgeryl,PhySiology2, King Khalid University Hospital,
Riyadh 11461, Saudi Arabia
The purpose of this study is to compare efficacy and safety of thorascopic cutting of post ganglionic and transthoracic endoscopic sympathectomy for 150 patients.
1 have managed 55 patients complaining of hyperdrosis in King Khalid University Hospital, Riyadh, Saudi Arabia. The procedure started by diathern-Lizing postganglionic of the second, third and fourth sympathetic chain. The sympathetic chain will be excised. The hand temperature is recorded during the procedure.
The first procedure rises the temperature 2-3'C. In contrast, the second technique rises the temperature, 0 to 0.5'C more.
Cutting postganglionic sympathetic nerve fibres may replace excision the sympåthetic chain and may decrease the incidence of post-operative rebound hyperdrosis.
DISTRIBUTION OF SYMPATHETIC RAMI ON THE INTERNAL SURFACE OF THE SECOND TO FOURTH RIBS IN PATIENTS WITH
Moriwaki KI, Hamada HI, Kusunoki SI, Uesugl FI, Fukuda
HI, Machara Yl, Yoshioka S2, Sasaki H3 and Yuge 01
IDept. of Anesthesiology and CCM, 22nd Dept.of Surgery,
Hiroshima University School of Medicine, and 3Dept.of
Anesthesiology and Intesive Care, Hiroshima City Funairi
Hospital, Hiroshima, Japan 734-8551
A study was conducted to investigate the distribut'on of sympathetic rami on the intemal surface of the second to fourth ribs in patients with palmar/axillar-y hyperhldrosis. Eighty patients (30 male and 40 female, mean+SD 26.2 + 8.9 years) who underwent video-assisted endoscoplc thoracic sympathectomy in our hospitals were studied prospectively. The sympathetie ran-li were observed using a 2.9-mm-diameter optic fiberscope (Olympus) and identlfied by palpation with an eleetroscope sling. Endoscopic sympathectomy was successful in all patients. Rarni appeared with an overall incldence of 85.0%. On both the second and third ribs, the presence of ran-ii on the right side was significantly more frequent than o@ the left (chi-squared test, p<0.05), and the number of rami was also significantly higher on the right (Wllcoxon test, p<0.0005). Rami on the fourth ribs were observed on the right side in 6.3% of patients and on the left in 3.8%, the difference being nonsignificant. The sympathetic rarni seemed to be present more frequently in our patient group than in cadavers reported by Kuntz in 1927, and were right-side-dominant.
*Acknowledgement: Supported in part by The Japanese Foundation for Research and Promotion of Endoscopy.
SYMPATHECTOMY THROUGH A
SINGLE SKIN INCISION OF 2-2.5MM.
H'deh'ro Yamaoto, MD, Masayoshi Okada, MD,
Akio Kanehira, M , and Munenori Kawamura, MD,
The aim of this technlque is to promote a further less invasive technlque of video-assisted thoracic sympathectomy .
A thoracoscope of 2 mm in diameter and a newly designed trocar by us were used. A skin inclsion of 2.02.5 mm was made on the 3rd intercostal space of midaxillary line. After neron of the trocar, thoracic sympathectomy was carfied out at the level of 2nd n'b using eleetrocautery.
Patients with palmar hyperhidrosis underwent this technique. The effect of thoracic sympathectomy was recognized in all patients. The operative wound mostly disappeared and complications including bleeding, pneumothorax, neuralgia, numbness and Horner's syndrome were none. The operative wound mostly disappeared within two weeks.
This technlque resuited in non-scar healing and improved patient's cosmesis. This technique might be called as one of needle scopic surgery.
ANATOMICAL POSITION OF UPPER THORACIC SYMPATHETIC NERVE TRUNK: -- A study by thoracoscopical observation---
K. HARANO, MD, 1. Ogawa, MD, T. Tono, MD, M. Takasaki, MD, and
T. Totoki, MD
Dept. of Anesthesiology and Critical Care Medicine, Saga Medical School, Japan.
Introduction: Thoracic sympathetic nerve block is commonly applied to malcirculation and complex regional pain syndrome (CRPS) of upper extremity. @is procedure is considered one of the most stressi] blockades for operators due to complications such as pneumothorax, puneture of vessel and neuritis caused by neurolytic agents. It is critical for operators to have a clear grasp of anatomy of thoracic sympathetie nerve for effective blotkade and to prevent complications. According to anatomy text books, ihere are mainly two different views of the lie
of thoracic sympathetic nerve trunk at T2 level: 1) head of the second rib and 2)
neck of the second rib. And there is no description of the differenee of the right
and left. In ihis study, we prospectively observed lie of upper thoracic
sympathetic nerve in patients who underwent thoracoscopic surgery.
Materiais and methods: Consent was obtained from 131 patients(56 males, 75 females, aged from 15 yrs to 62 yrs, average age 20.5 ± 10.3 yrs). Bilateral observation was carried out in 124 cases, and one-sided observation was done in 7 cases (total 127 observations in the right, 128 observations in the left). We classified zones that upper thoracic nerve lies , 1) medial head of ihe rib, 2) head of the rib, 3) neck of the rib and 4) Jateral neck of the rib, and observed at the level of the second to ihe fourth rib.
Resuits : Cases which sy@pathetic nerve lies on the medial head of the rib and the lateral neck of the rib were significantly low in all cases, and the nerk of ihe rib was the main zone in the right second rib. It was almost equal (number ) ihat the cases which sympathetic nerve lies on the head and the neek of the third and the fourth rib on the right side. In the left side on the second rih, cases that sympathetic nerve lies on the head of the rib and the neck of the rib were almosi equal, but cases that sympathetie nerve lies on the neck of the rib were significantly higher in the third and fourth ribs on the left side. Results shown in Fig .3a and b are ihe observations that focused on sex , but no sex difference was confirmed. Only 11 cases out of 124 cases (8.9%; 7 rnales and 4 females) had exactly the same lie of the thoracic nerve from the second to the fourth rib on both sides.
Conclusion: Anatomical position of upper thoracic syrnpathetic nerve has an individual differenee, and it is not symmetric, nor sex difference. We should not niention that the sympathetie nerve ]ies on the head of the rib nor on the neck of the rib at the 2nd rib, since the possibilities of its lie on the two are almost equal.
EFFECT ON PLASMA ATRIAL AND BRAIN NATRIURETIC PEPTIDE LEVELS OF ENDOSCOPIC TRANSTHORACIC SYMPATHICOTOMY IN HUMANS
uki0 Nakamura, Kouichi Shiraishi, Yoshiki Nagata, Yasushi Matsumoto, Takeshi Ueyama. Kanazawa National Hospital, Kanazawa, Ishikawa, Japan
To examine the effect of cardiac sympathetic nervous system on plasma atrial (ANP) and brain natriuretic peptide (BNP) levels in humans, we measured cardiac functional indices using echocardiography and plasma levels of ANP, BNP and norepinephrine before and after endoscopic transthoracic sympathicotomy (ETS) of Th2-Th3 in 31 patients with primary palmar hyperhidrosis. ETS decreased heart rate from 72±10 (mean±SD) to 62±10 bpm(p<0.01), mean blood pressure from 88±13 to 78±12 mmhg (p<0.01), systemic vascular resistanee from 1865±533 to 1642±446 unit (p<0.05), and plasma norepinephrine from 410±139 to 286±100 pg/m 1 (p<0.01), and increased LV end-diastolic volume from 92±18 to 98±19 ml (p<0.05), LV ejection fraction from 60±7 to 64±6 % (P<0.01). Left atrial diameter and LV end-systolic volume remained unchanged before and after ETS. Under these conditions, ETS increased plasma ANP fr@m 10.7±5.9 to 24.7±16.8 pg/m 1 (p<0.01) and plasma BNP from 5.1 ±4.2 to 19.7±21.5 pg/m 1 (p<0.01). These data suggest that cardiac sympathetic nervous system exerts a repressive effect upon plasma ANP and BNP concentrations in humans.
SYMPATHETIC SKIN RESPONSE (SSR) AND HYPERHIDROSISA PROSPECTIVE STUDY.
Kabiraj MNW, AIDohayan A.D AlTuwaijri AS King Saud University, Riyadh, Saudi Arabia
Objective.- To determine the sensitive role of SSR in the evaluation of the successful sympathectomy for hyperhidrosis.
Materials and methods: Patients suffering from excessive palmar, facial, axiflary and sweating from the solar aspects of foot were included in @ study. Median nerves contra-lateral to the recording sites were stimulated at the wrist with supr a-maximal stimuh. Four evoked electrodernud activities were recorded from each recording sites for analysis. The tests were repeated from day 1 to 7 post-operatively.
Results: A total of 16 Saudi males age ranged 17 to 44 years (mean 28 years) suffering from hyperhidrosis. Twelve had pahnar, one from forehead, one for face, one for thigh and one for axiha were studied. The mean SSR latency for hands (14 hands)=1.41 sec (ranged from 1.2 to.1.92 sec); feet (16 feet)=2.12 sec (ranged 1.12 to 3.06 sec); face=0.9 sec; chest--1.24 sec; forehead=1.24 sec; axffla=1.00 sec and thigh=1.78 sec. AR the responses were highly reproducible and were of higher amplitudes. Post-operative SSR studies in 10 pahnar hyperhidrosis and 1 patient with facial hyperhidrosis showed no reproducible potentials (flat cut-ves). The other patients are in the process of operative procedure. Our study showed 100% success of sympathectomy response for hyperhidrosis and correlates with the patients satisfaction hence SSR test should be routinely used for intraoperative/postoperative assessment of sympathetic for hyperhidrosis.
.. . . . . . . . .
WHICH SIDE OF THORACIC SYMPATHECTOMY INFLUENCES CARDIAC REPOLARIZATION INTENSELY ?
Yasushi Matsumoto Takeshi Ueyama, Masamitu Endo, Yoshinobu Abe, Shigeyuki Tomita, @atuki Kawashima, Hisao Sasaki
Department of carci ovascffl ar surgery & Cl ini cal reseach, Nationai hospital of Kanazawa Kanazawa,Japan
purpose: To apply thoracic sympathectomy for aati-airhythmie therapy, we ex ami ned the influence of unilaterai sympathetic nerve for carci ac repolarization accordng to intraoperative body surfaoemapping.
patients and method: 20 ca@ of palmarhyperhidrosis underwent EFS at ourinstitution (male:female was 8:12, averageage was 29yo.). We devived them into two groups (groupa : underwent right sideEFS inadvaace, group B: undrrwent left side ETS beforehand). Werecorded the intraoperativebody surface map pre EFS, post unilateral EIS, post EFS respecti vejy, and compared heart rete, QTcand others of these two groups. On the other hanct We ma& QR ST is oin tegral map which is av ail abl e for ex tracti ng abnormal ity of carci ac repol ari zati on such as is chemic injury. S t ati sti call y, means were ev alu ated wi th th e t- tes t for paired or unpai red sampi es.
A p-value of less than 0. OSwas considered sigaificant.
Re s ul ts: He@ mte(bpm ); group A (pre ET S 94 ± 7, pos t uni-ETS 78 ± 5, post EIS 70±3 ) group B (pre ETS 78 ±6, post uni-ETS 69 ±4, post ETS 64± 4). Heart rates were decreased postoperatively in both groups, but compaling group A wi th B, it wasn't consi dered si gni ficant. QTdsperston (m sec); group A(pm ErS 11 8.4 ± 6. 1, post uni-ETS 11 7.5± 9.8, post ETS 109.4± 7. 0), group B(pre EI'S 11 8.1 ± 8. 5, post uni-ETS 18.4± 9.7, po st ETS 100.9±7. 1). QT<ispersion decreased sigaificaatly in group B.QRST
1 .sointegrai map; In group A,any change of mapping pattem was't recogniz@ and the movment of minimal or maximal point had the various cirection. While in group B,two cases of multiple bipolarity map was noted,aad maximal point moved to the left side of the chest in ali cases after unilateral sympathectomy.
co mments:Unil atem(fight or left respecti vely)sympathetic nerve influences to the carciac mpolaiization cifferently. ltls suggestedleft sympathetie nurve may influenee intensely to carciac repoladzation thaa iight.
ENDOSCOPIC THORACIC SYMWATHICOTOMY
ATTENUATES REFLEX TACHYCARDIA DURING HEAD
UP TILTING IN LIGHTLY ANESTHETIZED YOUNG
ADULTS WITH ESSENTIAL HYPERHIDROSIS
T. Suzuki. @, Y. Masuda, Nffi', T. Maeda, Nffi', M. Nonaka, MD,
M. Kadokura, @, and A. Hosoyamada, MD'
Department of 'Anesthesiology and urgery (l), Showa University
School of Medicine, Tokyo, Japan
INTRODITCTION: Baroreflex-mediated reflex tachycardia during head up tilt (HUT) w-as studied before and after endoscopic thoracic sympathicotomy (ETS).
MFTHODS: Ten patients with essential palmer hyperhidrosis
scheduled for ETS were enrolled (@S group). F-ight volunteers
undergoing nunor surgery were employed as controls (control group).
Non'e was given premedication. In both groups, induction and
maintenance of anesthesia were siniilar (propofol, vecuronium, and sevofiurane/N20 in 02). After preparation of surgery was completed, administration of sevofiurane was paused. After the decline of the endtidal coneentration of sevofiurane (less than 0.2%) was confirtned, we started recording heart rate (HR) and arterial biood pressure at one niinute intervals. Then the patient was tilted to an upright posifion at
40' for 5 min. After surgery, the measurements identical to preoperative arrangement were perforined. The mean value of serial in three measurements immediately preceding HUT was defined as the
pre-HUT value. um changes in HR were used as
representatives of the during-HUT value.
Both groups are comparable in age and gender. The degree of increased HR was significantly reduced after surgery in
EFS group (32±18 to 14±12 bpm, p=0.030), although tiiere was a
slight change recorded in control group (26 ± 17 to 20 ± 12 bpm, p=0.493).
CONCI,IJSION: Our preliminary work suggest that EI'S may reduce the integrity of the baroreflex function.
ETS WITH A THIN THORACOSCOPE
Toshihiko Okura.MD. Takashi Suzuki,MD. Shuichi
2 2 2
Suzuki,MD. AkihikoKitami,MD. GoichiHori,MD . ,Shizuoka 1 Yokohama
Endoseopic Transthoracic Sympathectomy is a minimally invasive operation. Therefore has been appiied to patients with palmar hyperhidrosis. Usually the patients are young and healthy. Cosmetic quality they required is very high. Then we have operated 86 cases of ETS using a thin thoracoscope 2mm in diameter from 1996.
All patients underwent this ETS stopped palmar hyperhidrosis. No major complication was observed.
Operating method is simpie. All instruments we used were easy to obtain. A MiniSite GOLD laparoscope has been used for this study. This thoracoscope has given excellent visual field, and the operative injuries were only 2mm in siz@. For the patient, these small scars mean virtually 'no scar'.