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-Mung Ng 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.

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.

Telaranta T, 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

Yong Han Yoon, MD, Doo Yun Lee,MD, , Hae Kyoon Kim, MD, Jung Shin

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.

Thoracoseopic T2-sympathetie Block by Clamping in

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)

BILATERAL THORACIC

SYMPATHECTOMY THROUGH

RETROSTERNAL PULMONARY KISSING

Hidehiro Yamamoto, MD, Masayoshi Okada, MD, Akio

Kanehira, MD, and Munenori Kawamura, MD, Kobe,

JAPAN

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

Sympathectomy.

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.

INCLUSION OF THE NER'VE OF KUNTZ IN

THORACOSCOPIC SYMPATHECTOMY MINIMIZED THE RECURRENCE OF PALMAR HYPERHYDROSIS

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

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

K Koja

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

ENDOSCOPIC THORACIC SYMPATHECTOMY FOR PRIM-ARY HYPERHIDROSIS USING THIN TYPE

THORACOSCOPE AND ULTRASONICALLY ACTIVATED SCALPEL

T. lwai**

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.

LARYNGEAL MASK GENERAL ANESTHESIA

FOR THORACOSCOPIC SYMPATHETIC

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

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,

82 patcllts Illiti, severe 2

ik C**, Tygescll 14**, Elli,

Di-ott C *, Claes G*,Wcttel-N

ENDOCSCOPIC THORACIC

SYMPATHECTOMY THROUGH A

H'deh'ro Yama oto, MD, Masayoshi Okada, MD,

ANATOMICAL POSITION OF UPPER THORACIC SYMPATHETIC NERVE TRUNK: -- A study by thoracoscopical observation---

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

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.

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.