Anatomic Variation of Rami Communicantes in the Upper Thoracic Sympathetic Chain: A Human Cadaveric Study

Application of near-infrared fluorescence imaging with indocyanine green in mediastinal surgery

Intraoperative near-infrared (NIR) fluorescence imaging has emerged in recent years and is now used in many surgical procedures. Intraoperative fluorescence imaging can guide surgeons in identifying and localizing specific structures and boundaries, which can facilitate the optimization of surgical procedures. The components of the mediastinum are complex and functionally important, making identifying and locating different structures intraoperatively challenging, and NIR fluorescence imaging has potential clinical value in mediastinal surgery. Here we review the applications of NIR fluorescence imaging technology in mediastinal surgery in recent years.

Comparison of the efficacy of ETS with different segments for palmar, axillary and plantar hyperhidrosis

BACKGROUND

To compare the near and long-term outcomes of endoscopic thoracic sympathectomy (ETS) for palmar, axillary and plantar hyperhidrosis.

METHODS

We retrospectively analyzed the clinical data of 218 patients with hyperhidrosis who were admitted to the Department of Thoracic Surgery of Gansu Provincial People's Hospital for surgical treatment from April 2014 to August 2021. The patients were divided into three groups according to the method of ETS and the perioperative clinical data and postoperative follow-up data were collected to compare the near and long term outcomes of the three groups.

RESULTS

There were 197 eligible patients at follow-up, 60 patients in the R4 cut-off group, 95 patients in the R3 + R4 cut-off group and 42 patients in the R4 + R5 cut-off group. There were no statistically significant differences in baseline indicators such as sex, age and positive family history among the three groups (P > 0.05). There was no statistically significant difference between the three groups in terms of operative time (P = 0.148), intraoperative bleeding (P = 0.308) and postoperative hospital stay (P = 0.407). Postoperatively, all three groups showed significant relief of palmar hyperhidrosis symptoms, with the R3 + R4 group having an advantage in terms of relief of axillary hyperhidrosis symptoms, patient satisfaction and quality of life index at 6 months postoperatively and the R4 + R5 group having an advantage in terms of relief of plantar hyperhidrosis symptoms. The difference in compensatory hyperhidrosis at 12 months postoperatively was not statistically significant among the three groups (P = 0.867), but the incidence was higher in the R3 + R4 and R4 + R5 groups than that in the R4 group.

CONCLUSION

Patients with simple palmar hyperhidrosis can first consider R4 cut-off treatment; R3 + R4 cut-off is more effective in treating palmar hyperhidrosis combined with axillary hyperhidrosis; R4 + R5 cut-off is more effective in treating palmar hyperhidrosis combined with plantar hyperhidrosis. However, patients need to be informed that R3 + R4 and R4 + R5 dissection may increase the risk of severe compensatory hyperhidrosis after surgery.

Anatomical variations of the thoracic sympathetic ganglions and their effects on sympathicotomy for primary palmar hyperhidrosis

PURPOSE

The results and side effects of sympathicotomy for primary palmar hyperhidrosis (PPH) can vary due to anatomical variations of the sympathetic ganglions. The aim of our study was to clarify anatomical variations of the sympathetic ganglions by near-infrared (NIR) thoracoscopy and determine their effects on sympathicotomy for PPH.

METHODS

The cases of 695 consecutive patients with PPH treated with either R3 or R4 sympathicotomy either by normal thoracoscopy or by NIR fluorescent thoracoscopy between March 2015 and June 2021 were retrospectively reviewed and followed up.

RESULTS

The variation rate of third and fourth ganglions was 14.7% and 13.3% on the right side and 8.3% and 11.1% on the left side. Real T3 sympathicotomy (RTS₃) was more effective than real T4 sympathicotomy (RTS₄) in the short-term and long-term follow-up (p < 0.001 and p < 0.001, respectively). RTS₃ was more satisfactory than RTS₄ in the long-term follow-up (p = 0.03), but no significant difference was found in the short-term follow-up (p = 0.24). The incidence and severity of compensatory hyperhidrosis (CH) in the areas of the chest and back in the RTS₄ group were significantly lower than those in the RTS₃ group according to both the short-term results (12.92% vs. 26.19%, p < 0.001; 17.97% vs. 33.33%, p = 0.002, respectively) and the long-term results (19.66% vs. 28.57%, p = 0.017; 21.35% vs. 34.52%, p < 0.001, respectively).

CONCLUSIONS

RTS₃ may be more effective than RTS₄ for PPH. However, RTS₄ appears to be associated with a lower incidence and severity of CH in the areas of the chest and back than RTS_3. NIR intraoperative imaging of thoracic sympathetic ganglions may improve the quality of sympathicotomy surgeries.

Computed Tomography-Guided Percutaneous T4 Thoracic Sympathetic Radiofrequency Thermocoagulation for Primary Palmar Hyperhidrosis: A Retrospective Observational Trial

PURPOSE

To evaluate the efficacy, safety, and patient satisfaction of computed tomography (CT)-guided percutaneous T4 thoracic sympathetic radiofrequency thermocoagulation (RFT) for the treatment of primary palmar hyperhidrosis (PPHH).

MATERIALS AND METHODS

A total of 158 patients who underwent bilateral thoracic sympathetic RFT at the T4 level were analysed. Hyperhidrosis Severity Scale (HDSS), Dermatologic Quality of Life Index (DLQI), patient satisfaction, and adverse events were evaluated within 12 months after RFT.

RESULTS

The mean age of the patients was 25.27 years, and 95 (60.1%) were females. The technical success, defined as planned needle placement and completion of RFT, was 99.4%. After the procedure, 243 hands (77.4%) were completely dry; and 58 hands (18.4%) were partially dry. From before RFT to 12 months after RFT, the proportion of hands with the HDSS grades 3 and 4 from 100% decreased to 31.9%; and that with the DLQI scores D and E from 100% decreased to 4.0% (P < .001). The clinical success rate was 76.6%, and the patient satisfaction rate was 80.8% at 12 months after RFT. During the procedures, there was unilateral local bleeding in two patients (0.6%) and bradycardia in five patients (3.2%); after the procedures, unilateral pneumothorax occurred in 15 patients (4.7%) and closed thoracic drainage was performed in two patients (0.6%); thoracic neuralgia occurred in 24 patients (15.2%). The incidence of compensatory hyperhidrosis (CH) 12 months after RFT was 15.2%.

CONCLUSIONS

CT-guided percutaneous T4 thoracic sympathetic RFT is safe, effective, and minimally invasive for the treatment of PPHH.

LEVEL OF EVIDENCE

Level 2 observational study with dramatic effect.

Anatomical Variation of the Sympathetic Trunk and Aberrant Rami Communicantes and their Clinical Implications

Surgical interventions involving the sympathetic trunk are increasingly performed to alleviate symptoms of several disorders such as hyperhidrosis. Anatomical variation has been highlighted as one of the main causes behind surgical failure and symptoms recurrence following surgeries conducted on the chain or its surroundings. This study therefore aimed to record anatomical variants within spinal segments C8-T10 of the sympathetic trunk. Thirty Thiel-embalmed cadavers were investigated bilaterally. The stellate ganglion was recorded on 29 sides. Its size was significantly greater in males and on the right side when the coalescence extended to the subsequent ganglion. The intrathoracic nerve of Kuntz was observed on 21 sides and was significantly more prevalent in males. There was a significant positive association between the presence of this nerve and the descending ramus in the first intercostal space. Aberrant rami found between spinal root C8 and the ventral ramus of the first intercostal nerve were introduced as rami communicantes superi. Aberrant rami communicantes were recorded 50 times in total, of which 70% were found in males. Descending rami showed the highest prevalence in upper intercostal levels, especially in males within the first intercostal space. Aberrant neuronal pathways in upper levels were significantly more prevalent when the stellate ganglion was present. The scientific literature has proven to be stochastic as results were significantly higher in past studies in regard to some sympathetic variants. Anatomical findings of the current study as well as the inconsistency of previous data should be acknowledged and considered for better surgical planning.

Anatomical variations of the upper thoracic sympathetic chain: a review

OBJECTIVES

The objective of this study is to provide a thorough overview of the anatomical variations of the upper thoracic sympathetic trunk to improve clinical results of upper thoracic sympathectomy. In addition, this study strives for standardization of future studies regarding the anatomy of the upper thoracic sympathetic chain.

METHODS

The Web of Science, PubMed and Google Scholar databases were searched using keywords, alone or combined, regarding the anatomy of the thoracic sympathetic chain. The search was limited to studies performed in humans.

RESULTS

Fifteen studies were finally included. Cervicothoracic ganglion and nerve of Kuntz were present in 77% and 53%, respectively. The upper thoracic ganglia were predominantly located in their corresponding intercostal space with a relatively downwards shift at the lower thoracic levels. The right sympathetic trunk is prone to have more communicating rami then the left. The lower levels of ganglia tend to have more normal rami. No clear pattern was found concerning the presence of the ascending rami and there was a decrease in the number of descending rami as the chain runs caudally. The intercostal rami remain a rare anatomical variation.

CONCLUSIONS

This study presents an overview of the anatomy of the upper thoracic sympathetic chain. Its results may guide upper thoracic sympathectomy to improve clinical results. This review also provides a baseline for future studies on anatomical variations of the thoracic sympathetic trunk. More uniform reporting is necessary to compare different anatomical studies.

Long-Term Efficacy of T3 Versus T3+T4 Thoracoscopic Sympathectomy for Concurrent Palmar and Plantar Hyperhidrosis

BACKGROUND

More than 50% of patients with palmar hyperhidrosis (PAH) also have plantar hyperhidrosis (PLH). We compared the long-term results of T3 sympathectomy with those of combined T3+T4 sympathectomy among patients with concurrent PAH and PLH.

MATERIALS AND METHODS

We retrospectively analyzed the records of patients with concurrent PAH and PLH who underwent T3 alone or T3+T4 sympathectomy from January 1, 2012, to December 31, 2017. Preoperative and postoperative sweating (hyperhidrosis index) was evaluated through questionnaires, physical examination, and outpatient follow-up. The relief rates and hyperhidrosis index were used as outcome measures to compare the efficacy of the two approaches. Patients' satisfaction and side effects were also evaluated.

RESULTS

Of the 220 eligible patients, 60 underwent T3 sympathectomy (T3 group), and 160 underwent T3+T4 sympathectomy (T3+T4 group). Compared with the T3 group, the T3+T4 group showed higher symptom relief rates both for PAH (98.75% versus 93.33%, P = 0.048) and PLH (65.63% versus 46.67%, P = 0.01), and a greater postoperative decrease in both hyperhidrosis indices. The rate of severe compensatory hyperhidrosis also increased (10% versus 5%, P = 0.197), although the rates of overall satisfaction were comparable between the groups. The incidence of postoperative pneumothorax requiring chest tube placement and postoperative neuralgia was also similar. There were no cases of perioperative death, secondary operation, wound infection, or Horner syndrome in either group.

CONCLUSIONS

Compared with T3 alone, T3+T4 sympathectomy achieved a higher symptom relief rate and a lower hyperhidrosis index. T3+T4 sympathectomy may be a choice for the treatment of concurrent PAH and PLH; however, patients need to be informed that this kind of surgery may increase the risk of compensatory sweating.

Anatomic variations of the intrathoracic nerves and the neural connections of the second and third thoracic sympathetic ganglia to the brachial plexus

INTRODUCTION

This study investigated morphological variations of the intrathoracic nerves and the neural connections of the second and third thoracic sympathetic ganglia to the brachial plexus based on the existence of the intrathoracic nerves and the rami communicantes.

MATERIALS AND METHODS

Fifty thoracic sympathetic trunks from 26 Korean adult cadavers were used.

RESULTS

The first intrathoracic nerve connecting the first and second thoracic nerves was observed on 36 sides (72%), and the second intrathoracic nerve connecting the second and third thoracic nerves was found on three sides (6%). There were either one (62%) or two (10%) first intrathoracic nerves, and only one second intrathoracic nerve (6%). The neural connections of the second and third thoracic sympathetic ganglia to the first thoracic nerve were classified into three types based on the existence of the intrathoracic nerves: Type I (68%) had only the first intrathoracic nerve, Type II (26%) had no intrathoracic nerve, and Type III (6%) had both the first and second intrathoracic nerves. Types I, II, and III were further subdivided into 10, 6, and 3 types, respectively, according to the types of the rami communicantes arising from the second and third thoracic sympathetic ganglia.

CONCLUSIONS

Improved knowledge of the variations in intrathoracic nerves and upper thoracic sympathetic ganglia will be helpful to thoracic surgeons when they are disrupting the sympathetic supply to the hand for treating palmar hyperhidrosis, and contribute to successful diagnoses and treatments.

The safety and feasibility of intraoperative near-infrared fluorescence imaging with indocyanine green in thoracoscopic sympathectomy for primary palmar hyperhidrosis

Background

We investigated the safety and feasibility of intraoperative near‐infrared (NIR) imaging using indocyanine green (ICG) during sympathectomy in the management of primary palmar hyperhidrosis (PPH).

Methods

We performed a retrospective review of 142 patients (ICG group) who underwent endoscopic thoracic sympathectomy (ETS) between February 2018 and April 2019. All patients received a 5 mg/kg infusion of ICG 24 hours preoperatively. The vital signs before and after ICG injection and adverse reactions were recorded. Meanwhile, 498 patients (Non‐ICG group) who underwent ETS by normal thoracoscopy during August 2017 to April 2019 were also reviewed to compare the abnormal white blood cell (WBC) counts, alanine transaminase (ALT), aspartate transaminase (AST), blood urea nitrogen (BUN), and creatinine (Cr) levels before and after operation between two groups.

Results

For ICG group, the vital signs including body temperature, heart rate and blood pressure before and after ICG injection were stable. There was no significant difference in the abnormal WBC counts, ALT, AST, BUN, and Cr levels before and after operation between two groups. Only one patient had mild adverse reaction (0.7%) after ICG injection. The visibility rate of all sympathetic ganglions was 96.7% (1369/1415). The visibility rate from T1 to T5 was 98.23% (278/283), 98.23% (278/283), 97.17% (275/283), 95.76% (271/283), and 94.35% (267/283), respectively. There was no significant difference in the visibility rate with regard to age, gender, height, weight, body mass index, and PPH grade.

Conclusions

NIR fluorescence imaging with ICG for identifying sympathetic ganglions is relatively safe and feasible.

Key points

• Significant findings of the study.

NIR fluorescence imaging with ICG for identifying sympathetic ganglions is relatively safe and feasible.

• What this study adds.

This technology may take the place of the rib‐oriented method as standard practice for the precise localization of sympathetic ganglions, and may improve the effect of sympathectomies.

Topographical study of the connections of the rami communicantes from the first to the fifth thoracic sympathetic ganglia

This study investigated the morphological variations and histological patterns of the rami communicantes (RCs) arising from the first to the fifth thoracic sympathetic ganglia, and considered the clinical significance of these variations. Fifty upper thoracic portions from 26 adult Korean cadavers were used in this study. There were 731 RCs arising from the first to the fifth thoracic sympathetic ganglia. They were classified into three types depending on the connection between the sympathetic ganglion and the intercostal nerves: in type I, the RCs connected the ganglion to the corresponding intercostal nerve, and in types II and III, respectively, they connected it to the nerve one level above or below the corresponding intercostal nerve. Some RCs of types I and II could not be observed without additional preliminary surgical procedures. Diverse combinations of RC types arose from the first to the fifth thoracic sympathetic ganglia, combinations of types I and III being the most common (70%) in the first sympathetic ganglion and those comprising only type I being most frequent in the other ganglia. The RCs could not be identified by the naked eye in either fresh or fixed cadavers, so they were confirmed on the basis of their histological appearance. These results are expected to improve knowledge of morphological variations of the RCs in the upper five thoracic sympathetic ganglia, and to provide helpful information for clinical management in this region. Clin. Anat. 31:1151-1157, 2018. © 2018 Wiley Periodicals, Inc.

Near-infrared Intraoperative Imaging of Thoracic Sympathetic Nerves: From Preclinical Study to Clinical Trial

The sympathetic nervous system controls and regulates the activities of the heart and other organs. Sympathetic nervous system dysfunction leads to disease. Therefore, intraoperative real-time imaging of thoracic sympathetic nerves (ITSN) would be of great clinical significance for diagnosis and therapy. The aim of this experimental study was to evaluate the feasibility and validity of intraoperative ITSN using indocyanine green (ICG).

METHODS

ITSN using ICG was performed on 10 rabbits to determine its feasibility. Animals were allocated to two groups. The rabbits in one group received the same dose of ICG, but were observed at different times. The rabbits in the other group were administered different doses of ICG, but were observed at the same time. Signal to background ratio (SBR) was measured in regions of interest in all rabbits. Furthermore, fifteen consecutive patients with pulmonary nodules were intravenously injected with ICG 24 h preoperatively and underwent near-infrared (NIR) fluorescence imaging (FI) thoracoscopic surgeries between July 2015 and June 2016. A novel self-developed NIR and white-light dual-channel thoracoscope system was used. SBRs of thoracic sympathetic nerves were calculated in all patients.

RESULTS

In the preclinical study, we were able to precisely recognize each rabbit's second (T2) to fifth (T5) thoracic ganglia on both sides of the spine using ITSN with ICG. In addition, we explored the relationship between SBR and the injection time of ICG and that between SBR and the dose of ICG. Using the novel dual-channel thoracoscope system, we were able to locate the ganglia from the stellate ganglion (SG) to the sixth thoracic ganglion (T6), as well as the chains between these ganglia in all patients with a high SBR value of 3.26 (standard deviation: 0.57). The pathological results confirmed our findings.

CONCLUSION

We were able to use ICG FI to distinguish thoracic sympathetic nerves during NIR thoracoscopic surgery. The technique may replace the rib-oriented method as standard practice for mapping the thoracic sympathetic nerves.