Uniportal and Biportal Endoscopic Thoracic Sympathectomy

Brachial plexus injuries complicating video-assisted thoracic surgery

OBJECTIVE

Video-assisted thoracic surgery (VATS) is a less-invasive alternative to open thoracotomy. According to evidence-based medicine methodology, VATS is associated with better outcomes and the same complication rate as open thoracotomy.

CASE DESCRIPTION

Two women (19 and 21 years old) underwent VATS for treatment of pneumothorax. In an attempt to perform hemostasis, the subclavian arteries had to be occluded. Total sensorimotor deficit in both patients on the side where surgery was performed was noticed postoperatively. After 3½ months in patient 1, nerve roots C5 and C6 were neurolyzed. Neuromas of middle and lower trunks and posterior and medial cords were resected and graft repair with sural nerves was performed. In the second patient, 1 month after VATS the entire plexus was neurolyzed because of severe fibrosis. Following neurolysis, positive nerve action potentials (NAPs) were recorded. Patient 1 after the 6-year follow-up has full range of motion of the shoulder and elbow. Extension and flexion in the wrist and fingers recovered to M4/5. Pain sensation and two-point discrimination recovered. Patient 2 after 2½-year follow-up recovered full range of motion of the shoulder, elbow, and forearm. Pain sensation recovered in dermatomes C5 and C6.

CONCLUSIONS

The two presented cases show that VATS is not without severe complications, as evidence-based medicine methodology suggests. Surgical findings in our patients imply that if this type of complication happens, early surgical exploration could be the best option for the patients.

The correlation between the method of sympathetic ablation for palmar hyperhidrosis and the occurrence of compensatory hyperhidrosis: a review

BACKGROUND

Upper dorsal sympathectomy achieves excellent long-term results in the treatment of primary palmar hyperhidrosis. Compensatory hyperhidrosis (CHH) remains an unexplained sequel of this treatment, attaining in a small percentage of cases disastrous proportions. It has been claimed that lowering the level of sympathectomy (from T2 to T3 and even T4), substituting resection by other means of ablation, and limiting its extend reduce the occurrence of this sequel. This review was designed to evaluate the validity of these claims.

METHODS

A MEDLINE search was performed for the years 1990--2006 and all publications about thoracoscopic upper dorsal sympathectomy for hyperhidrosis were retrieved.

RESULTS

The search identified 42 techniques of sympathetic ablation. However, pertinent data for the present study were reported for only 23 techniques with multiple publications found only for 10. The only statistically valid results from this review point that T2 resection and R2 transection of the chain (over the second rib) ensue in less CHH than does electrocoagulation of T2. Further comparisons were probably prevented due to the enormous disparity in the reported results, indicating lack of standardization in definitions.

CONCLUSIONS

The compiled results published so far in the literature do not support the claims that lowering the level of sympathetic ablation, using a method of ablation other than resection, or restricting the extend of sympathetic ablation for primary palmar hyperhidrosis result in less CHH. In the future, standardization of the methods of retrieving and reporting data are necessary to allow such a comparison of data.