Parasympathetic, but not sympathetic denervation, suppressed colorectal cancer progression

Disruption in the nerve-tumor interaction is now considered as a possible anticancer strategy for treating various cancer types, particularly colorectal cancer. However, the underlying mechanisms are not still fully understood. Therefore, the present study aimed to evaluate the effects of sympathetic and parasympathetic denervation on the inhibition of colorectal cancer progression in early and late phases and assess the involvement of nerve growth factor in denervation mediated anticancer effects. One-hundred and fifty male Wistar rats were assigned into 15 groups. Seven groups comprising the control group, 1,2-dimethylhydrazine (DMH) group, sympathetic denervation group (celiac-mesenteric ganglionectomy and guanethidine sulphate administration), parasympathetic denervation group (vagotomy and atropine administration), and combination group were used in the early-stage protocol. For the late-stage protocol, eight groups comprising the control, DMH, surgical and pharmacological sympathetic and parasympathetic denervation groups, combination group, and 5-flourouracil group were considered. After 8 weeks, sympathetic and parasympathetic denervation significantly reduced ACF numbers in rats receiving DMH. On the other hand, in the late stages, parasympathetic but not sympathetic denervation resulted in significant reductions in tumor incidence, tumor volume and weight, cell proliferation (indicated by reduced immunostaining of PCNA and ki-67), and angiogenesis (indicated by reduced immunostaining of CD31 and VEGF expression levels), and downregulated NGF, β2 adrenergic, and M3 receptors. It can be concluded that parasympathetic denervation may be of high importance in colon carcinogenesis and suggested as a possible therapeutic modality in late stages of colorectal cancer.

Effect of Vagotomy and Sympathectomy on the Feeding Responses Evoked by Intra-Aortic Cholecystokinin-8 in Adult Male Sprague Dawley Rats

The vagus nerve and the celiaco-mesenteric ganglia (CMG) are required for reduction of meal size (MS) and prolongation of the intermeal interval (IMI) by intraperitoneal (ip) sulfated cholecystokinin-8 (CCK-8). However, recently we have shown that the gut regulates these responses. Therefore, reevaluating the role of the vagus and the CMG in the feeding responses evoked by CCK is necessary because the gut contains the highest concentration of enteric, vagal and splanchnic afferents and CCK-A receptors, which are required for reduction of food intake by this peptide, compared to other abdominal organs. To address this necessity, we injected sulfated CCK-8 (0, 0.1, 0.5, 1 and 3 nmol/kg) in the aorta, near the gastrointestinal sites of action of the peptide, in three groups of free-feeding rats (n = 10 rats per group), subdiaphragmatic vagotomy (VGX), celiaco-mesenteric ganglionectomy (CMGX) and sham-operated, and recorded seven feeding responses. In the sham group, CCK-8 reduced MS (normal chow), prolonged the intermeal interval (IMI, time between first and second meals), increased satiety ratio (SR, IMI/MS), shortened duration of first meal, reduced total (24 hrs) food intake and reduced number of meals relative to saline vehicle. Vagotomy attenuated all of the previous responses except IMI length and SR, and CMGX attenuated all of those responses. In conclusion, the feeding responses evoked by sulfated CCK-8 require, independently, the vagus nerve and the CMG.

Ancient schwannoma of cervical sympathetic chain masquerading as carotid body tumour

Schwannoma of cervical sympathetic chain is a rare cause of neck swelling. We report a 73- year-old male presented with anterior neck triangle swelling mimicking a carotid body tumour. Surgical excision was done, and the histopathological examination reported as ancient schwannoma. We would like to discuss the important differential diagnoses and highlight the possibility of an ancient schwannoma of cervical sympathetic chain masquerading as carotid body tumour. Also, to emphasise the importance of imaging for pre-operative planning and counselling.

Changes in Somatostatin-Like Immunoreactivity in the Sympathetic Neurons Projecting to the Prepyloric Area of the Porcine Stomach Induced by Selected Pathological Conditions

The aim of the present study was to define changes in the expression of somatostatin (SOM) in the sympathetic perikarya innervating the porcine stomach prepyloric area during acetylsalicylic-acid-induced gastritis (ASA) and experimentally induced hyperacidity (HCL) and following partial stomach resection (RES). On day 1, the stomachs were injected with neuronal retrograde tracer Fast Blue (FB). Animals in the ASA group were given acetylsalicylic acid orally for 21 days. On the 22nd day after FB injection, partial stomach resection was performed in RES animals. On day 23, HCL animals were intragastrically given 5 ml/kg of body weight of a 0.25 M aqueous solution of hydrochloric acid. On day 28, all pigs were euthanized. Then, 14-μm thick cryostat sections of the coeliac-superior mesenteric ganglion (CSMG) complexes were processed for routine double-labelling immunofluorescence. All pathological conditions studied resulted in upregulation of SOM-like (SOM-LI) immunoreactivity (from 14.97 ± 1.57% in control group to 33.72 ± 4.39% in the ASA group, to 39.02 ± 3.65% in the RES group, and to 29.63 ± 0.85% in the HCL group). The present studies showed that altered expression of SOM occurs in sympathetic neurons supplying the prepyloric area of the porcine stomach during adaptation to various pathological insults.

Transthoracic Median Arcuate Ligament Release and Mesenteric Revascularization

Surgical revascularization for chronic or acute mesenteric ischemia is often technically challenging. In many instances, because of the presence of hostile abdominal conditions or the lack of adequate intra-abdominal arterial inflow sources, alternative surgical approaches that avoid the abdomen and use a more proximal source of arterial inflow are necessary. In these situations, a bypass from the descending or ascending thoracic aorta to the mesenteric vessels may be the only viable option. However, the standard thoracoabdominal approach for mesenteric revascularization carries an extensive surgical insult, and in some situations, this approach does not obviate hostile abdominal pathology. We here describe a transthoracic surgical technique that allows antegrade celiac and mesenteric revascularization without a thoracoabdominal incision. This approach facilitates the easy transection of the median arcuate ligament of the diaphragm and, when needed, resection of the celiac autonomic ganglia. The transthoracic mesenteric revascularization is less invasive than a thoracoabdominal approach, whereas allowing a similar antegrade, short bypass to the mesenteric vessels from the descending thoracic aorta equal to that done through a thoracoabdominal exposure. This procedure provides a superb approach for the treatment of median arcuate ligament syndrome, and an excellent alternative for mesenteric revascularization when avoidance of the abdomen is advisable.

[EFFICACY OF RADIOFREQUENCY ABLATION OF AORTORENAL SYMPATHETIC NODES IN PATIENTS IN ARTERIAL HYPERTENSION]

Efficacy of radiofrequency ablation (RFA) of prevertebral sympathetic nodes, concern- ing the arterial pressure lowering in 36 patients, suffering hypertonic disease and coex- istent heart diseases, was analyzed. In 12 mo after RFA a systolic arterial pressure lowering at average throughout the group by (3.24 ± 1.15) kPa, or (24.3 ± 8.6) mm Hg, diastolic arterial pressure--by (1.51 ± 0.45) kPa, or (11.3 ± 3.4) mm Hg was noted. RFA of prevertebral sympathetic nodes have had promoted a stable lowering of arterial pressure in patients, suffering chronic hypersympathicotony.

5-Hydroxytryptamine does not reduce sympathetic nerve activity or neuroeffector function in the splanchnic circulation

Infusion of 5-hydroxytryptamine (5-HT) in conscious rats results in a sustained (up to 30 days) fall in blood pressure. This is accompanied by an increase in splanchnic blood flow. Because the splanchnic circulation is regulated by the sympathetic nervous system, we hypothesized that 5-HT would: 1) directly reduce sympathetic nerve activity in the splanchnic region; and/or 2) inhibit sympathetic neuroeffector function in splanchnic blood vessels. Moreover, removal of the sympathetic innervation of the splanchnic circulation (celiac ganglionectomy) would reduce 5-HT-induced hypotension. In anaesthetized Sprague-Dawley rats, mean blood pressure was reduced from 101±4 to 63±3mm Hg during slow infusion of 5-HT (25μg/kg/min, i.v.). Pre- and postganglionic splanchnic sympathetic nerve activity were unaffected during 5-HT infusion. In superior mesenteric arterial rings prepared for electrical field stimulation, neither 5-HT (3, 10, 30nM), the 5-HT1B receptor agonist CP 93129 nor 5-HT1/7 receptor agonist 5-carboxamidotryptamine inhibited neurogenic contraction compared to vehicle. 5-HT did not inhibit neurogenic contraction in superior mesenteric venous rings. Finally, celiac ganglionectomy did not modify the magnitude of fall or time course of 5-HT-induced hypotension when compared to animals receiving sham ganglionectomy. We conclude it is unlikely 5-HT interacts with the sympathetic nervous system at the level of the splanchnic preganglionic or postganglionic nerve, as well as at the neuroeffector junction, to reduce blood pressure. These important studies allow us to rule out a direct interaction of 5-HT with the splanchnic sympathetic nervous system as a cause of the 5-HT-induced fall in blood pressure.

Vascular skeletalization: a new concept to improve the resection rate in childhood neuroblastoma

AIM

The surgical resection rate in childhood neuroblastoma (Stage III and IV) is relatively low and influences the prognosis greatly. This study analyzes the primary resection rate neuroblastoma in children.

METHODS

The tumors are shrunk with pre-operative chemotherapy and surgical resection beginning from the iliac vessels is performed to skeletalize the large retroperitoneal vascular. Using this method, 22 cases of childhood neuroblastoma received resections and the outcomes were analyzed.

RESULTS

The tumors were completely removed in 21 out of the 22 cases (95.45% in total). There were no serious complications and perioperative deaths.

CONCLUSION

Using proper surgical methods and skeletalizing the large retroperitoneal vessels significantly increases the resection rate.

Pain affecting procedures in non-resectable pancreatic carcinoma

Pancreatic cancer is third most common cancer of the gastrointestinal tract in Bulgaria, accouting for 11, 6% in 2008. The leading symptom in patients with pancreatic cancer is the pain. The pain can be related with neoplasms and their metastasis. We should use all kind of resourses for pain relief: conventional drugs (according to the three steps strategy of WHO), interventional or surgical procedures.

AIM

To present the interventional and surgical techniques in our practice and to share our experience for pain control in patients with nonresectable pancreatic cancer to improve their quality of life.

MATERIAL

In a seven year period (2004-2011) we performed 59 thoracoscopic splanhnicectomies/30--bilateral/ 4 intraoperative resections of celiac ganglion, 25 CT--control celiac plexus neurolysis and 90 cases pain relief with epidural analgesia. Concerning the quality of life we applied a questionnaire of a spannish medical center " City of Hope" adapted for patients with cancer and the level of pain with visual analogue scale VAS.

RESULTS

The long-term duration of the pain relief technique depends on applied technic, of cancer invasion and of the technic itself. The technique with the longest effect are the intraoperative celiac ganglion removal and the bilateral thoracoscopic splanhnicectomy. On the other hand the shortest effect we report the celiac plexus neurolysis, and the epudural analgesia. These data are in correlation with the reduction of the pain shown using VAS thus improving the quality of life.

CONCLUSIONS

The surgical and interventional methods for control of cancer pain have their own collocation improving the quality of life of these patients. New strategies for the pain control are need in the future.

Effects of celiac superior mesenteric ganglionectomy on glucose homeostasis and hormonal changes during oral glucose tolerance testing in rats

The liver plays an important role in maintaining glucose homeostasis in the body. In the prandial state, some of the glucose which is absorbed by the gastrointestinal tract is converted into glycogen and stored in the liver. In contrast, the liver produces glucose by glycogenolysis and gluconeogenesis while fasting. Thus, the liver contributes to maintaining blood glucose level within normoglycemic range. Glycogenesis and glycogenolysis are regulated by various mechanisms including hormones, the sympathetic and parasympathetic nervous systems and the hepatic glucose content. In this study, we examined a rat model in which the celiac superior mesenteric ganglion (CSMG) was resected. We attempted to elucidate how the celiac sympathetic nervous system is involved in regulating glucose homeostasis by assessing the effects of CSMG resection on glucose excursion during an oral glucose tolerance test, and by examining hepatic glycogen content and hepatic glycogen phosphorylase (GP) activity. On the oral glucose tolerance test, CSMG-resected rats demonstrated improved glucose tolerance and significantly increased GP activity compared with sham-operated rats, whereas there were no significant differences in insulin, glucagon or catecholamine levels between the 2 groups. These results suggest that the celiac sympathetic nervous system is involved in regulating the rate of glycogen consumption through GP activity. In conclusion, the examined rat model showed that the celiac sympathetic nervous system regulates hepatic glucose metabolism in conjunction with vagal nerve innervations and is a critical component in the maintenance of blood glucose homeostasis.

Sympathetic paraganglioma in a patient with unrepaired tetralogy of Fallot: a case report and review of the literature

CONTEXT

Paragangliomas are a type of neuroendocrine tumor that has been reported to be present in patients with cyanotic congenital heart disease. This report documents the first case of a patient with successful resection of a sympathetic paraganglioma in the setting of unrepaired tetralogy of Fallot, the most common cause of cyanotic heart disease, with pulmonary atresia.

OBJECTIVE

We present a 33-yr-old woman with hypertensive crises from a paraganglioma who presented for surgical resection.

PATIENT AND METHODS

The patient's preoperative workup was consistent with a functioning sympathetic paraganglioma. Preoperative transesophageal echocardiogram displayed normal ventricular function, moderate-severe right ventricular hypertrophy, severe right ventricular hypertension, an overriding aorta, bidirectional shunting, pulmonary atresia, and aortopulmonary collaterals.

RESULTS

The patient underwent a successful laparoscopic resection of a functioning 7-cm paraganglioma after careful preoperative preparation and intraoperative monitoring. Pathology returned as a well-defined, partially hemorrhagic mass measuring 7.0 × 4.5 × 4.5 cm adjacent to and compressing the adrenal gland.

CONCLUSION

Surgical resection of paraganglioma tumors in rare patients such as this one is appropriate; however, surgery requires meticulous perioperative management with a multidisciplinary approach. Future studies are needed to determine whether there is a link between neuroendocrine tumors and cyanotic congenital heart disease.

Lateral hypothalamic area mediated the aggravated effect of microinjection of Baclofen into cerebellar fastigial nucleus on stress gastric mucosal damage in rats

Cerebellum, primarily believed as a subcortical somatic motor center, is increasingly considered to be implicated in visceral activities. However, little is known about its regulation on gastrointestinal organs. In this research, we investigated the aggravated effect of microinjection of gamma-aminobutyric acid receptor subtype B (GABA(B)R) agonist, Baclofen into cerebellar fastigial nucleus (FN) on stress gastric mucosal damage (SGMD) and its possible regulatory mechanism. The gastric mucosal damage index was chosen to indicate the severity of gastric mucosal injure. Immunohistochemistry and transferase-mediated dUTP-biotin nick-endlabeling (TUNEL) methods were used to detect the variations of lateral hypothalamic area (LHA) and gastric mucosa. It had been demonstrated that FN participates in regulation of SGMD via its GABA(B)R and GABA neural pathway, which passes through the decussation of superior cerebellar peduncle and projects to the GABA receptors in LHA. Meanwhile, celiac sympathetic nerve involves in this process via mediating neural discharge, which results in the decrease of gastric mucosal blood flow. Additionally, apoptosis, proliferation and oxidation in gastric mucosa, and gastric acid contribute in the mechanism. It could be expected that these results might suggest insights to the cerebellar and hypothalamic function, and the treatment of gastrointestinal diseases.

Gastrin releasing peptide-29 requires vagal and splanchnic neurons to evoke satiation and satiety

We have shown that gastrin-releasing peptide-29 (GRP-29), the large molecular form of GRP in rats, reduces meal size (MS, intake of 10% sucrose solution) and prolongs the intermeal interval (IMI). In these studies, we first investigated possible pathways for these responses in rats undergoing total subdiaphragmatic vagotomy (VGX, removal of vagal afferent and efferent innervation of the gut), celiaco-mesenteric ganglionectomy (CMGX, removal of splanchnic afferent and efferent innervation of the gut) and combined VGX and CMGX. Second, we examined if the duodenum communicates the feeding signals (MS and IMI) of GRP-29 (0, 0.3, 1.0, 2.1, 4.1, 10.3 and 17.2 nmol/kg) with the feeding control areas of the hindbrain by performing duodenal myotomy (MYO), a procedure that severs some layers of the duodenal wall including the vagal, splanchnic and enteric neurons. We found that GRP-29 (2.1, 4.1, 10.3, 17.2 nmol/kg) reduced the size of the first meal (10% sucrose) and (1, 4.1, 10.3 nmol/kg) prolongs the first IMI but did not affect the subsequent meals or IMIs. In addition, CMGX and combined VGX/CMGX attenuated reduction of MS by GRP-29 and all surgeries attenuated the prolongation of the IMI. Therefore, reduction of MS and prolongation of IMI by GRP-29 require vagal and splanchnic nerves, and the duodenum is the major conduit that communicates prolongation of IMI by GRP-29 with the brain.

Horner syndrome after carotid sheath surgery in a pig: anatomic study of cervical sympathetic chain

In an experimental model, iatrogenic Horner syndrome developed after a right carotid sheath surgery in an infant pig (Sus scrofa). Horner syndrome is a classic clinical triad consisting of ipsilateral eyelid ptosis, pupil miosis, and facial anhydrosis. This syndrome results from cervical sympathetic chain (CSC) paresis and usually is acquired in humans. To determine whether the development of Horner syndrome in this situation could be attributed to pig anatomy, we compared the anatomy of the CSC in pigs and humans, by using 10 infant (age, 1 to 3 wk) pig cadavers. The CSC and cranial cervical sympathetic ganglion (CCG) were dissected bilaterally under a surgical microscope. These structures were consistently within the carotid sheaths of the pigs. In contrast, the CSC and CCG are outside the carotid sheath in humans. Awareness of the anatomic variation of the CSC and CCG within the carotid sheath in the pig and the possibility of the same variation in humans may help surgeons to identify and preserve important structures while performing cervical surgery in pigs and humans. Furthermore, this knowledge can aid in the diagnosis and prognosis of schwannoma.

Endoscopic transthoracic limited sympathotomy for palmar-plantar hyperhidrosis: outcomes and complications during a 10-year period

OBJECTIVE

To review surgical results of endoscopic transthoracic limited sympathotomy for palmar-plantar hyperhidrosis during the past decade.

PATIENTS AND METHODS

We retrospectively reviewed 155 consecutive patients who underwent surgery from June 30, 2000, through December 31, 2009, for medically refractory palmar-plantar hyperhidrosis using a technique of T1-T2 sympathotomy disconnection, designed for successful palmar response and minimization of complications.

RESULTS

Of the 155 patients, 44 (28.4%) were male, and 111 (71.6%) were female; operative times averaged 38 minutes. No patient experienced Horner syndrome, intercostal neuralgia, or pneumothorax. The only surgical complication was hemothorax in 2 patients (1.3%); in 1 patient, it occurred immediately postoperatively and in the other patient, 10 days postoperatively; treatment in both patients was successful. All 155 patients had successful (warm and dry) palmar responses at discharge. Long-term follow-up (>3 months; mean, 40.2 months) was obtained for 148 patients (95.5%) with the following responses to surgery: 96.6% of patients experienced successful control of palmar sweating; 69.2% of patients experienced decreased axillary sweating; and 39.8% of patients experienced decreased plantar sweating. At follow-up, 5 patients had palmar sweating (3 patients, <3 months; 1 patient, 10-12 months; 1 patient, 16-18 months). Compensatory hyperhidrosis did not occur in 47 patients (31.7%); it was mild in 92 patients (62.2%), moderate in 7 patients (4.7%), and severe in 2 patients (1.3%).

CONCLUSION

In this series, a small-diameter uniportal approach has eliminated intercostal neuralgia. Selecting a T1-T2 sympathotomy yields an excellent palmar response, with a very low severe compensatory hyperhidrosis complication rate. The low failure rate was noted during 18 months of follow-up and suggests that longer follow-up is necessary in these patients.

Sympathicotomy affects cutaneous blood flow, temperature, and sympathicus-mediated reflexes

OBJECTIVE

To study the sympathetically mediated effects of transthoracic endoscopic sympathicotomy (TES) in the treatment of severe primary palmar hyperhidrosis.

MATERIALS AND METHODS

The effects of TES, on sympathetic ganglia at the thoracic level of 2-3, finger blood flow, temperature, and on heat and cold provocation were investigated. Middle cerebral artery (MCA) blood flow velocities were studied by transcranial Doppler.

RESULTS

The finger blood flow increased by about 700% after TES and finger temperature by 7.0 +/- 0.5 degrees C. Several autonomic reflexes were dramatically affected. A finger pulp-shrinking test showed a major decrease after surgery. MCA mean blood flow velocities were not affected by TES.

CONCLUSIONS

Besides the high success rate of good clinical effect of TES on palmar hyperhidrosis, major effects on local blood flow and temperature are elicited by TES. Complex autonomic reflexes are also affected. The patient should be completely informed before surgery of the side effects elicited by TES.

Radiofrequency cannula with active tip radio-opaque marker: image analysis for facet, gray ramus, and dorsal root ganglion techniques

BACKGROUND

Radiofrequency neurolysis is a common technique used in the treatment of chronic pain, particularly facet (zygapophyseal joint) arthralgia. A needle-like cannula is insulated except for the exposed active tip, which is positioned as parallel and adjacent as possible to the targeted nerve branch. Via an inserted probe connected to a radiofrequency generator, energy flowing from the tip of the cannula creates a heat lesion in the 80 - 85 degree Celsius range mostly about the length of the exposed active tip and in proportion to the diameter of the probe. The common active tip lengths used for neurolysis are 5mm or 10mm. The cannulae are FDA approved. The manufacturer advises physicians not to bend or otherwise modify a cannula prior to use. The cannulae are available straight or bent, sharp and blunt. The technique is guided under C-arm fluoroscopy. X-rays passing through the patient demonstrate in 2 dimensions the projected relative radio-opaque bony landmarks and the metallic cannula. Most currently available cannulae are uniform in their radio-opacity from tip to hub. The physician must make an educated guess as to the portion of the cannula that will be making the lesion in relationship to the bony landmark.

OBJECTIVE

A new radiofrequency cannula with a radio-opaque marker (ROC) delineates the proximal end of the active tip. The cannula was used in a phantom model. Images were reproduced with explanation of the potential advantage of the new device.

RESULT

The marker on the new cannula was visible and did help delineate the active tip as well as its orientation. It was also helpful in making sequential lesions at the same nerve using a "tip to tail" repositioning technique.

CONCLUSION

The ROC did represent an improvement over standard cannulae to optimize visualization of cannula and thus lesion placement using a phantom model. The applications described were only for conventional or "hot" RF.

[Usefulness of bilateral sympathectomy using video-assisted thorascopic surgery in the treatment of essential hyperhidrosis]

Essential, idiopathic, or primary hyperhidrosis is defined as excessive sweating in certain areas of the body due to factors unrelated to other disease. Clinical presentation can be categorized as palmar, plantar, axillary, or craniofacial. Medical treatment (aluminium salts, iontophoresis, anticholinergic drugs, and alpha2-agonists) is of questionable effectiveness. Intradermal injections of botulinum toxin are very effective for the treatment of axillary hyperhidrosis. Surgical treatment involves resection (sympathectomy) or electrocautery (sympathicolysis) of the thoracic sympathetic chain, or compression of the sympathetic chain with clips, in all cases via video-assisted thorascopic surgery. One or more ganglia between T2 and T5 are usually resected depending on the area affected by hyperhidrosis: T2 for craniofacial hyperhidrosis, T3 and T4 for palmar hyperhidrosis, and T3 to T5 for combined palmar and axillary hyperhidrosis. The technique is very useful and is effective in those patients with primary hyperhidrosis who have not responded to conservative treatment.

Transsacrococcygeal approach to ganglion impar block for management of chronic perineal pain: a prospective observational study

BACKGROUND

The ganglion impar or ganglion of Walther is a solitary retroperitoneal structure at the level of sacrococcygeal junction. It provides the nociceptive and sympathetic supply to the perineal structures. Chronic Perineal Pain (CPP) has been effectively managed by ganglion impar block. In this study we analyze the feasibility, safety, and efficacy of ganglion impar block by transsacrococcygeal approach.

DESIGN

An observational report.

METHODS

In this prospective study, 16 consecutive patients who required ganglion impar block for CPP were followed for two months. After informed and written consent, the ganglion impar was blocked under aseptic precautions, using a transsacrococcygeal approach. The Visual Analogue Scale for pain (VAS) at presentation time required for the pain to reduce by 50% to be considered effective and VAS was recorded at different time points during 2-month follow-up, and time required to perform the procedure, number of attempts, and any complications were also noted.

RESULTS

All the blocks were effective with a mean duration of 12+/-3 minutes for 50% reduction in VAS. The mean duration required to perform the procedure in neurolytic block patients was 7.8+/-2 minutes and 5.7+/-1 minutes in therapeutic block patients. There were no adverse events. All the patients had significant pain relief during 2 month follow-up (p <0.05 compared to baseline). The mean VAS at 2 months was about 2. Statistical analysis was done by using paired "t"/Wilcoxon signed rank test.

CONCLUSION

A transsacrococcygeal approach for a ganglion impar block is a technically feasible and safe technique. We recommend this technique for neurolysis or radiofrequency ablation of the ganglion impar and for diagnostic blocks, especially when the diagnosis and further plan of management is dependent on the response of the diagnostic block.

Complex regional pain syndrome in a patient with spinal cord injury: management with pulsed radiofrequency lumbar sympatholysis

STUDY DESIGN

Short communication.

OBJECTIVES

To report a case with bilateral lower extremity complex regional pain syndrome (CRPS) in a patient with paraplegia occurring following spinal disc herniation surgery, who was treated successfully with pulse radiofrequency (PRF) lumbar sympatholysis.

SETTING

Departments of Physical Medicine and Rehabilitation, Algology Department of Anaesthesiology and Nuclear Medicine, Medical Faculty of Ege University, Izmir, Turkey.

METHODS

A 55-year-old woman had neuropathic pain in her lower extremities after T12-L1 disc herniation surgery. The pain decreased to a tolerable level with conservative treatment and her condition remained stable for the following 6 months; then she developed swelling, redness and severe burning pain in both feet. Physical examination showed edema and redness in the feet. On the basis of clinical findings and Tc-99m methylene diphosphonate (MDP) three-phase bone scintigraphy, she was diagnosed to have CRPS.

RESULTS

The patient underwent a diagnostic sympathetic ganglion blockade with bupivacaine, which resulted in a marked decrease in the pain and edema of the feet. Consequently, PRF lumbar sympatholysis was performed with a successful outcome in pain, edema and color changes in the feet.

CONCLUSION

When treatment of CRPS fails with conventional modalities, PRF sympatholysis may be used for control of pain and other symptoms in such patients.

Cervical sympathetic schwannoma with postoperative first bite syndrome

Extracranial schwannomas occurring in the head and neck region may arise from cranial, peripheral or autonomic nerves. Determination of the nerve of origin is not often made until the time of surgery. Schwannomas arising from the cervical sympathetic chain are extremely rare. These interesting tumors along with schwannomas in general and the remaining class of neurogenic tumors are known for their ability to mimic the physical and radiological findings of carotid body tumors. Surgery is the treatment of choice and major complications are infrequent. However, we report a case of cervical sympathetic chain schwannoma with postoperative first bite syndrome.

Anatomical redistribution of sweating after T2–T3 thoracoscopic sympathicolysis: a study of 210 patients

BACKGROUND

The cutaneous influence areas of the different sympathetic ganglia have not been fully established to date. The aim of this study was to define the cutaneous influence area of sympathetic ganglia T2-T3.

METHODS

A total of 210 patients with primary hyperhidrosis (PH) underwent 420 thoracoscopic sympathicolysis procedures of ganglia T2-T3 in a prospective study. All completed a preoperative questionnaire and a second questionnaire 12 months after the operation. The questionnaires evaluated perspiration in the different body areas. Only the zones of anhidrosis were considered in delimiting the cutaneous expression of sympathetic ganglia T2-T3.

RESULTS

Redistribution of perspiration as reported by the patients comprised significant reduction in the palms, axillas, and soles, and an increase in the abdomen, back, and gluteal and popliteal regions. Regarding the incidence of anhidrosis by anatomical location, statistically significant changes were recorded in the head, hands, axillas, and soles (p < 0.001).

CONCLUSIONS

Bilateral upper thoracic sympathicolysis is followed by redistribution of body perspiration, with a clear decrease in the zones regulated by mental or emotional stimuli, and an increase in the areas regulated by environmental stimuli, though we are unable to establish the etiology of this redistribution.

Laser Doppler scanning study of palmar skin perfusion for patients with hyperhidrosis before and after thoracic sympathectomy

BACKGROUND

Palmar hyperhidrosis is effectively treated by thoracic sympathectomy. Previous reports revealed that palmar skin temperature and perfusion increased on focal palmar regions after treatment. This study aimed to investigate the blood flow change over the whole palmar surface after the procedure.

METHODS

Thirty patients with severe palmar hyperhidrosis were included for study. Each participant received measurement of palmar skin perfusion by a laser Doppler image scanner 1 day before and 1 day after surgery. Concomitantly, palmar skin temperature was recorded by a contact thermometer probe. One patient underwent intraoperative recording of palmar skin perfusion.

RESULTS

Palmar skin perfusion and temperature increased significantly after thoracic sympathectomy. Intraoperative measurement performed for a patient showed a similar trend of increment of palmar skin blood flow.

CONCLUSIONS

The global skin perfusion of palms can be analyzed in real time by the laser Doppler image scanner. This technique could be useful for analysis of blood flow changes in other body surface regions after thoracic sympathectomy.

Different outcomes between two sides after bilateral sympathetic ganglion interruption for hyperhidrosis

BACKGROUND

Although the determination of the correct ganglion under direct vision through thoracoscopy by an experienced surgeon is almost unerring, there is still a 4.3% rate of clipping at the unintended level.

METHODS

Through the review of the most recent patients (N = 117) with various sympathetic disorders undergoing thoracoscopic sympathetic interruption over different ganglions by clipping, we found that 5 cases were clipped at the unplanned level. The immediate manifestations were the different outcomes between both sides of the face, trunk, and extremities. The postoperative chest radiographs demonstrated the error.

RESULTS

All patients received a second operation in which the unintended clip was removed, and a new one was applied to the appropriate ganglion. The results were satisfactory.

CONCLUSIONS

Although the authors in this study have the experience of more than 1000 cases of hyperhidrosis, such an error is still inevitable. Luckily, by using the clipping method, the error is detectable and amendable.

Effects of cervical sympathectomy on vasospasm induced by meningeal haemorrhage in rabbits

This study investigates the role of cervical sympathectomy in the prevention of acute vasospasm induced by meningeal haemorrhage in rabbits. Sixteen adult English Norfolk rabbits were divided into 2 experimental groups: bilateral cervical sympathectomy of the superior sympathetic ganglion (SSSG, n=8), and bilateral SSSG and sympathectomy of the inferior sympathetic ganglion (SISG, n=8). Other 24 animals were used as controls. Basilar artery diameter was evaluated by angiography. SSSG protected the animals against developing cerebral vasospasm; SSSG associated with SISG did not increase this effect.

Local disruption of the celiac ganglion inhibits substance P release and ameliorates caerulein-induced pancreatitis in rats

Primary sensory neurons of the C and Adelta subtypes express the vanilloid capsaicin receptor TRPV1 and contain proinflammatory peptides such as substance P (SP) that mediate neurogenic inflammation. Pancreatic injury stimulates these neurons causing the release of SP in the pancreas resulting in pancreatic edema and neutrophil infiltration that contributes to pancreatitis. Axons of primary sensory neurons innervating the pancreas course through the celiac ganglion. We hypothesized that disruption of the celiac ganglion by surgical excision or inhibition of C and Adelta fibers through blockade of TRPV1 would reduce the severity of experimental pancreatitis by inhibiting neurogenic inflammation. Resiniferatoxin (RTX) is a specific TRPV1 agonist that, in high doses, selectively destroys C and Adelta fibers. Sprague-Dawley rats underwent surgical ganglionectomy or application of 10 microg RTX (vs. vehicle alone) to the celiac ganglion. One week later, pancreatitis was induced by six hourly intraperitoneal injections of caerulein (50 microg/kg). The severity of pancreatitis was assessed by serum amylase, pancreatic edema, and pancreatic myeloperoxidase (MPO) activity. SP receptor (neurokinin-1 receptor, NK-1R) internalization in acinar cells, used as an index of endogenous SP release, was assessed by immunocytochemical quantification of NK-1R endocytosis. Caerulein administration caused significant increases in pancreatic edema, serum amylase, MPO activity, and NK-1R internalization. RTX treatment and ganglionectomy significantly reduced pancreatic edema by 46% (P < 0.001) and NK-1R internalization by 80% and 51% (P < 0.001 and P < 0.05, respectively). RTX administration also significantly reduced MPO activity by 47% (P < 0.05). Neither treatment affected serum amylase, consistent with a direct effect of caerulein. These results demonstrate that disruption of or local application of RTX to the celiac ganglion inhibits SP release in the pancreas and reduces the severity of acute secretagogue-induced pancreatitis. It is possible that selectively disrupting TRPV1-bearing neurons could be used to reduce pancreatitis severity.

Cervical sympathectomy regulates expression of key angiogenic factors in the rat choroid

Age-related macular degeneration is the leading cause of blindness in people over the age of 55. In addition to an increased risk of vision loss due to macular degeneration, aging results in a substantial loss of sympathetic nerve activity. We have previously shown that loss of sympathetic nerve activity to the eye causes significant remodeling of the choroidal vasculature. The hypothesis of the present study was that the choroidal remodeling noted after sympathectomy was due to alterations in key angiogenic growth factors. To test this hypothesis, female Sprague-Dawley rats underwent superior cervical ganglionectomy, which eliminates all sympathetic innervation to the eye. Six weeks after surgery, eyes were removed, and the choroidal tissue was processed for real-time PCR to measure gene expression and western blot analysis to assess protein expression. Gene and protein expression were significantly increased for vascular endothelial growth factor (VEGF) and pigment epithelial-derived growth factor (PEDF) in the sympathectomized eye, as compared to the contralateral eye (P < 0.05). Protein expression was increased 4-fold for angiopoietin1, with no change in steady-state gene expression. For both p53 and placental growth factor, steady-state mRNA levels were significantly decreased, while protein expression was significantly increased. Protein expression for Flt-1 was decreased significantly, with reduced gene expression. These results suggest that the vascular remodeling noted in the choroidal blood vessels after sympathectomy is a complex process involving numerous growth factor families. Therefore, modulation of sympathetic nerve activity may be a suitable mechanism to prevent the vascular growth associated with macular degeneration.

The outcome of ganglion clipping in hyperhidrosis and blushing

A total of 114 patients with various sympathetic disorders underwent endoscopic sympathetic block over different thoracic ganglions by the clipping method. The advantages of this method include the recognition of the clipped level, changeability, and reversibility. However, 4.4% of patients were unilaterally clipped at the wrong level.

Thoracic sympathicolysis for primary hyperhidrosis: a review of 918 procedures

BACKGROUND

Bilateral upper thoracic sympathectomy or sympathicolysis, currently the standard treatment for palmar or axillary hyperhidrosis, is regarded as a safe procedure. This study evaluates the quantitative and qualitative incidence of intraoperative and postoperative complications resulting from bilateral thoracic sympathicolysis.

METHODS

From 1996 to 2004, 458 consecutive patients with primary hyperhidrosis underwent surgery. These patients comprised 143 men (31.2%) and 315 women (68.7%) with a mean age of 26 years (range, 14-52 years). In all but seven cases, the procedure was bilaterally synchronous.

RESULTS

No mortality was recorded. The anhydrosis rate was 97.4%, with a hypohidrosis rate of 2.4% and a failure rate of 0.2%. The latter was resolved with reintervention. The mean hospital stay was 17 h. The rate of major perioperative complications with conversion to thoracotomy was 0.4%. The overall rate of postoperative complications was 3.6%. The complications and rates observed were as follows: pneumothorax (2.06%), subcutaneous emphysema (1.08%), pleural bleeding (0.2%), hemothorax (0.1%), and atelectasis (0.1%). Compensatory hyperhidrosis was observed in 48.4% of the patients, but the sensation of compensatory hyperhidrosis was reported in 85.6% of the cases. Excessive dryness of the hands was reported in 0.38%, Horner's syndrome in 0.32%, and gustatory hyperhidrosis in 1.1% of the cases. The overall satisfaction rate was 88.5%.

CONCLUSIONS

The results suggest that endoscopic bilateral thoracic sympathicolysis is an effective method for managing primary hyperhidrosis, especially severe palmar hyperhidrosis, but it is necessary to inform patients fully concerning the undesirable effects.

[Cervical sympathetic chain neurilemmoma--a case report]

INTRODUCTION

Neurilemmoma is benign, slowly growing tumour that arise from nerves. Cervical sympathetic chain neurilemmoma is rare. The majority of neurilemmomas are asymptomatic at the time of presentation. The incidence of Horner's syndrome before excision has been reported only once. Surgical resection almost leaves the patient with a Horner's syndrome.

MATERIAL AND METHODS

A 28 years old woman was admitted to Otolaryngology Department with left side neck mass. The tumor was first noticed 6 month later, and it was slowly growing. It was completely asymptomatic. She underwent excision of the tumor through an incision parallel with the anterior border of the strenomastoid muscle.

RESULTS

Histology showed the tumour to be a neurilemmoma arising within the cervical sympathetic chain. During postoperative period in 2 day we observed a left side Horner's syndrome, completely asymptomatic.

CONCLUSIONS

Neurilemmomas very rarely arise from the cervical sympathetic chain. They usually present as asymptomatic neck mass. The only complication encountered after surgery is Horner's syndrome, which required no treatment.

Effects of lumbar sympathectomy on pain behavioral changes caused by nucleus pulposus-induced spinal nerve damage in rats

It has been suggested that lumbar sympathectomy can reduce pain behavior, including mechanical allodynia and thermal hyperalgesia, caused by ligation of the spinal nerve. One well-characterized model, which involves application of nucleus pulposus to the spinal nerve and displacement of the adjacent nerve, shows behavioral changes in rats. However, there have been no previous reports regarding sympathectomy performed in this model. Disk incision and adjacent spinal nerve displacement were performed with (n=6) or without (n=6) sympathectomy. Sham surgery was also performed with (n=6) or without (n=6) sympathectomy. The animals were tested for 3 days before surgery and on days 1, 3, 7, 14, and 21 after surgery. Non-noxious mechanical thresholds were tested by determining the hind paw withdrawal response to von Frey hair stimulation of the plantar surface of the footpad using a touch stimulator. Thermal nociceptive thresholds were tested using a sensitive thermal-testing device. While rats in the disk incision with displacement surgery group showed allodynia and hyperalgesia after surgery on the experimental side, sympathectomized animals did not. No allodynia was observed in the sham groups. Sympathectomy seemed to prevent the pain behavioral changes caused by the combination of disk incision and nerve displacement.

Sympathetic nervous control of the cerebral circulation in sleep

Cerebral vessels are extensively innervated by sympathetic nerves arising from superior cervical ganglia, and these nerves might play a protective role during the large arterial pressure surges of active sleep (AS). We studied lambs (n=10) undergoing spontaneous sleep-wake cycles before and after bilateral removal of the superior cervical ganglia (SCGx, n=5) or sham ganglionectomy (n=5). Lambs were instrumented to record cerebral blood flow (CBF, flow probe on the superior sagittal sinus), carotid arterial pressure (P(ca)), intra-cranial pressure (P(ic)), cerebral perfusion pressure (Pcp=Pca-Pic) and cerebral vascular resistance (CVR). Prior to SCGx, CBF (mL min-1) was significantly higher in AS than in Quiet Sleep (QS) and Quiet Wakefulness (QW) (17+/-2, 13+/-3, and 14+/-3 respectively, mean+/-SD, P<0.05). Following SCGx, baseline CBF increased by 34, 31, and 29% respectively (P<0.05). CVR also decreased in all states by approximately 25% (P<0.05). During phasic AS, surges of Pca were associated with transient increases in Pcp, Pic and CBF. Following SCGx, peak CBF and Pic during surges became higher and more prolonged (P<0.05). Our study is the first to reveal that tonic sympathetic nerve activity (SNA) constricts the cerebral circulation and restrains baseline CBF in sleep. SNA is further incremented during arterial pressure surges of AS, limiting rises in CBF and Pic, possibly by opposing vascular distension as well as by constricting resistance vessels. Thus, SNA may protect cerebral microvessels from excessive distension during AS, when large arterial blood pressure surges are common.

Endoscopic thoracic sympathectomy for palmar hyperhidrosis: efficacy of T2 and T3 ganglion resection

BACKGROUND

Endoscopic thoracic sympathectomy has been considered an effective treatment for palmar hyperhidrosis. However, the extent of resection has not been determined in terms of efficacy and complications. We compared the efficacy and complications of 2-ganglion and single-ganglion resection in patients with palmar hyperhidrosis.

METHODS

From 1995 to 2000, 75 patients underwent resection of thoracic ganglion T2 and T3. From 2000 to 2003, 67 patients underwent resection of only the T2 ganglion. Eighty of the 142 patients (56%) answered a detailed questionnaire, the results of which were analyzed.

RESULTS

Gender, age, family history, and distribution of sweating were similar in both groups. Recurrence rates 1 and 2 years after endoscopic thoracic ganglionectomy were between 0% and 3% in T2 and T3 resection, and between 15% and 19% in T2 resection only. In the combined T2 and T3 resection group, 100% of patients noticed compensatory sweating; in T2 resection, 90% of patients noticed compensatory sweating. As for rates of satisfaction, T2 and T3 resection was superior to T2 resection.

CONCLUSIONS

High recurrence rates of palmar hyperhidrosis after single-ganglion resection are reported in the present study. Two-ganglion resection is a superior surgical method to prevent recurrence of palmar hyperhidrosis.

Interindividual Variation in Distribution of Extramural Ganglion Cells in the Male Pelvis: A Semi-Quantitative and Immunohistochemical Study Concerning Nerve-Sparing Pelvic Surgery

OBJECTIVE

We examined distribution and numbers of extramural ganglion cells in the male pelvis, classifying them as sympathetic or parasympathetic.

METHODS

Specimens were obtained from 14 formalin-fixed donated male cadavers. Semiserial sections were processed for histologic examination, and for immunohistochemistry using anti-tyrosine hydroxylase (TH) or anti-peptide histidine isoleucine (PHI).

RESULTS

Like those along the sacral sympathetic trunk, most other pelvic ganglion cells were located in and along nerve components. Yet the ganglion cell clusters attached to pelvic viscera accounted for 22% to 38% of ganglion cells. These were seen at the dorsal aspect of the bladder, the bladder/prostate junction, the dorsal aspect of the seminal vesicle, and along the prostate, but not along the extrapelvic pudendal nerve, cavernous tissues including the penile hilum, the rhabdosphincter, retropubic fat or recto-urethral muscle. Two fold interindividual variation was seen for total ganglion cell number (3044 to 6522) in the pelvis. TH-positive and PHI-positive cells intermingled at various ratio in every ganglion cell cluster. Sympathetic TH-positive proportions tended to be site-specific.

CONCLUSIONS

Pelvic autonomic cells exist not only in nerve components but also along viscera. Even nerve-sparing radical prostatectomy can compromise visceral ganglia. Simple classification of pelvic nerve components as sympathetic or parasympathetic would seem misleading given coexistence of both cell types in a ganglion.

Impaired gastric motor activity after abdominal surgery in rats

Postoperative ileus (POI) is a transient bowel dysmotility that occurs following abdominal surgery. Several mechanisms have been proposed such as neural reflex and inflammatory changes. We focused on gastric motility after abdominal surgery in rats. To investigate the time course of gastric motility after surgery, gastric motility was continuously recorded before, during and after surgery. After laparotomy, terminal ileum was manipulated for 10 min. Gastric motility was recorded by a strain gauge transducer implanted on the serosal surface of the stomach. To investigate whether peripheral sympathetic nerve is involved in the pathogenesis of POI, effects of guanethidine and celiac ganglionectomy were tested on the postoperative gastric motility. Although isoflurane anaesthesia reduced the gastric motility to 40%, the motility recovered immediately when isoflurane was withdrawn. Intestinal manipulation reduced the postoperative gastric motility for 3-24 h after surgery, compared with preoperative levels. Guanethidine administration and celiac ganglionectomy restored the impaired gastric motility. Feeding increased the gastric motility in each group. It is suggested that the pathogenesis of postoperative gastric ileus induced by intestinal manipulation involves viscero-sympathetic pathways. Intestinal manipulation causes impaired gastric motility via inhibitory sympathetic efferent pathway. Feeding may improve the postoperative gastric motility.

Sympathetic Hypertensive Syndrome: A Possible Surgically Curable Type of Hypertension

Poorly controlled hypertension was incidentally cured after performing an endoscopic sympathetic block (ESB) in a patient with hyperhidrosis craniofacialis (HHC). A survey of the literature indicated that 30% to 40% of essential hypertension is of sympathetic origin. Patients with facial sweating associated with hypertension were then studied to determine whether blood pressure is lowered after performing ESB. Between November 2002 and July 2003, 17 hypertensive patients (13 males and 4 females) ranging in age from 22 to 62 years underwent ESB solely for HHC at the Department of Surgery of Kaohsiung Medical University, Taiwan. Their preoperative systolic blood pressure (SBP) values ranged from 170 +/- 6 to 200.7 +/- 7.6 mmHg, and their diastolic blood pressure (DBP) values ranged from 94.7 +/- 6.1 to 120.3 +/- 5.7 mmHg. Their heart rates were between 92.67 +/- 2.28 and 119.67 +/- 5.13 beats per minute (bpm). They were refractory to aggressive medical treatment, including lifestyle modifications and antihypertensive medications. Their postoperative blood pressure, heart rate and surgical outcomes were recorded. After performing ESB, HHC was cured in all 17 patients. Based on the reductions in blood pressure and heart rate, the patients could be divided into two groups, one showing high-level reductions (Group T) and one showing low-level reductions (Group S). The blood pressure of Group T (ten patients) was reduced to the range of 120.2 +/- 6.9 to 131.6 +/- 3.5 mmHg SBP and 74.8 +/- 3.1 to 85.4 +/- 4.5 DBP, and the heart rate of this group was reduced to the range of 65.36 +/- 4.63 to 85 +/- 3.60 bpm, while the blood pressure and heart rate of Group S (seven other patients) were reduced to the ranges of 145.9 +/- 5.7 to 160.5 +/- 5.5 mmHg SBP, 90 +/- 4 to 100.7 +/- 3.2 mmHg DBP, and 80 +/- 4 to 90.83 +/- 3.53 bpm, respectively. The patients in Group S were well controlled at 119.8 +/- 5.5 to 130.6 +/- 8.0 mmHg SBP and 70.1 +/- 3.8 to 84.5 +/- 5.7 mmHg DBP with a daily low-dose of calcium channel blocker. The average follow-up periods of the two groups were 17.00 +/- 2.906 and 17.43 +/- 2.37 months, respectively. We named this surgically curable form of hypertension "Sympathetic Hypertensive Syndrome" (SHS), which we define by the presence of all three of the following: 1) stage II hypertension; 2) HHC or other sympathetic disorders; and 3) heart rate > or = 100 bpm. If the patient is male the reductions of blood pressure after the surgery will be better, which might be due to the link with Y chromosome. Finally, we recommend that ESB should be performed in patients with SHS, although the female would respond less satisfactorily in terms of the blood pressure.

Cervical Sympathetic Chain Schwannoma

OBJECTIVES

Schwannomas are benign, slow-growing tumors that arise from nerves. Those originating from the sympathetic cervical chain are rare. We describe our experience with the clinical presentation, surgical management, and outcomes of patients with this pathology.

STUDY DESIGN

Retrospective chart review of a case series in a tertiary referral center.

METHODS

Four cases of cervical sympathetic chain schwannomas were reviewed. Patients presented with either an asymptomatic neck mass discovered on routine physical examination (1 patient), an enlarging neck mass (2), or an acute onset of a Horner's syndrome (1). All patients underwent preoperative imaging (magnetic resonance imaging, computed tomography, or both).

RESULTS

The location and soft-tissue characteristics of the mass, along with displacement of the carotid sheath vessels, were typical of a cervical sympathetic chain schwannoma. All patients underwent surgical excision of the mass. Postoperative Horner's syndrome was encountered in all patients. First bite syndrome was encountered in two patients.

CONCLUSIONS

Cervical sympathetic chain schwannomas are rare tumors. Preoperative imaging characteristics facilitate the diagnosis. First bite syndrome can occur and may be debilitating postoperatively. Long-term prognosis is excellent.

Subdiaphragmatic vagal deafferentation fails to block the anorectic effect of hydroxycitrate

We investigated the neural mediation of the feeding suppression through orally administered hydroxycitrate (HCA) in male rats that were fed a high-glucose diet (about 48% glucose). Ten-day ad libitum food intake and body weight regain after previous body weight loss (13% of initial body weight) due to restrictive feeding were measured in rats with sham deafferentation (SHAM; n = 6), subdiaphragmatic vagal deafferentation (SDA; n = 7), and SDA plus celiac-superior mesenteric ganglionectomy (SDA/CGX; n = 9). HCA suppressed the 10-day cumulative food intake in all surgical groups and body weight regain in SDA and SDA/CGX groups. Independent of HCA, SDA and SDA/CGX rats consumed less food and gained less weight compared to SHAM rats. These results demonstrate that all vagal afferents from below the diaphragm and vagal efferents of the dorsal trunk as well as splanchnic nerves (afferents and efferents) are not necessary for the feeding-suppressive effect of HCA in this animal model. Vagal afferents, however, appear to play a role in the control of intake when a high-glucose diet is consumed after a period of restrictive feeding.

Thoracoscopic sympathetic surgery for hand sweating

Recently, thoracoscopic surgery has been shown to be effective for the relief of hand sweating. Although it is not fatal if left untreated, the treatment aim is to improve the quality of daily life. Therefore, it is important to understand the complaints of the patient, and provide an adequate explanation regarding postoperative sequelae. Surgeons should also recognize that thoracoscopic surgery might cause problems when performed, as the general risk of surgery remains. Many patients have been helped by the procedure, as their choices in life have expanded, and satisfactory results can be obtained when indication is determined by a full examination of the patients condition. Between December 1999 and September 2002, we performed thoracoscopic sympathetic surgery in 556 consecutive patients. Five-hundred seventeen (93%) of these complained of profuse hand sweating. Based on the new concept presented, we consider that this method of operation is an effective treatment.

[Thoracic sympathectomy performed by videothoracoscopic technique]

Thoracic sympathectomy is a method for a segmental elimination of functions of the sympathetic system by the excision of its Th2-Th3 ganglia. The procedure can be performed both using open and videoscopic technique.

OBJECTIVE

The purpose of the study was the evaluation of efficacy of videoscopic thoracic sympathectomy.

MATERIAL AND METHOD

From 1993 to 2003 we performed 53 videoscopic thoracic sympathectomies in patients with Raynaud's syndrome and upper limb hyperhidrosis.

RESULTS

In all patients that underwent thoracic sympathectomy we obtained a positive reaction to a segmental excision of the sympathetic trunk. Patients with Raynaud's showed a significant improvement in symptoms in 76% of cases after a 4-year observation while patients with hyperhidrosis in 100%. The time of hospitalisation was 3.5 days in average. Postoperative complications were observed in two patients (3.7%). Videoscopic thoracic sympathectomy provides good therapeutic and cosmetic results and deserves more common use compared with open technique.

Anatomical basis for a successful upper limb sympathectomy in the thoracoscopic era

In this clinico-anatomical study, factors potentially responsible for unsuccessful upper limb sympathectomy (ULS) by the thoracoscopic route were evaluated. This study comprised two subsets: 1) in the clinical subset, 25 patients (n = 50 sides) underwent bilateral second thoracic ganglionectomy for palmar hyperhidrosis, and factors predisposing to unsuccessful ULS were identified; and 2) in the anatomical subset, the neural connections of the first and second intercostal spaces were bilaterally dissected in 22 adult cadavers (22 right, 21 left; n = 43 sides). Alternate neural pathways (ANP) were noted in 9 of 50 sides in the 25 clinical cases (18%). In three asthenic patients (5 sides), fascia overlying the longus colli muscle mimicked the sympathetic chain. The right superior intercostal vein (SIV) was located anterior to the second thoracic ganglion in 6 of 50 sides (12%) and predisposed to troublesome bleeding in 2 of 50 cases; the SIV was posterior to the ganglion in 19 of 50 sides (38%), posing no technical problem. On the left, the SIV was noted outside the field of dissection in all but one case. A successful outcome to sympathectomy was noted in all 25 patients. A spectrum of sympathetic contributions to the first thoracic ventral ramus for the first intercostal space was noted in 37 of 43 anatomical cases (86%). These were categorized according to the arrangements of the intrathoracic ramus between the second intercostal nerve and the first thoracic ventral ramus. The cervicothoracic ganglion (37/43 cases; 86%) and an independent inferior cervical ganglion (6/43 cases; 14%) were always located above the second rib. The second thoracic ganglion was consistently located in the second intercostal space. This study demonstrates that ANPs have little clinical significance when a second thoracic ganglionectomy is undertaken. Technical failures may be avoided if the surgeon is mindful of anatomical variations at surgery.

Experience with limited endoscopic thoracic sympathetic block for hyperhidrosis and facial blushing

Endoscopic thoracic sympathetic block (ESB) has recently become a popular modification of sympathetic surgery, as it offers the potential chance of reversibility. In order to reduce side effects such as compensatory sweating limited ESB at the levels of the T2, T3 or T4 ganglia has been recommended (Lin/Telaranta classification). We present our experience and initial results with this technique. From 6/2001 to 2/2003, 184 ESB procedures were performed in 94 patients. ESB4 was carried out in 53 patients for hyperhidrosis (HH) of the upper limb. In 23 patients ESB3 was performed for craniofacial HH and 18 patients suffering from facial blushing were treated by ESB2. Median follow-up was 5.2-7.5 months.Success rates were similar (~100%) in all groups. Compensatory sweating was found in 25% in the ESB3 compared to 12.5 % in the ESB2 and 8.5 % in the ESB4 group (p < 0.05). Gustatory sweating did not differ significantly between the groups (6.3 % in ESB2, 5% in ESB3 and 2.1 % in ESB4 group). Five patients were reoperated in the ESB3 group (3 because of a side-difference of the effect in the face, 1 patient due to incomplete Horner's syndrome and 1 due to massive compensatory sweating). In the ESB4 group all patients were satisfied with the outcome, whereas in the ESB2 group 6.3% and in the ESB3 group 13.9% were partly satisfied. Limited sympathetic surgery offers comparably high success and satisfaction rates along with a low rate of side effects.

Treatment of palmar hyperhidrosis by endoscopic clipping of the upper part of the T4 sympathetic ganglion

Endoscopic thoracic sympathetic surgery is a safe and effective method of treating palmar hyperhidrosis. Although hand dryness is the positive outcome of surgery, a residual amount of moisture in the hand is believed to improve the quality of life. Reflex sweating is a well-recognized and annoying complication that surgeons endeavor to avoid. From May 1, 2002 to July 31, 2002, 52 patients suffering from palmar hyperhidrosis were operated on by means of endoscopic clipping of the upper part of the T4-sympathetic ganglion (Upper ESB4). There were 24 males and 28 females with a mean age of 25 years. The mean follow-up period was 8.3 months. The patients answered a detailed questionnaire addressing the following issues: the recurrence rate, the degree of hand dryness, the extent of and areas of reflex sweating, the occurrence of gustatory and facial sweating, and the degree of satisfaction. The surgical outcome was satisfactory. Most patients demonstrated no or only slight hand sweating. Moderate sweating without discomfort was experienced in 9% of patients. Only 25% of patients required the use of lotion for hand dryness. Reflex sweating was observed in 87.5% of the patients but extremely uncomfortable in only 3.2%. Ninety-four percent of patients were satisfied. The remaining 6% were not satisfied but did not regret the operation. Although the duration of the follow-up period in this study was relatively short, we could obtain results comparable to other data in the literature. This is a simpler procedure and less damaging to the sympathetic system.