The. Thoma Ionescu - Victor Gomoiu Procedure: Cervicothoracic Sympathectomy for Angina Pectoris. The First Surgical Attempt to Treat the Coronary Heart Disease

Cervicothoracic Sympathectomy is a common indication in the treatment of Raynaud Syndrome, Palmer Hyperhidrosis or Acute Ischemia of the superior limb. Nonetheless, almost a century ago it represented one of the first innovative attempts in curing coronary heart disease. Nowadays, this indication is no more than a footnote in a volume on the History of Medicine, and a trivia fact for medical history enthusiasts. The operation's history is rather conflicting. A young Romaninan surgeon, Victor Gomoiu seems to have come up with the idea, in the early 20th century. However, his contribution remains unknown, after his successful collaboration with the famous surgeon and anatomist, Thoma Ionescu unfortunately turns into a dispute. This procedure was once thought cutting-edge. Furthermore it is the starting point for cardiovascular surgery. Whoever sparked the idea, gains an important place in the hall of fame of international surgery, that is why it is important to know its creator.

[Jaboulay, vascular surgeon at Lyon]

Mathieu Jaboulay was an excellent surgeon. He was the first to come up with the principles of vascular surgery as he made a surgical anastomosis between two arteries of a dog by an eversion circular suture. In 1902, he implemented a suture between an artery and a vein in an arteritis by obliteration. Jaboulay also tried the graft of an animal kidney on the crease of a human elbow in 1906. Jaboulay was an initiator for Alexis Carrel.

History of surgical treatment of ischemic heart disease--pre-'coronary bypass grafting' era

BACKGROUND AND AIM

To review the various concepts, surgical experiments, and actual procedures performed for the treatment of ischemic heart disease, which eventually led to the evolution of direct coronary artery bypass surgery.

METHODS

References were collected from original articles and through pubmed search.

RESULTS

Various concepts and procedures were introduced, all with the aim of increasing myocardial blood flow and relief of angina. These included creation of vascular adhesions, denervation, thyroidectomies, using other organs for providing blood supply, and intramyocardial implantation of bleeding systemic arteries.

CONCLUSION

Historically various innovative concepts existed and a variety of procedures were performed for treating ischemic myocardium, with variable results. These procedures continued till the evolution of direct coronary artery bypass grafting.

History of sympathetic surgery

The first reported operation on the upper sympathetic system was performed by Alexander in 1889. The initial indications (epilepsy, exophthalmic goiter, idiocy, glaucoma) are obsolete. For some subsequent indications (angina pectoris, vasospastic disorders, and painful conditions) sympathectomy has still a limited application. The main indications today are hyperhidrosis (since 1920) and blushing. Renewed attempts to perform the operation for psychological conditions have been reported. The technique of sympathectomy has been modified over the century, with a trend to minimize the extent of surgery: from open to endoscopic approaches; from resection of ganglia to thermoablation, thermotransection, and clipping. The sequelae of the operation (mainly compensatory hyperhidrosis) present a major problem in a small percentage of operated patients. Techniques of reversal (by nerve grafting and unclipping) have been proposed. Meticulous follow-up studies are required to evaluate the merits of these techniques. Improved knowledge of the functions and interrelations of the autonomic nervous system is required to understand the mechanism of these sequelae and learn how to avoid or treat them.

Application of spinal ablative techniques for the treatment of benign chronic painful conditions: history, methods, and outcomes

STUDY DESIGN

The literature on current neuroablative techniques for treating benign chronic painful conditions is comprehensively reviewed.

OBJECTIVE

To provide the reader with an understanding of the indications, techniques, and outcomes for the various ablative procedures used to treat chronic pain syndromes.

SUMMARY OF BACKGROUND DATA

Neuromodulatory techniques are rapidly supplanting the traditional neuroablative procedures used to treat many types of pain.

METHODS

A MEDLINE search was conducted for each of the following procedures: radiofrequency facet denervation, cordotomy, myelotomy, sympathectomy, DREZotomy, rhizotomy, and ganglionectomy. In the review of each article, special attention given to the outcome, length of follow-up, complications, and number of patients. Summaries of this data were compiled to provided historical perspective, current techniques, indications, and outcomes for each of the aforementioned procedures. The outcomes cited for each procedure generally represent the data from the three or four largest series with adequate follow-up length.

RESULTS

The aforementioned procedures have 30% to 90% success rates, with success defined as at least a 50% reduction in perceived pain. These results tend to diminish with time. However, most are associated with a significant degree of morbidity and relatively high complication rates. In addition, many of the techniques lead to deafferentation pain syndromes.

CONCLUSIONS

Ablative spinal techniques offer pain relief for many patients, but the use of these methods should be considered carefully in the light of available nondestructive procedures that may achieve similar goals with potentially lower morbidities.

The history of cervicothoracic sympathectomy

As early as in 1889 surgery on the cervical sympathetic nervous system was performed. During the following decades this operation was tried for a variety of diseases. In the early 1920s it was clarified that patients with hyperhidrosis, vasospastic conditions, and angina pectoris would benefit from stellectomy. It was, however, soon discovered that removal of the upper thoracic ganglia was required in order to obtain complete sympathetic denervation of the upper extremity. Several open surgical techniques for upper thoracic sympathectomy were described. During the 1940s a few pioneers started to excise sympathetic ganglia by thoracoscopy which had originally been described as a diagnostic tool by Jacobaeus in 1910. The endoscopic approach, amply documented by Kux in 1954, did not, however, gain widespread popularity until the 1980s. Like the general upsurge of interest in endoscopic surgery, thoracoscopic ablation of the upper thoracic sympathetic ganglia is now rapidly being adopted by surgeons.

Wittmoser's technique of thoracoscopic sympathectomy and vagotomy

His extensive developmental and clinical work made Raimund Wittmoser a major trailblazer in endoscopic surgery from the 1950s on. His single-puncture technique for operative thoracoscopy permitted surgical interventions of peerless quality on the sympathetic and vagal nerves. His basic surgical principle was to achieve the greatest possible selectivity by a segmental approach to the sympathetic rami communicantes or the individual branches of the vagus nerve. Besides his extraordinary surgical skills, his particular achievement was the development of new instrumental and ancillary technologies for endoscopic surgery. In addition to the development of new endoscopes and imaging systems, his pressure-regulated CO2 insufflation system and low frequency cautery technique had major impact on the further development of endoscopic surgery. Finally, Wittmoser's surgical interventions in the autonomic nervous system were of outstanding quality and set standards still observed by thoracoscopic surgeons today.

[Lumbar sympathectomy for arteritis. A reliable and (almost) seventy year-old technique]

The old procedure of lumbar sympathectomy has long been the only chance of avoiding amputation for arteritic patients. Its field of application has shifted as reconstructive surgery and medical therapy made progress, and it is no longer the only solution and has more precise indications. Proper evaluation of its chances of success according to the individual situations allows establishing its potential and limitations. This simple procedure, entailing no risk for the future, deserves remaining among the available means for the treatment of arteritis, despite its age.

[History of lumbar sympathectomy from its origin to the present]

The author first recalls the origins of the words "sympathetic" and "neurovegetative system" and then outlines the beginnings of surgery on the autonomic nervous system in general. This started with the section of the rami communicantes introduced by the Australians Royle and Hunter in surgery of the muscle tone. Then nearly at the same time in 1924. Adson in USA and J. Diez in Argentina resected the lumbar sympathetic chains; the latter mainly for treatment of thromboangeitis obliterans. From 1924 on, lumbar sympathectomy met with rapid success as shown at the Cairo Congress of 1935. Physiologic and pathologic effects of lumbar sympathectomy are analysed and the usual techniques are reviewed. The author then lists the specific postoperative complications, including the pain symdroms and the functional sexual disorders in males. Finally the principal indications where lumbar sympathectomy proved useful are named. Chronic obliterative arteriopathies are the first. For these lumbar sympathectomy still holds a palliative, supportive or absolute role. A scheme illustrates its beneficial actions.