Thoracic Sympathectomy Research Articles

Assessment of the learning curve of video-assisted thoracoscopic sympathectomy in a single neurosurgical trainee: a cumulative summation analysis

BackgroundVideo-assisted thoracoscopic sympathectomy (VATS) is a common procedure unusually practiced by neurosurgeons due to lack of training.ObjectiveTo evaluate the learning curve for VATS in a young neurosurgeon with no previous experience in open sympathectomy techniques or extracranial endoscopic procedures.MethodsThis is a retrospective review and analysis of prospectively collected data in 50 consecutive cases admitted to our facility with the diagnosis of essential palmar and axillary hyperhidrosis operated by a neurosurgical trainee under strict supervision of 2 experienced mentors. After an initial training phase, cumulative sum mation (CUSUM) analysis was used to evaluate the surgical performance of the trainee in terms of operating time, blood loss, hospital stay and failures.ResultsImprovement in operating time was noticed after the first 20 cases with significant affection by changes in OR team. The blood loss was significantly improved after the first 10 cases with less sensitivity to changes in OR team. Hospital stay and failures were steady and within expected values throughout the study.ConclusionAn average of 20 cases may be enough for a neurosurgeon with basal knowledge to attain technical competence in VATS sympathectomy. Mentored surgical training on VATS sympathectomy is a safe and effective training method with failures within expected limits. The experience of the OR team plays an important role in the rapid improvement and consistency of performance.

Compensatory sweating after thoracoscopic sympathectomy for primary focal hyperhidrosis in children: Are there patient‐related risk factors?

IntroductionCompensatory sweating (CS) is a common complication after thoracoscopic sympathectomy (TS) and is mainly associated with surgical technique. Our aim was to identify potential risk-factors for CS following TS for primary focal hyperhidrosis in children. MethodsA retrospective, single-center review of all bilateral TS was performed between 2017 and 2019. Hyperhidrosis disease severity scale was used for pre-operative severity assessment. Post-operative evaluations were performed after three and six months. ResultsMore than the 36-month period, 41 patients were submitted to T2–T4 TS, and 25 were females (60.9%). Median age at surgery was 15.5 years. CS was identified at the 3rd month in 17 (41%) children with most in the dorsolumbar region (56%). By the 6th month, there was a significant reduction in CS (41 to 32%, p = 0.02). The probability of resolution of CS by 6 months is about 50% in both the dorsolumbar and abdominal regions. Neither age, gender, body mass index, family history, or concomitant illnesses seemed to influence CS (p > 0.05). Axillary hyperhidrosis appears to be associated with the development of dorsolumbar CS (p = 0.037). ConclusionThoracoscopic sympathectomy for PFH is a safe and effective procedure, but compensatory sweating can be a common and debilitating side effect. Age, gender, and body mass index do not appear to influence CS. Axillary hyperhidrosis may be related to the development of dorsolumbar CS. Level of evidenceIII.

Anatomical variations of the upper thoracic sympathetic chain: a review.

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. 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. 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. 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.

The treatment of palmar hyperhidrosis - a systematic review.

Primary palmar hyperhidrosis (PH) can have a significantly negative impact on an individual's quality of life. Currently, there appears to be no review of the effectiveness of the different interventions for its management. A systematic review was performed using PRISMA guidelines, the Cochrane Database, and MEDLINE (OVID) to identify relevant studies published from 1997 to 2017. Of the 574 references yielded, six met the inclusion criteria and were analyzed for this review. Two studies evaluated the use of oral oxybutynin as an anticholinergic treatment for PH; this demonstrated high efficacy with over 80% of patients reporting symptom improvement; dry mouth was the most common adverse effect reported. One study looking at the use of iontophoresis reported 81% improvement in patients' symptoms. One randomized, double-blind, trial looked at the use of botulinum toxin A injections for the treatment of PH; it reported 90% of patients experienced an improvement in PH. The remaining two studies evaluated the use of endoscopic thoracic sympathectomy (ETS) in PH, and both reported over 95% patient symptom improvement. There are few good quality studies evaluating the treatment of primary PH. Based on the little available evidence, the interventions reviewed significantly improve the symptoms of PH. Anticholinergic medications are considered effective and safe. Both iontophoresis and botulinum toxin provided patients with symptom relief when administered regularly. ETS was reported as successful in the reduction of PH, however, it carries significant adverse effects such as compensatory sweating and the potential of complications associated with surgery.

Endoscopic Thoracic Sympathectomy for the Treatment of Hyperhidrosis

Background: Although hyperhidrosis is regarded as a benign sympathetic disorder, it can have a significant psychosocial impact on affected individuals while markedly affecting their quality of life (QoL). Objectives: We aimed to evaluate the effects of endoscopic thoracic sympathectomy (ETS) on the treatment of primary hyperhidrosis and patients’ QoL). Methods: This prospective interventional study included patients with primary hyperhidrosis referred to Shahid Mohammadi Hospital, Bandar Abbas, Iran, for ETS during 2012-2019. General characteristics including age, sex, and body mass index (BMI) were recorded for all patients. All participants underwent ETS by a single experienced surgeon. Patients were evaluated twice; once before the procedure and once one month after the procedure. The sites of hyperhidrosis, Hyperhidrosis Disease Severity Scale (HDSS), and QoL were the evaluated variables. Patients’ satisfaction, compensatory hyperhidrosis, and procedural complications such as pneumothorax were also assessed on follow-up. Results: From the 47 patients evaluated in this study with a mean ± SD age of 28.2±1.21 years, 27 (57.4%) were men. No patient experienced compensatory hyperhidrosis and procedural complications after the procedure. Also, 45 (95.7%) patients were 100% satisfied and 2 (4.3%) were 90% satisfied with the procedure. There was a significant reduction in the number of hyperhidrosis sites and HDSS score after one month compared with baseline (P=0.006 and P<0.001, respectively). Moreover, the QoL significantly improved after the procedure (P<0.001). Conclusion: ETS appears to be very safe and effective for the treatment of primary hyperhidrosis in terms of the reduction of hyperhidrosis sites and HDSS score, as well as improving QoL and patient satisfaction.

Influence of lumbar sympathectomy on blood chemistry, flowing from the hind limbs

From the moment when the role of the most important factor in a number of vital manifestations of the organism began to be attributed to the autonomic nervous system, interest in it began to grow every day, and attempts were made not only to study it in detail from the point of view of anatomical distribution

To Assess the Technical Feasibility of Ultrasound Lumbar Sympathetic Block with Electrical Stimulation Needle in Out-of-Plane Needle Orientation: A Prospective Interventional Study.

We describe the technical feasibility of a new technique of ultrasound lumbar sympathectomy validated by fluoroscopy. Prospective interventional study. Pain block area. Thirty patients with peripheral arterial disease with pain at rest (numerical rating score [NRS] ≥3) were recruited. In the lateral position, a curved probe (FUJIFILM SonoSite Edge, Bothell, WA, USA, 2-5 MHz) was placed transversely at the iliac crest. An electrical stimulation needle was inserted out of plane, below the lower pole of the kidneys, directed anterior to the vertebral body below. When the needle tip was not visualized, a current of 2.0 A was applied. Patients' quadriceps contractions, ultrasound psoas contractions, and bone contact guided needle placement, which was confirmed on fluoroscopy. Other parameters noted were the number of needle insertions, vertebral level, pain NRS at baseline and at 4 hours, 24 hours, 1 week, and 2 weeks after block, temperature rise, and any other complications. In all patients, the needle tip was correctly placed in one to three attempts. In 73% of patients, the needle tip was at L3. Baseline pain NRS was 8 (interquartile range 7-8), which decreased to 2 (interquartile range 2-3) at 1 week after the procedure, and it was maintained in this range until 2 weeks later. A temperature rise of >2ºC was noted in all patients. Ultrasound lumbar sympathectomy can be performed safely in patients with peripheral arterial disease by an out-of-plane approach in the lateral patient position with an electrical stimulation needle. Before injection of the drug, aspiration of blood should be ruled out in view of the possibility of aortocaval injection.

Evaluation of compensatory hyperhidrosis after sympathectomy: The use of an objective method

To investigate the prevalence of compensatory hyperhidrosis following videothoracic sympathectomy to treat palmoplantar hyperhidrosis and its effect on sweating in the chest, abdomen, back and thighs. Furthermore, to evaluate the concordance between a subjective and an objective method of assessment for compensatory hyperhidrosis. Forty patients with combined palmar and plantar hyperhidrosis who underwent video-assisted thoracoscopic sympathectomy (15 women and 25 men, with a mean age of 25 years) were prospectively followed for 1 year. Subjective and objective parameters were evaluated, using respectively a questionnaire and a sudorometer (Vapometer). In the subjective analysis, in the first month, only 10% of patients did not have compensatory hyperhidrosis, and 70% continued to report it at 1 or more sites after 1 year. In the objective analysis, 35% of the patients did not present compensatory hyperhidrosis after 1 month, and this number persisted stable, with 30% of patients remaining free of compensatory hyperhidrosis after 1 year. The most frequent area affected by compensatory hyperhidrosis was the back in both assessments. There was no positive concordance between the results of the objective and subjective analysis at any time in any of the 4 regions studied. Compensatory hyperhidrosis is a very common postoperative side effect after videothoracic sympathectomy, occurring early after the procedure and persisting for prolonged periods of time. The most frequently affected body area is the back, and no concordance between objective and subjective assessments was observed.

B-PO03-183 SURVIVAL FOLLOWING THORACOSCOPIC SYMPATHECTOMY FOR REFRACTORY VENTRICULAR TACHYCARDIA

Several studies have reported ventricular tachycardia (VT) outcomes after thoracoscopic sympathectomy (TS) for refractory VT. However, less is known about overall survival following TS. To assess survival following TS for refractory VT. We retrospectively evaluated all patients with a previously implanted ICD that underwent at least one TS for the treatment of refractory VT at Emory Healthcare between February 2015 and April 2020. Baseline characteristics and clinical outcomes were evaluated by chart review. The primary endpoint was overall survival and the secondary endpoint was survival free of recurrent ICD shocks. We identified 41 patients with a mean age of 60.7 ± 13.5 years, of which 33 (80.5%) were male. Thirty-six patients (87%) had bilateral sympathectomy. Twelve (29.3%) patients had ischemic heart failure (CHF) and 21 (51.2%) with non-ischemic CHF. They had failed on average 2.15 ± 1.01 antiarrhythmics. Thirty-two (78%) patients underwent unsuccessful VT ablation with an average of 1.52 ± 0.89 attempts. Mean duration of follow-up was 39.3 ± 4.3 months. Overall survival at 36 months post-TS was 75.6% (Figure). Recurrent ICD shocks occurred in 46.3% at 12 months after TS. Mean shock-free survival was 11.4 ± 2.18 months. Survival at 3 years following thoracic sympathectomy for refractory VT was 75.6%, with 46.3% recurrent ICD shocks at 12 months. These data suggest that TS is a safe adjunct to refractory VT management in this challenging group of patients.

Multivessel coronary artery vasospasm masquerading as surgical coronary atherosclerotic disease

We report a case of a 39-year-old lady presenting with worsening angina. This is a case report study. Clinical case data was retrieved from hospital paper and electronic records. Invasive coronary angiography revealed disease in the left main stem, proximal left anterior descending (LAD) artery and circumflex artery. The patient proceeded to on-pump coronary artery bypass grafting. Intraoperatively, there were multiple unsuccessful attempts to wean off cardiopulmonary bypass. An on-table angiogram-which initially triggered asystole requiring internal cardiac massage and institution of venoarterial extracorporeal membrane oxygenation (ECMO)- showed no native coronary artery disease. Instead, this angiogram revealed severe vasospasm with narrowing in the grafts and distal LAD. The patient received calcium channel blockers and bilateral thoracic sympathectomies to suppress any further coronary vasospasm. She was subsequently successfully weaned off ECMO. This case reveals the life-threatening nature and diagnostic dilemma posed by severe multivessel coronary vasospasm. We also highlight the novel role of thoracic sympathectomy for definitive management of refractory vasospastic angina.

How to do a retroperitoneoscopic lumbar sympathectomy.

Retroperitoneoscopic lumbar sympathectomy is a minimally invasive approach to surgical sympathectomy. We describe our approach with accompanying instructional video.

CURRENT SCENARIOS IN MANAGEMENT OF BUERGER'S DISEASE AT TERTIARY HOSPITAL UTTARAKHAND

Introduction / Background: Buerger's disease is a systemic vasculitis of unknown etiology, strongly associated with tobacco abuse worldwide. Buerger described Thromboangiitis obliterans (TAO) in 1908. High prevalence is found in Asian / Middle East countries. The survival rate of TAO is almost 90%. Presently, total abstinence from tobacco is the mainstay of treatment. Aim: To determine the incidence, progression, etiology, impact of seasonal variations on admission, as well as, presentations, and treatment outcomes at our tertiary health care hospital in Uttarakhand region. Materials: Patients of Buerger's disease admitted to our Institute during January 2015 to December 2019, were included in this study. Methods: Retrospective analysis and study of 142 patients of Buerger's disease admitted at our institute. Results: Most patients were males (97%), with mean age 38.6 years. The incidence & total TAO admission were overall decreasing during these years. Trends showed that eighty two (58%) patients were admitted between months of November to February (cold weather), while least in summers (15%). More than 50% were severe smokers (>30 bidi / cigarette per day). Pain in limbs was present in 77.4% cases. Major amputations were done in (12) 8% cases, while digital / finger / forefoot amputations in 31.69% / 3.52% / 10.58.% cases respectively. Lumbar sympathectomy was done in twelve cases. The median requirement of analgesic (opioids) by intravenous & oral route was 10 & 12 doses initially, & mean VAS score on day-1, 5 & 10 was 6.4, 4.1 & 2.9 respectively. Conclusion: We conclude that incidence of TAO overall shows a decreasing trend, with better health practices. Admissions peak in the cold season, along with complaints related to painful / ulcerated limbs, with a strong association with tobacco abuse. Complete stopping of tobacco can halt further progression of TAO.

Thoracoscopic T2-T3 versus T4 sympathectomy for primary palmar hyperhidrosis in children and adolescents: a randomized comparative study

BackgroundControversy exists regarding the appropriate level of sympathectomy for primary palmar hyperhidrosis (PH) as different levels are associated with variable postoperative patients’ satisfaction and potential complications. The aim of this study was to investigate the safety, efficacy, and outcome of T2-T3 thoracoscopic sympathectomy (TS) versus T4 TS in this age group.ResultsThis prospective study included 32 patients (17 males and 15 females) with primary PH treated at the department of pediatric surgery, in our institution during the period from February 2019 to February 2020. Inclusion criteria included moderate and/or severe degrees of PH not responding to conservative measures. The patients were divided randomly into two groups: group I treated by T2-T3 TS and group II underwent only T4 TS. All patients were evaluated regarding operative details and postoperative outcome. Follow-up ranged from 6 to 24 months. Group I included 18 patients (14 operated on both sides and 4 operated on one side), and group II included 14 patients (11 operated on both sides and 3 operated on one side). The ages ranged between 5 and 18 years (mean 14.25 ± 3.14 years). The difference in mean age among both groups (14.5 versus 13.9 years) was not statistically significant. The mean operative time was significantly longer in group I (22.4 versus 17.2 min, p value 0.046). The hospital stay (1 day) was similar for both groups. Postoperative compensatory hyperhidrosis (CH) was more frequent in group I (n=7, 50% versus n=5, 45.5%), but the difference was not statistically significant. Postoperative over dryness occurred in 5 patients in group I (28.6%) and temporary Horner’s syndrome in one patient (7.14%). No over dryness or Horner’s syndrome occurred in any patient in group II. The QOL score has improved in both groups; the degree of improvements was better in group II.ConclusionBoth T2-T3 TS and T4 TS are effective in treating primary palmar hyperhidrosis in children and adolescents. T4 TS is preferred than T2-3 TS due to less frequent postoperative complications and better patients’ satisfaction.

Sympathectomy in Postvascular Surgical Patients with Severe Pain in Distal Limb and/or Small Ulcers

Introduction: Sympathectomy is used principally in patients of inoperable peripheral vascular disease, small vessel disease, and vasospastic disease. It is useful to alleviate symptoms of rest pain and as an adjunct to heal ischemic ulcers. Aim and Objective: This is a clinical study to evaluate the role of sympathectomy in postvascular surgical patients with persistent pain in distal limb (causalgia) with or without ischemic ulcers on the foot or hand. Materials and Methods: This study was performed between February 2015 and February 2020. We did 823 arterial surgical interventions including embolectomies, endarterectomy with patch arterioplasty, and interposition grafting in upper or lower limb vessels. These patients were diagnosed on clinical bases and with investigational modalities such as arterial Doppler study and computed tomography angiography. All these patients had chronic vascular obstruction. Out of them, we selected 54 patients having persistent pain distal limb (causalgia) not relieved by medications. Besides causalgia, 24 patients had ischemic ulcers either on foot or hand. Postoperative arterial Doppler study was satisfactory in these patients. Their complaint persisted for 3–4 months in spite of all medications. Chemical sympathectomy was tried in 21 patients but was ineffective. We did thoracic sympathectomy in 28 patients and lumbar sympathectomy in 26 patients on side affected. Observation and Results: There were 46 males and 8 females. Majority of these patients were in active phase of life with a mean age of 35 (±2). Pain was relieved in all patients. Ischemic ulcers present in 24 patients also healed within 3–6 weeks. Conclusion: Although no clear guidance exists for the role of sympathectomy in postsurgical patients, we observe it is a boon for postvascular surgical patients with persistent pain and small ischemic ulcers.

CT-guided Chemical Lumbar Sympathectomy in the Treatment of Cold Hypersensitivity in the Hands and Feet

Cold hypersensitivity in the hands and feet is a common clinical symptom in Asian women. Currently, treatment of cold hypersensitivity in the hands and feet is still limited to traditional Chinese medicine, mainly herbal medicine. However, many patients with cold hypersensitivity in the hands and feet in China are not satisfied with the therapeutic effect of herbal medicine, and took medication for a longer time. Chemical lumbar sympathectomy is widely used in the treatment of plantar hyperhidrosis, diabetic foot, recalcitrant erythromelalgia, and other diseases. This study was conducted to evaluate the short-term as well as long-term efficacy, complications, and patient satisfaction of chemical lumbar sympathectomy during treatment cold hypersensitivity in the hands and feet. A retrospective, observational study. Department of Anesthesiology and Pain Medicine, Jiaxing, China. A retrospective study of 72 patients with cold hypersensitivity in the hands and feet who received chemical lumbar sympathectomy treatment in our hospital from January 2015 to October 2018 was conducted. The heart rate, non-invasive blood pressure, oxygen saturation, visual analog scale, perfusion index, and plantar temperature were monitored and recorded in before treatment (T1) and after treatment (T2) groups. The patients were followed up on day 1, at week 1, 1 month, 3 months, 6 months, one year, and 2 years after operation for satisfaction, complications, and recurrence. There were no significant differences in heart rate, non-invasive blood pressure, and oxygen saturation between T1 and T2 groups (P > 0.05). Perfusion index and plantar temperature in T2 group were remarkably higher than T1 group, and the difference was statistically significant (P < 0.01). The visual analog scale score of the T2 group was significantly reduced (P < 0.01). Of all the patients who underwent chemical lumbar sympathectomy, the postoperative therapeutic effect was effective in 63 cases (87.5%) and ineffective in 9 cases (12.5%). Among the effective patients, the postoperative curative effect was shown to be excellent in 47 cases and improved in 16 cases. According to the follow-up results at day 1, 1 week, 1 month, 3 months, 6 months, 1 year, and 2 years after operation, the satisfaction rate was 87.5%, 87.5%, 81.9%, 61.1%, 52.7%, 41.6%, and 34.7%, respectively. There were no serious complications observed and 23 patients relapsed after two years. Multivariate logistic regression analysis results showed that the effect of visual analog scale (OR = 7.312, 95% CI: 1.598 - 33.646, P = 0.011) and plantar temperature (OR = 0.470, 95% CI: 0.288 - 0.766, P = 0.002) on therapeutic effect showed has statistical significance; the effect of gender (OR = 0.654, 95% CI: 0.134 - 3.181, P = 0.599), age (OR = 0.975, 95% CI: 0.916 - 1.039, P = 0.441), perfusion index (OR = 0.710, 95% CI: 0.367 - 1.375, P = 0.310), and disease course (OR = 1.019, 95% CI: 0.997 - 1.042, P = 0.088) on therapeutic effect showed no statistical significance. The effect of gender (OR = 0.451, 95% CI 0.131 - 1.554, P = 0.207), age (OR = 0.961, 95% CI 0.912 - 1.013, P = 0.141), and course of disease (OR = 1.006, 95% CI 0.997 - 1.015, P = 0.203) on postoperative recurrence showed no statistical significance. The nonrandomized, single-center, small sample size, retrospective design is a major limitation of this study. Chemical lumbar sympathectomy is a valid treatment option for cold hypersensitivity in hands and feet, and computed tomography-guided percutaneous puncture chemical lumbar sympathectomy has the advantages of high success rate, less invasion, less complications, and repeatablity.

Treatment outcomes and objectification methods of the thoracoscopic sympathectomy in patients with focal hyperhidrosis and blushing syndrome

Uniportal video-assisted thoracoscopic sympathectomy (VATS) is an effective minimally invasive surgical method of choice for the treatment of primary focal hyperhidrosis and blushing syndrome due to uncontrolled operation of the sympathetic nervous system. The aim of this study was to provide an objective assessment of the improvement in the quality of life of patients with primary focal hyperhidrosis and blushing syndrome after bilateral monoport video-assisted thoracoscopic sympathectomy. Materials and methods. The results of surgical treatment were performed for 62 patients aged 17 to 42 years, 26 men and 36 women with a diagnosis of primary focal hyperhidrosis of the extremities and blushing syndrome. All patients underwent bilateral uniport video-assisted thoracoscopic sympathectomy. Patients are divided into 3 groups depending on the level of coagulation of the sympathetic trunk: the first group of the study (n = 9) includes patients after bilateral uniport sympathectomy at the level of R3 (isolated palmar hyperhidrosis), the second (n = 31) - at the level of R3-R4 (palmar and axillary hyperhidrosis), the third group (n = 22) - at the level of R2 (blushing syndrome). Results. In this study, coagulation and separation of the sympathetic trunk through a single port using a silicone port was performed. An excellent clinical result was achieved due to the minimally invasive operation - all 62 patients (100%) were satisfied with the achievement of a rapid stable effect. According to the results of the Dermatology Life Quality Index DLQI (1 month after surgery), the best quality of life measures were observed in patients who underwent separation of the sympathetic trunk at the R3 level – improvement from 20.3 ± 5.9 points to 0.8 ± 0.8 points. After the operation at the R3-R4 level scores the quality of life decreased from 22.77 ± 5.4 points to 2.3 ± 1.3 points, and at the level of R2 - from 16.5 points (QI 14 points - QIII 20 points) to 2 points (QI 1 point - QIII 3 points) p &lt;0.001). There was a difference in quality of life measures in our three groups of patients according to the severity of the disease before surgery. The lowest quality of life was determined in patients with the 4th degree of severity (33 people) and was 26.0 points (QI 23.0 points - QIII 27.3 points) compared with patients with 2d and 3d degrees of severity, 10.0 points (QI 7.7 points - QIII 10.0 points) and 17.0 points (QI 14.0 points - QIII 19.5 points) respectively (p &lt;0.001). After a single-port VATS in three groups there was an increase in quality of life measure, regardless of the severity of the disease before surgery. Conclusions. The most highly specific tests that allow to determine an objective assessment of the severity of the disease and a real assessment of the effectiveness of surgical treatment for hyperhidrosis was TEWL-metry, for blushing syndrome – capillaroscopy. VATS is an effective method of treating patients with hyperhidrosis and blushing syndrome, which significantly improves the quality of life according to the results of the Dermatological Index of Life Quality DLQI (p &lt;0.001) questionnaire.

Segmental branches emanating from saphenous nerve morphing into sympathetic trunks for innervation of saphenous artery and its clinical implication for arterial sympathectomy.

Sympathectomy of arteries has been adopted for the treatment of peripheral arterial disease and Raynaud's disease. However, the exact route for sympathetic axons to reach peripheral arteries awaits further investigation that could pave the way for development of new surgical strategies. In this study, saphenous neurovascular bundles from 10 neonatal Sprague‐Dawley rats first were harvested for whole‐mount immunostaining to show sympathetic innervation pattern of the artery. Secondly, 40 Sprague‐Dawley male rats weighing 350 to 400 g were assigned to five groups, receiving either sham, perivascular sympathectomy, nerve‐artery separation, nerve transection in the saphenous neurovascular bundle, or lumbar sympathectomy surgery that removes the lumbar sympathetic trunks. Immediately after surgery, the arterial perfusion and diameter were measured using laser speckling contrast imaging, and 1 week later the saphenous neurovascular bundles were harvested for immunostaining using antibodies against TH, neuron‐specific β‐tubulin (Tuj 1), and α‐SMA to show the presence or absence of the TH‐immuopositive staining in the adventitia. The differences among the five groups were determined using one‐way analysis of variance (ANOVA). We found that an average of 2.8 ± 0.8 branches with a diameter of 4.8 ± 1.2 μm derived from the saphenous nerve that morphed into a primary and a secondary sympathetic trunk for innervation of the saphenous artery. Nerve‐artery separation, nerve transection, and lumbar sympathectomy could eradicate TH‐immunopositive staining of the artery, resulting, respectively, in a 12%, 36%, and 59% increase in diameter (P < .05), and a 52%, 63%, and 201% increase in perfusion compared with sham surgery (P < .01). In contrast, perivascular sympathectomy did not have a significant impact on the TH‐immunopositive staining, the diameter, and perfusion of the distal part of the artery (P > .05). We conclude that the sympathetic innervation of an artery derives from segmental branches given off from its accompanying nerve. Nerve‐artery disconnection is a theoretic option in sympathectomy of an artery.

Evaluation of Endoscopic Thoracic Sympathectomy at T2 and T3 Ganglion Level for Primary Hyperhidrosis

Abstract Background: Primary hyperhidrosis is a benign and idio-pathic sympathetic disorder characterized by excessive sweet-ing with no apparent underlying cause and is aggravated during periods of stress and anxiety with a prevalence of 0.6- 2.8% of population. Aim of Study: To compare the effectiveness of thoracic endoscopic sympathectomy either at T2 and T3 regarding the patient's satisfaction, compensatory hyperhidrosis and post-operative complications. Patients and Methods: Forty patients between 13 and 30 years old with primary hyperhidrosis undergoing endoscopic thoracic sympathectomy were divided into two equal groups, the group I: T2 (20 patients) endoscopic thoracic sympathec-tomy at T2 ganglion level and group II (20 patients) at T3 ganglion level. Results: All patients in both groups had an immediate improvement after the operation with dry hands and 100% satisfaction. In group I with axillary hyperhidrosis only one patient (33.3%) had axillary dryness While in group II: Three patients (75%) had axillary dryness. In group I: Two patients (40%) had planter dryness while in group II: Three patients (75%) had planter dryness. 12 patients (60%) were complicated by compensatory sweating in group I, and eight patients (40%) in group II (in back, buttock and thigh), the difference was found statistically non-significant. Conclusion: Sympathectomy at the T2 or T3 levels pro-vided adequate long-term treatment for palmar hyperhidrosis in terms of initial surgery results, complications, and patient satisfaction. The most frequent complication was compensatory hyperhidrosis. Because of the lower severity of compensatory hyperhidrosis, we prefer the T3 level for treating palmar hyperhidrosis.

Outcome Using Either Intradermal Botox Injection or Endoscopic Thoracic Sympathectomy for Patients with Primary Palmar Hyperhidrosis: A Comparative Study

Hyperhidrosis, or excessive sweating, negatively impacts patients both physically and psychologically. It may be primary or secondary: the primary form is a benign condition, with its growing prevalence reaching 5% recently. Its medical treatments are transitory. Objectives: Comparison of the outcomes of patients with primary palmar hyperhidrosis (PPH) after intradermal Botox injection (IBI) versus endoscopic thoracic sympathectomy (ETS). Methods: Forty patients were randomly divided into two equal groups. Patients in the IBI group received an intradermal injection of a botulinum toxin A. Patients in the EST group received endoscopic electrocautery of the sympathetic chain. The patients were evaluated biweekly for 12 weeks, and patient satisfaction by outcome was evaluated using a 4-point satisfaction score. Results: At 12 weeks, 60% of the IBI group patients had maintained an improvement. Meanwhile, 40% of the patients were improved compared to pre-intervention scores, despite deterioration after remarkable improvement. On the other hand, 80% of ETS group patients maintained their Hyperhidrosis Disease Severity Scale (HDSS) up until the end of follow-up. Patient satisfaction scores were significantly higher for the IBI group compared to the ETS group. Conclusions: Intradermal Botox injection is a simple, safe, non-invasive, and effective therapeutic modality for PPH and achieved higher patient satisfaction compared to ETS.

Comparison of sympathectomy and cilostazol treatment results in non-revascularized critical leg ischemia

ABSTRACT&#x0D; Objective: The aim of this retrospective study is to compare the efficacy of sympathectomy and cilostazol therapy in critical limb ischemia that cannot be revascularized.&#x0D; Material and Method: This study was retrospectively conducted on 30 patients who underwent lumbar sympathectomy (Group 1) and received cilostazol treatment (Group 2) between January 2017 and August 2020. Demographic data, comorbidity, complications, wound healing, walking distance, and pain scale records of the patients were determined by examining the hospital registry system and statistical analysis was performed.&#x0D; Results: In the study, no significant difference was found between the two groups in terms of walking distance and ischemic pain in the statistical analysis of the data before treatment, at the 3rd, 6th, 12th, and 24th months (p&gt; 0.05). However, a statistically significant difference was found between the pre-treatment data and the data at the 3rd, 6th, 12th, and 24th months in both Group 1 and Group 2 in terms of walking distance and ischemic pain (p˂0.001 ). In the time periods followed in both groups, it was observed that there was an increase in walking distance and a decrease in ischemic pain.&#x0D; Conclusion: Cilostazol treatment may be preferred as a good alternative treatment method compared to lumbar sympathectomy in critical leg ischemia.&#x0D; Keywords: Critical leg ischemia; sympathectomy; cilostazol