Thoracic Sympathetic Ganglia Research Articles

Silent Myocardial Ischemia

Silent myocardial ischemia is defined as objective documentation of myocardial ischemia in the absence of angina or anginal equivalents. Since its original description in the 1970s, it has undergone intensive investigation, and its clinical significance is now well established. This review will serve as an update on the pathophysiology, detection, prevalence, prognosis, and treatment of silent ischemia in both asymptomatic patients and those with angina, whether stable or unstable. ### Pain Studies No discussion of silent ischemia is complete without consideration of the cardiac pain mechanism. Although much has been learned about this subject, much is still uncertain. The afferent fibers that run in the cardiac sympathetic nerves are usually thought of as the essential pathway for the transmission of cardiac pain (Figure 1). The atria and ventricles are abundantly supplied with sympathetic sensory innervation; from the heart, the sensory nerve endings connect to afferent fibers in cardiac nerve bundles, which in turn connect to the upper 5 thoracic sympathetic ganglia and the upper 5 thoracic dorsal roots of the spinal cord. Within the spinal cord, impulses mediated by this sympathetic afferent route probably converge with impulses from somatic thoracic structures onto the same ascending spinal neurons. This would be the basis for cardiac pain referred to the chest, wall, arm, back etc. In addition to this “convergence-projection theory,” the contribution of vagal afferent fibers must be acknowledged for an explanation of cardiac pain referred to the jaw and neck. How these vagal fibers are activated remains unclear. Furthermore, somatic localization of ischemic pain cannot predict the site of myocardial ischemia (anterior, inferior, or lateral) from one patient to the next. Figure 1. Mechanisms of cardiac pain. From Droste and Roskamm (used with permission).4 The actual “trigger” that stimulates the sensory nerve endings remains elusive. If a chemical pain stimulus is involved, …

Autonomic dysfunction in Parkinson's disease.

Autonomic dysfunction in patients with Parkinson's disease (PD) has been recognized since the original description by James Parkinson in 1817. Autonomic failure can be the clinical presentation of other diseases like pure autonomic failure (PAF) and multiple system atrophy (MSA). Both the central and peripheral autonomic nervous systems can be affected in PD. Rajput and Rozdilsky described cell loss and Lewy bodies within the sympathetic ganglia and antibodies to sympathetic neurons have been detected in PD patients. Lewy bodies can be seen in autonomic regulatory regions, including the hypothalamus, sympathetic (intermediolateral nucleus of the thoracic cord and sympathetic ganglia), and parasympathetic system (dorsal, vagal, and sacral parasympathetic nuclei). Lewy bodies were also found in the adrenal medulla and in the neural plexi innervating the gut, heart and pelvis. Symptoms of dysautonomia are variable, and include cardiovascular symptoms, gastrointestinal, urogenital, sudomotor and thermoregulatory dysfunction, pupillary abnormalities and sleep and respiratory disorders. They may represent a useful tool in the differential diagnosis of "atypical" or "complicated" parkinsonisms.

The role of the sympathetic nervous system in anxiety: Is it possible to relieve anxiety with endoscopic sympathetic block?

The function of the autonomic nervous system is divided so that the parasympathetic system spares central nervous system energy and the sympathetic system makes extra energy available and consumes it. The sympathetic nervous system then prepares our body for emergency and it always functions when our conscious or even unconscious mind notices a need for defence or to provide energy. A surgical procedure, where the upper thoracic sympathetic ganglions are ablated, either with cauterization or clamping with metallic clips, has been used to treat sweating of the hands and facial blushing for decades. Instead of ablating large areas of sympathetic trunk, which can cause severe side-effects such as reflex sweating of the body, the surgical procedure is nowadays carried out in a more precise symptom-mediating level of uppermost thoracic sympathetic ganglia. Blushing, hyperhidrosis of palms and head, and trembling are common in social phobia, and they seem to be provoked by the activation of the sympathetic nervous system. Preliminary studies show that some social phobia patients may benefit from the endoscopic sympathetic block (ESB). If the patient with generalized social phobia has not received help with adequate medication or psychotherapy, the ESB may be a new possible treatment of choice.

The Comparison of VATS Ramicotomy and VATS Sympathicotomy for Treating Essential Hyperhidrosis

This study was undertaken to determine if better results could be achieved by comparing the results of a thoracic sympathetic ramicotomy (division of rami communicantes) with a conventional thoracic sympathicotomy (division of sympathetic trunk) for treating essential hyperhidrosis. From August 2001 to February 2002, 29 consecutive patients underwent surgery of the sympathetic nerves in order to treat severe essential hyperhidrosis. Of these patients, a ramicotomy was performed under VATS (VATS-R) in 13 patients, sympathicotomy under VATS (VATS-S) in 13, a unilateral ramicotomy and contralateral sympathicotomy under VATS (VATS-RS) in 2 and a sympathicotomy via a thoracotomy (T-S) in 1. There was no significant difference between the VATS ramicotomy group (VATS-R, n=13) and VATS sympathicotomy group (VATS-S, n=13) in terms of gender, pleural adhesions or comorbidities. However, the age of the VATS-S group at surgery was higher than that of the VATS-R group (p=0.050). The operation times, and hospital stays of the groups were 51.5 and 41.9 minutes, and 2.0 and 2.3 days, respectively. The recurrence rate of the operated sites according to the surgical methods (ramicotomy and sympathicotomy regardless of VATS) was 21.4% (6/28) in the ramicotomy group and 6.7% (2/30) in the sympathicotomy group, but there was no statistical significance (p=0.101). This study compared the dryness of the enervated sites and the severity of compensatory sweating among the ramicotomy (n=11, excluded 2 re-operated cases from 13 VATS-R), sympathicotomy (n=14, VATS-S 13 and T-S 1) and the synchronous or metachronous ramicotomy/sympathicotomy groups (n=4, included 2 reoperated cases of VATS-R). The sympathicotomy group had an over-dryness of the enervated sites (dryness 1.4, from 1 to 3; 1:over-dried, 2:humid, 3:persistent sweating) and complained of severe compensatory sweating (severity 3.5, from 1 to 4; 1:absent, 2:mild, 3:embarrassing, 4:disabling). However, the patients whounderwent a ramicotomy maintained some humidity of the enervated sites (dryness 2.0, p=0.012) and showed milder compensatory sweating (severity 2.7, p=0.056) than those in the sympathicotomy group. Furthermore, the dryness of the ramicotomy side was different from that of the sympathicotomy side in 3 out of 4 ramicotomy / sympathicotomy (R+S) patients (the side of the ramicotomy was humid and that of the sympathicotomy was over-dried). The average dryness and the compensatory sweating at these sites were in the midst of the two groups (dryness and severity 1.6 and 3.0, respectively). A ramicotomy can prevent over-dryness of the enervated area and decrease the severity of compensatory sweating through the selective division of the rami communicantes of the thoracic sympathetic ganglia. Postoperatively, almost all ramicotomy patients had no functional problems in daily life or in their occupational activity, because they could maintain hand humidity. Moreover, they showed no more than a mild degree of compensatory sweating and reported high long-term satisfaction rates. Therefore, a sympathetic ramicotomy rather than a conventional sympathicotomy is recommended as a more selective and physiologic modality for treating essential hyperhidrosis.

Anatomic variations of the T2 nerve root (including the nerve of Kuntz) and their implications for sympathectomy

Objective: The aim of this study was to clarify the anatomic variations of the intrathoracic nerve of Kuntz, and this should help delineate the resection margins during video-assisted thoracic sympathectomy. Methods: Sixty-six thoracic sympathetic chains of 39 adult Korean cadavers were dissected on both sides of the thorax in 27 cadavers (54 sides) and on one side in 12 cadavers (12 sides). Results: The intrathoracic nerve was observed in 45 (68.2%) sides and was present bilaterally in 48.1% of cadavers. No intrathoracic nerve or ascending ramus communicans arising from the second thoracic nerve was observed in only 5 (7.6%) sides. The diameter of the intrathoracic nerve was 1.25 ± 0.55 mm on average. The arising point of the intrathoracic nerve from the second thoracic nerve was 7.3 mm on average from the sympathetic trunk. Presence of the stellate ganglion was noted in 56 (84.8%) sides, and 6 (9.1%) sides showed a single large ganglion formed by the stellate and the second thoracic sympathetic ganglia. The second thoracic sympathetic ganglion was most commonly located (50%) in the second intercostal space. Conclusion: The anatomic variations of the intrathoracic nerve of Kuntz and the second thoracic sympathetic ganglion were characterized in human cadavers. It is hoped that this study will help to improve the recurrence of symptoms caused by the intrathoracic nerve in an upper thoracic sympathectomy for hyperhidrosis.J Thorac Cardiovasc Surg 2002;123:498-501

The Effects of Thoracic Sympathetic Ganglion Block and Gabapentin in a Patient with Myokymia and Neuropathic Pain after a Thoracotomy

Myokymia is one of involuntary movement, which is characterized by undulatory muscle spasm, similar to the worm's crawl. Sometimes muscle pain, itchy sensation, dysautonomia and other symptoms are associated with it. Derangement of the peripheral or central nervous system after nerve or tissue damage is suspected as the source of impulse generators causing this symptom. We encountered a patient with neuropathic pain and myokymia after thoracotomy. Although several medications and nerve blocks have been applied, all have failed to provide symptom relief. We experienced improvement of the pain and involuntary movement with a thoracic sympathetic ganglion block and gabapentin.

Multiple effects of artemin on sympathetic neurone generation, survival and growth

To define the role of artemin in sympathetic neurone development, we have studied the effect of artemin on the generation, survival and growth of sympathetic neurones in low-density dissociated cultures of mouse cervical and thoracic paravertebral sympathetic ganglia at stages throughout embryonic and postnatal development. Artemin promoted the proliferation of sympathetic neuroblasts and increased the generation of new neurones in cultures established from E12 to E14 ganglia. Artemin also exerted a transient survival-promoting action on newly generated neurones during these early stages of development. Between E16 and P8, artemin exerted no effect on survival, but by P12, as sympathetic neurones begin to acquire neurotrophic factor independent survival, artemin once again enhanced survival, and by P20 it promoted survival as effectively as nerve growth factor (NGF). During this late period of development, artemin also enhanced the growth of neurites from cultured neurones more effectively than NGF. Confirming the physiological relevance of the mitogenic action of artemin on cultured neuroblasts, there was a marked reduction in the rate of neuroblast proliferation in the sympathetic ganglia of mice lacking the GFRalpha3 subunit of the artemin receptor. These results indicate that artemin exerts several distinct effects on the generation, survival and growth of sympathetic neurones at different stages of development.

Thoracic sympathetic block: A new approach

Although a number of approaches to the thoracic sympathetic ganglia are described, the risk of pneumothorax generally precludes this procedure for other than neurolytic ablation. The approach that is described uses the principle of inserting a needle in a direction away from a potential complication by taking advantage of very consistent anatomy. Making use of 2 radiologic landmarks, the tubercle of the costotransverse articulation and the costovertebral articulation, when superimposed, allows a line when subtended from the costotransverse articulation to the observer that is parallel to the neck of the rib. The triangular space formed by the reflection of the parietal pleura, which lies anteromedial to the costotransverse articulation and before its reflection onto the mediastinum, provides a relatively safe passage for a needle that is directed to its target at the costovertebral articulation. In the author's experience, the frequency of pneumothorax is less than 1%, and it has occurred only when the foregoing radiologic landmarks due to pathology are poorly discerned. The technique should increase the usefulness of thoracic sympathetic ganglion blockade for diagnostic, prognostic, and therapeutic use. Copyright © 2001 by W.B. Saunders Company

Changes in the expression of neuropeptide Y (NPY) during maturation of human sympathetic ganglionic neurons: correlation with tyrosine hydroxylase immunoreactivity

Developmental patterns of neuropeptide Y (NPY) and tyrosine hydroxylase (TH)-immunoreactivities (IR) were investigated using the method of indirect immunohistochemistry in the stellate and thoracic sympathetic ganglia of human neonates ranging in gestational age from 24 to 27 weeks (premature group) and from 38 to 41 weeks (mature group). In the paravertebral ganglia of premature neonates a small (up to 7%) population of NPY-IR nerve cells was revealed. With the gestational age increase (a mature group), a marked elevation of the number of NPY-IR ganglionic neurons (up to 41%) was noted. In contrast, in the sympathetic ganglia of premature neonates almost all the neurons were tyrosine hydroxylase immunoreactive and any change in pattern during maturation was insignificant. The results demonstrate an age-related increase of neuropeptide Y-immunoreactivity in human paravertebral ganglia during maturation, and suggest that peptidergic co-transmission arises later in development than do the classical autonomic messengers. Adaptability of the fetus to a new external environment at birth demands a qualitatively new activity level of the autonomic nervous system, and this is provided side by side with the classical messengers noradrenaline and acetylcholine by the co-transmitter and modulating role of the neuropeptides. The appearance of neuropeptide Y in the principal sympathetic ganglionic neurons defines not only a qualitatively new level in the functional regulation of target organs at birth, but serves as an index of neonatal maturity.

Investigation of the susceptibility of equine autonomic neuronal cell lines, clonally derived from the same paravertebral ganglion, to toxic plasma from equine dysautonomia (grass sickness) cases

In the autonomic nervous system (ANS) of equine grass sickness (GS) cases, some neurones show abnormal changes while neighbouring neurones are unaffected. To test whether noradrenergic neurones showed variable susceptibility to the GS toxin in culture, clonally-derived populations isolated from the same fetal thoracic sympathetic chain ganglion were challenged with plasma from GS cases previously shown to induce ANS damage when injected into normal horses. During the early stages of exposure to toxic plasma, cells within a clonal population showed variable susceptibility ranging from no obvious effect to characteristic patterns of pathology. However, after 3 days of exposure to toxic plasma all cells were killed. Dose response analysis on selected clonal populations showed no significant difference in TD 50 values.

Histopathological examination of chemo-sympathectomy in cats

In recent decades, there has been an increase in both the number of sympathectomy techniques, as well as the surgical findings of sympathetic anatomy. Currently the advanced technique of C-arm guided percutaneous thoracic chemo-sympathectomy is widely used for the treatment of palmar hyperhidrosis. However, a better understanding of chemical agents in sympathectomy is required. In this study, chemo-sympathectomy was performed in cats, using alcohol, glycerol and various concentrations of phenol, to determine the chronic neurotoxic effects of these chemical agents on the stellate ganglia. The stellate ganglia of 24 cats were exposed under endotracheal general anesthesia, then injected with about 0.02 ml of absolute alcohol, glycerol and phenol (10%, 25%, 50%, and 75% concentration) solutions, respectively. The stellate ganglia were taken for histological examination three weeks after the chemical injection. The results showed that the degenerative changes in the cytoplasm and nucleus of ganglionic cells and intercellular tissue were moderate and relatively moderate after the injection of alcohol and glycerol, respectively. Meanwhile, the stellate ganglia revealed mild, relatively moderate, serious and extremely serious degeneration after injection of 10%, 25%, 50%, and 75% phenol, respectively. In conclusion, we recommend a high concentration of phenol, in the least volume, as a chemical agent for clinical injection in the upper thoracic sympathetic ganglion. [Neurol Res 2000; 22: 420–5D;

The anterior approach for thoracic sympathetic ganglion block using a curved needle

AbstractFollowing cadaveric study, 20 patients suffering from Complex Regional Pain Syndrome (CRPS) underwent upper thoracic ganglion sympathetic blockade using a new anterior approach. Five patients obtained a favorable response to the diagnostic block. All five cases had pain relief following successful radiofrequency ablation to the second and third thoracic sympathetic ganglion using the anterior approach. Only one case of pneumothorax was reported which was treated conservatively. The anterior approach was technically easier to perform, and outcomes were comparable to the classical posterior approach.

Developmental Changes in the Transmitter Properties of Sympathetic Neurons That Innervate the Periosteum

During the development of sweat gland innervation, interactions with the target tissue induce a change from noradrenergic to cholinergic and peptidergic properties. To determine whether the change in neurotransmitter properties that occurs in the sweat gland innervation occurs more generally in sympathetic neurons, we identified a new target of cholinergic sympathetic neurons in rat, the periosteum, which is the connective tissue covering of bone, and characterized the development of periosteal innervation of the sternum. During development, sympathetic axons grow from thoracic sympathetic ganglia along rib periosteum to reach the sternum. All sympathetic axons displayed catecholaminergic properties when they reached the sternum, but these properties subsequently disappeared. Many axons lacked detectable immunoreactivities for vesicular acetylcholine transporter and vasoactive intestinal peptide when they reached the sternum and acquired them after arrival. To determine whether periosteum could direct changes in the neurotransmitter properties of sympathetic neurons that innervate it, we transplanted periosteum to the hairy skin, a noradrenergic sympathetic target. We found that the sympathetic innervation of the transplant underwent a noradrenergic to cholinergic and peptidergic change. These results suggest that periosteum, in addition to sweat glands, regulates the neurotransmitter properties of the sympathetic neurons that innervate it.

Establishment and characterization of equine autonomic ganglion cell lines to enable direct testing of candidate toxins involved in equine dysautonomia (grass sickness).

To enable direct testing of a range of potential toxins or pathogens that might be involved in grass sickness, equine thoracic sympathetic chain ganglion cell lines were established from primary cell cultures by retroviral-mediated transduction of the temperature-sensitive mutant of the establishment oncogene encoding SV40 large T antigen. Morphological and behavioral features, temperature dependence, and immunocytochemical characteristics of the cell lines were investigated. The majority of cells were noradrenergic neurons in which dopamine-beta-hydroxylase, the enzyme that catalyzes norepinephrine synthesis, and neuropeptide Y coexisted. Cells treated with plasma from grass sickness cases that had previously been shown to induce autonomic nervous system damage when injected into normal horses showed significantly decreased mitochondrial function after 1 day. After 3 days exposure most cells showed severe degeneration in contrast to those treated with normal plasma. Liver and lung cell lines were also susceptible to plasma, suggesting that the toxin is not specifically neurotoxic.

Xenografting human T2 sympathetic ganglion from hyperhidrotic patients provides short-term restoration of catecholaminergic functions in hemiparkinsonian athymic rats.

Previous studies have suggested that allografting peripheral sympathetic ganglia, such as superior cervical ganglia, partially relieves clinical or behavioral deficits in parkinsonian patients and animals. However, removal of these ganglia can cause Homer's syndrome, which limits the utilization of this approach. Hyperhidrosis, a disease of excessive sweating, is commonly seen in young Orientals. Treatment of hyperhidrosis often involves surgical removal of the second thoracic sympathetic ganglia (T2G), which contain catecholaminergic neurons. The purpose of our study was to investigate behavioral responses and tyrosine hydroxylase (TH) immunoreactivity in hemiparkinsonian rats at different time points after transplantation of human T2G from hyperhidrotic patients. Athymic Fisher 344 rats were injected unilaterally with 6-hydroxydopamine into the medial forebrain bundle to destroy the nigrostriatal dopaminergic (DA) pathway. The effectiveness of lesions was tested by measuring methamphetamine (MA)-induced rotations. These unilaterally lesioned rats were later transplanted with T2G or T2 fiber tract (T2F) obtained from adult hyperhidrotic patients. Animals grafted with T2G showed a reduction in MA-induced rotation by 2 weeks; however, rotation returned to the pregrafting levels by 3 months. Animals receiving T2F grafts did not show any reduction of rotation over a 3-month period. Animals were later sacrificed for TH immunostaining at different time points. Tyrosine hydroxylase-positive [TH(+)] cell bodies and fibers were found in the lesioned striatum 2-4 weeks after T2G grafting, suggesting the survival of transplants. Two to 3 months after grafting, TH(+) fibers were still found in almost all the recipients. However, TH(+) cell bodies were found in only three of seven rats studied. Animals receiving T2F grafting did not show any TH immunoreactivity in the lesioned striatum over the 3-month period. These data indicate that T2G transplants from adult hyperhidrotic patients can survive and provide transient normalization of the motor behavior in the hemiparkinsonian athymic rats. Because of the short-term improvement in behavior after grafting, the use of T2G in human trials should be cautious at the present time. Further laboratory research is required.

Negative Pressure Pulmonary Oedema Induced by Direct Suctioning of Endotracheal Tube Adapter

Purpose Negative pressure pulmonary oedema (NPPE) is a well-recognized but rare complication secondary to upper airway obstruction such as laryngeal spasm during emergence from general anaesthesia. Cauterization of the second and third thoracic sympathetic ganglia is a treatment for hyperhidrosis of the hands. We report a case of NPPE induced by direct suctioning of the endotracheal tube adapter during thoracic sympathetic ganglionectomy without recognized upper airway obstruction.

The origin of catecholaminergic nerve fibers in the subdiaphragmatic vagus nerve of rat

It is known that the vagus nerve contains catecholaminergic fibers. However, the origin of these fibers has not been systematically examined. In this study, we addressed this issue using retrograde tracing from the subdiaphragmatic vagus nerve combined with immunocytochemistry. The cervical and thoracic sympathetic trunk ganglia, the nodose ganglia and the dorsal motor nucleus of the vagus nerve were examined following injection of Fluoro-Gold or cholera toxin horseradish peroxidase conjugate into the trunks of the subdiaphragmatic vagus nerve of rats. Numerous retrogradely labeled neurons were seen in the nodose ganglion and the dorsal motor nucleus of the vagus nerve. Very few labeled neurons were found in the sympathetic ganglia (less than 0.06% of the neurons in either superior cervical ganglion or cervicothoracic ganglion were retrogradely labeled). Double labeling with immunofluoresence for catecholamine synthesizing enzymes revealed that: (1) 92% of all Fluoro-Gold retrogradely labeled tyrosine hydroxylase immunoreactive neurons were found in parasympathetic sources (75% in the dorsal motor nucleus of the vagus nerve and 17% in the nodose ganglia), and only 8% in the cervicothoracic sympathetic ganglia; (2) 12% of the retrogradely labeled catecholaminergic neurons in the dorsal motor nucleus of the vagus nerve were also dopamine-β-hydroxylase immunopositive neurons; (3) 70% of the retrogradely labeled neurons in the sympathetic ganglia were tyrosine hydroxylase immunopositive and 54% of these catecholaminergic neurons contained dopamine-β-hydroxylase, while 30% of the retrogradely labeled neurons were non-catecholaminergic neurons. These results indicate that catecholaminergic fibers in the abdominal vagus nerve are primarily dopaminergic and of parasympathetic origin, and that only an extremely small number of these fibers, mostly noradrenergic in nature, arise from postganglionic sympathetic neurons.

The Results of Thoracoscopic Sympathetic Trunk Transection for Palmar Hyperhidrosis and Sympathetic Ganglionectomy for Axillary Hyperhidrosis

Objectivesto review our total experience of thoracoscopic sympathetic trunk transection for the treatment of palmar hyperhidrosis and second and third thoracic sympathetic ganglionectomy for axillary hyperhidrosis.Designlongitudinal cohort study following up consecutive patients for 0.3 to 5.5 years.Subjectsfifty-four consecutive patients undergoing thoracoscopic sympathectomy for hyperhidrosis.Methodsprospective evaluation of immediate technical success, complications, late recurrence of hyperhidrosis and patient acceptability.Results100% initial cure for palmar hyperhidrosis, 91% of sympathetic ganglionectomies for axillary hyperhidrosis were technically successful and initially curative. Compensatory sweating 44% patients, most severe after bilateral sympathetic ganglionectomy. Complications occurred in 14% patients, all resolving without further intervention. There were no cases of Horner's syndrome. 13% patients reported a return of some palmar sweating. 5.4% patients developed recurrent palmar hyperhidrosis at 6, 15 and 21 months postoperatively.Conclusiontransection of the sympathetic trunk between the first and second thoracic sympathetic ganglia initially cures 100% of patients treated primarily for palmar hyperhidrosis. Technically successful 2nd and 3rd thoracic sympathetic ganglionectomy initially cures 100% of patients with axillary hyperhidrosis. Compensatory sweating is common after bilateral sympathectomy. Recurrent palmar hyperhidrosis occurs in 5.4% of cases, but can be cured by a second thoracoscopic sympathectomy. Horner's syndrome is an avoidable complication of thoracoscopic sympathectomy.

Reoperation for Essential Hyperhidrosis

Palmar hyperhidrosis has a recurrence rate of 0% to 5% after thoracic sympathectomy. From January 1992 to October 1997, thoracic sympathectomy was performed by video-assisted thoracoscopic surgery for hyperhidrosis in 490 patients of whom 5 (2 male and 3 female with a mean age of 20 years) experienced recurrent hyperhidrosis in the early (< 7 days) or late (up to 6 months) postoperative period. All patients had moderate to severe pleural adhesions in the previous sympathectomy sites but no operative complications or crossover to thoracotomy occurred. Surgery resulted in satisfactory outcomes showing that video-assisted thoracoscopic sympathectomy was effective in treating recurrent hyperhidrosis. Prevention of recurrence requires the identification and resection of the second thoracic sympathetic ganglion as well as the Kuntz fibers.

The motor functions the human esophageal body (EB) and lower esophageal sphincter (Les) are regulated by cervical and thoracic sympathetic ganglia (SG): Functional effects of a computer tomography (CT)-guided selective SG block

The motor functions the human esophageal body (EB) and lower esophageal sphincter (Les) are regulated by cervical and thoracic sympathetic ganglia (SG): Functional effects of a computer tomography (CT)-guided selective SG block