The Neuroendocrine-immune Network

Work from Livnat's laboratory, utilizing the the experimental approach following chemical sympathectomy, has documented extensive functional alterations in immune responses following denervation. In several strains of mice, sympathectomy diminished primary antibody responses by as much as 80% and 97% in spleens and lymph nodes, respectively and suppressed the secondary antibody response as well. T-cell mediated responses, such as delayed hypersensitivity to epicutaneous immunization and cytotoxic T-lymphocyte responses to alloantigens, were reduced by 50% or more in denervated mice. In contrast, proliferation, and possibly differentiation of lymphocytes (mainly B cells) in lymph nodes in the absence of immunization was markedly stimulated by sympathectomy. Furthermore natural killer cell (NK) activity in the spleen and lungs was augmented following denervation.

The Neuroendocrine-immune Network

By S. Freier

Published by CRC Press, 1990

ISBN 0849346258, 9780849346255

Sympathectomy suppresses baroreceptor function

The results suggest that cardiac sympathectomy induced by epidural anesthesia can suppress partially baroreceptor function by interrupting sympathetic efferent fibers innervating the heart during high levels of epidural anesthesia, but that lumbar sympathectomy during epidural anesthesia is unlikely to affect baroreceptor activity.

Anesth Analg. 1983 Sep;62(9):815-20
http://www.ncbi.nlm.nih.gov/pubmed/6881570?dopt=Abstract

suppression of baroreflex function can be detrimental

In this study, baroreflex control of HR was completely inhibited in 9 of 21 patients in the depressor test but in only 1 of 19 patients in the pressor test. All patients who showed complete inhibition had received bilateral T2-3 sympathectomy. Responses to decreased blood pressure are mediated by the sympathetic nervous system, whereas responses to increased blood pressure predominantly involve vagal compensation (13). Therefore, it seems that the effects of sympathetic denervation were most prominent in the depressor test after ETS.

The suppression of baroreflex function can be detrimental during anesthetic management. In particular, a poorly preserved baroreflex response to decreasing blood pressure may exaggerate hemodynamic perturbation after a sudden loss of circulating blood volume. In addition, it is possible that patients who have received ETS will show unexpected HR responses after the administration of a vasopressor or vasodilator. We conclude that baroreflex response as a compensatory function for hemodynamic changes is suppressed in patients who receive ETS.
Anesth Analg 2004;98:37-39
http://www.anesthesia-analgesia.org/cgi/content/full/98/1/37

Sexual dysfunction after sympathectomy

LS, like any other surgical procedure, is not without its share of complications which include failure of adequate denervation, brief paralytic ileus, hyperhydrosis in parts of the body which remain normally innervated, sexual dysfunction, and post-sympathectomy neuralgia.

http://www.ispub.com/ostia/index.php?xmlFilePath=journals/ijs/vol18n1/lumbar.xml

Pathophysiology of Diarrhea and Malabsorption

Disordered motility

• Post-vagotomy

• Post-sympathectomy

• Diabetic neuropathy

• Hyperthyroidism

• Addison’s disease (adrenal insufficiency)

• Irritable bowel syndrome

Laurence Scott Bailen, M.D.: Diarrhea and Malabsorption
http://ocw.tufts.edu/Content/48/lecturenotes/571075

Causes of Syncope:

g) *Syncope via autonomic failure:
i) Neuropathy with autonomic involvement
ii) Antihypertensives, esp. beta-blockers
iii) Surgical sympathectomy
iv) CNS autonomic failure: eg.primary autonomic failure, MSA, spinal cord lesion

Causes of *Collapse and Acute Decreased Conscious State. (* = collapse, as in sudden loss of consciousness). 1. Respiratory (O ...
www.medicine.utas.edu.au/teaching/year6/cam615_616/info/additionaltutes/additionaltutes/med.pdf

Authorised Publication of the School of Medicine
© University of Tasmania ABN 30 764 374 782

Profound Bradycardia

However, CTS (Chemical Thoracic Sympathectomy) in patients having high SDRR:SD sub [partial diffenrential] RR ratios can result in profound bradycardia.
Anesthesiology. 89(3):666-670, September 1998.
Hirose, Munetaka MD; Imai, Hiroto MD; Ohmori, Misako MD; Matsumoto, Yasunori MD; Amaya, Fumimasa MD; Hosokawa, Toyoshi
MD; Tanaka, Yoshifumi MD

The results of endoscopic sympathectomy deteriorate progressively from the immediate outcome

British Journal of Surgery ISSN 0007-1323

1999, vol. 86, no1, pp. 45-47 (12 ref.)

Infra-stellate upper thoracic sympathectomy results in a relative bradycardia during exercise, irrespective of the operated side

Several reports also demonstrate significantly lower heart rate increases during exercise in subjects who have undergone bilateral ISS [9–12] compared to pre-surgical levels. In spite of this high occurrence, recent reviews on the usual collateral effects of thoracic sympathectomy still do not include these possible cardiac consequences [6].
The aim of the present prospective study was to confirm that a significant impairment of the heart rate to workload relationship was consistently observed following unilateral and/or bilateral surgery.
Eur J Cardiothorac Surg 2001;20:1095-1100
http://ejcts.ctsnetjournals.org/cgi/content/full/20/6/1095

Palmar Hyperhidrosis worse after Sympathectomy

We describe a patient who underwent upper thoracic sympathectomy for palmar hyperhidrosis, and whose symptoms subsequently deteriorated, becoming worse than those on initial presentation.

Clinical and Experimental Dermatology

Volume 20 Issue 3, Pages 230 - 233

Published Online: 27 Apr 2006

Accepted for publication 6 January 1995

THE SYMPATHETIC NERVOUS SYSTEM AS A HOMEOSTATIC MECHANISM

The responses of intact rats to cold-exposure (4°C) include vasoconstriction, piloerection, shivering, adrenocorticotrophin (ACTH) hypersecretion and increased mobilization of free fatty acids and glucose. Adrenal demedullation prevents the increased mobilization of glucose and decreases survival time. Chemical sympathectomy blocks all of the responses except ACTH hypersecretion. Such animals lose body heat rapidly and die in a few hours. Total adrenalectomy has a similar effect. The damaging actions of chemical sympathectomy are reversed by administration of catecholamines while those of total adrenalectomy are reversed by cortisone. Thus, the sympathetic nervous system appears to be essential for existence at low environmental temperature.

http://jpet.aspetjournals.org/cgi/content/abstract/157/1/103

All possible side effects should be dealt with and written informed consent required

Thoracoscopic sympathicotomy by electrocautery is an irreversible procedure. Thus the indications must be meticulously considered before the final decision to operate is taken by both the surgeon and the patient. All possible side effects should be dealt with and written informed consent required.

http://www3.interscience.wiley.com/journal/106568639/abstract?CRETRY=1&SRETRY=0

Published Online: 2 Dec 2003

Copyright © 2002 Taylor and Francis Ltd

Sympathectomy impairs temperature homeostasis, decreases Cardiac output and myocardial work

The decrease in body temperature associated with the onset of central neuraxial block has three reported mechanism: loss of the patient's thermorgulatory capability, with impaired shivering and loss of the ablility to sense cold temperatures; sympathectomy induced peripheral vasodilation, resulting in admixing of peripheral (cool) with core (warm) blood (this mixing results in a 1C to 2C decrease in core temperature and is proporitonal to the extent of sympathetic block and patient's age, and loss of tissue heat below the level of sympathectomy due to vasodilation.

Neuraxial anesthesia decreases afterload by producing arterial vasodilation. This vasodilation however is not equivalent in all vascular beds. For instance, muscle and skin blood flow may be decreased by sympathectomy, whereas the total blood flow to the same extremity may be quadrupled. Additionally, the extent to which afterload is decreased by sympathetic denervation varies considerably from one patient to another.

The effectiveness of this reflex vasoconstriction in maintaining normotension is a function of the extent of the sympathetic block. If, for instance, sympathetic block reaches the fourth thoracic dermatome (T4) or higher, the intact upper limb vasculature may contribute only 5% of the total cardiac output. Even maximal vasoconstriction will be insuffiecient to compensate for the profound arterial vasodilation in the rest of the body.

Cardiac Function
Importantly, bradycardia during high (thoracic) levels of spinal or epidural anesthesia is due to two main factors: denervation of preganglionic cardiac accelerator fibers (T1-4) and diminished venous return to the right ventricle because of decreases in preload.

Cardiac Output
The extent of CO decrease is also a function of the degree of sympathetic denervation.
Conversely, assumption of an even slight head-up position during neuraxial anesthesia with high levels of sympathetic denervation (..) may have catastrophic consequences such as profound bradycardia, cerebral hypoperfusion and cardiac arrest. Reports of severe complications related to improper positioning of patients during high levels of spinal or epidural anesthesia have spanned the last six decades.

Myocardial Work
The significant decrease in myocardial work is due primarily to threee factors: Decrease in HR (heart rate), decrease in arterial/total peripheral resistance (afterload), and decrease in stroke volume of the left ventricle secondary to the decreased preload.

Supplemental Oxygen
The purpose of the supplemental oxygen is to assure that tissue oxygenation is maintained , despite decreases in CO and periperal blood low.

Complications in Anesthesiology

By Emilio B. Lobato, Nikolaus Gravenstein, Robert R. Kirby

Contributor Emilio B. Lobato, Nikolaus Gravenstein, Robert R. Kirby

Edition: 3, illustrated

Published by Lippincott Williams & Wilkins, 2007

ISBN 0781782635, 9780781782630

Shivering - a normal response during fever is eliminated by sympathectomy

During fever pyrogen is released from leucocytes and this agent causes the disturbed thermoregualtion (Atkins, 1960). For this response to occur, an intact efferent sympathetic system is required because fever can be markedly reduced by bilateral sympathectomy in the cat (Pinkston, 1935). In man, pyrogen seems to act above the level of the 5th cervical spinal cord segment; for a patient with a lesion at that level the intravennours administration of pyrogen produced shivering in normally innervated muscles only and no alteration in hand blood flow was seen (Cooper at al., 1964)

The Autonomic Nervous System: An Introduction to Basic and Clinical Concepts

By Otto Appenzeller, Emilio Oribe

Edition: 5, illustrated

Published by Elsevier Health Sciences, 1997

ISBN 0444827617, 9780444827616

Gustatory sweating occurred in 38% of patients, and 16% of patients regretted the operation

Follow-up by questionnaire was possible in 94% of patients after a median of 26 months. Compensatory sweating occurred in 89% of patients and was so severe in 35% that they often had to change their clothes during the day. The frequency of compensatory sweating was not significantly different among the three groups, but severity was significantly higher after Th2-4 sympathectomy for axillary hyperhidrosis (p = 0.04). Gustatory sweating occurred in 38% of patients, and 16% of patients regretted the operation.

http://ats.ctsnetjournals.org/cgi/content/abstract/78/2/427

Ann Thorac Surg 2004;78:427-431
© 2004 The Society of Thoracic Surgeons

Sympathectomy only as a last resort?

Endoscopic thoracic sympathectomy is still practiced here but its use is decreasing and it's really only advocated as the last resort for palmar [hand] hyperhidrosis or facial blushing, and it's only rarely used for axillary [underarm] hyperhidrosis.
Dr Goodman, Melbourne, Australia
http://www.sweathelp.org/english/CMN_Article.asp?ArticleCode=64750038&EditionCode=77446114

Sympathetic vasodilatation in human limbs

Along these lines, recent observations in animals indicate that chronic sympathectomy eliminates endothelial NO synthase expression
in sympathectomised blood vessels (Aliev et al. 1996). This suggests that normal NO-mediated responses to local and circulating factors would be present
following acute sympathectomy with local anaesthetics or drugs injected into the brachial artery, but that these responses would be absent in the months and
years following surgical sympathectomy.

http://jp.physoc.org/cgi/content/full/526/3/471

Alterations of the Three-Phase Bone Scan After Sympathectomy

The data demonstrated that alterations in TPBS after sympathectomy are identical to those reported in early RSD and these alterations bear no relationship to the success of sympathectomy regarding pain relief. The mechanisms underlying alterations of TPBS as well as the potential mechanisms of sympathectomy failures are discussed.

Clinical Journal of Pain. 10(2):146-155, June 1994

sympathectomy is based on poor quality evidence, uncontrolled studies and personal experience

The practice of surgical and chemical sympathectomy is based on poor quality evidence, uncontrolled studies and personal experience. Furthermore, complications of the procedure may be significant, in terms of both worsening the pain or producing a new pain syndrome; and abnormal forms of sweating (compensatory hyperhidrosis and pathological gustatory sweating). Therefore, more clinical trials of sympathectomy are required to establish the overall effectiveness and potential risks of this procedure.
Cochrane Database Syst Rev. 2003;(2):CD002918.

Painful sweating after nerve sprouting

The authors propose that after destruction of cutaneous nerves, aberrant regenerant sprouting innervates sweat glands, producing gustatory sweating as in auriculotemporal syndrome (Frey syndrome), and innervates nociceptors, producing pain.

http://www.neurology.org/cgi/content/abstract/63/8/1471

Sexual function after bilateral lumbar sympathectomy

In patients who had only bilateral sympathectomy, these complications occurred in 24% and mainly consisted of ejaculation disturbances. Only three patients became impotent, each having had aortic surgery.

http://www.ncbi.nlm.nih.gov/pubmed/7364866

Sympathectomy as a cure for psychiatric mischief...

Of those I have
met, however, some have been supposed to be subject to deep psychiatric
mischief, none has benefited from psychiatric treatment, and all have been
cured by sympathectomy. Furthermore it must be noted as a matter of
special interest that the cure is permanent, and the trouble does not recur
even in patients who show evidence of some return of sympathetic function.

SOME UNSOLVED PROBLEMS IN THE SURGERY OF THE
SYMPATHETIC NERVOUS SYSTEM
Bradshaw Lecture delivered at the Royal College of Surgeons of England
on 11th June, 1953
by
Professor Sir James Paterson Ross, K.C.V.O., F.R.C.S.
Vice-President, Royal College of Surgeons of England

Sympathectomy as psychiatric surgery

Use of stellate ganglion block for the treatment of psychiatric and behavioral disorders

United States Patent Application 20070135871

The present invention is directed to a method for the treatment of a patient suffering from psychiatric and behavioral disorders, including post partum depression, post traumatic stress disorder, compulsive smoking, attention deficit hyperactivity disorder, gambling addiction, comprising the step of administering a stellate ganglion block to the patient to alleviate the symptoms. The stellate ganglion block may be followed by a sympathectomy to provide permanent relief.

Lipov, Eugene (Chicago, IL, US)
http://www.freepatentsonline.com/y2007/0135871.html
Dr. Lipov is currently the Director of Research, Northwest Community Hospital and Medical Director, Advanced Pain Centers. He has had numerous appearances on network television for his innovative treatment of Hot Flashes and stimulators.

Sympathectomy impairs healing

"The effect of neuropathy on healing of the medial collateral ligament was studied in rats that
had undergone surgical sympathectomy (autonomic neuropathy) or femoral nerve transaction (sensory neuropathy). There were significant decreases in various neuropeptides, such as substance P, calcitonin gene-related peptide, and vasoactive intestinal peptide, in the denervated tissues. Impaired healing, demonstrated by significant decreases in failure force of the healing ligaments, was seen in both groups of rats."

Dangerous complications of sympathectomy reported

Endoscopic thoracic sympathectomy (ETS), a procedure used to correct palmar hyperhidrosis, facial sweating and blushing, can be accompanied by dangerous complications, according to a Feb 5, 2004, news release from John Wiley & Sons, Inc, publisher of the British Journal of surgery.

Complications of procedure to correct sweating reported. | Goliath Business News

"Lifestyle' Surgical Procedure Carries Unrecognized Risk of Complications" (news release, Hoboken, NJ: John Wiley &
Sons, Inc, British Journal of Surgery, Feb 5, 2004)

Left, but not right, one-lung ventilation causes hypoxemia during endoscopic transthoracic sympathectomy

Endoscopic transthoracic sympathectomy was
performed under general anesthesia, using a double-lumen endobronchial
tube, after induction of artificial pneumothorax plus insufflation of CO2 into
the operated chest. Via radial artery cannulae, one to three arterial blood
gas samples were taken during two-lung ventilation before surgery, at each
one-lung ventilation, in most cases during the period of two-lung ventilation
when switching between the operated sides, and after surgery.
Left-lung ventilation and right-chest operation caused profound decrease of arterial oxygen partial
pressure (PaO2), compared with two-lung ventilation.


J Cardiothorac Vasc Anesth. 1996 Feb;10(2):207-9.

early lymphocytosis was absent in sympathectomized subjects

Peripheral white and red blood cell changes were studied in response to acute insulin-induced hypoglycaemia in six normal, six splenectomized and five sympathectomized (tetraplegic) subjects. The normal subjects were restudied during beta (propranolol) and beta-selective (metroprolol)  adrenergic blockade.

In the normal subjects a lymphocytosis immediately followed the acute hypoglycaemic reaction (R) with a neutrophilia 2 h later. The early lymphocytosis was absent in sympathectomized subjects and reduced under beta blockade in normal subjects, indicating mediation via an adrenergic mechanism. 

Haemoglobyn, packed cell volume and total erythrocyte count rose maximally at R in all groups except the sympathectomized subjects in vhom all parameters declined progressively from basal values. 

Peripheral blood cell changes in response to acute hypoglycaemia in man

European Journal of Clinical Investigation, Volume 13 Issue 1, Pages 33-39, 1982

Arterial Hypercapnia is enhanced after cervical sympathectomy

The Cardiovascular System: A Critical, Comprehensive Presentation of Physiological Knowledge and Concepts

by Robert M. Berne, Nicholas Sperelakis, Stephen R. Geiger, 

Published by American Physiological Society, 1979

NA plasma levels are significantly decreased after sympathectomy for HH

Preoperative NA and A plasma levels were all within the normal limits used in our laboratory. After TS, mean NA plasma levels are significantly decreased...
We conclude that sympathetic overactivity in EH is limited to the upper dorsal sympathetic ganglia and that some of the cardiovascular and pulmonary effects that are observed after TS may be associated with the decrease in NA.
Eur J Clin Invest. 1997 Mar;27(3):202-5

Changes in cardiocirculatory autonomic function after thoracoscopic upper dorsal sympathicolysis for essential hyperhidrosis

Thoracoscopic D2-D3 sympathicolysis corrects this hyperfunction and has a partial beta-blocker-like activity, which results in a decrease in heart rate at rest and during maximal exercise, and in the diastolic blood pressure response to the handgrip test. Further studies are needed to assess the long-term consequences of this procedure.
J Auton Nerv Syst. 1996 Sep 12;60(3):115-20

Sympathectomy equated with autonomic neuropathy

"The effect of neuropathy on healing of the medial collateral ligament was studied in rats that
had undergone surgical sympathectomy (autonomic neuropathy) or femoral nerve transaction (sensory neuropathy)40. There
were significant decreases in various neuropeptides, such as substance P, calcitonin gene-related peptide, and vasoactive
intestinal peptide, in the denervated tissues. Impaired healing, demonstrated by significant decreases in failure force of the
healing ligaments, was seen in both groups of rats."

http://www.ejbjs.org/cgi/content/full/90/8/1800

The incidence of postsympathectomy compensatory hyperhidrosis

The incidence of postsympathectomy compensatory hyperhidrosis (PCH) varies with patient's geographic location, working environment, humidity, temperature, and the season when it is surveyed, so that the reported incidence varies greatly from 30 to 85% .

Ming-Chien Kao, MD, DM, Sc^a

^a Division of Neurosurgery, National Taiwan University Hospital, No. 7 Chung-Shan S. Rd, Taipei, Taiwan

Abnormal suntanning following transthoracic endoscopic sympathectomy

Transthoracic endoscopic sympathectomy (TES) has become the method of choice for treating patients with palmar hypcrhidrosis. There are few complications reported with this procedure. A complication not described previously is reported here.

British Journal of Surgery

Volume 83 Issue 12, Page 1782
Accepted: 25 January 1996

Hyperpigmentation after sympathectomy

CLAIRE SAMUEL,* D.R. BIRD ¹ J.L. BURTON ¹

¹ Departments of Dermatology, Royal Infirmary, Bristol BS2 8HW

Clinical and Experimental Dermatology

Copyright 1980 Blackwell Science Ltd

limited sympathectomy does not reduce postoperative compensatory sweating

J Vasc Surg. 2003 Jan;37(1):124-8.

Impaired healing after sympathectomy

"The effect of neuropathy on healing of the medial collateral ligament was studied in rats that
had undergone surgical sympathectomy (autonomic neuropathy) or femoral nerve transaction (sensory neuropathy)40. There were significant decreases in various neuropeptides, such as substance P, calcitonin gene-related peptide, and vasoactive intestinal peptide, in the denervated tissues. Impaired healing, demonstrated by significant decreases in failure force of the healing ligaments, was seen in both groups of rats."

Effect of cervical vagosympathectomy on myocardial catecholamine concentration

Dogs which survived a bilateral cervical vagosympathectomy showed a striking reduction in catecholamine concentration of right atrial tissue. Significant decreases in catecholamine concentration were noted also in the tissues of both ventricles and the interventricular septum. Unilateral cervical vagosympathectomy, either right or left, was not followed by a statistically significant decrease in the concentration of cardiac catecholamines. The cause of the depletion after bilateral cervical vagosympathectomy is not clear. It may be due to destruction of intracardiac adrenergic nerves or a relatively increased utilization of catecholamines, which exceeds the capacity of the cardiac tissues to synthesize, take up, or bind these substances.
Am J Physiol 209: 951-954, 1965;

Bradycardia and Permanent Pacing After Bilateral Thoracoscopic T2-Sympathectomy for Primary Hyperhidrosis

LAI, C.-L., et al.: A 23-year-old woman with craniofacial hyperhidrosis underwent bilateral thoracoscopic T2-sympathectomy. Marked sinus bradycardia with a mean heart rate of 49 beats/min by Holter ECG monitoring occurred after the procedure and persisted for > 2 years. Normal sinus node function was found by an invasive electrophysiological study and unopposed vagotonia after sympathectomy was diagnosed. A permanent pacemaker was implanted. Although reduced heart rate is a common phenomenon after bilateral dorsal sympathectomy, intractable bradycardia with permanent pacing is rare. This patient demonstrates one of the potential cardiac complications of bilateral sympathectomy.

http://www3.interscience.wiley.com/journal/119020027/abstract

orthostatic hypotension secondary to lumbar sympathectomy

Treatment of a 55-year-old woman with Raynaud's phenomenon and orthostatic hypotension secondary to lumbar sympathectomy performed for Raynaud's phenomenon is described.
Kochar MS.
Am J Med. 1983 Sep;75(3):537-40.

Acute cardiogenic shock after lumbar sympathectomy by phenol injection

Bulpa PA, De Wispelaere JF, Dive A, Haufroid V, Installé E.

Department of Intensive Care, Mont-Godinne University Hospital, Université Catholique de Louvain

Intensive Care Med. 2002 Jan;28(1):92-3. Epub 2001 Nov 23.

Sympathectomy causes Syncope

Syncope
Includes vasovagal (simple faint), orthostatic (volume depletion, sympathectomy [either functional or surgical], diabetes, Shy-Drager, ..."

Clinician's Pocket Reference

By Leonard G. Gomella, Steven A. Haist, University of Kentucky College of Medicine

Published by McGraw-Hill Professional, 2003, p.43

ISBN 0071402551, 9780071402552

Chronotropic incompetence is one of the consequences on sympathectomy

Chronotropic incompetence, an attenuated heart rate response to exercise, is a predictor of all-cause mortality in healthy populations. This association may be independent of exercise-induced myocardial perfusion defects.
Impaired Chronotropic Response to Exercise Stress Testing as a Predictor of Mortality
Michael S. Lauer, MD; Gary S. Francis, MD; Peter M. Okin, MD; Fredric J. Pashkow, MD; Claire E. Snader, MS; Thomas H. Marwick, MD
JAMA. 1999;281:524-529.

Chronotropic incompetence was defined as the failure to achieve 85% of the age-predicted maximal HR (APMHR), <80%>chronotropic response index (CRI).
Chronotropic incompetence, an attenuated heart rate (HR) response to exercise, is an independent predictor of cardiovascular mortality, but it is not known whether chronotropic incompetence is related to carotid atherosclerosis. The association between chronotropic incompetence and carotid atherosclerosis in 8567 (age 47.6±8.8 years) healthy men was examined.
http://eurheartj.oxfordjournals.org/cgi/content/abstract/27/8/954

Long-term efficiency of endoscopic thoracic sympathicotomy: survey 10 years after surgery

We detected 8 patients (53%) complaining about a decent to moderate recurrence of hand sweating and compensatory and gustatory sweating were observed in 9 (60%) and 5 (33%) patients, respectively. Reported side effects related to surgery were paresthesias of the upper limb and the thoracic wall in 8 patients (53%) and recurrent pain in the axillary region in 1. At an average 12 years after surgery 47% of patients were satisfied with the treatment results, 40% were disappointed. Six patients (40%) affirmed they would ask for the operation if it were to be redone. Our findings indicate that results of ETS deteriorate and compensatory sweating does not improve with time. It is mandatory to inform patients of the potential long-term adverse effects before surgery.
Interact Cardiovasc Thorac Surg. 2008 Sep 30.

Autonomic paresthesia

Lair L, Gibbons C, Freeman R.

Autonomic and Peripheral Nerve Laboratory, Dept. of Neurology, Beth Israel Deaconess Medical Center, 1 Deaconess Road, Boston, MA 02215, USA.

OBJECTIVE: To describe the biology of phantom sweating, a novel autonomic neuropathy symptom, based on a description of a patient with a small fiber and autonomic neuropathy. METHODS: Clinical and laboratory assessments. RESULTS: Evidence of a generalized small fiber and autonomic neuropathy. INTERPRETATION: Phantom sweating occurs frequently after sympathectomy but has not been reported previously in patients with a somatosensory or autonomic neuropathy. We suggest that this symptom is an autonomic paresthesia.

Clinical Autonomic Research

Volume 18, Number 6 / December, 2008

Cardiac arrest - a major complication of bilateral sympathectomy

Thoracic sympathectomy has usually minimal consequences if unilateral, especially on the right side. For
bilateral procedures, a mean reduction of the heart rate of 12% was reported. Around 50% of patients have bradycardia in the following minutes of abilateral surgery and mean and diastolic blood pressures significantly reduced.
Since the sympathectomy will block the chronotropic response, a significant increase of the ejection volume is observed when the patient moves in the erect position from dorsal decubitus.

We present a case of a patient who suffered from a 43 s asystolic cardiac arrest the night following a second contralateral thoracoscopic T2-T3 sympathectomy for severe axillary and truncal hyperhidrosis. The cardiovascular effects of cervico-dorsal sympathectomy will be reviewed. Evaluation required to prevent such a serious cardiac complication will also be discussed.
Interact Cardiovasc Thorac Surg. 2008 Nov 27.

Abnormal stress responses in patients with diseases affecting the sympathetic nervous system

Patients who lack baroreceptors have exaggerated blood pressure responses to stress. They have episodes of hypertension and hypotension that cause headaches and dizziness.

Patients with diseases of the sympathetic nervous system illustrate that everyday occurrences such as a change in posture or ambient temperature are stresses requiring a marked change in sympathetic nervous activity. Both physical and psychological stresses elicit large initial sympathetic neuronal responses that are subsequently damped by feedback inhibition from structures such as the baroreceptors. Damage to part of these feedback loops leads to exaggerated pressor responses to stress.

Ziegler MG, Ruiz-Ramon P, Shapiro MH.

Psychosom Med. 1993 Jul-Aug;55(4):339-46

abnormality of sympathetic function due to post-sympathectomy denervation

O'Hehir R, Esler M, Jennings G, Leonard P, Little P, Johns J, Panetta F.

The traditional biochemical tests of sympathetic nervous system function used in clinical diagnosis (urine and plasma catecholamine measurements) are indices of "overall" sympathetic nervous activity, and incapable of detecting localised changes in sympathetic tone confined to individual organs. Recently developed radiotracer methods, which enable the pattern of sympathetic nervous dysfunction in disease states to be delineated, were used to detect abnormalities in regional sympathetic nervous system activity in two patients presenting problems in management. In one, the abnormality of sympathetic function was iatrogenic, a post-sympathectomy denervation of the lower regions of the body, associated with incapacitating postural hypotension. In the other, unexplained persistent sinus tachycardia proved to be due to an increase in sympathetic nervous tone restricted to the innervation of the heart. Knowledge of the underlying sympathetic nervous pathophysiology in these patients influenced the choice of drugs subsequently used in their treatment.

Two patients with abnormalities of regional sympathetic nervous tone

Aust N Z J Med. 1984 Dec;14(6):855-9

The autonomic nervous system and cardiac arrhythmias

Disturbed autonomic nervous 'balance' of the sympathetic nervous and vagal outflows to the heart potentiates the experimental development of ventricular arrhythmias in laboratory animals. For some time the best evidence for the occurrence of a similar phenomenon in humans was provided by the long QT interval syndrome, sufferers of which are very prone to develop serious ventricular arrhythmias and in whom evidence exists of abnormal anatomy and function of the cardiac sympathetic nerves. Recently the case for disturbed autonomic function causing clinical arrhythmias has become more broadly based. Reduced baroreflex sensitivity after myocardial infarction, and low heart rate variability, both of which rest largely on vagal underactivity, have been shown to be associated with substantially increased risk of subsequent sudden death.
Esler M.
Baker Medical Research Institute, Prahran, Australia.
Clin Auton Res. 1992 Apr;2(2):133-5.

No sensation of 'thrill' on the sympathtectomized side of the body

Sweet has reported the case of a very intelligent patient, the dean of a graduate school, who after a unilateral sympathectomy to treat his upper limb hyperhydrosis, found that his previous and customary sensation of shivering while listening to a stirring passage of music
occurred in only one side and he could not be thrilled in the sympathectomized half of his body. These cases were interesting because emotions are usually experienced in a rather diffuse 
and bilateral fashion unless innervation has been specifically interrupted. 

Physical Control of the Mind: Toward a Psychocivilized Society
By José Manuel Rodríguez Delgado
Published by Harper & Row, 1969
p. 133-134

Central nervous system activation following peripheral chemical sympathectomy

Callahan TA, Moynihan JA, Piekut DT.

Brain Behav Immun. 1998 Sep;12(3):230-41.

Many studies have demonstrated that ablation of the sympathetic nervous system (SNS) alters subsequent immune responses. Researchers have presumed that the altered immune responses are predominantly the result of the peripheral phenomenon of denervation. We, however, hypothesized that chemicalsympathectomy will signal and activate the central nervous system (CNS).

Activation of the CNS was determined by immunocytochemical visualization of Fos protein in brains from male C57BL/6 mice at 8, 24, and 48 h following denervation. A dramatic induction of Fos protein was found in the paraventricular nucleus (PVN) of the hypothalamus and other specific brain regions at 8 and 24 h compared to vehicle control mice. Dual-antigen labeling demonstrates that corticotrophin releasing factor (CRF)-containing neurons in the PVN are activated by chemical sympathectomy; however, neurons containing neurotransmitters which may modulate CRF neurons, such as vasopressin, tyrosine hydroxylase, and adrenocorticotropin, do not coexpress Fos. Our findings suggest an involvement of the CNS in sympathectomy-induced alterations of immunity.

norepinephrine could not be synthesized and/or accumulated in the heart following bilateral cervical sympathectomy

After bilateral cervical sympathectomy, the norepinephrine content show a rapid decrease from 4 days to 7 days and a slow decrease within the following 14 days. No tendency of recovery was apparent in the heart for 50 days following the operation, the norepinephrine content remaining almost at an equal level.
It was postulated that norepinephrine could not be synthesized and/or accumulated in the heart following bilateral cervical sympathectomy, but that cardiac muscle might synthesize dopamine for itself.

Japanese circulation journal

Vol.29, No.1(19650120) pp. 11-15

KIMATA SHIN-ICHI ¹

¹The Third Department of Internal Medicine, Faculty of Medicine, University of Tokyo

sympathetic denervation with minor arrhythmias

Based on the above findings, we suggest myocardial sympathetic denervation with lowered initial H/M (heart-to-mediastinum count ratios) will develop following surgical sympathectomy at upper cervical ganglia, which will accompanied by compensated uptake-1 system on presynaptic nerve endings of postganglionic neuronal cells, demonstrated by lowered MWO, and preserved homodynamic function and ECG changes except for minor arrhythmias.

Hemodynamic and ECG changes associated with deteriorations in 123I-MIBG adrenergic myocardial imaging following surgical sympathectomy in SD rats

Cheng-Yi Cheng¹, Nien-Hsien Liou², Chieh-Ling Kao², An-Sui Yang³, Lei-Hang Shen³, Ging-Cheng Perng¹ and Wen-Sheng Huang¹

¹ Department of Nuclear Medicine, Tri-Service General Hospital and National Defense Medical Center, Taipei, Taiwan; ; ² Institute of Biology and Anatomy, National Defense Medical Center, Taipei, Taiwan; ; ³ Institute of Nuclear Energy Research, Taipei, Taiwan

http://jnumedmtg.snmjournals.org/cgi/content/meeting_abstract/48/MeetingAbstracts_2/226P-b

sympathectomy on muscle fibre composition

We have previously reported functional and histological studies in five beagle dogs with unilateral lumbar sympathectomy. Three months later, fatiguability in the gracilis muscles was increased on the denervated sides, and this was associated with an increase in the relative distribution of FT fibres. Biochemical studies now show that these changes were associated with an increase in cytosolic protein without change in DNA content; this is consistent with an increase in cell size. There was a reduction in the proportion of slow myosin light chain isoforms from 50 ± 7 to 34 ± 6%. Noradrenaline levels were increased on the denervated sides but this may reflect greater vascularity. Calcium content did not correlate with fibre type but there was a positive relation with both noradrenaline content (r= 0·73; P<0 class="i">r= 0·84; P<0 span=""> It is concluded that sympathectomy induces several biochemical changes in skeletal muscle which constitute a change and increase in fast myosin light chain synthesis and a corresponding fibre type transformation.

Correspondence to ¹ Department of Clinical Physiology, Karolinska Hospital, S-104 01 Stockholm, SwedenReceived 24 August 1987; accepted 26 October 1987
http://www3.interscience.wiley.com/journal/119466197/abstract

irreversible deterioration in cardiac function

The concept of posterior nerve root section was resurrected 10 years later, when Danielopolu (Director of the Second Medical Clinic at the University of Bucharest) criticized the Jonnesco-type sympathectomy on the grounds that it produced an irreversible deterioration in cardiac function. He therefore directed his surgical colleague, Hristide, to cut the posterior roots of the upper thoracic spinal nerves which divided only sensory fibres.
Danielopolou later declared cervicothoracic sympathectomy to be disastrous, from the therapeutic point of view, and concluded that removal of the stellate ganglion for angina was incompatible with life.

Landmarks in Cardiac Surgery

By Stephen Westaby, Cecil Bosher
Published by Informa Health Care, 1997

Phenol application Asynchronous wall motion Impaired nerve conduction Contraction disparity

EFFECT OF LOCAL CARDIAC SYMPATHECTOMY ON REGIONAL MYOCARDIAL CONTRACTION

KOMATSU EIICHI YAMAGUCHI ICHIRO MIYAZAWA KOZUI

These observations indicated that the abnormal pressure-length loop was derived from the delayed contraction in the phenol treated region.
Japanese circulation journal

Vol.52, No.7(19880720) pp. 617-623

Sympathectomy induces novel purinergic sensitivity

Twenty eight percent of the spontaneously active afferent fibres from sciatic nerves in the sympathectomyzed rats responded to ATP, either with an increase or with a decrease in spontaneous firing. However, none of the fibres from the sciatic nerves in the intact rats was activated by ATP.

Sympathectomy induces novel purinergic sensitivity in A afferents from sciatic nerve.
It is thought that this novel purinergic sensitivity may contribute to neuropathic paraesthesia and pain.
CHEN YONG, ZHANG YI-HONG, BIE BI-HUA, ZHAO ZHI-QI
Shanghai Institute of Physiology, Chinese Academy of Sciences
Acta Pharmacol Sin, 2000 Nov; 21 (11):1002-1004

Pulmonary function abnormalities following upper dorsal sympathectomy for hyperhidrosis

Spirometry 3 months after surgery showed a significant decrease in the forced vital capacity (−5.2%), the forced expiratory volume in the first second (−6.1%), and the forced expiratory flow between 25% and 75% of vital capacity (−5.1%). Whereas methacholine challenge testing before surgery was positive in 3 subjects (2 of whom were asthmatic), it was positive in 6 patients after the procedure; differences were not statistically significant. After 12 months, forced vital capacity started recovering, and forced expiratory volume in the first second and forced expiratory flow rate 25% to 75% showed a sustained and significant reduction (−2.8% and −11.2%, respectively.

The Journal of Thoracic and Cardiovascular Surgery , Volume 129 , Issue 6 , Pages 1379 - 1382

M . Ponce González , G . Julià Serdà , N . Santana Rodríguez , P . Rodríguez Suárez , G . Pérez Peñate , J . Freixinet Gilart , P . Cabrera Navarro

Sympathectomy on the Cardiac Neurovegetative Equilibrium

Since the first attempts of T. Jonnesco’ to treat angina pectoris by
means of cervico-thoracic sympathectomy, many surgeons have applied
similar techniques with satisfactory results in the majority of instances.2
Nearly without exception, the operations were performed with the de-
clared purpose to sever sensory, pain-conveying, afferent nervous path-
ways, and without realization of the fact that (except in the case of
exclusive section of the posterior roots), the norepinephrine-discharging,
pain-producing efferent sympathetic fibers3 were, likewise, interrupted.
In animal experiments, it has been shown that electrical stimulation
of the cardiac sympathetic nerves is followed by an accumulation of
catecholamines,4.s especially of norepinephrine,’ in the myocardium,
whereas the cardiac catecholamine stores are largely depleted by sym- 
pathectomy.7” 

The prolongation of the isometric (tension) period (TP) of the left ventricle which
occurred in the majority (72 per cent) of all cases after unilateral or bilateral trans-
thoracic sympathectomy (without or with unilateral or bilateral transthoracic splanch-
nicotomy) indicates a diminution of inotropic cardiac action. It can be assumed to
correspond to the cholinergic (vagal) preponderance which results from a partial or
complete sympathetic denervation of the heart. Reduction of the pulse pressure oc-
curred in 56 per cent of the cases, probably due to the same mechanism. The be-
havior of the heart rate was too irregular to permit any conclusions. Apparently, the
Inotropic mechanisms of the heart are more sensitive to sympathetic denervation than
the chronotropic ones. 

The seemingly paradoxical shortening of TP which was persistently maintained,
e.g., in the case of patient 16 over a period of more than five months, is possibly to
be explained as a manifestation of Cannon’s “law of denervation” according to which
the catecholamine sensitivity of sympathetically denervated structures Is greatly aug-
mented, and which has more recently been confirmed also in instances of functional
sympathetic “denervation” (catecholamine deprivation of cardiovascular tissues)
through gangllomc blockade” or rauwolfia drugs.’6 This would mean in the present
cases that their partly or wholly sympathectomized hearts had become oversensitive to
whatever active catecholamines (norepinephrine, eplnephrine) may have reached them
either from remaining sympathetic fibres or through the blood stream. Individual
differences in relative reactivity to two mutually antagonistic factors ([a] absolute
loss of catecholammes, and Eb] exaggerated catecholamine sensitivity, caused by [a 1),
combined with the individual magnitude of absolute cardiac cholinergic activity, may
account for the prevalence of either negative or positive Inotropic cardiac reactions
to sympathectomy.

DOI 10.1378/chest.38.4.423
1960;38;423-428 Chest

W. RAAB, E. KUX and H. MARCHET

Baroreflex Control of Heart Rate during Cardiac Sympathectomy

The results suggest that cardiac sympathectomy induced by epidural anesthesia can suppress partially baroreceptor function by interrupting sympathetic efferent fibers innervating the heart during high levels of epidural anesthesia, but that lumbar sympathectomy during epidural anesthesia is unlikely to affect baroreceptor activity.
Anesth Analg 1983; 62:815-820
http://www.anesthesia-analgesia.org/cgi/content/abstract/62/9/815

Ventricular Ectopic Rhythms and Ventricular Fibrillation Following Cardiac Sympathectomy

A. Sidney Harris, Antonio Estandia and Rex F. Tillotson
From the Department of Physiology, Baylor University College of Medicine, Huston, Texas
Am J Physiol 165: 505-512, 1951;

Chemical sympathectomy-induced changes in TH-, VIP-, and CGRP-immunoreactive fibers

Journal of Cellular Physiology

Volume 194 Issue 3, Pages 341 - 348

Published Online: 10 Jan 2003

http://www3.interscience.wiley.com/journal/102523100/abstract

Heat loss due to sympathectomy-induced vasodilation

Hypothermia (a decrease in core temperature) is common in patients undergoing surgery with epidural anesthesia an is thought to result from heat loss to the cold environment due to sympathectomy-induced vasodilation.
Sympathectomy-induced vasodilation produced central hypothermia via net convection of the heat from the warmer central to cooler peripheral tissues. The net effect is an increase in peripheral tissue temperature at the expense of decreased central temperature.

Neural Blockade in Clinical Anesthesia and Management of Pain

By Michael J. Cousins, Phillip O. Bridenbaugh

Contributor Michael J. Cousins

Published by Lippincott Williams & Wilkins, 1997

p. 277

Hyperpigmentation after sympathectomy

Clin Exp Dermatol. 1980 Sep;5(3):349-50.
Samuel C, Bird DR, Burton JL.

Disabling Orthostatic Hypotension Caused by Sympathectomies for Hyperhidrosis

Syncope Cases

Published Online: 16 Nov 2007

Editor(s): Roberto Garc�a-Civera, Gonzalo Bar�n-Esquivias, Jean-Jacques Blanc, Michele Brignole, Angel Moya i Mitjans, Ricardo Ruiz-Granell, Wouter Wieling

Print ISBN: 9781405151092 Online ISBN: 9780470995013

Copyright © 2006 by Blackwell Publishing

http://www3.interscience.wiley.com/cgi-bin/summary/116842153/SUMMARY

A mismatch between intravascular volume and the required cardiac output on standing up is the most common cause of orthostatic hypotension. In a small minority of cases, however, orthostatic hypotension is not caused by volume depletion, but by impairment of the autonomic reflexes required to maintain blood pressure in the upright position. This disorder is known as autonomic failure.

In patients with autonomic failure, orthostatic hypotension is caused by an impaired capacity of sympathetic nerves to increase vascular resistance. Downward pooling of venous blood and a consequent reduction in stroke volume and cardiac output lead to the orthostatic fall in arterial pressure.

Adrenal Insufficiency after sympathectomy

A Study of Adrenal Insufficiency After Treatment of Hypertension by Bilateral Sympathectomy Plus Unilateral Adrenalectomy

Chapter Author: P. Etienne-Martin

http://www3.interscience.wiley.com/cgi-bin/summary/119228241/SUMMARY

Copyright © 1954 Ciba Foundation

Structural changes of arteries after sympathectomy

The findings indicate that in renal hypertensive rats structural changes of both large arteries and veins may develop in the absence of an intact sympathoadrenergic system.

Effect of sympathectomy on arterial and venous changes in renal hypertensive rats

G. Simon
Am J Physiol Heart Circ Physiol 241: H449-H454, 1981;

The place of sympathectomy in the treatment of young married women

J Obstet Gynaecol Br Emp. 1954 Dec;61(6):797-803.

Related Articles, Links

GRANT TP.

The obstetrical future of woman having undergoing lumbodorsal sympathectomy for hypertension

Presse Med. 1953 Feb 21;61(12):227-9.
MILLIEZ P, FRITEL D.

PET Imaging of Oxidative Metabolism Abnormalities in Sympathetically Denervated Myocardium

The average percentage of the left ventricle denervated in the group I animals was 13.1% ±7.3%.
Significant reductions in oxidative metabolism were observed in the sympathectomized tissue both at 2 and 8 wk after surgery (22% and 15% reductions, respectively).

Gary D. Hutchins, Timothy Chen, Kathy A. Carlson, Richard L. Fain, Wendy Winkle, Triad Vavrek, Bruce H. Mock
and Douglas P. Zipes
J NucÃ-Med 1999; 40:846-853

hypersensitization of adenoreceptors in the sympathectomized area

Radiofrequency neurolysis (RFN) is becoming a popular method of sympathectomy among pain specialists. The advantages of RFN over chemical and surgical sympathectomy are decrease incidence of neuritis, avoidance of tinitus, blindness and urethral stricture that can occur with chemical sympathectomy, amelioration of anesthetic and surgical risks and early ambulation of the patient. The reasons for the failure of sympathectomy are incomplete sympathectomy, extensive interconnection of chains of sympathectomy ganglia cause rerouting of sympathetic impulse after removal of short chain of ganglia, and hypersensitization of adenoreceptors in the sympathectomized area.

Meraj Siddiqui, Shazia Siddiqui, J. Sue Ranasinghe & Fred Furgang: Complex Regional Pain Syndrome: A Clinical Review: Pain, Symptom Control and Palliative Care. 2001; Volume 2, Number 1.

http://ispub.com/IJPSP/2/1/8541

cardiovascular adjustment to exercise and sympathectomy

Mean arterial pressure and total peripheral resistance were significantly reduced at rest and during steady state of exercise as compared to controls prior to sympathectomy identical vO₂, whereas CO remained unchanged.

The significant fall in left circumflex coronary flow was proportional to the decline in external heart work due to sympathectomy both at rest and under exercise.

http://www.springerlink.com/content/k2n6j4555g16x773/

Coronary blood flow reduced by 50% after sympathectomy

However, at each level of exercise, mean coronary flow in sympathectomized ventricles was reduced by about 50% compared to control values. The slopes of coronary flow on pressure-rate product and tension-time index were also reduced. No difference in left ventricular oxygen extraction between control and sympathectomized hearts were observed. Thus, chronic ventricular sympathectomy altered the relationships between coronary flow and oxygen consumption, on the one hand, and ventricular oxygen-dependent performance and whole-body exercise level, on the other hand.
Med Sci Sports Exerc. 1988 Apr;20(2):126-35.
http://www.ncbi.nlm.nih.gov/pubmed/3367747

Sympathectomy impaired the PTH response to hypocalcaemia

Clinical Physiology and Functional Imaging

Volume 10 Issue 1, Pages 37 - 53
Published Online: 28 Jun 2008

surgical sympathectomy is known to induce resorption within mandibular and auditory bulla bone

Bone destruction causes hearing loss in various middle ear disorders. The mechanisms of such pathological remodeling are unknown.
Unilateral surgical sympathectomy is known to induce resorption within mandibular and auditory bulla bone. Explanation of the cause of this effect, however, may be confounded by hemodynamic changes induced by hemicranial sympathectomy and by uncertainty as to the neuroanatomical origins of sympathetic fibers.
Ann Otol Rhinol Laryngol. 1999 Nov;108(11 Pt 1):1078-87.
http://www.ncbi.nlm.nih.gov/pubmed/10579236