Cardiovascular collapse developing during thoracoscopic thoracic sympathectomy

Cardiovascular collapse developing during thoracoscopic thoracic sympathectomy in a patient with essential palmar hyperhidrosis: A case report.  
Park SJ, Jee DL.

Department of Anesthesiology and Pain Medicine, College of Medicine, Yeungnam University, Daegu, Korea. djee@medical.yeungnam.ac.kr

Thoracoscopic thoracic sympathectomy (TTS) is usually a safe and uncomplicated procedure for treating essential palmar hyperhidrosis. However, we report a case of cardiovascular collapse that developed in a healthy patient undergoing TTS. The surgeon performed the left sympathectomy without incident. However, scarcely had an incision been made in the skin of the right chest when the patient developed sinus bradycardia and sudden, severe hypotension. Pulseless ventricular tachycardia occurred immediately thereafter, which rapidly progressed to ventricular fibrillation and cardiovascular collapse. The patient required resuscitation with 200 J of direct current shock defibrillation along with an intravenous injection of epinephrine 1 mg. She recovered without sequelae. We believe the Bezold-Jarisch reflex was triggered by pooling of venous blood and surgical stimuli, and the patient developed cardiovascular collapse as a result.

In 70 % compensatory sweating severe, recurrence rates were 15% and 19% at 1 and 2 years after surgery

In T2 and T3 resection, all patients experienced Compensatory Sweating and over 70% of the patients felt it was severe. Even in T2 resection, 90% of patients experienced CS and in 50% of these it was severe. High rates of CS are reported in Asian countries with hot and humid climates.

In T2 resection, recurrence rates were 15% and 19% at 1 and 2 years after surgery.It was not rare for a patient to experience recurrence more than 3 years after surgery.
Motoki Yano, MD, PhD and Yoshitaka Fujii, MD, PhD

Volume 138, Issue 1, Pages 40-45 (July 2005)

a strong association of autonomic dysfunction and impaired cerebral autoregulation

Furthermore, we found a strong association of autonomic dysfunction and impaired autoregulation indicated by a correlation between the LF/HF ratio and Sx (p <>Drug and Alcohol Dependence
Volume 110, Issue 3, 1 August 2010, Pages 240-246

Conditions arising after Sympathectomy

After stellate ganglion blockade: HORNER'S SYNDROME

• Drooping eyelid
• Constricted pupil (impaired vision in low light)
• Absent/reduced sweating one side of the face and head
• Redness of eyes
• Facial flushing
  

After regional sympathectomy: DUMPING SYNDROME:

• Rapid emptying of the stomach: lower end of small intestine fills too quickly
• Early dumping: nausea/vomiting/bloating/diarrhoea/shortness of breath
• Late dumping: 1-3 hours after eating: weakness/sweating/dizziness
• Both types may co-exist.

http://www.theaword.org/index.php?option=com_content&view=article&id=223:conditions-arising-after-sympathectomy&catid=84:the-sympathetic-nervous-system&Itemid=41

Sympathectomy is one of the causes or Orthostatic Hypotension

Causes of Orthostatic Hypotension

Peripheral

Amyloidosis

Diabetic, alcoholic, or nutritional neuropathy

Familial dysautonomia (Riley-Day syndrome)

Guillain-Barré syndrome

Paraneoplastic syndromes

Pure autonomic failure (formerly called idiopathic orthostatic hypotension)

Surgical sympathectomy

http://www.merckmanuals.com/professional/sec07/ch069/ch069d.html

Bilateral sympathectomy produced fatal heart block in a few of their experiments

Mendlowitz. Schauer, and Gross⁴ pointed out that the heart rate became slower after removal of the sympathetic chain, but this bradycardia was only temporary. Bilateral sympathectomy produced fatal heart block in a few of their experiments.

American Heart Journal
Volume 22, Issue 4, October 1941, Pages 545-548

bradycardia and other cardiac complications common side effects?

The most common side effects of sympathectomy are compensatory sweating, gustatory sweating and cardiac changes including decreasing heart rate, systolic-diastolic and mean arterial pressure. The mechanism of bradycardia and other cardiac complications that develop after thoracic sympathectomy are still unclear. (2009)

http://tipbilimleri.turkiyeklinikleri.com/abstract_54802.html

"It is a lie that sympatholysis may specifically cure patients

with unqulified "reflex sympathetic dystrophy". This was already stated by the father of sympathectomy, Rene Leriche, more than half a century ago.
...it is not an error, but a lie. While conceptual errors are not only forgivable, but natural to inexact medical science, lies, particularly when entrepreneurially inspired are condemnable and call for a peer intervention.

J. Neurology (1999) 246: 875-879

unavoidable side effects and unforeseeable and unacceptable complications

Most of the difficulties associated with hyperhidrosis surgery are due to unavoidable side effects and unforeseeable and unacceptable complications. Careful patient selection is important before surgery so surgeons can avoid some of these pitfalls. Patients should also be fully informed of all potential side effects and complications before surgical

treatment.http://www.ncbi.nlm.nih.gov/pubmed/18557592

impairment of autoregulation after unilateral cervical sympathectomy

Although these findings argued against a neurogenic mechanism, James at al. (1969) reported impairment impairment of autoregulation after unilateral cervical sympathectomy in the babbon. Gotoh et al. (1971/1972) observed impairment of autoregulation in patients with the Shy-Drager syndrome.
It was concluded that the autonomic nervous system plays an important role in the mechanism of autoregulation of CBF and that his mechanism is independent of the chemical control of the cerebral vessels. This was confirmed by direct observation of the pial vessels in cats, where separate sites of action in the vascular tree for autoregulation and chemical control were demonstrated; the autoregulatory reaction was located in pial arteries with a diameter larger than 50 μ, and the reaction to carbon dioxide in pial arteries of smaller diameter (Gotoh et al. 1975).
They concluded that the arteries operating in autoregualtin were the larger ones with the dense innervation, while the smaller arteries with sparse innervation were involved in chemical control.
Coronna and Plum (1973) demonstrated the absence of CBF autoregulation in a patient with a Shy-Drager syndrome who had a postganglionic denervation....

Gotoh et al (1979) subsequently showed that autoregulation in patients with this syndrome was impaired irrespective of the localization of the damage to the cervical sympathetic nervous system (preganglionic, central, postganglionic) as judged by the eye instillation test.
Handbook of Clinical Neurology,

Vascular Diseases, Part I by P. J. Vinken, G. W. Bruyn, H. L. Klawans, and J. F. Toole

, Volume 53, Part 1

Elsevier Health Sciences, 1988

The practice of surgical and chemical sympathectomy is based on poor quality evidence, uncontrolled studies and personal experience

Cochrane Database Syst. Review
”The practice of surgical and chemical sympathectomy is based on poor quality evidence, uncontrolled studies and personal experience.“
Cochrane Database Syst Rev. 2003;(2):CD002918.

Side effects were common

UK Review of ETS surgery
We did not identify any controlled trials or cohort studies. The evidence about effectiveness, based on three case series, was therefore very limited. The main weakness of these studies was their lack of a comparison group and their resulting inability to exclude a placebo response to surgery. In addition, the methods of assessing outcome were poorly described and not validated, and the range of outcomes assessed was limited. The studies provided very limited evidence that sympathectomy improves blushing. Side effects were common.
London: Bazian Ltd (Editors), Wessex Institute for Health Research and Development, University of Southampton 2003: 11

"Lifestyle" surgical procedure carries unrecognized risk of complications.”

Wiley & Sons, Inc, news release - 2004

"Lifestyle" surgical procedure carries unrecognized risk of complications.”
Hoboken, NJ: John Wiley & Sons, Inc, British Journal of Surgery, Feb 5, 2004
Posted by Mia at 2/08/2011

The intervention leads to severe immediate complications in some of the patients

Finnish Review
Conclusions: The evidence of the effectiveness of ETS is weak due to a lack of randomized trials. The intervention leads to severe immediate complications in some of the patients, and to persistent side-effects for many of the patients.
UniversityofOuluand FinnishOfficeforHealthTechnologyAssessment
FinnishOfficeforHealthTechnologyAssessment
UniversityofHelsinki and FinnishOfficeforHealthTechnologyAssessment
UniversityofCopenhagenand FinnishOfficeforHealthTechnologyAssessment

poor evidence is available about ETS as regards side effects, risks, and short-term effects

Swedish Review
The findings by SBU Alert show that poor* evidence is available about ETS as regards side effects, risks, and short-term effects. There is no* scientific evidence demonstrating the long-term results of the method or its cost effectiveness in relation to other methods.
(Swedish Council on Technology Assessment in Health Care (SBU), the Medical Products Agency, the National Board of Health and Welfare, and the Federation of Swedish County Councils.
Published: 1999-08-30 Revised: 2002-09-30

Reported success stories on ETS are "prone to bias and have significant methodological problems"

Australian Review of ETS surgery - 2001
The four case series were not critically appraised because they are prone to bias and have significant methodological problems. These studies represent level IV evidence according to the NHMRC criteria and one should not draw firm conclusions from their findings.

To date, the benefits or side effects associated with endoscopic thoracic sympathectomy for treating facial blushing have not been properly evaluated and reported.

Further research using a well-designed controlled trial is warranted to assess the efficacy of endoscopic thoracic sympathectomy for treating facial blushing.

Centre for Clinical Effectiveness - Monash

There is potentially a number of safety issues associated with this procedure

Australian Review of ETS surgery
"A lack of high quality randomised trial evidence on ETS means that it is difficult to make a judgment on the safety and effectiveness of this technique. There is potentially a number of safety issues associated with this procedure. ASERNIP-s suggests that a full systematic review including all available comparative and case series information, together with clinical inpuut, should be undertaken to provide up-to-date and comprehensive assessment of the safety and effectiveness of ETS." (ASERNIP-s Report No. 71, August 2009)

After thoracoscopic sympathectomy for hyperhidrosis, very severe discomfort and hyperhidrosis in the neighboring non-sympathectomized regions occurred

Cousins and Bridenbaugh's Neural Blockade in Clinical Anesthesia and Pain Medicine by Michael J Cousins, Phillip O Bridenbaugh, Daniel B Carr, and Terese T Horlocker
Wolters Kluwer Health
Edition: 4 - 2008

Lack of disclosure to ETS patients is unethical and would be criminal in a just society

It is the doctor's moral and ethical duty to provide you with full and honest disclosure of the facts prior to surgery. The whole doctrine of informed consent is to prevent patients from having to realize they made a mistake in hindsight. You shouldn't have had to find out from a former patient's wife that the surgery would cause drenching sweating on your back. It was Garza's job to do that. He completely lied to you regarding the supposed reversibility. Anyone who goes through medical school knows that can't crush a nerve with a metal clamp, remove it later and have the nerve return to normal functioning.

Although it is not possible to predict exactly what will occur in each individual case, there is nearly 100 years of published scientific and medical research available on the effects of sympathectomy. That research paints a very different picture of the effects of this surgery than the one presented to patients considering this surgery. That's the issue. Generally, they lie and tell patients that CS is inconsequential in all but a tiny fraction of cases and simply fail to disclose a huge number of verified adverse effects of the surgery. They take advantage of the patient's ignorance on medical matter. It's unethical and would be criminal in a just society.

In short, you do have a way of knowing what will likely occur as a result of the surgery before you have it done. All the information necessary to make an informed decision exists. It's just not getting to patients.

http://etsandreversals.yuku.com/reply/22927/Would-you-do-it-again#reply-22927

Surgical sympathectomy listed as neurologic disorder

Other neurologic disorders
- Idiopathic orthostatic hypotension
- Multiple sclerosis
- Parkinsonism
- Posterior fossa tumor
- Shy-Drager syndrome
- Spinal cord injury with paraplegia
- Surgical sympathectomy
- Syringomyelia
- Syringobulbia
- Tabes dorsales (syphillis)
- Wernicke's encephalopathy
Dizziness: Classification and Pathophysiology
The Journal of Manual and Manipulative Therapy, Vol. 12, No 4 (2004)