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)

collateral effects of thoracic sympathectomy not disclosed to patients

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].

Eur J Cardiothorac Surg 2001;20:1095-1100

collateral events that may not be beneficial - reinnervation errors

Axonal regeneration and organ reinnervation are the necessary steps for functional recovery after a nerve lesion. However, these processes are frequently accompanied by collateral events that may not be beneficial, such as: (1) Uncontrolled branching of growing axons at the lesion site. (2) Misdirection of axons and target organ reinnervation errors, (3) Enhancement of excitability of the parent neuron, and (4) Compensatory activity in non-damaged nerves. Each one of those possible problems or a combination of them can be the underlying pathophysiological mechanism for some clinical conditions seen as a consequence of a nerve lesion. Reinnervation-related motor disorders are more likely to occur with lesions affecting nerves which innervate muscles with antagonistic functions, such as the facial, the laryngeal and the ulnar nerves. Motor disorders are better demonstrated than sensory disturbances, which might follow similar patterns. In some instances, the available examination methods give only scarce evidence for the positive diagnosis of reinnervation-related disorders in humans and the diagnosis of such condition can only be based on clinical observation. Whatever the lesion, though, the restitution of complex functions such as fine motor control and sensory discrimination would require not only a successful regeneration process but also a central nervous system reorganization in order to integrate the newly formed peripheral nerve structure into the prepared motor programs and sensory patterns.
Clinical Neurophysiology
Volume 122, Issue 2, February 2011, Pages 219-228

without any increase of nutritional blood flow

Techniques with effect on the sympathetic nerve system, sympathetic block or sympathectomy increase blood flow, mainly due to opening of arteriovenous shunts and without any increase of nutritional blood flow. However, some patients may benefit in terms of reduced pain.
Little evidence exists but a review from 1985 concluded that sympathectomy could be beneficial in patients with rest pain and pregangrene. It is, however, most unlikely that diabetic patients can respond as they usually have a reduced sympathetic tone in the ischemic leg.
Cardiovascular and Interventional Radiological Society of Europe / 2007
Clinical Practice in Interventional Radiology, Volume I,

82.9% Were Disturbed Because CS Was More Than Expected

Endoscopic thoracic sympathectomy (ETS) for palmar hyperhidrosis was performed using a 3-mm small endoscope at our hospital, and we conducted a questionnaire for the purpose of studying the conditions and satisfaction after surgery. The subjects were comprised of 50 patients, of which 35 patients (75%) answered the survey. The average age of the respondents was 27 years old (range: 12?62 years old) including 13 males and 22 females and the average postoperative observation period was 33 months (1?114 months). The results showed the good effects of surgery in all of the patients for palmar sweating while patient satisfaction was 79.4 points, which concluded that ETS was sufficiently accepted as treatment for palmar hyperhidrosis. However, compensatory sweating (CS) developed in 97.1% of the patients, and 82.9% answered that they were disturbed because it was more than they had expected. This result makes us realize further the importance of preoperative informed consent for CS. The problem of palmar hyperhidrosis is very serious for patients, and hence it is important to give treatment with a thorough understanding of the effectiveness and problems of ETS for palmar hyperhidrosis according to the analytical results of this questionnaire.

http://ci.nii.ac.jp/naid/110006980508/en

Sympathectomy limits blood flow to a vital organ like the brain

However, sympathetic blockade at the level of the neck eliminated the beta-1 blockade induced attenuation in delta MCA V(mean) (10.2 2.5 cm s(-1)). These results indicate that a reduced ability to increase CO during exercise limits blood flow to a vital organ like the brain and that this flow limitation is likely to be by way of the sympathetic nervous system.

PMID: 10971220 [PubMed - indexed for MEDLINE]
1. Acta Physiol Scand. 2000 Sep;170(1):33-8.

GAP-43 mRNA and calcitonin gene-related peptide mRNA expression in sensory neurons are increased following sympathectomy

Sympathectomy has been shown to result in an increased density of fibers immunoreactive for sensory peptides in peripheral targets innervated by both sensory and sympathetic neurons, providing evidence for functional interactions between sympathetic and sensory systems. These findings provided the background for examining the hypothesis that axonal outgrowth is induced from sensory neurons following sympathectomy. We examined the expression of GAP-43 mRNA, a specific marker for axonal outgrowth, in cervical (C3, C7, C8) and thoracic (T1, T2) dorsal root ganglia (DRG) of the rat following bilateral removal of the superior cervical ganglion, to assess whether the described increases in peptidergic afferent fibers reflected axonal outgrowth. In situ hybridization was used with ³⁵S labeled riboprobes complementary to GAP-43 mRNA, and to calcitonin gene-related peptide (CGRP) mRNA, a marker for a major subset of thin-fiber sensory neurons. The density of GAP-43 mRNA nearly doubled by 18 h following sympathectomy and reached a threefold increase by 3 days. By 45 days following surgery, the GAP-43 mRNA level was still nearly twice that of normal animals. CGRP immunoreactivity was also examined: the density of fibers in the iris and cornea of sympathectomized animals was considerably greater from two weeks to 45 days following surgery, than in sham-operated controls. Concomitantly, there was a slight but significant increase in CGRP mRNA expression in T1 and C3 DRG 14 days post

http://www.refdoc.fr/Detailnotice?idarticle=15110598

anatomic variations of the T2 nerve root

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.

Journal of thoracic and cardiovascular surgery Y. 2002, vol. 123, No. 3, pages 498-501 [bibl. : 14 ref.

http://www.refdoc.fr/Detailnotice?idarticle=9466218

immune privilege is lost in the absence of a functional sympathetic innervation of the eye

Mounting evidence points to a role for the sympathetic nervous system in suppressing inflammation. This role might be of specific relevance for immune privilege in the eye, where, sporadically, patients with denervated sympathetic fibers develop chronic inflammation. The present study used mice to investigate whether the robust innervation of intraocular structures by the sympathetic system plays a role in maintaining ocular immune privilege. We first performed surgical removal of the superior cervical ganglion, which supplies sympathetic fibers to the eye, and studied the immune response generated against soluble antigens or allogencic tumor cells injected into the ocular anterior chamber under these conditions. Our results show that in the absence of functional sympathetic fibers, the eye loses its ability to prevent either the immune rejection of intraocular allogeneic tumor cells or the suppression of delayed type hypersensitivity responses against soluble antigens injected in the anterior chamber. This loss of immune privilege is accompanied by a decrease in the concentration of transforming growth factor-β in the aqueous humor. These results suggest that immune privilege is lost in the absence of a functional sympathetic innervation of the eye, allowing intraocular immune responses to become exaggerated. We conclude that ocular sympathetic nerves are critical for the generation and maintenance of immune privilege in the eye through the facilitation of local transforming growth factor-β production.
http://cat.inist.fr/?aModele=afficheN&cpsidt=21889071

Results of life-style surgery:

The rate of compensatory sweating in group 2 (72.7%) was significantly lower than in group 1 (95.4%) (P<0.039). The chance of embarrassing and disabling compensatory sweating was lower in group 2 than in group 1; 76.5% (embarrassing in 8 patients, disabling in 9) in group 1, and 36.4% (embarrassing in 7 patients, disabling in 1) in group 2 which was statistically significant (P<0.006).

http://www.ejcts.ch/cgi/content/full/26/2/396

Sympathectomy is used to treat various conditions, including Raynaud's. But is it effective?

"Recurrent and enhanced vasoconstrictor function 3 months following endoscopic sympathetic block has major implications for its use to treat enhanced vasoconstriction."

http://www.ncbi.nlm.nih.gov/pubmed/12796529

bilateral ETS causes the suppression of cardiovascular response to exercise

HR and BP at rest and cardiovascular response to exercise were similar in patients with palmar hyperhidrosis before ETS and in the normal control population. Therefore, we consider that patients with palmar hyperhidrosis have no overactivity of the sympathetic nerve. However, because bilateral ETS causes the suppression of cardiovascular response to exercise, patients that has been treated with ETS need to be observed during high-level exercise.

http://iars.org/abstracts/browsefile/browse.asp?command=N&absnum=45&dir=S190

Undisclosed side-effects of ETS procedure

After a mean of 123 mo 36 patients could be re-evaluated. Eighteen patients (50%) were free from former symptoms, while sequels were still present in 18 patients (50%).

Numbness and paresthesia are rarely reported in the literature but are present in up to 10% of patients 1 year after a thoracoscopic procedure [2,9]. It is known that numbness and dysesthesia may decrease by time, but long-term results are not known.

Early postoperative sequels are frequently found in VATS procedures, but patients with pain even after years have a nearly 50% chance to eliminate their problems. In addition, numbness and dysesthesia seem to disappear almost completely several years after the procedure.

http://www.ejcts.ch/cgi/content/full/32/3/409

Sympathotomy Instead of Sympathectomy for Palmar Hyperhidrosis: Minimizing Postoperative Compensatory Hyperhidrosis

www.sweathelp.org/pdf/Atkinson.pdf
or
www.sciencedirect.com/science/article/pii/S0025619611625494

Mia: An elective surgical procedure enthusiastically declared "almost miraculous" needs modifications to reduce severe side-effects?

CNS activation following peripheral sympathectomy

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 chemical sympathectomy will signal and activate the central nervous system (CNS).

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 insympathectomy-induced

alterations of immunity.

Brain, Behavior, and Immunity

Volume 12, Issue 3, September 1998, Pages 230-241

Cervical sympathectomy affects the lower extremities, providing further evidence that the effects of this procedure is not local or limited

Bilateral cervical sympathectomy reduced mechanical allodynia and cold allodynia in the rat

model of neuropathic pain suggesting that neuropathic pain, although the lesions are localized in low extremities, may be correlated with functional disturbance of sympathetic nerve fibers of supraspinal or brain level and help explain the mechanism of neuropathic pain.

Korean J Anesthesiol. 1999 Feb;36(2):327-334. Korean.

Effect of cervical sympathectomy and circulatory hypoxia on time course of prostaglandin concentration in brain tissues

http://www.springerlink.c...ontent/j705306763158841/

Some workers suggest a possible "transmembrane" role of PG in the nervous system.

If the increase in the PG level during ischemia is regarded as a protective reaction, it must be admitted that no increase took place 1 day after CSE (cervical sympathectomy) and it was considerably weakened 7-40 days after CSE.

The effect of cerebral ischemia was virtually indistinguishable from the action of CSE itself.

It can be tentatively suggested that PGF plays the main role in the regulation of tone of the vascular wall and in the regulation of metabolism under conditions of ischemia when the sympathetic regulation is disturbed.

Correlation between Changes in Regional Cerebral Blood Flow and Pain Relief in Complex Regional Pain Syndrome Type 1

Clinical Nuclear Medicine:

June 2006 - Volume 31 - Issue 6 - pp 317-320

Objective: Analyzing changes in regional cerebral blood flow (rCBF) with SPECT in complex regional pain syndrome type 1 (CRPS 1), formerly known as reflex sympathetic dystrophy, is an optimal method for evaluating effective pain relief. We attempted to investigate the correlation of changes in rCBF with pain relief during treatments of sympathetic blockade and multimodal epidural pain control.

Case Report: We describe a patient with severe CRPS 1 in whom conventional treatment failed to relieve the pain.

Combined repeated lumbar sympathetic blocks and long-term epidural morphine, bupivacaine, and ketamine administration provided satisfactory pain relief and functional activity recovery. Six normal control subjects having one Tc-99m HMPAO scan each and the patient with CRPS having 3 Tc-99m HMPAO scans (once before treatment and twice at 4 months and 6 months after treatment, respectively). The patient with CRPS showed lower rCBF than normal

controls in the left thalamus and higher rCBF than normal controls in the right parietal lobe and left frontal lobe.

After subsequent treatment, the subtraction images showed increased rCBF in the left thalamus and decreased rCBF in the right parietal and left frontal lobes.

Conclusions: Tc-99m HMPAO SPECT showed a relationship of rCBF in the thalamus, parietal lobe, and frontal lobe with pain relief. rCBF alterations may provide an indicator for the quality of pain management for neuropathic pains.

Subtraction analysis between pre- and posttreatment, by using statistical parametric mapping (version 2), can be used as an objective indicator for the effectiveness of therapy.

The effects of vasoactive intestinal peptide on dura mater nitric oxide levels and vessel-contraction responses in sympathectomized rats

Nitric oxide (NO) and neurogenic inflammation in dura mater due to nociceptor activation has been implicated for pathophysiology of primary headache disorders. Development of migraine has also been observed in patients treated with ganglion blockage for sympathetic reflex dystrophy. Vasoactive intestinal peptide (VIP) is an antioxidant, anti-inflammatory, and neuroprotective neuropeptide. This study is intended to investigate the effects of VIP on dura mater NO levels and vessel-contraction responses in sympathectomized rats. In the experiments, 30 male rats in five groups were used. Group 1 sympathectomized: under anesthesia, superior cervical sympathetic ganglion was removed via incision at the center line in the neck area. Group 2 sympathectomized + VIP: postoperative VIP of 25 ng/kg/day (0.2 ml) intraperitoneally administered to the rats exposed to the same operations for 5 days. Group 3 sham: ganglia and nerves were exposed but not dissected. Group 4 control: no treatment was done. Group 5 VIP: only VIP was administered for 5 days. Sympathectomy induced a significant increase in dura mater NO levels and VIP decreased NO to control levels and increased the norepinephrine vessel-contraction responses of sympathectomized rats. VIP is an efficient NO modulator in superior cervical ganglionectomized rats.

http://www.ncbi.nlm.nih.gov/pubmed/19936638

An alternative treatment option for compensatory hyperhidrosis after endoscopic thoracic sympathectomy

Davies KD, Lawton N.

Dermatology Unit, North Devon Healthcare Trust, Barnstaple, UK. karen.davies@ndevon.swest.nhs.uk

http://www.ncbi.nlm.nih.gov/pubmed/20028410

Is this a proof that cervical sympathectomy affects function of the basal ganglia?

To retrospectively review the results of cervical perivascular sympathectomy (CPVS) in treating athetoid cerebral palsy and discuss the possible mechanism of the surgery.

METHODS: From 1998 to 2006,560 patients with athetoid cerebral palsy were treated with cervical perivascular sympathectomy and all had periodical follow-up at 1 week, 6 months and 1 year postoperatively. Among the 560 patients,there were 391 boys and 169 girls. The age at operation was from 3 to 25 years old with an average of 10.7 years.

RESULTS: At 1 year follow-up postoperatively, among the 560 cases, athetoid movement of the neck and head improved in 308 patients (55%), the movement of the hand and fingers improved in 403 patients (72%), standing and gait improved in 229 patients (41%), muscle tone reduced in 185 patients (33%), salvation reduction appeared in 252 patients (45%), eyeball movement improved in 174 patients (31%), speaking improved in 251 patients (45%); 310 patients (55%) agreed that the operation had curative effect for the patients. Short-term follow up results was better than long-term follow up results.

CONCLUSION: Primary results showed that CPVS had a curative effect on athetoid cerebral palsy, especially in improving athetoid movement of the neck and head, hand and fingers, standing and gait, speaking ability, eye-ball movement and so on. The possible mechanism of the CPVS in the treatment of athetoid cerebral palsy might be reducing the excitability of sympathetic nerve, improving microcirculation of the brain and eventually activating potential neurons. Long-term follow up is necessary.

http://www.ncbi.nlm.nih.gov/pubmed/20486384

postsympathectomy neuralgia is frequent

Surgical sympathectomy has a long heritage for the treatment of peripheral vascular disease and various chronic pain problems.

Despite concerns expressed as long ago as 1942 about the efficacy of surgical sympathectomy for the management of non-cancer pain, the procedure was enthusiastically pursued for the management of reflex sympathetic dystrophy or complex regional pain syndrome (CRPS), migraine, dysmenorrhea, epilepsy, chronic pancreatitis, postherpetic neuralgia of the trigeminal nerve, postdiscectomy syndrome, and phantom limb pain. However, systematic reviews have found no tangible evidence supportive of sympathectomy for the management of neuropathic pain. Furthermore, postsympathectomy neuralgia is a common complaint with a reported incidence between 15% to 50%.

Bonica's Management of Pain,

Lippincott Williams & Wilkins, 2009 - 2064 pages

interrupting sympathetic tone to the human brain - ETS

Sweating after sympathetic surgery is a reflex cycle between the sympathetic system and the anterior portion of the hypothalamus according to our investigations. Reflex sweating will not happen if hand sweating can be stopped without interrupting sympathetic tone to the human brain.
http://www.hyperhidrosis.com/symposium.htm

Sympathectomy Causes Aggravated Lesions and Dedifferentiation

http://content.karger.com/ProdukteDB/produkte.asp?Doi=93010

Degeneration patterns of postganglionic fibers following sympathectomy

Seven weeks after surgery, fragments of folded basement lamella and Remak bundles with condensed cytoplasm and numerous flat processes are persisting signs of the degeneration.

In addition to the differences in time course between the proximal and the distal site of observation, it was also noted that both the axonal degeneration and the reactions of the Schwann cells are more pronounced in the rcg than in the muscle nerve. For example there was abundant mitotic activity in the central endoneural and Schwann cells whereas we could not detect such activity in the periphery.

It is concluded that the time course of degeneration and the intensity of the degenerative and reactive processes is, to a considerable extent, determined by the distance between the site of nerve section and the site from which the specimen is taken. Many of the conflicting data in the literature can be explained by this finding.

http://www.ncbi.nlm.nih.gov/pubmed/4051190

Sympathectomy induces adrenergic excitability of cutaneous C-fiber nociceptors

http://www.ncbi.nlm.nih.gov/pubmed/8822575

J Neurophysiol. 1996 Jan;75(1):514-7.

pH changes in synovial fluid following perivascular sympathectomy

Proc Inst Med Chic. 1947 Nov 15;16(17):465.

http://www.ncbi.nlm.nih.gov/pubmed/18896440

sympathectomy induces mast cell hyperplasia

Long-term superior cervical sympathectomy induces mast cell hyperplasia and increases histamine and serotonin content in the rat dura mater.

Neuroscience. 2000;96(1):205-13.

Mast cell hyperplasia is found in different pathologies such as chronic inflammatory

processes, fibrotic disorders, wound healing or neoplastic tissue transformation. The

functional significance of the accumulation of mast cells in these processes is largely

unknown. It is now established that bone marrow-derived mast cell progenitors

circulate in peripheral blood and subsequently migrate into the tissue where they

undergo final maturation under the influence of local microenvironmental factors.

Cytokines are of particular importance for mast cell recruitment, development, and

function. Stem cell factor (SCF) is a unique mast cell growth factor, since mast cells

disappear completely in the absence of SCF. However, several other cytokines such

as IL-3 and IL-4 have been shown to influence mast cell proliferation and function

also. This review focuses on the role of cytokines in the regulation of mast cell

hyperplasia.

Allergy and Immunology, Vol. 127, No. 2, 2002

Ultrastructural Changes in the Cerebral Artery Wall Induced by Long-Term Sympathetic Denervation

This study was performed to determine to what extent the morphology of the rabbit middle cerebral artery is affected by the absence of the sympathetic nervous system. Six weeks after unilateral ablation of the superior cervical ganglion, which induced ipsilateral degeneration and disappearance of the perivascular noradrenergic nerve fibers, comparison between the ipsi- and the contralateral middle cerebral arteries revealed that the denervated arterial wall underwent significant thickening. This thickening was principally due to hypertrophy of the smooth muscle cells (SMC), together with an increase in the amount of medial and adventitial collagen. The hypertrophied SMC showed important morphological and ultrastructural modifications – irregular shape, increase in the number of organdies (particularly of Golgi apparatus, free ribosomes, rough endoplasmic reticulum and microtubules), large indented nuclei rich in euchromatin – indicating profound changes in their metabolic and contractile activity which could result in an alteration of their mechanical properties. As these alterations were strictly ipsilateral to the sympathectomy it is likely that they are the direct consequence of the suppression of a regulatory ‘trophic’ factor linked to the presence of sympathetic nerve fibers. This concept is reinforced by the fact that the first SMC affected are those situated at the media/adventitial border, in the vicinity of adventitial nerve bundles. Thus, the sympathetic nervous system appears to play a key role in the long-term regulation of the cerebral vascular tree structure.

Copyright © 1988 S. Karger AG, Basel

http://content.karger.com/ProdukteDB/produkte.asp?Doi=158727

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

The nerve endings in Schwann cells under the endothelium degenerated after sympathectomy

ep.physoc.org/content/52/1/31.full.pdf

patients with brain stem lesions and patients after sympathectomy have reduced or absent skin wrinkling on the affected side

Biomedecine & Pharmacotherapy
Volume 55, Issue 8, October 2001, Pages 475-478

After sympathectomy, denervation supersensitivity may be associated with recurrence of pain

Vascular disturbances in RSD are not due to constant overactivity of sympathetic vasoconstrictor neurons. Changes in vascular sensitivity to cold temperature and circulating catecholamines may be responsible for vascular abnormalities. Alternatively, RSD may be associated with an abnormal (side different) reflex pattern of sympathetic vasoconstrictor neurons due to thermoregulatory and emotional stimuli generated in the central nervous system. (3) After sympathectomy, denervation supersensitivity of blood vessels and intense vasomotion may be associated with recurrence of pain in some patients.
Pain
Volume 67, Issues 2-3, October 1996, Pages 317-326

Effects of Sympathectomy on Muscle

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<0·05) and DNA content (r= 0·84; P<0·05). 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.

Clinical Physiology (Oxford, England) 1988 Apr; vol 8 (issue 2): pp 181-91

2.
The objective of this paper was to study the effect of sympathetic innervation on morphological and histochemical aspects of skeletal muscle tissue. Rabbit masseter muscle was studied using histochemical and immunohistochemical methods for periods of up to 18 months post-sympathectomy. The morphological and enzymatic characteristics of control masseter muscles were similar on both the left and right sides. The main features were muscle fibres with a mosaic pattern and a predominance of type IIa fibres, followed by type I. Type IIb fibres showed very low frequency. Sympathectomized animals showed varying degrees of metabolic and morphological alterations, especially 18 months after sympathectomy. The first five groups showed a higher frequency of type I fibres, whilst the oldest group showed a higher frequency of type IIb fibres. In the oldest group, a significant variation in fibre diameter was observed. Many fibres showed small diameter, atrophy, hypertrophy, splitting, and necrosis. Areas with fibrosis were observed. Thus cervical sympathectomy induced morphological alterations in the masseter muscles. These alterations were, in part, similar to both denervation and myopathy.

International Journal of Experimental Pathology
Volume 82, Issue 2, pages 123–128, April 2001

CNS activation following peripheral sympathectomy

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 chemical sympathectomy 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.

Central Nervous System Activation following Peripheral Chemical Sympathectomy: Implications for Neural–Immune Interactions

Brain, Behavior, and Immunity

Volume 12, Issue 3, September 1998, Pages 230-241

Changes in hemodynamics of the carotid and middle cerebral arteries before and after endoscopic sympathectomy in patients with palmar hyperhidrosis

There was a significant reduction in diastolic pressure after T-2 sympathectomy (p = 0.003), but not in systolic pressure or heart rate. The vessel diameter was increased after sympathectomy in the left CAs and right CCA. The T-2 sympathectomy led to significant elevation of blood flow volume and Rl in the left CCA. ICA, and ECA (p < 0.05). The authors found significant increases in maximum flow velocity and RI in the left MCA (p < 0.05). Conclusions. Patients who underwent T-2 sympathectomy demonstrated a significant increase in blood flow volume and flow velocities of the CAs and MCA, especially on the left side. Asymmetry of sympathetic influence on the hemodynamics of the CAs and MCA was noted.
Journal of neurosurgery
1999, vol. 90, no3, pp. 463-467 (38 ref.)

Ultrastructural changes in the nerves innervating the cerebral artery after sympathectomy

http://www.springerlink.com/content/l7213648355u2088/

surgical sympathectomy produces hypersensitivity of the vessels.

Scand J Work En viron Health 13 (1987) 3 1 3 - 3 1 6

Depression of Endothelial Nitric Oxide Synthase

but Increased Expression of Endothelin-1 Immunoreactivity in Rat Thoracic Aortic Endothelium Associated With Long-term, but Not Short-term, Sympathectomy.

Original Contribution

Circulation Research. 79(2):317-323, August 1996.
Aliev, Gjumrakch; Ralevic, Vera; Burnstock, Geoffrey

Denervation supersensitivity in the denervated heart

The guanethidine sympathectomy in 4- and 8-week old white rats increased cardiac sensitivity to acetylcholine. An increase of sensitivity to adrenaline was observed in 8 to 20 weeks of postnatal period. The significance of the changes of extracardiac effects and the cardiac sensitivity to acetylcholine and adrenaline for its chronotropic control in sympathectomized 10-14 week old rats is discussed.
http://www.ncbi.nlm.nih.gov/pubmed/3569584

Indeed, local sympathectomy influences specific responses in immune organs.

Brain Research
Volume 888, Issue 2, 12 January 2001, Pages 227-234

Lumbar sympathectomy, which interferes with the sympathetic nerve supply to the colon

The autonomic nervous system: an introduction to basic and clinical concepts

By Otto Appenzeller, Emilio Oribe
Elsevier Health Sciences, 1997

absent sympathetic skin responses post ETS

Compared with the presympathectomy rate, the rate of absent SSR (sympathetic skin responses) also significantly increased after sympathectomy: from 20 to 76% after electrical stimulation and 36 to 64% after deep inspiration stimulation, respectively (p <>

CONCLUSIONS: In contrast to compensatory sweating in other parts of the body after T2-3 sympathetomy, improvement: in plantar sweating was shown in 72% and worsened symptoms in 6% of patients. The intraoperative plantar skin temperature change and perioperative SSR demonstrated a correlation between these changes.

http://www.ncbi.nlm.nih.gov/pubmed/11453433

A sympathectomy does not cure hyperhidrosis

A sympathectomy does not cure hyperhidrosis. It does not leave a person "free of hyperhidrosis". The best that can be said is that is stops all sweating in one large area of the body, and makes the other part of the body sweat a lot more.

http://editthis.info/corposcindosis/Brat_Dialog

experts agree that sympathectomy, like the other nerve-cutting operations, is getting out of hand

Sympathectomy, cutting of the sympathetic nerves, is causing the most violent arguments of all. The operation is now prescribed for a wide variety of ailments, from excessive sweating to high blood pressure. Nobody knows how many thousands of sympathectomies surgeons perform each year; there are an estimated 1,000 in Manhattan alone. Admittedly the operation is a life-saver in many cases of gangrene, angina pectoris, hypertension. But some sympathectomies may make men sterile. And because a sympathectomy reduces pain, some doctors consider it insidiously dangerous, e.g., a patient could have a perforating ulcer without pain. The experts agree that sympathectomy, like the other nerve-cutting operations, is getting out of hand.
Time Magazine,
Monday, Jun. 30, 1947 Losing Nerves

The anterior rami of the spinal nerves between the C4 and T2 innervate the skin of the upper limb

The area of skin supplied by one spinal nerve is known as dermatome. A knowledge of segmental innervation of the skin enables one to determine the level of injury to the spinal cord. It is also essential in the conduction and interpretation of the physical examination of a patient.
A lesion of a spinal nerve manifests itself as a motor or sensory disturbance along it's distribution.

Human Anatomy:Volume I: Upper Limb And Thorax, 2008

The T1 and T2 segments innervate the head and neck; T2 through T6 segments, the upper extremities and thoracic viscera

Basic neurosciences with clinical applications
By Eduardo E. Benarroch, Elsevier Health Sciences, 2006

discrepancies in denervation of the SNS

Surgical extirpation of portions of the sympathetic nervous system frequently fails to produce precisely that permanent peripheral denervation which is to be expected from text-book diagrams of the anatomical arrangement of the system.
The discrepancies are not uncommon even when the surgical technique is above suspiciion. They can in part, of course, be attributed to variations in the detailed anatomy of the sympathetic trunks or in the pattern of distribution of the branches and communications of these trunks. Such atypical arrangements in the autonomic nervous system are frequent. Thus, for example, during careful dissection of the cadaver, with all the relationships exposed, the correct identification of a particular paravertebral sympathetic ganglion can be very difficult; in the depths of a surgical incision, it is often impossible. But, even when the possibility of the usual anatomical anomalies of the sympathetic nervous system has been excluded, persistence of autonomic activity in unexpected areas may, and in certain regions always does, follow operative removal of parts of the system which should have caused complete sympathetic paralysis in the are or region concerned.
Intermediate sympathetic ganglia, J. D. Boyd, Univ. of Cambridge

• Oxford Journals
• Medicine
• British Medical Bulletin, Vol. 13 No. 3
  

Primer on the autonomic nervous system

Hyperthermia, heat intolerance, heat prostration and heat stroke may occur with widespread failure of thermoregulatory sweating, whereas local skin trophic changes occur with chronic postganglionic sudomotor neuropathy.

Primer on the autonomic nervous system, By David Robertson, Academic Press, 2004

more liable to develop reflex bronchospasm under light levels of anesthesia after ETS

Thus, patients with essential hyperhidrosis who have undergone bilateral thoracic sympathectomy, may be more liable to develop reflex bronchospasm under light levels of anesthesia.
CAN J ANESTH 2005 52:9

depletion of brain noradrenaline levels caueses a disturbance in cerebral microvasculatur tone

Chemical sympathectomy with six-hydroxydopamine leads to marked noradrenaline denervation in the nucleus ceruleus-innervated areas (Jonnson 1983) and to a decrease in noradrenaline levels measured in the cerebral cortex (Onesti et al. 1989).
Rats were subjected to chemical sympathectomy by stereotactic injection of 6-hydroxydopamine into the lateral ventricle. A hypertensive condition at a mean arterial pressure of about 160mm Hg was maintained for 1 hour by intravenous phenylephedrine. Compared with a control group CBF increased, cerebral autoregulation was impaired and specific gravity of the cerebral tissue revealed cerebral oedema. It was suggested that depletion of brain noradrenaline levels caueses a disturbance in cerebral microvasculatur tone and renders the cerebral blood vessels more vulnerable to hypertension (Kobayashi et al. 1991).

Topics in Neuroanaesthesia and Intensive Care

Experimental and Clinical Studies upon Cerebral Circulation, Metabolism and Intracranial Pressure

Cold, Georg E., Dahl, Bent L. 2002, XIV, 416 p., Hardcover ISBN: 978-3-540-41871-9

Effect of adrenalectomy or sympathectomy on spinal cord blood flow

We conclude that adrenalectomy near-totally ablates the hypothermia-associated increase in RSCBF measured in intact rats and that abdominal sympathectomy totally ablates it. This evidence complements morphological evidence for adrenergic innervation of the spinal cord vasculature.

http://ajpheart.physiology.org/cgi/content/abstract/260/3/H827
Am J Physiol Heart Circ Physiol 260: H827-H831, 1991;

Alterations in cytokine and antibody production following chemical sympathectomy

The Journal of Immunology, Vol 155, Issue 10 4613-4620, Copyright © 1995 by American Association of Immunologists

acinar degranulation following sympathectomy

Chronic bilateral postganglionic sympathectomy (4-6 weeks duration) caused a drastic reduction in the capacity of the gland to secrete saliva in response to parasympathetic stimulation, reaching only one-third of that from normal animals. The initial output of amylase was greater than in normal animals but the total output was similar. The control unstimulated sympathectomized glands appeared similar morphologically to normal resting glands. However, on the parasympathetically stimulated side, besides the usual amount of acinar degranulation, there was also a conspicuous development of acinar vacuolation, not seen in the other groups of animals.
September 1, 1988 The Journal of Physiology, 403, 105-116.

Elective treatment for sweaty palms is classified as psychosurgery

ETS can alter many bodily functions, including sweating , heart rate , heart stroke volume , blood
pressure , thyroid , baroreflex , lung volume , pupil dilation, skin temperature, goose bumps and
other aspects of the autonomic nervous system . It can diminish the body's physical reaction to
exercise and/or strong emotion, and thus is considered psychiatric surgery. In rare cases sexual
function or digestion may be modified as well.
LVHyperhidrosis.com
Aury Nagy MD

Catecholamine sensitivity of cat leg vessels after sympathectomy

Am J Physiol 212: 466-471, 1967;

Differences in the injury/sprouting response

While increased hilar and decreased distal NA innervation in arthritic rats was strikingly similar to that of non-arthritic 6-OHDA-treated rats, there were differences in splenic compartments innervated by sympathetic nerves between these groups. In 6-OHDA-treated rats, NA nerves re-innervated splenic compartments normally innervated by sympathetic nerves. In arthritic rats, sympathetic nerves returned to normally innervated splenic compartments, but also abundantly innervated red pulp. These findings suggest that splenic sympathetic nerves undergo a disease-associated injury/sprouting response with disease development that alters the normal pattern and distribution of NA innervation. The altered sympathetic innervation pattern is likely to change NA signaling to immune cell targets, which could exert long-term regulatory influences on initiation, maintenance, and resolution of immune responses that impact disease pathology.
Brain, Behavior & Immunity; Feb2009, Vol. 23 Issue 2, p276-285, 10p