Sympathectomy: "suppression of the neuroendocrine stress response"

p.254

Neuraxial blocks typically produce variable decrease in blood pressure that might be accompanied by a decrease in heart rate and cardiac contractility. These effects are generally proportional to the degree (level) of the sympathectomy. Vasomotor tone is primarily determined by sympathetic fibres arising from T5 to L1, innervating arterial and venous smooth muscle. Blocking these nerves causes vasodilation of the venous capacitance vessels, pooling of blood, and decreased vvenous terurn to the heart; in some instances, arterial vasodilation may also decrease systemic vascular resistance. The effects of arterial vasodilation may be minimized by compensatory vasoconstriction above the level of the block. A high sympathetic block not only prevents compensatory vasoconstriction but also blocks the sympathetic cardiac accelerator fibres that arise at T1-T4.
Profound hypotension may result from vasodilation combined with bradycardia and decreased contractility. These effects are further exaggerated if venous return is further compromised by a head-up position or from the weight of a gravid uterus. Unopposed vagal tone in some persons may explain cardiac arrest with spinal anesthesia.
p.261

The sympathetic system normally maintains some tonic vasoconstriction on the vascular tree. Loss off this tone following induction of anesthesia or sympathectomy frequently contributes to perioperative hypotension.
p.375

AV conduction abnormalities are usually manifested by abnormal ventricular depolarization (bundle-branch block) prolongation of the P-R interval (first degree AV block) failure of some atrial impulses to depolarize the ventricles (second degree AV block) or AV dissociation (third degree AV block or complete heart block).
p.428

Clinical anesthesiology

By G. Edward Morgan, Maged S. Mikhail, Michael J. Murray
McGraw-Hill, Edition: 3 - 2002

SUPERSENSITIVITY TO NE AFTER ADRENERGIC DENERVATION

H-NOREPINEPHRINE UPTAKE
Portal veins were incubated for 1 hour with 3H-NE 1,3, and 5 days after chemical sympathectomy with 6-OHDA (Fig. 3). Preparations treated with cocaine (10~5 M) were exposed to this drug 15 minutes before 3H-NE incubation and maintained in a cocaine-containing solution throughout the entire incubation period. One day after 6-OHDA treatment, NE uptake was reduced to approximately 21 %
of control; at 3 days it was 33% of controls and 5 days after 6-OHDA it was approximately 39% of controls. The decrease in NE uptake caused by 6-OHDA treatment was comparable to that caused by cocaine.

SUPERSENSITIVITY TO NE AFTER ADRENERGIC DENERVATION

CATECHOLAMINE DEPLETION AFTER CHEMICAL SYMPATHECTOMY

1977;41;198-206 Circ. Res.
Trophic influence of the sympathetic nervous system on the rat portal vein

more complex autonomic dysfunction than generalised sympathetic overactivity

Cardiac autonomic function in patients (n = 63) with primary focal hyperhidrosis and healthy controls (n = 28) was investigated by short-term frequency domain power spectral analysis of heart rate variability. The power of the very-low-frequency band (0.01-0.05 Hz) was significantly lower in patients with axillary hyperhidrosis than in controls. No differences between groups could be observed at investigation of the low-frequency band (0.05-0.15 Hz), which was a surprising finding because this band represents also sympathetic cardiac innervation. At the high-frequency band (0.15-0.5 Hz), which represents parasympathetic cardiac innervation, an interaction of type and position influencing spectral power was detected. Our highly interesting findings indicate that primary focal hyperhidrosis is based on a much more complex autonomic dysfunction than generalised sympathetic overactivity and seems to involve the parasympathetic nervous system as well.
Eur Neurol 2000;44:112-116 (DOI: 10.1159/000008207)
peter.birner@akh-wien.ac.at

Medical Tourism advertising Sympathectomy

http://mondialtourism.webfire.com.au/_webapp_117318/Endoscopic_Thoracic_Sympathectomy

Side Effects

There is the possibility of increased sweating in other areas of the body for example the back of the legs.

Recovery Period

Patients will normally stay one day in hospital. Pain may be present for around a week, patients are normally given medication to control this. Most patients will be able to carry out their daily activities and return to work within a week.

Associated Risks

As with all types of surgery there are certain risks involved, these include infection, bleeding, reaction to anesthesia or nerve damage. The main risk of the surgery as stated before is increased sweating in other areas of the body.

dissociation between conductance and microvascular perfusion

Complete sympathectomy was accompanied by a persistent increase in ear temperature and a dissociation between conductance and microvascular perfusion. Auricular conductance was transiently increased and then decreased to levels below preoperative control values. Microvascular perfusion is decreased immediately following amputation/replantation and thereafter increases.
Microsurgery ISSN 0738-1085 CODEN MSRGDQ

Source / Source

1998, vol. 18, n^o2, pp. 129-136 (26 ref.)

'Emotional' sweating regulated by neocortex and limbic cortex

Careful observations showed that the forearm sweating responded diversely to various mental stimuli, unlike the palmar sweating whose response was always an increase. Mental arithmetic, mental testing and physical exercise caused an immediate increase in the palmar sweating but often elicited a transient decrease in the forearm sweating, whereas pain, noise, and emotional stimuli consistently provoked an increase of sweating on the forearm as well as on the palm. These observations suggest that the activities of higher centers, presumably involving neocortex and limbic cortex, exert various influences on the central mechanisms of palmar and generalized sweating.
Jpn J Physiol. 1975;25(4):525-36.
http://www.ncbi.nlm.nih.gov/pubmed/1206808

90% may experience Gustatory sweating after surgery for Hyperhidrosis

Some individuals (up to 90%) may experience another type of sweating that is increased while eating or smelling certain foods (gustatory sweating) (Hornberger).

Source: Medical Disability Advisor

http://www.mdguidelines.com/sympathectomy

Chronic betablocker therapy can exactly mimic autonomic neuropathy

What is the ultimate effect of cardiac autonomic neuropathy.

Cardiac denervation. The manifestations are

• Tachycardia, exercise intolerance
• Orthostatic hypotension

http://stanford.wellsphere.com/heart-health-article/why-is-angina-pectoris-silent-in-diabetes-mellitus/549631

How Sympathectomy is described by the surgeons who offer the procedure: (Is this what Sympathectomy does - only?)

"With the nerve stimulation data, Dr. McCormack then cuts only those nerves that innervate sweat glands in the areas affected with hyperhydrosis. For example, a patient with palmar hyperhydrosis, T2 and T3 ganglion may individually, or both be involved. The intraoperative nerve testing precisely defines which ganglion has to be cut and avoids injury to the ganglion not involved. This is important because post-operative compensatory sweating problems increase with the number of ganglion cut."
http://www.nosweatsurgery.com/hyperhyd.htm

Gustatory sweating is a frequent side effect after thoracoscopic sympathectomy (32%)

Overall, gustatory sweating occurred in 32% of patients, and the incidence was significantly associated with extent of sympathectomy (p = 0.04). However, because the extent of sympathectomy was always decided by the location of primary hyperhidrosis, the latter may also explain the risk of gustatory sweating. CONCLUSIONS: Gustatory sweating is a frequent side effect after thoracoscopic sympathectomy. This is the first study to report that its incidence is significantly related to the extent of sympathectomy or the location of primary hyperhidrosis. Although there is no pathophysiologic explanation of gustatory sweating, these findings should be considered before planning thoracoscopic sympathectomy and patients should be thoroughly informed.
The Annals of thoracic surgery (Ann Thorac Surg), 2006-Mar; vol 81 (issue 3) : pp 1043-7

Incidence of chest wall paresthesia 50.0%

Paresthetic discomfort distinguishable from wound pain was described by 17 patients (50.0%). The most common descriptions were of ‘bloating’ (41.2%), ‘pins and needles’ (35.3%), or ‘numbness’ (23.5%) in the chest wall. The paresthesia resolved in less than two months in 12 patients (70.6%), but was still felt for over 12 months in three patients (17.6%).
Eur J Cardiothorac Surg 2005;27:313-319

Abolition of sympathetic skin responses following endoscopic thoracic sympathectomy

http://www.ncbi.nlm.nih.gov/pubmed/8618555?dopt=Abstract

Muscle Nerve. 1996 May;19(5):581-6.

abnormal sympathetic skin response may lead to peripheral vascular failure or the reduced cardiac chronotropic response may impair the body

An already impaired cardiovascular system is recognized to be a significant risk factor for development of heat stroke. In the post-sympathectomy patient, the abnormal sympathetic skin response may lead to peripheral vascular failure or the reduced cardiac chronotropic response may impair the body’s capacity to compensate for shock. These may have contributed to the rapid development of shock and severe multiple organ dysfunction syndrome in this patient.
He had multiple organ dysfunction syndrome develop, with severe renal and hepatic failure, grade II hepatic encephalopathy, and disseminated intravascular coagulation. He responded remarkably well to aggressive supportive measures including forced alkaline diuresis, and he was eventually discharged home after 1 month. The patient was previously a healthy, physically fit, nonsmoker. He worked as a body building trainer and led an active, sporty lifestyle. The only significant medical history was that he had received thoracic sympathectomy for axillary hyperhidrosis 4 years ago at another hospital.

http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

sympathectomy can impair the autonomic nervous system’s increase of the heart rate in response to exercise

it has been shown that thoracic sympathectomy can impair the autonomic nervous system’s increase of the heart rate in response to exercise [6]. Although absolute tachycardia is not eliminated, given the endocrine and paracrine stimuli during exercise, the maximum heart rate reached during exercise has been shown to be significantly reduced after sympathectomy. Thus for a given workload during exercise, there will be a relative bradycardia. This may possibly affect the circulatory system’s ability to convey heat from the body core to the extremities for heat loss.
http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

abnormal peripheral vascular responses to temperature

thoracic sympathectomy has been demonstrated to abolish or alter sympathetic vasoconstrictive responses in the skin, and this may contribute to abnormal peripheral vascular responses to temperature [4]. Paradoxically it has been suggested that in some cases there may be abnormal vasoconstriction rather than the expected vasodilatation after sympathectomy [5]. It is not impossible that such atypical peripheral vascular responses to rising body temperature may have contributed to impaired heat loss during exercise or to an inappropriate response to shock on the development of the heat stroke.
http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

impaired overall heat loss

the abolition of sweating from the upper body as well as the axillae and both upper limbs may have significantly reduced the capacity of the patient to lose heat through sweating during exercise. Anhidrosis in the head and neck after sympathectomy affects a proportion of patients, but is often neglected in most reports of post-sympathectomy complications [3]. The loss of head and neck sweating in this patient may have further impaired overall heat loss. However we would also note that the degree of heat loss impairment after sympathectomy has never been quantified, and its effect on body temperature during exercise remains to be established.
http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

facial anhidrosis and disturbed cardiovascular responses to temperature after sympathectomy for hand sweating

"Although thoracic sympathectomy is commonly used to reduce upper limb sweating, it may also lead to facial anhidrosis and disturbed cardiovascular responses to temperature. The resultant effect on overall body heat loss has not been documented. We present a case of a young patient with previous thoracic sympathectomy who suffered severe heat stroke after heavy exercise. http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

Changes in hemodynamics of the carotid and middle cerebral arteries

Jeng and associates observed an increase in cerebral blood flow after T2 sympathectomy, and they suggested the possibility of using such a surgical approach to improve cerebral blood flow in patients with cerebral vascular insufficiency.
Sympathectomy for Pain
ANTONIO A. F. DE SALLES I JOHN PATRICK JOHNSON


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. The usefulness of sympathectomy for the treatment of ischemic cardiovascular and cerebrovascular disease deserves further investigation.
Jeng JS, Yip PK, Huang SJ, et al: Changes in hemodynamics of the carotid and middle cerebral arteries before and after endoscopic sympathectomy in patients with palmar hyperhidrosis: Preliminary results.
J Neurosurg 90:463–467, 1999

side effects, ranging from trivial to devastating

There seem to be no controlled studies demonstrating efficacy of neurolytic sympathetic blocks. Possible side effects, ranging from trivial to devastating, are of even greater importance with these more permanent procedures—painful sequelae may include phenol or alcohol neuritis and postsympathectomy pain (sympathalgia), which can also occur after surgical sympathectomy.⁶

BMJ. 1998 March 14; 316(7134): 792–793.

Sympathectomy induces adrenergic excitability of cutaneous C-fiber nociceptors

1. The effects of ipsilateral removal of the superior cervical ganglion on the subsequent responsiveness of C-fiber polymodal nociceptors (CPMs) of the ear to close-arterial injections of norepinephrine (NE) were evaluated in adult, anesthetized rabbits. 2. In normal unanesthetized rabbits, the two ears were usually at the same temperature.
Immediately after the ganglionectomy, the ipsilateral ear was warmer; however, at the time of electrophysiological recordings (4-23 days) the majority of animals had the ipsilateral ear cooler by > or = 1 degree C, suggestive of denervation supersensitivity. 3.
NE (50 ng) did not activate any CPMs (n = 28) from intact animals. 4. Seven of 22 CPMs recorded from sympathectomized ears were activated by NE (50 ng). The responses varied considerably but typically consisted of 2-4 impulses in the 60 s after the NE injection. In some instances, repetitive activity continued for many minutes. Such prolonged discharge differs from the adrenergic responses seen after partial nerve damage. 5. The induction of adrenergic excitability in CPMs by sympathectomy is
suggested to be a counterpart to postsympathectomy neuralgia in human beings and a possible part of the mechanism leading to sympathetically related pain states.
http://www.ncbi.nlm.nih.gov/pubmed/8822575

Chemical thoracic sympathectomy (CTS) resulted in profound bradycardia

In the CTS group, however, the SD_RR:SD∂_RR ratio decreased significantly from 1.72 ± 0.20 to 1.23 ± 0.11 just after CTS. The previous patient, who had a high SD_RR:SD∂_RR ratio of 3.45 before CTS, exhibited severe bradycardia (22 beats/min).
The decrease in the SD_RR:SD∂_RR ratio indicates a reduction of cardiac sympathetic activity. However, CTS in patients having high SD_RR:SD∂_RR ratios can result in profound bradycardia.

Anesthesiology ISSN 0003-3022

1998, vol. 89, n^o3, pp. 666-670 (12 ref.)

ETS reduces myocardial oxygen demand and plasma noradrenaline levels

"The sympathetic ganglion is not a simple relay station but a site modulated by short inter-neurons and a variety of neurotransmitters and receptors. Therefore, [T2-T3] ETS might have modified the sympathetic regulation of adrenaline secretion from the adrenal medulla. [T2-T3] ETS increases the plasma level of atrial natriuretic peptide, which has widespread sympatholytic activity. [T2-T3] ETS might have influenced the amount of adrenaline secreted from the adrenal medulla via changes in humoral factors such as atrial natriuretic peptide."(Nakamura 2002)

Stroke index and systemic vascular resistance were similar both at rest and at submaximal exercise before and after ETS. Thus, ETS reduces myocardial oxygen demand and plasma noradrenaline levels both at rest and during exercise without significantly depressing cardiac function in terms of stroke volume.
http://www.ncbi.nlm.nih.gov/pubmed/11954949?dopt=Abstract

a technique that is associated with a number of potential problems

Transthoracic endoscopic sympathectomy is now considered the treatment of choice for patients with upper limb hyperhidrosis requiring sympathetic ablation. This procedure requires the use of an endobronchial double lumen tube and subsequent one-lung anaesthesia, a technique that is associated with a number of potential problems. Full patient monitoring is thus required and includes pulse, ECG, non-invasive blood pressure measurement, pulse oximetry, end-tidal carbon dioxide concentration and peak inspiratory airway pressure.

Anaesthetic implications for transthoracic endoscopic sympathectomy.

PMID: 7524779 [PubMed - indexed for MEDLINE] Eur J Surg Suppl. 1994;(572):33-6.

Hypoxaemia is of a major concern during thorascopic sympathectomy

However the pathophysiology of hypoxaemia and consequent decrease in SpO2 differs between the two anaesthetic techniques.

The normal physiological response to massive atelectasis is an increase in pulmonary vascualr resistance (hypoxic pulmonary vasoconstriction) with re-routing of blood to well ventilated lung zones and consequent improvement of in PaO2. However, during endobronchial anaesthesia for thoracic sympathectomy there is an apparent failure of this compensatory mechanism. When more than 70% of the lung is atelectatic, compensation by hypoxic pulmonary vasonstriction appears to be ineffective. Furthermore, in in vitro and animal studies, inhalation anaesthetic agent have been shown to depress hypoxic pulmonary vasoconstriction.

In a study by Hartrey and colleagues, SpO2<95%>20 mm Hg in 21% of patients. Similarly, we have reported sudden hypotension and bradycardia after injudicious carbon dioxide insufflation.

In an interesting study of the delayed cardiac effects of T2-4 sympathectomy, Drott and colleagues demmonstrated significantly reduced heart rate at rest, and during both exercise and the recovery phase of the exercise.
Changes in the electrical axis and shortening of the QT interval have also been reported.
B. Fredman, D. Olsfanger, R. Jedeikin
British Journal of Anaesthesia 1997; 79: 113-119

Loss of coordinated autonomic responses to demands on heart rate and vascular tone

Autonomic dysreflexia - Spinal cord injuries (SCI) above T6 may be complicated by a phenomenon known as autonomic dysreflexia, a manifestation of the loss of coordinated autonomic responses to demands on heart rate and vascular tone [5,6]. Uninhibited or exaggerated sympathetic responses to noxious stimuli lead to diffuse vasoconstriction and hypertension. A compensatory parasympathetic response produces bradycardia and vasodilation above the level of the lesion, but this is not sufficient to reduce elevated blood pressure. SCI lesions lower than T6 do not produce this complication, because intact splanchnic innervation allows for compensatory dilatation of the splanchnic vascular bed.

The estimated frequency of this complication is quite variable, ranging from 20 to 70 percent of patients with SCI lesions above T6 [5,6]. Autonomic dysreflexia is unusual within the first month of SCI but usually appears within the first year [7,8].

Common clinical manifestations are headache, diaphoresis, and increased blood pressure [7]. Flushing, piloerection, blurred vision, nasal obstruction, anxiety, and nausea may also occur. Bradycardia is common; however, some patients have tachycardia instead. The severity of attacks ranges from asymptomatic hypertension to hypertensive crisis complicated by profound bradycardia and cardiac arrest or intracranial hemorrhage and seizures. The severity of the SCI influences both the frequency and severity of attacks.

CAD mortality also appears to be higher among SCI patients [4]. One contributing factor may be that SCI lesions above the T5 level may lead to atypical presentations for cardiac ischemia; manifestations may include autonomic dysreflexia or changes in spasticity rather than typical chest pain.

The autonomic nervous system dysfunction that results from SCI disrupts normal cardiovascular hemostasis. With SCI above the T6 level, baseline blood pressure is usually reduced, and baseline heart rate may be as low as 50 to 60 beats per minute [12,16]. This is generally not a clinical problem, but may contribute to hemodynamic instability and exercise intolerance.

Acute cervical SCI is associated with a risk of cardiac arrhythmia due to excess vagal tone, as well as complicating hypoxia, hypotension, and fluid and electrolyte imbalances.

http://www.uptodate.com/patients/content/topic.do?topicKey=~VwAwFq7EG6jGfV

bradycardia as likely, compensatory sweating as obligatory after Sympathectomy

Clin Auton Res. 2003 Dec;13 Suppl 1:I36-9.

Sequelae of endoscopic sympathetic block.

Schick CH, Horbach T.

Dept. of Surgery, University of Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany. schick@hyperhidrosis.de

Endoscopic sympathetic block as a treatment for primary hyperhidrosis is associated with certain sequelae. The reported occurrence of side effects still varies in the literature. As the majority of patients describe sequelae after sympathetic surgery, the frequency and importance of these persisting changes are still underestimated. Patient's informed consent should include and define side effects like gustatory sweating, olfactory sweating and bradycardia as likely, and compensatory sweating as obligatory.

PMID: 14673671 [PubMed - indexed for MEDLINE]

Räf L, Claes G. Complications are frequent after surgery for excessive hand sweating. Patients should be informed about the risks

Lakartidningen 1999;96:930-2. (In Swedish.)

ETS for palmar HH results in systemic (non-localized) changes of the ANS function

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.
Associated change in plantar temperature and sweating after transthoracic endoscopic T2-3 sympathectomy for palmar hyperhidrosis.

Chen HJ, Liang CL, Lu K.

Department of Neurosurgery, Chang Gung University and Medical Center at

Kaohsiung, Taiwan. chenmd@ms8.hinet.net
PMID: 11453433 [PubMed - indexed for MEDLINE]

Forced vital capacity, forced expiratory volume were all slightly but significantly decreased after sympathectomy

J Clin Neurosci 2001 Nov;8(6):539-41

Thoracoscopic sympathectomy for palmar hyperhidrosis: effects on pulmonary function.

Tseng MY, Tseng JH.

tmy59100@ms4.hinet.net

Palmar hyperhidrosis, probably caused by an over-reactivity of sympathetic nerves passing through the second and the third thoracic sympathetic ganglia (T2 & T3 ganglia), can only be cured by sympathectomy. Such sympathetic denervation may also alter pulmonary function. In order to investigate the effect of sympathectomy, pulmonary function was compared before and four weeks after operation in 20 patients. Forced vital capacity (FVC) (-2.3%), forced expiratory volume in one second (FEV1) (-6.1%), and FEV1/FVC (-4.6%) were all slightly but significantly decreased four weeks after thoracoscopic sympathectomy. Also the instantaneous forced expiratory flow at 75%, 50% and 25% of the FVC (Vmax25, Vmax50, Vmax75) in flow-volume curves were decreased (-1.6%, -8.4%, and -20% respectively).

PMID: 11787462 [PubMed - indexed for MEDLINE]

baroreflex response for maintaining cardiovascular stability is suppressed in the patients who received the ETS

Our results indicated that T2-3 sympathectomy suppressed baroreflex control of heart rate
in both pressor and depressor tests in the patients with palmar hyperhidrosis. We should
note that baroreflex response for maintaining cardiovascular stability is suppressed in the
patients who received the ETS.

Anesthesiology 2001; 95:A160

PAROTID DEGENERATION SECRETION FOLLOWING SYMPATHECTOMY

January 1, 1982 Experimental Physiology, 67, 7-15.

Correspondingly the acini were loaded with secretory granules at 12 and 48 hours but were extensively depleted of granules at 24 hours. This loss of granules is considered to be due to sympathetic "degeneration secretion" caused by the release of noradrenaline from the degenerating adrenergic nerves between 12 and 24 hours after ganglionectomy. This is thought to be the first example of morphological change resulting from "degeneration activation" to be recorded microscopically.
Cell Tissue Res. 1975 Sep 16;162(1):1-12.

Degeneration Secretion and Supersensitivity in Salivary Glands following Denervations, and the Effects on Choline Acetyltransferase Activity.
Garrett JR, Ekstr�m J, Anderson LC (eds): Neural Mechanisms of Salivary Gland Secretion.Front Oral Biol. Basel, Karger, 1999, vol 11, pp 166-184
(DOI: 10.1159/000061117)

Circulating catecholamines, however, influence the amount of amylase and peroxidase secreted by the rat parotid gland in response to parasympathetic nerve stimulation and account for most of the increased secretion of these enzymes following chronic sympathectomy.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1193204

There was a reduction in all proline-rich proteins (PRP) in the saliva following sympathectomy.
http://www.find-health-articles.com/rec_pub_2450385-influences-short-term-sympathectomy-composition-proteins-rat-parotid.htm

Sympathectomy decreases the release of tissue plasminogen activator (t-PA) from blood vessels

Sympathectomy decreases and adrenergic stimulation increases the release of tissue plasminogen activator (t-PA) from blood vessels: Functional evidence for a neurologic regulation of plasmin production within vessel walls and other tissue matrices http://www3.interscience.wiley.com/journal/63500193/abstract

Left cardiac sympathectomy prevents exercise-induced QTc prolongation in congenital long QT syndrome

Exp Clin Cardiol. 2003 Spring; 8(1): 31–32.

PMCID: PMC2716198

Copyright © 2003, Pulsus Group Inc. All rights reserved

Lexin Wang, MD PhD

School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, Australia

Correspondence and reprints: Dr Lexin Wang, School of Biomedical Sciences, Charles Sturt University, Wagga Wagga, NSW 2650, Australia. Telephone +61-2-6933-2909, fax +61-2-6933-2587, e-mail, lwang@csu.edu.au

ability of blood platelets to aggregate is significantly lower

It is shown that the ability of blood platelets to aggregate in partially and completely sympathectomized rats is significantly lower than in intact animals. The blood clotting system of sympathectomized rats is hyperactive. The sympathectomy-provoked changes may be due to the increased content of adrenaline in the blood.

	Cellular and Molecular Life Sciences
Publisher	Birkhäuser Basel
ISSN	1420-682X (Print) 1420-9071 (Online)
Issue	Volume 36, Number 7 / July, 1980

esidual pneumothorax is common,gas exchange may be impaired and the lung is at some risk of recollapse

Editor- Cameron may not advocate that bilateral thoracoscopic sympathectomy should be staged but I certainly do .It may be eccentric but it is safe.Immediate sustained full reexpansion and perfect functioning of a lung that was completely deflated a few minutes before cannot be guaranteed. Residual pneumothorax is common,gas exchange may be impaired and the lung is at some risk of recollapse.To collapse the contralateral normal lung in such circumstances might be the practice of a majority of surgeons but it is still unwise.Collapse of one lung is a misfortune, collapse of both lungs is not compatible with life.

Cameron`s claim that there has been only one death attributable to synchronous bilateral thoracoscopic sympathectomy is implausible. Surgeons and anaesthetists are reticent in publicizing such events and Civil Law Reports of settled cases are an inadequate measure of the current running total. The custom of a majority is no guarantee of safety and is seldom a guide to best medical practice.
Jack Collin,
Consultant Surgeon
Oxford
http://www.bmj.com/cgi/eletters/320/7244/1221

After unilateral sympathectomy the incidence of medial calcinosis on the operated side was significantly higher than on the non-operated side

Six to eight years after uni- or bilateral lumbar sympathectomy 60 patients were investigated radiologically for medial calcinosis of foot arteries. Of 60 patients, 55 had Mönckeberg's sclerosis. In 93% of the patients who had undergone bilateral operation medial calcification was seen in both feet. After unilateral sympathectomy the incidence of medial calcinosis on the operated side was significantly higher than on the non-operated side (88% versus 18%, p less than 0.01). There was no significant difference between diabetics and non-diabetics. These findings suggest that medial calcification is related to autonomic neuropathy of peripheral vessels. Fifty-two of 160 patients (32.5%) with severe arterial occlusive disease of the lower limbs showed medial calcification of foot arteries. Mönckeberg's sclerosis was significantly associated with the peripheral type of vascular disease (p less than 0.025).
Klin Wochenschr. 1985 Mar 1;63(5):211-6.
PMID: 3990163 [PubMed - indexed for MEDLINE

Medial arterial calcification (MAC) is a frequent vascular finding in patients with type II diabetes mellitus. Morphologically distinct from focal calcifications of atherosclerosis its radiographically distinct tramline pattern is frequently encountered in the arteries of the lower extremities. MAC is inconsistently related to age, duration and therapy of diabetes. In contrast, a strong association with diabetic polyneuropathy and familial aggregation have been documented. Although initially considered benign MAC is now recognized as a strong predictor of cardiovascular morbidity and mortality in diabetic patients. Investigations into MAC pathogenes and into its role in vascular pathophysiology are underway.

	Zeitschrift für Kardiologie
Publisher	Steinkopff
ISSN	0300-5860 (Print) 1435-1285 (Online)
Issue	Volume 89, Number 14 / February, 2000
DOI	10.1007/s003920070107

Reduced brain perfusion and cognitive performance

Chronically low blood pressure is accompanied by a variety of complaints including fatigue, reduced drive, faintness, dizziness, headaches, palpitations, and increased pain sensitivity [1–4]. In addition, hypotensive individuals report cognitive impairment, above all deficits in attention and memory. Nevertheless, it is generally the case that in research, as well as in clinical practice, relatively little importance is ascribed to hypotension. One reason for this is that, despite mental symptoms, cerebral dysfunction generally is not taken into account [1]. This is a consequence of the current doctrine that low systemic blood pressure is compensated by autoregulatory processes which prevent reduced blood perfusion of the brain [5, 6].

Some recent findings challenge this doctrine: reduced cognitive performance in hypotension has been demonstrated by neuropsychological testing, and EEG studies have revealed diminished cortical activity. Moreover, the assumption of unimpaired brain perfusion in hypotension no longer holds. In the present review the necessity of a reappraisal concerning hypotension is discussed in light of the relationship between blood pressure and cerebral functioning.

Clin Auton Res. 2007 April; 17(2): 69–76. Published online 2006 November 14. doi: 10.1007/s10286-006-0379-7.

PMCID: PMC1858602

Stefan Duschek and Rainer Schandry
Stefan Duschek, Phone: +49-89/2180-5297, Fax: +49-89/2180-5233, Email: duschek@psy.uni-muenchen.de

Only 20.3% suffered from severe CH

Sympathectomy is the treatment of choice for primary hyperhidrosis. One curious occurrence that is difficult to explain from an anatomophysiological point of view in cases of video-assisted thoracoscopic sympathectomy (VATS) for the treatment of palmar hyperhidrosis (PH) is the observed improvement in plantar hyperhidrosis (PLH). Nevertheless, current reports on VATS rarely describe the effect on PLH or just give superficial data. The aim of this study was to prospectively investigate, how surgery affects PLH in patients with PH and PLH over one-year period. From May 2003 to January 2004, 70 consecutive patients with combined PH and PLH underwent VATS at the T2, T3, or T4 ganglion level (47 women and 23 men, with mean age of 23 years). Immediately after the operation, all the patients said they were free from PH episodes, except for two patients (2.8%) who suffered from continued PH. Compensatory hyperhidrosis (CH) of various degrees was observed in 58 (90.6%) patients after one year. Only 13 (20.3%) suffered from severe CH. There was a great initial improvement in PLH in 50% of the cases, followed by progressive regression, such that only 23.4% still presented that improvement after one year. The number of cases without overall improvement increased progressively (from 17.1% to 37.5%) and the numbers with slight improvement remained stable (32.9–39.1%). Of the 24 patients with no improvement after one year, 6 patients graded plantar sweating worse.

Wolosker, Nelson¹ nwolosker@yahoo.com.br
Yazbek, Guilherme¹
Milanez de Campos, José²
Kauffman, Paulo¹
Ishy, Augusto²
Puech-Leão, Pedro¹

Source:

Clinical Autonomic Research; Jun2007, Vol. 17 Issue 3, p172-176, 5p, 1 chart

statistically significant changes were recorded in the head, hands, axillas, and soles

Redistribution of perspiration as reported by the patients comprised significant reduction in the palms, axillas, and soles, and an increase in the abdomen, back, and gluteal and popliteal regions. Regarding the incidence of anhidrosis by anatomical location, statistically significant changes were recorded in the head, hands, axillas, and soles ( p < 0.001). Bilateral upper thoracic sympathicolysis is followed by redistribution of body perspiration, with a clear decrease in the zones regulated by mental or emotional stimuli, and an increase in the areas regulated by environmental stimuli, though we are unable to establish the etiology of this redistribution.
Surgical Endoscopy; Nov2007, Vol. 21 Issue 11, p2030-2033, 4p, 2 charts

Elimination of the dominant signal (e.g., surgical sympathectomy) may allow a secondary- signal to control phase

Sympathetic input modulates, but does not determine, phase of peripheral circadian oscillators.

American Journal of Physiology: Regulatory, Integrative & Comparative Physiology; Jul2008, Vol. 64 Issue 1, pR355-R360, 6p, 2 charts, 2 graphs

Similar pathological effects of sympathectomy and hypercholesterolemia on arterial smooth muscle cells and fibroblasts

Acta Histochemica; Jul2008, Vol. 110 Issue 4, p302-313, 12p

Six percent of the patients regret the surgery because of severe CS

European Journal of Cardio-Thoracic Surgery; Sep2008, Vol. 34 Issue 3, p514-519, 6p

Pulmonary Function and Bronchial Hyperresponsiveness.

Of 46 patients who had a negative result for methacholine challenge preoperatively, 12 (26%) became positive after surgery. In terms of the level of sympathectomy, T3 sympathectomy significantly increased the ratio of patients exhibiting a positive response to methacholine (from 19% to 34%, respectively) (p <>sympathectomy can adversely affect lung function early after surgery, although the clinical significance is uncertain. It may also exert an influence on the development of bronchial hyperresponsiveness, especially when performed at the T3 level.
Journal of Asthma; Apr2009, Vol. 46 Issue 3, p276-279, 4p, 3 charts

sympathectomy can produce capillary abnormalities in the retina similar to those seen in early diabetes

Diabetes can cause damage to sympathetic nerves, and we have previously shown that experimental sympathectomy can produce capillary abnormalities in the retina similar to those seen in early diabetes.
Experimental Eye Research; Jun2009, Vol. 88 Issue 6, p1014-1019, 6p

Steinle, Jena J.¹ jsteinl1@utmem.edu
Kern, Timothy S.²
Thomas, Steven A.³
McFadyen-Ketchum, Lisa S.⁴
Smith, Christopher P.⁴

Bilateral surgical sympathectomy provides a valuable tool for future investigations of the cellular basis of supersensitivity in the myocardium

Volume 234, Issue 1, pp. 280-287, 07/01/1985
Copyright © 1985 by American Society for Pharmacology and Experimental Therapeutics

Long-Term Denervation of Vascular Smooth Muscle Causes Not Only Functional but Structural Change

Rosemary D. Bevan, Hiromichi Tsuru

Department of Pharmacology, School of Medicine, University of California, Los Angeles, Calif.

Address of Corresponding Author

Blood Vessels 1979;16:109-112 (DOI: 10.1159/000158197)

Bilateral cervical sympathectomies should be avoided because of the destruction of cardioaccelerator tone

http://www.hiesiger.com/physicians/physicianrfl.html

Receptor hypersensitivity is a common problem after significant sympathetic injury

Because of their size and location, injuries to the sympathetic ganglia or chain is rarely indicated or performed. Receptor hypersensitivity is a common problem after significant sympathetic injury, including clammy hands, erythema, and allodynia. When sympathetic nerves regenerate, they may establish aberrant connections to sensory receptors, muscles, or other sympathetics receptors; this may lead to an over-response or abnormal response.
http://wiki.cns.org/wiki/index.php/Injury,_Sympathetic_Nerve

Long-term cardiopulmonary function after thoracic sympathectomy

Lung function tests revealed a significant decrease in forced expiratory volume in 1 second (FEV(1)) and forced expiratory flow between 25% and 75% of vital capacity (FEF(25%-75%)) in both groups (FEV(1) of -6.3% and FEF(25%-75%) of -9.1% in the conventional thoracic sympathectomy group and FEV(1) of -3.5% and FEF(25%-75%) of -12.3% in the simplified thoracic sympathectomy group). Dlco and heart rate at rest and maximal values after exercise were also significantly reduced in both groups (Dlco of -4.2%, Dlco corrected by alveolar volume of -6.1%, resting heart rate of -11.8 beats/min, and maximal heart rate of -9.5 beats/min in the conventional thoracic sympathectomy group and Dlco of -3.9%, Dlco corrected by alveolar volume of -5.2%, resting heart rate of -10.7 beats/min, and maximal heart rate of -17.6 beats/min in the simplified thoracic sympathectomy group).
J Thorac Cardiovasc Surg 2009 Jun 25.

blocks the cardiac sympathetic fibers and consequently decreases heart rate, cardiac output and contractility

The CEA (Cervical Epidural Anaesthesia) blocks the cardiac sympathetic fibers and consequently decreases heart rate, cardiac output and contractility. The mean blood pressure is unchanged or decreased, depending on peripheral systemic vascular resistance changes. The baroreflex activity is also partly impaired. Sympathetic blockade also decreases myocardial ischaemia. The cardiovascular changes induced by CEA are also partly due to the systemic effect of the local anaesthetic. The respiratory effects are minimal and depend on the extent of the blockade and the concentration of the local anaesthetic. A moderate restrictive syndrome occurs. Since the phrenic nerves originate from C3 to C5, ventilation may be impaired by CEA. Extension of the block may also impair intercostal muscle function, with a risk of respiratory failure when a CEA is used in patients with compromised respiratory function. The potential specific complications, mainly cardiovascular and respiratory, are the exacerbation of the effects of CEA. Side effects such as bradycardia, hypotension and acute ventilatory failure in relation to respiratory muscle paralysis, may be observed. Close monitoring of haemodynamics, respiratory rate and level blockade is required.
Ann Fr Anesth Reanim. 1993;12(5):483-92.
PMID: 8311355 [PubMed - indexed for MEDLINE

response varies depending on the degree of sympathetic tone before the block

Individual cardiovascular response to different levels of sympathetic blockade varies widely, depending on the degree of sympathetic tone before the block.
High TEA added to general anaesthesia significantly decreased the cardiac acceleration in response to decreasing blood pressure, suggesting that baroreflex-mediated heart rate response to a decrease in arterial blood pressure depends on the integrity of the sympathetic nervous system.
Anaesthesia and Intensive Care. Edgecliff: Dec 2000. Vol. 28, Iss. 6, p. 620-35 (16 pp.) Australian Society of Anaesthetists

HPA-axis plays a crucial role in the development and intensity of autoimmune diseases

Like in man, in animals the HPA-axis plays a crucial role in the development and intensity of autoimmune diseases. Corticosteroids, in particular, are known to suppress T-cell induced autoimmune reaction in animal models, at the beginning, and are capable to support spontaneous recovery.

EAE derived data support that increased HPA-axis reactivity is accompanied by enlarged capacity to secrete and produce Th-2-cytokines. While decreased HPA-reactivity is accompanied by enlarged capacity to secrete and produce Th-1-cytokines.

Sympathectomy and axanotomy were accompanied by stress-induced increases of EAE immunological responses. Transferred Th1-cells of such sympathectomized animals to healthy animals resulted in increased EAE.
In: Research Focus on Cognitive Disorders ISBN 1-60021-483-5
Editor: Valerie N. Plishe © 2007 Nova Science Publishers, Inc.

sympathectomy might suppress immune functions

It has been found that sympathectomy might influence tumorigenesis. The published data suggests that sympathectomy might suppress immune functions.

Sympathectomy might influence thermogenesis by modulating the activity the activity of the immune system in two ways - by reducing the modulatory influences of catecholamines on immune cells as well as by increasing the secretion of glucocorticoids.
Seminars in Cancer Biology 18 (2008)
Bors Mravec, Yori Gidron, Ivan Hulin

The altered pattern of the response suggests that the nitric oxide-dependent portion may be accelerated in sympathectomized limbs

J Appl Physiol. 2002 Feb;92(2):685-90.

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

Circulation Research. 1996;79:317-323

sympathectomy results in an increased collagen content in the vascular wall

From animal experiments, it is known that long-term sympathectomy results in an increased collagen content in
the vascular wall, suggesting a stiffening of the vessel wall (9). Giannattasio et al.

MEDICINE & SCIENCE IN SPORTS & EXERCISE®
Copyright © 2005 by the American College of Sports Medicine
DOI: 10.1249/01.mss.0000174890.13395.e7

adverse effects and complications are not systematically reported

Studies (corresponding to 5,425 patients) classified compensatory hyperhidrosis either as minor (insignificant) or major (quite disabling). In these studies, 26.3% or one quarter of patients with compensatory hyperhidrosis considered the complication major and disabling. The average time between surgical sympathectomy and the appearance of compensatory hyperhidrosis was 4 months (range 1-6 months). (82;93;118) The incidence of compensatory hyperhidrosis did not seem to be different after open or endoscopic approach.

The weighted mean incidence of gustatory sweating after upper extremity surgical sympathectomy was 32.3% (range 0-79)

The weighted mean incidence of phantom sweating was 38.6 % (range 0-59%), with data extracted from 13 papers (that specifically reported the phenomenon) and 1,539 patients.

The weighted mean incidence of neuropathic pain complications was 11.9% (range 0-87%),with data extracted from 37 papers and 1,979 patients.

Given the fact that most of the existing literature is geared towards a) assessing only the effectiveness of the surgical sympathectomy procedures, and b) publishing only studies with positive results, adverse effects and complications are not systematically reported but rather as a secondary outcome. It seems, therefore, highly likely that the complications as reported here, are truly underestimated.

The study indicates that surgical sympathectomy, irrespective of operative approach and indication, may be associated with many and potentially serious complications.

A Systematic Literature Review of Late Complications

Andrea Furlana,c MD, Angela Mailisa,bMD, MSc, FRCPC

(PhysMed) and Marios Papagapioua Msc

unable to establish the etiology of redistribution

Regarding the incidence of anhidrosis by anatomical location, statistically significant changes were recorded in the head, hands, axillas, and soles ( p < 0.001).
Bilateral upper thoracic sympathicolysis is followed by redistribution of body perspiration, with a clear decrease in the zones regulated by mental or emotional stimuli, and an increase in the areas regulated by environmental stimuli, though we are unable to establish the etiology of this redistribution.
Surgical Endoscopy; Nov2007, Vol. 21 Issue 11

migration of adventitial fibroblasts and loss of medial smooth muscle cells

In a previous study, we showed that after sympathectomy, the femoral (FA) but not the basilar (BA) artery from non-pathological rabbits manifests migration of adventitial fibroblasts (FBs) into the media and loss of medial smooth muscle cells (SMCs). The aim of the present study was to verify whether similar behaviour of arteries occurred in the pathological context of atherosclerosis.
Our results show that in the media of FAs hypercholesterolemia induces changes similar to those observed in sympathectomized rabbits in non-pathological conditions, i.e., migration of adventitial FBs to the media and loss of medial SMCs. These latter changes, which can be ascribed to pathological events, were accentuated after sympathectomy in the hypercholesterolemic rabbits. The present study reveals that pathological events, including migration and phenotypic modulation of vascular FBs and loss of SMCs, may be under the influence of sympathetic nerves.
Acta Histochemica; Jul2008, Vol. 110 Issue 4, p302-313, 12p

elevated susceptibility to ventricular fibrillation after sympathectomy

We conclude that chemical sympathectomy downregulates the expression of selective Kv channel subunits and decreases myocardial Ito channel activities, contributing to the elevated susceptibility to ventricular fibrillation.
Canadian Journal of Physiology & Pharmacology; Oct2008, Vol. 86 Issue 10,

Side effect of elective surgery - disastrous proportions

Compensatory hyperhidrosis (CHH) remains an unexplained sequel of this treatment, attaining in a small percentage of cases disastrous proportions.

The search identified 42 techniques of sympathetic ablation. However, pertinent data for the present study were reported for only 23 techniques with multiple publications found only for 10. The only statistically valid results from this review point that T2 resection and R2 transection of the chain (over the second rib) ensue in less CHH than does electrocoagulation of T2. Further comparisons were probably prevented due to the enormous disparity in the reported results, indicating lack of standardization in definitions. The compiled results published so far in the literature do not support the claims that lowering the level of sympathetic ablation, using a method of ablation other than resection, or restricting the extend of sympathetic ablation for primary palmar hyperhidrosis result in less CHH. In the future, standardization of the methods of retrieving and reporting data are necessary to allow such a comparison of data.
World Journal of Surgery; Nov2008, Vol. 32 Issue 11, p2343-2356, 14p

High incidence of nausea and vomiting after sympathectomy

Although complications are rare, patients should be clearly warned that it is not a minor procedure [1,4]. Nevertheless, effective analgesia, radiologie follow-up and strict antiemetic prophylaxis measures are recommended [6].
Because of the high Incidence of nausea and vomiting in our study, we have reconsidered antiemetic prophylaxis in patients at moderate risk (two risk factors). We also recommend strategies for lowering underlying risk such as using total intravenous anaesthesia, keeping opioid use to a minimum and intravenously administering a large volume of preoperative balanced salt solution [6]. We found no reason to explain the high incidence of nausea and vomiting in these patients other than failure to implement these measures. There might have been an effect of starting to drink in the postoperative intensive care area;
however, we could not establish a correlation between start of drinking and the onset of nausea and vomiting.
Thoracic sympathectomy by videothoracoscopy on an outpatient basis can be performed safely if strict control
of pain is established and vomiting and surgical complications are avoided. Nevertheless, the anaesthesiologist
should be alert to the possibility of serious complications associated with this type of surgery.

European Journal of Anaesthesiology 2009, Vol 26 No 4

SNS regulates cerebral blood flow

Thus, in the conscious dog, stimulation of the carotid chemoreceptor reflex elicits significant sympathetically mediated vasoconstriction in cerebral vessels.
Am J Physiol. 1980 Apr;238(4):H594-8.

sympathetic denervation-hypersensitivity and migraine

Regional cerebral blood flow (rCBF) and cerebral vasomotor responses to 5% CO₂ inhalation were measured before and after pharmacologic μ- or β-adrenoceptor manipulation in Migraine (M) and Cluster headaches (C).
There appears to be an asymmetrical adrenoceptor disorder in M and C possibly due to sympathetic denervation-hypersensitivity.

Headache: The Journal of Head and Face Pain

Volume 20 Issue 6, Pages 321 - 335

Published Online: 22 Jun 2005

http://www3.interscience.wiley.com/journal/119584269/abstract

Complications of endoscopic sympathectomy

Alan E. P. Cameron

Abstract

Four cases are presented in which complications occurred during or after thoracic endoscopic sympathectomy (TES). In one patient inappropriate TES resulted in disabling hyperhidrosis. In one patient laceration of the subclavian artery required major surgery. In two cases intraoperative cerebral damage occurred. Training in TES is essential.

European Journal of Surgery

See Also:

• British Journal of Surgery

Volume 164 Issue S1, Pages 33 - 35

Published Online: 2 Dec 2003

Catastrophic complications - tension pneumothorax

Catastrophic complications such as delayed recognition of tension
pneumothorax from left sided CO2 insufflation, leading to fatal and
disabling consequences was reported.

Doolabh N, Horswell S, Williams M, Huber L, Syma Prince S, Meyer
DM, and Mack MJ. Thoracoscopic Sympathectomy for Hyperhi-
drosis: Indications and Results. Ann Thorac Surg 2004; 77: 410 – 414.

medical sects and cults that propagate the Absurd

“...when irrational beliefs are shared with a surrounding community of sympathetic thinkers, errors become institutionalized. Thus are generated medical sects and cults that propagate the Absurd....
The guardians that usually keep the institution of medicine from reeling off into irrationality are social contracts built into medical science and ethical behavior. The academic community guards the contractual borders of science, while laws and regulations encode our ethical system. For the Absurd to have advanced, there must have been some breakdown of these social guardians.”
Propagation of the Absurd: demarcation of the Absurd revisited
Wallace Sampson, MD Editor and Clinical Professor of Medicine, Stanford University
Kimball Atwood IV, MD, Anaesthesiologist; and Assistant Clinical Professor, Tufts University School of Medicine Medical Journal of Australia Dec. 2005

Arthritis exacerbated following sympathectomy

"...capsaicin-eenhanced DRRs are blocked by sympathecotmy. In contrast, arthritis even be exacerbated following sympathectomy. Surgical sympathectomy does exert profound effects on immune system stimulation in the early stages of adjuvant arthritis and may therefore affect disease progression through this action."

Furthermore, the sympathetic nervous system may play a regulatory role in secondary lymphoid organs as it has been shown that selective sympathectomy in secondary lympoid organs exacerbates experimental arthritis.

Neurogenic Inflammation in Health and Disease, Volume 8 (NeuroImmune Biology)  By Gabor Jancso

Morphological and functional studies revealed a complex system of primary sensory neurons which parallels the autonomic nervous system not only in its extent, but probably also in its significance. Neuropeptides released from activated nociceptive afferent nerves play a pivotal role in inflammatory reactions and pain, significantly modulate cardiac, vascular, respiratory, gastrointestinal and immune functions and influence the protective, restorative and trophic functions of somatic and visceral tissues.

Publication Date: 2009-01-01

Publisher: Elsevier Science & Technol

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

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.
Brain, Behavior, and Immunity
Volume 12, Issue 3, September 1998, Pages 230-241

International Society for Sympathetic Surgery founded

Here are the basics of our new classifications:
ESB2 (clamp upper end of T2 only): 2.5%, (in Europe 15%)
Facial blushing, Craniofacial sweating, Some psychic disorders, Rosacea, Vibration disorder (?), Parkinsonism (?)...
ESB3: 2.5%, (in Europe 50%)
Hyperhidrosis Palmaris with Craniofacial sweating, blushing, or any other craniofacial sympathetic disorders
ESB4: 95%, (in Europe 20%)
Hyperhidrosis Palmaris with or without axillary hyperhidrosis (Bromidrosis)
Unilateral ESB: (in Europe 15%)
Social phobia, schizophrenia, sleep disorders, addiction, cardiac arrhythmias

http://www.hyperhidrosis.com/symposium.htm

The 4^th International Symposium on Sympathetic Surgery was held in Finland in June 2001, and was attended by the world’s most renowned ETS surgeons, including its Chairman, Dr. Timo Telaranta. Louis Stein of Surgical Team was there to listen to the experts.

· International Society for Sympathetic Surgery founded
International Society for Sympathetic Surgery was founded during the Symposium. It has a council of five members:

- Dr. Christer Drott from Sweden - The Society’s first Chairman
- Dr. Christoph Schick from Germany
- Dr. Timo Telaranta from Finland
- Dr. Chien-Chih Lin from Taiwan
- Dr. Moshe Hashmonai from Israel

Dr. Alan Cameron from England joined as an English language expert, especially for the revision of the by-laws.

Significant reductions in maximal heart rate (HR) and oxygen and carbon dioxide uptakes were observed

Ten patients had positive bronchial challenge test results that remained positive 3 months after surgery, and 2 patients whose challenge test results were negative before surgery became positive after sympathectomy. Significant reductions in maximal heart rate (HR) and oxygen and carbon dioxide uptakes were observed during the maximal exercise test.
CHEST October 2005 vol. 128 no. 4 2702-2705

Role of sympathoadrenergic mechanisms in arrhythmogenesis

The NA content in the heart was not measured but it is likely to be small at least at the 10-day period. It is known that three days after chemical sympathectomy NA content is only 7% of normal value [6]. Second, the development of adrenoceptor supersensitivity in the transplanted heart was demonstrated clearly with enhanced heart rate responses to NA or propranolol (at Day 10) [1]. As dennervation sensitization increases the arrhythmia susceptibility [6], it is thus possible that, in the presence of receptor supersensitivity, adrenergic activation occurs by either increase in circulating catecholamines and possibly local release of residual NA, which might still have been sufficient to contribute to arrhythmia development.
Role of sympathoadrenergic mechanisms in arrhythmogenesis
Xiao-Jun Du* and Anthony M. Dart
Baker Medical Research Institute, Melbourne, Victoria, Australia
Cardiovascular Research 1999 43(4):832-834;

Surgeons should be aware of adverse effects such as bradycardia

The heart rate and systolic blood pressure decreased significantly after T2-T3 ganglionectomy.

A prolonged QT interval was also recorded (p<> 0.05). The decrease was significant in the sympathectomy group.

Our study also, it was revealed that sympathectomy significantly prolonged the QT interval.

Surgeons should be aware of adverse effects such as bradycardia during thoracic sympathectomy. This study suggested that careful monitoring was required during thoracic sympathectomy and early postoperative period.

Orhan YÜCEL, MD

GATA, Department of

Thoracic Surgery, Ankara,

TÜRKİYE/TURKEY

Sympathetic nervous system regulation of immunity

"suppressor T cells through an immune-privileged site requires an intact sympathetic nervous system."

Journal of Neuroimmunology
Volume 147, Issues 1-2, February 2004, Pages 87-90

Sympathectomy-induced alterations in immunity

These experiments indicate that an inflammatory response is not likely to be responsible for sympathectomy-induced immune alterations, eliminating a potential confounding factor in interpreting sympathectomy studies.
Brain, behavior and immunity ISSN 0889-1591
2002, vol. 16, n^o1, pp. 33-45 [13
CALLAHAN Tracy A. ; MOYNIHAN Jan A. ;

Reduced Heart Rate Variability associated with incresed mortality

These results support an association between CAN (cardiovascular autonomic neuropathy) and increased risk of mortality. The stronger association observed in studies defining CAN by the presence of two or more abnormalities may be due to more severe autonomic dysfunction in these subjects or a higher frequency of other comorbid complications that contributed to their higher mortality risk. Future studies should evaluate whether early identification of subjects with CAN can lead to a reduction in mortality.

1. Raelene E. Maser, PHD1,
2. Braxton D. Mitchell, PHD2,
3. Aaron I. Vinik, MD, PHD3 and
4. Roy Freeman, MD4

Sympathectomy also results in reduced heart rate variability

"Cardiovascular autonomic neuropathy (CAN) is the most prominent focus because of the life-threatening consequences and the availability of direct tests of cardiovascular autonomic function.. .CAN results from damage due to the autonomic nerve fibers that innervate the heart and blood vessels and results in abnormalities in heart rate control and vascular dynamics. Reduced heart variation is the earliest indicator of CAN."

"CAN is the most studied and clinically important form of DAN. Meta-analyses of published data demonstrate that reduced cardiovascular autonomic function as measured by heart rate variability (HRV) is strongly associated with an increased risk of silent myocardial ischemia and mortality. The determination of the presence of CAN is usually based on a battery of autonomic function tests..."

TECHNICAL REVIEW: Standard of Care - Diabetic Autonomic Neuropathy

Aaron I. Vinik, MD, PHD; Braxton D. Mitchell, PHD
Raelene E. Maser, PHD; Roy Freeman, MD

Skin denervation

Epidermal nerve fiber densities were significantly reduced in the skin of all patients, consistent with concomitant small-fiber neuropathies. Perivascular infiltration by T cells and macrophages was demonstrated by immunohistochemistry. All patients experienced neurologic improvement in muscle strength and alleviation of sensory symptoms after immunotherapy with corticosteroids, plasma exchange, or cyclophosphamide. Conclusions: Small-diameter sensory nerves are affected in vasculitis in addition to the well-known effect of vasculitis on large-diameter nerves. Significant inflammatory vasculopathy is present in the skin despite the absence of clinically active vasculitic lesions.
Archives of neurology ISSN 0003-9942 CODEN ARNEAS
2005, vol. 62, n^o10, pp. 1570-1573 [4 page(s) (article)] (24 ref.)

sympathetic vascular innervation in sympathectomized patients

We measured arterial and venous plasma catecholamines and used laser-Doppler flowmetry to measure cutaneous microcirculatory flow in the sympathectomized and in the intact limbs of 3 patients who had undergone regional sympathectomies. Venous concentrations of norepinephrine, the sympathetic neurotransmitter, exceeded arterial concentrations in the intact limbs--a normal finding--but invariably were less than arterial in the sympathectomized limbs of the same patients, both during baseline conditions and during sympathetic stimulation using tilt, standing and the cold pressor test (mean arteriovenous decrement about 40%). Arterial epinephrine levels exceeded venous levels with or without sympathectomy. Skin microvascular flow rapidly decreased during the cold pressor test and the Valsalva maneuver in the intact but not in the sympathectomized limbs, and spontaneous flow oscillations occurred in the sympathectomized limbs. The results suggest that an arteriovenous increment in plasma norepinephrine reflects local release of norepinephrine from sympathetic nerve endings, whereas removal of circulating catecholamines can occur with or without sympathetic neural impulses. Laser-Doppler flowmetry can measure reflexive sympathetically mediated responses of skin microvascular flow and so can detect sympathetic denervation.
PMID: 3517118 [PubMed - indexed for MEDLINE

Impaired skin vasomotor reflexes

Not surprisingly, diminished vasoconstrictor responses, similar to the current findings, have been found
in patients with sympathetic dystrophies [26], dysautomias [27], post-regional sympathectomy [28] and
diabetic neuropathies [11].


Additionally, there have been a few reports of EM patients benefitting from sympathectomy or neurolitic
irreversible blocks of the lumbar sympathetic ganglia [22,23], while others have found the symptoms of EM to
be aggravated by such treatment [24,25], possibly as a result of denervation supersensitivity.
Clinical Science (1999) 96, 507ñ512 (Printed in Great Britain)
Roberta C. LITTLEFORD, Faisel KHAN and Jill J. F. BELCH
University Department of Medicine, Section of Vascular Medicine and Biology, Ninewells Hospital and Medical School,
Dundee DD1 9SY, Scotland, U.K.

Peripheral Nervous System Disease

Combined with loss of active vasodilation, anhidrosis places tetraplegic patients at risk for hyperthermia.

Peripheral Nervous System Disease

With normal aging, thermoregulatory sweat output declines due to peripheral neural and eccrine glandular factors, which vary in degree depending on genetic predisposition and level of physical conditioning.^[75] Extensive anhidrosis may also accompany disease of the peripheral nervous system. When exposed to an elevated ambient temperature or physical exercise, these individuals may present with symptoms of heat intolerance, dizziness, weakness, flushing, dyspnea, or palpitations and may be at risk for heat exhaustion and hyperthermia.

Peripheral Neuropathy

Distal anhidrosis, although often subclinical, is detectable by clinical sudomotor testing in many patients with peripheral neuropathy.^[76,77] Diabetes mellitus, the most common cause of autonomic neuropathy in the developed world, typically impairs thermoregulatory sweating in a stocking and glove distribution.^[78] As the neuropathy progresses, asymmetric truncal anhidrosis or global anhidrosis may develop.^[76]

Some immune-mediated neuropathies selectively target the autonomic neuron. Autoimmune autonomic neuropathy typically presents with sicca complex, anhidrosis, gastrointestinal hypomotility, orthostatic hypotension, abnormal pupillary light reflexes, and neurogenic bladder that may be subacute or insidious in onset. Autoantibodies to the ganglionic acetylcholine receptor have been demonstrated in these patients.^[29,79,80] Subacute autonomic neuropathy may signal an occult malignancy, most commonly small cell lung carcinoma. The dysautonomia in paraneoplastic autonomic neuropathy can be manifested mainly by cholinergic failure presenting as gastrointestinal dysfunction and anhidrosis.

Hypohidrosis commonly occurs in the autonomic neuropathy associated with Sjögren's syndrome.^[83,84] Hypohidrosis also accompanies neuropathies due to amyloidosis, alcoholism, Tangier disease, vasculitis, and Fabry's disease.^[85] Focal areas of hypohidrosis may be found in patients with leprosy.^[86]

Anhidrosis is a prominent feature of hereditary sensory and autonomic neuropathies type IV and V (congenital insensitivity to pain with anhidrosis), in which absent skin innervation is associated with mutations of the NTRK1 gene encoding the neurotrophic tyrosine kinase receptor type 1.^[30]

^{http://www.medscape.com/viewarticle/473206_3}

Link between skin innervation and neuropathic pain

Nerve conduction studies for large-diameter motor and sensory nerves were normal. This report documents a pure small-fibre sensory neuropathy after prolonged use of linezolid, and the relationship between skin innervation and corresponding neuropathic pain.

Journal of Neurology, Neurosurgery, and Psychiatry 2008;79:97-99

Some patients demonstrate unexpected responses

The indications for neurolytic or surgical sympathectomy are uncertain. There is no clear correlation between the degree or duration of pain relief and the actual period of sympathetic blockade and the same patient may show variable responses on different occasionsv (Loh et al 1980). Some patients demonstrate unexpected responses such as contralateral or delayed blocks and some are made worse (Purcell-Jones &Justins 1988, Evans et al 1980, Kleiman 1954)

Neurological Rehabilitation

by R. Greenwood
"All neurological diseases can cause short- and long-term disability..."

• Publisher: Psychology Press; New edition edition (February 1, 1997)
• Language: English
• ISBN-10: 0863774849

Nerve 'injury' and consequences well observed in animals

Ligation injury of the L5/L6 nerve roots in rats produces behavioral signs representative of clinical conditions of neuropathic pain, including tactile allodynia and thermal and mechanical hyperalgesia.

Anesthesiology:

January 1997 - Volume 86 - Issue 1 - pp 196-204

Laboratory Investigation

the ablated segment becomes hypersensitive to acetylcholine

The injured tissue distal to the ablated segment becomes hypersensitive to acetylcholine. This can explain why CH may appear very early after sympathectomy.

All patients except one suffered from compensatory sweating, which was the main cause of patients' dissatisfaction postoperatively. Seventeen percent of the patients (12 of 72 patients) experienced new symptoms of gustatory sweating (facial sweating associated with eating). Twenty-one patients experienced other complications, including pneumothorax, Horner's syndrome, nasal obstruction, and intercostal neuralgia.

CONCLUSION: Transthoracic endoscopic sympathectomy is an effective and simple modality to treat palmar hyperhidrosis. However, all patients need to be warned of the common complications, particularly compensatory hyperhidrosis, before surgery.

by MC Kao - 1998

Neurosurgery:

July 1997 - Volume 41 - Issue 1 - pp 110-115

sympathectomy abolished the Psychogalvanic Reflex

Some P.G.R. studies in a female subject who had bilateral cervical sympathectomy were described. It was found that sympathectomy abolished P.G.R. and that intra-arterial infusion of acetylcholine evoked marked P.G.R. changes in the sympathectomized limb. These findings support the theory that the P.G.R. is mediated through the cholinergic fibres of the sympathetic nervous system.

Submitted on May 22, 1967
The British Journal of Psychiatry (1968) 114: 639-642. doi: 10.1192/bjp.114.510.639
© 1968 The Royal College of Psychiatrists

Sympathetic Innervation of Cerebral Arteries: Prejunctional Supersensitivity to Norepinephrine After Sympathectomy

© 1975 American Heart Association, Inc.