Effects of Endoscopic Transthoracic Sympathicotomy on Hemodynamic and Neurohumoral Responses to Exercise in Humans.

Abstract

ndoscopic transthoracic sympathicotomy (ETS) is a recently developed technique to divide sympathetic nerves and has been used successfully in the treatment of palmar hyperhidrosis, causalgia, or ischemia of the upper extremities. 1,2 Because of its minimal morbidity and mortality, renewed interest has been expressed in ETS as a palliative approach to patients with severe angina pectoris, who are not suitable for coronary artery bypass grafting or angioplasty. 3,4 Anatomically, the upper third or fourth thoracic, stellate, and cervical sympathetic ganglia receive the preganglionic fibers from the upper 4 thoracic segments of the spinal cord and direct the postganglionic fibers to the targets, including the heart, the upper extremities, and the cranial vessels. 5 Endoscopic transthoracic sympathicotomy blocks efferent sympathetic nerves to the heart as well as the upper extremities; however, the effect of ETS on the cardiovascular system remains unclear. The purpose of the present study was to examine the effect of Th 2-3 ETS on hemodynamic and neurohumoral responses to exercise in patients with palmar hyperhidrosis. Methods Patient SelectionTwenty-one patients with primary palmar hyperhidrosis Circulation Journal Vol.66, April 2002(10 males and 11 females, mean age 28±3 years; mean ± SEM) participated in the study. None of these patients had cardiac disease nor were receiving any drug that might affect autonomic function directly or indirectly. All patients gave their informed consent before participating. Endoscopic Transthoracic SympathicotomyThe operative technique, which has been described in detail elsewhere, 2,6 has been used in more than 400 patients with palmar hyperhidrosis at National Kanazawa Hospital since 1993. Patients were intubated with an endotracheal tube under general anesthesia and placed in a semireclining position with both arms in abduction. (In the semireclining position, the pneumothorax is located in the apical region.) Approximately 2 liters of carbon dioxide was insufflated into the pleural cavity through a Surgineedle entered via the axillary fossa. A modified urological electroresectoscope was introduced via the same incision into the axillary fossa, thus obtaining an excellent view of the upper thoracic cavity. The sympathetic chain can be identified lying over or in the immediate vicinity of the costovertebral joint. The second and third thoracic sympathetic ganglia, including rami communicantes, were destroyed by electrocautery. After exsufflation of the gas, the procedure was repeated on the opposite side. Operation time was within 30 min. The patient was discharged from hospital the day after operation and the hospital stay was 2 days. Most patients resumed work within a few days and resumed sports activities within 2 weeks. Treadmill Exercise TestSubmaximal, graded, upright treadmill exercise was performed according to a modified Bruce protocol comprising Circ J 2002; 66: 357 -361 (Received July 25, 2001; revised manuscript received December 11, 2001; accepted January 10, 20...

Effect of Endoscopic Transthoracic Sympathicotomy on Plasma Natriuretic Peptide Concentrations in Humans

“…These findings suggest that cardiac sympathetic nervous system exert a repressive effect on ANP and BNP concentrations in humans and that ETS removed the inhibitory effects of the cardiac sympathetic nerves on natriuretic peptide secretion. Consistent with a previous report, 15 heart rate, arterial pressure, and systemic vascular resistance decreased after ETS, but the cardiac index remained unchanged. Therefore, the decrease in arterial pressure following ETS is mainly from reduced systemic vascular resistance.…”

Thoracic sympathectomy and cardiopulmonary responses to exercise

“…These effects were attributed to the surgical denervation, not unlike those consequent to badrenergic blockade. Similar effects of thoracoscopic sympathectomy have been demonstrated in several other studies (Marty et al 1986;Nakamura et al 2002;Noppen et al 1995). However, other investigators (Ben-Dov et al 2000) found no meaningful effect of ETS on these, and other, indices of pulmonary function, although they too demonstrated a significant reduction in HR both at rest and at maximal exercise.…”

“…Studies on the specific effects of ETS on cardiovascular-related function during exercise are sparse and with inconsistent results (Borow et al 1985;Nakamura et al 2002;Otton and Wilson 1966;Sullivan et al 1990). Nakamura et al (2002) reported that systemic vascular resistance tended to be decreased after ETS whereas cardiac output did not change; this, however, was observed in resting subjects. During exercise, the systemic vascular resistance did not change following ETS but cardiac output decreased because of the blunted HR response.…”

Incidência de pneumotórax residual após simpatectomia torácica videotoracoscópica com e sem drenagem pleural e sua possível influência na dor pós-operatória

“…(11) Some patients complain of persistent pain, retrosternal at times, sometimes at the trocar sites and sometimes in the posterior and upper regions of the thoracic wall. (12)(13)(14)(15) The routine of the procedure varies immensely, taking into account the type of tracheal intubation used, the technique for dissection, blockage or excision of the sympathetic chain, postoperative closed pleural drainage or not, among other aspects. (4,9,12,(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28) However, findings in the literature seem to agree on key points: resections of the chain should be as minimal as possible; we should never remove more than one ganglion from the chain; and dissection should begin as caudally as possible, bearing in mind the final objective.…”