Thoracoscopic Sympathectomy



Sympathectomy involves cauterizing and removing a portion of the sympathetic nerve chain T2-4 that runs down the back inside the chest, parallel to the spine. This operation permanently interrupts the nerve signal that is causing the body to sweat excessively. Starting on one side of the body, the anesthesiologist deflates the lung so that the surgeon will be able to get to the sympathetic nerve chain. He or she makes one or two small incisions underneath the armpit, usually between the second and third ribs.


The most common indication for thoracic sympathectomy are focal hyperhidrosis (which specifically affects the hands and armpits), Raynaud's phenomenon, and facial flushing accompanied by focal hyperhidrosis. It can also be used to treat Bromhidrosis, although usually respond to non-surgical treatment, and sometimes with human olfactory reference syndrome represents surgeons ask sympathectomy. There are reports of ETS used to achieve cerebral revascularization for persons with moyamoya disease and the treatment of headache, bronchial hyperactivity, with long QT syndrome, social phobia, anxiety and other conditions.

A small camera device, or videoscope called thoracoscope in this case, is placed through the incision in order to see inside the chest and identify the sympathetic nerve chain. Through the scope, a cautery device to cut and seal the appropriate level, as determined in advance by the patient's symptoms, is placed.

Patients with severe hyperhidrosis who have exhausted other medical treatments are finding that the thoracoscopic sympathectomy surgery offers a permanent solution to their problem. In almost all cases, it cures excessive sweating in the hands and underarms, and many people experience the side benefit of decreased sweating in the feet. Moreover, the effect of the surgery is often immediate. Patients are often amazed when they wake up and find their hands warm and dry for the first time in years.

The risks associated with the thoracoscopic sympathectomy procedure are minimal, but still need to be taken into account. Many patient have reported experiencing side effects, either as a result of the procedure itself or from complications that may occur during the surgery.

Surgical Procedure

ETS involves dissecting the main sympathetic chain in the upper thoracic region of the sympathetic nervous system, which inevitably changes the neural messages that are likely to travel to many organs, glands and muscles. It is through these nerves of the autonomic nervous system, the brain is able to make adjustments in the body in response to changing environmental conditions, mood changes, conditions of exercise and other factors to maintain homeostasis of the body. Because these nerves also regulate conditions such as redness or excessive sweating, is a process designed to remove regulatory functions of these physiological mechanisms to prevent or perform significantly affect sympathectomy. There is much disagreement among ETS surgeons about the best surgical method, the optimal location of nerve dissection, and the nature and extent of the primary and secondary effects resulting effects. When performed endoscopically as is often the case, the surgeon penetrates the chest cavity to make more cuts around the diameter of a straw between ribs. This allows the surgeon to insert a camera (endoscope) into the hole and a surgical instrument to another. The operation is performed dissection of the nervous tissue of the main sympathetic chain. Another technique, a method for fixing, also known as "endoscopic sympathetic block" (BSE) most fasten titanium towards the nerve to the muscle, and was developed as an alternative to older methods, in a failed attempt to procedure reversible. Technical reversal procedure tightening must be performed in a short period of time after pressing (estimated to be a few days or weeks at most), and the recovery, the evidence suggests, will not be complete.

Sympathectomy works by disabling part of the autonomic nervous system (and thus interrupts the signal from the brain) due to surgery, hoping to eliminate or mitigate the identified problem. Many doctors do not consider this questionable practice of ETS especially because its goal is to destroy functionally disordered nerves, but anatomically typical. ETS accurate results it is impossible to predict, due to the considerable anatomical variation in the function of the nerve from one to another, and also due to variations in surgical technique. The autonomic nervous system is anatomically correct and can be unpredictable connections are made when the nerves are disabled. This is demonstrated by the significant number of patients after sympathectomy on the same level of sweating hands, but the goal of reducing or eliminating sweat is introduced, unlike the other which is not affected so. No reliable operation of the feet are sweating, if the lumbar sympathectomy, at the opposite end of the sympathetic chain (like wood region). Thoracic sympathectomy distort many bodily functions, including sweating, vascular reactions, heart rate, stroke volume of the heart, thyroid, baroreceptorski reflex, lung volume, pupil dilation, skin condition with other area autonomic nervous system such as fight or flight essential. Reduces physiological response to strong emotions such as fear and laughter response, reduces the body's response to physical pain and pleasure, and inhibits skin sensations such as goose bumps.

ETS has normal risk surgery, such as bleeding, infection, conversion of open chest surgery and a number of specific risks, including constant and inevitable changes in nerve function. It is reported that the number of patients -9 of 2010, many among the young ladies lost their lives during that process due to intrathoracic major bleeding and cerebral disorders. Bleeding during and after surgery can be significant to 5% of patients. Pneumothorax (decreased lung) may occur (2% of patients). Compensatory hyperhidrosis (reflex or hyperhidrosis) is common in the long term, that is, according to a study for 1-2 percent of patients complain about what he had surgery. Heavy compensatory sweating rate considerably along the studies, between 92% of the patients. Among patients who developed this side effect, about a quarter in one survey said that is a big problem on and off. Thoracic sympathectomy possible serious consequences corposcindosis (syndrome split-body), in which the patient feels he or she lives in two separate bodies, because the function of the sympathetic nerve is divided into two different regions, one dead and the other hyperactive.

Long-term side effects include:

• Changes in ultrastructural wall cerebral artery caused by long-term sympathetic denervation

• Sympathectomy eliminates GSR

• Cervical sympathectomy reduces the heterogeneity of oxygen saturation in venules cerebrocortical

• Sympathetic denervation is one of the causes of multiple Mönckeberg

• T2-3 sympathectomy suppressed baroreceptorski reflex control of heart rate in patients with palm hyperhidrosis. Note that baroreceptorski reflex response to maintain cardiovascular stability is suppressed in patients who received ETS.

• Heat stroke during exercise.

• Morphofunctional changes in the myocardium following sympathectomy.

Other side effects have been able to raise the heart rate during exercise enough with cases requiring a pacemaker after developing bradycardia was reported after the operation. Finnish Office for Health Technology Assessment has recently been found in the 400 pages of endoscopic thoracic sympathectomy systematic review has been associated with an abnormally high number of direct significant adverse effects and the long term.

Sympathectomy was developed in the mid-19th century, when it became known that the autonomic nervous system functions in almost all organ systems, glands and muscles in the body. It was hypothesized that these nerves play a role in how the body regulates many different functions in the body in response to changes in the external environment and emotions.

The first sympathectomy was carried out by Alexander in 1889. The Thoracic Sympathectomy is indicated for hyperhidrosis (excessive sweating) since 1920, when Kotzareff showed that it would lead to anhidrosis (total inability to sweat) from the nipple line up. Lumbar sympathectomy is also developed and used to treat excessive foot sweating and other diseases, but usually leads to impotence and retrograde ejaculation in males. The lumbar sympathectomy is still offered as a treatment for plantar hyperhidrosis, or as healing process for patients that have bad results ("compensatory sweating" extreme) after thoracic sympathectomy for hyperhidrosis of the palm or redness; Extensive risk sympathectomy hypotension. Endoscopic Sympathectomy itself is relatively easy to achieve; However, access to the nerve tissue in the chest cavity by conventional surgical methods is difficult, painful, and gave birth to a number of different approaches in the past. Rear approach was developed in 1908 and requires resection (cutting) off the coast. Supraclavical (above the collarbone) approach was developed in 1935, which is less painful than the back, but is likely to damage the sensitive nerves and blood vessels. Because of these problems, and for disabling consequences associated with sympathetic denervation, conventional sympathectomy or "open" has never been a popular procedure, although it is still practiced for hyperhidrosis, Raynaud's disease and various psychiatric disorders. With the popularization of memory lobotomy in the 1940s, sympathectomy fell out of favor as a form of psychosurgery. Endoscopic thoracic sympathectomy version developed Goren Claes and Christer DROTT in Sweden towards the end of the 1980, the development of endoscopic "minimally invasive surgery" reduce recovery time after surgery and increased readiness. Currently, ETS surgery is practiced in many countries around the world, mainly vascular surgeon.

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