Sympathetic chain injury called 'complication'. Now this same 'complication' is marketed for people with palmar hyperhidrosis and blushing.

Sympathetic chain injury called 'complication'. Now this same 'complication' is marketed for people with palmar hyperhidrosis and blushing.

Cervical sympathetic chain injury is a rare complication of surgery for thyroid and parathyroid conditions.
ANZ Journal of Surgery. 74(6):442-445, June 2004.
HARDING, JANE L. MB BS; SYWAK, MARK S. MB BS, FRACS; SIDHU, STAN MB BS, PhD, FRACS; DELBRIDGE, LEIGH W. MD, FRACS

Eye innervation - part of the thermoregulatory system

Our results show that cold thermoreceptors sensitive to small temperature changes are distributed throughout the entire ocular surface, most frequently in the highly vascularized perilimbal episclera, but also in the posterior segment of the eye. Nerve fibers activated by cold had spotlike receptive fields and responded to temperature reductions with a nerve impulse discharge that started as soon as the local temperature began to decline, and increased monotonically in firing frequency in parallel with the decrease in temperature.
http://www.iovs.org/cgi/content/full/44/2/697

Transection of the sympathetic chain

Activating transcription factor 3 immunoreactivity identifies small populations of axotomized neurons in rat cervical sympathetic ganglia after transection of the preganglionic cervical sympathetic trunk.

These data indicate that, after transection of the CST, neuronal labeling in the SCG and MICG is restricted to axotomized neurons but that in addition there is extensive labeling of glial cells associated with anterograde degeneration within the SCG.
http://www.nextbio.com/b/literature/literature.nb?id=17583680&query=Right+cervical+sympathetic+trunk&author=

Selective brain cooling following sympathectomy

We have investigated the role of the sympathetic innervation of the vasculature of the head in the control of selective brain cooling of sheep, during exposure to high and low ambient temperatures and during endotoxin-induced fever. Bilateral removal of the superior cervical ganglia resulted in a significant reduciton of hypothalamic temperture during all procedures. Respiratory rate was also depressed by the sympathectomy, apparently mainly as a result of a decrease in nasal airway patency. Rectal temperature changes after sympathectomy were dependent on the experimental conditions, and the rectal — hypothalamic temperature difference was enhanced during heat exposure and fever. Our results support the contention that sympathetically mediated changes in nasal blood flow and in venous return from the nasal cavity, via the angularis oculi and facial veins, may be involved in the control of selective brain cooling in sheep.

	Pflügers Archiv European Journal of Physiology
Publisher	Springer Berlin / Heidelberg
ISSN	0031-6768 (Print) 1432-2013 (Online)
Issue	Volume 417, Number 4 / December, 1990

various other central physiological and metabolic events in cervical sympathectomized animals

Studies were conducted confirming supersensitivity to catecholamines on intraocular pressure and pupil size following bilateral superior cervical ganglionectomy in rabbits.
At the termination of these studies we examined changes in cyclic adenylic acid and prostaglandin content in jugular vein effluent and various brain and ocular tissues and fluids of the sympathectomized versus control animals. In the blood effluent we found significant elevation of cyclic adenylic acid and significant lowering of prostaglandin F1alpha in the sympathectomized animals. Although we found elevation of prostaglandin in certain tissues of the sympathectomized animals, there were no significant changes in cyclic adenylic acid levels between sympathectomized and control animals in the tissues examined. The findings of prostaglandin (blood and tissue) and cyclic adenylic acid (blood) changes in sympathectomized animals, associated with known changes in intraocular pressure and pupil size (due to catecholamine supersensitivity) must elicit further interest in the correlation and interpretation of various other central physiological and metabolic events in cervical sympathectomized animals.
http://www.ncbi.nlm.nih.gov/pubmed/213796?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=3&log$=relatedarticles&logdbfrom=pubmed

Sympathectomy can result in Dysautonomia

Dysautonomia is any disease or malfunction of the autonomic nervous system.
In some cases, dysautonomia results in a reduction in the ability of the heart and circulatory system to compensate for changes in posture, such as causing dizziness or fainting when standing or even sitting up. In other cases, inappropriate sinus tachycardia may cause the heart to race for no apparent reason. Other symptoms can include severe migraines, excessive urination.
Causes of dysautonomias are not fully understood, but they are thought to include viral illness, genetic factors, exposure to chemicals, pregnancy, autoimmune disorders, and a physical trauma or injury which damages the autonomic nervous system.^[3]

There is no cure for dysautonomia, medications are used to stablize the condition on a long-term basis.

galanin and VIP mRNA after sympathectomy

Large changes in neuronal gene expression occur in adult peripheral neurons after axonal transection. In the rat superior cervical ganglion, for example, neurons that do not normally express vasoactive intestinal peptide (VIP) or galanin do so after postganglionic nerve transection. These effects of axotomy could result from a number of aspects of the surgical procedure. To test the idea that the important variable might be the disconnection of axotomized neuronal cell bodies from their target tissues, we examined the effects of producing such a disconnection by means of the compound 6-hydroxydopamine (6-OHDA), a neurotoxin that causes degeneration of sympathetic varicosities and avoids many of the complications of surgery. Two days after 6-OHDA treatment, VIP and galanin immunoreactivities had increased two- and 40-fold, respectively. Nevertheless, these increases were substantially smaller than the 30- and 300-fold changes seen after surgical axotomy. When expression of VIP and galanin was examined at the mRNA level, however, comparable increases were found after either procedure. The results indicate that chemical destruction of sympathetic varicosities produces an equivalent signal for increasing VIP and galanin mRNA as does axonal transection.

Chemical sympathectomy and postganglionic nerve transection produce similar increases in galanin and VIP mRNA but differ in their effects on peptide content.

H. Hyatt-Sachs, M. Bachoo, R. Schreiber, S. A. Vaccariello, R. E. Zigmond *

Department of Neurosciences, Case Western Reserve University, School of Medicine, Cleveland, Ohio 44106-4975

Received: 9 January 1996; Accepted: 3 April 1996

Journal of Neurobiology

A reduction in heat tolerance after Sympathectomy

Role of splanchnic and lumbar sympathetic nerves in physiologic responses to fever and hypoxia in dogs

W. G. Kubicek ¹, W. F. Geber ¹, J. W. Geiger ¹, and E. A. Johnson ¹
Am J Physiol 196: 685-690, 1959;
The most important function of the splanchnic and lumbar sympathetic nerves was apparently the control of the circulatory system and secondly the partial regulation of blood glucose probably through liberation of epinephrine from the adrenal medulla. A reduction in heat tolerance of the animals was observed after sympathectomy.

DOPAMINE, AROUSAL, CREATIVE DRIVE AND IDEA GENERATION

Dopamine in the mesolimbic pathway increases general arousal and goal directed behaviors and decreases latent inhibition; all three effects increase the creative drive of idea generation. This has led to a three-factor model of creativity involving the frontal lobes, the temporal lobes, and mesolimbic dopamine.^[34]

Behavior disorders

Pharmacological blockade of brain dopamine receptors increases rather than decreases drug-taking behavior. Since blocking dopamine decreases desire, the increase in drug-taking behaviour may be seen as not a chemical desire but as a deeply psychological desire to just 'feel something'.

The effect of reduced DOPAMINE

In humans, however, drugs that reduce dopamine activity (neuroleptics, e.g. some antipsychotics) have been shown to reduce motivation, and to cause anhedonia a.k.a. the inability to experience pleasure.^[13] Selective D2/D3 agonists pramipexole and ropinirole, used to treat Restless legs syndrome, have limited anti-anhedonic properties as measured by the Snaith-Hamilton Pleasure Scale.^[14] (The Snaith-Hamilton-Pleasure-Scale (SHAPS), introduced in English in 1995, assesses self-reported anhedonia in psychiatric patients.)

Additionally, users of stimulants often have depleted dopamine levels after withdrawal from these sometimes addictive substances.

Sociability is also closely tied to dopamine neurotransmission. Low D2 receptor-binding is found in people with social anxiety. Traits common to negative schizophrenia (social withdrawal, apathy, anhedonia) are thought to be related to a hypodopaminergic state in certain areas of the brain.

Abnormalities in dopaminergic neurotransmission have also been demonstrated in painful clinical conditions, including burning mouth syndrome,^[26] fibromyalgia ^{[27] [28]} and restless legs syndrome.^[29]

Salience

Dopamine may also have a role in the salience ('noticeableness') of perceived objects and events, with potentially important stimuli such as: 1) rewarding things or 2) dangerous or threatening things seeming more noticeable or important.^[31] This hypothesis argues that dopamine assists decision-making by influencing the priority, or level of desire, of such stimuli to the person concerned.

Since blocking dopamine decreases desire, the increase in drug-taking behaviour may be seen as not a chemical desire but as a deeply psychological desire to just 'feel something'.

Deficits in dopamine levels are implicated in attention-deficit hyperactivity disorder (ADHD), and stimulant medications used to successfully treat the disorder increase dopamine neurotransmitter levels, leading to decreased symptoms.

Dopamine is reduced by Sympathectomy

Dopamine has many functions in the brain, including important roles in behavior and cognition, motor activity, motivation and reward, inhibition of prolactin production (involved in lactation), sleep, mood, attention, and learning. Dopaminergic neurons (i.e., neurons whose primary neurotransmitter is dopamine) are present chiefly in the ventral tegmental area (VTA) of the midbrain, substantia nigra pars compacta, and arcuate nucleus of the hypothalamus.
In the frontal lobes, dopamine controls the flow of information from other areas of the brain. Dopamine disorders in this region of the brain can cause a decline in neurocognitive functions, especially memory, attention, and problem-solving. Reduced dopamine concentrations in the prefrontal cortex are thought to contribute to attention deficit disorder. It has been found that D1 receptors are responsible for the cognitive-enhancing effects of dopamine.^[7]

Effect of reduced Dopamine

Enlargement of the Breast—A New Side Effect of Transaxillary Cervical Sympathectomy: Case Report

http://ves.sagepub.com/cgi/content/abstract/20/1/50

Breast enlargement after thoracoscopic sympathectomy
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7XNJ-4S7S2X0-1&_user=10&_rdoc=1&_fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=3f96573d845688f9c13551c594353d73

Mia: Dopamine is also a neurohormone released by the hypothalamus. Its main function as a hormone is to inhibit the release of prolactin from the anterior lobe of the pituitary.

Prolactin has many effects including regulating lactation, orgasms, and stimulating proliferation of oligodendrocyte precursor cells.

It stimulates the mammary glands to produce milk (lactation): Increased serum concentrations of prolactin during pregnancy cause enlargement of the mammary glands of the breasts.

A comparison is made with the present opinion on activation of parasympathetic and blockade of sympathetic nerves to explain the various symptoms of a cluster attack.

The Involvement of Trigeminal Substance P Neurons in Cluster Headache. An Hypothesis

Jan Erik Hardebo , M.D.

From the Department of Neurology and Department of Histology, University of Lund, Lund, Sweden.

Headache: The Journal of Head and Face Pain

Volume 24 Issue 6, Pages 294 - 304

Published Online: 22 Jun 2005

The present evidence suggests that the tonic discharge of normally functioning sympathetic nerves is capable of facilitating the response to angiotensin and that sympathectomy results in an abolition of this effect.

Effect of Acute Sympathectomy on Responses to Angiotensin and Norepinephrine

B. G. Zimmerman Ph.D.¹
(Circulation Research. 1962;11:780.)
© 1962 American Heart Association, Inc.

Parallels between post sympathectomy patient's symptoms and Chronic Fatigue Syndrome

Dr. Goldstein's CFS/FM protocol revolves around his understanding of these ailments as neurosomatic disorders. In helping to define such disorders, Dr. Goldstein says patients afflicted "do not feel, think, or function properly because the brain does not handle information properly." According to his research, Dr. Goldstein believes brain circuitry and transmittal of data for proper bodily function and health have become altered in conditions like CFS. Further, Dr. Goldstein comments "how the brain, the immune system, and the hormonal system simultaneously regulate the function of each other…is usually 'out of whack' in various ways in patients with neurosomatic disorders."

Dr. Goldstein believes that neurotransmitters, chemical substances that act as information messengers in the brain, are abnormally low in this condition. Norepinephrine and dopamine are two such neurotransmitters lacking in CFS patients. When these are decreased, the brain has difficulty assessing relevance of the numerous messages it constantly receives. Because of this, mentally challenging situations such as taking a test or sensory stimulating situations such as a shopping at a mall can be overwhelming.

Another cause of this easily distractible state is elevated levels of substance P. Substance P is a chemical that transmits pain messages. Overproduction of substance P results in increased sensations of pain.
Article by John W. Addington on Jay A. Goldstein's book:

Betrayal by the Brain: The Neurologic Basis of Chronic Fatigue Syndrome, Fibromyalgia Syndrome, and Related Neural Network Disorders

Published by Haworth Press, 1996

Blockade of the sympathetic nervous system substantially degrades ligament

Kelley W. Dwyer,1,2 Paolo P. Provenzano,1,2 Peter Muir,3 Wilmot B. Valhmu,1 and Ray Vanderby, Jr.1,2
J Appl Physiol 96: 711–718, 2004.

The alpha-adrenergic sensitivity of smooth muscle following sympathectomy

The data obtained suggest alteration of pharmacological characteristics of smooth muscle alpha-adrenoceptors after interruption of the sympathetic nerve.
Fiziol Zh SSSR Im I M Sechenova. 1988 Sep;74(9):1287-93.

CARDIOVASCULAR REACTIVITY AS A MEASURE OF AUTONOMIC OR SYMPATHOADRENAL FUNCTION

http://www.psychosomaticmedicine.org/cgi/content/full/65/1/9

Compensatory sweating occurred in 87% of the patients serious in 36% and incapacitating in 6%)

Ann Thorac Surg. 2004 Nov;78(5):1801-7.

haemodynamic response to cardiac sympathetic denervation corresponded to the efferent effect of beta-receptor blockade

The sympathetic denervated heart showed little chronotropic response to anaesthetic and surgical stimulation. On the contrary, the parasympathetic response was predominant. An episode of severe bradycardia occurred during endotracheal suctioning prior to extubation. The haemodynamic response to cardiac sympathetic denervation corresponded to the efferent effect of beta-receptor blockade.
The haemodynamic effect of thoracoscopic cardiac sympathectomy
Lim-Sim Lee, Chien-Chih Lin, Seok-Mun Ng, Chung-Fai Au

European Journal of Surgery, British Journal of Surgery

Volume 164 Issue S1, Pages 37 - 38, Published Online: 2 Dec 2003

http://www3.interscience.wiley.com/journal/106568649/abstract

orthostatic hypotension increased significantly after ETS

Endoscopic thoracic sympathectomy attenuates reflex tachycardia during head-up tilt in lightly anesthetized patients with essential plamar hyperhidrosis

Journal of Anesthesia
Publisher	Springer Japan
ISSN	0913-8668 (Print) 1438-8359 (Online)
Issue	Volume 16, Number 1 / February, 2002

http://www.springerlink.com/content/dk8tq89wnhq4naqy/
The increase in heart rate in response to HUT (head-up tilt) was significantly reduced after surgery in the ETS group (from 34 ± 18 to 14 ± 11 beats·min⁻¹; P <>−1; P = 0.911). Orthostatic hypertension disappeared completely after ETS (from 5 of 11 to none of 11 patients; P = 0.035), whereas the prevalence of orthostatic hypotension increased significantly after ETS (from 3 of 11 to 9 of 11 patients; P = 0.030). In the control group, the prevalence of neither orthostatic hypertension nor orthostatic hypotension changed after surgery.

Norepinephrine activates pain pathways after nerve injury

Norepinephrine activates pain pathways after nerve injury

According to MedicineNet, RSD involves "irritation and abnormal excitation of nervous tissue, leading to abnormal impulses along nerves that affect blood vessels and skin."

Animal studies indicate that norepinephrine, a catecholamine released from sympathetic nerves, acquires the capacity to activate pain pathways after tissue or nerve injury, resulting in RSD.
http://arthritis.about.com/od/rsd/a/rsd.htm

Sympathectomy suppresses cell-mediated (T helper-1) responses

In vivo, chemical sympathectomy suppresses cell-mediated (T helper-1) responses, and may enhance antibody (T helper-2) responses. Noradrenergic innervation of spleen and lymph nodes is diminished progressively during aging, a time when cell-mediated immune function also is suppressed. In animal models of autoimmune disease, sympathetic innervation is reduced prior to onset of disease symptoms, and chemical sympathectomy can exacerbate disease severity.
Annu Rev Pharmacol Toxicol. 1995;35:417-48.

Substance P has a proinflammatory role

These studies have been carried out in a large number of patients with long-standing autoimmune diseases. It turned out that sympathetic nerve fibers are lost in chronically inflamed tissue, while substance P-positive nerve fibers sprout into the inflamed area.

Brain Behav Immun. 2007 Jul;21(5):528-34. Epub 2007 May 22. Links

http://www.ncbi.nlm.nih.gov/pubmed/17517488?ordinalpos=58&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

Brain-Adipose tissue cross talk

Local injections of the sensory nerve neurotoxin capsaicin into WAT selectively destroy this innervation. Just as surgical removal of WAT pads triggers compensatory increases in lipid accretion by non-excised WAT depots, capsaicin-induced sensory denervation triggers increases in lipid accretion of non-capsaicin-injected WAT depots, suggesting that these nerves convey about body fat levels to the brain.
Proc Nutr Soc. 2005 Feb;64(1):53-64.
http://www.ncbi.nlm.nih.gov/pubmed/15877923?ordinalpos=21&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSuminformation

risk of vascular insufficieny and subsequent dysfunction of thoracolumbar autonomic outflow to the head and neck

Cadaveric studies of the blood supply to the human cervical sympathetic chain and ganglia are lacking in the English literature. This study seeks to elucidate the gross blood supply of the cervical sympathetic chain so as to avoid surgical disruption of these vessels and thus decrease the risk of vascular insufficieny and subsequent dysfunction of thoracolumbar autonomic outflow to the head and neck.

Conclusions: Although sympathetic injury is a rare consequence of cervical operations, the current data should be useful to the surgeon who operates in the cervical region so as to avoid potential complications from disruption of the primary blood supply of the cervical sympathetic chain and ganglia.
European Journal of Morphology, Volume 40, Issue 5 December 2002 , pages 283 - 288
http://www.informaworld.com/smpp/content~content=a725290831~db=all

Parallels between post sympathectomy symptoms and Spinal Cord Injury symptoms

Autonomic component of spinal cord injury:

Hypotension, Skin Hyperaemia, Bradycardia (unopposed vagatonia), Low body temperature - high skin temperature,

Spinal shock involves loss of sympathetic autonomic function.

Secondary changes:
-Accumulation of extracellular neurotransmitters: Serotonin, Catecholamines, Glutamate are TOXIC to cells
-Free radical accumulation

http://209.85.173.132/search?q=cache:Yir6NMnAPdEJ:www.drramani.com/presentations/Acute_Spinal_Cord_Injury.pdf+compression+of+the+cervical+sympathetic+chain&hl=en&ct=clnk&cd=69&gl=au&client=firefox-a

Posted by Mia 0 comments

Unsubstantiated statements by ETS surgeon can be misleading

"The incidence of compensatory hyperhidrosis is

proportional to the surface area rendered anhidrotic."

"The statement is based on my own observations.  It is
original and does not refer to any other article.
You have already discovered the
original source.

It is a clinical observation.  I have done no
measurements that is/yet to be subjected to
scientific study.
You can quote it as a clinical
hypothesis that I have postulated."

Jack Collin,
consultant surgeon
Oxford

Mia: the only study done (and posted on this blog)
so far, states that 
Sympathectomy will INCREASE the total
amount of body sweat. 

Cervical sympathectomy reduces the heterogeneity of oxygen saturation in small cerebrocortical veins

Sympathectomy significantly reduced this heterogeneity in the anterior cortex through a reduction in the number of low O2 saturation veins (coefficient of variation 11.7%).

H. M. Wei, A. K. Sinha and H. R. Weiss
Department of Anesthesia, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Piscataway 08854-5635

Anterior cingulate cortex: includes both the ventral and dorsal areas of the cingulate cortex, and appears to play a role in a wide variety of autonomic functions, such as regulating blood pressure and heart rate, as well as rational cognitive functions, such as reward anticipation, decision-making, empathy and emotion.

Cardiovascular collapse caused by carbon dioxide insufflation during sympathectomy

Carbon dioxide insufflation into the pleural space during one-lung anaesthesia for thoracoscopic surgery is used in some centres to improve surgical access, even though this practice has been associated with well-described cardiovascular compromise. The present report is of a 35-year-old woman undergoing thoracoscopic left dorsal sympathectomy for hyperhidrosis. During one-lung anaesthesia the insufflation of carbon dioxide into the non-ventilated hemithorax for approximately 60 seconds, using a pressure-limited gas inflow, was accompanied by profound bradycardia and hypotension that resolved promptly with the release of the gas.

Australian Society of Anaesthetists 2002

sympathectomy on spinal cord blood flow

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

Heart and Circulatory Physiology, Vol 260, Issue 3 827-H831, Copyright © 1991 by American Physiological Society

A. Iwai, W. W. Monafo and S. G. Eliasson
Department of Surgery, Washington University School of Medicine, St. Louis, Missouri 63110.

Marked MAP instability following sympathectomy

Marked MAP instability following sympathectomy

In this study, conscious freely behaving rats with functional sympathetic denervation of the vessels, as evidenced by the disappearance of pressor responses to tyramine, did not show any change in the mean level of blood pressure but had a striking increase in the spontaneous MAP (mean arterial pressure) variability as compared with intact rats. This exaggerated blood pressure lability was associated with an increase in the variability of mesentric conductance with no change in that of the hindquarters vascular bed, which is the sum of vascular conductances of all regional hemodynamic changes after sympathectomy and suggest that the sympathetic nervous system may play an important role in reducing short-term hemodynamic variability.
In conclusion, the results of the present study suggest a major role for the sympathetic nervous system in the regulation of regional circulations, the loss of which in sympathectomized rats results in a marked instability of MAP. The vasodilator component of MAP lability after sympathectomy does not appear to depend on an episodic release of NO synthesized by the L-arginine pathway.

Genetic Hypertension, by Jean Sassard

Under the patronage of: Ministère de la recherche et de la technologie, Ministère délégué à la santé, INSERM, CNRS (Départment des sciences de la vie), Conseil général du Rhône, Mairie de Lyon, Chambre de commerce et d'industrie de Lyon
Genetic Hypertension: Proceedings of the 7th International Symposium on SHR and Related Studies Held in Lyon (France), Ecole Normale Supérieure, October 28-30, 1991 = Hypertension Génétique

Orthostatic hypotension following sympathectomy can lead to syncope

8. Describe the reflex compensations when someone suddenly stands up from a supine position. What would happen in a patient who just had a sympathectomy?

Sudden standing causes pooling of blood in the leg veins. This results in decreased venous return to the heart, which leads to decreased cardiac output (Frank-Starling mechanism), which leads to decreased MAP. This decrease in MAP is detected by the carotid sinus baroreceptors, which relay a message to the medullary cardiovascular control center, which increases sympathetic outflow and decreases parasympathetic outflow, this causes:

• An increase in HR and myocardial contractility, tending to restore cardiac output.
• Vasoconstriction in skeletal musculature, skin, kidneys and gut, reducing blood flow to these organs and increasing TPR.
• Venoconstriction decreasing capacitance and increasing venous return

A patient with a sympathectomy would experience what's referred to as orthostatic hypotension (which might lead to syncope). Orthostatic hypotension is a decrease in arterial pressure when going from supine to a standing position. A person with a normal baroreceptor mechanism will try to restore MAP. In a person who had a sympathectomy, the sympathetic component of the baroreceptor mechanism is absent.

9. Will the capillary pressure increase or decrease in the following situations?

1. Arteriolar vasodilation: increase

2. Venodilation: decrease (however, Dr. Gray points out that capillary beds of lower extremities will experience an increase in pressure due to back pressure exerted by the column of blood in the dilated veins!
   
3. M.A.S.T.E.R. Learning Program, UC Davis School of Medicine
4. Date Revised: Jan 16, 2002

5. Revised by: Gordon Li and Carolyn Nguyen

autoregulatory breakthrough is eliminated when the arterial baroreflex is interrupted

The effects of sympathetic section blockade are greater during systemic hypercapnia than during normocapnia: a decrease in cerebrovascular resistance has been demonstrated in cats and rabbits after bilateral sympathectomy when PaCO2 was below 62-67 mmHg.
Blockade of sympathetic activity causes a significant further increase in CBF during hypoxia.

..sympathetic activation exerts a significant protective action on CBF and blood-brain barrier (BBB) permeability (Bill and Lander 1976) an effect which is also seen in the presence of moderate increase increases in BP, where autoregulation maintains CBF almost constant.

The vasodilation which characterizes autoregulatory breakthrough is eliminated when the arterial baroreflex is interrupted (Talman et al. 1994), which suggests that it is an active process. It is possible that the breakthrough depends on release of nitric oxide or a NO donor associated with the removal of the sympathetic innervation of cerebral vessels (Talman and Dragon 1995).

Intoxications of the Nervous System

By Pierre J. Vinken, F. A. de Wolff, George W. Bruyn, Otto Appenzeller, Harold L. Klawans

Published by Elsevier Health Sciences, 1999

ISBN 0444828133, 9780444828132

Sympathectomy frequently causes perioperative hypotension

Vasomotor output is modified by inputs from throughout the central nervous system, including the hypothalamus, cerebral cortex, and the other areas in the brain stem. Areas in the posterolateral medulla receive input from both the vagal and the glossopharyngeal nerves and play an important role in mediating a variety of circulatory reflexes. The sympathetic system normally maintains some tonic vasoconstriction on the vascular tree. Loss of this tone following induction of anesthesia or sympathectomy frequently contributes to perioperative hypotension.

Clinical Anesthesiology

By G. Edward Morgan, Maged S. Mikhail, Michael J. Murray

Published by McGraw-Hill Professional, 2005

ISBN 0071423583, 9780071423588

Changes in Electrophysiology following sympathectomy

Chemical sympathectomy was obtained following intravenous injection of 50 mg·kg^–1 of 6-hydroxydopamine. Sympathectomised dogs presented significant increases in: basic sinus period, sino-atrial conduction time (SACT), AH and HV intervals of the His bundle electrogram, atrial functional (AFRP) and effective (AERP) refractory periods, atrio-ventricular node functional (AVNFRP) and effective (AVNERP) refractory periods, ventricular functional (VFRP) and effective (EVRP) refractory periods and atrial (AMAP) and ventricular (VMAP) monophasic action potential durations. Corrected sinus recovery time (CSRT) was not affected by chemical sympathectomy. Neither was the atrial ERP/MAP duration ratio. This new form of sympathectomy affects all the levels of the cardiac conduction system. Such results are in accordance with those obtained with surgical sympathectomy or the use of beta-blocking agents.

DIANE GODIN^*, CLAUDE GUIMOND, RÉGINALD A NADEAU and A ROBERT LEBLANC

From the Department of Physiology, Faculty of Medicine, Université de Montréal and Centre de recherche, Hôpital du Sacré-Coeur, Montréal, Canada

Cardiovascular Research 1982 16(9):524-529; doi:10.1093/cvr/16.9.524
© 1982 by European Society of Cardiology

Long-term superior cervical sympathectomy induces mast cell hyperplasia and increases histamine and serotonin content

Nerve fibres and mast cells are often described in close morphological and functional interactions in various organs such as the dura mater. The respective roles of mast cell activation and sympathetic impairment in cluster headache and migraine attacks have been repeatedly suggested. We have thus investigated the long-term effects of sympathectomy on mast cell morphology and content in the rat dura mater.
After unilateral ganglionectomy, the histamine content increased progressively and significantly 30–60 days post-surgery in both hemi-dura, whereas the serotonin content became significantly different from that of sham only 60 days post-surgery in the ipsilateral dura. After bilateral ganglionectomy, the histamine level significantly increased in both hemi-dura 15–60 days post-surgery, whereas the serotonin level had significantly increased at 60 days post-surgery.

These results clearly demonstrate, for the first time, a long-term trophic effect of sympathetic nerve degeneration on mast cells in the dura mater.

A. Bergerot^*, A. -M. Reynier-Rebuffel^†, J. Callebert^‡ and P. Aubineau

Copyright © 1999 IBRO. Published by Elsevier Science Ltd.

Sympathectomy causes diminished capacity for physical sensation

Results: In the hot-plate analgesia test, sympathectomized rats increased their hot-plate latency time compared with that of sham-operated rats. Density of calcitonin gene-related peptide immunoreactive fibers in sympathectomy side of the lumbar dura mater decreased to 45.5% compared with the contralateral side. The number and size of calcitonin gene-related peptide immunoreactive cells in dorsal root ganglia showed no difference between sympathectomized and contralateral side.

Conclusion: Sympathectomy increased the pain threshold and made the sympathectomized rats hypesthetic.

An Anatomic Study of Neuropeptide Immunoreactivities in the Lumbar Dura Mater After Lumbar Sympathectomy.

Spine. 21(8):925-930, April 15, 1996.
Sekiguchi, Yasufumi MD *+; Konnai, Yasunobu MD *+; Kikuchi, Shinichi MD, PhD *; Sugiura, Yasuo MD, PhD +

Abnormal pain following nerve sprouting

Collectively, our findings indicate that as a result of autonomic sprouting due to CCI of the MN, remaining intact nociceptive fibres may potentially develop sensitivity to sympathetic and parasympathetic stimulation, which may have a role in the generation of abnormal pain following nerve injury.

---

Received 22 October 2004, revised 17 February 2005, accepted 23 February 2005

C. Grelik ¹ , G. J. Bennett ^3,4,5 and A. Ribeiro-da-Silva ^1,2,5

¹ Department of Pharmacology & Therapeutics, McGill University, 3655 Prom. Sir-William-Osler, Montreal, Quebec, Canada H3G 1Y6
² Department of Anatomy and Cell Biology,
³ Department of Anesthesia,
⁴ Faculty of Dentistry, and
⁵ McGill Centre for Research on Pain, McGill University, Montreal, Quebec, Canada

complex alterations of vascular reactivity

Enhanced vascular reactivity in the sympathectomized rat: studies in vivo and in small isolated resistance arteries.

Conclusions: In conclusion, we showed that sympathectomy produces complex alterations of vascular reactivity both in vivo and in isolated vessels, which shift the balance of the sensitivity of the vessel between vasoconstrictor and vasodilating agents towards an increased constriction. These results are unlikely to simply reflect denervation supersensitivity; their underlying receptor, post-receptor and/or contractile mechanisms are yet to be identified.

Journal of Hypertension. 18(8):1041-1049, August 2000.
Rizzoni, Damiano 1; Perlini, Stefano 2,3; Mircoli, Luca 2; Porteri, Enzo 1; Franzelli, Cristina 2; Castellano, Maurizio 1; Rosei, Enrico Agabiti 1; Ferrari, Alberto U. 2,4

disturbed peripheral vascular and heart rate responses

Thoracic sympathectomy can result in reduced sweating and disturbed peripheral vascular and heart rate responses. Patients should be warned that these mechanisms may play a role in the development of exertional heat stroke.

Is Previous Thoracic Sympathectomy a Risk Factor for Exertional Heat Stroke?

Alan D.L. Sihoe, FRCSEd(CTh)^a,_*, Raymond W.T. Liu, MRCP^b, Alex K.L. Lee, MRCP^b, Chak-Wah Lam, FHKAM^b, Lik-Cheung Cheng, FRCS

Sympathectomy and avoidance learning

Di Giusto, E. L.; King, M. G.

Journal of Comparative and Physiological Psychology. 1972 Dec Vol 81(3) 491-500

Reports results of 5 experiments with male Wistar rats (N = 108). Depletion of peripheral sympathetic noradrenaline induced by administration of 6-hydroxydopamine, ip, led to significant decrements in escape and avoidance responding when the required response was difficult, but not when it was relatively easy to acquire. Results are similar to previous findings obtained with adrenal-demedullated Ss. Findings clarify the role of the sympathetic nervous system in the motivation of behavior elicited by aversive stimulation.
http://psycnet.apa.org/index.cfm?fa=main.doiLanding&uid=1973-08610-001

Chemical sympathectomy augments the severity of experimental allergic encephalomyelitis

神经肽Y及Th1/Th2细胞与多发性硬化Multiple sclerosis, neuropeptide Y ...

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Multiple sclerosis, neuropeptide Y and Th1/Th2 cell .... Chemical sympathectomy augments the severity of experimental allergic encephalomyelitis 《Journal ... scholar.ilib.cn/Abstract.aspx?A=xdkf200521094 - Similar pages - Note this

Maintenance of blood pressure is mostly dependent on sympathetic “tone”, and the sympathetic nerve innervates the entire vascular bed

Pharmacology and Physiology of Perivascular Nerves Regulating Vascular Function Role of Perivascular Sympathetic Nerves and Regional Differences in the Features of Sympathetic Innervation of the Vascular System

Hiromichi Tsuru1), Noriaki Tanimitsu2) and Tomohisa Hirai2)

1) Department of Pharmacology, Toho University School of Medicine 2) Department of Otorhinolaryngology, Hiroshima University School of Medicine

ABSTRACT: Maintenance of blood pressure is mostly dependent on sympathetic “tone”, and the sympathetic nerve innervates the entire vascular bed, excepting the capillaries. Although norepinephrine (NE) is the principal neurotransmitter released upon sympathetic nerve stimulation, neuropeptide Y and ATP are cotransmitters in various vascular tissues. In addition, dopamine and epinephrine, as well as acetylcholine, have been shown to be sympathetic neurotransmitters in specific vasculatures. Transmitter NE release is modified by a number of endogenous substances including the transmitter itself. Chronic denervation of the preganglionic fiber induces an increase in NE release per pulse, indicating postganglionic neuronal supersensitivity. So far, three main adrenoceptor types have been shown, α1, α2 and β, each of which is further divided into at least three subtypes, as well as the α1L-adrenoceptor, a phenotype of the cloned α1a-adrenoceptor, in the blood vessel. Thus, the response of vessels with different receptor types to a transmitter varies quantitatively and even qualitatively from one vessel to another. The remarkable diversity in the sympathetic innervation mechanism in the vascular system may play an important role in regional variations in the regulation of blood flow. The sympathetic nerve also exerts long-term trophic action on the blood vessel. In conclusion, the sympathetic nervous system plays an important role not only in the regulation of cardiovascular dynamics but in the maintenance of the vessel structure, as well.

The Japanese Journal of PharmacologyVol. 88 (2002) , No. 1 pp.9-13

The significant fall in left circumflex coronary flow was proportional to the decline in external heart work due to sympathectomy both at rest and und

E. Bassenge¹, J. Holtz¹, W. v. Restorff¹ and K. Oversohl¹

(1)	Physiologisches Institut der Ludwig-Maximilian-Universität München, Germany

Received: 18 April 1973

The exercise capacity and the increase of coronary and systemic hemodynamics under treadmill exercise were studied in 5 dogs, chemically sympathectomized with 6-hydroxy-dopamine.

Completeness of adrenergic denervation was verified by stimulation of the right stellate ganglion, by intravenous administration of tyramine, and by demonstration of supersensitivity to exogenous norepinephrine.

These dogs demonstrated a retarded adaptation of hemodynamics to a sudden start of exercise. A fall in mean arterial pressure below 45 mmHg within 10 to 15 sec lead to collapse. After a recovery period of 60–90 sec, moderate treadmill exercise could be continued; steady state attainment of hemodynamic parameters was considerably delayed.

A steady state of exercise with an O₂-consumption (vO₂) of 29.6±2.6 ml/min · kg and a cardiac outupt (CO) of 307±16 ml/min · kg was tolerated for at least 20 min.

An increase of vO₂ up to 42.0±1.7 ml/min · kg and of CO up to 357±13 ml/min · kg under exercise was tolerated for 5 min with steady state, maximal heart rate being 160±4 min^–1 at this level of exercise.

Mean arterial pressure and total peripheral resistance were significantly reduced at rest and during steady state of exercise as compared to controls prior to sympathectomy identical vO₂, whereas CO remained unchanged.

The significant fall in left circumflex coronary flow was proportional to the decline in external heart work due to sympathectomy both at rest and under exercise.

Differential Effects of Chemical Sympathectomy on Expression and Activity of Tyrosine Hydroxylase and Levels of Catecholamines and DOPA

Tyrosine hydroxylase (TH) mRNA and activity and concentrations of 3,4-dihydroxyphenylalanine (DOPA) and catecholamines were examined as markers of sympathetic innervation and catecholamine synthesis in peripheral tissues of sympathectomized and intact rats. Chemical sympathectomy with 6-hydroxydopamine (6-OHDA) markedly decreased norepinephrine and to a generally lesser extent TH activities and dopamine in most peripheral tissues (stomach, lung, testis, duodenum, pancreas, salivary gland, spleen, heart, kidney, thymus). Superior cervical ganglia, adrenals and descending aorta were unaffected and vas deferens showed a large 92% decrease in norepinephrine, but only a small 38% decrease in TH activity after 6-OHDA.

Minoru Kawamura^{1, 2}, Joan P. Schwartz¹, Takuo Nomura¹, Irwin J. Kopin¹, David S. Goldstein¹, Thanh-Truc Huynh¹, Douglas R. Hooper¹, Judith Harvey-White¹ and Graeme Eisenhofer¹

(1)	Clinical Neuroscience Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, 20892

(2)	Institute of Bio-Active Science, Nippon Zoki Pharmaceutical Co., Ltd. Hyogo, 673-14, Japan

Volume 24, Number 1 / January, 1999
JournalNeurochemical Research

the sympathetic nervous system regulates the clinical and pathological manifestations of experimental autoimmune encephalomyelitis (EAE)

Neuropeptide Y (NPY) suppresses experimental autoimmune encephalomyelitis: NPY1 receptor-specific inhibition of autoreactive Th1 responses in vivo.

[My paper] Sammy Bedoui, Sachiko Miyake, Youwei Lin, Katsuichi Miyamoto, Shinji Oki, Noriyuki Kawamura, Annette Beck-Sickinger, Stephan von Hörsten, Takashi Yamamura

Department of Immunology, National Institute of Neuroscience, NCNP, Ogawahigashi, Kodaira, Tokyo, Japan.

Prior studies have revealed that the sympathetic nervous system regulates the clinical and pathological manifestations of experimental autoimmune encephalomyelitis (EAE), an autoimmune disease model mediated by Th1 T cells. Although the regulatory role of catecholamines has been indicated in the previous works, it remained possible that other sympathetic neurotransmitters like neuropeptide Y (NPY) may also be involved in the regulation of EAE. Here we examined the effect of NPY and NPY receptor subtype-specific compounds on EAE, actively induced with myelin oligodendrocyte glycoprotein 35-55 in C57BL/6 mice. Our results revealed that exogenous NPY as well as NPY Y(1) receptor agonists significantly inhibited the induction of EAE, whereas a Y(5) receptor agonist or a combined treatment of NPY with a Y(1) receptor antagonist did not inhibit signs of EAE. These results indicate that the suppression of EAE by NPY is mediated via Y(1) receptors. Furthermore, treatment with the Y(1) receptor antagonist induced a significantly earlier onset of EAE, indicating a protective role of endogenous NPY in the induction phase of EAE. We also revealed a significant inhibition of myelin oligodendrocyte glycoprotein 35-55-specific Th1 response as well as a Th2 bias of the autoimmune T cells in mice treated with the Y(1) receptor agonist. Ex vivo analysis further demonstrated that autoimmune T cells are directly affected by NPY via Y(1) receptors. Taken together, we conclude that NPY is a potent immunomodulator involved in the regulation of the Th1-mediated autoimmune disease EAE.

J. Immunol. 2003 Oct 1;171 (7):3451-8 14500640 (P,S,E,B) Cited:3

Autonomic innervation of immune organs and neuroimmune modulation.

Autonomic & Autacoid Pharmacology. 23(1):1-25, February 2003.
Mignini, F.; Streccioni, V.; Amenta, F.

Abstract:
Summary: 1 Increasing evidence indicates the occurrence of functional interconnections between immune and nervous systems, although data available on the mechanisms of this bi-directional cross-talking are frequently incomplete and not always focussed on their relevance for neuroimmune modulation.

2 Primary (bone marrow and thymus) and secondary (spleen and lymph nodes) lymphoid organs are supplied with an autonomic (mainly sympathetic) efferent innervation and with an afferent sensory innervation. Anatomical studies have revealed origin, pattern of distribution and targets of nerve fibre populations supplying lymphoid organs.

3 Classic (catecholamines and acetylcholine) and peptide transmitters of neural and non-neural origin are released in the lymphoid microenvironment and contribute to neuroimmune modulation. Neuropeptide Y, substance P, calcitonin gene-related peptide, and vasoactive intestinal peptide represent the neuropeptides most involved in neuroimmune modulation.

4 Immune cells and immune organs express specific receptors for (neuro)transmitters. These receptors have been shown to respond in vivo and/or in vitro to the neural substances and their manipulation can alter immune responses. Changes in immune function can also influence the distribution of nerves and the expression of neural receptors in lymphoid organs.

5 Data on different populations of nerve fibres supplying immune organs and their role in providing a link between nervous and immune systems are reviewed. Anatomical connections between nervous and immune systems represent the structural support of the complex network of immune responses. A detailed knowledge of interactions between nervous and immune systems may represent an important basis for the development of strategies for treating pathologies in which altered neuroimmune cross-talking may be involved.

NPY in the regulation of autoimmune Th1 cells

Substantial evidence indicates a dysfunctional communication between the sympathetic nervous system and the immune system in Th1-mediated autoimmune diseases, such as rheumatoid arthritis and multiple sclerosis. In this Opinion, we propose that the sympathetic regulation of immunity is not only mediated by catecholamines but also involves neuropeptide Y (NPY), an additional postganglionic SNS transmitter that is shown to modulate various immunological functions in vitro and in vivo. Based on recent experimental findings, we believe that a more precise understanding of the role of NPY in the regulation of autoimmune Th1 cells will provide novel insights into the neuroimmunological basis of autoimmunity.

Sammy Bedoui^a, Sachiko Miyake^c, Rainer H. Straub^b, Stephan von Hörsten^a and Takashi Yamamura^c,

^aDepartment of Functional and Applied Anatomy, Medical School of Hannover, 30625 Hannover, Germany

^bDepartment of Internal Medicine I, University Hospital Regensburg, 93042 Regensburg, Germany

^cDepartment of Immunology, National Institute of Neuroscience, 4-1-1 Ogawahigashi, Kodaira, Tokyo 187-8502, Japan

Available online 20 August 2004.

dual pro- and anti-inflammatory role of the sympathetic nervous system (SNS) in inflammatory joint disease - Sympathetic Neurotransmitters in Joint Inflammation

Rainer H. Straub MD^, and Peter Härle MD

Laboratory of Neuroendocrinoimmunology, Department of Internal Medicine I, University Hospital Regensburg, FJS-Allee 11, 93042 Regensburg, Germany

Available online 5 January 2005.

This article is not included in your organization's subscription. However, you may be able to access this article under your organization's agreement with Elsevier.

This article demonstrates the dual pro- and anti-inflammatory role of the sympathetic nervous system (SNS) in inflammatory joint disease (IJD) by way of distinct adrenoceptors. The dual role of the SNS depends on involved compartments, timing of distinct effector mechanisms during the inflammatory process, availability of respective adrenoceptors on target cells, and an intricate shift from β-to- adrenergic signaling in the progressing course of the inflammatory disease (β-to- adrenergic shift). Additional critical points for the dual role of the SNS in inflammation are the underlying change of immune effector mechanisms during the process of disease progression and the behavior of sympathetic nerve fibers in inflamed tissue (nerve fiber loss). This is accompanied by a relative lack of anti-inflammatory glucocorticoids in relation to inflammation. In quintessence, in early stages of IJD, the SNS plays a predominantly proinflammatory role, whereas in late stages of the disease the SNS most probably exerts anti-inflammatory effects.

Does bilateral thoracic sympathectomy predispose to reflex bronchospasm following tracheal intubation?

A 31 year old old non-smoking woman, 60 kg, withouth a history of allergy or asthma was scheduled for left knee arthroscopy. Two months previously she had an uneventful general anesthetic for bilateral thorascopic sympathectomy to treat essential hyperhidrosis.

Immediately following intubation, ventilation became difficult. Chest auscultation revealed bilateral expiratory wheezing associated with decreased air entry and increased airway pressure up to 60 cm H2O. Oxygen saturation, as monitored by pulse oximetry, decreased from 100% to 80%.

The severe bronchospams occured immediately following tracheal intubation, suggesting that it may have been a reflex response which was triggered by instrumentation of the airway under light level of anesthesia.

Sympathectomy results in a decrease of plasma norepinephrine, and parasympathetic predominance which may increase airway resistance.

Thus, patients with essential hyperhidrosis who have undergone bilateral thoracic sympathectomy, may be more liable to develop reflex bronchospams under light levels of anesthesia.

Ahed Zeidan MD
Nazih Nahle MD
Anis Baraka MD FRCA
Sahel General Hospital, American Universisty of Beirut Medical Center

Hypoxaemia is of a major concern during thorascopic sympathectomy

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 vascular resistance (hypoxic pulmonary vasoconstriction) with re-routing of blood to well ventilated lung zones and consequent improvement in PaO2. HOWEVER, DURING ENDOBRONCHIAL ANAESTHESIA FOR THORACIC SYMPATHECTOMY THERE IS AN APPARENT FAILURE OF THIS COMPENSATORY MECHANISM. When more then 70% of the lung is atelectatic, compensation by hypoxic pulmonary vasoconstriction appears ineffective.

During carbon dioxide insufflation using endobronchial intubation, Hartrey and colleagues reported a decrease in systolic arterial pressure of >20mm Hg in 21% of patients. Similarly we have reported sudden hypotension and bradycardia after injudicious carbon dioxide insufflation.

Although extremely rare, sudden cardiac arrest has been reported after left T2-3 sympathetic nerve transection. While the exact pathophysiology of this occurence is unclear, it is postulated that before complete transection of the sympathetic trunk, continuous sympathetic stimulation to the stellate ganglions results in a reduction in the ventricular finrillation threshold, arrhythmia and cosequent cardiac arrest.
In an iteresting study of the delayed cardiac effects of T2-$ symtpathectomy, Drott and colleagues demonstrated significantly reduced heart rate at rest, and during both exercise and the recovery phase of exercise. Changes is the electrical axis and shortening of the QT interval have also been reported.

Irrespective of the technique used the reported incidence of postoperative pneumpthorax is variable, occuring in 2-15% of cases.
In a study by Gothberg, Drott and Claes, postoperative chest x-ray after 1274 procedures, in 602 patients demonstrated that a small apical pneumothroax was a usual occurence.

Conclusion: Because of the anaesthetic implications and possible surgical complications, many surgeons are reluctant to perform transthoracic sympathectomy.

British Journal of Anaesthesia 1997; 79: 113-119
B. Fredman, D. Olsfanger and R. Jedeikin

Left, but not right, one-lung ventilation causes hypoxemia during endoscopic transthoracic sympathectomy

Anesth Analg 2000;90:28
© 2000 International Anesthesia Research Society

---

CARDIOVASCULAR ANESTHESIA

Sequential Changes of Arterial Oxygen Tension in the Supine Position During One-Lung Ventilation

Seiji Watanabe, MD, Eiko Noguchi, MD, Shinichi Yamada, MD, Nobuya Hamada, MD, and Tatsuhiko Kano, MD

Department of Anesthesiology, Kurume University School of Medicine, Fukuoka, Japan

Implications: Close observation and prompt counteractions including termination of one-lung ventilation (OLV) are crucial for patients under OLV in the supine position, because life-threatening hypoxemia frequently occurs approximately 10 min after starting OLV, even under 100% oxygen inhalation. The left semilateral decubitus position was as effective as the left lateral decubitus position in avoiding life-threatening hypoxemia during OLV.

Incidence of chest wall paresthesia after needlescopic video-assisted thoracic surgery for palmar hyperhidrosis

Alan D.L. Sihoe, Clement S.K. Cheung, Ho-Kei Lai, Tak-Wai Lee, Kin-Hoi Thung, Anthony P.C. Yim^*

Department of Surgery, Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China

Received 5 September 2004; received in revised form 28 September 2004; accepted 22 October 2004.

^* Corresponding author. Tel.: +86 852 2632 2629; fax: +86 852 2647 8273. (E-mail: yimap@cuhk.edu.hk).

Objective: Chest wall paresthesia is a reported sequela of thoracotomy and Video-Assisted Thoracic Surgery (VATS) which is distinct from wound pain. Although needlescopic VATS confers less post-operative pain and better cosmesis, the incidence of paresthesia after needlescopic VATS has not been quantified. Methods: For homogeneity of the patient cohort, we studied 50 patients who received bilateral needlescopic VATS sympathectomy (T2-T4 excision) for palmar hyperhidrosis using 2 or 3mm instruments during a 36-month period at a single institute. A standard questionnaire was administered by telephone interview, with 34 patents responding (68.0%). The median post-operative observation time was 16.5 months (range: 10–40 months). Collected data were compared with a historical group who received conventional VATS using 10mm ports. Results: 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%). Post-operative paresthesia and pain did not impact on patient satisfaction with the surgery, whereas compensatory hyperhidrosis in 24 patients (70.6%) did (P=0.001). The rates and characteristics of the paresthesia following needlescopic VATS are similar to those observed after conventional VATS. Conclusions: Chest wall paresthesia affects a significant but previously overlooked proportion of patients following needlescopic VATS

The effects of hypoxemia, G-6-PD deficiency and sympathectomy might all add to the development of acute pulmonary edema

Transaxillary endoscopic sympathectomy of thoracic ganglia (T₂-T₃) has recently gained wider acceptance as the treatment of choice for palmar hyperhidrosis. It requires one-lung ventilation to facilitate the surgery. One-lung ventilation, however, is not without complications, among which acute pulmonary edema has been reported. In this case report, we present a patient with palmar hyperhidrosis complicated by glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, who received bilateral endoscopic sympathectomy under alternate one-lung anesthesia, and developed acute pulmonary edema immediately after recruitment of the successive collapsed lung. The effects of hypoxemia, G-6-PD deficiency and sympathectomy might all add to the development of acute pulmonary edema secondary to reexpansion of each individual lung after alternate one-lung ventilation. The possibilities of the inferred causes are herein discussed.

Source: Acta Anaesthesiologica Scandinavica, Volume 45, Number 1, January 2001

Haemodynamic changes during thoracoscopic surgery

Haemodynamic changes during thoracoscopic surgery: The effects of one-lung ventilation compared with carbon dioxide insufflation.

Main Articles

Anaesthesia. 55(1):10-16, January 2000.
Brock, H. 1; Rieger, R. 2; Gabriel, C. 3; Polz, W. 4; Moosbauer, W. 1; Necek, S. 5

Abstract:
Summary: We investigated the haemodynamic and respiratory effects of one-lung ventilation and carbon dioxide insufflation in 13 adult patients undergoing video-assisted thoracoscopy. Cardiorespiratory variables were determined during carbon dioxide insufflation at intrahemithoracic pressures of 5, 10 and 15 mmHg, and after 5 and 15 min of one-lung ventilation. Carbon dioxide insufflation was associated with a clear deterioration in circulatory function. The cardiac index decreased subsequent to increasing intrathoracic pressures. The mean cardiac index (SD) at pressures of 10 and 15 mmHg was 1.86 (0.39) and 1.52 (0.46), respectively, and may be compared with the reduced venous return consistent with tension pneumothorax. One-lung ventilation did not affect haemodynamic variables but reduced arterial oxygenation indices (PaO2/FIO2) from 424.29 (160.79) after induction of anaesthesia, to 207.72 (125.50) after 5 min and 172.04 (72.03) after 15 min of one-lung ventilation, respectively. The oxygenation index was not influenced by intrahemithoracic carbon dioxide insufflation. One-lung ventilation via a double-lumen endobronchial tube is safe and convenient for video-assisted thoracoscopic surgery. It has no further consequences on haemodynamic variables, whereas the compression of the lung by carbon dioxide insufflation may cause circulatory dysfunction.

one-lung ventilation causes hypoxemia during endoscopic transthoracic sympathectomy

Hypoxemia is an abnormal deficiency in the concentration of oxygen in arterial blood (Mosby's Medical Dictionary). A frequent error is made when the term is used to describe poor tissue diffusion as in hypoxia. It is possible to have a low oxygen content (e.g., due to anaemia) but a high PO₂ in arterial blood so incorrect use can lead to confusion.

Journal of Vascular Surgery : Reply - Published by Elsevier

2 Y Katz, E Zisman, S Isserles and B Rosenberg,
Left, but not right, one-lung ventilation causes hypoxemia during endoscopic transthoracic sympathectomy.

ETS sympathetically maintained pain, and vasospastic or ischemic vascular disease

Sympathectomy for Pain and Hyperhidrosis: Based on the Breakfast Seminar of April 24, 2001, at the 69th Annual Meeting of the American Association of Neurological Surgeons, Toronto, Ontario, Canada.

Article

Neurosurgery Quarterly. 12(2):89-99, June 2002.
Wilkinson, Harold A.

Abstract:
Summary: Surgical resections of sympathetic ganglia from the thoracic, splanchnic, and lumbar area have been carried out for more than 100 years. In the past decade, neurosurgeons have become more interested in surgery on the sympathetic nervous system as less invasive techniques have been developed. Percutaneous radiofrequency and video-assisted endoscopic techniques have largely replaced open surgical thoracic sympathectomy. Lumbar and splanchnic sympathetic ablation is commonly done by percutaneous chemical techniques or, occasionally, by radiofrequency ablation, but the open techniques are still widely used. Sympathectomy is most widely employed for pathologic hyperhidrosis (especially the palmar component), sympathetically maintained pain, and vasospastic or ischemic vascular disease. The less invasive techniques are especially attractive for treating the sympathetically mediated cardiac diseases, including Prinzmetal angina, "syndrome X," and congenital long Q-T interval syndrome.

Surgical complications are usually manageable, but deaths have occurred (even with endoscopic techniques).

Endoscopic sympathetic block in the treatment

In this study, endoscopic sympathetic block was useful in reducing the symptoms of severe social phobia. Although the method is surgical and the effect hence mainly biological, the psychological symptoms of social phobia were also significantly reduced. The results are best if the main symptoms are blushing or palpitation, but even a smaller reduction in the other symptoms is important if it helps the patient to break his isolation.
Knowledge of the elimination of embarrassing physical symptoms in social situations helps the patient to expose himself to formerly impossible situations, and success in them also causes psychological symptoms to subside. But the relief of psychological symptoms may also be due to direct a biological effect of the operation on the anxiety-mediating areas in the nervous system. The only meaningful side effect is compensatory sweating of the trunk, but not even that is significant when modern surgical method are used.
Clamping is as good as bilateral cauterisation, and the results may be equally good with unilateral and bilateral clamping, but because there were only eight patients who had undergone a unilateral clamping procedure, the material is not sufficient to allow definite conclusions concerning that. The results remain unchanged over time, which shows that they were not due to a placebo effect. In the future, it is important to compare this treatment to traditional treatment in order to find out its place among the other, officially approved methods of treating social phobia.
http://informahealthcare.com/doi/abs/10.1080/08039480310000266

A qualitative study of the development of social phobiaHomeostatic responses mediated by the autonomic

PÄIVI POHJAVAARA
SOCIAL PHOBIA: AETIOLOGY, COURSE
AND TREATMENT WITH ENDOSCOPIC
SYMPATHETIC BLOCK (ESB)
A qualitative study of the development of social phobia
and its meaning in people's lives and a quantitative study
of ESB as its treatment
Academic Dissertation to be presented with the assent of
the Faculty of Medicine, University of Oulu, for public
discussion in the Väinö Pääkkönen Hall of the Department
of Psychiatry, on December 3rd, 2004, at 12 noon.

Thanks to modern research techniques, we know a lot of the location of attention, emo-
tion and arousal modulation in the brain. Arousal requires involvement of the brain stem,
the thalamus and the cortex, while attention is maintained by the function of the right
frontal lobe (Kaplan & Sadock 1998, Nagahama et al. 2001). The amygdala rates the
emotional importance of an experience, and the limbic system is the centre of human
drives, whose regulation appears to require an intact frontal cortex. Crude emotions are
produced and handled in the midbrain structures and the olfactory cortex, while distinct-
ly human emotions are generated in the cortex (Kaplan & Sadock 1998).

Homeostatic responses mediated by the autonomic
nervous system are achieved by altering the balance between the sympathetic, parasympa-
thetic and different hormonal systems (Mosqueda-Garcia 1996). The most apparent link
between the autonomic and endocrine systems is manifested by the interactions between
the adrenal cortex and the adrenal medulla.

The neuroanatomical circuits, which support fear and anxiety behaviour, are modulated
by a variety of chemical neurotransmitter systems (Charney 2003). These include the
peptidergic neurotransmitters, corticotrophin-releasing hormone (CRH), neuropeptide
Yand substance P, the monoaminergic transmitters, norepinephrine, serotonin and dopam-
ine, and the amino acid transmitters, gamma-aminobutyric acid and glutamate.
The connection between the sympathetic nervous system and the psyche is best seen in
anxiety and especially in social phobia. The observed usefulness of beta-adrenergic antag-
onists in performance phobia supports this hypothesis (Sutherland & Davidson 1995).

There are studies indicating possible supersensitivity of the central serotonin systems in
social phobia and schizophrenia patients (Tancer et al. 1995, Malhotra et al. 1998). It has
been shown using SPECT (Pirker et al. 2000) that, in a solitary case study, the decreased
5-HTT activity of a social phobic patient was normalized by a sympathetic block (Kuikka
et al. 2000). Among the many neurotransmitters implicated in social anxiety disorder, the
complex interactions between the noradrenergic and serotonergic systems and the HPA
axis overlap those found seen in fear and anxiety (Marcin & Nemeroff 2003).

The physical symptoms of social phobia might be treated by blocking the sympathetic
system at the upper thoracic level with a surgical procedure (Crozier 2001, Telaranta
1998). Sympathectomy was first used to treat the exophthalmos of Basedow disease
(Jonnesco 1896) and angina pectoris (Le Riche 1913, Jonnesco 1921) in the late 19th and
early 20th centuries. Its beneficial effect on the treatment of facial sweating was noticed
as early as the 1930s, and its impact on palmar sweating was reported in the 1950s, when
the procedure was already carried out endoscopically (Kux 1954).

Endoscopic sympathicotomy and endoscopic sympathetic block strongly influence typical symptoms of patients with social phobia

Social phobia is an anxiety disorder which causes fear and anxiety in social interaction or performance situations and can in its worst forms be very debilitating. The patients tend to isolate themselves and suffer from comorbid disorders such as depression, other anxiety disorders and drug and alcohol abuse. Traditional treatment methods such as medication and psychotherapy cause improvement in only 50–70% of patients. METHODS: 164 patients who had been suffering from social phobia for at least 5 years and who were resistant to conservative treatment (medication and/or psychotherapy) were enrolled in this open, uncontrolled, prospective follow-up study. 71 patients underwent endoscopic sympathicotomy (cauterisation); 93 underwent endoscopic sympathetic block (clamping) of the T2–T3 ganglia. Severity of psychic and physical symptoms was assessed by a modified version of Davidson’s brief social phobia scale and patients’ satisfaction was evaluated 1, 6, and 12 months postoperatively. RESULTS: Fear of observation, performance anxiety and embarrassment were alleviated and alertness increased. Likewise, palpitations, trembling of hands and heads, blushing and hyperhidrosis were relieved. All changes were statistically significant. Patients’ satisfaction was high and remained stable over time. Gender, age, and education did not influence satisfaction rates. CONCLUSIONS: Endoscopic sympathicotomy and endoscopic sympathetic block strongly influence typical symptoms of patients with social phobia.
JournalEuropean Surgery
Volume 37, Number 3 / June, 2005


http://www.springerlink.com/content/w986882515290647/