Cardiovascular collapse developing during thoracoscopic thoracic sympathectomy in a patient with essential palmar hyperhidrosis: A case report / 대한마취과학회지

Thoracoscopic thoracic sympathectomy (TTS) is usually a safe and uncomplicated procedure for treating essential palmar hyperhidrosis. However, we report a case of cardiovascular collapse that developed in a healthy patient undergoing TTS. The surgeon performed the left sympathectomy without incident. However, scarcely had an incision been made in the skin of the right chest when the patient developed sinus bradycardia and sudden, severe hypotension. Pulseless ventricular tachycardia occurred immediately thereafter, which rapidly progressed to ventricular fibrillation and cardiovascular collapse. The patient required resuscitation with 200 J of direct current shock defibrillation along with an intravenous injection of epinephrine 1 mg. She recovered without sequelae. We believe the Bezold-Jarisch reflex was triggered by pooling of venous blood and surgical stimuli, and the patient developed cardiovascular collapse as a result.

The Adequate Extent of Thoracic Sympathectomy for Essential Palmar Hyperhidrosis

Essential palmar hyperhidrosis is a disease characterized by excessive perspiration on the palms and hands due to the hyperaction of sympathetic nervous discharge. In severe cases, excessive sweating is seen on the face, axilla, trunk, and soles. Several therapeutic modalities were applied but surgical resection of the sympathetic ganglion is the only curative method. Numerous open surgeries of the thoracic sympathetic ganglia for the treatment of palmar hyperhidrosis have been advocated, but they have also produced several complications. A new therapeutic technique for this disorder has been introduced by combining a thoracoscope and video system. Nowadays, thoracoscopic transthoracic sympathectomy is accepted as the treatment of choice for essential palmar hyperhidrosis. This technique is safe and easy. It also reduces the operating time and admission period. It has also very few complications. Compensatory hyperhidrosis on the trunk, back, and thigh, etc. is commonly an unwanted and unsolved complication after thoracic sympathectomy. Through my experience of thoracic sympathectomy, I thought that the incidence of compensatory hyperhidrosis was closely related to the extent of thoracic sympathectomy. So I restricted the extent of thoracic sympathectomy as a T2 sympathetic ganglion from September 1995. From Mar., 1989 To Aug., 1995, T2, T3 sympathetic ganglionectomies were performed for palmar hyperhidrosis patients and from Sept. 1995 T2 sympathetic ganglionectomies were performed. Using questionnaires, I compared these 2 groups. The results of this study are summarized as follows; 1) Using thoracoscopic transthoracic sympathectomy, operating time, admission period and complications could be reduced. 2) The risk of bleeding during the operation(especially bleeding from the hemiazygous vein) could be reduced in the T2 sympathectomy group. 3) The treatment effect of T2 sympathectomy is no different from T2, T3 sympathectomy for essential palmar hyperhidrosis. 4) The incidence of compensatory hyperhidrosis is less in the T2 sympathectomy group than in the T2, T3 sympathectomy group. From the above results, I concluded thoracoscopic transthoracic sympathectomy is the treatment of choice for essential palmar hyperhidrosis and the adequate extent for sympathectomy is T2 sympathetic ganglion.