Predictive procedure for compensatory hyperhidrosis before sympathectomy: preliminary findings.

OBJECTIVE: Compensatory hyperhidrosis is one of the most common and serious adverse effects following sympathectomy. We performed a local anesthetic procedure that predicts the occurrence and severity of compensatory hyperhidrosis, and evaluated the feasibility, safety, and efficacy of the procedure. METHODS AND METHODS: From July 2009 to July 2010, 20 patients with severe primary palmar hyperhidrosis underwent predictive procedures. A sympathetic nerve block was obtained via thoracoscopic approach under local anesthesia. The patients were evaluated for compensatory hyperhidrosis 1 week after the procedure before deciding whether to proceed with sympathectomy. RESULTS: Of the 20 patients, 17 patients proceeded with sympathectomy and 3 refused the final procedure. Following sympathectomy, the occurrence and severity of compensatory hyperhidrosis in the remaining 17 patients were statistically analyzed with two tailed paired t test, and there is no significant difference between the predictive and final procedures (t = 1.69, df = 16, p > 0.1). CONCLUSION: Predictive procedure using local anesthesia to detect compensatory hyperhidrosis before sympathectomy may be useful for helping patients to decide whether to undergo the operation.

Cardiac morphologic changes after the Nuss operation for correction of pectus excavatum.

BACKGROUND: Pectus excavatum results in compression of the heart and may compromise cardiac function. Several studies have shown that surgical correction improves cardiac function as assessed on echocardiography. However, morphologic changes to support this have not been reported. METHODS: Between July and December 2011, 109 patients underwent the Nuss operation. We measured the Haller index and other variables. To identify the location of the heart within the chest cavity, the distances from the middle of the spine to the right and left heart walls and from the anterior border of the spine to the anterior and posterior heart walls were measured. To characterize dimensional changes, the anteroposterior, transverse lateral, and right and left oblique longest lengths were measured. RESULTS: The postoperative Haller index was significantly different from the preoperative one (2.52±0.40 versus 4.50±1.45; p<0.001). The location changes in the anterior, rightward, and leftward directions were 4.97±8.03 mm (p<0.01), 1.66±7.89 mm (p=0.027), and -2.70±11.12 mm (p=0.01), respectively. The dimensional changes in anteroposterior and right oblique lengths were 5.42±6.42 mm and 16.33±7.77 mm (p<0.01), respectively. CONCLUSIONS: The heart moved positively in the anterior and rightward directions and negatively in the leftward direction, and the anteroposterior and right oblique dimensions were increased after surgical correction. These data suggest that the heart tends to return to a normal position and shape, and that these changes may contribute to improvement in cardiac function.

Short-term and intermediate-term results after unclipping: what happened to primary hyperhidrosis and truncal reflex sweating after unclipping in patients who underwent endoscopic thoracic sympathetic clamping?

Endoscopic thoracic sympathetic clamping (ETC) is used to treat patients with primary hyperhidrosis because it offers the potential of a reversal operation (unclipping) when severe reflex sweating (RS) occurs. Although unclipping has been reported to be effective, the short-term or intermediate-term results after unclipping are unclear. From March 2002 to October 2006, 15 (12.9%) out of 116 patients with primary hyperhidrosis, who underwent ETC, had the endoclip(s) removed as a result of RS. Fourteen patients could be followed up for more than 6 months. The patients answered a telephone interview on the severity of RS, the recurrence of the primary site, and their level of satisfaction. There was no mortality or significant morbidity encountered. On the follow-up, 9 (64%) of the 14 patients who underwent unclipping reported symptomatic recovery from RS. Of these 9 patients with early unclipping (within 4 wk after ETC), only 7 (78%) were satisfied with the outcomes. This suggests that early unclipping does not always guarantee satisfactory recovery from RS. Because early unclipping does not guarantee a full recovery in all patients, special consideration in ETC is needed to determine when to remove the clamp and how strongly to apply the clamp to achieve better results.

Off-pump open pulmonary embolectomy for patients with major pulmonary embolism.

Acute major pulmonary artery embolism (AMPE) requires rapid diagnosis and early intensive treatment to optimize patient outcomes. Most patients with AMPE and hemodynamic instability need open pulmonary embolectomy (OPE). We modified the technique of OPE to include a minimally invasive procedure without the use of cardiopulmonary bypass (CPB). From March 1988 to April 2006, we performed OPE on a total of 12 patients (21 sides) with AMPE. Seven patients (13 sides) underwent conventional OPE with CPB and 5 patients underwent off-pump OPE (OPPE), 4 (8 sides) with AMPE and 1 with catheter embolus with thrombosis. In patients who underwent conventional OPE, there was 1 hospital death in a patient with severe right ventricle dysfunction and 2 significant cases of airway bleeding. In patients who underwent OPPE, there was 1 case of minimal airway bleeding. Mean systolic pulmonary artery pressure in conventional OPE and OPPE patients, respectively, decreased from 50.3 +/- 14 mmHg and 35.4 +/- 6.6 mmHg pre-operatively to 41.7 +/- 20 and 28 +/- 3 mmHg postoperatively. During the long-term follow-up, there were 2 cancer-related deaths but no recurrence of PE. All surviving patients maintained functional class I (n = 10) or II (n = 1). Compared with conventional OPE, OPPE was effective for treating AMPE in our selected cases. Modification of conventional CPB and systemic full heparinization to minimal use of systemic heparinization without CPB may be helpful in treating selected patients with AMPE.

New protocol for a reversal operation in endoscopic thoracic sympathetic clamping: pulling back the suture sling linked to the clip under local anesthesia.

Endoscopic thoracic sympathetic clamping (ETC) has widely been used for treating the patients with primary hyperhidrosis, as it offers the potential of reversal operation (unclipping) under general anesthesia (GA) when severe reflex sweating would occur. However, we modified ETC to unclip under local anesthesia. From March 2002 to January 2005, we performed ETC in 87 patients with primary hyperhidrosis. From September 2002 on, the suture sling which was made with a 3-0 propylphylene suture was additionally placed between the endoclip and the subcutaneous tissue of the thoracoport. When unclipping was needed, the endoclip was removed by being pulled back under portable fluoroscopy. Four of 53 patients (7.5%) who underwent ETC alone underwent unclipping under GA. By contrast, unclipping was successfully performed under local anesthesia in 5 of 34 patients (14.7%) who underwent the modified ETC. ETC will be more effective operation if it is modified concomitantly with the suture sling; otherwise the reversal operation will need GA for the unclipping.

Off-pump open pulmonary embolectomy for major bilateral pulmonary emboli: report of a case.

Acute massive or submassive pulmonary artery thromboembolism causes sudden hemodynamic deterioration, warranting immediate surgery. We report the case of a 67-year-old woman who suffered a syncopal attack resulting in shock, 3 weeks after undergoing orthopedic surgery. Preoperative radiologic imaging studies, including a lung perfusion scan, chest scan, and venography, showed a major bilateral pulmonary artery embolism (PE) originating from a leg vein. An inferior vena cava filter was inserted preoperatively during the venography. We performed an open pulmonary embolectomy without cardiopulmonary bypass by using a submammary trans-sternal bilateral thoracotomy approach. The patient recovered uneventfully and has been well for 13 months.

Thoracoscopic sympathetic clamping in a patient with an azygos fissure.

We believe that an azygos fissure may predispose to bleeding during thoracoscopic surgery. An azygos fissure causes important morphologic changes in the superior mediastinum and thereby poses a risk of massive bleeding during thoracoscopic procedures. We report on a successful thoracoscopic procedure conducted in a patient with palmar hyperhidrosis and an azygos fissure and emphasize that the course of the thoracic sympathetic chain runs laterally along the base of the azygos fissure.