Effectiveness of bilateral clipping of the thoracic sympathetic chain for the treatment of severe palmar and/or axillary hyperhidrosis and facial flushing. / Efectividad de la interrupción de la transmisión nerviosa de la cadena simpática torácica bilateral con clip para el tratamiento de la hiperhidrosis palmar y/o axilar severa y el rubor facial.

INTRODUCTION: Division of the thoracic sympathetic chain is the standard treatment for severe palmar and/or axillary hyperhidrosis and facial flushing. Clipping is an alternative option which allows the block to be reverted in cases of intolerable compensatory sweating. METHODS: This is a prospective study performed to assess: a) results of clipping of the thoracic sympathetic chain in patients with palmar and/or axillary hyperhidrosis and facial flushing; and b) to determine the improvement obtained after removal of the clip in patients with unbearable compensatory sweating. We included 299 patients (598 procedures) diagnosed with palmar hyperhidrosis (n=110), palmar and/or axillary hyperhidrosis (n=78), axillary hyperhidrosis (n=35), and facial flushing (n=76), who underwent videothoracoscopic clipping between 2007 and 2015. RESULTS: 128 men and 171 women were treated, with mean age of 28 years. A total of 290 patients (97.0%) were discharged within 24hours. The procedure was effective in 92.3% (99.1% in palmar hyperhidrosis, 96,1% in palmar and/or axillary hyperhidrosis, 74.3% in axillary hyperhidrosis, and 86.8% in facial flushing). Nine patients (3%) presented minor complications. Compensatory sweating developed in 137 patients (45.8%): moderate in 113 (37.8%), severe in 16 (5.3%) and unbearable in 8 (2.7%). The clip was removed in these 8 patients; symptoms improved in 5 (62.8%), with sustained effect on hyperhidrosis in 4 of them. CONCLUSIONS: Clipping of the thoracic sympathetic chain is an effective and safe procedure. If incapacitating compensatory sweating develops, this technique allows the clips to be removed with reversion of symptoms in a considerable number of patients.

Inyección de pintura a alta presión en la mano: una grave lesión que no debe ser subestimada / High-pressure injection of paint into the hand: a severe injury that should not be underestimated

La inyección de alta presión en la mano causa una pequeña lesión cutánea pero severo daño tisular subcutáneo que puede provocar pérdida funcional permanente o amputación. Un tratamiento urgente y adecuado es determinante. Presentamos el caso de un pintor industrial que se inyectó pintura con base de aceite con su pistola de alta presión en el dedo índice izquierdo. Ingresó en Urgencias, donde se le administró profilaxis antitetánica y antibioterapia intravenosa y, antes de transcurridas cuatro horas, se le realizó un desbridamiento quirúrgico. Al año de la lesión el paciente presentaba movilidad activa y pasiva del dedo completa con palidez cutánea, hipersensibilidad y disfunción con la exposición al frío. Hay que reconocer la severidad de estas lesiones con apariencia inicial benigna y realizar un amplio desbridamiento quirúrgico inmediato de todo el tejido isquémico, ya que el retraso en realizarlo se asocia con altas tasas de complicaciones

High-pressure injection into the hand causes a small skin lesion but severe subcutaneous tissue damage, which can result in permanent functional loss or amputation. Urgent and appropriate treatment is decisive. We present the case of an industrial painter who injected oil-based paint with a high-pressure gun into his left index finger. He was admitted to Accidents and Emergencies, where tetanus prophylaxis and antibiotic therapy were administered. Then, within four hours of his arrival at the hospital, the patient was brought to the operating room for surgical debridement. A year after the injury the finger's active and passive range of motion was complete, although paling of the skin together with hypersensitivity and dysfunction occurred on exposure to cold. The severity of these lesions, even if their initial appearance is benign, must be recognized and an immediate surgical debridement of the entire ischemic tissue should be performed, because delay in treatment is associated with higher rates of complication

Sympathetic ganglionectomy for facial blushing using application of laser speckle flow graph.

OBJECTIVE: Endoscopic thoracic sympathectomy at the second rib level is considered effective as a therapeutic treatment for facial blushing. However, 10% to 15% of patients do not benefit from this intervention. No additional procedure has been developed for this disorder. Recently, ganglionectomy using application of laser speckle flow graph has been evaluated for the treatment of compensatory sweating. We report our results of ganglionectomy for facial blushing as a redo surgery. METHODS: Between August 2012 and April 2017, 8 patients with facial blushing who underwent an initial sympathectomy reported symptom recurrence. Seven patients had undergone transection of the sympathetic trunk at the second rib and 1 patient had undergone transection of the sympathetic trunk at the second and third ribs. These patients were treated using ganglionectomy guided by application of laser speckle flow graph. After temporary decreases in facial skin blood perfusion were confirmed by stimulating the sympathetic ganglions, ganglionectomy was performed. RESULTS: All patients' symptoms improved. There were no side effects, including deterioration of compensatory sweating, worsening of gustatory sweating, or Horner syndrome. There were no cases of mortality or conversion to open surgery. CONCLUSIONS: This study shows the effectiveness of ganglionectomy for the treatment of facial blushing, representing a new treatment option for this condition. Considering the mechanism of facial blushing, it is important to recognize that ganglionectomy is effective after the interception of the sympathetic trunk on the cranial side.

The efficacy of oral anticholinergics for sympathetic overactivity in a thoracic surgery clinic.

OBJECTIVE: Little is known of the success rates of oral anticholinergics for the treatment of primary hyperhidrosis and facial blushing as alternatives to surgical intervention. We examine predictors of success with these medications. METHODS: A retrospective review was performed at a single institution, including all patients presenting with symptoms of primary hyperhidrosis, facial blushing, or both from 2004 to 2015. All patients were offered a trial of oral anticholinergics. If oral anticholinergic therapy was not successful, patients were offered surgery. Statistical analyses were performed to compare patients who declined surgery given the trial of oral anticholinergics with those who proceeded with surgery. RESULTS: A total of 381 patients presented with symptoms of primary hyperhidrosis (86.6%), facial blushing (2.4%), or both (11.0%). A total of 230 patients (60.4%) declined surgery after using oral anticholinergics, and 151 patients (39.6%) chose surgery. Patients who declined surgery were more likely to have symptoms of primary hyperhidrosis without facial blushing (89.6% vs 82.1%; P = .02) or have primary symptoms involving the axilla, torso, scalp, or groin. Patients who proceeded with surgery had higher rates of palmar symptoms as a primary site (77.6% vs 61.1%; P = .01) and were more likely to have facial blushing alone or in combination with primary hyperhidrosis. Presentation with palmar symptoms and greater number of prior therapy attempts were independent predictors of proceeding with surgery after controlling for concomitant symptom type and location (P = .01 and P < .0001, respectively). CONCLUSIONS: The majority of patients presenting with sympathetic overactivity decline surgery when a trial of oral anticholinergics is included in the treatment algorithm. Facial blushing and palmar symptoms were each associated with choosing surgery.

Predictors of outcome following endoscopic thoracic sympathectomy.

BACKGROUND: Endoscopic thoracic sympathectomy (ETS) provides definitive management for primary focal hyperhidrosis and facial blushing. These conditions are debilitating and not uncommon, but many clinicians avoid ETS due to the risk of complications, particularly compensatory sweating (CS). This retrospective cohort study aimed to evaluate the degree of symptom resolution, patient satisfaction and adverse reactions after ETS and to identify subgroups of patients more likely to achieve a satisfactory outcome. METHODS: From 2004 to 2010, 210 patients underwent ETS performed by a single surgeon. These patients responded to a questionnaire regarding levels of satisfaction, symptom resolution and complications encountered, particularly CS. RESULTS: Palmar hyperhidrosis (97%) and scalp/facial hyperhidrosis (93%) demonstrated greater degrees of symptom resolution than axillary hyperhidrosis (71%) and facial blushing (71%) (P < 0.001). Rates of severe CS were lowest in patients with palmar hyperhidrosis (8%) and highest in patients with axillary (26%) and scalp/facial (44.5%) hyperhidrosis (P = 0.0003). The probability of experiencing no CS was highest at young ages and decreased with age (P = 0.0006). Satisfaction rates also fell as age increased (P = 0.004). Satisfaction rates were highest in patients with palmar (90%) and lowest in patients with scalp/facial (52%) hyperhidrosis (P < 0.02). DISCUSSION: Patient satisfaction following ETS is highest among younger patients and those undergoing the procedure for palmar hyperhidrosis. Dissatisfaction arises from failure to achieve the desired aim as well as the development of severe CS, which is more common in older patients and those undergoing ETS for axillary and scalp/facial hyperhidrosis.

Experiencia inicial de un programa de clipaje del sistema nervioso simpático para el tratamiento de la hiperhidrosis y el rubor facial / Initial experience of a program of clipping the sympathetic nervous system for the treatment of hyperhidrosis and facial flush

Introducción y objetivo Evaluar los resultados de nuestro programa de clipaje del sistema nervioso torácico simpático (SNTS) para el tratamiento del rubor facial y/o hiperhidrosis (HH) y comparar la metodología-resultados de la fase de desarrollo del programa (A: enero 2007-abril 2009) y la fase de consolidación del mismo (B: mayo 2009-marzo 2010).Población y métodos Se ha incluido a 44 pacientes (88 procedimientos) sometidos a clipaje videotoracoscópico del SNTS en régimen de cirugía mayor ambulatoria (CMA). Los datos fueron recogidos prospectivamente y analizados retrospectivamente. Se ha realizado estudio estadístico descriptivo y comparativo entre los 2 grupos. Resultados La morbilidad global fue de 5 casos (11,3%). La tasa de recidiva postquirúrgica de HH fue del 4,54% (2 casos), la incidencia de sudoración compensadora (SC) fue del 65,9% (mínima en 26 de los 29 casos). Al comparar el período B con el A, se aprecia: disminución significativa del tiempo quirúrgico, desaparición de la recidiva de HH, disminución de la morbilidad en un 30%, reducción a la mitad de la incidencia de SC moderada-severa e incremento del grado de satisfacción. En uno de los casos de SC mal tolerada se retiraron los clips consiguiéndose la desaparición de esta. Conclusiones El clipaje del SNTS es una técnica segura en régimen de CMA, con una curva de aprendizaje corta (20 casos) tras la cual se obtienen resultados equiparables o, incluso mejores, que los de la simpaticolisis. Estos resultados, junto a su potencial reversibilidad, la convierten, en nuestra opinión, en la técnica de elección en la cirugía del SNTS (AU)

Introduction and objective: To evaluate the results of our program of clipping the thoracicsympathetic nervous system (TSNS) for the treatment of facial (..) (AU)

[Initial experience of a program of clipping the sympathetic nervous system for the treatment of hyperhidrosis and facial flush]. / Experiencia inicial de un programa de clipaje del sistema nervioso simpático para el tratamiento de la hiperhidrosis y el rubor facial.

INTRODUCTION AND OBJECTIVE: To evaluate the results of our program of clipping the thoracic sympathetic nervous system (TSNS) for the treatment of facial flush and/or hyperhidrosis (HH), and to compare the methodology-results of the program development phase (A: January 2007-April 2009) and its consolidation phase (B: May 2009-March 2010). MATERIAL AND METHODS: The program included a total of 44 patients (88 procedures) subjected to videothoracoscopy and clipping of the TSNS in a one day surgery unit. Data were collected and analysed retrospectively, and a descriptive and comparative statistical analysis was performed between the two periods (A and B). RESULTS: The overall morbidity was 5 cases (11.3%). The post-surgical occurrence rate of HH was 4.54% (2 cases), and the incidence of compensatory sweating was 65.9% (minimal in 26 of the 29 cases). On comparing period B with period A, there was a significant decrease in surgical time, disappearance of recurrence of HH, a decrease of 30% in morbidity, reduction by half in the incidence of moderate to severe compensatory sweating, and an increase in the level of satisfaction. The clamps were removed in one of the poorly tolerated compensatory sweating cases, resulting in its disappearance. CONCLUSIONS: Clipping the TSNS is a safe technique in the one day surgery unit, with a short learning curve (20 cases) after which comparable, or even better, results are obtained than those of sympatholysis. These results, together with their potential reversibility, makes it, in our opinion, the technique of choice in the surgery of the TSNS.

Resultados del tratamiento videotoracoscópico del blushing / Results of Video-Assisted Thoracoscopic Sympathectomy for Facial Blushing

Introducción: El blushing es una disautonomía que afecta al área craneofacial y se manifiesta en forma de rubor facial que puede conllevar trastornos psíquicos. La eficacia del tratamiento farmacológico y de la terapia cognitivo conductal es anecdótica y no hay estudios rigurosos que demuestren su validez. Objetivo: Evaluar la efectividad de la simpaticotomía videotoracoscópica, así como las variables de personalidad y ansiedad fóbica en una serie de pacientes cuyo motivo de consulta fue el enrojecimiento facial incontrolable (blushing). Material y métodos: Se realizó un estudio observacional retrospectivo durante un periodo de 7 años (2001-2008) en los pacientes afectos de blushing a los que se les efectuó simpaticotomía torácica bilateral videotoracoscópica. Todos los pacientes fueron visitados por un dermatólogo, un psicólogo y un cirujano torácico e informados de los efectos secundarios y expectativas de la intervención. Resultados: Doscientos cuatro pacientes, con una distribución por sexos similar y una edad media de 34 años (rango: 15-67) fueron incluidos en el estudio. Solamente un 10% tuvo un resultado no esperado de la invervención, debido a la poca eficacia o a un excesivo sudor reflejo posquirúrgico que fue considerado grave en un 2% de los casos. No hubo mortalidad y solo un caso de síndrome de Horner transitorio. Se realizó una toracotomía videoasistida por sínfisis pleural y 5 pacientes desarrollaron un neumotórax, de los cuales uno requirió drenaje pleural. Conclusiones: La simpaticotomía videotoracoscópica es un tratamiento seguro, eficaz y permanente del blushing incapacitante. La ansiedad medida prequirúrgicamente es reactiva al blushing y no al revés (AU)

Background: Involuntary craniofacial erythema, or blushing, due to autonomic dysfunction can be a cause of psychological distress. Although anecdotal reports have suggested that pharmacologic treatments or cognitive behavioral therapy can be used to treat the condition, no rigorous analyses of their efficacy have been reported. Objectives: To assess the efficacy of video-assisted thoracoscopic sympathectomy and to study phobic anxiety and other personality traits in a series of patients with involuntary facial blushing. Materials and methods: We carried out a retrospective observational study of patients treated with bilateral video-assisted thoracoscopic sympathectomy for blushing over a 7-year period (2001-2008). All the patients were treated by a dermatologist, a psychologist, and a thoracic surgeon and were informed of the predicted outcomes. Results: A total of 204 patients with a mean age of 34 years (range, 15-67 years) were included; the numbers of males and females were similar. Only 10% had unpredicted outcomes; in such cases, either the procedure was insufficiently effective or postoperative reflex sweating developed (and was considered serious in 2%). There were no deaths and only 1 case of transient Horner syndrome. Video-assisted thoracotomy was required for pleural symphysis in 1 patient; 5 patients developed pneumothorax, but only 1 of them required pleural drainage. Conclusions: Video-assisted sympathectomy is a safe, effective and definitive treatment for disabling blushing. Anxiety that is detected before surgery is a reaction to blushing rather than a cause of it (AU)

[Results of video-assisted thoracoscopic sympathectomy for facial blushing]. / Resultados del tratamiento videotoracoscópico del blushing.

BACKGROUND: Involuntary craniofacial erythema, or blushing, due to autonomic dysfunction can be a cause of psychological distress. Although anecdotal reports have suggested that pharmacologic treatments or cognitive behavioral therapy can be used to treat the condition, no rigorous analyses of their efficacy have been reported. OBJECTIVES: To assess the efficacy of video-assisted thoracoscopic sympathectomy and to study phobic anxiety and other personality traits in a series of patients with involuntary facial blushing. MATERIALS AND METHODS: We carried out a retrospective observational study of patients treated with bilateral video-assisted thoracoscopic sympathectomy for blushing over a 7-year period (2001-2008). All the patients were treated by a dermatologist, a psychologist, and a thoracic surgeon and were informed of the predicted outcomes. RESULTS: A total of 204 patients with a mean age of 34 years (range, 15-67 years) were included; the numbers of males and females were similar. Only 10% had unpredicted outcomes; in such cases, either the procedure was insufficiently effective or postoperative reflex sweating developed (and was considered serious in 2%). There were no deaths and only 1 case of transient Horner syndrome. Video-assisted thoracotomy was required for pleural symphysis in 1 patient; 5 patients developed pneumothorax, but only 1 of them required pleural drainage. CONCLUSIONS: Video-assisted sympathectomy is a safe, effective and definitive treatment for disabling blushing. Anxiety that is detected before surgery is a reaction to blushing rather than a cause of it.

Endoscopic thoracic sympathectomy: long-term results for treatment of upper limb hyperhidrosis and facial blushing.

BACKGROUND: Endoscopic thoracic sympthectomy (ETS) is frequently used in the management of patients with hyperhidrosis and excessive blushing. Long term-follow up is scarce. We retrospectively reviewed long-term morbidity, success and overall patient satisfaction rates in patients operated in our department. METHOD: Data of all patients undergoing ETS for either upper limb hyperhidrosis or facial blushing and sweating between January 1994 and December 2006 were reviewed. A standard questionnaire inquiring on relief of symptoms, satisfaction with the operation and occurrence of compensatory sweating (CS) was sent out in January 2008. RESULTS: We performed bilateral thoracoscopic sympathectomies in 73 patients. There were no operative mortalities, minor complications occurred in 22%. Initial success rate was 88%. Median follow up was 93 (24-168) months, response rate to the questionnaire was 85%. Sixty-nine per cent of patients continued to have relief of initial symptoms, whereas patient satisfaction rate was 56%. CS was present in 42 patients (68%). Long-term satisfaction rates per initial indication group were 42% for facial blushing and 65% for hyperhidrosis (n.s.), and CS was present in 79% vs 61%, respectively. CONCLUSION: ETS appears a safe treatment for upper limb hyperhydrosis with acceptable long-term results. For excessive blushing, however, long-term satifaction rates of ETS are severely hampered by a high incidence of disturbing compensatory sweating. ETS should only be indicated in patients with unbearable symptoms refractory to non-surgical treatment. The patient information must include the long-term substantial risk for sever CS and regret of the procedure.

Treatment of Harlequin syndrome by costotransversectomy and sympathectomy: case report.

BACKGROUND AND IMPORTANCE: Harlequin syndrome is a rare neurological condition involving various degrees of unilateral hyperhidrosis and erythema of the head and neck. We present a clinical presentation and description of curative therapy in a patient with a sudden onset of Harlequin syndrome following a thoracotomy. CLINICAL PRESENTATION: A 42-year-old female with a history of mastectomy for right-sided breast cancer subsequently had a left partial pneumonectomy for a metastasis. Postoperatively, she had onset of contralateral neck and facial flushing and sweating. Flushing was triggered by emotion and exercise, but also occurred spontaneously at random intervals. Magnetic resonance imaging of the brain, cervical spine, and thoracic spine were negative for pathology. Because of the patient's surgical history and negative workup, she was given a diagnosis of Harlequin syndrome. Surgical intervention consisted of a partial right T3 costotransversectomy with T2 sympathectomy. Postoperatively, the patient's symptoms of Harlequin syndrome resolved. The procedure was complicated by T1 radicular pain, which responded well to Gabapentin. CONCLUSION: The diagnosis of Harlequin syndrome is relatively new, and the majority of the scientific literature is concerned with descriptive case presentations. We present a surgical technique for the treatment of Harlequin syndrome.

Excision of sympathetic ganglia and the rami communicantes with histological confirmation offers better early and late outcomes in Video assisted thoracoscopic sympathectomy.

BACKGROUND: Video-Assisted Thoracoscopic Sympathectomy (VATS) is an established minimally invasive procedure for thoracic sympathetic blockade in patients with hyperhidrosis, facial flushing and intractable angina. Various techniques using clips, diathermy and excision are used to perform sympathectomy. We present our technique of excision of the sympathetic chain with histological proof and the analysis of the early and late outcomes. METHODS: We evaluated 200 procedures in 100 consecutive patients, who underwent Video Assisted Thoracoscopic Sympathectomy by a single surgeon in our centre between September 1996 to March 2007. All patients had maximum medical therapy prior to surgery and were divided into 3 groups based on indications, Group 1(hyperhidrosis: 48 patients), Group 2 (facial flushing: 26 patients) and Group 3(intractable angina: 26 patients). The demography and severity of symptoms for each group were analysed. The endpoints were success rate, 30 day mortality, complications and patient's satisfaction. RESULTS: 99 patients had bilateral VATS sympathectomy and 1 had unilateral sympathectomy. The conversion rate to open was 1(1%). All patients had successful removal of ganglia proven histologically with no perioperative mortality in our series. The complications included pneumothorax (5%), acute coronary syndrome (2%), transient Horner's syndrome (1%), transient paraesthesia (1%), wound infection (4%), compensatory hyperhidrosis (18%), residual flushing (3%) and wound pain (5%). There were five late deaths in the intractable angina group at a mean follow up of 36.7 months. Overall success rates of abolishing the symptoms were 96.3%, 87.5% and 95.2% for Group 1, 2 and 3 respectively. CONCLUSION: Excision of the sympathetic chain with histological confirmation during VATS sympathectomy is a safe and effective method in treating hyperhidrosis, facial flushing and intractable angina with good long term results and satisfaction.

Thorascopic sympathectomy performed using laser.

INTRODUCTION: Thorascopic sympathectomy is accepted as an effective treatment for palmar hyperhidrosis, facial blushing and to a lesser extent for digital ischaemia and axillary hyperhidrosis. PATIENTS AND METHODS: Data were collected retrospectively on patients undergoing thorascopic sympathectomy at St Peter's Hospital between 1987 and 2006. Patients were followed up by telephone interview. RESULTS: A total of 233 thorascopic sympathectomy procedures were performed by a single operator in 123 patients. Ages ranged from 9-71 years and 75 were women. In patients, 105 had a bilateral and 13 a unilateral procedure, 5 patients had a bilateral procedure performed in two stages. In 6 upper limbs, the procedure could not be done. Overall, 110 patients (90%) had the procedure performed for palmar hyperhidrosis, 8 (6%) for facial blushing and in 5 (4%) patients the operation was performed for digital ischaemia with tissue loss. There were no deaths and all patients were discharged on day 1 following the procedure. Complications included bleeding (2), pulmonary oedema (1) and failed procedure (2); however, no incidences of Horner's syndrome occurred. Only 40 of 123 (32.5%) patients gave follow-up information. Of this small group, 33 of 40 (83%) were cured, 4 of 40 (10%) were better, 2 of 40 (5%) were unchanged and 1 patient was worse. Only 22 out of 40 (55%) of these patients were troubled by compensatory sweating, with only 4 of 40 (10%) reporting this as a major problem. CONCLUSIONS: Thorascopic sympathectomy is safe and can be carried out as a single bilateral procedure in the majority of cases. The laser allows the use of a single port, requires less dissection than surgical or clipping techniques, is more precise than diathermy and may be less likely to cause a Horner's syndrome.

Upper dorsal endoscopic thoracic sympathectomy: a comparison of one- and two-port ablation techniques.

OBJECTIVE: Facial blushing and hyperhidrosis, particularly in the facial, axillary or palmar distribution, are socially, professionally, and psychologically debilitating conditions. Endoscopic thoracic sympathectomy can be carried out through multiple ports or by using a single port and a modified thoracoscope with integrated electrocautery. We reviewed our own experience to compare outcomes between these methods. METHODS: One hundred and nine consecutive endoscopic thoracic sympathectomies performed on 96 patients (M:F, 30:66) were examined with respect to operative method, symptom control, and patient satisfaction. Complete follow-up was available on 144 treated sides in 77 patients (80.2%), 38 treated with two ports, 39 performed by a one-port procedure. Mean age was 32.6 years (range 18-63) with a median follow-up of 25 months (range 5-85). Pooled data showed that the mean duration hospital stay was 1.6 nights with no deaths, conversions, or neurological injuries. RESULTS: The one-port group showed superior outcomes in terms of hospital stay, rate of postoperative pneumothorax, and the need for chest drain insertion; however, there was no correlation between number of ports and patient satisfaction. The mean overall satisfaction rating out of 5 was 3.3 with 76.6% of patients rating the outcome as 3 or more. 90.9% had an initial improvement in symptoms, although 21 patients (27.3%) described a late return of symptoms. CONCLUSION: Endoscopic thoracic sympathectomy can be safely and effectively carried out using a single port with similar results to the traditional two-port procedure. The one-port procedure may allow for a shorter duration of stay and lower complication rate.

[Video-assisted thoracoscopic sympathectomy for the treatment of facial flushing: ultrasonic scalpel versus diathermy]. / Simpatectomía torácica por videotoracoscopia para el tratemiento del rubor facial: bisturí ultrasónica frente a diaterma.

OBJECTIVE: To evaluate the advantages of the ultrasonic scalpel compared to electrocoagulation in patients undergoing video-assisted thoracoscopic sympatholysis or sympathectomy for uncontrolled facial blushing. METHODS: Two hundred bilateral video-assisted thoracoscopic procedures to interrupt transmission in the thoracic sympathetic nerve were performed in 100 patients with incapacitating facial blushing. In 2 cases, the video-assisted approach was chosen because of pleural symphysis. The mean age of patients was 34 years (range: 15 to 67). The sympathetic chain was interrupted from the lower portion of the first thoracic ganglion through the third. RESULTS: All patients were discharged within 24 hours with the exception of one on whom an emergency thoracotomy had been performed. No complications were reported in the group in which a harmonic scalpel was used. One case of temporary Horner syndrome (4 months) and 3 cases of persistent chest pain (more than 2 weeks) were reported in the diathermy group. There were 9 cases of partial and asymptomatic pneumothorax that resolved without treatment or prolonged hospital stays. CONCLUSION: Dissection of the sympathetic nerve is accomplished more reliably and with better visualization with the ultrasonic scalpel. Peripheral lesions in lung parenchyma and adjacent tissues (intercostal vessels and nerves) are avoided, as is Horner syndrome, which can be caused by dispersion of heat. Use of the ultrasonic scalpel would also lead to a lower incidence of postoperative neuralgia.

Minimally invasive video-endoscopic sympathectomy by use of a transaxillary single port approach.

OBJECTIVES: This is a prospective study to evaluate the long-term outcome and the value of a transaxillary single port thoracic sympathectomy by use of a modified paediatric cystoresectoscope in a consecutive series of patients with facial blushing and/or hyperhidrosis. MATERIALS AND METHODS: All patients who underwent a thoracic transsection of the sympathetic chain from T2 to T5 by use of a 7-mm single port approach and a modified urologic electroresectoscope between 1996 and 1998 were prospectively analysed regarding postoperative morbidity and outcome (clinical evaluation, visual analogue scale) in order to validate this technique. RESULTS: 37 patients (18 men, 19 women) with an age ranging from 18 to 67 years (mean 34 years) underwent 74 bilateral video-assisted thoracic sympathectomies. The indications for sympathectomy included facial blushing in 32%, hyperhidrosis in 52%, or both in 16% of the patients. Ninety-five percent of the patients were discharged from the hospital on the next day, the 30-day mortality was zero, and there was no conversion to an open procedure. A severe complication with crossed emboli and motor aphasia was noted. A unilateral transient Horner's syndrome was observed in two patients. Three-month follow-up revealed an excellent cosmetic and functional result, with no residual pain. Complete relief of symptoms was observed in 89% and in 100% of the patients with facial blushing and palmar hyperhidrosis, respectively, after a follow-up of 34.5 months. Recurrence of the symptoms after initial regression was noted in 5.7% of the patients 3 years after surgery. Compensatory sweating of the lower extremities was significantly increased in patients with hyperhidrosis and facial blushing; however, sweating of the trunk was only increased in patients with hyperhidrosis. Improvement of quality of life was observed in 94.6% of the patients. CONCLUSIONS: Single port thoracoscopic sympathectomy by use of a modified paediatric cystoresectoscope and transsection from T2 to T5 gives an excellent cosmetic and functional outcome, with better results in patients with hyperhidrosis.