Thoracoscopic sympathectomy for Buerger's disease of the upper extremities

Thoracic sympathectomy: a review of current indications

BACKGROUND

Thoracic sympathetic ablation was introduced over a century ago. While some of the early indications have become obsolete, new ones have emerged. Sympathetic ablation is being still performed for some odd indications thus prompting the present study, which reviews the evidence base for current practice.

METHODS

The literature was reviewed using the PubMed/Medline Database, and pertinent articles regarding the indications for thoracic sympathectomy were retrieved and evaluated. Old, historical articles were also reviewed as required.

RESULTS AND CONCLUSIONS

Currently, thoracic sympathetic ablation is indicated mainly for primary hyperhidrosis, especially affecting the palm, and to a lesser degree, axilla and face, and for facial blushing. Despite modern pharmaceutical, endovascular and surgical treatments, sympathetic ablation has still a place in the treatment of very selected cases of angina, arrhythmias and cardiomyopathy. Thoracic sympathetic ablation is indicated in several painful conditions: the early stages of complex regional pain syndrome, erythromelalgia, and some pancreatic and other painful abdominal pathologies. Although ischaemia was historically the major indication for sympathetic ablation, its use has declined to a few selected cases of thromboangiitis obliterans (Buerger's disease), microemboli, primary Raynaud's phenomenon and Raynaud's phenomenon secondary to collagen diseases, paraneoplastic syndrome, frostbite and vibration syndrome. Thoracic sympathetic ablation for hypertension is obsolete, and direct endovascular renal sympathectomy still requires adequate clinical trials. There are rare publications of sympathetic ablation for primary phobias, but there is no scientific basis to support sympathetic surgery for any psychiatric indication.

Guidelines on surgery of the thoracic sympathetic nervous system

Thoracic sympathetic nervous system (TSNS) surgery has increased in importance in the last few years, generating great expectations among the general population and the scientific community. This has been due to the excellent results obtained by videothoracoscopy-assisted thoracic sympathectomy in the treatment of essential hyperhidrosis and other TSNS disorders. This minimally invasive surgical technique has been shown to be effective, and with a low morbidity it is accepted as one of the best therapeutic options for the treatment of palmar and bilateral axillary hyperhidrosis and the number of patients consulting with the intention of having the operation has increased considerably. Although compensatory sweating, which is occasionally intense, often occurs after the surgery, this and other secondary effects of the technique are well tolerated by patients. The current evidence on TSNS and the treatment of essential hyperhidrosis is based on observational studies, making it difficult to compare series and draw conclusions. There has been much discussion on standardising the technique, defining the most favourable levels for clipping, and choosing the type of denervation with least secondary effects. This has led to the need to draw up these guidelines which should clarify and standardise the criteria for managing patients with disorders of TSNS.

A 7-year Experience with Thoracoscopic Sympathectomy for Critical Upper Limb Ischemia

BACKGROUND

Severely symptomatic arterial insufficiency of an upper limb not suitable for revascularization is a difficult condition to manage. Thoracoscopic sympathectomy (TS) can be an effective procedure in this setting.

METHODS

Our experience with 18 consecutive thoracoscopic sympathectomy (TS) procedures over a period of 7 years has been reviewed. Indications, operative technique, complications, and outcome of surgery are analyzed.

RESULTS

We performed 18 TS procedures on 17 patients during this period. There were no deaths. One patient had intraoperative hemorrhage necessitating conversion to open thoracotomy. Mean postoperative hospital stay was 2.3 days. Follow-up ranged from 6 to 72 months. All patients demonstrated clinical benefit from the procedure.

CONCLUSIONS

Thoracoscopic sympathectomy is a useful option in patients with severely symptomatic hand and digital ischemia from occlusive small arterial disease like thromboangitis obliterans.

Thoracoscopic sympathectomy for symptomatic arterial obstruction of the upper extremities

BACKGROUND

Severely symptomatic arterial insufficiency of the hand and upper extremities requires adequate treatment. Medical therapy and local care are usually unsuccessful, and thoracic sympathectomy can represent an effective procedure to control pain, to help ulcer healing, and to prevent or delay amputation.

METHODS

We performed 20 thoracoscopic sympathectomies in 15 patients (13 men and 2 women) with upper extremity ischemia. Mean age was 47 years (range 21 to 72 years). All patients were thought to have organic blockage of digital arteries. The condition was unilateral in 10 patients and bilateral in 5. Primary diagnosis was digital arteriosclerosis in 8 patients, Buerger's disease in 4 patients and the remaining 3 were drug abusers with severe ischemia due to accidental intraarterial injection of drugs. Eleven patients (73%) presented with terminal digital necrosis, gangrene, or ulceration of the fingers associated with severe pain. Four patients complained of coldness, pain, and some degree of soft tissue infection without permanent loss of tissue.

RESULTS

We performed 10 unilateral and five bilateral staged (mean interval was 3 months) thoracoscopic sympathectomies. We had two minor complications and no mortality. Mean duration of postoperative chest drainage was 2.5 +/- 0.4 days and mean postoperative hospital stay was 5.3 +/- 0.5 days. Follow-up ranged from 3 to 71 months, with a mean of 33 months. All patients demonstrated clinical benefit after operation.

CONCLUSIONS

Thoracoscopic sympathectomy in patients with severe ischemia of upper limb extremities permits optimal symptomatic control and maximum tissue salvage. Because the procedure is minimally invasive, safe, and associated with a low rate of complications, it should be considered earlier the natural course of this disease.

Pedicled omental transfer for limb salvage in Buerger's disease

We performed pedicled omental transfer in 62 patients with Buerger's disease at the Department of Surgery, J.L.N. Hospital, Ajmer between January 1990 and December 1996. All were male and had evidence of limb ischaemia. Post-operative results in these patients consisted of relief of intermittent claudication in 92%, disappearance of rest pain in 94%, disappearance of limb coldness in 83%, disappearance of discolouration in 82%, and healing of ischaemic ulcers in 83%. Tissue oxygen saturation in the affected limb improved from a mean of 84.8+/-3.6% in the preoperative period, to 89+/-1.5% at 12 h, 93.1+/-1.8% at 72 h and 96+/-1.2% at the end of 2 months of follow-up. Claudication distance improved from a mean of 75+/-20 m in the pre-operative period to 1000+/-110 m at 2 months of follow-up in 57 of 62 patients. Major amputations were not required in any patient, thus conserving the limb. We conclude that pedicled omental transfer offers promising results in patients with limb ischaemia due to Buerger's disease.

[Buerger's disease or thromboangiitis obliterans]

PURPOSE

To review clinical data, pathophysiology and treatment of thromboangiitis (Buerger's disease).

DATA SYNTHESIS

Buerger's disease or thromboangiitis obliterans (TAO) is an obliterative vascular disease that affects medium and small sized arteries as well as superficial veins. Young males and smokers are preferentially afflicted with the disease. TAO accounts for 0.5 to 5% of occlusive vascular disease. Though TAO has a world-wide distribution, it can be found with greater prevalence in Eastern Europe, the Mid-East, Asia, and Southeast Asia. Women account for 10 to 20% of the patients and 5 to 10% are more than 60-years-old. Approximately 95% are smokers and disease activity is strongly associated with the use of tobacco. The pathogenesis is poorly understood and most hypotheses are controversial. There is no specific marker of the disease and the diagnosis is based on clinical and angiographic criteria. The disease spontaneously leads to tissue loss and major amputations. This can generally be avoided by discontinuing smoking. Induced hypervolemia and prostacyclins are effective treatments of critical limb ischemia in TAO.

CONCLUSION

If pathophysiology is still poorly understood, spontaneous evolution can be avoided by stopping tobacco and prostacyclin.

Buerger's disease in Hong Kong: a review of 89 cases

BACKGROUND

A retrospective analysis of 103 case records from 1978 to 1996 with a provisional diagnosis of Buerger's disease was undertaken at the Department of Surgery, University of Hong Kong, Queen Mary Hospital. The aim of the study was to elucidate the clinical course and evaluate the results of surgical intervention of Buerger's disease in Hong Kong Chinese people.

METHODS

Fourteen patients were subsequently excluded from the study because of inability of fulfil our diagnostic criteria. Data on clinical presentation, investigations, indications and results of surgical intervention were reviewed. Sympathectomies and arterial reconstructions were performed on 42 and four patients, respectively, for critical ischaemia or rest pain. Outcome was analysed with respect to the rate of ulcer healing, pattern of recurrence and limb loss.

RESULTS

The patients were all young male heavy smokers with a mean age of 36.5 years. The majority of patients (80%) presented with ischaemic ulceration or gangrene. Vascular reconstruction was undertaken in four patients and satisfactory long-term results were obtained in three patients. Sympathectomy was able to relieve symptoms in 87% of operated patients and ischaemic ulceration healed in 2.6 (mean) +/- 1.7 (SD) months after the operation. If the patient continued to smoke, surgical intervention did not exempt the patient from a relapse or amputation.

CONCLUSION

Sympathectomy provides short-term pain relief and promotes ulcer healing in patients with Buerger's disease but carries no long-term benefit. Complete abstinence from smoking is the only means of arresting the progression of the disease.