Pyloric Sympathectomy: A Novel Way to Get Pylorus Relaxation? Report of Two Bariatric Cases

Objective: This case report aimed to demonstrate a possible neuromuscular effect of pyloric sympathectomy on the pylorus motility, leading to its permanent relaxation, observed in two bariatric surgical cases, one primary and the other, revisional. Background: Pyloric sphincter is a physiological barrier to free gastric emptying. In sleeve gastrectomy and in Roux-en-Y gastric bypass revisions, that put the remnant stomach in transit, the pylorus can contribute to generate a high intragastric pressure, which could lead to acute gastric fistulas and/or chronic gastroesophageal reflux disease. The possibility of functionally relaxing the pylorus, promoting intragastric pressure reduction, could represent a protective maneuver against these complications. Methods: We describe herein a surgical maneuver applied in two cases of bariatric surgeries, with the intention of facilitating antrum-duodenal region exposure, in a sleeve gastrectomy and in a Roux-en-Y gastric bypass conversion to SADI-S. For this, a ligation of terminal peripyloric vessels was done, allowing a passage of a tape, which surrounded the pylorus, for its traction. In both cases, 30-day and 1-year endoscopic evaluations were done, to assess esophagitis signs, anastomosis healing and anatomical pouch aspect. A clinical evaluation was also done, to assess gastroesophageal symptoms (validated questionnaire). Results: In the postoperative endoscopic evaluations, no esophagitis were observed in any case and the gastric pouches had normal aspect, with the expected anatomical findings, compatible with the surgeries performed. The anastomosis healed without problems, in the revisional case. Interestingly, in both cases, it was observed a complete pyloric sphincter relaxation, which lasted until 1-year endoscopic evaluation. There were no fistulas, nor esophagitis in any of these cases. Clinically, there were no symptoms of gastroesophageal reflux disease (validated questionnaire). Conclusion: The observation of a pyloric durable atomy, that followed peripyloric dissection and vessels ligation (arterial branches), with its concomitant sympathectomy, can represent a new way of decompressing gastric chamber, either in primary or revisional bariatric surgeries. This maneuver can be protective against acute fistulas and gastroesophageal disease. Additional studies are necessary to confirm this hypothesis.

Recovery of sympathetic nerve function after lumbar sympathectomy is slower in the hind limbs than in the torso

Local sympathetic denervation by surgical sympathectomy is used in the treatment of lower limb ulcers and ischemia,but the restoration of cutaneous sympathetic nerve functions is less clear.This study aims to explore the recovery of cutaneous sympathetic functions after bilateral L2-4 sympathectomy.The skin temperature of the left feet,using a point monitoring thermometer,increased intraoperatively after sympathectomy.The cytoplasm of sympathetic neurons contained tyrosine hydroxylase and dopamineβ-hydroxylase,visualized by immunofluorescence,indicated the accuracy of sympathectomy.Iodine starch test results suggested that the sweating function of the hind feet plantar skin decreased 2 and 7 weeks after lumbar sympathectomy but had recovered by 3 months.Immunofluorescence and western blot assay results revealed that norepinephrine and dopamineβ-hydroxylase expression in the skin from the sacrococcygeal region and hind feet decreased in the sympathectomized group at 2 weeks.Transmission electron microscopy results showed that perinuclear space and axon demyelination in sympathetic cells in the L5 sympathetic trunks were found in the sympathectomized group 3 months after sympathectomy.Although sympathetic denervation occurred in the sacrococcygeal region and hind feet skin 2 weeks after lumbar sympathectomy,the skin functions recovered gradually over 7 weeks to 3 months.In conclusion,sympathetic functional recovery may account for the recurrence of hyperhidrosis after sympathectomy and the normalization of sympathetic nerve trunks after incomplete injury.The recovery of sympathetic nerve function was slower in the limbs than in the torso after bilateral L（2-4） sympathectomy.

Functional Cardiological Changes Resulting from Thoracoscopic Thoracic Sympathectomy: Systematic Review

Hyperhidrosis is a condition resulting from a systemic sympathetic hyperactivity. The gold standard treatment is the resection or surgical ablation of the paravertebral sympathetic chain: the endoscopic thoracoscopic sympathectomy (ETS). Non-cardiac thoracic surgeries carry a considerable incidence of pathological postoperative cardiac events, raising attention to possible worsen cardiac functional capacity after the resection of a pair of thoracic sympathetic ganglia. The aim of this study is to investigate literature evidences of postoperative cardiovascular functional changes on patients submitted to ETS as treatment for hyperidrosis. This is a systematic review of the literature. Clinical studies published between January 1999 and April 2019 were analyzed. The PICO strategy was used to construct the question of systematic reviews research. The process of selecting articles was organized according to PRISMA Diagram. The search in electronic databases resulted in seven articles, of which one was excluded for being out of scope of the research, leaving six articles. All studies showed a pattern of heart rate (HR) reduction after endoscopic thoracic sympathectomy. It was suggested a relation between the extension of the procedure and the presence of cardiac functional alterations. There was an improvement in myocardial physical conditioning and maintenance of functional capacity. To elucidate the real mechanisms involved in the maintenance of myocardial function, and even its improvement, it is necessary to develop further studies that directly evaluate them.

Intraoperative Rise of Surface Temperature Monitors Success of Sympathectomy in Palmoaxillary Hyperhidrosis

Objectives: Patients with hyperhidrosis suffer from an extreme perspiration that cannot be aligned with natural or situational standards. Endoscopic sympathectomy is a meaningful option for palmar and axillary hyperhidrosis. A standardized method of monitoring the immediate intraoperative success has not been established yet. The presented investigation shows one proposed sollution by monitoring skin surface temperature. The main aspect is to demonstrate a significant rise in temperature with utility for monitoring the immediate success of surgery. Methods: Twenty patients with primary hyperhidrosis were observed and treated in a standardized setting against a control group (n = 10). We obtained diverse data that permit determination of a point of time of measurement of surface temperature and definition of a degree of temperature variance. Results: After 5 minutes a significant change of 0.5? Celcius was noted on the palms;after 10 minutes on average 1.2? Celcius. Axillary temperature had significantly changed after 10 minutes with a mean temperature variation of 0.8? Celcius on the right side and 0.6? Celcius on the left side. Conclusions: Under consideration of appropriate time intervals of measurement and determined changes in surface temperature an early control of correct clip application in ETS is possible. In the palmar aspect an increase of 0.5? Celcius at an 5 minutes interval, and more than 1? Celcius at 10 minutes after placement of the clip as compared to basic values before application of the clip can be proposed.

Uniportal versus biportal video-assisted thoracoscopic sympathectomy for palmar hyperhidrosis

Background Video-assisted thoracoscopic sympathectomy had replaced open surgery. The aim of this study was to compare the outcomes of using a single port and two ports to perform video-assisted thoracoscopic sympathectomy for palmar hyperhidrosis. Methods Between April 2006 and February 2008, 20 cases underwent video-assisted thoracoscopic sympathectomy through one port （uniportal group） and 25 cases through two ports （biportal group）. The variables including the operating time, hospital stay, pain scores, postoperative complications, incidence of symptom recurrence and patient satisfaction were compared. The mean postoperative follow-up period was 11.5 months （range, 3-25 months）. Results The hands of all patients were warm and dry after operation. No conversion to open surgery was necessary, and no operative mortality was recorded in either group. The mean inpatient pain scores were significantly higher in the biportal group （1.2±0.6） than that in the uniportal group （0.8±0.5, P=0.025）. For the first three weeks after operation, four out of 20 （20%） patients in the uniportal group constantly suffered from mild or moderate residual pain while eight out of 25 （32%） cases in the biportal group （P=0.366）. Among them, two cases in the uniportal group and five cases in the biportal group need to take analgesics. Our mean operative time （bilateral sympathectomy） in the uniportal group （（39.5±10.0） minutes） was shorter than that in biportal group （（49.7±10.6） minutes, P=0.02）. There were no significant differences between two groups in terms of the mean hospital stay, compensatory sweating, and patient satisfaction. Two patients in the biportal group and three in the uniportal group experienced a unilateral pneumothorax. None of them required chest drainage. No patient experienced Homer＇s syndrome, and no recurrent symptoms were observed in either groups Conclusions Both uniportal and biportal video-assisted thoracoscopic sympathectomy are effective, safe, and minimally invasive for palmar hyperhidrosis. Comparing with the biportal approach, the uniportal approach causes less postoperative pain and less operative time, and is a more reasonable procedure in treatment of palmar hyperhidrosis.

Does the advantage of transcutaneous oximetry measurements in diabetic foot ulcer apply equally to free flap reconstruction?

BACKGROUND Transcutaneous oxygen pressure(TcpO2)is a precise method for determining oxygen perfusion in wounded tissues.The device uses either electrochemical or optical sensors.AIM To evaluate the usefulness of TcpO2 measurements on free flaps(FFs)in diabetic foot ulcers(DFUs).METHODS TcpO2 was measured in 17 patients with DFUs who underwent anterolateral thigh(ALT)-FF surgery and compared with 30 patients with DFU without FF surgery.RESULTS Significant differences were observed in the ankle-brachial index;duration of diabetes;and haemoglobin,creatinine,and C-reactive protein levels between the two groups.TcpO2 values were similar between two groups except on postoperative days 30 and 60 when the values in the ALT-FF group remained<30 mmHg and did not increase>50 mmHg.CONCLUSION Even if the flap is clinically stable,sympathectomy due to adventitia stripping during anastomosis and arteriovenous shunt progression due to diabetic polyneuropathy could lead to low TcpO2 values in the ALT-FF owing to its thick fat tissues,which is supported by the slow recovery of the sympathetic tone following FF.Therefore,TcpO2 measurements in patients with DFU who underwent FF reconstruction may be less accurate than in those who did not.

Renal sympathetic nervous system and the effects of denervation on renal arteries

Resistant hypertension is associated with chronic activation of the sympathetic nervous system resulting in various comorbidities. The prevalence of resistant hypertension is often under estimated due to various reasons. Activation of sympathetic nervous system at the renal-as well as systemic-level contributes to the increased level of catecholamines and resulting increase in the blood pressure. This increased activity was demonstrated by increased muscle sympathetic nerve activity and renal and total body noradrenaline spillover. Apart from the hypertension, it is hypothesized to be associated with insulin resistance, congestive heart failure and obstructive sleep apnea. Renal denervation is a novel procedure where the sympathetic afferent and efferent activity is reduced by various techniques and has been used successfully to treat drug-resistant hypertension improvement of various metabolic derangements.Renal denervation has the unique advantage of offering the denervation at the renal level, thus mitigating the systemic side effects. Renal denervation can be done by various techniques including radiofrequency ablation, ultrasound guided ablation and chemical ablation. Various trials evaluated the role of renal denervation in the management of resistant hypertension and have found promising results. More studies are underway to evaluate the role of renal denervation in patients presenting with resistant hypertension in different scenarios. Appropriate patient selection might be the key in determining the effectiveness of the procedure.

Lower limb pain in sympathetic-sensory coupling

Previous studies have shown that sympathetic nerves are related to certain types of pain, and this phenomenon is referred to as sympathetic-sensory coupling. Chronic pain resulting from nerve injury can be exacerbated by sympathetic stimulation or relieved by sympathetic inhibition. In the present study, the correlation between pain and sympathetic nerves was analyzed in patients with severe pain in lower limbs, as we^l as in a chronically compressed dorsa~ root ganglion ~CCD） rat model （model of low back pain and sciatica）. Patients with severe pain in the lower limbs underwent chemical lumbar sympathectomy （CLS）, and the analgesic effects of CLS were compared with painkillers. Results demonstrated significantly relieved lower limb pain following CLS, and the analgesic effects of CLS were superior to those seen with painkillers. In the CCD rat model, dorsal root ganglion neuronal activity significantly increased as a result of electrical stimulation to the sympathetic nerves. These results suggest that sympathetic nerves are closely associated with pain and sympathetic-sensory coupling is likely in lower limb pain in both patients and rat models of CCD.

THE STUDY OF THE CHANGES AND MECHANISM OF HINDQUARTER VASCULAR RESISTANCE IN RATS WITH MYOCARDIAL INFARCTION

Studies were performed on female WJ rats.Hindquarter vascular resishatc(HVR)inrats 8￣11 weeks after left coronary thery occluslou was measured.Animal model of perfusedhindquarter with its own blood by pump control was used.The results showed:①OHVR in rats withmyocardial infarction(MI)rose;②HVR in rats with small myocards inflect size decreased afterlumbar sympethatic chain(LSC)denervation;③HVR in rats with large myocardial infarct size didnot change obviously after LSC denervation. Therefore,neuregenic influence Predominated in mechanism of eleretion of HVR in myoardial infarct rats.

Ventilatory effect of normal frequency jet ventilation in non-intubated anesthesia in the treatment of the palmar hyperhidrosis

Objective: To evaluate the ventilatory effect of normal frequency jet ventilation via Wei jet nasal airway in non-intubated anesthesia in the treatment of the palmar hyperhidrosis (PH). Methods: 62 patients with PH undergoing video-assisted thoracoscopic sympathectomy, aged 18~35 years, ASA I-II, were randomized into two groups: intubated group (group T) and normal-frequency jet ventilation group (group J). After induction tracheal tubes were inserted in Group T and Wei nasal airway were inserted in group J. The heart rate(HR),saturation pulse oxygen (SPO2), mean artery pressure (MAP) and end-tidal carbon dioxide partial pressure (PETCO2) were recorded at following time points: before induction (T0),1 min after induction (T1), 1 min after tube insertion/ intubation (T2), when trocars were inserted and carbon dioxide was inflated (T3), during lung recruitment maneuver and the chest closure (T4), the moment of extubation (T5), 15 min after extubation (T6). Blood samples were taken from left radial artery for blood gas analysis to monitor carbon dioxide partial pressure, arterial oxygen partial pressure, PH ,the BE at T0, T4, T6.The duration of anesthesia, awaking time ,the dosage of the propofol and the remifentanil, the intraoperative and postoperative adverse events were recorded. Results: Compared with group T, the HR and MAP were more stable in group J. The awaking time in the group J were significantly shorter than those in group T (P<0.05), the dosage of the remifentanil in group J was significantly less than that in group T (P<0.05), The incidences of throat discomfort, nausea and vomiting were lower than those in group T (P<0.05). Conclusion: Normal-frequency jet ventilation via Wei jet nasal airway in non-intubated anesthesia in the treatment of the (PH)is feasible, which can reduce stress response and make hemodynamics stable without the complications of tracheal intubation.

Bradycardia and hypotension during pediatric scoliosis surgery-hypovolemia or spinal shock?

We present the case of a 13-year-old boy undergoing scoliosis repair utilizing skull-femoral traction who developed sudden, sustained bradycardia and hypotension during scoliosis repair, associated with loss of somatosensory evoked potentials and motor evoked potentials to all four limbs. A diagnosis of spinal shock and hypovolemia was made after ruling out primary cardiac causes, sepsis, anaphylaxis and intra-spinal pedicle screw placement. Acute complications of surgical scoliosis repair are reviewed along with anatomy of the sympathetic nervous system. In this case spinal shock may have been due to hypovolemia as well as spinal cord manipulation during T12 vertebral column resection that was needed to effect scoliosis correction. Treatment included volume expansion and inotropic support. Anesthesiologists caring for these patients should be mindful of the possibility of spinal shock during correction of severe scoliosis, particularly when vertebral column resection is undertaken.

Single-Port Bilateral Thoracscopic Dorsal Sympathectmy for Primary Hyperhidrosis:Long-Term Outcome

Background: Primary hyperhidrosis of the upper limbs is characterized by over activity of the eccrine sweat glands, primarily occurring on palmar, plantar and axillary regions. It is distressing and often socially disabling condition. Conservative treatment is usually not effective in controlling the disease mainly due to adverse effect of therapies. Endoscopic thoracic sympathectomy is considered as the treatment of choice, causing minimal morbidity and high success rates and patient satisfaction. Objective: The study aims to evaluate the long-term outcomes of single port bilateralthoracoscopic dorsal sympathectomyin treatment of primary hyperhidrosis of the palm and axilla. Methods: In this prospective study, performed primarily by a single surgeon, between August 1st 2010, and August 1st 2012, we performed 200 thoracoscopies on 100 patients with signs and symptoms of primary palmar and axillary hyperhidrosis in different age groups and in both genders, and all were studied and analyzed following treatment by single-port bilateral thoracoscopic dorsal sympathectomy in Sulaimani teaching hospital. Results: Total of 99 patients were satisfied with the outcome of post-surgery with a follow-up in the mean of 27 months and only one patient was reported no change in symptoms postoperatively. Complications reported in 6 patients inform of compensatory sweating (n = 2), Gestatory sweating (n = 1), Pneumothorax (n = 1), Intraoperative minor bleeding (n = 1) and only 1% failure rate was reported. No mortality was reported. Conclusions: Single port bilateral thoracoscopic thoracic sympathectomy is a very effective method in the management of primary hyperhidrosis. Single port provides less postoperative pain, safety, short operative time, and quick method for the treatment of primary hyperhidrosis in comparison to two or three ports approaches.

Chinese expert consensus on the surgical treatment of primary palmar hyperhidrosis(2021 version)

Primary palmar hyperhidrosis(PPH)is a pathologic condition of excessive sweating on hands that has adverse impacts on patients’social activity,professional life,and psychological state.Endoscopic thoracic sympathicotomy(ETS)is by far the treatment choice for PPH with the most stable and durable curative effects,but special attention should be given to the side effects of the surgery,especially compensatory hyperhidrosis(CH).This consensus is the second version of the Chinese Expert Consensus on the Surgical Treatment of PPH by the China Expert Committee on Palmar Hyperhidrosis(CECPH),which was published 10 years ago.This consensus emphasizes the need for special attention and careful assessment of the patients’feelings,as well as their emotional and mental state,and emphasizes that distress due to palmar sweating and the desire for treatment are prerequisites for diagnosis.It also provides a more nuanced delineation of CH and reviews all new attempts to prevent and treat this side effect.New evidence of the epidemiology,pathogenesis of PPH,and indications for surgery were also assessed or recommended.

Renal sympathetic denervation for the treatment of resistant hypertension with chronic renal failure： first-in-man experience

A39-year-old man with resistant hypertension,presented with headache and dizziness at theemergency department on January 6, 2012. The patient had a history of hypertension for 3 years, his highest blood pressure was 250/110 mmHg, and he was taking antihypertensive medication regimens for at least 6 months. A mitral replacement by bioprosthetic valve had been implanted 6 months before. The patient was in chronic renal failure （CRF） uremia, maintenance of which he underwent the standard hemodialysis treatment three times a week for 6 months.

Effect of oxytocin on gastric ischemia-reperfusion injury in rats

The effect of peripherally administered oxytocin(OT)on gastric ischemia-reperfusion injury(GI-RI)and its possible mechanism were investigated.The Sprague-Dawley(SD)rats were randomly divided into different treatment groups(n=6).The animal GI-RI model was established by clamping the celiac artery for 30 min to induce ischemia and then released to allow reperfusion for 1 h,and the degree of GI-RI was assessed by scoring the gastric mucosal damage index(GMDI),the gastric fluid output,gastric fluid output,gastric acidity were measured and the surgical preparations of vagotomy and sympathectomy were used to investigate the possible mechanism of OT on GI-RI.The results were as follows.Compared with the control group(NS plus GI-R only,GMDI 121.33P10.40,n=6),the intra peritoneal(ip)administration of oxytocin(20,100μg/0.5 mL)obviously attenuated GI-RI(P<0.05),GMDI were 82.33P14.26,53.5P5.58 respectively(n=6);the gastric fluid output and the gastric acidity(evaluated by pH)of the control group were(430.17P87.36)μL,1.55P0.25(n=6),and those of the OT group were(102.45P48.00)μL,2.65P0.40(n=6)res pectively;differences had statistical significance(P<0.01).The effect of oxytocin was reversed by atosiban,a selective oxytocin receptor antagonist.The GMDI of the group given atosiban 10 min before OT was 138.17P24.06(n=6),which had no significant difference with the control group.Oxytocin further attenuated GI-RI after vagotomy and sympathectomy(GMDI 6.83P8.89,29.67P5.54,n=6),compared with the GI-R group and the oxytocin group(P<0.01).These results indicated that the oxytocin could significantly protect gastric mucosal against injury induced by ischemia-reperfusion,and the oxytocin receptor was involved.This effect of oxytocin may be mediated through the vagus and sympathetic nerve,and then lead to the reduction of gastric juice output and the depression of gastric acidity.