Search

Thoracic surgical sympathectomy is often performed to treat primary palmar and axillary hyperhidrosis. An increase in palmar skin temperature is frequently used to identify the success of the procedure. Because changes in palmar skin temperature occur secondary to changes in skin blood flow, the objective of this study was to test the hypothesis that monitoring palmar skin blood flow would provide greater temporal resolution relative to monitoring palmar skin temperature. In 11 patients with palmar and/or axillary hyperhidrosis, we measured palmar skin temperature and blood flow (via laser Doppler flowmetry) throughout the sympathectomy procedure. Five minutes after the initial cautery, skin blood flow increased from 48 +/- 7 perfusion units to 121 +/- 17 perfusion units (P0.001), whereas no significant change in temperature was observed (31.0 degrees C +/- 0.5 degrees C to 31.3 degrees C +/- 0.5 degrees C; P0.05). The time required to reach peak skin blood flow (22 +/- 3 min) was significantly less than the time required to reach peak skin temperature (34 +/- 0.3 min; P0.001). Finally at 5, 10, and 15 min after the initial cautery, skin blood flow increased to a larger percentage of the total increase in skin blood flow relative skin temperature (all P0.006). These data suggest that monitoring skin blood flow provides greater temporal resolution when compared with monitoring skin temperature during thoracic sympathectomy. However, the initial cautery of the parietal pleura over the ganglion may result in increases in skin blood flow before physical disruption of the ganglion. This occurrence may limit the utility of skin blood-flow measurements in identifying the success of the procedure.

In this issue of the Journal, Prof Esler [1] highlights the numerous questions that Symplicity 3 [2] has left in its wake. He is right to advise readers not to simply think that denervation “does not work.” First, Prof Esler notes the mid-20th century practice of surgical thoracolumbar sympathectomy, which provided startling results. One article reports a halving of the 5-year mortality rate in patients chosen for this invasive procedure versus non-randomized controls [3]. The practice was replaced by ganglionic blocking drugs for the very reason that the resultant hypotension, syncope and sexual dysfunction from the surgical procedures were intolerable to patients, but it provided an important proof of concept. Second, he elegantly shows that animal experiments have proven sympathetic efferents to the kidney stimulate renin release and hence sodium reabsorption and hypertension. Third, he skillfully details experiments showing that renal injury leads to an overall increase in total body sympathetic activity, mediated by renal afferents to the hypothalamus. In this tour-de-force of science, Prof Esler argues that with this evidence for the role of both renal sympathetic efferents and afferents in the pathogenesis of hypertension, the results of Symplicity HTN 3 are as surprising as they are disappointing. He feels that the small point estimate of effect size in the overall group may well be due to ineffective delivery of denervation in many patients.

Dr. James Leonard Poppen (1903–1978) was one of the most renowned American neurosurgeons of the 20th century. The now eponymous Poppen approach to the pineal region is still used routinely in current neurosurgical practice. He was also one of the first to describe and practice the prefrontal lobotomy and appears to be one of the surgeons in the case of Eva Peron in 1952. Poppen was born in a Dutch family on February 28, 1903, in the town of Drenthe, Michigan. Poppen described the occipital transtentorial approach to the pineal region, this operative technique to access a deep-seated area was novel and effective, and now bears his name. His other well-known contribution includes the description of a tacking suture to prevent the formation of postoperative extradural hematomas (Poppen's stitch). Besides these, he described many novel procedures including bilateral lumbar sympathectomy, cervical rhizotomy for torticollis, and thoracolumbar sympathectomy and splanchnicectomy through small incisions. He was the first to advocate wrapping of an aneurysm neck with muscle or plastic rather than sacrificing the parent artery in difficult-to-clip aneurysms. His famous atlas on neurosurgical techniques was published in 1960. He retired from this post in 1970; however, he continued his practice of neurosurgery until his death. This historical vignette aims to highlight the work of James L. Poppen and the evolution of the surgery of the “Seat of the Soul.” His work has had a lasting influence on neurosurgeons and neuroscientists over the years.

The most important measure of the value of an operation designed for the treatment of hypertension is the degree of fall in the blood pressure postoperatively. When results are discussed, the change in the levels of the blood pressure far outrank in importance the other measures of improvement, such as symptomatic relief, regression in cardiac size, improvement in the electrocardiogram and the eyegrounds. Smithwick 1 has emphasized the need for determining the blood pressure in the lying, sitting and standing positions preoperatively and postoperatively because of the significant effect of posture on its level. As a result of some interesting experimental data obtained by Blakemore and King, 2 we have studied the effect of moderate exercise on the blood pressure of a group of patients suffering from advanced hypertension before and after thoracolumbar sympathectomy. Blakemore and King observed that the blood pressure of normal dogs exercised on a treadmill did

A case of primary aldosteronism is described. The presenting features were some indefinite unsteadiness of gait, with incidental hypertension discovered on routine examination. Symptoms of polyuria, polydipsia and attacks of generalised weakness did not develop until ten months later, shortly after a thoracolumbar sympathectomy had been performed for the hypertension. After a diagnosis of primary aldosteronism had been made, balance studies were performed over a period of seven weeks preoperatively and three weeks postoperatively. The biochemical findings are discussed. At operation an aldosterone-secreting tumour was removed from the left suprarenal gland. Except for the persistence of (a less marked) hypertension the patient has remained normal for the twenty-four months since the operation.

THE surgical treatment of hypertension had its origin in the pioneer work of Crile,1 Adson et al.,2 , 3 Page and Heuer,4 Peet5 and others, but it was not until the brilliant clinical studies of Smithwick,6 first published in 1940, that a truly effective operative procedure was available. The extent of the operation described by Smithwick and employed by him for the past eight years included removal of the thoracolumbar chain from the eighth or ninth thoracic ganglion through the first or second lumbar ganglion, along with portions of the greater, lesser and least splanchnic nerves. Hinton and Lord7 reported 152 hypertensive . . .

Summary The difficulty of selecting the proper surgical procedure in the treatment of chronic relapsing pancreatitis is stressed. The clinical and pathologic features of the disease are discussed. Our experience with, and preference for, the various surgical maneuvers commonly employed in the management of the disease are detailed. Thoracolumbar sympathectomy appears to offer temporary relief. Pancreatoduodenectomy offers the best chance for permanent relief.

ConclusionThe potentiating effect of postganglionic sympathectomy, by a celiac ganglionectomy, on histamine induced ulcer in dogs is abolished by a bilateral thoracolumbar sympathectomy or adrenal medullectomy.

As greater numbers of patients are subjected to thoracolumbar sympathectomy for essential hypertension, it becomes of increasing importance to learn how this operation affects the function of the organism in relation to its environment. Although it has long been known that denervation of the sympathetic nerve supply results in abolition of the sweating mechanism in the area involved, there have been to our knowledge no cases reported in which this deficiency has proved clinically deleterious to the patient. For this reason we are reporting in detail 2 cases of hyperpyrexia which occurred during the heat wave of Aug. 25 to 30, 1948, in New York City. Both patients had almost complete absence of the sweating mechanism due to previous bilateral thoracolumbar sympathectomy done by the technic of Hinton and Lord. 1 REPORT OF CASES Case 1.— A. R., a 45 year old lithographer, was admitted to the hospital for the

Infusions of 2-deoxy-d-glucose (2-DG), in concentrations of 50 mg/kg body wt, produced a consistent and pronounced increase in urinary epinephrine output in subjects with intact adrenal glands. They also produced a significant rise in urinary epinephrine in patients with Addison's disease classified as idiopathic by clinical criteria, but not in those whose disease was considered tuberculous in origin, or in subjects with adrenalectomy or thoracolumbar sympathectomy. A rise in blood glucose has been demonstrated to correlate well with the increase in urinary epinephrine that follows 2-DG administration. Measurement of these substances affords a clinically useful means for evaluating the functional capacity of the adrenal medulla.

This study was begun in March, 1950, after a subtotal adrenalectomy was completed in a patient in whom severe hypertension had recurred one year after a thoracolumbar sympathectomy was performed. As our series of patients increased, we reported encouraging results 1 after employing various types of sympathectomy and various degrees of adrenal resection. This analysis includes 99 such patients followed for from 1 to 37 months after operation. It is our present feeling that sympathectomy combined with adrenalectomy is more effective than either sympathectomy or adrenalectomy alone. We feel, however, that further observations are required to prove or disprove this impression. INDICATIONS AND CONTRAINDICATIONS We have required that all three of the following indications be present before operation is attempted. 1. Average diastolic blood pressures should be 120 mm. Hg or more. 2. There should be failure to respond to intensive medical therapy. 3. There should be evidence of progressive

Following Conn's original description1-3of the syndrome of primary aldosteronism in 1955, more than 50 patients have been reported in whom the disease was clearly present.4,5We feel that the patient described in this report is of unusual interest for several reasons: She survived 8 years of severe hypertension before the discovery and removal of an adrenal cortical adenoma. As in another instance, our patient was subjected to bilateral thoracolumbar sympathectomies several years prior to the diagnosis of primary aldosteronism. Chlorothiazide, used in our patient in an attempt to lower her blood pressure prior to the discovery of her adrenal adenoma, appeared to precipitate symptoms of generalized muscular weakness such as have been associated with primary aldosteronism.4,5Since the use of chlorothiazide and related drugs in the treatment of hypertension is by now widespread, it is possible that investigation of other patients who demonstrate similar responses to

A case of congenital dextrocardia with situs inversus complicated by cardiovascular disease is presented. The interesting features are that the symptomatic, roentgenographic, and electrocardiographic findings due to hypertension were reversed by a Smithwick thoracolumbar sympathectomy, leaving the patient with his original congenital anomaly. There is no record of any other similar case, but presumably, if sympathectomies in hypertensive disease become more frequent, other such cases will be encountered.

The principal measures which are available for the treatment of patients with essential hypertension at the present time are (1) diets, especially those low in sodium; (2) drugs having a general sedative effect or a specific hypotensive effect, and (3) surgery of the sympathetic nervous system with or without resection of adrenal tissue. The first operative attempt to influence hypertension by resection of the abdominal sympathetic system is accredited to Pieri in 1930. He performed a resection of the greater splanchnic nerve. Adson and Brown in 1934 described intraspinal rhizotomy. Adson and Peet in 1935 described the procedures that are generally known by their names. Thoracolumbar sympathectomy was first performed by Smithwick, in 1938, and described by him in 1940. Green first attempted total bilateral adrenalectomy and reported the results in one case in 1950. 1 We recently have reported our experience with 126 patients subjected to combined sympathectomy-adrenalectomy. 2

The effect of thoracolumbar sympathectomy on labor is illustrated by a report of a case in which this operation was performed for hypertension following a woman's first delivery but prior to her second pregnancy. This extensive interruption of uterine motor and sensory nerve pathways did not interfere with normal labor.

The recent advent of more energetic medical regimens for the treatment of essential hypertension has led to the need for reevaluating the patients who were treated surgically for this disease by means of thoracolumbar sympathectomy. The pertinent questions to be answered by such an evaluation are the extent of long-term symptomatic improvement, the degree and duration of blood pressure depression, and, finally, the predictability as to which patient will benefit from such an operative procedure. Material Studied By means of recent correspondence or personal examination, patients who underwent surgery at least eight years prior to this study were evaluated. Ninety patients from the private surgical services of the Strong Memorial Hospital were studied. The distribution according to sex was four males to five females. The average age of the females and males was essentially identical at 42.5 years. The oldest patient in this group was 57 and the youngest 20.

The various methods now employed in the selection of patients for thoracolumbar sympathectomy appear to be unsatisfactory. Certainly no single test has been used which is capable of yielding reliadle data as to whether or not sympathectomy will favorably influence hypertension. As the hypertensive state in man "appears to be the result of a number of different factors joining together in an infinite variety of combinations," careful evaluation of the neurogenic component seems essential for a decisive answer to the problem of selection. The sodium amytal, sodium nitrite and cold pressor tests have been found of limited prognostic value in relation to surgery, since they provide an inaccurate index of "sympathetic tone." Thus, poor results have been reported in many cases in which these tests had forecast a favorable outcome. The observations of Hindson and Edwards, 1 as well as our own, 2 have convinced us that continuous caudal anesthesia may be

In April 1948 Evans and Bartels, 1 in reviewing the results of high thoracolumbar sympathectomy for essential hypertension, expressed dissatisfaction with the fact that anginal pain had been relieved in only 11 (73 per cent) of 15 patients subjected to the usual resection (fourth thoracic to second lumbar ganglions) of Poppen. For patients with severe angina we resolved in the future to remove a greater part of the anginal pathway which had been demonstrated by White, Garrey and Atkins 2 in the dog to include the first four thoracic sympathetic ganglions. Removal of these ganglions had been performed by Lindgren and Olivecrona 3 in 71 patients with angina pectoris, not all of whom had hypertension, with complete relief of pain in 44 per cent and partial relief in 41 per cent. White and Bland 4 reported that their results in 8 patients, 2 of whom had hypertension, showed that "resection

SINCE the advent of thoracolumbar sympathectomy as a treatment for primary hypertensive vascular disease, various tests have been used postoperatively to determine the extent of the sympathetic resection. One of the tests commonly employed is the Minor starch-iodine test, which is based on the change in color occurring when a starch-iodine mixture becomes moist with the occurrence of sweating. The actual mechanism of sweating is not well understood. Best and Taylor1stated that the stimulus for sweat secretion is a rise in blood temperature, which has a twofold effect: the stimulation of nerve centers in the brain and the stimulation of heat receptors in the skin, which reflexly cause the secretion. This contention has been supported by other investigators.2With these two concepts of the mechanism of sweating in mind, i. e., direct stimulation via the sympathetic nerve fibers from the heat centers in the brain and stimulation