Endoscopic versus transaxillary thoracic sympathectomy for primary axillary and palmar hyperhidrosis and/or facial blushing: 5-year-experience.

Thoracic sympathectomy is effective in the permanent cure of primary axillary and palmar hyperhidrosis and facial blushing, which can be so troublesome for patients that their social and professional relations can be affected. Between October 1988 and April 1994, a total of 50 thoracic sympathectomies (10 surgical and 40 endoscopic) were performed on 5 and 23 patients, respectively. The operations were performed unilaterally, followed by the contralateral intervention after a period of 6-8 weeks. The thoracic ganglia T2-T5 were resected for hyperhidrosis. If the patient suffered from blushing, the lower 1/3 of the stellate ganglion was also resected. Postoperatively, all the operated limbs were warm and dry. In the group of patients who were operated bilaterally, only one had persistent facial blushing. The efficacy for blushing in this series was therefore 93.3%. The late relapse rate of sympathetic activity was 14.3%. Compensatory sweating was seen in 67%, gustatory sweating in 37.5% and phantom sweating in 29% of the patients. None of them considered these side effects to be troublesome. Although there is no difference between transaxillary thoracic sympathectomy and the endoscopic intervention in terms of efficacy, the latter is associated with less postoperative pain, shorter hospital stay and a rapid recovery. The thoracic sympathectomy is the treatment of choice for primary hyperhidrosis and excessive facial blushing.

Myocardial contusion as a result of isolated sternal fractures: a fact or a myth?

Isolated sternal fractures are seen with an increasing frequency in traffic road accidents especially after the introduction of the seatbelt legislation. In most cases, the victims are young, otherwise healthy individuals. The medical records of all patients who were treated with a diagnosis of sternal fracture over the past 10 years were retrospectively reviewed. All patients with a radiologic diagnosis of sternal fracture were admitted for cardiac monitoring for at least 24 hours. ECG, determinations of cardiac enzyme levels CK (creatinephosphokinase) and CK-MB and evaluation by a cardiologist were routinely performed. An echocardiography was performed when indicated by the cardiologist. A total of 86 patients had sustained a sternal fracture during the 10-year study period. There were 39 males and 47 females with a mean age of 50 years (range 15-97 years). Serial 12-lead electrocardiograms, which were performed in 83 (97%) patients, revealed no information about myocardial contusion or cardiac arrhythmias with consequent therapy. In eight patients, a significant elevation in cardiac enzyme levels (elevation of CK-MB fraction above 10% of CK) was observed. All were normalized within 24 hours without development of any arrhythmias. Echocardiography was performed in 31 patients. In two patients, dyskinesia of the right ventricle (without enzyme elevations or arrhythmias) was observed. Within 24 hours these abnormalities resolved. The cardiac rhythm was monitored in 61 (71%) patients for a total of 1550 hours. No arrhythmias were observed. The cardiac enzyme studies, ECG and echocardiography revealed no consequent information about arrhythmias. In case of a sternal fracture, we recommend a chest X-ray to exclude other associated intrathoracic injuries. If no abnormalities are identified, admission to hospital is not necessary.

Endoluminal pulse oximetry of the sigmoid colon and the monitoring of the colonic circulation.

Colonic ischaemia is a frequently observed serious complication following abdominal aortic reconstruction. For adequate treatment of this disorder, early diagnosis and resection of the diseased colon is essential. The purpose of this study was to evaluate a new method, based on pulse oximetry, to detect colonic ischaemia at an early preclinical stage. During a 7-year period (1989-1995) colonoscopy and pulse oximetry were performed in all patients at risk of colonic ischaemia: complicated acute or elective aortic reconstructions, colostomies with superficial necrosis and in patients who underwent uncomplicated aortic reconstruction and non-ischaemic colonic problems (n = 90). The sensitivity, specificity and positive predictive values, and negative predictive value, were calculated. All patients, except four for whom an acute relaparotomy was necessary, subsequently underwent colonoscopy combined with endoluminal pulse oximetry. Of the 90 patients, 30 had colonic ischaemia according to endoscopy (n = 26) or relaparotomy (n = 4), and in 33 patients the absence of pulsatile signal was detected by means of pulse oximetry. Thus, in three patients, pulse oximetry was falsely positive for colonic ischaemia. The calculated sensitivity and specificity of pulse oximetry were 100 and 95%, respectively. In comparison to other methods used for early detection of colonic ischaemia, pulse oximetry appears to be a promising method for the evaluation and monitoring of colonic ischaemia because it is non-invasive and easy to apply with a high sensitivity and specificity.

Endoluminal aortic shunting for distal perfusion during thoracic aortal cross-clamping in a pig model.

PURPOSE OF THE STUDY: To investigate the haemodynamic properties of a direct endovascular aortic shunt to maintain distal aortic perfusion as an alternative of a distal shunt (left-left-, Gott shunt) in thoracic aortic aneurysm repair. METHODS: A shunt was developed and tested in an in vitro model which should be capable of transporting a flow of 3-4 L/min with a decrease in blood pressure < 20 mmHg. Thereupon the shunt was tested in an in vivo experiment in six pigs to assess the possibility of its use with normal distal blood pressure. The shunt was inserted in the thoracic aorta and stayed in place for 1.5 h. Parameters were measured at six time intervals to assess organ perfusion, -function, cardiac output, proximal- and distal blood pressure and aortic- and shunt flow. PRINCIPLE FINDINGS: The mean blood flow through the shunt was 2.5 L/min. The difference of the mean blood pressure over the shunt was on average 14.20 mmHg. Parameters for coagulation disturbance and organ ischaemia were tested. The decrease in mean thrombocyte count was 299-158 (p<0.02). The venous lactate and the venous mesenteric lactate as parameters for intestinal ischemia did not increase significantly. No significant changes occurred in angiotensin II levels. Pulsatile flow was maintained but significantly suppressed (60%) distal from the shunt. The clamp time needed to insert the shunt and the venous mesenteric lactate, as well as the venous lactate, showed high correlation, r(s) = 0.9 (p<0.05) and r(s) = 0.94 (p<0.01). This also accounted for the 2nd clamp time, both r(s) = 0.95 (p<0.05). CONCLUSION: The shunt is capable of transporting a blood flow of 2-4 L/min with an acceptable decrease in distal blood pressure. However, the time, needed to insert the shunt, was significantly associated with parameters of organ ischaemia.

The effect of inhibition of renin-angiotensin system by valsartan during hypovolemic shock and low flow sigmoideal ischaemia in pigs.

The aim of this experiment was to study the effect of Renin-Angiotensin System (RAS) blockade by means of valsartan on the colonic and systemic circulation in pigs during low flow sigmoideal ischemia in combination with hypovolemic shock. This condition resembles the situation that occurs in patients suffering from a ruptured aneurysm and a compromised colonic circulation. An experimental study in pigs was performed : 6 pigs with low flow sigmoideal ischemia and hypovolemic shock were treated with valsartan and a control group of 5 pigs with low flow sigmoideal ischemia and hypovolemic shock without medical treatment.Valsartan, 3 mg/kg, was administered intravenously. The operation was performed via left sided lumbotomy. The distal aorta was partially occluded to a flow reduction of 30% of the initial value. Hypovolemic shock was induced by withdrawing 20 ml/kg blood in 45 min. Resuscitation with 30 ml/kg haemaccel was iniated after 2 h of shock. The following parameters were measured: blood pressure, cardiac output; hemoglobin, lactate, angiotensin II in mixed venous blood (obtained from pulmonary artery) and in splanchnic blood (obtained from caudal mesenteric vein); and endoluminal pulse oximetry of the sigmoideal mucosa. Statistical analysis was performed by ANOVA and Wilcoxon signed rank test. There was a significant increase of lactate levels both in systemic and splanchnic circulation (P<0.05) in both groups. In the control group, the mean angiotensin II concentrations in the systemic circulation increased, after induction of ischaemia and shock. In the experimental group, the increase in angiotensin concentrations after resuscitation was significantly more prominent. In the colonic circulation, in both groups, there was a significant increase in angiotensin II levels in the splanchnic circulation following ischaemia and reperfusion (P<0.05), but there was no significant difference between the groups. There were no detectable mucosal signals measured by pulse oximetry after induction of shock throughout the experiment, whereas in the experimental group, median mucosal oxygen saturations of 81, 74.5 and 85% were achieved after resuscitation and declamping (P<0.01).In conclusion, angiotensin II inhibition during hypovolemic shock improves the colonic circulation, measured by pulse oximetry. However, other parameters of tissue ischaemia did not improve.

The renin-angiotensin system in swine during hypovolaemic shock combined with low-flow ischaemia of the sigmoid colon.

Colonic ischaemia is a serious complication after aortic surgery, and is most frequent after repair of ruptured aortic aneurysms. It was felt that the increased risk of colonic ischaemia during shock might be the result of a local effect of the renin-angiotensin system in the splanchnic circulation, which is exacerbated by poor perfusion. In order to evaluate the activity of the renin-angiotensin system in the colonic circulation, a subtotal occlusion of the distal aorta was induced in nine pigs. A colonic flow reduction of 70% was created for 4 hours. In the experimental group (n = 6), induce hypovolaemic shock, 20 cm3/kg blood was sampled at 45 min before resuscitation was performed with 20 cm3/kg haemaccel. The sham group (n = 3) did not have hypovolaemic shock induced. Blood samples were taken for determinations of angiotensin II, haemoglobin and lactate. Blood gas was obtained from the pulmonary artery and the caudal mesenteric vein for blood gas analysis and lactate determinations. ANOVA and the Wilcoxon sum rank test were used for statistical analysis. There was a significant increase in angiotensin II after induction of ischaemia in both groups. The increase in angiotensin II in the splanchnic circulation was more prominent than the increase in the systemic circulation (P < 0.01). In the experimental group, there was a sustained increase in angiotensin II levels in the splanchnic circulation following shock and reperfusion (P < 0/01). The increase in lactate concentrations, which was significantly higher in the experimental group (P < 0.05), was evidence of intestinal ischaemia. There was a significant decline in cardiac output and blood pressure during the period of shock (P < 0.05). The combination of colonic ischaemia and hypovolaemic shock followed by reperfusion leads to an increase in angiotensin II activity. The increase of the local activity of the renin-angiotensin system in the splanchnic circulation is more prominent after ischaemia and reperfusion. This is probably caused by a selective response of the splanchnic vasculature to shock, ischaemia and reperfusion.

Endoluminal pulse oximetry combined with tonometry to monitor the perfusion of the sigmoid during and after resection of abdominal aortic aneurysm.

Early detection of colonic ischaemia after aortic grafting is essential if mortality is to be decreased when this complication develops. The aim of this study was to determine changes in the sigmoid colon during and after abdominal aortic grafting using endoluminal pulse oximetry (SmO2). Oxygen saturation was measured on the mucosa (SmO2) and serosa (SsO2) of 20 sequential patients undergoing elective surgery for abdominal aortic aneurysm; intramural pHi was also measured. Initially, all patients had a normal SmO2 in the sigmoid; however, before cross-clamping eight patients had a reduction in the SmO2. The pulse curve disappeared immediately after cross-clamping in 15 patients, with only five still showing a pulse curve in the sigmoid colon. Before declamping, 13 patients regained their pulse curve. The intraluminal pHi showed a large interindividual variation (2 S.D. approximately 0.4). Patients were classified into three groups according to SmO2: group A, no pulse; group B, diminished saturation (< 90%); and group C, normal saturation (> or = 90%). There was significant correlation with the pHi after cross-clamping in all groups. One patient who developed ischaemia of the sigmoid colon demonstrated a prolonged reduction in the SmO2, a decreased perioperative pHi, and an increased oxygen saturation in the inferior mesenteric vein during cross-clamping.