Sympathicotomy for isolated facial blushing: long-term follow-up of a randomized trial.

OBJECTIVES: Thoracoscopic sympathicotomy may be an effective treatment for disabling facial blushing in selected patients. Short- and mid-term results are good but very long-term results are scarce in the medical literature and there is no knowledge which extent of sympathicotomy is better long-term for isolated facial blushing. METHODS: We previously randomized 100 patients between a rib-oriented R2 or R2-R3 sympathicotomy for isolated facial blushing, and reported local effects, side effects and quality of life after 12 months. In the present study, we sent identical questionnaires to all patients after a median of 16 years (interquartile range 15-17 years). RESULTS: The response rate was 66%. Overall, 82% reported excellent or satisfactory results on facial blushing, with significant better local effect after R2 sympathicotomy compared with R2-R3 sympathicotomy. Patients who underwent R2 sympathicotomy were also significantly more satisfied with the operation. We found no significant difference between R2 and R2-R3 sympathicotomy in quality of life or rates of compensatory sweating (77%) and recurrence of blushing (41%) which was milder than preoperatively in most patients. CONCLUSIONS: R2 sympathicotomy should be the preferred approach for isolated facial blushing because of better local effect and higher satisfaction rates. Although this was a very long-term follow-up of the only randomized trial of its kind the response rate was limited leaving a risk of undetected bias.

A Diaphragmic Traction Suture Increases Pleural Cavity Volume and Surgical Field Overview During Video-Assisted Thoracoscopic Surgery.

OBJECTIVES: An elevated hemidiaphragm may impair surgical field overview during video assisted thoracoscopic surgery (VATS) and may consequently jeopardize a safe surgical procedure or prolong the duration of surgery. The aim of this study was to evaluate if tension applied to a diaphragmatic suture improves the surgical field overview. METHODS: Following informed consent and at the surgeon's discretion during elective VATS procedures, a single stitch was placed at the posterior tendinous border of the diaphragm and retracted through the camera port. The surgical field overview was evaluated using a numeric rating scale (1-10) by the surgeon before and after applying tension during the procedure, and later by 9 VATS surgeons (> 10 years' experience) using video recordings. RESULTS: During a 4-month period, 43 patients scheduled for elective VATS by two surgeons gave informed consent to participate. The hemidiaphragm was elevated to such an extent in 27 patients that the surgeon placed a diaphragmatic stitch suture. When tension was applied to the suture, surgical field overview improved significantly (p < 0.001). CONCLUSION: A diaphragmatic traction suture improves surgical field overview in selected patients with elevation of the hemidiaphragm. This simple procedure may facilitate VATS in patients with impaired surgical field overview and consequently improve safety during VATS. CLINICAL TRIAL NUMBER: http://ClinicalTrials.gov (No. NCT04837950).

Short-term outcomes after minimally invasive oesophagectomy.

INTRODUCTION: Minimally invasive oesophagectomy (MIO) has gained increasing popularity. This study reports the results of the first patients operated using this technique at our department. METHODS: All procedures were prospectively registered in a database. Patients were followed until death, two years after surgery or 1 January 2019. RESULTS: A total of 150 procedures were performed (from 23 November 2015 to 27 February 2018). The median proced-ure time decreased from 350 minutes for the initial 75 pa-tients to 320 minutes for the final 75 patients (p < 0.05). Blood loss decreased from 200 ml to 100 ml (p < 0.05), respectively. The conversion rate for the abdominal procedure was 7% for the initial 75 patients and 8% for the final 75 patients (not significant (NS)). For the thoracic procedure, the corresponding figures were 11% and 7% (NS), respectively. Anastomotic leakage was seen in 17% (initial patients) and 11% (final patients) (NS); however, less than 20% of the leakages needed surgical treatment. The median length of post-operative stay was nine days for both groups. For all 150 patients, pulmonary complications were observed in 18% and cardiac complications in 11%. The 30-day mortality rate was 2% and the one-year survival rate was 86% (124 registered patients). CONCLUSIONS: MIO was introduced at our department with acceptable morbidity and mortality rates and the short-term oncological result was not compromised. FUNDING: none. TRIAL REGISTRATION: The study was approved as a quality project by the Region of Southern Denmark (18/37355).

A national study of nodal upstaging after thoracoscopic versus open lobectomy for clinical stage I lung cancer.

BACKGROUND: Nodal upstaging after surgical intervention for non-small cell lung cancer (NSCLC) occurs when unsuspected lymph node metastases are found during the final evaluation of surgical specimens. Recent data from The Society of Thoracic Surgery (STS) database demonstrated significantly lower nodal upstaging after thoracoscopic (VATS) lobectomy than after thoracotomy. STS data, however, may be biased from voluntary reporting, and survival was not investigated. We used a complete national registry to compare nodal upstaging and survival after lobectomy by VATS or thoracotomy. METHODS: The Danish Lung Cancer Registry was used to identify patients who underwent lobectomy for clinical stage I NSCLC from 2007 to 2011. Patient demographics, comorbidity, preoperative staging, surgical approach, number of lymph nodes harvested, final pathology, and survival were evaluated. Nodal upstaging was identified by comparing cT N M with pT N M. RESULTS: Lobectomy for clinical stage I NSCLC was performed in 1,513 patients: 717 (47%) by VATS and 796 (53%) by thoracotomy. Nodal upstaging occurred in 281 patients (18.6%) and was significantly higher after thoracotomy for N1 upstaging (13.1% vs 8.1%; p<0.001) and N2 upstaging (11.5% vs 3.8%; p<0.001). Overall unadjusted survival was significantly higher after VATS, but after adjusting for differences in sex, age, comorbidity, and pT N M by Cox regression analysis, we found no difference between VATS and thoracotomy (hazard ratio, 0.98; 95% confidence interval, 0.80 to 1.22, p=0.88). CONCLUSIONS: National data confirm that nodal upstaging was lower after VATS than after open lobectomy for clinical stage I NSCLC. Multivariate survival analysis, however, showed no difference in survival, indicating that differences in nodal upstaging result from patient selection for reasons not captured in our registry.

Sympathicotomy for isolated facial blushing: a randomized clinical trial.

BACKGROUND: Facial blushing is one of the most peculiar of human expressions. The pathophysiology is unclear, and the prevalence is unknown. Thoracoscopic sympathectomy may cure the symptom and is increasingly used in patients with isolated facial blushing. The evidence base for the optimal level of targeting the sympathetic chain is limited to retrospective case studies. We present a randomized clinical trial. METHODS: 100 patients were randomized (web-based, single-blinded) to rib-oriented (R2 or R2-R3) sympathicotomy for isolated facial blushing at two university hospitals during a 6-year period. Quality of life (QOL) was investigated preoperatively and after 12 months by Short Form 36. Local effects and side effects were assessed by questionnaire. RESULTS: The male/female ratio was 27/73. The median age was 29 years (range, 18-56 years. The response rate was 93%. QOL increased significantly in all social and mental domains in both groups. Overall, 85% of the patients had an excellent or satisfactory result, with no significant difference between the R2 procedure and the R2-R3 procedure. Mild recurrence of facial blushing occurred in 30% of patients within the first year. One patient experienced Horner's syndrome. Compensatory sweating occurred in 93% of patients, gustatory sweating 36%, and dry hands in 66%; 13% of patients regretted the operation despite thorough preoperative selection and information. CONCLUSIONS: There were no significant differences in local effects or side effects between R2 and R2-R3 sympathicotomy for isolated facial blushing. Both were effective, and QOL increased significantly. Despite very frequent side effects, the vast majority of patients were satisfied. Surprisingly, many patients experienced mild recurrent symptoms within the first year; this should always be discussed with patients preoperatively.

Isolated pleural metastases from renal cell carcinoma.

A 71-year-old female was referred with three right-sided intrathoracic tumours. In 2003, she underwent radical left nephrectomy for renal cell cancer (RCC) clinical stage 1. She was since followed at her local hospital with annual computed tomography (CT)-scans during the first five years and did not present any symptoms until October 2009 when she was admitted with shortness of breath, cough and tiredness. The patient was scheduled for a diagnostic thoracoscopy when it was discovered that her lesions were not located in the lung parenchyma but were protruding nodules from the parietal pleura. Histology demonstrated metastases from RCC which apparently can reach the parietal pleura without lung metastases.

Efficacy and safety of TachoSil® versus standard treatment of air leakage after pulmonary lobectomy.

OBJECTIVES: Alveolar air leakage remains a serious problem in lung surgery, being associated with increased postoperative morbidity, prolonged hospital stay and greater health-care costs. The aim of this study was to evaluate the sealing efficacy and safety of the surgical patch, TachoSil®, in lung surgery. METHODS: Patients undergoing elective pulmonary lobectomy who had grade 1 or 2 air leakage (evaluated by the water submersion test) after primary stapling and limited suturing were randomised at 12 European centres to open-label treatment with TachoSil® or standard surgical treatment (resuturing, stapling or no further treatment at the surgeons' discretion). Randomisation was performed during surgery using a centralised interactive voice response system. Duration of postoperative air leakage (primary end point), reduction of intra-operative air leakage intensity (secondary end point) and adverse events (AEs), including postoperative complications, were assessed. RESULTS: A total of 486 patients were screened and 299 received trial treatment (intent-to-treat (ITT) population: TachoSil®, n=148; standard treatment, n=151). TachoSil® resulted in a reduction in the duration of postoperative air leakage (p=0.030). Patients in the TachoSil® group also experienced a greater reduction in intra-operative air leakage intensity (p=0.042). Median time until chest drain removal was 4 days with TachoSil® and 5 days in the standard group (p=0.054). There was no difference between groups in hospital length of stay. AEs were generally similar in both groups, including postoperative complications. CONCLUSIONS: TachoSil® was superior to standard surgical treatment in reducing both postoperative air leakage duration and intra-operative air leakage intensity in patients undergoing elective pulmonary lobectomy.

Resympathicotomy.

BACKGROUND: Endoscopic thoracic sympathicotomy (ETS) is a well-established treatment for primary hyperhidrosis and facial blushing. Not everyone has the desired local effect either from primary failure of the operation or because symptoms recurred. The incidence varies in the literature and treatment by resympathicotomy (re-ETS) is controversial. There is no information in the literature if re-ETS has any influence on compensatory sweating. METHODS: We conducted a follow-up study of consecutive patients who underwent re-ETS during a ten-year period (1997 to 2007). All patients received a questionnaire of primary effects and side effects. RESULTS: A total of 669 patients underwent rib-oriented ETS for primary hyperhidrosis or facial blushing. Forty-eight patients (7%) underwent re-ETS for unilateral primary failure (n=29), bilateral primary failure (n=6) or recurrent symptoms (n=13) after a median of 24 months (range, 1 to 69 months). One patient died from carcinoma of the breast during follow-up. Of the remaining 47 patients, 42 (86%) answered the questionnaire. In 25 patients with unilateral primary failure (96%) symptoms improved after re-ETS. Success was lower after re-ETS for bilateral primary failure (50%) or recurrent symptoms (75%). Overall, compensatory sweating occurred in 80% of the patients after the first operation and 38% described worsening of the intensity after re-ETS, particularly after re-ETS for primary failure. CONCLUSIONS: Primary technical failure is fairly common after sympathicotomy with simple transection of the sympathetic chain. It occurs at all locations of primary hyperhidrosis as well as facial blushing and re-ETS is an effective treatment. It is important to inform patients that unilateral technical failures occur and in that case compensatory sweating may worsen after re-ETS.

Flexible thoracoscopy may facilitate video-assisted thoracoscopic lobectomy.

BACKGROUND: Video-assisted thoracoscopic lobectomy was introduced in the early 1990s but has not yet gained widespread acceptance. The VATS approach is still controversial although several studies suggest less postoperative morbidity compared with open thoracotomy. Nevertheless, some patients report long-lasting chest wall pain following VATS procedures, and, in theory, such pain may be related to intercostal nerve injury. The present study presents our experience with a commercially available flexible thoracoscope. METHODS: The study was designed as a case-control series of prospectively collected data to determine if performing VATS with a flexible thorascope could have benefits for both the patient and the surgeon. RESULTS: During the last 24 months 128 of 274 consecutive lobectomies (47%) were scheduled as VATS procedures with a new flexible high-definition thoracoscope. Six operations (4.6%) were converted to open surgery but only one case was converted during the last 12 months. There was no hospital mortality. The median duration of the operation was 105 min (range: 50-289 min), and the median postoperative hospital stay was 4 days (range: 2-27 days). At routine follow-up 2 weeks postoperatively all but three patients (2%) were considered pain free, which was significantly less than in 15 consecutive VATS lobectomies with rigid thoracoscopy performed prior to the introduction of flexible VATS (p = 0.02). CONCLUSIONS: Video-assisted thoracoscopic lobectomy by flexible thoracoscopy is feasible and in our opinion easier and safer compared with rigid thoracoscopy. In our experience all parts of the operation are better visualized and many surgical pitfalls may be avoided. Even during early phases of setting up the VATS lobectomy program, the duration of the operation is comparable with open surgery, and postoperative pain is low, possibly because porthole angulation is minimized.

Thoracoscopic sympathectomy for isolated facial blushing.

BACKGROUND: Facial blushing is one of the most peculiar of human expressions and has become a cardinal symptom of social phobia. The pathophysiology is unclear and the prevalence is unknown. Thoracoscopic sympathectomy may cure the symptom, but very few surgeons treat patients with isolated facial blushing. The literature is limited, and there are few long-term follow-up studies. METHODS: A follow-up study by questionnaire in 180 consecutive patients who underwent thoracoscopic sympathectomy for isolated facial blushing at two Danish university hospitals during a 6-year period. Patients routinely underwent T2 sympathectomy at the university hospital in Aarhus (n = 101) and T2-T3 sympathectomy at the university hospital in Odense (n = 79). RESULTS: The questionnaire was returned by 96% of the patients after a median follow-up time of 20 months. Overall, 90% of the patients had some effect from the operation, and the result was excellent or satisfactory in 75%. There was no significant difference between the two extents of sympathectomy. Compensatory sweating occurred in 88% of all patients and was significantly more frequent after T2-T3 sympathectomy (p = 0.02) Ten percent of our patients regretted the operation because of side effects or no effect of the operation. CONCLUSIONS: This study demonstrates that thoracoscopic sympathectomy is an effective treatment for isolated facial blushing. The majority of patients achieve an excellent or satisfactory long-term result. Our results suggest that a T2 sympathectomy is superior for patients with isolated facial blushing because side effects are lower compared with a T2-T3 sympathectomy.

Thoracoscopic sympathectomy for axillary hyperhidrosis: the influence of T4.

BACKGROUND: Recent data suggest that severe compensatory sweating after sympathectomy for hyperhidrosis is more common than previously reported. In particular, T2-T4 sympathectomy for axillary hyperhidrosis leads to significantly more disabling sweating compared with T2-T3 sympathectomy for palmar hyperhidrosis. However, it is not known whether this is a result of the additional transection of the T4 segment or if patients with primary axillary hyperhidrosis are more prone to experience disabling compensatory sweating. METHODS: A follow-up study by questionnaire was made of 100 consecutive patients who underwent thoracoscopic sympathectomy for axillary hyperhidrosis at two university hospitals. Patients underwent T2-T3 sympathectomy (n = 35) or T2-T4 sympathectomy (n = 65) depending on the surgeon's preference. RESULTS: The questionnaire was returned by 91% of patients after a median of 31 months. Compensatory sweating occurred in 90% of patients and was so severe in 61% that they often had to change clothes during the day. There were no significant differences in occurrence or severity of compensatory sweating between the two extents of sympathectomy. Surgical outcome, however, was significantly better after T2-T4 sympathectomy. CONCLUSIONS: In contrast with previous reports, the incidence of compensatory sweating was not significantly related to the extent of sympathectomy for axillary hyperhidrosis. This result suggests that patients with primary axillary hyperhidrosis are more prone to experience compensatory sweating. Although the majority of patients with axillary hyperhidrosis were satisfied after thoracoscopic sympathectomy, many regret the operation. Patients should undergo surgery only if medical treatments fail; and provided there is an indication, we recommend T2-T4 sympathectomy.