Percutaneous Full-Endoscopic C2 Ganglionectomy for the Treatment of Intractable Occipital Neuralgia: Technical Note.

BACKGROUND: The C-2 dorsal root ganglionectomy procedure can provide effective treatment for intractable occipital neuralgia (ON). However, the traditional microsurgery of C2 ganglionectomy needs a wide incision and significant paraspinous muscle dissection for adequate visualization. The indications of endoscopic spine surgery are ever expanding, with the development of endoscopic armamentaria and technological innovations. OBJECTIVE: To validate the feasibility of the approach and describe several operative nuances based on the authors' experience. In this paper, the authors describe a patient with intractable ON who was successfully treated with a percutaneous full-endoscopic C2 ganglionectomy. METHODS: We describe the case of an 83-yr-old female with a 2-yr history of left ON who did not respond to a series of treatments, including physical therapy, drug therapy, injection therapy, and radiofrequency therapy. After careful examination, we performed a percutaneous, full-endoscopic left C2 ganglionectomy. RESULTS: The patient was successfully treated with a percutaneous full-endoscopic ganglionectomy. Afterwards, her intractable and constant pain was relieved. There was no cerebrospinal fluid leakage, incision infection, neck deformity, or other complications. CONCLUSION: C2 ganglionectomy can be accomplished successfully using a full-endoscopic uniportal surgical technique under continuous irrigation, which has the advantages of excellent illumination and visualization, reduced surgery-related trauma, and reduced bleeding.

Abdominal Pain Associated With Anorexia Nervosa and Median Arcuate Ligament Syndrome: A Rare Condition Shadowed by a Postoperative Conversion Disorder.

Median arcuate ligament syndrome (MALS) is an often discounted and vexing condition that may go unnoticed in a population of patients with complex comorbid conditions or those with poor psychiatric health. We report a unique case of a patient with anorexia nervosa in whom the successful operation for MALS was briefly complicated by a postoperative conversion disorder.

Reperfusion Arrhythmias Increase after Superior Cervical Ganglionectomy Due to Conduction Disorders and Changes in Repolarization.

Pharmacological concentrations of melatonin reduce reperfusion arrhythmias, but less is known about the antiarrhythmic protection of the physiological circadian rhythm of melatonin. Bilateral surgical removal of the superior cervical ganglia irreversibly suppresses melatonin rhythmicity. This study aimed to analyze the cardiac electrophysiological effects of the loss of melatonin circadian oscillation and the role played by myocardial melatonin membrane receptors, SERCA2A, TNFα, nitrotyrosine, TGFß, KATP channels, and connexin 43. Three weeks after bilateral removal of the superior cervical ganglia or sham surgery, the hearts were isolated and submitted to ten minutes of regional ischemia followed by ten minutes of reperfusion. Arrhythmias, mainly ventricular tachycardia, increased during reperfusion in the ganglionectomy group. These hearts also suffered an epicardial electrical activation delay that increased during ischemia, action potential alternants, triggered activity, and dispersion of action potential duration. Hearts from ganglionectomized rats showed a reduction of the cardioprotective MT2 receptors, the MT1 receptors, and SERCA2A. Markers of nitroxidative stress (nitrotyrosine), inflammation (TNFα), and fibrosis (TGFß and vimentin) did not change between groups. Connexin 43 lateralization and the pore-forming subunit (Kir6.1) of KATP channels increased in the experimental group. We conclude that the loss of the circadian rhythm of melatonin predisposes the heart to suffer cardiac arrhythmias, mainly ventricular tachycardia, due to conduction disorders and changes in repolarization.

Dorsal Capsular Defect and Synovial Fistula to the Fourth Extensor Compartment: A Late Complication after Arthroscopic Dorsal Wrist Ganglionectomy.

Arthroscopic dorsal wrist ganglionectomy is demonstrably a safe procedure with recurrence rates comparable to open surgery. We present a patient with wrist pain following arthroscopic ganglion excision. MRI and arthroscopic findings showed a large dorsal capsular defect, synovial fistula to the fourth extensor compartment, and dorsal radiocarpal ligament resection. Ligament reconstruction and capsular imbrication resolved her symptoms. We postulate that this complication resulted from a large capsular resection. Because we feel that it can be difficult to judge the size of the debridement through an arthroscope, the need for adequate capsular resection in dorsal wrist ganglionectomy needs to be balanced by consideration of potential complications from more aggressive capsular debridement, and thus we feel that capsular resection should be limited to no more than 1 cm2.

[The experience with thoracoscopic sympathectomy for the treatment of distal lesions of limb arteries].

The study included 107 patients with distal lesions of limb arteries treated with the use of thoracoscopic sympathectomy. The best results in the early postoperative period were obtained in patients with Raynaud's disease. Modifications introduced into the methods of its treatment permitted to retain effectiveness of sympathectomy till the late postoperative period in 90% of the patients. Surgery for obliterative endarteritis and atherosclerosis was viewed as a possibility to preserve the supporting function of the limb. This purpose was attained in 73.2 and 62.5% of the patients respectively in the early and in 62 and 25% in the late postoperative periods.

Laparoscopic versus open celiac ganglionectomy in patients with median arcuate ligament syndrome.

OBJECTIVE: Median arcuate ligament syndrome (MALS) is a rare disorder characterized by abdominal pain and compression of the celiac artery. Traditional management consists of open MAL division, with or without arterial reconstruction. We present our outcomes using a laparoscopic approach and compare them to patients treated with open MAL division during the same period. METHODS: A retrospective medical records review of all patients with MALS treated at the University of California-Los Angeles from January 1999 to 2009 was performed. RESULTS: Fourteen patients with MALS were treated. All patients underwent an extensive preoperative gastrointestinal (GI) workup with 10 undergoing attempted laparoscopic division of the MAL and celiac ganglion (laparoscopic ganglionectomy [LG]). Two intraoperative conversions were performed for bleeding. Six patients were treated in the open surgery group (open ganglionectomy [OG]). There were no deaths or reoperations in either group. Median time to feeding was 1.0 vs 2.8 days (P≤.05) in the LG and OG groups, respectively, which was statistically significant. Median length of hospitalization was also significantly lower in the LG group compared with the OG group (2.3 vs 7.0 days; P≤.05). Eight patients had LG (100%) and 5 patients had OG (83%) and had immediate symptom resolution (postoperative day 1). Three patients with recurrent symptoms after LG underwent angiography demonstrating persistent celiac stenosis, then an angioplasty was performed. Median follow-up was 14.0 months (2-65 months) for all patients. Three patients who received LG (38%) and 3 patients who received OG (50%) had persistent pain at last follow-up. Six patients in the OG group (100%) and 7 patients in the LG group (88%) had ceased taking chronic oral narcotics at their last follow-up visit. CONCLUSION: Both laparoscopic and open MAL division and celiac ganglionectomy can be safely performed with minimal patient morbidity and mortality. Late recurrence is frequently seen; however, this seems to be milder than the presenting symptoms. The laparoscopic approach results in avoidance of laparotomy and was associated with shorter inpatient hospitalization and decreased time to feeding in our study. Optimal patient selection and prediction of clinical response in these patients remains a challenge.

The extent of laminectomy affects pain-related behavior in a rat model of neuropathic pain.

One of the unresolved questions in neuropathic pain research is whether we can prevent or reverse mechanical hyperalgesia by rhizotomy or ganglionectomy. However, one of the obstacles in answering that question is lack of a standardized surgical procedure used in experimental ganglionectomy. We tested the hypothesis that laminectomy performed during ganglionectomy induces lumbar column deformity. We further examined whether spinal deformity is a source of pain-related behavior. Five conditions were studied. Fifth and sixth lumbar (L5 and L6) ganglionectomy were performed in rats using either minimal or extensive laminectomy technique. Two other groups had minimal and extensive laminectomy without ganglionectomies. A final control group had no surgery. Sensory responsiveness of the plantar aspect of the hind paw was repeatedly tested, and a plain radiograph in anteroposterior projection was made to assess the extent of deformity by measurement of deformity angles. Hyperalgesia resulted in groups with extensive laminectomy regardless of performance or absence of ganglionectomy, while in groups with minimal laminectomy there was no increase in pain-related behavior. Lateral deformity of the spine was observed in rats with or without ganglionectomy, confirming that laminectomy can produce deformity. The extent of deformity was more pronounced in rats exposed to the extensive laminectomy. Our results indicate that laminectomy can produce spine deformity and that there is a direct relationship between the extent of laminectomy and the development of mechanical hypersensitivity. The data presented suggest that there is a need for standardization of laminectomy procedure in rat experimental pain models.

Robotic versus human camera holding in video-assisted thoracic sympathectomy: a single blind randomized trial of efficacy and safety.

Our objective is to compare surgical safety and efficacy between robotic and human camera control in video-assisted thoracic sympathectomy. A randomized-controlled-trial was performed. Surgical operation was VATS sympathectomy for hyperhidrosis. The trial compared a voice-controlled robot for holding the endoscopic camera robotic group (Ro) to human assisted group (Hu). Each group included 19 patients. Sympathectomy was achieved by electrodessication of the third ganglion. Operations were filmed and images stored. Two observers quantified the number of involuntary and inappropriate movements and how many times the camera was cleaned. Safety criteria were surgical accidents, pain and aesthetical results; efficacy criteria were: surgical and camera use duration, anhydrosis, length of hospitalization, compensatory hyperhidrosis and patient satisfaction. There was no difference between groups regarding surgical accidents, number of involuntary movements, pain, aesthetical results, general satisfaction, number of lens cleaning, anhydrosis, length of hospitalization, and compensatory hyperhidrosis. The number of contacts of the laparoscopic lens with mediastinal structures was lower in the Ro group (P<0.001), but the total and surgical length was longer in this group (P<0.001). Camera holding by a robotic arm in VATS sympathectomy for hyperhidrosis is as safe but less efficient when compared to a human camera-holding assistant.

Sympathicotomy affects cutaneous blood flow, temperature, and sympathicus-mediated reflexes.

OBJECTIVE: To study the sympathetically mediated effects of transthoracic endoscopic sympathicotomy (TES) in the treatment of severe primary palmar hyperhidrosis. MATERIALS AND METHODS: The effects of TES, on sympathetic ganglia at the thoracic level of 2-3, finger blood flow, temperature, and on heat and cold provocation were investigated. Middle cerebral artery (MCA) blood flow velocities were studied by transcranial Doppler. RESULTS: The finger blood flow increased by about 700% after TES and finger temperature by 7.0 +/- 0.5 degrees C. Several autonomic reflexes were dramatically affected. A finger pulp-shrinking test showed a major decrease after surgery. MCA mean blood flow velocities were not affected by TES. CONCLUSIONS: Besides the high success rate of good clinical effect of TES on palmar hyperhidrosis, major effects on local blood flow and temperature are elicited by TES. Complex autonomic reflexes are also affected. The patient should be completely informed before surgery of the side effects elicited by TES.

Evaluation of compensatory sweating after bilateral thoracoscopic sympathectomy for palmar hyperhidrosis.

The study is a retrospective review of 60 patients undergoing bilateral T2-T3 thoracoscopic sympathectomy for palmar hyperhidrosis in our department between 1997 and 2003. The study was based on a telephone questionnaire and medical chart review. Forty patients (67%) replied to the questionnaire and were included in the study. Postoperative complications, therapeutic results, patient satisfaction, and the severity of compensatory sweating (CS) were assessed. In all patients both palms were dry at the end of surgery. Postoperative complications included permanent unilateral Horner syndrome, wound infection, and residual pneumothorax resolving after thoracal drainage, in one patient each. CS with different severity occurred in 35 patients (87.5%). Six patients (15%) regretted undergoing the operation due to the extent and severity of the CS seriously affecting their quality of life. Thoracoscopic sympathectomy is a simple procedure with a high success rate. However, CS is a serious complication and a significant number of patients may regret undergoing the operation; a careful selection of patients and comprehensive explanation are advisable.

Limited thoracoscopic ganglionectomy for primary hyperhidrosis.

Sympathetic ganglionectomy is universally accepted as an effective and enduring treatment for primary hyperhidrosis. However, the variable extent of the ganglionectomy to treat this condition has been reported to be associated with a troublesome compensatory hyperhidrosis in between 22% and 81% of patients. In this prospective evaluation of a limited second thoracic ganglionectomy this approach, in addition to always being effective for pallmar hyperhidrosis, proved useful in up to 90% of patients with associated axillary and plantar hyperhidrosis. A compensatory hyperhidrosis rate of 13% was noted, confirming that a limited ganglionectomy should be standard practice in the management of primary hyperhidrosis.

Reversal surgery for reducing the side effects of ETS. A case report.

Endoscopic sympathetic surgery has become a widespread surgery for handsweating and facial blushing all over the world. There are not many side effects in the normal train of the surgery, only lower body sweating is known to happen in some degree to nearly everyone. When the side effects exceed the expectation of the patient, she may demand the reversal of the surgery due to the regrets of the side effects. To better cope with this demand, we have developed an endoscopic method to restore the continuity of the sympathetic trunks. A typical course of recovery of one such reversal case is presented.

Intermediate-term results of endoscopic transaxillary T2 sympathectomy for primary palmar hyperhidrosis.

BACKGROUND: This report examines the intermediate-term results of endoscopic transaxillary T2 sympathectomy for palmar hyperhidrosis. METHODS: A retrospective review was carried out of 91 consecutive patients, 38 men and 53 women, with a mean age of 23 years. Attention was focused on patient satisfaction, late complications and morbidity. RESULTS: After operation, no patient died or developed Horner's syndrome. Nine of 21 patients with craniofacial, five of 16 with axillary and 17 of 73 with plantar hyperhidrosis showed simultaneous improvement. Fifteen patients (16 per cent) developed recurrent sweating, but none required reoperation. The overall mean satisfaction rate was 78 per cent with a median 80 per cent improvement using a visual linear analogue scale from 0 (poor) to 100 per cent (excellent). Twelve patients (13 per cent) were dissatisfied with the operative results, mainly owing to compensatory hyperhidrosis, which occurred in 88 patients (97 per cent) within the first year. CONCLUSION: The results of endoscopic sympathectomy deteriorate progressively from the immediate outcome.

Endoscopic transthoracic sympathectomy in the treatment of primary hyperhidrosis. A review of 290 sympathectomies.

OBJECTIVES: To describe the surgical technique of endoscopic transthoracic sympathectomy for the treatment of palmar hyperhidrosis and to identify associated complications. DESIGN: Prospective clinical study. SETTING: University referral center. PATIENTS: A consecutive series of 150 patients with primary palmar hyperhidrosis. INTERVENTION: The surgical procedure is performed under general anesthesia. A trocar and endoscope are inserted into the chest cavity. The sympathetic chain and the second, third, and fourth ganglia are then identified, cauterized, and cut. After reinflation of the lung, the procedure is repeated on the other side. RESULTS: Two hundred ninety sympathectomies were performed with a 98% success rate. Complications of the procedure included pneumothorax in seven patients (2.4%), hemothorax in three (1.0%), and temporary Horner's syndrome in two (0.7%). Severe postoperative pain during the first 2 to 4 hours required treatment. Of 60 patients who were followed up for 12 months, 50% developed compensatory sweating and 8.3% developed rebound sweating. Hyperhidrosis recurred in three patients. CONCLUSION: Endoscopic transthoracic sympathectomy is an effective form of treatment for palmar primary hyperhidrosis, is associated with a low morbidity, and can be performed as an ambulatory procedure.

Thoracoscopic ganglionectomy for hyperhidrosis.

Thoracoscopic sympathectomy for the treatment of hyperhidrosis has been carried out with techniques that involve either monopolar coagulation or laser injury to the T2 ganglion. Although this has the advantage of being minimally invasive, it has not been established whether these techniques are superior to complete ganglion excision, as carried out during open surgery. A new technique of complete T2 ganglion excision for palmar hyperhidrosis (with T3 ganglionectomy for axillary sweating) was developed using thoracoscopic techniques. Sixteen patients were treated with thoracoscopic T2 ganglion excision on the right side, and simple coagulation (Nd-YAG laser or monopolar) on the left side. Results were excellent with no posttreatment differences between hands at 1 year follow-up. However, long-term follow-up of these patients will be carried out to determine whether differences exist between these two techniques.

Rapid progression of hip subluxation in cerebral palsy after selective posterior rhizotomy.

Rapid progression of hip subluxation was noted in the year after selective dorsal rhizotomy in seven hips (six patients). The hips that subluxed progressed from a lateral extrusion index averaging 25% preoperatively as compared with 50% after rhizotomy. Although preexistent hip dysplasia was a predisposing factor, hips with an intermediate degree of preoperative lateral extrusion (12-25%) had variable results. Ongoing and more frequent evaluation of hip stability is necessary after dorsal rhizotomy.

Studies and reevaluations of some aspects on thyroid function after superior cervical sympathetic gangliectomy in rats.

The results of 11 experiments in a total of 571 rats (initial body weight of 150-250 g) are reported and some findings differing from those by others are discussed. It was repeatedly found that the animals after bilateral or even unilateral superior cervical sympathetic gangliectomy (GX) did not gain body weight during the first week after surgery. Though they started to grow later, for several weeks their body weight remained significantly less than that of sham operated controls (SH). Though such phenomenon has not yet been described, it may well explain the increase of thyroid weight (as expressed per body weight) after gangliectomy alone or combined with antithyroid drug treatment or hypophysectomy as described by others. It was suggested that such changes may depend on general metabolic changes resulting in a striking inhibition of body weight gain rather than on some specific effect of GX on the thyroid. This view was supported by evaluating the data on absolute and relative thyroid weight from 4 experiments in a total of 265 animals. The level of thyroxine (T4) and thyrotropic hormone (TSG) was repeatedly found to be significantly decreased after GX for until about 72 h and 24 h after surgery, respectively, which was in agreement with the data reported by others. However, the onset of such decrease was repeatedly found to appear at 6 or 8 h after surgery (in one experiment even at 3 h after surgery) which is also contrasting to the onset of T4 decrease at 14 h after surgery as found by others who suggested a correlation of such thyroid depression with a depletion of noradrenaline from the thyroid and may be even from median eminence. In these experiments, however, a decrease of T4 level was found several hours before the depletion of noradrenaline from the thyroid which appeared at 12 h after surgery and remained at similar level until 40 days, while no remarkable changes of that were found in SH animals (with the excretion of slight increase after 24 h). Between about 4 and 40 days after surgery no significant changes in T4 and TSH levels after GX were found as compared with SH animals is in agreement with others.4+n one experiment the increase of T4 at 2 h after TRH injection, resulting apparently from the effect of endogenous TSH, was significantly inhibited in GX animals at 8 days after surgery, while in other experiments (at 8 and 40 days after surgery) no difference in T4 level increase was found in GX animals as compared with SH ones. In general, it may be suggested that superior cervical sympathetic gangliectomy may result in some temporary and perhaps transient changes in pituitary-thyroid function in rats.