Two-year outcome of laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity: results from a Swedish Nationwide Study (AMOS).

CONTEXT: The prevalence of obesity among adolescents has increased and we lack effective treatments. OBJECTIVE: To determine if gastric bypass is safe and effective for an unselected cohort of adolescents with morbid obesity in specialized health care. DESIGN, SETTING AND PATIENTS: Intervention study for 81 adolescents (13-18 years) with a body mass index (BMI) range 36-69 kg m(-2) undergoing laparoscopic gastric bypass surgery in a university hospital setting in Sweden between April 2006 and May 2009. For weight change comparisons, we identified an adult group undergoing gastric bypass surgery (n=81) and an adolescent group (n=81) receiving conventional care. MAIN OUTCOME MEASUREMENTS: Two-year outcome regarding BMI in all groups, and metabolic risk factors and quality of life in the adolescent surgery group. RESULTS: Two-year follow-up rate was 100% in both surgery groups and 73% in the adolescent comparison group. In adolescents undergoing surgery, BMI was 45.5 ± 6.1 (mean ± s.d.) at baseline and 30.2 (confidence interval 29.1-31.3) after 2 years (P<0.001) corresponding to a 32% weight loss and a 76% loss of excess BMI. The 2-year weight loss was 31% in adult surgery patients, whereas 3% weight gain was seen in conventionally treated adolescents. At baseline, hyperinsulinemia (>20 mU l(-1)) was present in 70% of the adolescent surgery patients, which was reduced to 0% at 1 year and 3% at 2 years. Other cardiovascular risk factors were also improved. Two-thirds of adolescents undergoing surgery had a history of psychopathology. Nevertheless, the treatment was generally well tolerated and, overall, quality of life increased significantly. Adverse events were seen in 33% of patients. CONCLUSIONS: Adolescents with severe obesity demonstrated similar weight loss as adults following gastric bypass surgery yet demonstrating high prevalence of psychopathology at baseline. There were associated benefits for health and quality of life. Surgical and psychological challenges during follow-up require careful attention.

Dysphagia in adults operated on for esophageal atresia--use of a symptom score to evaluate correlated factors.

INTRODUCTION: Dysphagia is not unusual following repair of esophageal atresia (EA). The lack of a uniform definition has led to a variance when it comes to reporting the prevalence of dysphagia among patients operated on for EA. Our aim is to estimate the occurrence and degree of dysphagia, using a numerical score with its statistical versatility independent of a specific definition. The results are used to find early risk factors of dysphagia within this patient group. The results are also used to see whether we can find a correlation between dysphagia and symptoms of gastroesophageal reflux (GER) and quality of life (QoL). METHODS: 79 consecutive survivors operated on for EA in Gothenburg between 1968 and 1983 were located. Hospital charts were reviewed and patients received questionnaires on dysphagia, symptoms of GER and QoL. Dysphagia was measured by a numerical score, symptoms of GER were extracted using a predetermined questionnaire (GerdQ), and QoL was determined using the generic questionnaire SF-36. RESULTS: 73 patients (92.4%) returned the questionnaires. In order to make the study group as homogeneous as possible with regard to the malformation we choose to study the 63 patients representing the vast majority: those with Gross type C. 36 patients (57%) had symptoms of dysphagia to varying degrees. We did not find any aggravating factors in their hospital charts nor did we find any correlation to the most recent demographics. There was a significant difference in dysphagia scores when we compared Gross type C to the often more complex type A (p<0.05). We did not find any correlation to heartburn but a strong correlation to regurgitation with an OR of 2.8 (95% CI: 1.2-6.6). The QoL was good for this patient group, and we did not find any correlation between QoL and the dysphagia score. CONCLUSIONS: The dysphagia score provides easy-to-use results when it comes to evaluating the potential influence of dysphagia. Dysphagia is common within this patient group. Patients operated on for EA Gross type A seem to do worse when it comes to dysphagia. Regurgitation is associated with dysphagia, which could imply that GER is an aggravating factor. Further studies to support this finding will show whether there is a correlation between the dysphagia score and the results of 24-h pH-monitoring. If so, this could mean that treating GER might decrease dysphagia, at least in this patient group.

[Long-term effects after surgery for hand sweating and facial blushing. Patients are satisfied in spite of troublesome side-effects]. / Långtidsresultat efter operation mot handsvett och ansiktsrodnad. Patienterna nöjda trots besvärande biverkningar.

The thoracoscopic technique has simplified surgery on the upper thoracic chain. This comparatively minimally traumatic approach has resulted in a pronounced increase in the number of procedures. The effect of ETS on severe palmar hyperhidrosis and facial blushing is very good. These conditions often cause social, professional and emotional handicaps. Side-effects, especially compensatory sweating (increased sweating on the trunk and legs), can, however, be severe. The procedure should be used only when the hyperhidrosis or facial blushing is severely detrimental to the quality of life. The expected effects, side-effects and risks for complications must be made clear before patients are accepted for ETS.

Pharmacokinetics of orally administered omeprazole in children. International Pediatric Omeprazole Pharmacokinetic Group.

OBJECTIVES: The aim of this study was to examine the pharmacokinetics of orally administered omeprazole in children. METHODS: Plasma concentrations of omeprazole were measured at steady state over a 6-h period after administration of the drug. Patients were a subset of those in a multicenter study to determine the dose, safety, efficacy, and tolerability of omeprazole in the treatment of erosive reflux esophagitis in children. Children were 1-16 yr of age, with erosive esophagitis and pathological acid reflux on 24 h-intraesophageal pH study. The "healing dose" of omeprazole was that at which subsequent intraesophageal pH study normalized. Children remained on this dose for 3 months, and during this period the pharmacokinetics were measured. RESULTS: A total of 57 children were enrolled in the overall healing phase of the study. Pharmacokinetic study was optional for subjects and was performed in 25 of the 57 enrolled. The doses of omeprazole required were substantially higher doses per kilogram of body weight than in adults. Values of the pharmacokinetic parameters of omeprazole were generally within the ranges previously reported in adults. However, the plasma levels, area under the plasma concentration versus time curve (AUC), plasma half-life (t(1/2)), and maximal plasma concentration (Cmax), were lower in the younger age group, when the AUC and Cmax were normalized to a dose of 1 mg/kg. Furthermore, within the group as a whole, these values showed a gradation from lowest in the children 1-6 yr of age to higher in the older age groups. CONCLUSIONS: The pharmacokinetics of omeprazole in children showed a trend toward higher metabolic capacity with decreasing age, being highest at 1-6 yr of age. This may explain the need for higher doses of omeprazole on a per kilogram basis, not only in children overall compared with adults but, in many cases, particularly in younger children.

Regional renal haemodynamics of angiotensin II infusion under prostaglandin, kinin or converting enzyme inhibition in the Wistar rat.

AIMS: Renal medullary blood flow is important in blood pressure regulation and is surprisingly unaffected by the vasoconstrictor action of angiotensin II (Ang II). This study tested if the effect of Ang II on the renal papillary circulation is modulated by bradykinins, prostaglandins or NO (NO). In anaesthetised Wistar rats, total renal blood flow (RBF) was measured, as was cortical (CBF) and papillary (PBF) blood flow, using the laser-Doppler technique, in responses to Ang II (30 ng kg(-1) min(-1)) alone and after ACE inhibition (enalapril) or bradykinin/prostaglandin synthesis inhibition (ketoprofen, aprotinin). PBF was also measured after blockade of NO formation with or without pretreatment with an Ang II receptor antagonist (losartan). MAJOR FINDINGS: (i) PBF did not change in response to Ang II infusion but MAP increased (+ 10%) and RBF and CBF decreased. (ii) Treatment with aprotinin and ketoprofen left MAP, RBF and CBF unchanged but decreased PBF. Ang II did not decrease PBF further but a significant increase in MAP was seen. (iii) Enalapril treatment left PBF unchanged but decreased MAP and increased RBF and CBF. When Ang II was infused PBF and MAP increased markedly. (iv) L-NAME reduced PBF independently of losartan treatment. PRINCIPAL CONCLUSION: Bradykinin and prostaglandins do not appear to cause the lack of renal papillary vasoconstriction to Ang II. However, the increase in PBF to Ang II seen after enalapril treatment suggests that enalapril treatment, possibly via its effects on kinin breakdown and subsequent NO formation, might affect the sensitivity of renal papillary autoregulation. This may be an important aspect of the blood pressure lowering effect of ACE inhibitors.

Effects on regional renal blood flow when unclipping a two-kidney, one-clip hypertensive Wistar rat during renal nerve stimulation.

Blood pressure (BP) is rapidly normalized when removing the obstruction from the renal artery of a two-kidney, one-clip renovascular hypertensive rat (unclipping). This study tested whether efferent renal nerve stimulation (ERNS) of the unclipped kidney affects this drop in BP or the associated changes in diuresis-natriuresis and regional renal blood flow. Three groups of anesthetized renovascular hypertensive Wistar rats were studied: 1) W(C) (time control); 2) W(UC) (unclipped after 30 min); and 3) W(UC+NS) (unclipped after 30 min, with ERNS at 5 Hz for 2 h). Renal excretion and regional hemodynamics (laser Doppler) were monitored in the unclipped kidney. Medullary and cortical blood perfusion increased by 84% and 95%, respectively, in W(UC) 30 min after unclipping (P < .001) but only with 8% and 9%, respectively, in W(UC+NS) (P = NS). Unclipping induced a marked increase in diuresis-natriuresis that was largely unaffected by ERNS. In W(UC) and W(UC+NS) BP returned to normotensive levels within 4 h. However, during the first 30 min, average BP decreased significantly less in W(UC+NS) (9%, 20 mm Hg) than in W(UC) (16%, 35 mm Hg) (P < .05). ERNS at 5 Hz effectively prevented the increase in medullary blood perfusion but did not affect the fall in blood pressure or the pressure diuretic/natriuretic response seen after unclipping. The results suggest that both the reduction in BP and the pressure-induced increase in diuresis/natriuresis seen when unclipping the 2K,1C renovascular hypertensive rat occurs largely independently of ERNS and an increase in medullary blood perfusion.

[Treatment of facial blushing with endoscopic thoracal sympathicotomy. 85 per cent of patients are satisfied, but there are adverse effects]. / Behandling av ansiktsrodnad med endoskipisk torakal sympatikotomi. 85 procent av patienterna nöjda, men biverkningar finns.

Endoscopic transthoracic sympathicotomy, otherwise an established treatment for palmar hyperhidrosis, was used to treat patients troubled by facial blushing, one of the commonest symptoms of social phobia. The results were evaluated by means of a questionnaire answered by 90 per cent (219/244) of the patients, who rated their symptoms on a visual analogue scale (0-10) after a mean follow-up of eight months. According to the ratings, blushing was significantly reduced from a mean (+/- SEM) of 8.7 +/- 0.1 to 2.2 +/- 0.2 (p < 0.0001). Of the series as a whole, 85 per cent declared themselves satisfied with the outcome.

Successful treatment of facial blushing by endoscopic transthoracic sympathicotomy.

Facial blushing is one of the cardinal symptoms of social phobia and has a strong negative impact on the quality of life. Traditional therapeutic options are psychotherapy and pharmacological treatment. The results of these treatments on facial blushing are poorly documented. To investigate whether endoscopic bilateral transection of the upper thoracic sympathetic chain is efficient in the treatment of facial blushing, 244 consecutive patients were treated with bilateral endoscopic transthoracic sympathicotomy (ETS). The results were evaluated by questionnaire and symptoms assessed with visual analogue scales (0-10). There was no mortality nor conversion to open surgery. No Horner's syndrome occurred. Two patients with postoperative pneumothorax were treated with intercostal drainage and one small pulmonary embolus was detected. The questionnaire was answered by 219 patients (90%) a mean (+/- SEM) of 8 months (+/- 9 days) after surgery. Facial blushing (mean +/- SEM) was reduced from 8.7 +/- 0.1 to 2.2 +/- 0.2, P < 0.0001, by the operation. Heart palpitations in stressful situations were also reduced (3.7 +/- 0.3 to 1.3 +/- 0.1, P < 0.0001). The quality of life was substantially improved. The main side-effect was redistribution of sweating from the upper to the lower part of the body. Increased sweating of the trunk occurred in 75% of the patients. Overall, 85% of the patients were satisfied with the result and 15% were to some degree dissatisfied, mainly due to insufficient effect, but only four patients (2%) regretted the operation. As this is an open study, the results must be viewed with caution. ETS, however, appears to be an efficient, safe and minimally invasive surgical method for the treatment of facial blushing.

The Borås experience of endoscopic thoracic sympathicotomy for palmar, axillary, facial hyperhidrosis and facial blushing.

OBJECTIVE: To study the outcome of endoscopic thoracic sympaticotomy (ETS) for palmar, axillary, facial hyperhidrosis and facial blushing. SUBJECTS: 1152 patients, 59% women and 41% men. INTERVENTION: ETS was performed by transection of the sympathetic chain where it overlies the second and third rib. The nerve was divided also over the fourth rib in patients with axillary hyperhidrosis. Questionnaires were sent to all patients. MAIN OUTCOME MEASURES: The effect of surgery was assessed by a 10 grad visual analogue scale (VAS) by the patients. The results were divided into effect rate (the effect on the symptom) and overall satisfaction rate, taking into account any side effects and complications apart from the effect. RESULTS: The response rate was 90%. The mean follow up time, effect rate and overall satisfaction rate were: 38 months for palmar hyperhidrosis, 99.4% and 87%; 26 months for axillary hyperhidrosis, 94.5% and 68%; 31 months for facial hyperhidrosis, 97% and 76%; 8 months for facial blushing, 96% and 85%. CONCLUSION: ETS is a very effective procedure in palmar, axillary and facial hyperhidrosis and facial blushing. The overall satisfaction rate is very good for palmar hyperhidrosis and facial blushing, not equally good but acceptable for facial hyperhidrosis. The lower satisfaction rate in patients with axillary hyperhidrosis makes this a questionable indication for ETS.

Renal medullary blood flow and renal medullary antihypertensive mechanisms.

It has long been recognised that the kidneys take part in blood pressure control via both their exocrine and endocrine functions. An endocrine antihypertensive function of the renal medulla has been proposed. The renal medullary depressor substances ("medullipins"), are released in response to increased renal perfusion pressure. It has been suggested that the release of "medullipin" is controlled via changes in renal medullary blood flow. Recent observations also suggest that renal medullary blood flow is involved in the control of the pressure/natriuretic-diuretic action of the kidney. In this review we outline a unified hypothesis for blood pressure control via a combination of the plasma volume regulating pressure-natriuresis mechanism and the powerful antihypertensive actions of the "medullipins" (i.e. vasodilatation, inhibition of sympathetic drive and a diuretic action). It is hypothesised that the activity of both these systems are under control by renal medullary blood flow.

Effect of nitric oxide and renal nerves on renomedullary haemodynamics in SHR and Wistar rats, studied with laser Doppler technique.

The threshold for activation of the humoral renal antihypertensive system, presumably residing in the renomedullary interstitial cells (RIC), is substantially reset upwards in the spontaneously hypertensive rat (SHR). Depressor reactions, normally elicited by an increased renal perfusion pressure, can be inhibited either by high frequency renal nerve stimulation or blockade of nitric oxide synthesis, i.e. manoeuvres decreasing renal blood flow at this high perfusion pressure. The present study was designed to explore the effects on regional renal haemodynamics of blocking NO synthesis with N-omega-nitro-L-arginine (L-NNA) in chloralose anaesthetized SHR and Wistar rats. Mean arterial blood pressure (MAP), heart rate (HR), renal blood flow (RBF), cortical blood perfusion (CBP) and papillary blood perfusion (PBP) were measured in renally innervated and denervated SHR (Si n = 8, Sd n = 8) and in Wistar rats (Wi n = 10, Wd n = 10). An innervated non-treated Wistar group served as control (Ci n = 12). The laser Doppler technique was used to record CBP and PBP. MAP increased in all groups receiving L-NNA while HR, RBF and CBP simultaneously decreased. The relative decreases in RBF were more marked into the two SHR groups than in the corresponding Wistar groups. After L-NNA PBP also decreased in all four groups despite the increased MAP and more so in the Si group; Wi -19 +/- 8 (P < 0.05), Wd -17 +/- 6 (P = 0.07), Si -50 +/- 9 (P < 0.01) and Sd -25 +/- 9% (P < 0.05). We conclude that NO is important for maintaining PBP especially in SHR. The more marked decrease in PBP in the innervated SHR suggests a NO/renal nerve interaction in the control of renomedullary blood flow in SHR. This finding may be of importance for the regulation of the humoral renal depressor mechanism.

Efferent renal nerve stimulation inhibits the antihypertensive function of the rat renal medulla when studied in a cross-circulation model.

The aim of this study was to investigate the effects of renal nerve stimulation on the humoral renal antihypertensive system. An isolated kidney (IK) was perfused at normal or high arterial pressures from a normotensive assay rat by means of a perfusion pump. Perfusion pressure (PP) to the IK was 90 mmHg for a control period of 30 min. In three of five experimental groups PP was then increased to 175 mmHg. In two of the groups the renal nerves were stimulated at 2 (P-175(2Hz)) or 5 Hz (P-175(5Hz)) for 60 min. The remaining group served as a control (P-175C). In two groups IK pressure was maintained at 90 mmHg with 5 Hz nerve stimulation (P-90(5Hz) or without nerve stimulation (P-90C). MAP of the assay rat decreased by 22 and 27% (P < 0.001) in the P-175C and P-175(2Hz) groups, respectively during the 60 min period of nerve stimulation, but remained stable in P-175(5Hz). Renal blood flow increased in the IK when PP was increased in P-175C, but did not change significantly in P-175(2Hz) or P-175(5Hz). Blood pressure remained constant in the assay rat when the IK was perfused at 90 mmHg. The renal excretory functions of the IK decreased in a frequency dependent manner by 2 and 5 Hz renal nerve stimulation compared with P-175C. We conclude that 5 Hz renal nerve stimulation inhibits the pressure dependent release of humoral depressor substances from an IK perfused at 175 mmHg, whereas this is not seen when stimulating at 2 Hz. It is suggested that hte release of antihypertensive substances from the renal medulla requires an increased renomedullary blood flow.

Endoscopic transthoracic sympathectomy: an efficient and safe method for the treatment of hyperhidrosis.

BACKGROUND: Hyperhidrosis of the palms, axillae, and face has a strong negative impact on the quality of life for many persons. Existing nonsurgical therapeutic options are far from ideal. Definitive cure can be obtained by upper thoracic sympathectomy. The traditional open surgical technique is a major procedure; few patients and doctors have found that risk-benefit considerations favor surgery. Endoscopic minimal invasive surgical techniques are now available. OBJECTIVE: We investigated whether endoscopic ablation of the upper thoracic sympathetic chain is efficient and safe in the treatment of hyperhidrosis. METHODS: We treated 850 patients with bilateral endoscopic transthoracic sympathectomy. RESULTS: There was no mortality or life-threatening complication. Nine patients (1%) required intercostal drainage because of hemothorax or pneumothorax. Treatment failure occurred in 18 cases (2%) and symptoms recurred in 17 patients (2%). At the end of follow-up (median, 31 months) 98% of the patients reported satisfactory results. CONCLUSION: Endoscopic transthoracic sympathectomy is an efficient, safe, and minimally invasive surgical method for the treatment of palmar, axillary, and facial hyperhidrosis.

Efferent renal sympathetic nerve stimulation in vivo. Effects on regional renal haemodynamics in the Wistar rat, studied by laser-Doppler technique.

Intrarenal blood flow regulation probably affects long-term blood pressure homeostasis. We have previously shown that 5 Hz renal sympathetic stimulation inhibits a humoral renal depressor mechanism, otherwise activated when increasing perfusion pressure to an isolated kidney in a cross-circulation set-up. This inhibition was suggested to occur as a result of a reduction of renomedullary blood flow. Little is known about nervous blood flow regulation within the medulla. Therefore in this study, total renal (RBF), cortical (CBF) and papillary (PBF) blood flows were separately measured by ultrasonic and laser-Doppler techniques in Wistar rats during graded renal sympathetic stimulations. Periods of 15 min stimulation at 0.5, 2 and 5 Hz were performed in random order. RBF decreased at 0.5 Hz by 1%, at 2 Hz by 16% (P < 0.001) and at 5 Hz by 49% (P < 0.001). In a similar fashion (r = 0.73, P < 0.001), CBF decreased by 1%, 10% (P < 0.001) and 37% (P < 0.001), respectively. By contrast, PBF increased by 2% at 0.5 Hz and 4% at 2 Hz, while it decreased at 5 Hz, by 4% (P < 0.05, compared with 2 Hz). It seems therefore, that superficial renocortical and total renal blood flows are closely regulated by renal sympathetic nerves with increasing vasoconstriction at higher frequencies, while medullary blood flow, on the other hand, seems to be under strong local control, tending to offset neurogenic flow restrictions.

Renal and haemodynamic effects of nitric oxide blockade in a Wistar assay rat during high pressure cross-circulation of an isolated denervated kidney.

Blockade of NO synthesis with N-omega-nitro-L-arginine (L-NNA) inhibits the vasodepressor response seen in intact Wistar assay rats in which isolated kidneys perfused via an extracorporeal circuit are perfused at high pressure. This study explores the renal and haemodynamic changes associated with this inhibition. Isolated kidneys (IK) were perfused at high pressure (175 mmHg) by a pump in series with intact Wistar assay rats in which blood pressure (BP), haemodynamics and renal function were studied. Nitric oxide (NO) synthesis was blocked by L-NNA (2.5 mg kg-1) in 13 experiments (175NO) while 14 control experiments (175C) were performed. IK was perfused at 90 mmHg in seven experiments (90C). The BP drop in the 175C assay rat was blocked by L-NNA in 175NO (P < 0.01). However, when the blockade was reversed with L-arginine infusion (20 mg kg-1 min-1) BP declined also in 175NO. Effective renal plasma flow (ERPF) and glomerular filtration rate (GFR) fell dramatically after L-NNA in both the assay rat and in IK despite a high perfusion pressure. The marked increase in filtration fraction (FF) after L-NNA suggests a dominating postglomerular vasoconstriction. The natriuretic response in IK to 175 mmHg was also markedly blunted by L-NNA. We conclude that NO blockade inhibits the renomedullary depressor mechanism probably by restricting renal blood flow, and also blunts the pressure induced natriuretic response as a result of a reduced sodium filtration. Finally, the autoregulation of whole kidney blood flow seems to be more efficient although set at a higher level of vasoconstriction.

Physiology of the renomedullary depressor system.

THE LOCATION OF A DEPRESSOR MECHANISM IN THE RENAL MEDULLA: The late Eric Muirhead was the first to identify a depressor mechanism in the renal medulla. He located it in the renomedullary interstitial cells and was able to extract a lipid substance with the properties of a blood-pressure lowering hormone from papillary tissue, from renomedullary interstitial cells grown as monolayer tissue culture and from the venous outflow of high-pressure perfused kidneys. CHARACTERISTICS OF THE MECHANISM: The reversal of Goldblatt renovascular hypertension induces a reduction in blood pressure associated with an unchanged or slightly decreased heart rate, reduced efferent sympathetic activity and a decrease in vascular resistance in the splanchnic region. If the renal medulla is destroyed chemically by 2-bromoethylamine hydrobromide the blood pressure does not fall to normal levels. Extracorporeal crossperfusion of an isolated normal kidney at high pressure activates the renal depressor mechanism, inducing a decrease in blood pressure, also in association with reduced heart rate and sympathetic nervous activity in the normotensive assay rat. Diuresis and natriuresis are also increased when the mechanism is activated, as when the lipid extracts are given intravenously. FEEDBACK CONTROL: Stimulation of efferent sympathetic activity to the kidney can block the initiation of the depressor mechanism. Also, if nitric oxide synthase is blocked, the depressor mechanism cannot be activated. CONCLUSIONS: The renomedullary depressor mechanism, together with the renin-angiotensin system, provides the kidney with the ability to perfectly control blood pressure homeostasis. The antihypertensive effect of this hormonal system is brought about by sympathetic inhibition (cardioprotective), vascular relaxation (vasoprotective) and increased diuresis/natriuresis (renoprotective), which are the characteristics of modern treatment of hypertension.

Thoracoscopic sympathicotomy for hyperhidrosis--surgical technique, complications and side effects.

Thoracic sympathectomy is a very effective treatment of palmar hyperhidrosis. The described endoscopic technique has given good primary results in 99% of patients. After another session with this type of "minimal invasive surgery" 100% of the hands were satisfactorily dry. The hospital stay is just one post-operative day and the sick-leave is about a week. The drawbacks are minimal. Pain is tolerable and only eight patients needed a post-operative Bülau-drainage because of pneumothorax or bleeding. About 50% of patients experience a compensatory increased sweating of the trunk, but this is related to a warm environment and regulation of body temperature and seems to decrease with time. This technique makes it possible to treat all those suffering from palmar hyperhidrosis which can be a substantial, but underestimated handicap. To meet this kind of patient after a successful operation is extremely satisfying even for the surgeon. The post-operative wet and cold hand has immediately post-operatively become warm and dry.

Thoracoscopic sympathicotomy for arterial insufficiency.

Arterial insufficiency of the hands due to vascular spasm-morbus Raynaud is an extremely unpleasant condition. Elicited by cold temperatures, the disease can make it impossible for the patient to go out in cold environments. The condition seldom leads to skin necrosis, which is the case in arterial insufficiency caused by vascular occlusion. In both cases arterial insufficiency may be diminished by thoracic sympathectomy. Our test series of operations included 14 patients with m. Raynaud or vascular occlusion. All experienced improvement, with warm, dry hands and satisfactory healing after thoracoscopic sympathicotomy. However, after six months, the original symptoms recurred in all the patients with m. Raynaud, while the improvement continued in the patients with vascular occlusion during the two to four year period of observation.