SUPERSENSITIVITY TO NE AFTER ADRENERGIC DENERVATION

SUPERSENSITIVITY TO NE AFTER ADRENERGIC DENERVATION

H-NOREPINEPHRINE UPTAKE
Portal veins were incubated for 1 hour with 3H-NE 1,3, and 5 days after chemical sympathectomy with 6-OHDA (Fig. 3). Preparations treated with cocaine (10~5 M) were exposed to this drug 15 minutes before 3H-NE incubation and maintained in a cocaine-containing solution throughout the entire incubation period. One day after 6-OHDA treatment, NE uptake was reduced to approximately 21 %
of control; at 3 days it was 33% of controls and 5 days after 6-OHDA it was approximately 39% of controls. The decrease in NE uptake caused by 6-OHDA treatment was comparable to that caused by cocaine.

SUPERSENSITIVITY TO NE AFTER ADRENERGIC DENERVATION

CATECHOLAMINE DEPLETION AFTER CHEMICAL SYMPATHECTOMY

1977;41;198-206 Circ. Res.
Trophic influence of the sympathetic nervous system on the rat portal vein

more complex autonomic dysfunction than generalised sympathetic overactivity

Cardiac autonomic function in patients (n = 63) with primary focal hyperhidrosis and healthy controls (n = 28) was investigated by short-term frequency domain power spectral analysis of heart rate variability. The power of the very-low-frequency band (0.01-0.05 Hz) was significantly lower in patients with axillary hyperhidrosis than in controls. No differences between groups could be observed at investigation of the low-frequency band (0.05-0.15 Hz), which was a surprising finding because this band represents also sympathetic cardiac innervation. At the high-frequency band (0.15-0.5 Hz), which represents parasympathetic cardiac innervation, an interaction of type and position influencing spectral power was detected. Our highly interesting findings indicate that primary focal hyperhidrosis is based on a much more complex autonomic dysfunction than generalised sympathetic overactivity and seems to involve the parasympathetic nervous system as well.
Eur Neurol 2000;44:112-116 (DOI: 10.1159/000008207)
peter.birner@akh-wien.ac.at

Medical Tourism advertising Sympathectomy

http://mondialtourism.webfire.com.au/_webapp_117318/Endoscopic_Thoracic_Sympathectomy

Side Effects

There is the possibility of increased sweating in other areas of the body for example the back of the legs.

Recovery Period

Patients will normally stay one day in hospital. Pain may be present for around a week, patients are normally given medication to control this. Most patients will be able to carry out their daily activities and return to work within a week.

Associated Risks

As with all types of surgery there are certain risks involved, these include infection, bleeding, reaction to anesthesia or nerve damage. The main risk of the surgery as stated before is increased sweating in other areas of the body.

dissociation between conductance and microvascular perfusion

Complete sympathectomy was accompanied by a persistent increase in ear temperature and a dissociation between conductance and microvascular perfusion. Auricular conductance was transiently increased and then decreased to levels below preoperative control values. Microvascular perfusion is decreased immediately following amputation/replantation and thereafter increases.
Microsurgery ISSN 0738-1085 CODEN MSRGDQ

Source / Source

1998, vol. 18, n^o2, pp. 129-136 (26 ref.)

'Emotional' sweating regulated by neocortex and limbic cortex

Careful observations showed that the forearm sweating responded diversely to various mental stimuli, unlike the palmar sweating whose response was always an increase. Mental arithmetic, mental testing and physical exercise caused an immediate increase in the palmar sweating but often elicited a transient decrease in the forearm sweating, whereas pain, noise, and emotional stimuli consistently provoked an increase of sweating on the forearm as well as on the palm. These observations suggest that the activities of higher centers, presumably involving neocortex and limbic cortex, exert various influences on the central mechanisms of palmar and generalized sweating.
Jpn J Physiol. 1975;25(4):525-36.
http://www.ncbi.nlm.nih.gov/pubmed/1206808

90% may experience Gustatory sweating after surgery for Hyperhidrosis

Some individuals (up to 90%) may experience another type of sweating that is increased while eating or smelling certain foods (gustatory sweating) (Hornberger).

Source: Medical Disability Advisor

http://www.mdguidelines.com/sympathectomy

Chronic betablocker therapy can exactly mimic autonomic neuropathy

What is the ultimate effect of cardiac autonomic neuropathy.

Cardiac denervation. The manifestations are

• Tachycardia, exercise intolerance
• Orthostatic hypotension

http://stanford.wellsphere.com/heart-health-article/why-is-angina-pectoris-silent-in-diabetes-mellitus/549631

How Sympathectomy is described by the surgeons who offer the procedure: (Is this what Sympathectomy does - only?)

"With the nerve stimulation data, Dr. McCormack then cuts only those nerves that innervate sweat glands in the areas affected with hyperhydrosis. For example, a patient with palmar hyperhydrosis, T2 and T3 ganglion may individually, or both be involved. The intraoperative nerve testing precisely defines which ganglion has to be cut and avoids injury to the ganglion not involved. This is important because post-operative compensatory sweating problems increase with the number of ganglion cut."
http://www.nosweatsurgery.com/hyperhyd.htm

Gustatory sweating is a frequent side effect after thoracoscopic sympathectomy (32%)

Overall, gustatory sweating occurred in 32% of patients, and the incidence was significantly associated with extent of sympathectomy (p = 0.04). However, because the extent of sympathectomy was always decided by the location of primary hyperhidrosis, the latter may also explain the risk of gustatory sweating. CONCLUSIONS: Gustatory sweating is a frequent side effect after thoracoscopic sympathectomy. This is the first study to report that its incidence is significantly related to the extent of sympathectomy or the location of primary hyperhidrosis. Although there is no pathophysiologic explanation of gustatory sweating, these findings should be considered before planning thoracoscopic sympathectomy and patients should be thoroughly informed.
The Annals of thoracic surgery (Ann Thorac Surg), 2006-Mar; vol 81 (issue 3) : pp 1043-7

Incidence of chest wall paresthesia 50.0%

Paresthetic discomfort distinguishable from wound pain was described by 17 patients (50.0%). The most common descriptions were of ‘bloating’ (41.2%), ‘pins and needles’ (35.3%), or ‘numbness’ (23.5%) in the chest wall. The paresthesia resolved in less than two months in 12 patients (70.6%), but was still felt for over 12 months in three patients (17.6%).
Eur J Cardiothorac Surg 2005;27:313-319

Abolition of sympathetic skin responses following endoscopic thoracic sympathectomy

http://www.ncbi.nlm.nih.gov/pubmed/8618555?dopt=Abstract

Muscle Nerve. 1996 May;19(5):581-6.

abnormal sympathetic skin response may lead to peripheral vascular failure or the reduced cardiac chronotropic response may impair the body

An already impaired cardiovascular system is recognized to be a significant risk factor for development of heat stroke. In the post-sympathectomy patient, the abnormal sympathetic skin response may lead to peripheral vascular failure or the reduced cardiac chronotropic response may impair the body’s capacity to compensate for shock. These may have contributed to the rapid development of shock and severe multiple organ dysfunction syndrome in this patient.
He had multiple organ dysfunction syndrome develop, with severe renal and hepatic failure, grade II hepatic encephalopathy, and disseminated intravascular coagulation. He responded remarkably well to aggressive supportive measures including forced alkaline diuresis, and he was eventually discharged home after 1 month. The patient was previously a healthy, physically fit, nonsmoker. He worked as a body building trainer and led an active, sporty lifestyle. The only significant medical history was that he had received thoracic sympathectomy for axillary hyperhidrosis 4 years ago at another hospital.

http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

sympathectomy can impair the autonomic nervous system’s increase of the heart rate in response to exercise

it has been shown that thoracic sympathectomy can impair the autonomic nervous system’s increase of the heart rate in response to exercise [6]. Although absolute tachycardia is not eliminated, given the endocrine and paracrine stimuli during exercise, the maximum heart rate reached during exercise has been shown to be significantly reduced after sympathectomy. Thus for a given workload during exercise, there will be a relative bradycardia. This may possibly affect the circulatory system’s ability to convey heat from the body core to the extremities for heat loss.
http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

abnormal peripheral vascular responses to temperature

thoracic sympathectomy has been demonstrated to abolish or alter sympathetic vasoconstrictive responses in the skin, and this may contribute to abnormal peripheral vascular responses to temperature [4]. Paradoxically it has been suggested that in some cases there may be abnormal vasoconstriction rather than the expected vasodilatation after sympathectomy [5]. It is not impossible that such atypical peripheral vascular responses to rising body temperature may have contributed to impaired heat loss during exercise or to an inappropriate response to shock on the development of the heat stroke.
http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

impaired overall heat loss

the abolition of sweating from the upper body as well as the axillae and both upper limbs may have significantly reduced the capacity of the patient to lose heat through sweating during exercise. Anhidrosis in the head and neck after sympathectomy affects a proportion of patients, but is often neglected in most reports of post-sympathectomy complications [3]. The loss of head and neck sweating in this patient may have further impaired overall heat loss. However we would also note that the degree of heat loss impairment after sympathectomy has never been quantified, and its effect on body temperature during exercise remains to be established.
http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

facial anhidrosis and disturbed cardiovascular responses to temperature

"Although thoracic sympathectomy is commonly used to reduce upper limb sweating, it may also lead to facial anhidrosis and disturbed cardiovascular responses to temperature. The resultant effect on overall body heat loss has not been documented. We present a case of a young patient with previous thoracic sympathectomy who suffered severe heat stroke after heavy exercise.
http://ats.ctsnetjournals.org/cgi/content/full/84/3/1025

Changes in hemodynamics of the carotid and middle cerebral arteries

Jeng and associates observed an increase in cerebral blood flow after T2 sympathectomy, and they suggested the possibility of using such a surgical approach to improve cerebral blood flow in patients with cerebral vascular insufficiency.
Sympathectomy for Pain
ANTONIO A. F. DE SALLES I JOHN PATRICK JOHNSON


Patients who underwent T-2 sympathectomy demonstrated a significant increase in blood flow volume and flow velocities of the CAs and MCA, especially on the left side. Asymmetry of sympathetic influence on the hemodynamics of the CAs and MCA was noted. The usefulness of sympathectomy for the treatment of ischemic cardiovascular and cerebrovascular disease deserves further investigation.
Jeng JS, Yip PK, Huang SJ, et al: Changes in hemodynamics of the carotid and middle cerebral arteries before and after endoscopic sympathectomy in patients with palmar hyperhidrosis: Preliminary results.
J Neurosurg 90:463–467, 1999

side effects, ranging from trivial to devastating

There seem to be no controlled studies demonstrating efficacy of neurolytic sympathetic blocks. Possible side effects, ranging from trivial to devastating, are of even greater importance with these more permanent procedures—painful sequelae may include phenol or alcohol neuritis and postsympathectomy pain (sympathalgia), which can also occur after surgical sympathectomy.⁶

BMJ. 1998 March 14; 316(7134): 792–793.

Sympathectomy induces adrenergic excitability of cutaneous C-fiber nociceptors

1. The effects of ipsilateral removal of the superior cervical ganglion on the subsequent responsiveness of C-fiber polymodal nociceptors (CPMs) of the ear to close-arterial injections of norepinephrine (NE) were evaluated in adult, anesthetized rabbits. 2. In normal unanesthetized rabbits, the two ears were usually at the same temperature.
Immediately after the ganglionectomy, the ipsilateral ear was warmer; however, at the time of electrophysiological recordings (4-23 days) the majority of animals had the ipsilateral ear cooler by > or = 1 degree C, suggestive of denervation supersensitivity. 3.
NE (50 ng) did not activate any CPMs (n = 28) from intact animals. 4. Seven of 22 CPMs recorded from sympathectomized ears were activated by NE (50 ng). The responses varied considerably but typically consisted of 2-4 impulses in the 60 s after the NE injection. In some instances, repetitive activity continued for many minutes. Such prolonged discharge differs from the adrenergic responses seen after partial nerve damage. 5. The induction of adrenergic excitability in CPMs by sympathectomy is
suggested to be a counterpart to postsympathectomy neuralgia in human beings and a possible part of the mechanism leading to sympathetically related pain states.
http://www.ncbi.nlm.nih.gov/pubmed/8822575

Chemical thoracic sympathectomy (CTS) resulted in profound bradycardia

In the CTS group, however, the SD_RR:SD∂_RR ratio decreased significantly from 1.72 ± 0.20 to 1.23 ± 0.11 just after CTS. The previous patient, who had a high SD_RR:SD∂_RR ratio of 3.45 before CTS, exhibited severe bradycardia (22 beats/min).
The decrease in the SD_RR:SD∂_RR ratio indicates a reduction of cardiac sympathetic activity. However, CTS in patients having high SD_RR:SD∂_RR ratios can result in profound bradycardia.

Anesthesiology ISSN 0003-3022

1998, vol. 89, n^o3, pp. 666-670 (12 ref.)

ETS reduces myocardial oxygen demand and plasma noradrenaline levels

"The sympathetic ganglion is not a simple relay station but a site modulated by short inter-neurons and a variety of neurotransmitters and receptors. Therefore, [T2-T3] ETS might have modified the sympathetic regulation of adrenaline secretion from the adrenal medulla. [T2-T3] ETS increases the plasma level of atrial natriuretic peptide, which has widespread sympatholytic activity. [T2-T3] ETS might have influenced the amount of adrenaline secreted from the adrenal medulla via changes in humoral factors such as atrial natriuretic peptide."(Nakamura 2002)

Stroke index and systemic vascular resistance were similar both at rest and at submaximal exercise before and after ETS. Thus, ETS reduces myocardial oxygen demand and plasma noradrenaline levels both at rest and during exercise without significantly depressing cardiac function in terms of stroke volume.
http://www.ncbi.nlm.nih.gov/pubmed/11954949?dopt=Abstract

a technique that is associated with a number of potential problems

Transthoracic endoscopic sympathectomy is now considered the treatment of choice for patients with upper limb hyperhidrosis requiring sympathetic ablation. This procedure requires the use of an endobronchial double lumen tube and subsequent one-lung anaesthesia, a technique that is associated with a number of potential problems. Full patient monitoring is thus required and includes pulse, ECG, non-invasive blood pressure measurement, pulse oximetry, end-tidal carbon dioxide concentration and peak inspiratory airway pressure.

Anaesthetic implications for transthoracic endoscopic sympathectomy.

PMID: 7524779 [PubMed - indexed for MEDLINE] Eur J Surg Suppl. 1994;(572):33-6.

Hypoxaemia is of a major concern during thorascopic sympathectomy

However the pathophysiology of hypoxaemia and consequent decrease in SpO2 differs between the two anaesthetic techniques.

The normal physiological response to massive atelectasis is an increase in pulmonary vascualr resistance (hypoxic pulmonary vasoconstriction) with re-routing of blood to well ventilated lung zones and consequent improvement of in PaO2. However, during endobronchial anaesthesia for thoracic sympathectomy there is an apparent failure of this compensatory mechanism. When more than 70% of the lung is atelectatic, compensation by hypoxic pulmonary vasonstriction appears to be ineffective. Furthermore, in in vitro and animal studies, inhalation anaesthetic agent have been shown to depress hypoxic pulmonary vasoconstriction.

In a study by Hartrey and colleagues, SpO2<95%>20 mm Hg in 21% of patients. Similarly, we have reported sudden hypotension and bradycardia after injudicious carbon dioxide insufflation.

In an interesting study of the delayed cardiac effects of T2-4 sympathectomy, Drott and colleagues demmonstrated significantly reduced heart rate at rest, and during both exercise and the recovery phase of the exercise.
Changes in the electrical axis and shortening of the QT interval have also been reported.
B. Fredman, D. Olsfanger, R. Jedeikin
British Journal of Anaesthesia 1997; 79: 113-119

Loss of coordinated autonomic responses to demands on heart rate and vascular tone

Autonomic dysreflexia - Spinal cord injuries (SCI) above T6 may be complicated by a phenomenon known as autonomic dysreflexia, a manifestation of the loss of coordinated autonomic responses to demands on heart rate and vascular tone [5,6]. Uninhibited or exaggerated sympathetic responses to noxious stimuli lead to diffuse vasoconstriction and hypertension. A compensatory parasympathetic response produces bradycardia and vasodilation above the level of the lesion, but this is not sufficient to reduce elevated blood pressure. SCI lesions lower than T6 do not produce this complication, because intact splanchnic innervation allows for compensatory dilatation of the splanchnic vascular bed.

The estimated frequency of this complication is quite variable, ranging from 20 to 70 percent of patients with SCI lesions above T6 [5,6]. Autonomic dysreflexia is unusual within the first month of SCI but usually appears within the first year [7,8].

Common clinical manifestations are headache, diaphoresis, and increased blood pressure [7]. Flushing, piloerection, blurred vision, nasal obstruction, anxiety, and nausea may also occur. Bradycardia is common; however, some patients have tachycardia instead. The severity of attacks ranges from asymptomatic hypertension to hypertensive crisis complicated by profound bradycardia and cardiac arrest or intracranial hemorrhage and seizures. The severity of the SCI influences both the frequency and severity of attacks.

CAD mortality also appears to be higher among SCI patients [4]. One contributing factor may be that SCI lesions above the T5 level may lead to atypical presentations for cardiac ischemia; manifestations may include autonomic dysreflexia or changes in spasticity rather than typical chest pain.

The autonomic nervous system dysfunction that results from SCI disrupts normal cardiovascular hemostasis. With SCI above the T6 level, baseline blood pressure is usually reduced, and baseline heart rate may be as low as 50 to 60 beats per minute [12,16]. This is generally not a clinical problem, but may contribute to hemodynamic instability and exercise intolerance.

Acute cervical SCI is associated with a risk of cardiac arrhythmia due to excess vagal tone, as well as complicating hypoxia, hypotension, and fluid and electrolyte imbalances.

http://www.uptodate.com/patients/content/topic.do?topicKey=~VwAwFq7EG6jGfV

bradycardia as likely, compensatory sweating as obligatory after Sympathectomy

Clin Auton Res. 2003 Dec;13 Suppl 1:I36-9.

Sequelae of endoscopic sympathetic block.

Schick CH, Horbach T.

Dept. of Surgery, University of Erlangen-Nürnberg, Krankenhausstrasse 12, 91054, Erlangen, Germany. schick@hyperhidrosis.de

Endoscopic sympathetic block as a treatment for primary hyperhidrosis is associated with certain sequelae. The reported occurrence of side effects still varies in the literature. As the majority of patients describe sequelae after sympathetic surgery, the frequency and importance of these persisting changes are still underestimated. Patient's informed consent should include and define side effects like gustatory sweating, olfactory sweating and bradycardia as likely, and compensatory sweating as obligatory.

PMID: 14673671 [PubMed - indexed for MEDLINE]

Räf L, Claes G. Complications are frequent after surgery for excessive hand sweating. Patients should be informed about the risks

Lakartidningen 1999;96:930-2. (In Swedish.)