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J Thorac Cardiovasc Surg 2001;122:633
© 2001 The American Association for Thoracic Surgery

Letters to the Editor

Reply

Department of Surgery, Division II Kobe University School of Medicine,
Kobe, Japan

Reply to the Editor:

My colleagues and I have learned from and referred to the basic knowledge of sympathectomy in your contributions to the literature, and we respect your academic contributions. We greatly appreciate your kindness in pointing out a descriptive error in our article. ¹ We want to change one sentence on page 277 (column 1, lines 20-22) from "an increase of microvascular perfusion and an elevation of temperature of more than 50% above the original level" to "an increase of microvascular perfusion of more than 50% above the original level and an elevation of temperature."

However, your second comment regarding the position of the patients and the use of a single-lumen endobronchial tube was not applicable to this needlescopic technique. The operative thoracoscope used in your patients was 10 mm in diameter. ² Such a thoracoscope is much harder than the needlescope and the newly designed scope guide shown in Figs 1 and 2. ¹ Because these instruments used in needlescopic surgery were 2.0 to 2.5 mm in diameter, even when the patients were treated with a single-lumen endobronchial tube and double-lung ventilation, the visual field through such a thin scope was usually shaky. This impairment in vision was caused by the scope being in contact with the ventilated lung. When a rigid, thick scope 10 mm in diameter was placed, the shaking of visual field could be minimized. However, in needlescopic surgery, a long, thin scope was always used and strong mechanical power to the needlescope had to be avoided. Therefore, we advocated that the patients be seated upright and have enough forced pneumothorax to avoid contact of the needlescope with the lung as much as possible. Of course, ventilation on the side of the operation should be stopped. Thus, we use 1-lung ventilation anesthesia. In our experience with more than 1000 patients, there have been no operative accidents and no damage to the needlescope or the scope guides.

To address your third comment regarding rib counting, endoscopic sympathectomy navigated by anatomic landmarks was thought uncertain and risky. We often find the landmarks that you pointed out to be helpful. However, we believe that fluoroscopic determination including intraoperative chest radiography is necessary because of occasional variations of anatomic landmarks as a result of pneumopleural adhesions, severe dense fatty pads, cervical ribs, and aberrant veins. Furthermore, Horner syndrome has been reported to be one of the annoying complications of thoracic sympathectomy and sympathicotomy. Unfortunately, there are no effective treatments for this syndrome. Generally speaking, resection of the sympathetic trunk on the first rib results in Horner syndrome. When Horner syndrome develops postoperatively, the patients want to examine the operative record and intraoperative findings to ensure that correct procedures were followed, including rib counting. In the treatment of palmar hyperhidrosis, you pointed out a risk of Horner syndrome. We have not had this complication after more than 1152 operations. Included in our series were 5 patients who had cervical ribs and 9 in whom the number of ribs was misjudged. We believe that fluoroscopic confirmation (video recording or intraoperative radiograph) of rib counting revealed anatomic variation and prevented mistakes. Fluoroscopic evidence is necessary for identifying the intraoperative anatomic landmarks and the number of ribs.

12/8/115417

doi:10.1067/mtc.2001.115417

References

1. Yamamoto H, Kanehira A, Kawamura M, Okada M, Okita Y. Needlescopic surgery for palmar hyperhidrosis. J Thorac Cardiovasc Surg. 2000;120:276-9.[Abstract/Free Full Text]
   
2. Kao MC. Video endoscopic sympathectomy using a fiberoptic CO₂ laser to treat palmar hyperhidrosis. Neurosurgery. 1992;30:131-5.[Medline]
   

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