New method
Experimental endoscopy
Feasibility of endoscopic transesophageal thoracic sympathectomy (with video)

https://doi.org/10.1016/j.gie.2009.07.016Get rights and content

Background

Thoracoscopic sympathectomy is the preferred surgical treatment for patients with disabling palmar hyperhidrosis. Current methods require a transthoracic approach to permit ablation of the thoracic sympathetic chain.

Objective

To develop a minimally invasive, transesophageal endoscopic technique for a sympathectomy in a swine model.

Design

Nonsurvival animal study.

Setting

Animal trial at a tertiary care academic center.

Subjects

This study involved 8 healthy Yorkshire swine.

Interventions

After insertion of a double-channel gastroscope, a Duette Band mucosectomy device was used to create a small esophageal mucosal defect. A short, 5-cm submucosal tunnel was created by using the tip of the endoscope and biopsy forceps. Within the submucosal space, a needle-knife was used to incise the muscular esophageal wall and permit entry into the mediastinum and chest. The sympathetic chain was identified at the desired thoracic level and was ablated or transected. The animals were killed at the completion of the procedure.

Main Outcome Measurements

Feasibility of endoscopic transesophageal thoracic sympathectomy.

Results

The sympathetic chain was successfully ablated in 7 of 8 swine, as confirmed by gross surgical pathology and histology. In 1 swine, muscle fibers were inadvertently transected. On average, the procedure took 61.4 ± 24.5 minutes to gain access to the chest, whereas the sympathectomy was performed in less than 3 minutes in all cases. One animal was killed immediately after sympathectomy, before the completion of the observation period, because of hemodynamic instability.

Limitations

Nonsurvival series, animal study.

Conclusions

Endoscopic transesophageal thoracic sympathectomy is technically feasible, simple, and can be performed in a porcine model.

Section snippets

Materials and methods

This study was approved by the subcommittee for research animal care at the Massachusetts General Hospital, Boston, MA. The aim of the study was to assess the technical feasibility of peroral transesophageal sympathectomy in a nonsurvival animal model. The 8 fasted Yorkshire swine underwent general anesthesia with induction by Telazol 4.4 mg/kg intramuscular (A.H. Robins, Richmond, VA) plus xylazine 2.2 mg/kg intramuscular and endotracheal intubation. Anesthesia was maintained with isoflurane

Results

Transesophageal NOTES access to the mediastinum and chest cavity was successfully performed in all swine (mean weight 45.3 ± 5 lb). There were no complications during mucosectomy, creation of the submucosal tunnel, or entrance into the mediastinum. A colonoscope was used in 2 swine to perform a sympathectomy at the higher T2 level. Later, it was discovered that a standard 2-channel gastroscope provided adequate maneuverability and length to reach target sites. Sympathectomy was performed in 7 of

Discussion

This study reports the first use of transesophageal NOTES access to perform thoracic sympathectomy and demonstrates technical feasibility of the transesophageal approach. We were able to successfully visualize and identify the appropriate thoracic level in all animals and performed sympathectomy at the desired location in 7 out of 8 swine. In our early experience with the procedure, the sympathetic chain was difficult to identify, and muscle fibers were transected in lieu of ganglia. Even in

Acknowledgment

We thank Cook Medical, Inc, for their generous donation of supplies.

References (9)

There are more references available in the full text version of this article.

Cited by (18)

  • The History of Sympathetic Surgery

    2016, Thoracic Surgery Clinics
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    However, the instigators of this technique have been using it in humans56 with apparent success.57 A second access was examined by the NOTES (natural orifice translumenal endoscopic surgery) principle in an animal study using the transesophageal route.58 The investigators succeeded in performing a bilateral thoracic sympathetic ablation by this technique, proving the feasibility of the method.

  • One-year follow-up period after transumbilical thoracic sympathectomy for hyperhidrosis: Outcomes and consequences

    2014, Journal of Thoracic and Cardiovascular Surgery
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    The main explanation for these problems was the trauma to the intercostal nerve when the trocars were introduced into the pleural cavity. To find surgical procedures that avoid chest incisions and reduce the number of ports, Turner et al9 and Yang et al10 conducted an animal study using the technique of NOTES to perform endoscopic thoracic sympathetic trunk resection via the esophagus or oral vestibular incision. Despite the substantial work in the NOTES field, it is clear that there is a long way to go from the present animal experiments to clinical practice.

  • A novel approach to treat women patients with palmar hyperhidrosis: Transumbilical thoracic sympathectomy with an ultrathin gastroscope

    2013, Annals of Thoracic Surgery
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    There is a trend of growing application of flexible endoscopic surgery in thoracic practice, such as peroral endoscopic myotomy and endoscopic submucosal dissection [11–13]. Turner and colleagues [14] used a flexible endoscope to conduct transesophageal thoracic sympathectomy in animal models; however, this method was technically demanding, which precluded its widespread application to patients. By drawing on flexible endoscopic surgery, we developed a novel surgical technique for performance of sympathectomy by natural orifices transumbilical surgery in women patients without thoracotomy.

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DISCLOSURE: This project was fundedby the Center for Integration of Medicine and Innovative Technology. Dr Brugge disclosed a consultant relationship with Boston Scientific. All other authors disclosed no other financial relationships relevant to this publication.

The video from this article was presented at the 4th International NOSCAR Conference on NOTES, July [9-11], 2009, Boston, MA.

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