Long-term pulmonary function after thoracic sympathectomy

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Long-term pulmonary function after thoracic sympathectomy
   2005;129:1379-1382  J Thorac Cardiovasc Surg Navarro Rodríguez Suárez, Gregorio Pérez Peñate, Jordi Freixinet Gilart and Pedro Cabrera Miguel A. Ponce González, Gabriel Julià Serdà, Norberto Santana Rodríguez, Pedro  Long-term pulmonary function after thoracic sympathectomy  http://jtcs.ctsnetjournals.org/cgi/content/full/129/6/1379located on the World Wide Web at: The online version of this article, along with updated information and services, is 2005 American Association for Thoracic Surgery Association for Thoracic Surgery and the Western Thoracic Surgical Association. Copyright © is the official publication of the American The Journal of Thoracic and Cardiovascular Surgery  on June 11, 2013  jtcs.ctsnetjournals.orgDownloaded from  Long-term pulmonary function after thoracicsympathectomy Miguel A. Ponce González, MD, a Gabriel Julià Serdà, MD, a Norberto Santana Rodríguez, MD, b Pedro Rodríguez Suárez, MD, b Gregorio Pérez Peñate, MD, a Jordi Freixinet Gilart, MD, b andPedro Cabrera Navarro, MD a Background:  The purpose of this study was to evaluate the long-term and midtermeffects of thoracic sympathectomy on pulmonary function and to assess the influ-ence of the sympathetic nervous system on bronchomotor tone. Methods:  Thirty-seven consecutive patients were diagnosed with primary hyperhi-drosis requiring thoracic sympathectomy and were included in this study. Spirom-etry and methacholine challenge testing were performed before and 3 months aftersurgery. To assess the long-term effects of the intervention, another spirometricstudy was performed 1 year later. Results:  Spirometry 3 months after surgery showed a significant decrease in theforced vital capacity (  5.2%), the forced expiratory volume in the first second(  6.1%), and the forced expiratory flow between 25% and 75% of vital capacity(  5.1%). Whereas methacholine challenge testing before surgery was positive in 3subjects (2 of whom were asthmatic), it was positive in 6 patients after theprocedure; differences were not statistically significant. After 12 months, forcedvital capacity started recovering, and forced expiratory volume in the first secondand forced expiratory flow rate 25% to 75% showed a sustained and significantreduction (  2.8% and  11.2%, respectively); however, patients remained asymp-tomatic. Conclusions:  We conclude that thoracic sympathectomy generates a mild, althoughsignificant, impairment of the bronchomotor tone, with no clinical consequences.These results suggest that the sympathetic nervous system is involved in pulmonarybronchomotor tone. P rimary hyperhidrosis is characterized by excessive idiopathic eccrine sweat-ing. It stems from a dysfunction of the autonomic nervous system that ismediated by cholinergic sympathetic fibers. 1 It most frequently affects theupper limbs (palmar and axillary zones). The definitive treatment of hyperhidrosisis the complete excision, or the ablation with electrocautery or laser, of the T2 andT3 sympathetic ganglia in palmar forms, with the additional excision of the T4ganglion in axillary forms. Video-assisted endoscopic thoracic sympathectomy (TS)was first described by Kux 2 in 1954, and its further development in the 1990s madeit suitable as the treatment of choice for primary hyperhidrosis, given the goodresults and the minimal morbidity and mortality associated with the procedure. 3 The sympathetic trunks are 2 ganglionic nervous cords comprising severalsegments: cervical, thoracic, abdominal, and pelvic. The pulmonary sympatheticinnervation derives mainly from the thoracic sympathetic chain (T2 to T8), but thereare also fascicles from the cervical sympathetic chain (cervicothoracic branches),the stellate ganglion, and the cardiac plexus and fibers from intercostal nerves 4 From the Departments of Pulmonary Medi-cine a and Thoracic Surgery, b Hospital Uni-versitario de Gran Canaria Dr Negrín, LasPalmas de Gran Canaria, Spain.Received for publication July 3, 2004; ac-cepted for publication Aug 23, 2004.Address for reprints: Miguel A. PonceGonzález, MD, Department of PulmonaryMedicine, Hospital Universitario de GranCanaria Dr Negrín, C/ Barranco de la Bal-lena s/n, 35020, Las Palmas de Gran Cana-ria, Spain (E-mail: migp@arrakis.es).J Thorac Cardiovasc Surg 2005;129:1379-820022-5223/$30.00Copyright © 2005 by The American Asso-ciation for Thoracic Surgerydoi:10.1016/j.jtcvs.2004.08.026 Ponce González et al Cardiopulmonary Support and Physiology The Journal of Thoracic and Cardiovascular Surgery  ● Volume 129, Number 6 1379         C        S        P  on June 11, 2013  jtcs.ctsnetjournals.orgDownloaded from  (Figure 1). Therefore, the TS procedure leads to a partialsympathetic pulmonary denervation. 5 The parasympathetic nervous system (PNS) regulatesthe bronchomotor tone through the vagus nerve and isinvolved in other functions, such as glandular secretion.However, the role of the PNS in bronchomotor tone is notfully understood. It is generally accepted that bron-chomotor tone in humans is not controlled by sympa-thetic nervous system (SNS) innervation but by circulat-ing mediators and membrane receptors. 6 Some authorsconsider that the SNS helps to modulate the bronchomo-tor tone, which exhibits a cholinergic preponderance,particularly in conditions with increased tone, such asbronchial asthma. 7 Moreover, sympathetic innervation isless abundant and comprises smaller fascicles than para-sympathetic innervation. 4,7 However, some studies showthat sympathetic innervation reaches even the distal area,because amyelinic sympathetic nervous fibers have beendetected within bronchiolar smooth muscle and alveolarducts. 8 This has been confirmed by electron microscopy,which provided evidence for the presence of adrenergicnerves in the lower respiratory tract. 9 Taking advantage of the partial sympathetic denervation,we studied the effects of TS on pulmonary function anddetermined whether a sympathetic/parasympathetic imbal-ance could contribute to impairment of the bronchomotortone. Patients and Methods Patients The sample included 37 consecutive patients with primary hyper-hidrosis unresponsive to conservative treatment and for whom theindication of surgical treatment by video-assisted thoracoscopicsympathectomy was ultimately established. The study protocolwas approved by the ethics committee at our institution. Pulmonary Function Tests Forced spirometry was performed before and 3 months after sur-gery in all patients. Thirty-two patients had a new spirometry test1 year after the TS. The same spirometer was used throughout thestudy (Master Screen; Jaeger, Wuerzburg, Germany), and theAmerican Thoracic Society guidelines for spirometry were fol-lowed. 10 Recorded parameters were forced vital capacity (FVC),forced expiratory volume in the first second (FEV 1 ), peak expira-tory flow (PEF), and forced expiratory flow during the middle half of FVC (FEF 25%-75%). A methacholine challenge test was alsoperformed before and 3 months after surgery, according to theAmerican Thoracic Society standards. 11 This was methacholinetesting with a dosimeter inhalation protocol (Jaeger). The teststarted with the administration of saline followed by increasingconcentrations of methacholine (0.195, 0.39, 1.56, 6.25, 12.5, and25 mg/mL). Thirty and ninety seconds after the last inhalation,flow-volume curves were obtained to calculate FEV 1 . The test wasconsidered positive when an equal or greater than 20% decrease inpostinhalation FEV 1  was observed and the PC 20  (provocativemethacholine concentration causing a 20% decrease in FEV 1  frombaseline) was established. Video-Assisted Thoracoscopic Sympathectomy Video-assisted thoracoscopic sympathectomy was performed un-der general anesthesia with selective bronchial intubation with adouble-lumen endotracheal tube. The patient was placed in supineposition with both arms in abduction. Two incisions of 5 and 11.5mm were made 3 cm apart on the medial and anterior axillarylines, respectively. The sympathetic chain was electrocoagulatedwith a video-endoscope and an endodissector between T2 and T3for palmar hyperhidrosis, T3 and T4 for axillary hyperhidrosis, andT2 and T4 for palmar and axillary hyperhidrosis. A pleural drainwas inserted and removed after lung expansion in the operatingroom. The patient was transferred to a recovery room, where achest radiograph was obtained to verify complete lung expansion. Statistical Analyses The pulmonary function data are expressed as mean and SD.Comparisons between the methacholine challenge testing resultsbefore and after TS were performed by a    2 test. A paired Student t   test was performed to compare the pulmonary function data of the37 patients before and 3 months after surgery. Finally, the analysisof variance test for repeated measures was applied to analyze the Figure 1. Diagram of pulmonary innervation derived from thecervicothoracic sympathetic chain.Cardiopulmonary Support and Physiology Ponce González et al 1380 The Journal of Thoracic and Cardiovascular Surgery  ● June 2005  C   S  P    on June 11, 2013  jtcs.ctsnetjournals.orgDownloaded from  pulmonary function data obtained from the 32 patients 12 monthsafter surgery. The Bonferroni test was used as a post hoc test. Results The study population consisted of 28 female and 9 malepatients with a mean age of 22.5 years (range, 15-50 years).Two patients had asthma but were asymptomatic and re-quired no bronchodilators. None of the patients was takingany medication with cardiopulmonary effects, and none of them was a smoker. No other patients, besides the 2 withasthma, had any respiratory disease.After TS, all patients fully recovered from hyperhidrosis,which confirmed the interruption of the sympathetic chainand the resulting partial pulmonary denervation. There wereno respiratory complications except for a pneumothorax in1 patient. Spirometric parameters before surgery werewithin the normal range (Table 1).The methacholine challenge testing result was positive in3 patients, 2 of whom were known to have asthma. In thethird patient, the result was considered a false positive,because he had recently had a flulike syndrome.Three months after the surgery, significant reductions inFVC (0.193  0.273 L;  5.2%), FEV 1  (0.150  0.212 L;  6.1%), and FEF 25% to 75% (0.170  0.458 L/s;  5.1%)were observed (Table 1). The PEF did not show significantdifferences. Regarding the respiratory system, the patientsremained totally asymptomatic. The methacholine chal-lenge testing 3 months after surgery was positive in 6patients (2 of whom were known to have asthma). Theestimated PC 20  for the 4 patients was always higher than 2mg (2.599, 2.343, 2.855, and 2.510 mg). The observeddifferences were not statistically significant.In 32 of the 37 patients who started the study, controlspirometry was performed 12 months after surgery. Theresults showed a slight recovery in FVC (3.99    0.70 L;  1.5%), which seemed to be nonsignificant. Significantreductions in FEV 1  (3.43  0.64 L;  2.8%) and FEF 25%to 75% (3.59    1.15 L/s;   11.2%) were observed, com-pared with the values obtained 3 months after TS. Onceagain, the differences in PEF were not statistically signifi-cant (Table 2). Patients remained asymptomatic 12 monthsafter TS. Discussion Studies describing impairment of pulmonary function afterTS are scarce. Such studies have evaluated short-term andmidterm pulmonary function changes (1, 3, and 6 monthsafter TS). 5,12-14 This study aimed to confirm the few exist-ing data on pulmonary function after TS and to assess thepotential effects of this procedure on bronchial reactivity.We studied patients 1 year after surgery to provide new datafrom which conclusions were drawn regarding the role of SNS in respiratory physiology and to test whether TS is asafe technique devoid of long-term risks.The first 2 studies on pulmonary function after TS werepublished by Molho and colleagues 12,13 in the 1970s and1980s. They performed and compared sympathectomy withthoracotomy through either the supraclavicular or thetransaxillary approach and observed a reduction in pulmo-nary volumes and flows at 3 weeks and 3 and 6 months aftersurgery. The surgical technique may have partially contrib-uted to this decrease, as demonstrated by Furrer and asso-ciates, 15 who found that pulmonary function became closeto normal 4 months after surgery. Therefore, the observedreduction can be ascribed, at least in part, to thoracotomy,which causes a restrictive pattern in pulmonary functiontests. 15 However, the persistence of low volumes and flows6 months after surgery also suggests an impairment of thebronchomotor tone, as demonstrated in our study.Tseng and Tseng 14 and Noppen and Vincken 5 conductedstudies in which TS was performed with video-assistedendoscopy. The first study showed a reduction in FEV 1 (  6.1%), FVC (  2.3%), and FEF 75% (  8%) 1 monthafter the procedure. Even for minimally invasive operations,the postsurgical period allowed was excessively short, and TABLE 1. Changes in pulmonary function 3 months aftersurgery VariableBefore TS(mean  SD)3 mo after TS(mean  SD)  P   value FVC (L) 4.21  0.81 4.01  0.77   .05FVC (%) 107  11.7 101.8  9.6   .05FEV 1  (L) 3.72  0.68 3.57  0.66   .05FEV 1  (%) 111.1  13.4 105  11.7   .05FEF 25-75  (L/s) 4.18  1.08 4.01  1.1   .05FEF 25-75  (%) 103.4  25.3 98.3  28.7   .05PEF (L) 8.23  2.03 8.55  2.09 .11 TS,  Thoracic sympathectomy;  FVC,  forced vital capacity;  FEV  1 ,  forcedexpiratory volume in the first second;  FEF  25-75  ,  forced expiratory flow during the middle half of FVC;  PEF,  peak expiratory flow. TABLE 2. Changes in pulmonary function 3 and 12 monthsafter surgery VariableBefore TS(mean  SD)3 mo after TS(mean  SD)12 mo after TS(mean  SD) FVC (L) 4.12  0.75 3.96  0.73* 3.99  0.70FVC (%) 105.4  11.61 101.4  10* 102.9  13FEV 1  (L) 3.65  0.67 3.52  0.67* 3.43  0.64*FEV 1  (%) 109.9  13.4 105.2  12.4* 102.4  16.7*FEF 25-75  (L/s) 4.17  1.13 4.02  1.22 3.59  1.15*FEF 25-75  (%) 102.3  28.2 99  28.4 87.8  30.1*PEF (L) 8.07  2.06 8.49  2.14 7.68  1.59 TS,  Thoracic sympathectomy;  FVC,  forced vital capacity;  FEV  1 ,  forcedexpiratory volume in the first second;  FEF  25-75  ,  forced expiratory flow during the middle half of FVC;  PEF,  peak expiratory flow.  * P   .05 compared withpre-TS values. Ponce González et al Cardiopulmonary Support and Physiology The Journal of Thoracic and Cardiovascular Surgery  ● Volume 129, Number 6 1381         C        S        P  on June 11, 2013  jtcs.ctsnetjournals.orgDownloaded from  this left open the possibility that changes were directlyrelated to the surgical technique. In the second study, pul-monary function tests performed 3 months after the proce-dure revealed a significant reduction in FEV 1  (  2.8%),FVC (  1.9%), and FEF 75% (  6.5%). These values per-sisted 6 months later in the case of FEV 1  (  3%) and FEF75% (  8.6%), whereas FVC showed an initial recovery.Our data on FEV 1  and midexpiratory flows confirmed the3-month postoperative findings from Noppen and Vincken. 5 Moreover, we observed a sustained and significant decreasein FEV 1  and FEF 25% to 75% 12 months after the surgicalintervention. We consider that a postoperative period of 1year is long enough to determine whether TS can generatebronchomotor tone disturbances independently of the sur-gical trauma itself. A reduction in FVC after 3 months couldbe due to restrictive constraints imposed by the surgicaltechnique, because this parameter recovered by 12 months,whereas the reductions in FEV 1  and FEF 25% to 75%remained. 15 The finding that FVC returned to a preoperativerange, together with a persistent reduction in FEV 1  and FEF25% to 75%, indicates that partial sympathetic denervationis responsible for the long-term increased bronchomotortone. Such changes, although significant, are small andclinically irrelevant. None of the 32 patients had respiratorysymptoms. They all had adequate exercise tolerance andgood general conditions. Together, these results allow us toconclude that TS is a safe exploratory procedure that isdevoid of long-term secondary respiratory effects.With the aim of assessing SNS/PNS balance, we alsoperformed methacholine challenge testing in the patientswho underwent TS. Our starting hypothesis was that sym-pathetic denervation would cause an increase in cholinergictone, so we could expect a significant number of positiveresults 3 months after surgery. However, the differencesobserved were not significant. This result is consistent withthe less abundant and smaller fascicles of sympathetic in-nervation compared with parasympathetic innervation. 4,7 Also, TS generates partial sympathetic denervation withsome remaining cervicothoracic branches, with the capacityto innervate the bronchial tree. 4 Alternatively, methacholinecould stimulate cholinergic receptors and induce a PNS-mediated bronchial constriction. In this way, methacholinechallenge testing evaluates the role of PNS on the airways,which is theoretically normal in patients subjected to TS.Among our patients, there were 2 known to have asthma instable condition that did not require continuous medication.In these patients, the methacholine testing was positivebefore and after TS; during follow-up, they experiencedneither particular respiratory symptoms nor the need forrescue bronchodilators, which would suggest a worseningof their background condition. Among the patients studied,3 with a prior negative methacholine challenge test had apositive result after surgery. We have no clear explanationfor this observation; the patients were asymptomatic, andtheir PC 20  values were high—close to the maximal doseestablishing the test as positive 11 —suggesting that thesevalues could lay within the variability range attributable tothe test. 16 The results from our research enabled us to conclude thatTS is a safe technique in the long term, because the reduc-tion of volumes and flows is minimal and clinically irrele-vant. We also demonstrated that SNS is involved in pulmo-nary bronchomotor tone, at least in patients with primaryhyperhidrosis. The evidence for this is the sustained andsignificant long-term decrease in FEV 1  and FEF 25% to75%. To our knowledge, this is the first report in theliterature assessing long-term effects of TS on pulmonaryfunction 1 year after surgery. References 1. Shih CJ, Wu JJ, Lin MT. Autonomic dysfunction in palmar hyperhi-drosis.  J Auton Nerv Syst.  1983;8:33-43.2. Kux E. Thorakoskopische Eingriffe am Nervensystem. Stuttgart:Georg Thieme Verlag; 1954.3. Neelan D, Shannon H, Mary W, Lynne H, Syma P, Meyer DM, et al.Thoracoscopic sympathectomy for hyperhidrosis: indications and re-sults.  Ann Thorac Surg.  2004;77:410-4.4. Lazorthes G. Cadena simpática laterovertebral. In: Lazorthes G, editor.Descripción, sistematización y exploración del sistema nervioso au-tónomo. Capítulo XXIV, Barcelona: Toray-Mason; 1976. p. 325-57.5. Noppen M, Vincken W. Thoracoscopic sympathicolysis for essentialhyperhidrosis: effects on pulmonary function.  Eur Respir J.  1996;9:1660-4.6. Richardson J, Beland J. Non adrenergic inhibitory nervous system inhuman airways.  J Appl Physiol.  1976;41:764-71.7. Barnes PJ. Neural control of human airways in health and disease.  Am Rev Respir Dis.  1986;134:1289-314.8. Testud L. Pulmones: vasos y nervios a nivel de lobulillos pulmonares.In: Testud L, Latarjet A, editors. Tratado de anatomía humana. Tomo3, volume III, 9th ed. Barcelona: Salvat; 1988. p. 995-1002.9. Laitinen A, Partanen M, Hervonen A. Electron microscopy study onthe innervation of the human lower respiratory tract: evidence of adrenergic nerves.  Eur J Respir Dis.  1985;67:208-15.10. Standardization of spirometry, 1994 update. American Thoracic Soci-ety.  Am J Respir Crit Care Med  . 1995;152:1107-36.11. Crapo RO, Casaburi R, Coates AL, Enright PL, Hankinson JL, IrvinCG, et al. Guidelines for methacholine and exercise challenge test-ing—1999. This official statement of the American Thoracic Societywas adopted by the ATS Board of Directors, July 1999.  Am J Respir Crit Care Med.  2000;161:309-29.12. Molho M, Kurchin A, Ohry A, Bass A, Adar R. Pulmonary functionalabnormalities after upper dorsal sympathectomy.  Am Rev Respir Dis. 1977;116:879-83.13. Molho M, Shemesh E, Gordon D, Adar R. Pulmonary functional abnor-malities after upper dorsal sympathectomy.  Chest.  1980;77:651-5.14. Tseng MY, Tseng JH. Thoracoscopic sympathectomy for palmar hy-perhidrosis: effects on pulmonary function.  J Clin Neurosci.  2001;8:539-41.15. Furrer M, Rechsteiner R, Eigenmann V, Signer C, Althaus U, Ris H.Thoracotomy and thoracoscopy: postoperative pulmonary function,pain and chest wall complaints.  Eur J Cardiothorac Surg.  1997;12:82-7.16. Balzano G, Delli Carri I, Gallo C, Cocco G, Melillo G. Intrasubjectbetween-day variability of PD20 methacholine assessed by the dosim-eter inhalation test.  Chest.  1989;95:1239-43. Cardiopulmonary Support and Physiology Ponce González et al 1382 The Journal of Thoracic and Cardiovascular Surgery  ● June 2005  C   S  P    on June 11, 2013  jtcs.ctsnetjournals.orgDownloaded from
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