THORACOSCOPIC SYMPATHECTOMY FOR BUERGER’S DISEASE: A CASE REPORT
Hrvoje Hochstädter, Miroslav Bekavac Bešlin, Drago DeSyo, August Mijić and Dubravka Žalić
Department of Surgery, Sestre milosrdnice University Hospital, Zagreb, Croatia
SUMMARY – A case is presented of thoracoscopic sympathectomy in a 40-year-old male patient with a diagnosis of Buerger’s disease, who presented with vasospastic symptoms of coldness and pain at rest in his upper extremities, and a syndrome of analgesic overdosage. The patient was scheduled for operation. The operation was assisted by an experienced vascular surgeon. No major complications were observed during the operation. Postoperative recovery of the patient was fast, and he was discharged from the hospital on the second postoperative day, free from vasospastic symptoms and with no analgesia required.
Key words: Thromboangiitis obliterans, surgery; Sympathectomy; methods; Thoracoscopy;
Introduction
Buerger’s disease is a specific, idiopathic, recurrent, segmental, inflammatory obliterative vascular disease involving medium-sized arteries and veins of the limbs1. Upper thoracic sympathectomy has an established role in the treatment of selected patients with hyperhidrosis, causalgia, Raynaud’s disease, long QT syndrome, and Buerger’s disease2. Sympathectomy with the removal of the second thoracic ganglion of the ipsilateral side effectively reduces the sympathetic drive to the hand by removing the preganglionic fibers to the upper extremities and results in relief of vasospastic symptoms, in dryness of the palm and relief of pain and trophic ulcera1-3.
Several open surgery approaches are available. Although the supraclavicular route is commonly used, the abundance of important structures in the root of the neck makes the approach difficult. The posterior approach, although direct, necessitates partial rib resection and is consequently painful4. The transthoracic approach is convenient as it is direct and the access is good, but it requires a thoracotomy. Presently, as open thoracoscopy is being replaced by minimal access video-thoracoscopy techniques, the transthoracic route has attracted even greater popularity than before4,5.
Operative Method
The patient requires general anesthesia with double-lumen endotracheal intubation for single lung ventilation. Positioning of the patient is similar to other types of thoracoscopic procedures, i.e. the full lateral position with the affected side upward.
The video-endoscope port is 10 mm in size and is introduced in the 4th intercostal space in the midaxillary line after prior deflation of the lung. Two 5-mm operating ports are also placed along the anterior axillary line at the 4th and 6th intercostal spaces.
The thoracic view of the inlet of the chest shows the ribs in concentric alignment. The sympathetic chain is identified as a white ’beaded’ cord beneath the parietal pleura and lying over the neck of the ribs.
Each ganglion is represented by a slight dilatation at intervals along the nerve chain. The first thoracic ganglion is usually fused with the lower cervical ganglion to form the stellate ganglion. The second and third thoracic ganglia are fusiform and lie in relation to the neck of the third and fourth ribs, respectively.
The sympathetic chain lies underneath the parietal pleura and may not be distinct video-endoscopically until the pleura has been incised and dissected off to expose the nerve trunk. The individual ganglia should be clearly identified to avoid injury to the lower cervical/first thoracic (stellate) ganglion, which will result in an ipsilateral Horner’s syndrome. The upper resection margin of the second thoracic ganglion should not extend above the lower border of the second rib if injury to the stellate ganglion is to be avoided. Division of the overlying pleura in the line of the sympathetic trunk allows the ganglion to be easily approached. The second thoracic ganglion is freed by dissection, and ablative surgery can be completed by either electrocautery or complete excision of the whole ganglion. The sympathetic chain is divided twice, once below the first thoracic ganglion, just above the upper border of the third rib, with laparoscopic hook scissors or microscissors. The second thoracic ganglion is then completely removed for histologic examination.
Postdivision of the ganglion results in a rise of blood flow to the hand. A cutaneous temperature probe can be used to show changes in skin temperature following sympathectomy.
A chest drain is inserted through the 10-mm port at the end of the lung reinflation.
Results
The patient, a 40-year-old man with a diagnosis of Buerger’s disease, presented with vasospastic symptoms of coldness and pain at rest in both of his arms. The patient had been operated on by lumbar sympathectomy using an open method at another hospital.
Now, the patient suffered from heavy analgesic overdosing and trophic ulcers of the fingers, resistant to conservative therapy. He was scheduled for thoracoscopic sympathectomy, in consultation with an experienced vascular surgeon. Bilateral thoracoscopic sympathectomy was performed as described above.
During the operation, no major complications occurred. Postoperative recovery of the patient was quite fast. A minor subcutaneous emphysema resorbed on the second day postoperatively, when the patient was discharged from the hospital. Vasospastic symptoms disappeared, and the patient required no analgesic therapy anymore. Outpatient follow-up showed rapid disappearance of the trophic ulcers and restoration of the skin continuity.
Discussion
Thoracoscopic sympathectomy is an easy to perform and safe method in comparison with open surgery thoracotomy. It enables fast recovery and short hospitalization of the patient. Thoracoscopic sympathectomy points to a potential of further improvement in the surgical treatment for Buerger’s disease.
Correspondence to: Hrvoje Hochstädter, M.D., Department of Surgery, Sestre milosrdnice University Hospital, Vinogradska c. 29, HR-10000 Zagreb, Croatia
Received November 11, 1999, accepted March 2, 2000
References
1. HARDY JD. Hardy’s textbook of surgery. Philadelphia: JB Lippincott Company, 1983:845-8.
2. ISHIBASHI H, HAYAKAWA N. Thoracoscopic sympathectomy for Buerger’s disease: a report on the successful treatment of four patients. Surg Today 1995;25:180-3.
3. KOMORI K, KAWASAKI K, OKAZAKI J. Thoracoscopic sympathectomy for Buerger’s disease of the upper extremities. J Vasc Surg 1995;22:344-6.
4. MACK P. Manual of basic operative laparoscopic and thoracoscopic surgery. Singapore Forces Publications, 1993.
5. WATFANASIRICHAIGOON S, KATKHOUDA N, NGAORUNSGARI U. Totally extraperitoneal laparoscopic lumbar sympathectomy. End Surgery 1994;12:122-5.
Sažetak
TORAKOSKOPSKA SIMPATEKTOMIJA KOD BUERGEROVE BOLESTI: PRIKAZ BOLESNIKA
H. Hochstädter, M. Bekavac Bešlin, D. DeSyo, A. Mijić i D. Žalić
Prikazan je slučaj torakoskopske simpatektomije u 40-godišnjeg bolesnika s dijagnozom Buergerove bolesti sa simptomima hladnoće ruku i bolova u mirovanju, kao i predoziranosti analgeticima. Bolesnik je određen za operacijsko liječenje, koje je izvedeno uz asistenciju iskusnog vaskularnog kirurga. Za vrijeme operacije nije bilo većih komplikacija. Poslijeoperacijski oporavak bio je brz i bolesnik je otpušten iz bolnice drugoga dana nakon operacije, uz nestanak vazospastičnih simptoma i bez potrebe za analgeticima.
Ključne riječi: Tromboangiitis obliterans, operacija; Simpatektomija, metode; Torakoskopija