UPPER LIMB SYMP ATHECTOMY IN CURRENT SURGICAL PRACTICE by Bhugwan Singh Submitted in fulfilmentof the requirements for the degree of DOCTOR OF MEDICINE in the Department of Surgery Nelson R Mandela School of Medicine University of Natal 2002 ii <fomy wifeJfmeeta, aaueliterJuli� son !Nikjiaifet, my teacliers iii ABSTRACT Operations on the sympathetic chain have had a long and colourful history and were often considered for a disparate group of medical conditions. Currently recognised indications for sympathectomy are hyperhidrosis and Chronic Regional Pain Syndrome (CRPS). The role of sympathectomy for non-reconstructible peripheral vascular disease PVD) and Raynaud's disease not responding to medical treatment is controversial. Presently, the perceived benefits and wide availability of thorascoscopic sympathectomy has resulted in large numbers of this procedure being undertaken. A greater understanding of the anatomy relevant to upper limb sympathectomy is appropriate given the confusing and complex arrangement of the proximal sympathetic chain. Instances of unsuccessful sympathectomy have often been attributed to the anatomical arrangement of the sympathetic chain. The pathogenesis of conditions treated by sympathectomy is unknown; the possible aetiology of these conditions may be gleaned from the histopathological changes occurring in ganglia frompatients treated successfully. Aims This study has 3 components 1. Clinical • a review of the clinical experience, including a comparison of the supraclavicular and thoracoscopic approaches and evaluating the extent of sympathetic ganglionectomy. • anaesthetic considerations, evaluating the role of a single-lumen endotracheal tube. • defining the role and timing of sympathectomy for CRPS 2. Anatomical • to define the surgical anatomy appropriate to a safe and effective upper limb sympathectomy • to evaluate a modifiedanterior approach for stellate ganglion blockade (SGB) 3. Pathological • to evaluate the possibility of excised ganglia harbouring an inflammatory process using immunohistochemical techniques. iv Outcome I. Clinical In 498 patients, a total of939 sympathectomies were undertaken for hyperhidrosis (n=884), CRPS (n=43), Raynaud's disease (n=9) and non-reconstructable peripheral vascular disease (n= 3). When compared to the supra-clavicular approach, the thoracoscopic approach was shown to be superior in terms of safety, technical demand and cost. A limited 2 nd thoracic ganglionectomy was effective for palmar hyperhidrosis (100% and in associated axillary hyperhidrosis [8 1.2%] and plantar hyperhidrosis [53%]). A compensatory hyperhidrosis rate of 12 .6% was noted. The single lumen endotracheal tube was found to be as effective but safer than the double lumen endotracheal tube. When undertaken early (within 3 months), the outcome to sympathectomy for CRPS was excellent 2. Anatomical A total of41 proximal sympathetic chains were evaluated. Three categories of alternateneural pathways to the upper limb were defined (total incidence 90.5%). When correlated with the clinical outcome to a limited 2 nd thoracic ganglionectomy, it is suggested that these alternateneural pathways are of no clinical significance. The modified anterior SGB was always effective in blockade of the clinically significant 2 nd thoracic ganglion. 3. Pathological There is strong evidence for an autoimmune hypothesis in both primary hyperhidrosis as well as CRPS. The mechanisms responsible forthe development of the symptoms in these conditions appear to be different. V DECLARATION This study represents original work by the author and has not been submitted in any form to another University. Where use was made of the work of others, it has been duly acknowledged in the text B. SINGH vi SUPPORTING SERVICES In this research surgical procedures were undertaken in the Durban Metropolitan Hospitals; the anatomical evaluations and interpretations were done with the support of the Department of Anatomy, University of Durban-Westville; the immunohistochemical analysis of the sympathetic ganglia was undertaken with the support of the Department of Anatomical Pathology, University of Natal vii PREFACE It is 110 years since the first operation on the sympathetic chain was undertaken (Alexander, 1890). The evolution of this practice has been associated with the search for the appropriate indications and a rational and safesurgical technique. The anatomy - varied and confusing at best - has long been held responsible for instances of unsuccessful sympathectomy; however, current techniques for sympathectomy are consistently successful. A re-appraisal of the relevant anatomy and the pathology of conditions successfullytreated by sympathectomy is thereforetimeous. viii PUBLICATIONS AND SCIENTIFIC PRESENTATIONS The author is indebted to his co-workersfor their contributions to the following publications and scientific presentations JOURNAL PUBLICATIONS I. Singh B, Haffejee AA, Moodley J, Naidu AG, Rajaruthnam P. Thoracoscopic Sympathectomy. The Durban experience. SAJS 1996;34: 11-17. 2. Singh B, Moodley, Haffejee AA et al. Resympathectomy for sympathetic regeneration. Surg Lap Endosc 1998; 8: 257-260. 3. Singh B, Moodley J, Haffejee AA. The current status of sympathectomy in general surgery. Hospital Supplies May 1999; 3-11 4. Ramsaroop L, Singh B, Partab P, Satyapal KS. Thoracic origin of the sympathetic supply to the brachial plexus : the 'nerve of Kuntz' revisited. J Anat. 2001; 199 : 675-682 5. Singh B, Moodley J, Ramdial PK, Ramsaroop L, Satyapal KS. Pitfalls in thoracoscopic sympathectomy : Mechanisms for failure. Surg Laparosc Endosc Percutan Tech. 200 I; 11 (6) : 364-367 6. Singh B, Moodley J, Ramdial PK, Shaik AS. Prospective evaluation of limited thoracoscopic ganglionectomy. SA J Surg. 2002; 40(2): 50-53 7. Singh B, Moodley J, Shaik A, Robbs JV. Sympathectomy for Chronic Regional Pain Syndrome in the upper extremity Journal of Vascular Surgery(in press # 2020586 ) MANUSCRIPTS SUBMITTED I. A thoracoscopic view of the nerve of Kuntz. Ramsaroop L, Singh B, Pather N, Partab P, Satyapal KS 2. Thoracoscopy : a new anatomy. KS Satyapal, B Singh, P Partab, L Ramsaroop, N Pather ix SCIENTIFIC NATIONAL AND INTERNATIONAL CONFERENCE PRESENTATIONS 1994 Thoracoscopic sympathectomy Singh B, Moodley J, Naidu AG SASES Meeting, August, 1994 1995 Open vsthoracoscopic sympathectomy Singh B, Moodley J South AfricanSociety of Endoscopic Surgeons Meeting, 1995 lnsufflation vs desufflationin thoracoscopic sympathectomy Singh B, Moodley J and Bosenberg AT South AfricanSociety of Endoscopic SurgeonsMeeting, 1995 Anatomy Alive, Current approach to cervical sympathectomy. Singh B University ofDurban Westville, 1995 1996 Role of sympathectomy Singh B, Shaik AS, Moodley J, Abdool Carrim A TO, Rubin J.Durban Pain Symposium, 1996 Early Sympathectomy for CRPS Singh B, Shaik AS, Moodley J, Abdool Carrim ATO, Rubin J FacultyResearch Day (UND) Association ofSurgeons, 1996 Early Sympathectomy forCRPS Singh B, Shaik AS, Moodley J, abdool Carrim A TO, Rubin J Surgical Research Society, Midrand,Gauteng, 1996 1997 Destructive sympathectomy in pain syndromes Singh B Pain Symposium, University of Natal, Durban, 1997 Surgery for palmar hyperhidrosis Singh B Controversies in Surgery, Pretoria (Sept), 1997 Early sympathectomy for CRPS Shaik AS, Singh B Surgical Research Society, Nottingham UK (Sept), 1997 X 1998 Role of sympathectomy in current surgical practice Singh,B Irish - South African College of Medicine Meeting, Durban, 1998 Sympathetic distribution to the upper limb Ramsaroop L, Partab P, Satyapal KS, Singh B. Anatomical Society of South Africa, Maputo, Mozambique. 1999 Do alternate neural connections affectlimited sympathetic ganglionectomy? Ramsaroop L, Partab P, Satyapal KS, Singh B 27th Surgical Research Societyof Southern Africa, Annual Congress, Bloemfontein, August 1999 Alternate neural connections of the sympathetic chain and upper thoracic intercostal nerves Ramsaroop L, Partab P, Satyapal KS, Singh B Twenty Ninth Annual Congress of the Anatomical Societyof Southern Africa, Sun City, April 1999 Limited ganglionectomy : an anatomical basis. Ramsaroop L, Singh B, Partab P , Satyapal KS FacultyDay, UND 2000 Limited sympathetic ganglionectomy : An anatomical basis Satyapal KS, Ramsaroop L, Partab P, Singh B Joint Meeting of the American Association of Clinical Anatomists and British Association of Clinical Anatomists, Cambridge, United Kingdom, July 2000 The nerves of Kuntz forupper limb sympathetic denervation Ramsaroop L, Partab P, Satyapal KS, Singh B 28'11 Surgical Research Society of Southern Africa, Annual Congress, Cape Town, July 2000 The nerves of Kuntz revisited L Ramsaroop, P Partab, B Singh, KS Satyapal 30'11 Anatomical Societyof SouthernAfrica Conference, Stellenbosch, South Africa, April 2000 Sympathetic distribution to the upper limb L Ramsaroop, P Partab, B Singh, KS Satyapal 30th Anatomical Societyof Southern Africa Conference, Stellenbosch, South Africa, April 2000 Incidence, topography and distribution of the stellate ganglion N Pather, L Ramsaroop, P Partab, B Singh, KS Satyapal 30th Anatomical Societyof SouthernAfrica Conference, Stellenbosch, South Africa,April 2000 xi 2001 Stellate ganglion blockade : a re-appraisal P Partab, B Singh, N Pather, L Ramsaroop, KS Satyapal XV/thInternational Symposium on Morphological Sciences, Sun City, South Africa, July 2001 Classificationof the nervesof Kuntz L Ramsaroop, P Partab, B Singh, KS Satyapal XV/thInternational Symposium on Morphological Sciences, Sun City, South Africa,