Meei-Feng Huang

Treatment of Palmar Hyperhidrosis: T4 Level Compared With T3 and T2

Objective:The aim of this study was to compare the outcomes of 3 different levels of sympathectomy. Summary Background Data:Most surgeons still perform T2 or T2–3 sympathectomy for palmar hyperhidrosis, but both these treatments can cause severe side effects. Some recent articles have advocated T4 sympathectomy and obtained satisfactory results. Methods:Between January 2000 and August 2004, 234 records of patients treated for palmar hyperhidrosis were retrospectively reviewed. Of them, 86 patients were treated with endoscopic thoracic sympathectomy of T2 (ETS2), 78 patients with ETS3, and 70 patients with ETS4. Follow-up data were collected using a telephone questionnaire with a scoring system. Multiple linear regressions were used to model markers for degree of satisfaction and severity of compensatory sweating (CS), including descriptive data, level of sympathectomy, clinical outcomes, and postoperative complications. Results:Mean follow-up was 47.1 ± 17.2 months. All 3 levels of sympathectomy could have achieved comparable improvement of palmar hyperhidrosis (P = 0.162). However, 88.5% of the patients noticed CS. Patients with ETS4 presented the lowest incidence of CS (P = 0.030), had the least severity of CS (β = −1.537, P = 0.002), and felt the least palmar overdryness (P < 0.001). None expressed regret for the procedure in the ETS4 group (P = 0.022). Being obese did not increase the incidence of CS, but the severity of CS was directly related to body mass index (β = 0.917, P < 0.001). The patients would be more satisfied if the severity of CS was minimal (β = −0.185, P = 0.002). The degree of satisfaction may decrease with time (β = −0.025, P = 0.003) and was lower when their palms were overdry (β = −1.463, P < 0.001). Conclusions:Different from the current procedure of T2 or T3 sympathectomy for palmar hyperhidrosis, T4 sympathectomy would be a better and more effective procedure with minimal long-term complications.

Early Video-Assisted Thoracic Surgery for Primary Spontaneous Hemopneumothorax

IntroductionPrimary spontaneous hemopneumothorax (PSHP) is a rare surgical emergency. The aim of this study was to compare the previous strategy of tube thoracostomy followed by thoracotomy when complications developed with early video-assisted thoracic surgery (VATS) for PSHP.MethodsBetween November 1989 and May 2005, a total of 24 consecutive patients with PSHP were retrospectively reviewed. Before January 2000, there were 13 patients who were subjected to the treatment strategy of initial tube thoracostomy and underwent operation if the condition deteriorated or later complications occurred (group T). Under this strategy, all of these patients later required operations. After January 2000, another 11 patients were treated with VATS as soon as their condition stabilized after tube thoracostomy and resuscitation (group V). The data for the two groups were compared: sex, age, involved side, initial heart rate (HR) and mean blood pressure (BP), initial hemoglobin (Hb), preoperative blood loss, operating time, amount of blood transfusion, period of chest tube drainage (POD), length of hospital stay (LOS), complications, and length of follow-up.ResultsThe sex, age, involved side, and the initial HR, BP, and Hb of the two groups were similar. The patients of group V had a significantly longer operating time [group V, 111 minutes (mean); group T, 85 minutes, P = 0.002]; less preoperative blood loss (group V, 946 ml; group T, 1687 ml, P = 0.003); less blood transfusion (group V, 465 ml; group T, 1044 ml, P = 0.002); shorter POD (group V, 4 days; group T, 7 days, P = 0.011); and shorter LOS (group V, 5 days; group T, 10 days, P = 0.002). No mortality or recurrence was noted in the entire series.ConclusionsOur study suggests that surgery should be undertaken for PSHP as soon as possible after the clinical condition has stabilized. Under this strategy, VATS is an acceptable approach. It allows a shorter hospital stay and is exempt from unnecessary blood transfusion. Later complications, such as empyema and impaired lung reexpansion, can also be avoided.

Is prophylactic treatment of contralateral blebs in patients with primary spontaneous pneumothorax indicated

OBJECTIVES More than 50% of patients with primary spontaneous pneumothorax have contralateral blebs/bullae, and about a quarter will develop a contralateral pneumothorax. The purpose of this prospective study was to determine the need for elective treatment of asymptomatic contralateral blebs/bullae in patients presenting with primary spontaneous pneumothorax. METHODS From May 2006 through June 2008, results from 35 patients with ipsilateral primary spontaneous pneumothorax without contralateral blebs receiving unilateral video-assisted thoracic surgery, 35 patients with ipsilateral primary spontaneous pneumothorax with contralateral blebs receiving unilateral video-assisted thoracic surgery, and 16 patients with ipsilateral primary spontaneous pneumothorax receiving bilateral video-assisted thoracic surgery for positive contralateral blebs were collected. Their demographic and operating data were also recorded. RESULTS There was no significant difference in age, gender, smoking percentage, body mass index (kg/m(2)), blood loss, and postoperative pain among groups. There was longer operative time and length of stay in group receiving bilateral surgery. Within the follow-up period of 16.68 +/- 9.91 months (median, 17.50), no recurrence on either lung was found in the group operated on both sides, while contralateral occurrence was found in 17.14% of the group with ipsilateral primary spontaneous pneumothorax with contralateral blebs receiving unilateral video-assisted thoracic surgery within the period of 18.15 +/- 8.07 months (median, 21). CONCLUSION The study showed that the preemptive video-assisted thoracic surgery for the contralateral blebs/bullae effectively prevented the contralateral occurrence.

The outcome of ganglion clipping in hyperhidrosis and blushing

A total of 114 patients with various sympathetic disorders underwent endoscopic sympathetic block over different thoracic ganglions by the clipping method. The advantages of this method include the recognition of the clipped level, changeability, and reversibility. However, 4.4% of patients were unilaterally clipped at the wrong level.

Needlescopic Video-assisted Thoracic Surgery for Primary Spontaneous Pneumothorax

Minimally invasive surgery is the current trend of approach in various fields. Since May 2006, our team has started implementing needlescopic video-assisted thoracic surgery as the standard surgical treatment for primary spontaneous pneumothorax. During a seventeen-month period, 62 consecutive patients with primary spontaneous pneumothorax were operated on. The ages, sex ratio, operative times, blood loss, postoperative pain in visual analog scale (VAS), length of stay and hospital costs were recorded and compared with that of another 62 consecutive patients who received conventional video-assisted thoracic surgery between July 2004 and April 2006. Only the postoperative pain in VAS was significantly lower in the needlescopic video-assisted thoracic surgery group; the rest remained the same. Also the wounds were almost undetectable in the needlescopic video-assisted thoracic surgery patients. There were no major complications, mortality or recurrence in either group. Needlescopic video-assisted thoracic surgery is a high-tech technique which provides safety, effectiveness, economy and outcome comparable to that of conventional techniques. It is also associated with less pain and better cosmetics.

Transthoracic or Transhiatal Resection for Middle- and Lower-Third Esophageal Carcinoma?

Transthoracic esophagectomy (TTE) and transhiatal esophagectomy (THE) are two common methods of resection for esophageal cancer. Although many studies have been performed in Western countries, there are still controversies over which method is the better procedure. In this study, postoperative improvement in dysphagia and the degree of postoperative pain were compared. The cases of 50 patients undergoing TTE and 23 undergoing THE for esophageal cancer between March 1997 and October 2002 were retrospectively reviewed. The location of the lesion, clinical stage (TNM), operative time, operative blood loss, hospital stay, complications, number of lymph nodes dissected, and survival duration were recorded. Pre‐ and postoperative dysphagia scores and postoperative pain perception (using a visual analog scale) were analyzed. Preoperative clinical stage and lesion site were not significantly different in the TTE and THE groups. The operative time was longer and the number of lymph nodes removed was larger in the TTE group. However, there were no differences in operative blood loss, hospital stay, complications, survival duration, and improvement in dysphagia. Pain perception in the THE group was significantly better than that in the TTE group. THE is a safe and rapid procedure, with recovery and survival periods similar to those for TTE. Both patient groups enjoyed the same ability to eat. Therefore, THE is an acceptable alternative to TTE for patients with middle‐ and lower‐third esophageal cancer. Moreover, THE caused much less postoperative pain than TTE, which made patients more comfortable.

Comparison of needlescopic and conventional video-assisted thoracic surgery for primary spontaneous pneumothorax

Abstract Whether the outcome of primary spontaneous pneumothorax (PSP) when treated with needlescopic video-assisted thoracic surgery is positive is still under scrutiny. The present study was conducted to compare the needlescopic approach with the conventional approach. One-hundred and six patients with primary spontaneous pneumothorax who had undergone needlescopic video-assisted thoracic surgery (NVATS) between May 2006 and August 2008 were reviewed. Their age, gender, smoking status, BMI, side of attack, operative indications, operative time, intraoperative blood loss, postoperative length of stay, postoperative pain in visual analog scale (VAS), postoperative recurrence and follow-up period were recorded. These data were compared with those of 89 patients with PSP who had undergone conventional video-assisted thoracic surgery (CVATS) between June 2002 and April 2006. The operative time was shorter (NVATS: 82.36 ± 35.58 min, CVATS: 99.78 ± 35.74 min; p = 0.008) and intraoperative blood loss was less (NVATS: 16.67 ± 25.90 ml, CVATS: 24.36 ± 26.86 ml; p = 0.04) for the NVATS group. The postoperative pain in VAS was significantly less in NVATS. No major complication or mortality was found in either group. For treatment of primary spontaneous pneumothorax, NVATS is a safe and effective option. Further, it has the added benefit of less pain and improved cosmetics.

Sympathetic Hypertensive Syndrome: A Possible Surgically Curable Type of Hypertension

Poorly controlled hypertension was incidentally cured after performing an endoscopic sympathetic block (ESB) in a patient with hyperhidrosis craniofacialis (HHC). A survey of the literature indicated that 30% to 40% of essential hypertension is of sympathetic origin. Patients with facial sweating associated with hypertension were then studied to determine whether blood pressure is lowered after performing ESB. Between November 2002 and July 2003, 17 hypertensive patients (13 males and 4 females) ranging in age from 22 to 62 years underwent ESB solely for HHC at the Department of Surgery of Kaohsiung Medical University, Taiwan. Their preoperative systolic blood pressure (SBP) values ranged from 170±6 to 200.7±7.6 mmHg, and their diastolic blood pressure (DBP) values ranged from 94.7±6.1 to 120.3±5.7 mmHg. Their heart rates were between 92.67±2.28 and 119.67±5.13 beats per minute (bpm). They were refractory to aggressive medical treatment, including lifestyle modifications and antihypertensive medications. Their postoperative blood pressure, heart rate and surgical outcomes were recorded. After performing ESB, HHC was cured in all 17 patients. Based on the reductions in blood pressure and heart rate, the patients could be divided into two groups, one showing high-level reductions (Group T) and one showing low-level reductions (Group S). The blood pressure of Group T (ten patients) was reduced to the range of 120.2±6.9 to 131.6±3.5 mmHg SBP and 74.8±3.1 to 85.4±4.5 DBP, and the heart rate of this group was reduced to the range of 65.36±4.63 to 85±3.60 bpm, while the blood pressure and heart rate of Group S (seven other patients) were reduced to the ranges of 145.9±5.7 to 160.5±5.5 mmHg SBP, 90±4 to 100.7±3.2 mmHg DBP, and 80±4 to 90.83±3.53 bpm, respectively. The patients in Group S were well controlled at 119.8±5.5 to 130.6±8.0 mmHg SBP and 70.1±3.8 to 84.5±5.7 mmHg DBP with a daily low-dose of calcium channel blocker. The average follow-up periods of the two groups were 17.00±2.906 and 17.43±2.37 months, respectively. We named this surgically curable form of hypertension “Sympathetic Hypertensive Syndrome” (SHS), which we define by the presence of all three of the following: 1) stage II hypertension; 2) HHC or other sympathetic disorders; and 3) heart rate ≥100 bpm. If the patient is male the reductions of blood pressure after the surgery will be better, which might be due to the link with Y chromosome. Finally, we recommend that ESB should be performed in patients with SHS, although the female would respond less satisfactorily in terms of the blood pressure.

Video-assisted thoracoscopic surgery for postoperative recurrent primary spontaneous pneumothorax

OBJECTIVES Postoperative recurrent primary spontaneous pneumothorax (PSP) is a troublesome complication and an important issue to be discussed. This study is to determine whether Re-video assisted thoracoscopic surgery (VATS) should be performed for postoperative recurrent PSP (PORP). MATERIALS AND METHODS Patients who had underwent needlescopic VATS for PSP between Jan. 2007 and Dec. 2011 were reviewed. RESULTS VATS was initially performed on 239 patients with PSP in total. Eleven patients were found to have PORP during a follow-up period of 36.95 months. Nine patients received Re-VATS and only two patients receiving conservative treatment had no further recurrence. No conversion to thoracotomy, blood transfusion and prolong air leak were recorded. CONCLUSIONS Even for smaller size cases, Re-VATS, which is technically feasible, safe and effective with better cosmetics and minor postoperative pain, should be a strong contender as priority treatment.

Aortobronchial fistula after esophagectomy for esophageal cancer—A very rare complication

Most aorto‐respiratory fistulas are related to aortic pathology or procedures, but fistula formation after esophageal resection has never been reported in the literature. We are now reporting a case of hemoptysis that occurred after esophagectomy for locally advanced esophageal cancer. Aortobronchial fistula was detected by computed tomography scan. The patient was finally saved by emergency surgery—Dacron graft interposition of the descending thoracic aorta. There was no malignant cell in the postoperative specimen of the fistula. The erosion of the ligaclips (Johnson & Johnson) might be responsible for the aortobronchial fistula formation. For esophageal surgery, avoidance of trauma to aortic wall and careful using of ligaclips are important to circumvent this complication.