Thoracoscopic sympathetic surgery for hyperhidrosis

Resectional surgery of sympathetic nerves has been known to be the most effective treatment for essential hyperhidrosis and the application of thoracoscopic electrocauterization has provided a minimally-invasive procedure with the least morbidity and a resultant higher satisfaction rate. This paper describes our experience on the 1,167 cases of thoracoscopic sympathetic surgery for the treatment of essential hyperhidrosis. A total of 1,167 patients (674 males (58%) and 493 females (42%), mean age of 26.4 years with palmar (930), craniofacial (190) or axillary (47) hyperhidrosis underwent thoracoscopic sympathetic surgery from July 1992 to March 1999. Since the T2-4 sympathectomy, first performed in July 1992 for a patient of palmar hyperhidrosis, the operative methods have been altered to achieve a higher satisfaction level with the least complication by adopting less invasive procedures. Our current standard procedures being performed are T3 and T2 clipping for palmar and craniofacial hyperhidrosis and T3,4 sympathicotomy for axillary hyperhidrosis, all using a 2 mm needle thoracoscope. As the surgical procedures have been transited to a less invasive method with limited resection using the newest endoscopic devices, the average operation time and complications such as Horner's syndrome and compensatory hyperhidrosis have gradually decreased and thus the long-term satisfaction rate has been raised up to 98% for palmar hyperhidrosis, 92% for craniofacial hyperhidrosis and 89% for axillary hyperhidrosis. The recurrent cases (14/1167) were treated successfully with reoperations of thoracoscopic sympathetic surgery. The optimal goal of therapy could be achieved by complete elimination of the hyperhidrotic symptom, by decreasing the incidence and degree of compensatory hyperhidrosis through a selective and limited resection, and by adopting the least invasive procedures. Sympathicotomy has provided the advantages of a limited extent of denervation and the resultant decrease of compensatory hyperhidrosis compared to sympathectomy. The reversible method of clipping may be an effective, provisionary means for cases of severe, intractable compensatory sweating. For craniofacial hyperhidrosis, T2 sympathicotomy or clipping has been proven to be superior to the T1 sympathectomy due to the decreased occurrence of Horner's syndrome and T3,4 sympathicotomy providing a satisfactory outcome with less compensatory hyperhidrosis for axillary hyperhidrosis.     

Wrinkly skin syndrome: phenotype and additional manifestations

The wrinkly skin syndrome is an autosomal recessive disorder characterized by wrinkling of the skin of the dorsum of the hands and feet, decreased elastic recoil of the skin, an increased number of palmar and plantar creases, multiple musculoskeletal abnormalities, microcephaly, and mental retardation. Our patient is characteristic of the syndrome as previously described, and confirms the presence of mental retardation and microcephaly as component manifestations, with the additional findings of connective tissue abnormalities evidenced by an atrial septal aneurysm.     

Digital Thermography of the Fingers and Toes in Raynaud's Phenomenon

The aim of this study was to determine whether skin temperature measurement by digital thermography on hands and feet is useful for diagnosis of Raynaud''s phenomenon (RP). Fifty-seven patients with RP (primary RP, n = 33; secondary RP, n = 24) and 146 healthy volunteers were recruited. After acclimation to room temperature for 30 min, thermal imaging of palmar aspect of hands and dorsal aspect of feet were taken. Temperature differences between palm (center) and the coolest finger and temperature differences between foot dorsum (center) and first toe significantly differed between patients and controls. The area under curve analysis showed that temperature difference of the coolest finger (cutoff value: 2.2℃) differentiated RP patients from controls (sensitivity/specificity: 67/60%, respectively). Temperature differences of first toe (cutoff value: 3.11℃) also discriminated RP patients (sensitivity/specificity: about 73/66%, respectively). A combination of thermographic assessment of the coolest finger and first toe was highly effective in men (sensitivity/specificity : about 88/60%, respectively) while thermographic assessment of first toe was solely sufficient for women (sensitivity/specificity: about 74/68%, respectively). Thermographic assessment of the coolest finger and first toe is useful for diagnosing RP. In women, thermography of first toe is highly recommended.

Graphical Abstract

相似文献   

游离双股前外侧皮瓣修复全手脱套伤可行性研究

目的　探索游离双侧股前外侧皮瓣瓦合修复全手脱套伤的可行性。 方法　（1）对50例健康、无手部残疾和疾病的成年人,分别测量手部掌、背侧皮肤纵长及横宽,记录测量数据及统计分析,计算修复全手脱套伤所需手供皮量;（2）在2具新鲜尸体标本上,建立左手全手脱套伤模型,将全手脱套伤的模型分成掌侧和背侧两部分分区修复。掌侧创面设计一侧股前外侧皮瓣修复,背侧创面则设计对侧股前外皮瓣修复,两块皮瓣瓦合后修复全手脱套伤创面。 结果　50例活体测量数据,掌侧皮肤纵长为(13.84±0.88)cm(12.51~15.03cm),宽为(14.48±1.11)cm(12.85~16.66cm),背侧皮肤纵长为(12.15±1.09)cm(10.77~13.77cm),宽为(14.92±1.11)cm(14.92~17.33)cm,均较文献报道股前外侧皮瓣的最大可切取值小。结论　游离双侧股前外侧皮瓣完全可以覆盖手掌侧、背侧创面,设计两块皮瓣瓦合修复全手脱套伤术式具有可行性。     

Cold-induced vasoconstriction at forearm and hand skin sites: the effect of age

During mild cold exposure, elderly are at risk of hypothermia. In humans, glabrous skin at the hands is well adapted as a heat exchanger. Evidence exists that elderly show equal vasoconstriction due to local cooling at the ventral forearm, yet no age effects on vasoconstriction at hand skin have been studied. Here, we tested the hypotheses that at hand sites (a) elderly show equal vasoconstriction due to local cooling and (b) elderly show reduced response to noradrenergic stimuli. Skin perfusion and mean arterial pressure were measured in 16 young adults (Y: 18–28 years) and 16 elderly (E: 68–78 years). To study the effect of local vasoconstriction mechanisms local sympathetic nerve terminals were blocked by bretylium (BR). Baseline local skin temperature was clamped at 33°C. Next, local temperature was reduced to 24°C. After 15 min of local cooling, noradrenalin (NA) was administered to study the effect of neural vasoconstriction mechanisms. No significant age effect was observed in vasoconstriction due to local cooling at BR sites. After NA, vasoconstriction at the forearm showed a significant age effect; however, no significant age effect was found at the hand sites. [Change in CVC (% from baseline): Forearm Y: −76 ± 3 vs. E: −60 ± 5 (P < 0.01), dorsal hand Y: −74 ± 4 vs. E: −72 ± 4 (n.s.), ventral hand Y: −80 ± 7 vs. E: −70 ± 11 (n.s.)]. In conclusion, in contrast to results from the ventral forearm, elderly did not show a blunted response to local cooling and noradrenalin at hand skin sites. This indicates that at hand skin the noradrenergic mechanism of vasoconstriction is maintained with age.     

Effect of ambient temperature on the thermal profile of the human forearm,hand, and fingers

Forearm, hand, and finger skin temperatures were measured on the right and left sides of seven resting men. The purpose was to determine the bilateral symmetry of these segmental temperature profiles at ambient temperatures from 10 to 45°C. Thermistors placed on the right and left forearms, hands, and index fingers were used to monitor the subjects until equilibration was reached at each ambient temperature. Additionally, thermal profiles of both hands were measured with copper-constantan thermocouples. During one experimental condition (23°C ambient), rectal, ear canal, and 24 skin temperatures were measured on each subject. Average body and average skin temperatures are given for each subject at the 23°C ambient condition. Detailed thermal profiles are also presented for the dorsal, ventral, and circumferential left forearm, hand, and finger skin temperatures at 23°C ambient. No significant differences were found between the mean skin temperatures of the right and left contralateral segments at any of the selected ambient temperatures.     

Delineation of the Costello syndrome.

We present a 15-year-old girl with mental retardation, short stature, coarse face, unusually thick, loose skin of the hands and feet, deep plantar and palmar creases, and nasal papillomata. Her history and physical findings are compared to those of 2 children initially reported by Costello and to 1 child recently reported by Der Kaloustian et al.     

Del(2q) — cause of the wrinkly skin syndrome?

We report the cases of a mother and her two sons with de1(2) (q32). Their phenotypes are compared with those of 20 individuals reported previously in the literature. All described cases apparently have identical deletions. Common manifestations include small size at birth, retarded growth and development, craniofacial dysmorphism and skeletal and ocular anomalies. Our patients also have symptoms of the wrinkly skin syndrome (WSS), which is characterized by the wrinkling of the abdominal skin and of the skin of the dorsum of the hands and feet, decreased elastic recoil of the skin, an increased number of palmar and plantar creases, musculoskeletal anomalies, microcephaly, mental retardation and an old appearance. Our three patients show a striking pattern in skin biopsies when viewed by light microscopy, and a peculiar grimacing was noted in the boys. Their serum copper and caeruloplasmin levels are slightly raised.     

Report on two patients with Costello syndrome and sialuria

We report on 2 unrelated patients with Costello syndrome. The first is a 5-year-old girl with “coarse” face, nasal papillomata, redundant skin of feet and hands, hyperextensible hand and finger joints, curly hair, feeding problems due to oral motor apraxia, growth and psychomotor retardation. The second is a 3-year-old boy with “coarse” face, loose skin on hands and feet, curly hair, oral motor apraxia, severe growth and psychomotor retardation. In both patients urine sialic acid levels were found to be repeatedly high. The meaning of this biochemical abnormality is discussed. © 1993 Wiley-Liss, Inc.     

Dermatoclyphic Patterns in Angiographically Proven Coronary Artery Disease

Dermatoglyphics is the scientific study of epidermal ridges and their configurations on the palmar region of hand and fingers and plantar region of foot and toes. Against the genetic background of dermatoglyphic patterns and coronary artery disease, the study was undertaken to determine the correlation between them. The present study includes 150 cases of angiographically proven coronary artery disease (CAD) and 150 cases of healthy normal individuals. The palmar prints of both hands were taken on white paper by Ink method as described by Cummins and Midlo. It is noted that there is significant decrease in loops with corresponding increase in whorls in males, (M+F) combined series and left hand of CAD patients. The true palmar pattern is significantly decreased in thenar area in females; third interdigital area in (M+F) combined series and right hand; and fourth interdigital area in left hand of CAD patients. There is significant increase in ‘4’ palmar triradii in males, (M+F) combined series and right hand; and ‘5’ palmar triradii in females with significant decrease in ‘6’ palmar triradii in both sexes and both hands of CAD patients. The mean value of atd angle is significantly increased in males, (M+F) combined series and left hand of CAD patients as compared to the controls. There is no significant correlation in ab ridge count and CAD.     

Hypothesis: Is the skin and tissue loss associated with septic purpura fulminans temperature related? Parallels with the anatomical distribution of frostbite

Purpura fulminans is a life threatening complication of many septic states, most notably meningococcaemia. It can also occur due to congenital deficiency of anticoagulant proteins. The pathophysiology of purpura fulminans is complex and not fully understood, but involves abnormalities of coagulation pathways, damage to vessel walls, and abnormal vasoconstriction which may lead to ischaemia and organ dysfunction. After the acute illness has resolved purpuric lesions may lead to extensive tissue loss and prolonged morbidity. Although vascular beds throughout the body are affected, and lesions can be seen in all areas of the skin, the distribution of permanent lesions is often confined to the peripheries, resulting in amputation of digits, hands and feet, or even limbs. Many pharmacological strategies have been used in attempts to reduce the tissue loss, but as yet none have proved to be consistently safe and effective. The distribution of this tissue loss is remarkably similar to that seen in frostbite, and raises the hypothesis that local temperature may have some contributing effect on the severity of these lesions. Hypothermia is known to be associated with vasoconstriction (in an attempt to preserve core temperature) and abnormalities of coagulation. This generally leads to an anticoagulated state, however the severe vasoconstriction and hypovolaemia associated with the early (pre-resuscitation) phases of acute sepsis results in peripheral skin temperatures approaching ambient. The effect on coagulation at these temperatures is not as well understood, but recent work has suggested increased platelet aggregation, adverse effects on blood rheology and increased intravascular thrombosis at temperatures of 31-34 degrees C. We hypothesise that low temperature leads to worsening of purpuric lesions and that active warming of the peripheries may reduce the tissue loss associated with resolving purpuric illnesses.     

Temperature-dependent interaction between vasoconstrictor and vasodilator mechanisms in human skin

The putative influence of the thermoregulatory state on skin blood-flow responses to various stimuli was studied in 17 healthy subjects exposed to different ambient temperatures. Skin blood flow was monitored by laser Doppler flowmeters and photoelectrical pulse plethysmographs. Stimuli included painful intraneural electrical stimulation (INS) in the median nerve at the wrist, mental stress, arousal stimuli and deep breaths. Intraneural electrical stimulation and mental stress were accompanied by virtually identical changes in skin blood flow, warm subjects responding with cutaneous vasoconstriction whereas cold subjects responded with vasodilatation. Similar but less pronounced responses were obtained with arousal stimuli and single deep breaths. The data indicate that the thermoregulatory state profoundly influences the extent and direction of various cutaneous vasomotor reflex responses. Furthermore, there were differences between responses in hands and feet, suggesting a spatial organization of vasomotor control.     

Fall in skin temperature during exercise

During light work using the arm in a warm environment, skin temperatures of the arms and chest fell and remained at lower levels during work. The fall in skin temperature during work was not observed in a cool environment. The fall in skin temperature was nearly proportional to work intensity and was observed in both static and dynamic work. Leg work of moderate intensity produced an initial decline and a subsequent rise in skin temperatures of the hands, thighs and legs. A significant fall in skin temperature was observed not only in the foot but also in inactive regions such as the epigastrium. The mean skin temperature remained practically unchanged during work. The fall in skin temperature during work was not due to increased evaporative cooling, but was the result of segmental vasoconstriction probably caused as a reflex in the spinal cord by non-thermal afferents from exercising muscles or moving tissues. The effect of thermoregulatory vasodilation was reduced by the reflex vasoconstriction caused by non-thermal factors. The rise in internal temperature during work could be explained by decreased heat loss due to persistently lower skin temperature.     

Ice-water hand immersion causes a reflex decrease in skin temperature in the contralateral hand

Cutaneous receptors stimulated by ice-water immersion of one hand will increase sympathetic nerve activity to the palm skin in the nonimmersed contralateral hand and reduce blood flow, reflecting on a decrease in skin surface temperature under a constant ambient environment. To test the hypothesis that gender might affect the contralateral vasoconstrictor response, we analyzed the spatiotemporal pattern of palm skin surface temperature during ice-water immersion for 10 min using thermography in eight males and eight females. As soon as the left hand was immersed in ice-water, palm skin temperature in the nonimmersed right hand quickly decreased in all subjects, particularly in the periphery of the digits and palm. The reduction in skin temperature was short-lasting in 63% of males and 38% of females, but it lasted throughout immersion in the remaining subjects. The average decrease in palm skin temperature was not significantly different between males and females, though it tended to be greater in males. The mean arterial blood pressure significantly increased and heart rate decreased during immersion in males, whereas no substantial cardiovascular changes were observed in females. Cold sensation was well coincident with the appearance of a reduction in the palm skin temperature. In consideration of all these results, we suggest that cutaneous cold stimuli increased skin sympathetic nerve activity in the nonimmersed hand and reduced skin blood flow. We also contend that gender difference in the contralateral vasoconstrictor response was denied because the time course and magnitude of the decrease in palm skin temperature were not different between males and females.     

Cerebral evoked responses to skin warming recorded from human scalp

Summary Responses evoked by warming the glabrous palmar skin were recorded maximally from a contralateral parietal scalp site that approximated the hand projection area of sensorimotor cortex. A smaller and later occurring response was also seen at the corresponding ipsilateral site. The temperature to which the skin was adapted was critical and was maintained at 35 ° C rather than at 30 ° C as it was in an earlier study where no responses were seen. Peak latencies ranged from 280 msec to 356 msec for stimulus intensities of 8 ° C presented at a rate of 19 ° C/sec. This warm evoked response appeared to have its origin in the specifically sensitive primary warm afferents. The presence of an evoked response when warming occurred from the 35 ° C adapting temperature (AT) and its absence at the 30 ° C AT coincide with the greater sensitivity of warm receptors at the higher AT. Comparison of these results with those for evoked responses to skin cooling and tactile tap suggest that the cortical organization of temperature (both warm and cool stimuli) in human is similar to that of touch.This research was supported by USPHS Grant No. NS 02992     

Three-dimensional interactions of mean body and local skin temperatures in the control of hand and foot blood flows

Purpose

Much is known about the control of blood flow, yet gaps remain concerning the interactions of deep-body and peripheral thermal feedback. In this experiment, changes in the vascular tone of the hands and feet were mapped to demonstrate the separate and combined influences of mean body and local skin temperature changes.

Methods

Eight males participated in three trials. Three pre-experimental conditions were established via water immersion (oesophageal temperatures: 36.1, 37.0, 38.5 °C), with core and mean skin temperatures then clamped (water-perfusion garment) whilst five thermal treatments were applied to the right hand and left foot (5, 15, 25, 33, 40 °C). This yielded 15 thermal combinations under which hand and foot blood flows were measured (displacement plethysmography).

Results

Lower volume-specific blood flows were observed at the foot for almost all temperature combinations. When thermoneutral and moderately hyperthermic, the cutaneous thermosensitivity of the hand was significantly greater: thermoneutral: 0.2 vs. 0.1 (foot) mL 100 mL^?1 min^?1 °C^?1 (P < 0.05); moderate hyperthermia: 0.4 vs. 0.2 (foot) mL 100 mL^?1 min^?1 °C^?1 (P < 0.05). The hand was 13 times more responsive to core temperature elevations than an equivalent local skin temperature change. For the foot, this thermosensitivity differed by a factor of 26.

Conclusion

These observations identified the hands as heat radiators, with the feet resisting heat loss, and reinforce the dominance of central thermal feedback, particularly in controlling foot blood flow. However, thermosensitivity to local skin temperature changes was highly plastic, site-specific and dictated by thermal and regional variations in vaso- and venoconstrictor tone.     

Sympathetic skin response and R-R interval variation in cases with rheumatoid arthritis

To investigate the autonomic nervus system involvement in cases with rheumatoid arthritis (RA) by assesing sympathetic skin response (SSR) and R-R interval variation (RRIV), 14 healthy women and 10 women with RA, all of them without clinic dysautonomies were examined. SSR's were recorded palmar surface of both hands and soles of both feet, after stimulating median and tibial nerves individually. RRIV's were assessed at rest and during six deep breathing in one minute with electrodes placed on dorsal surfaces of both hands. SSR could not be obtained from lower extremities of one case with RA. We could not find any significant difference between two groups in terms of SSR latencies. RRIV values obtained during deep breathing to those recorded at rest (D%/R%) was found to be significantly lower in RA cases than healthy controls. RRIV values increased with deep breathing in healthy subjects, while they decreased in 50% of the RA cases. We conclude that assessment of SSR and RRIV are valuble methods for revelation of subclinical autonomic involvement in cases with RA.     

45例掌腱膜挛缩症临床分析

目的 探讨掌腱膜挛缩症的病变特点和治疗方法。方法 45例掌腱膜挛缩症,76只手行掌腱膜切除,手掌及手指挛缩皮肤“Z”字成形术。10只手掌腱膜及受累皮肤切除后游离植皮术,送病检查7例。结果 术后平均随访5年,仅5例复发,其余挛缩解除,疗效确定。其中15只手出现神经损伤、皮下血肿、皮片部分坏死等并发症。结论 掌腱膜挛缩症在国外为常见病,国人发病率相对较低,好发于中、老年男性,国内患者就诊时多已经形成明显挛缩,故多采用手术疗法,其效果可靠,早期手术术后效果好。     

The trainability and contralateral response of cold-induced vasodilatation in the fingers following repeated cold exposure

Cold-induced vasodilatation (CIVD) is proposed to be a protective response to prevent cold injuries in the extremities during cold exposure, but the laboratory-based trainability of CIVD responses in the hand remains equivocal. Therefore, we investigated the thermal response across the fingers with repeated local cold exposure of the whole hand, along with the transferability of acclimation to the fingers of the contralateral hand. Nine healthy subjects immersed their right hand up to the styloid process in 8 degrees C water for 30 min daily for 13 days. The left hand was immersed on days 1 and 13. Skin temperature was recorded on the pads of the five fingertips and the dorsal surface of the hand. The presence of CIVD, defined as an increase in finger skin temperature of 0.5 degrees C at any time during cooling, occurred in 98.5% of the 585 (9 subjects x 5 sites x 13 trials) measurements. Seven distinct patterns of thermal responses were evident, including plateaus in finger temperature and superimposed waves. The number (N) of CIVD waves decreased in all digits of the right hand over the acclimation period (P = 0.02), from average (SD) values ranging from 2.7 (1.7) to 3 (1.4) in different digits on day 1, to 1.9 (0.9) and 2.2 (0.7) on day 13. Average (SD) finger skin temperature (T (avg)) ranged from 11.8 (1.4) degrees C in finger 5 to 12.7 (2.8) degrees C in finger 3 on day 1, and then decreased significantly (P < 0.001) over the course of the training immersions, attaining values ranging from 10.8 (0.9) degrees C in finger 4 to 10.9 (0.9) degrees C in finger 2 on day 13. In the contralateral hand, N was reduced from 2.5 to 1.5 (P < 0.01) and T (avg) by approximately 2 degrees C (P < 0.01). No changes were observed in thermal sensation or comfort of the hand over the acclimation. We conclude that, under conditions of whole-hand immersion in cold water, CIVD is not trainable and may lead to systemic attenuation of thermal responses to local cooling.     

New findings on intermetacarpal fat pads: anatomy and imaging

Many studies have focused on the functional importance of the gliding structures of the hand. These structures are clinically important in reconstructive surgery and mechanically essential for an efficient hand grasp. The aims of this study were to first review the intermetacarpal space and then focus on its fatty tissue, the intermetacarpal fat pad. This study used dissections and histological analysis of fetal and adult hands and CT scans of adult hands. The intermetacarpal fat pads are well-defined adipose structures located between the heads of the second, third, fourth and fifth metacarpal bones. They are located in spaces defined by the palmar fascia and its deep expansions. These spaces are closed distally but open proximally into the tunnels surrounding the flexor tendons (Legueu and Juvara canals). The pads are composed of non-mobilizable fat; they protect the neurovascular pedicles of the fingers. They may act with the palmar skin to mitigate compressive and shear forces during gripping. Finally they may be involved in neurological symptoms if their size is increased by any trauma or inflammatory process.