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Rutherford's 193: Current Role of Sympathectomy Upper and Lower скачать в хорошем качестве

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Rutherford's 193: Current Role of Sympathectomy Upper and Lower
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Rutherford's 193: Current Role of Sympathectomy Upper and Lower

#Sympathectomy #VATS #Hyperhidrosis #CRPS #ChronicPain #Raynauds #VascularSurgery #SympatheticNervousSystem #Surgery #PainManagement This video, drawing from Rutherford's Vascular Surgery and Endovascular Therapy, provides a deep dive into Sympathectomy, a surgical procedure targeting the Sympathetic Nervous System. Historically, it was used as early as 1920 for hyperhidrosis (excessive sweating) and vascular issues like Thromboangitis Obliterans and Raynaud Disease. Lumbar Sympathectomy was a common treatment for lower limb peripheral artery disease before modern revascularization existed. The procedure evolved from invasive open methods to video-assisted thoracoscopic sympathectomy (VATS) in the late 1980s/1990s, offering less morbidity, better cosmetic results, and shorter hospital stays. The sympathetic pathway involves a three-neuron relay from the hypothalamus to the spinal cord (T1-L2) and then to paravertebral ganglia (the sympathetic chain) before reaching target organs like blood vessels and sweat glands. Specific ganglia control different areas: stellate ganglion for arms/head, lumbar/sacral for legs/feet, and splanchnic nerves bypass the chain to abdominal ganglia. Sympathetic nerves mainly use adrenergic signals to cause blood vessel constriction, except for sweat glands which use cholinergic signals. Sympatectomy reduces blood vessel constriction (especially in smaller arterioles) and interrupts sweating signals. Current indications are more limited. For the upper body, main uses include severe essential hyperhidrosis (palmar, axillary, craniofacial), selected cases of critical hand ischemia (e.g., from TAO), Complex Regional Pain Syndrome (CRPS), refractory long QT syndrome, and severe Raynaud’s disease unresponsive to other treatments. Lumbar sympathectomy is now primarily for essential plantar hyperhidrosis, rarely for critical leg ischemia or lower limb CRPS/Raynaud’s. VATS involves small incisions and a camera, often deflating one lung for access. The sympathetic chain is located over the ribs and is typically divided with electro-cautery or clipped. Clipping offers potential reversibility for early, severe compensatory hyperhidrosis. Chemical sympathectomy using phenol is another option. Surgical targeting is precise; for palmar hyperhidrosis, G4 or G3 ganglia are targeted to reduce side effects like Horner syndrome and compensatory hyperhidrosis compared to higher targets. Stellate + G2/G3 are targeted for wider denervation in conditions like CRPS. Outcomes are excellent for hyperhidrosis (96-100% for palms). Compensatory hyperhidrosis (sweating elsewhere) is very common, severe in 1-4%. Results for CRPS can be very effective if done early (80-90% success), but are often temporary for Raynaud’s. Complications of VATS include pneumothorax (1-3% requiring a tube), temporary nerve issues, and Horner syndrome (1%). Failure can occur due to incomplete denervation or nerve reorganization. Reversal is difficult after permanent ablation but explored with clips or future techniques. The procedure requires careful patient selection and understanding of potential downsides.

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