title: Thoracoscopic sympathectomy is a valuable addition in the management of recreational intra-arterial drug injection. Pilot study.
abstract: BACKGROUND
  Intra-arterial Injection (IAI) of illicit substances by drug abusers may result in acute ischemia, limb loss or permanent functional deficit. No prospective human studies have shown that any specific treatment is superior to another. Thoracoscopic sympathectomy (TS) has proven efficacy in upper limb ischemia due to organic blockade. This is a pilot study to evaluate the effect of thoracoscopic sympathectomy addition to the management protocol of recreational intra-arterial drug injection.
  
  
  METHODS
  A total of 11 victims of upper limb IAI of recreational drug were recruited (10 males) with age range from 18 to 43 years old (average 30+/-8.3 years). Tissue Ischemia Score (TIS) was used for pretreatment assessment of the degree of ischemic injury and severity of pain was evaluated pre- and post-operatively using visual analog score (VAS) and compared using Student's t test. Pre-operative VAS score was 6.9+/-1.8. All enrolled patients were treated according to the following protocol; anticoagulation, calcium channel blocker, opiates for pain, and TS. Patients received the stated protocol for minimum of 72h (range 3-8 days; mean 5; average 4.7+/-1.5 days). Freedom of amputation and improvement of pain scores were the study endpoints.
  
  
  RESULTS
  No mortality, yet one case had bleeding secondary to anticoagulant and one case of post-operative pneumothorax that required chest tube drainage for 24h. No patients had wet gangrene or spreading infection. Freedom of amputation was achieved in nine patients, 81% (7 patients had normal outcome and other two had permanent neurological deficit). Two patients (18%) had tissue necrosis with dry gangrene and mummification of the affected digits with eventual amputation. Postoperative VAS pain score was 2.09+/-1.37 (p<0.05). Pain medications were suspended in 6 patients (54.5%), reduced in 4 (36%) and unchanged in 1 (9%). All patients with TIS score 2 or less had a normal outcome while those with scores 3 and 4 had a variable outcome. Using regression analysis, initial TIS was significant for outcome prediction (p=0.043) while age, arterial site, drug injected and time delay were not significant.
  
  
  CONCLUSIONS
  The addition of TS was an attempt to halt the ischemic process after IAI which permitted, in our belief, optimal symptom control with maximum tissue salvage. Because the procedure is minimally invasive, safe, and associated with a low complication rate; it worth consideration whenever IAI is encountered.
authors.affiliation: General and Vascular Surgery, Faculty of Medicine, Cairo University, 20 C 198 Street, Degla, Maadi Cairo 11435 Egypt. samadoni2005@hotmail.com
authors.forename: Ayman
authors.initials: A
authors.lastname: El Samadoni
authors.forename: Ahmad
authors.initials: A
authors.lastname: Nada
authors.forename: Hisham
authors.initials: H
authors.lastname: Mostafa
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D006801:Humans; D007269:Injections, Intra-Arterial / Q000009:adverse effects*; D007511:Ischemia / Q000139:chemically induced* / Q000601:surgery*; D008297:Male; D010147:Pain Measurement; D010149:Postoperative Pain; D019966:Substance-Related Disorders / Q000150:complications*; D013562:Sympathectomy / Q000009:adverse effects; D013906:Thoracoscopy; D034941:Upper Extremity / Q000098:blood supply* / Q000294:innervation; D055815:Young Adult