title: Sympathetic block by metal clips may be a reversible operation.
abstract: OBJECTIVE
  Thoracoscopic sympathectomy is now used routinely to treat patients with disabling primary hyperhidrosis or facial blushing. Published results are excellent, but side effects, such as compensatory sweating, are also very frequent. The surgical techniques used and the levels of targeting the sympathetic chain vary tremendously. Most surgeons transect or resect the sympathetic chain, but application of a metal clip that blocks transmission of nerve impulses in the sympathetic chain is used increasingly worldwide. This approach offers potential reversibility if patients regret surgery, but the question of reversibility remains controversial. Two recent experimental studies found severe histological signs of nerve damage 4-6 weeks after clip removal, but they only used conventional histopathological staining methods.
  
  
  METHODS
  Thoracoscopic clipping of the sympathetic trunk was performed in adult sheep, and the clip was removed thoracoscopically after 7 days. Following another 4 weeks (n = 6) or 12 weeks (n = 3), the sympathetic trunks were harvested and analysed by conventional and specific nerve tissue immunohistochemical stains (S100, neurofilament protein and synaptophysin). The contralateral sympathetic chains were used as controls.
  
  
  RESULTS
  Conventional and immunohistochemical stains demonstrated severe signs of neural damage on the operated side 4 weeks after clip removal. After 12 weeks, these changes had decreased markedly and conventional histology had almost normalized.
  
  
  CONCLUSIONS
  Conventional and immunohistochemical stains confirmed that application of metal clips to the sympathetic chain caused severe histological damage in the sympathetic trunk that remained visible 4 weeks after clip removal. However, after 12 weeks, these signs of damage had clearly decreased, which suggests in theory that application of metal clips to the sympathetic chain is a reversible procedure if only the observation period is prolonged. Further studies with longer periods between application and removal as well as investigations of nerve conduction should be encouraged, because we do not know whether histological reversibility at cellular level translates into physiological reversibility and possible correlation of nerve trauma with the duration of the applied clip.
authors.affiliation: Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark.
authors.forename: Lars L
authors.initials: LL
authors.lastname: Thomsen
authors.affiliation: Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark.
authors.forename: Rasmus T
authors.initials: RT
authors.lastname: Mikkelsen
authors.affiliation: Department of Neurophysiology, Odense University Hospital, Odense, Denmark.
authors.forename: Miroslawa
authors.initials: M
authors.lastname: Derejko
authors.affiliation: Department of Clinical Pathology, Odense University Hospital, Odense, Denmark.
authors.forename: Henrik D
authors.initials: HD
authors.lastname: Schrøder
authors.affiliation: Department of Cardiothoracic Surgery, Odense University Hospital, Odense, Denmark peter.licht@rsyd.dk.
authors.forename: Peter B
authors.initials: PB
authors.lastname: Licht
mesh_terms: D000818:Animals; D015415:Biomarkers / Q000378:metabolism; D020878:Device Removal; D004867:Equipment Design; D005260:Female; D008670:Metals; D023421:Models, Animal; D009407:Nerve Block / Q000295:instrumentation* / Q000379:methods; D020127:Recovery of Function; D012086:Reoperation; D012756:Sheep; D013525:Surgical Instruments; D013562:Sympathectomy / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods; D013564:Sympathetic Nervous System / Q000378:metabolism / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D013906:Thoracoscopy / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods; D013997:Time Factors
chemical_list: D015415:Biomarkers; D008670:Metals
keywords: Experimental; Immunohistochemistry; Nerve block; Reversibility; Sympathectomy