Minimally Invasive Sympathicotomy for Palmar Hyperhidrosis and Facial Blushing:Current Status and the Hyperhidrosis Expert Center Approach

Hyperhidrosis, the medical term for excessive sweating beyond physiological need, is a condition with serious emotional and social consequences for affected patients. Symptoms usually appear in focal areas such as the feet, hands, axillae and face. Non-surgical treatment options such as topical antiperspirants or systemic medications are usually offered as a first step of treatment, although these therapies are often ineffective, especially in severe and intolerable cases of hyperhidrosis. In the treatment algorithm for patients suffering from hyperhidrosis, surgical thoracoscopic sympathicotomy offers a permanent solution, which is particularly effective in the treatment of palmar hyperhidrosis and facial blushing. In this review, we describe the current status of thoracoscopic sympathicotomy for palmar hyperhidrosis and facial blushing. In addition, we share the specific treatment approach, technique and results of our Hyperhidrosis Expert Center. Last, we share recommendations to ensure an effective, reproducible and safe application of single-port thoracoscopic sympathicotomy for palmar hyperhidrosis and facial blushing, based on our extensive experience

S1P(1) Receptor Modulation Preserves Vascular Function in Mesenteric and Coronary Arteries after CPB in the Rat Independent of Depletion of Lymphocytes

BACKGROUND: Cardiopulmonary bypass (CPB) may induce systemic inflammation and vascular dysfunction. Sphingosine 1-phosphate (S1P) modulates various vascular and immune responses. Here we explored whether agonists of the S1P receptors, FTY720 and SEW2871 improve vascular reactivity after CPB in the rat. METHODS: Experiments were done in male Wistar rats (total n = 127). Anesthesia was induced by isoflurane (2.5-3%) and maintained by fentanyl and midazolam during CPB. After catheterization of the left femoral artery, carotid artery and the right atrium, normothermic extracorporeal circulation was instituted for 60 minutes. In the first part of the study animals were euthanized after either 1 hour, 1 day, 2 or 5 days of the recovery period. In second part of the study animals were euthanized after 1 day of postoperative period. We evaluated the contractile response to phenylephrine (mesenteric arteries) or to serotonin (coronary artery) and vasodilatory response to acethylcholine (both arteries). RESULTS: Contractile responses to phenylephrine were reduced at 1 day recovery after CPB and Sham as compared to healthy control animals (Emax, mN: 7.9 ± 1.9, 6.5 ± 1.5, and 11.3 ± 1.3, respectively). Mainly FTY720, but not SEW2871, caused lymphopenia in both Sham and CPB groups. In coronary and mesenteric arteries, both FTY720 and SEW2871 normalized serotonin and phenylephrine-mediated vascular reactivity after CPB (p<0.05) and FTY720 increased relaxation to acetylcholine as compared with untreated rats that underwent CPB. CONCLUSION: Pretreatment with FTY720 or SEW2871 preserves vascular function in mesenteric and coronary artery after CPB. Therefore, pharmacological activation of S1P1 receptors may provide a promising therapeutic intervention to prevent CPB-related vascular dysfunction in patients

Ensemble machine learning prediction and variable importance analysis of 5-year mortality after cardiac valve and CABG operations

Despite having a similar post-operative complication profile, cardiac valve operations are associated with a higher mortality rate compared to coronary artery bypass grafting (CABG) operations. For long-term mortality, few predictors are known. In this study, we applied an ensemble machine learning (ML) algorithm to 88 routinely collected peri-operative variables to predict 5-year mortality after different types of cardiac operations. The Super Learner algorithm was trained using prospectively collected peri-operative data from 8241 patients who underwent cardiac valve, CABG and combined operations. Model performance and calibration were determined for all models, and variable importance analysis was conducted for all peri-operative parameters. Results showed that the predictive accuracy was the highest for solitary mitral (0.846 [95% CI 0.812-0.880]) and solitary aortic (0.838 [0.813-0.864]) valve operations, confirming that ensemble ML using routine data collected perioperatively can predict 5-year mortality after cardiac operations with high accuracy. Additionally, post-operative urea was identified as a novel and strong predictor of mortality for several types of operation, having a seemingly additive effect to better known risk factors such as age and postoperative creatinine.Peer reviewe

Clinical Effectiveness of Centrifugal Pump to Produce Pulsatile Flow During Cardiopulmonary Bypass in Patients Undergoing Cardiac Surgery

Although the centrifugal pump has been widely used as a nonpulsatile pump for cardiopulmonary bypass (CPB), little is known about its performance as a pulsatile pump for CPB, especially on its efficacy in producing hemodynamic energy and its clinical effectiveness. We performed a study to evaluate whether the Rotaflow centrifugal pump produces effective pulsatile flow during CPB and whether the pulsatile flow in this setting is clinically effective in adult patients undergoing cardiac surgery. Thirty-two patients undergoing CPB for elective coronary artery bypass grafting were randomly allocated to a pulsatile perfusion group (n = 16) or a nonpulsatile perfusion group (n = 16). All patients were perfused with the Rotaflow centrifugal pump. In the pulsatile group, the centrifugal pump was adjusted to the pulsatile mode (60 cycles/min) during aortic cross-clamping, whereas in the nonpulsatile group, the pump was kept in its nonpulsatile mode during the same period of time. Compared with the nonpulsatile group, the pulsatile group had a higher pulse pressure (P <0.01) and a fraction higher energy equivalent pressure (EEP, P = 0.058). The net gain of pulsatile flow, represented by the surplus hemodynamic energy (SHE), was found much higher in the CPB circuit than in patients (P <0.01). Clinically, there was no difference between the pulsatile and nonpulsatile groups with regard to postoperative acute kidney injury, endothelial activation, or inflammatory response. Postoperative organ function and the duration of hospital stay were similar in the two patient groups. In conclusion, pulsatile CPB with the Rotaflow centrifugal pump is associated with a small gain of EEP and SHE, which does not seem to be clinically effective in adult cardiac surgical patients

Responses to phenylephrine (in mesenteric arteries), serotonin (in coronary artery), acetylcholine and sodium nitroprusside in Control, Sham and CPB following different recovery periods.

<p>Data are given as mean±SEM. Abbreviations: Ach, acetylcholine; CPB, cardiopulmonary bypass; Emax, the maximal response; PE, phenylephrine; SE, serotonine; SN, sodium nitroprusside; %- percent of the relaxation.</p><p><b>a</b>-P<0.05 vs Control, One-Way ANOVA with post-hoc Bonferroni test; <b>b</b>- p<0.05 vs Control, t\test.</p

Neutrophils, Lymphocyte and Monocyte counts in blood.

<p>Values were normalized to Hctc (10⁹/l at a Hctc of 0.4). Baseline values were obtained prior to administration of compounds. Abbreviations: CPB, cardiopulmonary bypass; baseline, 15 min after injection of the experimental compound of the vehicle; start ECC, 15 min before extracorporeal circulation; end ECC, 15 min after extracorporeal circulation; 24 h, scarification at 24 h later the end of the extracorporeal circulation.</p><p>a- p<0.05 vs Baseline, t-test; b- p<0.05 untreated CPB 24 h vs all other CPB untreated groups, One-Way ANOVA, Bonferroni test; c-p<0.05 vs Sham FTY720 baseline, One-Way ANOVA on ranks, Dunn's Method (SigmaStat); d- p<0.05 vs Sham FTY720 baseline, One-Way ANOVA, Bonferroni test; e- p<0.05 vs CPB FTY720 baseline, One-Way ANOVA, Bonferroni test; f- p<0.05, vs Sham SEW2871 baseline, One-Way ANOVA, Bonferroni test;</p><p>g- p<0.05 CPB SEW2871 24 h vs all other CPB2871 groups, One-Way ANOVA, Bonferroni test.</p

Contractile reactivity after short and long-term recovery following Sham or CPB.

<p><i>Left panels</i>: contractile reactivity of mesenteric arteries to PE. <b>A</b>: concentration-response curves for Sham groups, mN; <b>B</b>: concentration-response curves for CPB groups, mN; <b>C</b>: AUC values of the contractile responses to PE, au. <i>Right panels</i>: contractile reactivity of coronary arteries to SE. <b>D</b>: concentration-response curves for Sham groups, mN; <b>E</b>: concentration-response curves for CPB groups, mN; <b>F</b>: AUC values of the contractile responses to SE, au. Abbreviations: CBP, cardiopulmonary bypass; PE, phenylephrine; SE, serotonin. Data are mean±SEM. <b>a</b>- indicates P<0.05 vs Control-Vehicle, Repeated measurements ANOVA, Bonferroni test; <b>b</b>- indicates P<0.05 vs CPB-Vehicle, One Way ANOVA, Bonferroni test.</p

Acute Kidney Injury Classification Underestimates Long-Term Mortality After Cardiac Valve Operations

Background. Perioperative acute kidney injury (AKI) is an important predictor of long-term all-cause mortality after coronary artery bypass (CABG). However, the effect of AKI on long-term mortality after cardiac valve operations is hitherto undocumented. Methods. Perioperative renal injury and long-term allcause mortality after valve operations were studied in a prospective cohort of patients undergoing solitary valve operations (n = 2,806) or valve operations combined with CABG (n = 1,260) with up to 18 years of follow-up. Postoperative serum creatinine increase was classified according to AKI staging 0 to 3. Patients undergoing solitary CABG (n = 4,938) with cardiopulmonary bypass served as reference. Results. In both valve and valve+CABG operations, postoperative renal injury of AKI stage 1 or higher was progressively associated with an increase in long-term mortality (hazard ratio [HR], 2.27, p <0.05 for valve; HR, 1.65, p <0.05 for valve+CABG; HR, 1.56, p <0.05 for CABG). Notably, the mortality risk increased already substantially at serum creatinine increases of 10% to 25%-that is, far below the threshold for AKI stage 1 after valve operations (HR, 1.39, p <0.05), but not after valve operations combined with CABG or CABG only. Conclusions. An increase in serum creatinine by more than 10% during the first week after valve operation is associated with an increased risk for long-term mortality after cardiac valve operation. Thus, AKI classification clearly underestimates long-term mortality risk in patients undergoing valve operations. (C) 2018 by The Society of Thoracic Surgeon