Eguchi, Daihiko

Kawasaki, Katsumi

Komori, Kimihiro

Mawatari, Kyoutaro

Okadome, Kenichiro

Okazaki, Jin

Sadanaga, Noriaki

Sugimachi, Keizo

Elsevier - Publisher Connector 

Thoracoscopic sympathectomy for Buerger's disease of the upper extremities 

JOURNAL OF VASCULAR SURGERY 
344 Letters to the Editors September 1995 
that assure the return ofvenous blood from the lower limb 
to the heart. 
In early 1949, that is, about 2 years after I began to see 
hirn in the clinic, Jobst remrned for his usual monthly 
examination. He did not have his Sooey boot on but 
instead was wearing a light-weight, knitted, knee-length 
hosiery. His stasis ulcer was markedly improved. 
In answer to my astonished inquiry, he explained that 
he had fabricated the stocking on the principle of "gra- 
dient pressure." Because he understood that the problem 
of his venous circulation was the lack of functional valves, 
he conceived that the blood in his leg will require a 
constricting pressure that was greater near the ankle than 
it is near any given level above; this would provide an 
upward driving force. Thus he constructed a pattern or 
template by measuring at several evels about 11/2 inches 
apart the circumference of bis leg from the anlde to the 
knee and then reduced the measures of circumference as
he proceeded from the ankle to the ka~ee, thus ereating 
a propelling force upward. He had some problem before 
he found a light-weight knitted material for making the 
stocking. The first phase of the fabrication of the stockäng 
consisted of a flat piece of t:abric with a width that varied 
according to the principle mentioned above and which 
then was simply sewn together as a seam in the back of 
the leg. He had to try several degrees of compression 
before he settled on the measurements that he found both 
comfortable and effective. 
For the use of those who wished to be fitted with the 
new support, he stamped out a yard-long paper tape 
measure with side-tails for estimating the circumference of
the limb at various levels. (The tape was in use for many 
years.) The approach, of course, may have been unsophis- 
ticated but the result was unmistakably excellent, and only 
a fool would have overlooked its practical value. 
I myselfwas impressed and encouraged Jobst's plan to 
make the invention available for medical use. At this point 
I began graduaUy to become Jobst's consultant in ethical 
promotion. He first wanted to advertise his product in the 
daily newspapers and commercial publications. I pointed 
out that the nature of the device in itself would make this 
type of popularization impractical and even risky. The 
efficient performance of the device depended on individual 
fitting, and this requirement made buying it over the 
counter virtually impossibte. The long range success of the 
product, I said, would depend on being accepted by 
physicians who could provide individual fitting. But first 
the effectiveness of this new tool had to be proven. I gave 
Jobst the list of names of surgeons in the near Midwest 
(from the roster of the Central Surgical Association) with 
advice that he visit as many of these as he could and leave 
with them samples, requesting at the same time the favor 
of a written testimony if they found it as claimed. In the 
possession of a sufficient number of endorsements hethen 
could apply to the Committee on Physical Appliances of 
the Amcrican Medical Association (AMA) (long since 
discontinued) and request approval. With this approval he 
could advertise the stocking in ethical medical journals and 
in particular in the Journal of the American Medical 
Association. 
Jobst accepted this way to proceed. During the first few 
months, while he was popularizing his device, he showed 
persistence and energy seldom seen. He taust have visited 
dozens of doctor's oft]ces and eventually collected the 
endorsements needed for the approval of the AMA 
committee. 
Orte more episode in this historical retrospective that 
is perhaps worth recording was an offer in 1953 or 54 
by Jobst to me to become a partner in his firm (by then 
highly successful). I politely refused, and he did not seem 
to be offen&d, but afterwards our relationship ercep- 
Uvely cooled. Of course, our doctor-patient association 
had ceased earlier because his ulcer had healed, lobst later 
became sick with kidney d_isease and died of it in 
1957. 
It would be a very sensible question to ask why I have 
not made public earlier this connection with a modest but 
highly beneficial invention that was also a spectacularly 
successful commercial venture. Perhaps the main reason 
was that I always considered my relation with Jobst a 
personal rather than medical or scientific or commercial 
one, and I have never liked making personal matters public. 
But I taust also confess that I, almost subconsciously, 
underrated the medical significance of the entire episode. In 
the mid 1950s when Jobst's enterprise became aworldwide 
success, I was involved in a great adventure: surgery of the 
arteries. It was a common conceit among those who 
participated in the early history of modern vascular surgery 
to look at superficial venous disease as a problem worthy of 
little attention. In retrospect, his was a mistake. 
D. Emerick Sz~Tagyi, MD 
Division of Vascular Surgery 
Henry Ford Hospital 
2799 W. Grand Blvd. 
Detroit, MI 48202 
24/41/65663 
Thoracoscopic sympathectomy for Buerger's disease 
of  the upper extremities 
To the Editors: 
With the development of arterial reconstruction tech- 
niques, the optimal surgical therapy for chronic arterial 
occlusive disease has shifted from sympathectomy to direct 
revascularization. However, sympathectomy is still widely 
used in the treatment of Buerger's disease because arterial 
reconstruction is frequcntly not feasible because of the 
peripheral localization of the lesions. 
New endoscopic instruments and imaging equipment 
have recently made thoracoscopic surgery feasible. Tho- 
racoscopy provides a wide view of the pleural cavity and 
mediastinum and has been shown to be useful for 
resection of lung bullae, 2for the dissection of mediastinal 
cysts, and for thoracic sympathectomy in patients with 
hyperhidrosis. ~-S However, little information is available 
about the utility of thoracic sympathectomy for patients 
JOUKNAL OF VASCULAR SURGERY 
Volume 22, Number 3 Letters to the Editors 345 
Tab le  I .  Demograph ics  o f  pat ients 
Case Age (yrs O Sex History of smoking Symptom 
1 29 M + Rest pain 
2 35 M + Dry gangrene 
3 35 M + Rest pain 
4 42 M + Ulcer 
5 33 F + Ulcer 
6 48 M + Dry gangrene 
7 38 M + U/cer 
8 60 M + Dry gangrene 
9 48 M + Rest pain 
10 42 M + Ulcer 
11 28 M + Ulcer 
12 37 M + Ulcer 
13 29 M + Ulcer 
M, Male; F, female. 
The patients in cases 1 to 7 underwent open sympathectomy, whereas the patients in cases 8 to 13 underwent endoscopic sympathectomy. 
Tab le  I I .  In t raoperat ive  and postoperat ive  parameters  
' Operation time Duration of Postoperative Additional 
Case (min) drainage hospitalization treatment Complication +
1 110 2 days 11 days ( - )  (+) 
2 155 2 days 14 days Amputation ( - )  
3 90 2 days 12 days ( - ) ( + ) 
4 90 3 days 14 days ( - ) ( + ) 
5 80 2 days 10 days ( - ) ( + ) 
6 85 3 days l l  days ( - )  ( - )  
7 68 5 days 13 days ( - )  ( - )  
8 102 1 day 9 days Amputation ( - )  
9 75 1 day 6 days ( - ) ( - ) 
10 100 1 day 8 days ( - )  ( ) 
I I  70 3 days 7 days Skin graft ( - )  
12 90 1 day 7 days ( - )  ( - )  
13 95 2 days 7 days ( - )  ( - )  
qndicates difficulty elevating the upper extremity as a result of pain at the operative site. 
The patients in cases 1 to 7 underwent open sympathectomy, whereas the patients in cases 8 to 13 underwent endoscopic sympathectomy. 
with Buerger's disease. The purpose of this study was to 
compare retrospectively the efficacy of endoscopic tho- 
racic sympathectomy with that of open thoracic sympa- 
thectomy. 
In the period from January 1987 to December 1994, 
13 consecutive patients (12 men and i woman) underwent 
thoracic sympathectomy (Table I). The first seven patients 
underwent open thoracic sympathectomy (group 1). The 
remaining six underwent thoracoscopic sympathectomy 
(group 2). In group 1, the average patient age was 
37.1 _+ 2.4 years (range 29 to 48 years). In group 2, the 
average patient age was 40.7 _+ 5.0 years (fange 28 to 60 
years). There were no significant differences between the 
two groups. 
All of the patients had a history of smoking. Indi- 
cations for surgery included gangrene or ulcer (76.9%), 
rest pain (92.0%), and coldness or paresthesia (84.6%). 
Pulsations of the radial artery were palpable in the 11 of 
13 patients. Preoperative angiography demonstrated oc- 
clusion of the radial and digital arteries in the two patients 
who did not have palpable pulses (patients 8 and 10). 
In the 11 other patients, the digital artery was occluded 
or narrowed. 
After the operations, all patients demonstrated satis- 
factory clinical responses to sympathectomy asmanifested 
by a warm, dry hand and upper extremity. There were no 
perioperative deaths. 
The estimated blood loss was low in both groups 
(group 1, 91.7 _+ 24.8 ml; group 2, 30.0 -+ 3.7 ml). The 
difference between the groups was statistically signif- 
icant. No blood transfusions were required. There were 
no significant differences in operative time between the 
two groups (Table II). All of the patients resumed a 
normal diet on the first postoperative day. The duration 
of chest tube drainage was 2.7 _+ 0.4 days in group 1 
and 1.5 _+ 0.3 days in group 2 (p < 0.05). The postop- 
erative hospitälization was significantly shorter in group 
2 (7.3 +_ 0.4 days) compared with group 1 (12.1 -+ 0.6 
days) (p < 0.05). 
Additional treatment was required for nonhealing 
JOURNAL OF VASCULAR SURGERY 
346 Letters to the Editors September 1995 
ulcers or gangrene, including amputation at the distal 
interphalangeal joint (n = 2), or skin grafting (n = 1). 
There were no complications in group 2. In Group 1, one 
patient had atelectasis, and four (57.1%) had difficulty 
elevating the upper extremity as a result of pain at the 
operative site. 
Buerger's disease is characterized by peripheral arterial 
occlusions in the extremities of young smokers. True 
Buerger's lesions in locations other than the extremities are 
rare. Mthough the incidence of the disease is low in Europe 
and the United States, it is still one of the most important 
problems in vascular surgery in Asia becanse of its high rate 
of occurrence in chronic peripheral arterial occlusive 
disease. 1
To our knowledge, this is the first report comparing 
the efficacy of thoracoscopic and open thoracic sympa- 
thectomy for Buerger's disease of the upper extrem- 
ities. Thoracoscopic sympathectomy was successful in all 
of these cases, and out patients were satisfied with the 
eärly postoperative outcome, although three patients 
needed an additional treatment such as amputation or skin 
grafting. 
On the basis of our experiences, the advantages of 
thoracoscopic sympathectomy include lower operative 
losses, shorter duration of chest tube drainage, less pain, 
shorter hospitalization, superior cosmetic results, and a 
better outcome. Thoracoscopic sympathectomy should be 
the treatment of choice for patients with Buerger's disease 
of the upper extremities. 
IGmihiro Komoß MD, PhD 
Katsumi Kawasaki, dVLD 
Jin Okazaki, B/ID 
Daihiko Eguchi, AffD 
Kyoutaro zl4awatari, MD 
I@nichiro Okadome, MD, PhD 
Noriaki Sadanaga, Md) 
Keizo Sugimachi, A/AD, PhD 
The Second Department of Surgery 
Faculty of Medicine 
Kyushu University 
Department of Surgery 
Saiseikai Fukuoka Sogo Hospital 
Fukuoka 812, Japan 
REFERENCES 
1. Shionoya S. Buerger's disease: pathology, diagnosis and 
treatment. Nagoya: The University of Nagoya Press, 1990. 
2. Bagnato VJ. Treatment of recurrent spontaneous pneumotho- 
rax. Surg Laparosc Endosc 1992;2:100-3. 
3. Byrne I, Walsh TN, Hederman WP. Endoscopic transthoracic 
electrocautery of the sympathetic chain for palmar and axillary 
hyperhidrosis. Br I Surg 1990;77:1046-9. 
4. Herbest F, Plas EG, Fugger R, Fritsch. Endoscopic thoracic 
sympathectomy forprimary hyperhidrosis ofthe upper lirnbs. 
Ann Surg 1994;1:86-90. 
5. Ahn SS, Machleder HI, Concepcion B, Moore W. Thoraco- 
scopic cervicodorsal sympathectomy. Preliminary results. 
J VASC SURG 1994;20:511-9. 
24/41/65970 


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Thoracoscopic sympathectomy for Buerger's disease of the upper extremities

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