Feasibility of endoscopic transesophageal thoracic sympathectomy (with video)

Background: Thoracoscopic sympathectomy is the preferred surgical treatment for patients with disabling palmar hyperhidrosis. Current methods require a transthoracic approach to permit ablation of the thoracic sympathetic chain.

Objective: To develop a minimally invasive, transesophageal endoscopic technique for a sympathectomy in a swine model.

Design: Nonsurvival animal study.

Setting: Animal trial at a tertiary care academic center.

Subjects: This study involved 8 healthy Yorkshire swine.

Interventions: After insertion of a double-channel gastroscope, a Duette Band mucosectomy device was used to create a small esophageal mucosal defect. A short, 5-cm submucosal tunnel was created by using the tip of the endoscope and biopsy forceps. Within the submucosal space, a needle-knife was used to incise the muscular esophageal wall and permit entry into the mediastinum and chest. The sympathetic chain was identified at the desired thoracic level and was ablated or transected. The animals were killed at the completion of the procedure.

Main outcome measurements: Feasibility of endoscopic transesophageal thoracic sympathectomy.

Results: The sympathetic chain was successfully ablated in 7 of 8 swine, as confirmed by gross surgical pathology and histology. In 1 swine, muscle fibers were inadvertently transected. On average, the procedure took 61.4+/-24.5 minutes to gain access to the chest, whereas the sympathectomy was performed in less than 3 minutes in all cases. One animal was killed immediately after sympathectomy, before the completion of the observation period, because of hemodynamic instability.

Limitations: Nonsurvival series, animal study.

Conclusions: Endoscopic transesophageal thoracic sympathectomy is technically feasible, simple, and can be performed in a porcine model.