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±24.5minutes to gain access to the chest, whereas the sympathectomy was performed in less than 3minutes 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.