The principle of total mesorectal excision (TME) standardizes the resection range and surgical dissection plane in radical rectal cancer surgery, reduces the local recurrence rate and improves the long-term survival. TME is the "gold standard" in radical rectal cancer surgery. However, with the progress of laparoscopic surgical instruments and techniques in recent years, further understanding of pelvic membrane anatomy and autonomic nervous system has been gained, which makes the surgical plane of TME more accurate and the autonomic nervous system better preserved. According to anatomical discovery and histological confirmation, there is a fascia between the mesorectal fascia and pelvic parietal fascia, called pre-hypogastric nerve sheath, in which autonomic nervous system courses, including the superior hypogastric plexus, left and right hypogastric nerves, pelvic plexus and the neurovascular bundles, from the abdominal to the pelvic cavity behind the mesorectal fascia. It fuses with the end of the mesorectum at the superior border of musculi puborectalis, and goes around the mesorectum to join with Denonvillier fascia. On the basis of anatomical studies and empirical anatomical observations, we put forward the concept of network preservation of the autonomic nervous system: the main trunk as well as the nerve branches of the pelvic autonomic nervous system and accompanying blood vessels should be preserved to ensure the integrity of the nerve reflex arc. The concept allows the radical resection of rectal cancer to follow the principle of TME, and meanwhile, protect patient's urination function and sexual function to the greatest extent, improving the quality of life of patients after surgery.
Autonomic Nervous System ; Humans ; Neoplasm Recurrence, Local ; Pelvis ; Quality of Life ; Rectal Neoplasms/surgery* ; Rectum

Harlequin syndrome is a rare disorder of the sympathetic nervous system characterized by unilateral facial flushing and sweating. Although its etiology is unknown, this syndrome appears to be a dysfunction of the autonomic nervous system. To the best of our knowledge, thus far, very few reports on perioperative Harlequin syndrome after thoracic surgery have been published in the thoracic surgical literature. Here, we present the case of a 6-year-old patient who developed this unusual syndrome following the resection of a posterior mediastinal mass.
Autonomic Nervous System ; Child ; Flushing ; Ganglioneuroma* ; Humans ; Sweat ; Sweating ; Sympathetic Nervous System ; Thoracic Surgery

The clinical effect of laparoscopic rectal cancer curative excision with pelvic autonomic nerve preservation (PANP) was investigated. This study evaluated the frequency of urinary and sexual dysfunction of 149 male patients with middle and low rectal cancer who underwent laparoscopic or open total mesorectal excision with pelvic autonomic nerve preservation (PANP) from March 2011 to March 2013. Eighty-four patients were subjected to laparoscopic surgery, and 65 to open surgery respectively. The patients were followed up for 12 months, interviewed, and administered a standardized questionnaire about postoperative functional outcomes and quality of life. In the laparoscopic group, 13 patients (18.37%) presented transitory postoperative urinary dysfunction, and were medically treated. So did 12 patients (21.82%) in open group. Sexual desire was maintained by 52.86%, un-ability to engage in intercourse by 47.15%, and un-ability to achieve orgasm and ejaculation by 34.29% of the patients in the laparoscopic group. Sexual desire was maintained by 56.36%, un-ability to engage in intercourse by 43.63%, and un-ability to achieve orgasm and ejaculation by 33.73% of the patients in the open group. No significant differences in urinary and sexual dysfunction between the laparoscopic and open rectal resection groups were observed (P>0.05). It was concluded that laparoscopic rectal cancer radical excision with PANP did not aggravate or improve sexual and urinary dysfunction.
Adult ; Autonomic Nervous System ; injuries ; Humans ; Laparoscopy ; adverse effects ; Male ; Middle Aged ; Peripheral Nerve Injuries ; etiology ; prevention & control ; Postoperative Complications ; Rectal Neoplasms ; surgery ; Sexual Dysfunction, Physiological ; etiology ; Urologic Diseases ; etiology

OBJECTIVETo further understand the anatomical basis of pelvic autonomic nerve preservation.

METHODSAutopsy of five adult male donated cadavers was performed. Meanwhile, ten videos of laparoscopic total mesorectal excision for male mid-low rectal cancer admitted from January to June 2012 were observed and studied. Anatomical features of pelvic autonomic nerve were compared between autopsy and laparoscopic appearance.

RESULTSAutopsy observations indicated that:the abdominal aortic plexus was situated upon the sides and front of the aorta, between the origins of the superior and inferior mesenteric arteries. The superior hypogastric plexus was a plexus of nerves situated on the the bifurcation of the abdominal aorta to sacrum; after incision of sacrum fascia was done cling to the sacrum; the pelvic splanchnic nerves and sacral splanchnic nerves were demonstrated; pelvic splanchnic nerves were splanchnic nerves that arised from ventral rami of the second, third, and often the fourth sacral nerves to provide preganglionic parasympathetic innervation to the hindgut;sacral splanchnic nerves providing postganglionic fibers, emerged from the sympathetic trunk, were then joined by the pelvic splanchnic nerves to form the inferior hypogastric plexuses which were placed lateral to the rectum.Laparoscopic observations showed that:abdominal aortic plexus and superior hypogastric plexus were unclear; at the level of sacroiliac joint, the hypogastric nerve began where the superior hypogastric plexus split into a right and left plexus, situated under the loose connective tissue, and continued inferiorly on its corresponding side of the body at the level of the 3rd sacral vertebra;left hypogastric nerve was closed to posterior of mesorectum;denonvilliers fascia was thin, reflective fascial structure, and easily removed together with mesorectum excision because of anterior loose structure.

CONCLUSIONSLigation of the inferior mesenteric artery at its origin is safe.Excessive dissection of the connective tissue covering the surface of the aorta should be avoided to protect the abdominal aortic plexus.Sharp dissection performed by pursuing the outer surface of the mesorectum maintaining the integrity of mesorectum, could avoid the superior hypogastric plexus and hypogastric nerves injury posteriorly, and protect the inferior hypogastric plexues while cutting lateral ligament laterally. The integrity of Denonvilliers fascia during anterior resection of rectum should be confirmed to avoid urogenitalis aparatus branches damage.

Adult ; Autonomic Nervous System ; anatomy & histology ; Autopsy ; Humans ; Laparoscopy ; Male ; Pelvis ; innervation ; Rectal Neoplasms ; surgery

PURPOSE: To observe the evolution of heart rate variability (HRV) in patients with palmar hyperhidrosis before and after endoscopic thoracic sympathotomy and to evaluate the effects of the surgery on the autonomic nervous system. MATERIALS AND METHODS: Endoscopic thoracic sympathotomy was performed on 20 patients with palmar hyperhidrosis. The thoracic sympathetic chain at the level of the third to fourth rib (R3-R4) was transected, but the ganglia were left in position without removal. A slightly larger ramus, in comparison to the other rami, that arose laterally from the sympathetic chain was interrupted to achieve adequate sympathetic denervation of the upper extremity. Before and on the day after the surgery, 24-hour Holter Electrocardiograph was performed, obtaining time domain and frequency domain parameters. RESULTS: Compared with preoperative variables, there was a significant increase in the number of adjacent normal R wave to R wave (R-R) intervals that differed by more than 50 ms, as percent of the total number of normal RR intervals (pNN50); root mean square difference, the square root of the mean of the sum of squared differences between adjacent normal RR intervals over the entire 24-hour recording; standard deviation of the average normal RR interval for all 5-minute segments of a 24-hour recording (SDANN) after thoracic sympathotomy. Low frequencies (LF, 0.04 to 0.15 Hz) decreased significantly. There was no statistical difference in high frequencies (HF, 0.15 to 0.40 Hz), LF/HF ratio (LF/HF), or standard deviation for all normal RR intervals for the entire 24-h recording (SDNN) before and after thoracic sympathotomy. CONCLUSION: There was a significant improvement in HRV in patients with palmar hyperhidrosis after thoracic sympathotomy. This may be attributable to an improvement autonomic nervous system balance and parasympathetic predominance in the early postoperative stage.
Adolescent ; Adult ; Autonomic Nervous System/*surgery ; Electrocardiography ; Female ; Heart Rate/*physiology ; Humans ; Hyperhidrosis/*surgery ; Male ; Thoracic Surgery, Video-Assisted/*methods ; Young Adult

BACKGROUNDVideo-assisted thoracic sympathetic block is an effective, safe, and minimally invasive method for treatment of primary hyperhidrosis. The purpose of this study was to decide which one of using electrocautery hook and titanium clip is the appropriate procedure for primary palmar hyperhidrosis by assessing the compensatory sweating (CS) and quality of life (QOL) of patients after sympathetic block.

METHODSBetween October 2007 to August 2010, 120 patients with primary palmar hyperhidrosis were randomly divided into two groups, electrocautery hook group (60 patients) and titanium clip group (60 patients). All patients were treated by sympathetic block at T4 level. The CS was graded based on severity and location; the QOL was classified to 5 different levels based upon the summed total scores (range from 20 to 100) before and after surgery. The variables were compared.

RESULTSThe postoperative follow-up period was 2 months. All patients were cured. Three patients in electrocautery hook group and 1 patient in titanium clip group had a unilateral pneumothorax on chest X-ray, but none of them was necessary to have chest drainage. Neither perioperative mortality nor serious complications such as cardiac arrhythmia or arrest were observed during the operation. No bradycardia or Horner's syndrome occured. CS was not more common in patients in titanium clip group than in those in electrocautery hook group (P = 0.001). Moderate and severe CS was few in all patients, and there was no significant difference between two groups (P = 0.193). Most of the patients feel a notable improvement of the the QOL; nevertheless, there was no significant difference between the groups (P = 0.588).

CONCLUSIONSBoth electrocautery hook and titanium clip used for sympathetic block at the T4 level are effective, safe, and minimally invasive for palmar hyperhidrosis. Because of the lower severity of CS and the similar improvements in the QOL after operation, we prefer to use of titanium clip for treating palmar hyperhidrosis.

Adult ; Autonomic Nerve Block ; instrumentation ; methods ; Female ; Humans ; Hyperhidrosis ; surgery ; Male ; Postoperative Complications ; Quality of Life ; Sweating ; physiology ; Sympathetic Nervous System ; surgery ; Titanium ; Treatment Outcome ; Young Adult

OBJECTIVETo evaluate the role of anterior decompression with resection of the posterior longitudinal ligament (PLL) on the cervical degenerative disease with sympathetic symptoms and to primarily validate our speculation on the mechanism of this entity.

METHODSForty-seven cases suffered from cervical spondylosis from 2002 to 2007 were retrospectively reviewed. The inclusive criteria were: (1) cervical myelopathy or radiculopathy or both secondary to cervical degenerative disease; (2) complaining of unexplainable and irrelievable sympathetic symptoms such as dizziness, vertigo, etc; (3) performed with anterior cervical decompression with PLL resection and internal fixation. The JOA scores were recorded and evaluated. The sympathetic symptoms were evaluated by both 20 points evaluation system and patient's satisfaction evaluation. The posterior longitudinal ligaments of 8 rabbits were harvested and stained by Sucrose-Phosphate-glyoxylic acid (SPG) to distinguish the sympathetic nerve fibers. The results were observed and evaluated by fluorescent microscope and Image-pro plus 5.0.

RESULTSAll the patients were followed up for 10 to 48 months. The JOA scores before operation were 12.6 and increased to 15.2 at the final follow up. The sympathetic symptoms evaluation was 6.0 before operation and 2.8 after. The satisfactory evaluation was excellent in 19 cases, good in 16, fair in 8 and poor in 4. The effective rate was 87.5%. The SPG stain showed that there were plenty of sympathetic post-ganglia fibers in the cervical PLL, which were distributed like a web, and there were more fibers distributed at the interspaced zone than at the vertebral body zone. The density of the sympathetic nerve fibers in the C(2/3), C(3/4) and C(4/5) were greater than those in C(5/6) and C(6/7); while the density in the shallow layer were greater than those in the deep layer.

CONCLUSIONSThe sympathetic nerve fibers distributed in the cervical PLL maybe another one significant factor causing sympathetic symptom of cervical spondylosis. The anterior cervical decompression with resection of PLL can relieve the sympathetic symptoms of the patients.

Adult ; Aged ; Animals ; Autonomic Nervous System Diseases ; etiology ; Decompression, Surgical ; methods ; Female ; Follow-Up Studies ; Humans ; Laminectomy ; Longitudinal Ligaments ; innervation ; surgery ; Male ; Middle Aged ; Rabbits ; Retrospective Studies ; Spinal Fusion ; methods ; Spinal Osteophytosis ; complications ; surgery ; Spondylosis ; complications ; surgery

BACKGROUNDCervical spondylotic myelopathy (CSM) is managed by conservative or surgical measures. While surgery is often performed in cases of longstanding or severe CSM, there is a lack of evidence concerning its efficacy. Transcranial magnetic stimulation (TMS) is a quick, safe, painless and non-invasive technique to study conduction in the descending corticospinal pathways in the spinal cord. The conduction time from the motor cortex to the anterior horn cell [central motor conduction time (CMCT)] is a measure of the integrity of corticospinal pathways. We have previously established the role of TMS in diagnosis and screening of CSM. In this study, we further investigate the use MEPs obtained with TMS in the outcome prediction of severe CSM patients requiring operative intervention.

METHODSWe prospectively evaluated 46 consecutive patients (mean age, 57.6 years; range, 36 to 84 years; 28 men) presenting with clinical features of CSM over a 2-year period. Disease duration ranged from 6 to 24 months. A total of 45 healthy controls were studied for comparison. All patients underwent clinical scoring. Patients' initial clinical score (S1) and postoperative scoring at 6 months (S2) were based on a modified Japan Orthopedic Association Scoring Scale. A Modified Recovery Rate (MRR) was calculated based on the formula: (S2 - S1/17 - S1) x 100. We regarded a good surgical outcome as MRR of 50 or above. This was depicted as MRR50. The patients were separated into 4 groups according to the degree of cord compression by degenerative osteo-cartilaginous elements at the most significant level on MRI. TMS studies were performed before surgery. Each investigator was blinded to the results of the other investigators.

RESULTSThe upper limb (UL) CMCT (r = -0.507, P <0.0005) and lower limb (LL) CMCT (r = - 0.452, P = 0.002) were significantly and negatively correlated with S1. Similarly, UL MEP amplitude (r = 0.494, P <0005) and LL MEP amplitude (r = 0.305, P = 0.039) were significantly correlated with S1. Surgery consisted of anterior or posterior decompression with cervical laminoplasty, performed by an experienced team of orthopaedic surgeons. No significant intraoperative or postoperative complications were documented. Surgery resulted in significantly improved clinical scoring (unpaired t test, P <0.0005). No correlation between clinical scoring with patients' age, disease duration, severity or levels of cord compression on MRI was found. ULCMCT and MEP amplitude abnormality were significantly associated with improvement in clinical scoring after surgery (Mann-Whitney test, P <0.05). The UL CMCT was the independent predictor of a good clinical outcome after surgery (odds ratio, 9.09; P = 0.011).

CONCLUSIONSIn early CSM, lateral corticospinal tracts are first to be affected. It is thus possible that UL CMCT abnormality reflect more severe affectation of the corticospinal tracts placed relatively more medially in the cervical cord. Surgical intervention may have then effectively relieved the clinically significant compression, leading to a better outcome. This was further corroborated by our finding of negative correlation of S1 with UL CMCT, suggesting that patients who were clinically more severe were also electrophysiologically more abnormal, and subsequently benefited more from surgical decompression relative to patients with normal UL CMCT. This the largest series, to our knowledge, showing for the first time that UL CMCT abnormality obtained with TMS is an independent predictor of good surgical outcome in severe CSM.

Adult ; Aged ; Aged, 80 and over ; Autonomic Nervous System ; Cervical Vertebrae ; physiopathology ; Electrophysiology ; Evoked Potentials, Motor ; Female ; Humans ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Prospective Studies ; Spinal Cord Compression ; diagnosis ; surgery ; Spinal Osteophytosis ; diagnosis ; physiopathology ; Transcranial Magnetic Stimulation

OBJECTIVETo evaluate the regional anatomy between the abdominal autonomic nerves including the abdominal aortic plexus (AAP) and the inferior mesenteric artery (IMA), and explore the safe ligation point on the IMA and the optimal dissection method to avoid autonomic nerve injuries.

METHODS AND RESULTSDissections and observation were carried out on 16 fixed male cadavers. The AAP located in the thin fascia layer covering the surface of the aorta and its branches. No autonomic nerves were found in the area around the root of the IMA, and the point where the IMA and the left trunk of the AAP intersected was highly variable. The left trunk of the AAP adhered more closely to the IMA than to the aorta.

CONCLUSIONSIn view of autonomic nerve preservation, the only safe site for ligation of the IMA is at its origin, and no other such sites are available along the IMA trunk and its branches. The IMA and the posterior fascia layer containing the autonomic nerves constitute the optimal surgical plane for IMA ligation, which should be performed following skeletonization of the IMA with careful preservation of the integrity of the posterior fascia layer.

Autonomic Pathways ; anatomy & histology ; surgery ; Cadaver ; Dissection ; methods ; Humans ; Ligation ; adverse effects ; methods ; Mesenteric Artery, Inferior ; surgery ; Preservation, Biological ; Rectal Neoplasms ; surgery ; Rectum ; surgery ; Trauma, Nervous System ; etiology ; prevention & control

OBJECTIVETo evaluate the impact on sexual function, local recurrence and survival after total mesorectal excision (TME) with autonomic nerve preservation (PANP) of rectal cancer.

METHODSOne hundred and five patients after TME with PANP were followed by means of questionnaire on postoperative genital function [TME + PANP(+) group], and the results of 110 patients after TME without PANP [TME + PANP(-) group] were compared with, also their local recurrence and 5-year survival were retrospectively analyzed.

RESULTSTME + PANP(+) group was compared to TME + PANP(-) group: the erection dysfunction, 33.3% vs 63.2%; the ejaculation dysfunction, 43.8% vs 70.0% (P < 0.01), there were significant differences between two groups, but no difference in local recurrent rate and 5-year survival rate (7.6% vs 5.5%; 63.4% vs 59.7%, P > 0.05).

CONCLUSIONThe TME with PANP of rectal surgery ensure the radical cure of rectal cancer, at the same time reasonably save the postoperative sexual function and obtain satisfactory postoperative survival.

Adult ; Aged ; Autonomic Nervous System ; injuries ; Follow-Up Studies ; Humans ; Male ; Mesentery ; surgery ; Middle Aged ; Neoplasm Recurrence, Local ; prevention & control ; Postoperative Complications ; prevention & control ; Rectal Neoplasms ; mortality ; surgery ; Retrospective Studies ; Sexual Dysfunction, Physiological ; etiology ; prevention & control ; Survival Rate ; Treatment Outcome