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The Influence of Sympathectomy on The Gastrointestinal Tract
THE INFLUENCE OF SYMPATHECTOMY ON THE GASTROINTESTINAL TRACT WINCHELL McK. CRAIG, CARL
G.
MORLOCK AND NICHOLAS C.
HIGHTOWER, JR.
The adoption of operations upon the sympathetic nervous system in the treatment of essential hypertension and peripheral vascular disease has created serious and widespread concern that the procedures may have a deleterious effect upon the gastro-intestinal tract. This is based upon the known relationship between the sympathetic nervous system and the gastm-intestinal tract, namely, that the sympathetic fibers carry motor inhibitory impulses to, and visceral afferent pain impulses from, the gastro-intestinal tract. As early as 1930 Adson began to section the spinal nerves intervertebrally, and in 1932 one of us (Craig3 ) was the first to section the splanchnic nerves for the relief of hypertension. This resection of the splanchnic nerves and first lumbar sympathetic ganglia was modified in 1934 by Adson and associates2 who increased the scope of the operation to include the splanchnic nerVBS, a portion of the celiac ganglion and the lumbar sympathetic ganglia. This procedure became known as "subdiaphragmatic sympathectomy." Peet in 1933 began removing a portion of the sympathetic nervous system above the diaphragm. He removed the tenth, eleventh and twelfth thoracic ganglia with an associated amount of the splanchnic nerves. This procedure became known as "supradiaphragmatic sympathectomy." Smithwick in 1940 combined the subdiaphragmatic and supradiaphragmatic procedures and found that this operation, being more extensive in its surgical scope, allowed for greater denervation of the vascular tree and therefore produced a more marked physiologic effect. Grimson in 1941 recommended the removal of the entire thoracolumbar chain of ganglia and the splanchnic nerves. Thus we see that, extending over a period of years, surgical procedures on the sympathetic nervous system for the treatment of hypertension have varied in extent. The relief of pain in the upper part of the abdomen and particularly that associated with chronic pancreatitis by sectioning the splanchnic nerves has been described by one of us (Craig). This stimulated extensive discussion, and the possibility was suggested that sympathectomy may remove the protective mechanism of pain appreciation which this nerve supply affords, thereby subjecting the patients to the danger of acute abdominal complications. Recently the literature has contained reports of cases in which painless perforation of abdominal viscera as well as sudden gastro-intestinal hemorrhage without previous symptoms have occurred following sympathectomy. From these observations, the questions that have arisen have been: "What are we doing to a patient besides treating his hypertension?" and "What is the incidence of gas1035
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w.
M. CRAIG, C. G. MORLOCK, N. C. HIGHTOWER, JR.
tro-intestinal complications in cases in which sympathectomy has been performed?" Our investigation was undertaken to see if we could offer at least a partial answer to these questions. METHOD OF STUDY
We reviewed 963 cases in which sympathetic ganglionectomy and splanchnic resection had been done in a fifteen-year period, namely
• y,y.;.::....-._ ......
'1
i
a.
~--------~'~
,,
,, ,
I
i
i
i' Thoraco> lumbar
.subdiaphragmatic .
! I
',._._.-
Fig. 272. Diagram illustrating the anatomy of the sympathetic nervous system. Dotted and broken lines indicate surgical procedures.
from 1935 to 1949, inclusive. In all but one of these cases, the procedure was done for the relief of severe hypertension. The one exception was a case of locomotor ataxia and gastric crises. This was included in this series because of an associated duodenal ulcer. During the fifteen-year period, the extent of the sympathectomy has changed. In some of the cases only a sUbdiaphragmatic sympathectomy was performed while in others a thoracolumbar type of procedure was performed. We have, therefore, divided our material into these 2 categories, Figure 272 illus-
1037
SyMPATHECTOMY AND GASTRO-INTESTINAL TRACT
trates the anatomy of the sympathetic nervous system involved and the extent of the surgical procedures under discussion. The histories of patients who were known to have had gastro-intestinal disease before an operation on the sympathetic nervous system was performed and the histories of those in whom some gastro-intestinal disease exclusive of malignant disease developed after sympathectomy were carefully studied. There were 22 patients with proved organic disease of the gastrointestinal tract. Twenty of these had duodenal ulcer, 1 patient had a gastrojejunal ulcer and 1 had chronic ulcerative colitis. Thus, the term "gastro-intestinal disease" refers to duodenal ulcer except in these 2 instances. The presence of ulcer was proved roentgenographically in each case. TABLE 1 EFE'ECT OF SUBDIAPHRAGMATIC AND THORACOLUMBAR SYMPA'l'HECTOMY ON THE GASTRO-INTESTINAL TRACT
Type of Sympathectomy Group
1. 2. 3. 4.
Symptoms Symptoms Symptoms Symptoms
Subdiaphragmatic
Thoracolumbar
4 1 5 3
3 2 3 1
developed only after sympathectomy ... worse after sympathectomy ......... ... unaltered after sympathectomy .... .... improved after sympathectomy ..... ....
-------------------------- ------ -----Totals ..... ........ . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . 13 9 I
CLASSIFICATION OF CASES
The 22 cases were separated into 2 main categories: (1) those in which a subdiaphragmatic sympathectomy was performed, and (2) those in which a thoracolumbar sympathectomy was performed. Each category was further divided into 4 groups as follows: group 1 includes cases in which no known gastro-intestinal disease was present before sympathectomy but in which symptoms developed for the first time after sympathectomy; group 2 includes cases in which known gastro-intestinal disease became worse after sympathectomy; group 3 includes cases in which known gastro-intestinal disease was unaltered by sympathectomy, and group 4 includes cases in which known gastro-intestinal disease improved after sympathectomy (table 1). SUBDIAPHRAGMATIC SYMPATHECTOMY
Group 1. No Known Gastro-intestinal Disease Until After Subdiaphragmatic Sympathectomy. There were 4 cases in the group. In all of these cases symptoms of duodenal ulcer developed for the first time sub-
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M. CRAIG, C. G. MORLOCK, N. C. HIGHTOWER, JR.
sequent to the sympathectomy, and the lesion was later proved to be present roentgenographically. The onset of symptoms of duodenal ulcer occurred soon after the first stage of the sympathectomy in 1 case; and in the other 3 cases, the symptoms occurred one, two and nine years respectively after the operation. Three of the four patients had distress typical of duodenal ulcer; in one case, the symptoms were atypical and mild. The onset of symptoms in 1 case was associated with an acute free perforation nine years after the sympathectomy. Bleeding was the initial symptom of ulcer in 1 case. The following case is representative of this group. CASE 1. The first stage of a subdiaphragmatic sympathectomy was performed on a man, aged 44 years, in May, 1942, for the relief of essential hypertension. With the exception of the hypertension, his health had been excellent. He had not had any symptoms of gastro-intestinal disease. On the seventh postoperative day he began to complain of nausea, and he vomited several times. On the fifteenth postoperative day the second stage of the sympathectomy was done. Following this he again had several episodes of nausea and vomiting, and transient gastric retention developed. After the patient returned home, "heartburn" and ulcer-like dyspepsia developed. The gastric distress occurred two to three hours after meals, especially after the patient had eaten highly spiced foods. It was relieved by the use of antacids. The patient returned to the Clinic in 1944. He said that his gastric symptoms had persisted. The symptoms were episodic and characteristic of ulcer. A roentgenologic examination demonstrated the presence of a duodenal ulcer.
Group 2. Gastro-intestinal Disease Increasing in Severity After Subdiaphragmatic Sympathectomy. There was but 1 case in this group. CASE 2. A thirty-nine year old man came to the Clinic in February, 1937, because of hypertension and indigestion. For five years he had had recurrent dyspepsia associated with epigastric burning. The distress had occurred two or three hours after meals and had been relieved by food, milk or soda. A duodenal ulcer was demonstrated roentgenologically. A subdiaphragmatic sympathectomy was done because of the presence of essential hypertension. Seven months after the sympathectomy, the patient had a severe gastro-intestinal hemorrhage which required hospitalization and multiple transfusions of whole blood. In September 1938, another gastro-intestinal hemorrhage occurred. The patient was last seen in 1939 when it was found that he still had symptoms of an active duodenal ulcer even though he had carefully followed an ulcer regimen.
Group 3. Gastro-intestinal Disease Unaltered by Subdiaphragmatic Sympathectomy. There were 5 cases in this group. All of the 5 patients were known to have had a duodenal ulcer previous to sympathectomy. In all of the 5 cases, the symptoms of duodenal ulcer were unaltered by the sympathectomy. The following case is typical of this group. CASE 3. A forty-seven year old man gave a history typical of duodenal ulcer of eight to ten years' duration, and the ulcer was demonstrated roentgenographi" cally when the patient was first seen at the Clinic in 1937. He had had hema-
SYMPATHECTOMY AND GASTRO-INTESTINAL TRACT
1039
temesis in 1936. A subdiaphragmatic sympathectomy was done in June, 1937, for severe essential hypertension. The postoperative convalescence was uneventful. The patient was seen again in 1940 and in 1941. On those occasions he stated that his ulcer symptoms had continued unchanged. In 1943, he had a severe gastro-intestinal hemorrhage. After this, a small gastric ulcer and a duodenal ulcer were demonstrated by roentgenoscopy. A partial gastric resection was performed. The symptoms which this patient had after sympathectomy were practically identical with those he experienced prior to sympathectomy. Bleeding from the ulcer occurred both prior to the sympathectomy and after it. The fact that a small gastric ulcer was found in addition to the duodenal ulcer six years after the sympathectomy can hardly be construed as being significant since multiple lesions in ulcer-bearing patients are not uncommon. Group 4. Gastro-intestinal Disease Improved After Subdiaphragmatic Sympathectomy. This group included 1 case of gastrojejunal ulcer, 1 case of duodenal ulcer and 1 case of chronic ulcerative colitis. Symptoms of gastro-intestinal disease in each case improved after the sympathectomy. As illustrative of this group we cite the following case. CASE 4. A forty-four year old man had had stomach trouble for many years. This had consisted of burning epigastric pain which had been relieved by food. In 1935 he had had a gastro-intestinal hemorrhage and symptoms of pyloric obstruction had developed. A gastro-enterostomy had been done for an obstructing duodenal ulcer. After this, he had continued to have intermittent ulcer distress, and he again had had severe bleeding in 1936 and 1944. He was first seen at the Clinic in June of 1946. A roentgenogram at that time revealed a gastrojejeunal ulcer. Because of a severe essential hypertension, a subdiaphragmatic sympathectomy was done. The immediate postoperative course was uneventful. Two years after the sympathectomy, the patient returned to the Clinic. He said that he had not had any symptoms of ulcer since the sympathectomy. Roentgenogra,phic examination at that time revealed a duodenal deformity due to a previous ulcer; the pylorus was patent, and the gastro-enteric stoma was freely functioning. There was no evidence of gastrojejunal ulceration. THORACOLUMBAR SYMPATHECTOMY
Group 1. No Known Gastro-intestinal Disease Until After Thoracolumbar Sympathectomy. There were 3 cases in this group and none of the patients had had symptoms of gastro-intestinal disease prior to the sympathectomy. In all of the 3 cases, symptoms characteristic of duodenal ulcer developed after operation, and the presence of a duodenal ulcer was proved by roentgenography. The following case is cited as characteristic of this group. CASE 5. A thirty-nine year old man came to the Clinic in July, 1946, because of severe hypertension of seven years' duration. He said that he had not had any gastro-intestinal symptoms at any time. An extensive thoracolumbar sympathectomy was done for the relief of the hypertension. He made an excellent recovery
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M. CRAIG, C. G. MORLOCK, N. C. HIGHTOWER, JR.
from this operation. He was seen for a follow-up examination in November of 1947. It was found then that epigastric pain characteristic of ulcer had developed four months previously. Three days after the onset of this symptom, he had severe hematemesis and melena which had required hospitalization and transfusions of blood. He continued to have periodic burning epigastric pain which occurred when his stomach was empty and the pain was relieved by taking food and soda. A roentgenogram of the stomach and duodenum revealed a duodenal ulcer. His symptoms were alleviated fairly well by means of a strict ulcer regimen. In March of 1948, these symptoms returned, and in November of that year he had another episode of melena. When last heard from in 1949, he reported that he was having continued trouble with recurrent episodes of ulcer pain. The pain which the patient described was typical of ulcer and indistinguishable from that which one would expect to find in a case of duodenal ulcer in which the sympathetic pathways are intact.
Group 2. Gastro-intestinal Disease Increasing in Severity After Thoracolumbar Sympathectomy. There were 2 cases in this group. One of these is cited. CASE 6. A forty-four year old woman came to the Clinic in May of 1947 because of severe hypertension. She gave a history of having had periodic severe recurrent epigastric distress characteristic of duodenal ulcer for twenty years. These symptoms had followed an acute free perforation which was closed surgically. A roentgenogram of the stomach and duodenum revealed a duodenal ulcer. On June 18, 1947, a right thoracolumbar sympathetic ganglionectomy and splanchnic resection was done. Four days after this operation, sudden severe pain developed in the right lumbar area lateral to the third lumbar vertebra. The pain at first extended into the rightlower quadrant of the abdomen and later shifted to the epigastric region just below the xiphoid process. The clinician who saw her felt that her pain was characteristic of that seen in cases in which duodenal ulcer penetrates to involve the head of the pancreas and mesocolon. An ulcer regimen caused the symptoms to subside. On July 9,1947, a left extensive thoracolumbar sympathetic ganglionectomy and splanchnic resection was done. A few days later, there was a severe recurrence of pain in the epigastrium and in the left hypochondrium. This pain was of a steady boring character, and marked tenderness and voluntary spasm were present in the epigastrium and in the left hypochondrium. This distress again responded satisfactorily to a strict ulcer regimen. At the time of her dismissal from the Clinic, the ulcer symptoms were under complete control.
It is interesting that in this case the ulcer symptoms were severe and that the pain appeared to be aggravated rather than relieved by the sympathectomy. .
Group 3. Known Gastro-intestinal Disease Unaltered by Thoracolumbar Sympathectomy. There were 3 cases in this group. In each case the ulcer symptoms were unaltered by the sympathectomy. The following case report is illustrative of this group. CASE 7. A thirty-five year old man came to the Clinic because of severe essential hypertension. For many years he had had indigestion characterized by epigastric burning and "heartburn" which had occurred after meals and had
SYMPATHECTOMY AND GASTRO-INTES'l'INAL TRACT
1041
been relieved by soda but not by food. He occasionally had experienced pain at night. A roentgenogram of the stomach and duodenum revealed a duodenal ulcer. In February, 1947, a thoracolumbar sympathectomy was done for the relief of the hypertension. When he returned for a recheck in December of 1949, he said that he had continued to have recurrent epigastric burning similar to that which he had had prior to the sympathectomy. This distress, as before, was relieved by soda but not by food. A roentgenogram of the stomach and duodenum again revealed a duodenal ulcer.
Group 4. Gastro-intestinal Disease Improved After Thoracolumbar Sympathectomy. There was but 1 case in this group. CASE 8. The patient was a man fifty years of age who came to the Clinic in May, 1946, because of severe essential hypertension. He gave a history of epigastric distress of seven years' duration. The pain had been seasonal in occurrence and had been most severe in the early morning and often had wakened him from sleep. It had been relieved promptly by milk and antacids. Roentgenologic examination disclosed a duodenal ulcer. A thoracolumbar sympathectomy was done in July, 1946, for the relief of the hypertension. In July of 1947, the patient returned and said that he had not adhered to any dietary regimen since his operation. He had taken no food between meals and had not used any antacids. He also said that during all of that time he had not had any indigestion whatsoever. COMMENT
The view that sympathectomy may remove a protective mechanism, so exposing the patient to the risk of gastro-intestinal disease or a complication of pre-existing gastro-intestinal disease, does not seem well founded in the light of our findings. In 2 of the 7 cases in which symptoms of duodenal ulcer developed for the first time after sympathectomy, the initial symptom was painless bleeding. In both cases this occurred approximately one year after sympathectomy and was followed by typical ulcer distress. This is not an uncommon event, for Bockus has said that approximately 25 per cent of patients at the time of their initial ulcer hemorrhage will deny the existence of prodromal ulcer symptoms. Eusterman and Morlock also have reported that the initial or sole symptom of duodenal ulcer is painless bleeding in 5 per cent of patients with this disease. The initial symptom of 1 patient in this group was an acute free perforation. This complication occurred nine years after the sympathectomy and few prodromal symptoms were present. Bockus states that in approximately 25 per cent of cases of perforated peptic ulcer no previous history of stomach trouble is given. The fact that duodenal ulcer was found for the first time following sympathectomy in only 0.74 per cent of the 963 cases reviewed suggests that there is probably no relationship between sympathectomy and the development of duodenal ulcer. The fact that 3 patients with duodenal ulcer became worse after sympathectomy and 3 improved after the operation and that the symptoms in 8 cases were
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M. CRAIG, C. G. MORLOCK, N. C. HIGHTOWER, JR.
unaltered lends further evidence that the sympathectomy does not exert a baneful influence on the course of duodenal ulcer. In one patient with a gastrojejunal ulcer and in one with chronic ulcerative colitis, the symptoms became less severe or disappeared completely. This is not an unusual event for it is known that in both peptic ulcer and chronic ulcerative colitis remissions of the disease are the rule rather than the exception. When the 22 cases of gastro-intestinal disease were divided into 2 categories, it was apparent that the per cent of cases in each group was essentially the same. This lends support to the impression that a more extensive sympathectomy does not expose the patient to an increased risk of gastro-intestinal complications. A follow-up by letter of a large series of patients who had undergone sympathectomy for hypertension was also made. It is interesting and significant, we believe, that in all cases the answers received to the inquiries indicated that few patients complained of gastro-intestinal symptoms. Our findings indicate that sympathectomy as carried out for the relief of hypertension has little effect on the gastro-intestinal tract. This is probably explained by the fact that the surgical procedures now employed for the relief of hypertension do not completely denervate the gastro-intestinal tract of its sympathetic nervous supply. The fact that 17 out of 20 patients with duodenal ulcer had symptoms that we would consider characteristic of the disease does not indicate that pain appreciation has been removed by this type of sympathectomy. SUMMARY
We have reviewed 963 cases in which sympathectomy was performed. in all but 1 case the sympathectomy was done for the relief of severe essential hypertension. In this large group, there were only 22 cases of proved gastro-intestinal disease. Of the 22 patients with gastro-intestinal disease, twenty had duodenal ulcer, one had a gastrojejunal ulcer and one had chronic ulcerative colitis. Symptoms of duodenal ulcer developed for the first time following sympathectomy in 7 (0.74 per cent) of the 963 cases. There were 14 cases in which duodenal ulcer was known to have been present before sympathectomy. In 8 of these cases, the symptoms were unaltered; in 3 cases, the symptoms became worse and in 3 cases, the symptoms became less severe. In 1 case each of gastrojejunal ulcer and chronic ulcerative colitis, the symptoms became less severe after sympathectomy. In an analysis of 20 cases in which duodenal ulcer existed prior to sympathectomy or developed after this procedure, the symptoms were found to be entirely characteristic of this disease in 17 cases. The results of this investigation would neither suggest that a sympathectomy exposes a patient with known gastro-intestinal disease to an increased hazard of complications nor that it predisposes to the development of gastro-intestinal disease.
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REFERENCES
i:
1. Bockus, H. L.: Gastroenterology. Philadelphia, W. B. Saunders Company, 1943, vol. 1, 831 pp. 2. Brown, G. E., Craig, W. McK. and Adson, A. W.: The Treatment of Severe Essential Hypertension; Effects of Surgical Procedures Applied to the Sympathetic Nervous System. Minnesota Med. 18 :132-138 (Mar.) 1935. 3. Craig, W. McK. and Brown, G. E. : Resection of the Splanchnic Nerves in Cases of Hypertension. Proc. Staff Meet., Mayo Clin. 8 :373-376 (June 14) 1933. 4. Eusterman, G. B. and Morlock, C. G.: Gastro-intestinal Hemorrhage From Otherwise Symptomless Lesions With Special Reference to Duodenal Ulcer. Am. J. Digest. Dis. 6:647-651 (Nov.) 1939. 5. Grimson, K. S.: Total Thoracic and Partial to Total Lumbar Sympathectomy and Celiac Ganglionectomy in the Treatment of Hypertension. Ann. Surg. 114:753-767 (Oct.) 1941. 6. Peet, M. M.: Splanchnic Section for Hypertension: Preliminary Report. Univ. Hosp. Bull., Ann Arbor. 1 :17-18 (June) 1935. 7. Smithwick, R. H.: A Technique for Splanchnic Resection for Hypertension; Preliminary Report. Surgery. 7 :1-8 (Jan.) 1940.
G.
MORLOCK AND NICHOLAS C.
HIGHTOWER, JR.
The adoption of operations upon the sympathetic nervous system in the treatment of essential hypertension and peripheral vascular disease has created serious and widespread concern that the procedures may have a deleterious effect upon the gastro-intestinal tract. This is based upon the known relationship between the sympathetic nervous system and the gastm-intestinal tract, namely, that the sympathetic fibers carry motor inhibitory impulses to, and visceral afferent pain impulses from, the gastro-intestinal tract. As early as 1930 Adson began to section the spinal nerves intervertebrally, and in 1932 one of us (Craig3 ) was the first to section the splanchnic nerves for the relief of hypertension. This resection of the splanchnic nerves and first lumbar sympathetic ganglia was modified in 1934 by Adson and associates2 who increased the scope of the operation to include the splanchnic nerVBS, a portion of the celiac ganglion and the lumbar sympathetic ganglia. This procedure became known as "subdiaphragmatic sympathectomy." Peet in 1933 began removing a portion of the sympathetic nervous system above the diaphragm. He removed the tenth, eleventh and twelfth thoracic ganglia with an associated amount of the splanchnic nerves. This procedure became known as "supradiaphragmatic sympathectomy." Smithwick in 1940 combined the subdiaphragmatic and supradiaphragmatic procedures and found that this operation, being more extensive in its surgical scope, allowed for greater denervation of the vascular tree and therefore produced a more marked physiologic effect. Grimson in 1941 recommended the removal of the entire thoracolumbar chain of ganglia and the splanchnic nerves. Thus we see that, extending over a period of years, surgical procedures on the sympathetic nervous system for the treatment of hypertension have varied in extent. The relief of pain in the upper part of the abdomen and particularly that associated with chronic pancreatitis by sectioning the splanchnic nerves has been described by one of us (Craig). This stimulated extensive discussion, and the possibility was suggested that sympathectomy may remove the protective mechanism of pain appreciation which this nerve supply affords, thereby subjecting the patients to the danger of acute abdominal complications. Recently the literature has contained reports of cases in which painless perforation of abdominal viscera as well as sudden gastro-intestinal hemorrhage without previous symptoms have occurred following sympathectomy. From these observations, the questions that have arisen have been: "What are we doing to a patient besides treating his hypertension?" and "What is the incidence of gas1035
1036
w.
M. CRAIG, C. G. MORLOCK, N. C. HIGHTOWER, JR.
tro-intestinal complications in cases in which sympathectomy has been performed?" Our investigation was undertaken to see if we could offer at least a partial answer to these questions. METHOD OF STUDY
We reviewed 963 cases in which sympathetic ganglionectomy and splanchnic resection had been done in a fifteen-year period, namely
• y,y.;.::....-._ ......
'1
i
a.
~--------~'~
,,
,, ,
I
i
i
i' Thoraco> lumbar
.subdiaphragmatic .
! I
',._._.-
Fig. 272. Diagram illustrating the anatomy of the sympathetic nervous system. Dotted and broken lines indicate surgical procedures.
from 1935 to 1949, inclusive. In all but one of these cases, the procedure was done for the relief of severe hypertension. The one exception was a case of locomotor ataxia and gastric crises. This was included in this series because of an associated duodenal ulcer. During the fifteen-year period, the extent of the sympathectomy has changed. In some of the cases only a sUbdiaphragmatic sympathectomy was performed while in others a thoracolumbar type of procedure was performed. We have, therefore, divided our material into these 2 categories, Figure 272 illus-
1037
SyMPATHECTOMY AND GASTRO-INTESTINAL TRACT
trates the anatomy of the sympathetic nervous system involved and the extent of the surgical procedures under discussion. The histories of patients who were known to have had gastro-intestinal disease before an operation on the sympathetic nervous system was performed and the histories of those in whom some gastro-intestinal disease exclusive of malignant disease developed after sympathectomy were carefully studied. There were 22 patients with proved organic disease of the gastrointestinal tract. Twenty of these had duodenal ulcer, 1 patient had a gastrojejunal ulcer and 1 had chronic ulcerative colitis. Thus, the term "gastro-intestinal disease" refers to duodenal ulcer except in these 2 instances. The presence of ulcer was proved roentgenographically in each case. TABLE 1 EFE'ECT OF SUBDIAPHRAGMATIC AND THORACOLUMBAR SYMPA'l'HECTOMY ON THE GASTRO-INTESTINAL TRACT
Type of Sympathectomy Group
1. 2. 3. 4.
Symptoms Symptoms Symptoms Symptoms
Subdiaphragmatic
Thoracolumbar
4 1 5 3
3 2 3 1
developed only after sympathectomy ... worse after sympathectomy ......... ... unaltered after sympathectomy .... .... improved after sympathectomy ..... ....
-------------------------- ------ -----Totals ..... ........ . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . 13 9 I
CLASSIFICATION OF CASES
The 22 cases were separated into 2 main categories: (1) those in which a subdiaphragmatic sympathectomy was performed, and (2) those in which a thoracolumbar sympathectomy was performed. Each category was further divided into 4 groups as follows: group 1 includes cases in which no known gastro-intestinal disease was present before sympathectomy but in which symptoms developed for the first time after sympathectomy; group 2 includes cases in which known gastro-intestinal disease became worse after sympathectomy; group 3 includes cases in which known gastro-intestinal disease was unaltered by sympathectomy, and group 4 includes cases in which known gastro-intestinal disease improved after sympathectomy (table 1). SUBDIAPHRAGMATIC SYMPATHECTOMY
Group 1. No Known Gastro-intestinal Disease Until After Subdiaphragmatic Sympathectomy. There were 4 cases in the group. In all of these cases symptoms of duodenal ulcer developed for the first time sub-
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M. CRAIG, C. G. MORLOCK, N. C. HIGHTOWER, JR.
sequent to the sympathectomy, and the lesion was later proved to be present roentgenographically. The onset of symptoms of duodenal ulcer occurred soon after the first stage of the sympathectomy in 1 case; and in the other 3 cases, the symptoms occurred one, two and nine years respectively after the operation. Three of the four patients had distress typical of duodenal ulcer; in one case, the symptoms were atypical and mild. The onset of symptoms in 1 case was associated with an acute free perforation nine years after the sympathectomy. Bleeding was the initial symptom of ulcer in 1 case. The following case is representative of this group. CASE 1. The first stage of a subdiaphragmatic sympathectomy was performed on a man, aged 44 years, in May, 1942, for the relief of essential hypertension. With the exception of the hypertension, his health had been excellent. He had not had any symptoms of gastro-intestinal disease. On the seventh postoperative day he began to complain of nausea, and he vomited several times. On the fifteenth postoperative day the second stage of the sympathectomy was done. Following this he again had several episodes of nausea and vomiting, and transient gastric retention developed. After the patient returned home, "heartburn" and ulcer-like dyspepsia developed. The gastric distress occurred two to three hours after meals, especially after the patient had eaten highly spiced foods. It was relieved by the use of antacids. The patient returned to the Clinic in 1944. He said that his gastric symptoms had persisted. The symptoms were episodic and characteristic of ulcer. A roentgenologic examination demonstrated the presence of a duodenal ulcer.
Group 2. Gastro-intestinal Disease Increasing in Severity After Subdiaphragmatic Sympathectomy. There was but 1 case in this group. CASE 2. A thirty-nine year old man came to the Clinic in February, 1937, because of hypertension and indigestion. For five years he had had recurrent dyspepsia associated with epigastric burning. The distress had occurred two or three hours after meals and had been relieved by food, milk or soda. A duodenal ulcer was demonstrated roentgenologically. A subdiaphragmatic sympathectomy was done because of the presence of essential hypertension. Seven months after the sympathectomy, the patient had a severe gastro-intestinal hemorrhage which required hospitalization and multiple transfusions of whole blood. In September 1938, another gastro-intestinal hemorrhage occurred. The patient was last seen in 1939 when it was found that he still had symptoms of an active duodenal ulcer even though he had carefully followed an ulcer regimen.
Group 3. Gastro-intestinal Disease Unaltered by Subdiaphragmatic Sympathectomy. There were 5 cases in this group. All of the 5 patients were known to have had a duodenal ulcer previous to sympathectomy. In all of the 5 cases, the symptoms of duodenal ulcer were unaltered by the sympathectomy. The following case is typical of this group. CASE 3. A forty-seven year old man gave a history typical of duodenal ulcer of eight to ten years' duration, and the ulcer was demonstrated roentgenographi" cally when the patient was first seen at the Clinic in 1937. He had had hema-
SYMPATHECTOMY AND GASTRO-INTESTINAL TRACT
1039
temesis in 1936. A subdiaphragmatic sympathectomy was done in June, 1937, for severe essential hypertension. The postoperative convalescence was uneventful. The patient was seen again in 1940 and in 1941. On those occasions he stated that his ulcer symptoms had continued unchanged. In 1943, he had a severe gastro-intestinal hemorrhage. After this, a small gastric ulcer and a duodenal ulcer were demonstrated by roentgenoscopy. A partial gastric resection was performed. The symptoms which this patient had after sympathectomy were practically identical with those he experienced prior to sympathectomy. Bleeding from the ulcer occurred both prior to the sympathectomy and after it. The fact that a small gastric ulcer was found in addition to the duodenal ulcer six years after the sympathectomy can hardly be construed as being significant since multiple lesions in ulcer-bearing patients are not uncommon. Group 4. Gastro-intestinal Disease Improved After Subdiaphragmatic Sympathectomy. This group included 1 case of gastrojejunal ulcer, 1 case of duodenal ulcer and 1 case of chronic ulcerative colitis. Symptoms of gastro-intestinal disease in each case improved after the sympathectomy. As illustrative of this group we cite the following case. CASE 4. A forty-four year old man had had stomach trouble for many years. This had consisted of burning epigastric pain which had been relieved by food. In 1935 he had had a gastro-intestinal hemorrhage and symptoms of pyloric obstruction had developed. A gastro-enterostomy had been done for an obstructing duodenal ulcer. After this, he had continued to have intermittent ulcer distress, and he again had had severe bleeding in 1936 and 1944. He was first seen at the Clinic in June of 1946. A roentgenogram at that time revealed a gastrojejeunal ulcer. Because of a severe essential hypertension, a subdiaphragmatic sympathectomy was done. The immediate postoperative course was uneventful. Two years after the sympathectomy, the patient returned to the Clinic. He said that he had not had any symptoms of ulcer since the sympathectomy. Roentgenogra,phic examination at that time revealed a duodenal deformity due to a previous ulcer; the pylorus was patent, and the gastro-enteric stoma was freely functioning. There was no evidence of gastrojejunal ulceration. THORACOLUMBAR SYMPATHECTOMY
Group 1. No Known Gastro-intestinal Disease Until After Thoracolumbar Sympathectomy. There were 3 cases in this group and none of the patients had had symptoms of gastro-intestinal disease prior to the sympathectomy. In all of the 3 cases, symptoms characteristic of duodenal ulcer developed after operation, and the presence of a duodenal ulcer was proved by roentgenography. The following case is cited as characteristic of this group. CASE 5. A thirty-nine year old man came to the Clinic in July, 1946, because of severe hypertension of seven years' duration. He said that he had not had any gastro-intestinal symptoms at any time. An extensive thoracolumbar sympathectomy was done for the relief of the hypertension. He made an excellent recovery
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from this operation. He was seen for a follow-up examination in November of 1947. It was found then that epigastric pain characteristic of ulcer had developed four months previously. Three days after the onset of this symptom, he had severe hematemesis and melena which had required hospitalization and transfusions of blood. He continued to have periodic burning epigastric pain which occurred when his stomach was empty and the pain was relieved by taking food and soda. A roentgenogram of the stomach and duodenum revealed a duodenal ulcer. His symptoms were alleviated fairly well by means of a strict ulcer regimen. In March of 1948, these symptoms returned, and in November of that year he had another episode of melena. When last heard from in 1949, he reported that he was having continued trouble with recurrent episodes of ulcer pain. The pain which the patient described was typical of ulcer and indistinguishable from that which one would expect to find in a case of duodenal ulcer in which the sympathetic pathways are intact.
Group 2. Gastro-intestinal Disease Increasing in Severity After Thoracolumbar Sympathectomy. There were 2 cases in this group. One of these is cited. CASE 6. A forty-four year old woman came to the Clinic in May of 1947 because of severe hypertension. She gave a history of having had periodic severe recurrent epigastric distress characteristic of duodenal ulcer for twenty years. These symptoms had followed an acute free perforation which was closed surgically. A roentgenogram of the stomach and duodenum revealed a duodenal ulcer. On June 18, 1947, a right thoracolumbar sympathetic ganglionectomy and splanchnic resection was done. Four days after this operation, sudden severe pain developed in the right lumbar area lateral to the third lumbar vertebra. The pain at first extended into the rightlower quadrant of the abdomen and later shifted to the epigastric region just below the xiphoid process. The clinician who saw her felt that her pain was characteristic of that seen in cases in which duodenal ulcer penetrates to involve the head of the pancreas and mesocolon. An ulcer regimen caused the symptoms to subside. On July 9,1947, a left extensive thoracolumbar sympathetic ganglionectomy and splanchnic resection was done. A few days later, there was a severe recurrence of pain in the epigastrium and in the left hypochondrium. This pain was of a steady boring character, and marked tenderness and voluntary spasm were present in the epigastrium and in the left hypochondrium. This distress again responded satisfactorily to a strict ulcer regimen. At the time of her dismissal from the Clinic, the ulcer symptoms were under complete control.
It is interesting that in this case the ulcer symptoms were severe and that the pain appeared to be aggravated rather than relieved by the sympathectomy. .
Group 3. Known Gastro-intestinal Disease Unaltered by Thoracolumbar Sympathectomy. There were 3 cases in this group. In each case the ulcer symptoms were unaltered by the sympathectomy. The following case report is illustrative of this group. CASE 7. A thirty-five year old man came to the Clinic because of severe essential hypertension. For many years he had had indigestion characterized by epigastric burning and "heartburn" which had occurred after meals and had
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been relieved by soda but not by food. He occasionally had experienced pain at night. A roentgenogram of the stomach and duodenum revealed a duodenal ulcer. In February, 1947, a thoracolumbar sympathectomy was done for the relief of the hypertension. When he returned for a recheck in December of 1949, he said that he had continued to have recurrent epigastric burning similar to that which he had had prior to the sympathectomy. This distress, as before, was relieved by soda but not by food. A roentgenogram of the stomach and duodenum again revealed a duodenal ulcer.
Group 4. Gastro-intestinal Disease Improved After Thoracolumbar Sympathectomy. There was but 1 case in this group. CASE 8. The patient was a man fifty years of age who came to the Clinic in May, 1946, because of severe essential hypertension. He gave a history of epigastric distress of seven years' duration. The pain had been seasonal in occurrence and had been most severe in the early morning and often had wakened him from sleep. It had been relieved promptly by milk and antacids. Roentgenologic examination disclosed a duodenal ulcer. A thoracolumbar sympathectomy was done in July, 1946, for the relief of the hypertension. In July of 1947, the patient returned and said that he had not adhered to any dietary regimen since his operation. He had taken no food between meals and had not used any antacids. He also said that during all of that time he had not had any indigestion whatsoever. COMMENT
The view that sympathectomy may remove a protective mechanism, so exposing the patient to the risk of gastro-intestinal disease or a complication of pre-existing gastro-intestinal disease, does not seem well founded in the light of our findings. In 2 of the 7 cases in which symptoms of duodenal ulcer developed for the first time after sympathectomy, the initial symptom was painless bleeding. In both cases this occurred approximately one year after sympathectomy and was followed by typical ulcer distress. This is not an uncommon event, for Bockus has said that approximately 25 per cent of patients at the time of their initial ulcer hemorrhage will deny the existence of prodromal ulcer symptoms. Eusterman and Morlock also have reported that the initial or sole symptom of duodenal ulcer is painless bleeding in 5 per cent of patients with this disease. The initial symptom of 1 patient in this group was an acute free perforation. This complication occurred nine years after the sympathectomy and few prodromal symptoms were present. Bockus states that in approximately 25 per cent of cases of perforated peptic ulcer no previous history of stomach trouble is given. The fact that duodenal ulcer was found for the first time following sympathectomy in only 0.74 per cent of the 963 cases reviewed suggests that there is probably no relationship between sympathectomy and the development of duodenal ulcer. The fact that 3 patients with duodenal ulcer became worse after sympathectomy and 3 improved after the operation and that the symptoms in 8 cases were
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unaltered lends further evidence that the sympathectomy does not exert a baneful influence on the course of duodenal ulcer. In one patient with a gastrojejunal ulcer and in one with chronic ulcerative colitis, the symptoms became less severe or disappeared completely. This is not an unusual event for it is known that in both peptic ulcer and chronic ulcerative colitis remissions of the disease are the rule rather than the exception. When the 22 cases of gastro-intestinal disease were divided into 2 categories, it was apparent that the per cent of cases in each group was essentially the same. This lends support to the impression that a more extensive sympathectomy does not expose the patient to an increased risk of gastro-intestinal complications. A follow-up by letter of a large series of patients who had undergone sympathectomy for hypertension was also made. It is interesting and significant, we believe, that in all cases the answers received to the inquiries indicated that few patients complained of gastro-intestinal symptoms. Our findings indicate that sympathectomy as carried out for the relief of hypertension has little effect on the gastro-intestinal tract. This is probably explained by the fact that the surgical procedures now employed for the relief of hypertension do not completely denervate the gastro-intestinal tract of its sympathetic nervous supply. The fact that 17 out of 20 patients with duodenal ulcer had symptoms that we would consider characteristic of the disease does not indicate that pain appreciation has been removed by this type of sympathectomy. SUMMARY
We have reviewed 963 cases in which sympathectomy was performed. in all but 1 case the sympathectomy was done for the relief of severe essential hypertension. In this large group, there were only 22 cases of proved gastro-intestinal disease. Of the 22 patients with gastro-intestinal disease, twenty had duodenal ulcer, one had a gastrojejunal ulcer and one had chronic ulcerative colitis. Symptoms of duodenal ulcer developed for the first time following sympathectomy in 7 (0.74 per cent) of the 963 cases. There were 14 cases in which duodenal ulcer was known to have been present before sympathectomy. In 8 of these cases, the symptoms were unaltered; in 3 cases, the symptoms became worse and in 3 cases, the symptoms became less severe. In 1 case each of gastrojejunal ulcer and chronic ulcerative colitis, the symptoms became less severe after sympathectomy. In an analysis of 20 cases in which duodenal ulcer existed prior to sympathectomy or developed after this procedure, the symptoms were found to be entirely characteristic of this disease in 17 cases. The results of this investigation would neither suggest that a sympathectomy exposes a patient with known gastro-intestinal disease to an increased hazard of complications nor that it predisposes to the development of gastro-intestinal disease.
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REFERENCES
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1. Bockus, H. L.: Gastroenterology. Philadelphia, W. B. Saunders Company, 1943, vol. 1, 831 pp. 2. Brown, G. E., Craig, W. McK. and Adson, A. W.: The Treatment of Severe Essential Hypertension; Effects of Surgical Procedures Applied to the Sympathetic Nervous System. Minnesota Med. 18 :132-138 (Mar.) 1935. 3. Craig, W. McK. and Brown, G. E. : Resection of the Splanchnic Nerves in Cases of Hypertension. Proc. Staff Meet., Mayo Clin. 8 :373-376 (June 14) 1933. 4. Eusterman, G. B. and Morlock, C. G.: Gastro-intestinal Hemorrhage From Otherwise Symptomless Lesions With Special Reference to Duodenal Ulcer. Am. J. Digest. Dis. 6:647-651 (Nov.) 1939. 5. Grimson, K. S.: Total Thoracic and Partial to Total Lumbar Sympathectomy and Celiac Ganglionectomy in the Treatment of Hypertension. Ann. Surg. 114:753-767 (Oct.) 1941. 6. Peet, M. M.: Splanchnic Section for Hypertension: Preliminary Report. Univ. Hosp. Bull., Ann Arbor. 1 :17-18 (June) 1935. 7. Smithwick, R. H.: A Technique for Splanchnic Resection for Hypertension; Preliminary Report. Surgery. 7 :1-8 (Jan.) 1940.