NEW YORK Digital sympathectomy appeared highly effective for pain relief in patients with severe, longstanding Raynaud's phenomenon associated with limited cutaneous systemic sclerosis, Andrew D. Thomas, M.D., said at the annual meeting of the American Society for Surgery of the Hand.
Raynaud's phenomenon in the context of CREST syndrome, the symptoms of which can include calcinosis, esophageal dysmotility, sclerodactyly, and telangiectasia, is initially treated with calcium channel blockers.
Biofeedback, smoking cessation, and avoidance of cold also are central to management, Dr. Thomas said.
But if medical management fails, patients can face intractable fingertip pain and severe digital ulceration requiring amputation.
Studies have demonstrated that digital sympathectomy improves blood supply to the chronically ischemic hand. However, the long-term outcomes are unknown because of the infrequency with which it is performed and the diversity of conditions it is used to treat.
"We have attempted to clarify the effectiveness by analyzing the results from 17 patients, each with a firmly established diagnosis of CREST syndrome and painfully disabling Raynaud's phenomenon," said Dr. Thomas, a surgical resident at St. Luke's-Roosevelt Hospital, New York.
The patients underwent a total of 95 digital sympathectomies. Chronic ulceration was present in 22 digits, and 14 of the ulcers were 1 cm or greater. Bony exposure was present in five.
By way of standard microsurgical techniques, the digital artery was stripped of its sympathetic innervation and fibrotic adventitia for 2.5-3 cm distal to its origin from the common digital artery, he explained.
In 10 digits with major pulp loss, local flap resurfacing was performed to enhance wound healing, he said.
"All but one patient reported pain relief following the operation, and all 22 ulcerations healed after a period of meticulous local wound care," Dr. Thomas said at the meeting.
The time until healing ranged from 39 to 125 days based on the size and depth of the lesion. No amputations were necessary. Patient satisfaction was consistently high, he said.
Five patients developed recurrent ulcers after the initial healing, but these rehealed by secondary intention with meticulous outpatient care.
Follow-up ranged from 1.5 to 8 years.
"Despite the progressive nature of scleroderma, this study indicates that the efficacy of digital sympathectomy can persist for periods as long as 8 years after surgery," he said.
Of 17 patients who underwent the procedure, 16 reported pain relief after the operation. There were no amputations. Courtesy Dr. Andrew D. Thomas