Visualization of the thoracic sympathetic chain in MLS embalmed body donors: a feasibility study and surgical perspective

Introduction

Sympathetic surgery targets the thoracic sympathetic chain for a broad spectrum of disorders, including primary hyperhidrosis (PHH), facial blushing, complex pain syndromes, and, among others, refractory ventricular tachycardia (VT) (1).

PHH, being one of the most frequent indications for sympathetic surgery, is characterized by sweat production that exceeds thermoregulatory needs and affects an estimated 5% of the population (2,3). While its exact pathophysiology remains unclear, treatment options range from topical agents to minimally invasive thoracoscopic sympathetic interruption (TSI), offering excellent outcomes (4).

Across all indications, surgical success and complication profiles depend fundamentally on precise anatomical identification of the sympathetic ganglia, interganglionic branches, and the white [rami communicantes albi (RCA)] and grey [rami communicantes grisei (RCG)] communicating branches. The operative approach, its level and extent, is guided by the specific surgical aim and indication. Persistent or recurrent sympathetic activity may occur, at times attributed to “Alternate Neural Pathways” (ANP), including the pathway first described by Albert Kuntz (Kuntz 1927). Incomplete identification of the sympathetic trunk is another possible cause of procedural failure, highlighting the importance of precise anatomical knowledge (5). Surgical training on human body donors has been shown to enhance these skills, improving surgical confidence, subjective skill assessment, and, at least in the short term, objective performance (6,7). For this purpose, both Thiel’s and modified Larssen solution (MLS) body donors are valued for their high and realistic tissue fidelity, though according to available literature MLS embalming is available at a fraction of the cost compared with Thiel’s fixation (8).

This study explores the feasibility of using MLS-embalmed body donors for anatomical training in thoracic or sympathetic surgery.

By integrating insights from both the anatomical wet lab and available literature, this study focuses on the anatomical and procedural nuances, as well as potential pitfalls, rather than providing a comprehensive review of sympathetic surgery. Additionally, we examine the economic aspects of using MLS-embalmed human body donors for anatomical training, with a focus on chemical costs.

To our knowledge, the use of MLS-embalmed body donors in the context of thoracic sympathetic surgery has not been specifically explored. Accordingly, this study is intended as a descriptive feasibility assessment emphasizing anatomical visualization and procedural context, rather than as an investigation of training efficacy, comparative performance, or clinical impact. We present this article in accordance with the SRQR reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0749/rc).

Methods

An MLS-embalmed human body donor was dissected bilaterally with exposure of both thoracic cavities. Fixation was performed according to the protocol described by Bilge (9), with the sole modification that the body was not frozen after fixation. The female body donor, weighing 65 kg, was 90 years of age at the time of death. The death-to-fixation interval was 4 days, and the postmortem interval at the time of dissection was 32 days. In addition, we examined the existing literature to address three key aspects of the surgical treatment of sympathetically mediated conditions: (I) anatomical considerations, (II) clinical considerations, and (III) pitfalls and opportunities, as well as the economic aspects of using MLS-embalmed body donors for research and surgical training. Given the single-specimen design, this study is not intended to provide quantitative anatomical data or assess interindividual anatomical variability.

Cost calculations were limited to cost of chemicals and based on the unit sizes routinely ordered by our department from a major German chemical supplier (Carl Roth). All prices reflect the supplier’s listed rates as of December 1, 2025.

For illustrative purposes, existing anatomical plastinations from an 84-year-old female donor were examined.

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments, and was approved by the local ethics committee at the Medical Faculty, University of Leipzig (No. 129/21-ck).

Results

Anatomical dissection

Tissue preservation was sufficient for clear identification of all relevant anatomical structures.

A median skin incision was performed extending from the jugular (suprasternal) notch to the xiphoid process. The posterior aspect of the manubrium and sternal body was then bluntly mobilized in a cranio-caudal direction, assisted by an overhauled grasper, after which the sternum was divided using bone shears.

Following the median sternotomy, bilateral rectangular costal windows were created. Each window measured approximately 10 cm laterally from the parasternal line and extended cranially from the sternoclavicular joints to the caudal level of the costochondral junctions of the inferior ribs articulating with the sternum. After opening these windows, a sternal retractor was positioned at the jugular notch.

Both lungs were then mobilized, and sequential bilateral pneumonectomies were carried out. This was followed by a cardiectomy. The ascending aorta, aortic arch, and thoracic aorta were dissected free. After placement of clamps on the thoracic esophagus, the esophageal segment within the thoracic cavity was resected. Finally, the trachea, including the bifurcatio tracheae and carina tracheae, was excised. We ensured that all neural structures within the thoracic cavity remained intact throughout the procedure.

Segmental levels of the sympathetic trunk were identified (Figures 1,2). Inspection of both pleural cavities revealed no abnormalities, and a pleurectomy was carried out from the medial aspect of the sympathetic trunk to the lateral thoracic wall (Figures 3,4). Subsequently, the tissue surrounding the sympathetic trunk was carefully dissected while preserving all RCA and RCG (Figures 5,6). Once the sympathetic trunk was adequately exposed, surrounding adipose and connective tissue was removed to enhance visualization. Representative exposure of the RCA and RCG at the level of thoracic ganglion 4 is shown in Figures 7,8. Dissection proceeded in a cranio-caudal direction, starting at the first rib. No accessory communicating branches of the sympathetic trunk were observed. The tactile properties of the tissues closely resembled those of live lung, pleural, and neural structures. In our selected anatomical plastinate (Figure 9), the sympathetic trunk is clearly identifiable. The absence of identifiable ANP in this specimen should be interpreted with caution, as it does not reflect their reported prevalence in the literature and cannot be used to infer their frequency or detectability in MLS-embalmed donors.

Figure 1 Right view of the thoracic cavity before pleura removal. Heart, lungs, trachea, esophagus (partially) removed. R, rib; ST, sympathetic trunk.

Figure 2 Left view of the thoracic cavity before pleura removal. Heart, lungs, trachea, esophagus (partially) removed. ST, sympathetic trunk.

Figure 3 Right view of the thoracic cavity after pleura removal. R, rib; ST, sympathetic trunk.

Figure 4 Left view of the thoracic cavity after pleura removal. ST, sympathetic trunk.

Figure 5 Right view of the thoracic cavity after further dissection. R, rib; ST, sympathetic trunk.

Figure 6 Left view of the thoracic cavity after further dissection. R, rib; ST, sympathetic trunk.

Figure 7 Detailed view of left RCA at level T4. R, rib; RCA, ramus communicans albus; ST, sympathetic trunk; T, thoracic ganglion.

Figure 8 Detailed view of left RCG at level T4. R, rib; RCG, ramus communicans griseus; ST, sympathetic trunk; T, thoracic ganglion.

Figure 9 Axial plastinate of the thoracic cavity of a different body donor. CL, Clavicle; R, rib; ST, sympathetic trunk.

Economical aspects

The following cost per body donor was calculated excluding the acquisition and storage costs of the donor itself. Labour costs were not included, as they vary considerably between countries. Based on our experience, however, approximately 2-3 hours of labour should be anticipated. The total cost of fixation chemicals amounted to 73.80 € per body donor for the complete 1700 ml MLS formulation. A detailed breakdown of all expenses is provided in Table 1. Chemical prices reflect current market costs at the time of writing (December 2025).

Discussion

Anatomical considerations

Anatomy forms the foundation of all surgical interventions. In TSI, the principal target structures include the sympathetic ganglia, the interganglionic branches linking them, the RCA and RCG (Figures 5-8) (10,11).

A major milestone in understanding the neural pathways of the sympathetic trunk, was the introduction of the “Lin-Teleranta-Classification”. It linked an observed dermatomal-like pattern of sympathetic innervation to tailored levels of thoracic sympathectomy (12).

Based on four clinical groups ranging from facial blushing and hypertension to isolated axillary hyperhidrosis, progressively caudal target levels for bilateral cranial and caudal clamp-blocking from T2 to T5 were recommended. Their recommendations align closely with contemporary surgical practice, underscoring the lasting significance of Lin’s and Telaranta’s work.

In our specimen and our selected plastinate, we were able to demonstrate the thoracic sympathetic trunk (Figures 1-6,9) along with its afferent and efferent neural pathways (Figures 7,8). Beyond the RCA and RCG, additional communicating branches, bypassing routes for the sympathetic nerve fibres, have been described and are commonly referred to as ANP (13). The first intercostal space often contains one such pathway described by Albert Kuntz (14), commonly termed Kuntz’s nerve. This first intercostal space represents the most frequent site of ANP, with reported prevalences exceeding 40%, followed by a gradual decline in more caudal intercostal spaces. Nevertheless, ANP remain detectable at least as far as the fifth intercostal space and up to 3 cm lateral to the sympathetic chain (13,15). Filion and Lamb further observed that ANP, specifically Kuntz’s nerves, were more prevalent in males, accounting for approximately 70% of cases in their cadaveric study of Thiel-fixed body donors. In our single dissection, no ANP were identified. To exclude a potential influence of the fixation method on the apparent prevalence, larger anatomical studies on MLS-embalmed body donors should be considered.

While acquiring body donors for research and wet-lab training is associated with considerable cost, they remain invaluable because of their high anatomical realism and suitability for safely practicing complex procedures (8). In our laboratory, we are currently evaluating both the economic and storage-related aspects of working with MLS-embalmed body donors. The chemical cost per fixation in our setting amounts to approximately 74 € (Table 1), which is comparable to values reported in the literature (9). Compared with other commonly used fixation methods, most notably Thiel fixation, with estimated chemical costs of approximately 437 €, MLS fixation is roughly six times less expensive (16). Because Thiel fixation uses substantial boric acid, MLS has the added benefit of eliminating the need for costly disposal of boric acid-containing waste. However, the present cost analysis is limited to chemical expenses and does not account for specimen acquisition, labor, or storage costs.

Thiel-embalmed body donors are well known for their life-like visual and haptic properties of skin, muscle, and internal organs, with the exception of hyaline cartilage, making them suitable for various fields of surgical training. Major disadvantages include a potentially disturbing odor, air leakage during laparoscopic procedures, and limited suitability for biomechanical testing (8,16). Beyond its economic advantages in terms of chemical expenses, MLS embalming is characterized by realistic properties of muscle, fascia, adipose tissue, nerves, and vessels, and the absence of disturbing odors. A known limitation is epidermal peeling, which may lead to localized dryness (8,9). These favorable haptic and visual properties were consistent with our own observations of the heart, lungs, mediastinum, pleural sheaths, and sympathetic trunk. We perceived a distinct but non-disturbing odor, possibly attributable to the fact that the body donor had not been frozen at any point.

A common challenge in anatomical and surgical dissection lies in the removal or destruction (e.g., cauterization) of the connective tissues surrounding the target structure. The role of both watery connective tissues and the sympathetic nervous system has been discussed in the pathogenesis of other idiopathic upper-extremity disorders, such as Raynaud’s syndrome and carpal tunnel syndrome (17). To specifically address the role of connective tissues in conditions affecting the sympathetic nervous system, however, more extensive and tissue-sparing (histo) anatomical studies are required.

Clinical considerations

This study is qualitative and laboratory-based. However, anatomical insights form an important foundation for clinical decision-making. The following clinical considerations are derived from previously published literature and are not based on findings of the present anatomical study. They are included to contextualize the anatomical observations rather than to imply any causal or functional relationships demonstrated by our data.

Over the decades, TSI achieved reported surgical success rates exceeding 90% for common indications like PHH (4,18). Common ways to achieve TSI include transection or clipping. Although the latter has been suggested as potentially reversible, this is not convincingly supported by the data (10). The previously discussed Lin-Teleranta Classification provided a framework for targeted TSI. In our dissection, distinct ganglion borders were clearly visualized (Figures 3-6).

Depending on the site, extent and diagnosis, different levels of TSI are recommended to optimize outcomes. For palmar PHH, the 2011 Society of Thoracic Surgeons (STS) expert consensus for the surgical treatment of hyperhidrosis advises a single-level interruption at level R4 to achieve good results with more manageable compensatory hyperhidrosis (CH) rates (10). We exemplary visualized this level in Figures 7,8. While effective at both R3 and R4 levels, recent evidence supports low-level single-segment TSI, as moderate to severe CH is more frequently observed after procedures involving higher or multiple segments. TSI at level T4 (R4) is also associated with improved outcomes regarding overly dry hands and gustatory sweating (19-22).

For axillary PHH, the aforementioned STS consensus recommends performing TSI at both R4 and R5 (Figure 6), noting that each level alone has supporting evidence (10). More recent studies reinforce this approach, however, demonstrating higher success rates and 7-fold lower CH risk for lower-level compared with higher-level TSI (91% vs. 79%) (19). An additional R3 intervention may be considered, if additional palmar symptoms are a major concern (23).

For craniofacial PHH the 2011 STS consensus recommends an isolated R3 transection, as it offers more favorable rates of CH and a lower risk of Horner’s syndrome compared with R2 or combined R2 & R3 transection (10). Following TSI, studies consistently demonstrate high rates of upper-body CH. To address this, Moon et al. proposed a technique involving transection at R2 and transection and ablation from R4-R7. The rationale was to “redirect” CH toward the lower extremities in an effort to improve patient satisfaction (24). Evidence supporting this approach, however, remains limited.

For severe plantar PHH, lumbar sympathectomy may be considered as a surgical treatment. Transection at L3 and L4 is regarded as effective, balancing therapeutic efficacy with a reduced risk of retrograde ejaculation (25,26).

Modulation of cardiac function constitutes another important therapeutic application of TSI in the form of cardiac denervation (CD). Indications include refractory VT and structural heart disease (27). CD has been shown to reduce VT recurrence and implantable cardioverter-defibrillator (ICD) shocks by up to 88%, with a one-year shock-free survival of approximately 50% (28). While potentially life-saving, ICD shocks are also known to increase morbidity and mortality and significantly impair quality of life (28,29). More recent literature describes CD as an effective bailout therapy for multimorbid patients with severe ventricular dysfunction following failed catheter ablation, even in non-urgent to emergent clinical settings. Reported outcomes appear promising, with major procedure-related complications reportedly occurring in fewer than 10% of cases and freedom from ICD shocks achieved in 76.9% of patients. However, major in-hospital adverse events (pulmonary embolism, etc.) were observed in approximately 38% of patients (27). Conventional CD includes resection of the stellate ganglion and thoracic ganglia T2-T4. Simplified left-sided denervation, limited to T2-T4, is less invasive and showed marked reductions in VT episodes and ICD shocks without major peri-procedural complications in a small series (n=7), though shock-free survival appears inferior compared with bilateral denervation (28,30).

Recent procedural developments aim to further refine the intervention by targeting specific components of the sympathetic chain, particularly the RCA and RCG. These techniques, referred to as “ramicotomies,” aim to minimize sympathetic disruption. In the treatment of PHH, ramicotomies have shown lower severity of CH than conventional TSI, with additional improvements when selectively transecting either the RCA or the RCG alone. The selective approach demonstrated the additional benefit of preserving residual hand moisture (11). The clear visibility of the RCA and RCG at thoracic ganglion 4 in our MLS specimen may indicate potential applicability for anatomical demonstration in the context of targeted ramicotomy approaches (Figures 7,8). Broader studies are needed however, to confirm MLS-embalmed specimen as a training platform for ramicotomies.

Pitfalls and opportunities

While this study focuses on the feasibility of using MLS-embalmed body donors in thoracic surgery training, clinical procedural failure can result from several factors. Although not observed in our study, ANP may serve as a bypass for sympathetic neural activity to neighboring segments. Given their reported location up to 3 cm lateral to the ganglion, meticulous identification and complete resection of these structures are considered important in surgical practice (13,31). Singh et al. further emphasized the importance of detailed anatomical training, reporting procedural failure directly attributable to misidentification of sympathetic trunk structures (5). This highlights the potential of structured anatomical training on body donors, potentially also on MLS-embalmed donors, supported by the clear visualization of the sympathetic chain, ganglia, RCA and RCG in our specimen (Figures 7,8).

Individual thoracic ganglia do not just mediate a single isolated function, hence even anatomically correct interruption may lead to characteristic postoperative side effects. Among them, Horner’s syndrome and permanent bradycardia have been reported as rare complications of TSI (Cerfolio et al. 2011). In contrast, literature shows that CH affects a substantial proportion of patients after TSI for PHH. To date, neither its exact pathomechanism nor definitive risk factors are fully understood. However, besides level of and extent of TSI, smoking, higher age, BMI above 28.5, and axillary involvement have all been associated with increased CH incidence. One-time bilateral TSI may further elevate this risk. Conversely, higher hemoglobin levels, cannabinoid consumption, and female sex correlate with lower CH incidence (31,32). Although literature suggests that more selective or lower-level interventions may be associated with reduced rates of CH, these observations are based on clinical data and cannot be substantiated by the present anatomical feasibility study.

To improve patient satisfaction and predictability, temporary preoperative sympathetic blocks with local anesthetics (e.g., ropivacaine) have been implemented (33). This procedure is not yet widespread and has not been evaluated in this study.

Limitations

This study is limited by the dissection of a single MLS-embalmed body donor, thereby restricting the generalizability of the findings and assessment of both tissue properties and interindividual anatomical variability. Tissue characteristics were evaluated qualitatively, without biomechanical validation, and no direct comparison with alternative embalming techniques was performed. Furthermore, the observed tissue properties cannot be reliably extrapolated to minimally invasive surgical settings, particularly due to the absence of thoracoscopic visualization, insufflation-related effects, and constrained operative angles characteristic of minimally invasive approaches.

The median sternotomy approach and (partial) removal of intrathoracic structures facilitated clear visualization of the sympathetic trunk and communicating branches. However, this approach alters the spatial relationships and visual constraints encountered during thoracoscopic procedures. Consequently, the anatomical exposure achieved in this study does not replicate the operative environment of minimally invasive sympathectomy. To further evaluate the potential of MLS-embalmed donors in the context of TSI, broader studies implementing minimally invasive surgical simulations would be necessary.

The economic analysis was limited to fixation material costs and did not account for acquisition, infrastructure, personnel-related expenses, or other location-dependent factors.

Conclusions

Literature shows thoracoscopic sympathectomy to be an established and effective treatment for sympathetically mediated disorders. Its success, however, is dependent on precise anatomical knowledge, appropriate level selection, and careful consideration of anatomical variants such as ANP. More selective, tissue-sparing techniques may potentially preserve efficacy while reducing adverse effects, such as CH.

With chemical expenses of approximately 74 € per donor, MLS embalming represents a cost-effective alternative that could enable broader access to realistic wet-lab surgical training without compromising anatomical detail.

In our dissection, our MLS-embalmed body donor demonstrated excellent anatomical fidelity and life-like tissue characteristics. Larger-scale comparative studies are required, however, to evaluate the economic implications, confirm the reproducibility of the observed anatomical quality and level of detail, and assess training efficacy and clinical relevance.

This study demonstrates the feasibility of visualizing the thoracic sympathetic chain and its communicating branches in an MLS-embalmed body donor under conditions of extensive surgical exposure. Through detailed anatomical visualization, this study may contribute to an improved understanding of thoracic sympathetic anatomy in a surgical context and may support the use of MLS-embalmed donors as a practical and accessible platform for future anatomical and surgically oriented investigations.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SRQR reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0749/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0749/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0749/prf

Funding: The study was supported by the Open Access Publishing Fund of Leipzig University.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-0749/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments, and was approved by the local ethics committee at the Medical Faculty, University of Leipzig (No. 129/21-ck).

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Hashmonai M, Cameron AE, Licht PB, et al. Thoracic sympathectomy: a review of current indications. Surg Endosc 2016;30:1255-69. [Crossref] [PubMed]
2. Nawrocki S, Cha J. The etiology, diagnosis, and management of hyperhidrosis: A comprehensive review: Etiology and clinical work-up. J Am Acad Dermatol 2019;81:657-66. [Crossref] [PubMed]
3. Lycett MJ, Ng K. Hyperhidrosis: don't sweat it. Intern Med J 2025;55:1626-31. [Crossref] [PubMed]
4. Martínez-Hernández NJ, Estors-Guerrero M, Galbis-Caravajal JM, et al. Endoscopic thoracic sympathectomy for primary hyperhidrosis: an over a decade-long follow-up on efficacy, impact, and patient satisfaction. J Thorac Dis 2024;16:8292-9. [Crossref] [PubMed]
5. Singh B, Moodley J, Ramdial PK, et al. Pitfalls in thoracoscopic sympathectomy: mechanisms for failure. Surg Laparosc Endosc Percutan Tech 2001;11:364-7. [Crossref] [PubMed]
6. James HK, Chapman AW, Pattison GTR, et al. Systematic review of the current status of cadaveric simulation for surgical training. Br J Surg 2019;106:1726-34. [Crossref] [PubMed]
7. Nakamura S, Ueno H, Imamura Y, et al. A novel program of cadaver surgical training for young surgeons at the Clinical Anatomy Laboratory Nagoya (CALNA). Gen Thorac Cardiovasc Surg 2025;73:935-41. [Crossref] [PubMed]
8. Pinar SA, Morrow JJ, Kong CY. A systematic review of the use of human body donor models for postgraduate laparoscopic surgical training. Anat Sci Int 2026;101:241-67. [Crossref] [PubMed]
9. Bilge O, Celik S. Cadaver embalming fluid for surgical training courses: modified Larssen solution. Surg Radiol Anat 2017;39:1263-72. [Crossref] [PubMed]
10. Cerfolio RJ, De Campos JR, Bryant AS, et al. The Society of Thoracic Surgeons expert consensus for the surgical treatment of hyperhidrosis. Ann Thorac Surg 2011;91:1642-8. [Crossref] [PubMed]
11. Vanaclocha V, Guijarro-Jorge R, Saiz-Sapena N, et al. Selective T3-T4 sympathicotomy versus gray ramicotomy on outcome and quality of life in hyperhidrosis patients: a randomized clinical trial. Sci Rep 2021;11:17628. [Crossref] [PubMed]
12. Lin CC, Telaranta T. Lin-Telaranta classification: the importance of different procedures for different indications in sympathetic surgery. Ann Chir Gynaecol 2001;90:161-6.
13. Filion W, Lamb C. Anatomical variation of the sympathetic trunk and aberrant rami communicantes and their clinical implications. Ann Anat 2023;245:151999. [Crossref] [PubMed]
14. Kuntz A. Distribution of the Sympathetic Rami to the Brachial Plexus. Arch Surg 1927;15:871-7.
15. Street E, Ashrafi M, Greaves N, et al. Anatomic Variation of Rami Communicantes in the Upper Thoracic Sympathetic Chain: A Human Cadaveric Study. Ann Vasc Surg 2016;34:243-9. [Crossref] [PubMed]
16. Hammer N, Löffler S, Bechmann I, et al. Comparison of modified Thiel embalming and ethanol-glycerin fixation in an anatomy environment: Potentials and limitations of two complementary techniques. Anat Sci Educ 2015;8:74-85. [Crossref] [PubMed]
17. Aliev D, Winter K, Henkelmann J, et al. The median nerve’s system of connective tissue distal to the pronator teres to the carpal tunnel. Ann Anat 2024;255:152295. [Crossref] [PubMed]
18. Doolabh N, Horswell S, Williams M, et al. Thoracoscopic sympathectomy for hyperhidrosis: indications and results. Ann Thorac Surg 2004;77:410-4; discussion 414. [Crossref] [PubMed]
19. Felisberto Júnior G, Rubira CJ, Berumudes JP, et al. Comparison between high and low levels thoracic sympathectomy for the treatment of palmar and axillary primary hyperhidrosis: systematic review and meta-analysis. Rev Col Bras Cir 2016;43:486-92. [Crossref] [PubMed]
20. Zhang W, Yu D, Jiang H, et al. Video-Assisted Thoracoscopic Sympathectomy for Palmar Hyperhidrosis: A Meta-Analysis of Randomized Controlled Trials. PLoS One 2016;11:e0155184. [Crossref] [PubMed]
21. Zhang W, Yu D, Wei Y, et al. A systematic review and meta-analysis of T2, T3 or T4, to evaluate the best denervation level for palmar hyperhidrosis. Sci Rep 2017;7:129. [Crossref] [PubMed]
22. Zhang W, Wei Y, Jiang H, et al. R3 versus R4 Thoracoscopic Sympathectomy for Severe Palmar Hyperhidrosis. Thorac Cardiovasc Surg 2017;65:491-6. [Crossref] [PubMed]
23. Vannucci F, Araújo JA. Thoracic sympathectomy for hyperhidrosis: from surgical indications to clinical results. J Thorac Dis 2017;9:S178-92. [Crossref] [PubMed]
24. Moon DH, Kang DY, Kim DW, et al. Early results of new endoscopic thoracic sympathectomy for craniofacial hyperhidrosis. J Thorac Dis 2018;10:3627-31. [Crossref] [PubMed]
25. Rieger R. Management of Plantar Hyperhidrosis with Endoscopic Lumbar Sympathectomy. Thorac Surg Clin 2016;26:465-9. [Crossref] [PubMed]
26. Lima SO, de Santana VR, Valido DP, et al. Retroperitoneoscopic lumbar sympathectomy for plantar hyperhidrosis. J Vasc Surg 2017;66:1806-13. [Crossref] [PubMed]
27. König S, Schröter T, Borger MA, et al. Outcomes following cardiac sympathetic denervation in patients with structural heart disease and refractory ventricular arrhythmia. Europace 2022;24:1800-8. [Crossref] [PubMed]
28. Vaseghi M, Barwad P, Malavassi Corrales FJ, et al. Cardiac Sympathetic Denervation for Refractory Ventricular Arrhythmias. J Am Coll Cardiol 2017;69:3070-80. [Crossref] [PubMed]
29. Li A, Kaura A, Sunderland N, et al. The Significance of Shocks in Implantable Cardioverter Defibrillator Recipients. Arrhythm Electrophysiol Rev 2016;5:110-6. [Crossref] [PubMed]
30. Krieger K, Park I, Kemper T, et al. Simplified left cardiac sympathetic denervation as an acute strategy for recurrent ventricular tachycardia in multimorbid patients with structural heart disease: A case series. Heart Rhythm O2 2025;6:1652-8. [Crossref] [PubMed]
31. Nachira D, Vita ML, Napolitano AG, et al. Predictors of Compensatory Sweating and Satisfaction Following Endoscopic Thoracic Sympathetic Chain Clipping for Palmar/Axillary Hyperhidrosis. J Clin Med 2025;14:326. [Crossref] [PubMed]
32. Martínez-Hernández NJ, Estors-Guerrero M, Galbis-Caravajal JM, et al. Long-term outcomes and predictors of compensatory sweating after bilateral endoscopic thoracic sympathectomy. Eur J Cardiothorac Surg 2025;67:ezaf108. [Crossref] [PubMed]
33. Yoo GY, Jeong JY, Lee J, et al. Achieving high patient satisfaction after sympathectomy through preoperative thoracoscopic sympathetic nerve block in primary hyperhidrosis. J Thorac Dis 2025;17:2050-5. [Crossref] [PubMed]