Current clinical roles

• Refractory ventricular arrhythmias / VT storm: left-sided or bilateral cardiac sympathetic denervation may be considered at specialist centers after antiarrhythmic drugs and catheter ablation have failed. A stellate ganglion block is often used first to assess short-term response. The Washington Manual of Medical Therapeutics, p. 259.
• Historically for upper-limb vasospastic disease such as severe Raynaud phenomenon. Open cervical sympathectomy was generally unsuccessful and is largely obsolete. Bailey and Love's Short Practice of Surgery, p. 1045.
• In severe Raynaud-related digital ischemia, local digital sympathectomy is generally preferred when surgery is considered. Cervical or thoracic procedures may give initial relief but symptoms can recur within 12-18 months. Andrews' Diseases of the Skin, p. 589.
• Modern endoscopic thoracic sympathectomy, rather than an open cervical operation, is selectively used for severe refractory palmar or axillary hyperhidrosis. Bailey and Love's Short Practice of Surgery, p. 1045.

Important adverse effects

• Horner syndrome from injury near the stellate ganglion: ptosis, miosis, and reduced facial sweating on the affected side
• Compensatory or gustatory sweating
• Pneumothorax, bleeding, neuralgia, infection
• Hypotension and altered temperature regulation
• Recurrence or incomplete benefit

Surgical management of acute lower GI bleeding

1. Initial principles before operation

• ABC resuscitation, two large-bore IV lines, cross-match blood, correct coagulopathy, and stop/reverse anticoagulants when appropriate.
• A patient with massive hematochezia and shock may have an upper GI source. Consider urgent upper endoscopy when suspected.
• Localize the bleeding source whenever possible:
  • Colonoscopy in stable patients
  • CT angiography for brisk ongoing bleeding or instability
  • Catheter angiography with superselective embolization after positive CTA or when colonoscopy is not feasible
• Early involvement of colorectal/general surgery and interventional radiology is appropriate in severe bleeding.

2. Indications for surgery

1. Persistent massive bleeding with hemodynamic instability despite aggressive resuscitation.
2. Failure of endoscopic hemostasis and angiographic embolization, or when these facilities are unavailable.
3. Recurrent severe bleeding refractory to endoscopic and angiographic treatment.
4. A large ongoing transfusion requirement, often cited as more than 6 units of blood products with continued bleeding.
5. A surgically correctable lesion, such as:
   • Bleeding colorectal cancer
   • Meckel diverticulum
   • Ischemic or perforated bowel
   • Persistent severe hemorrhoidal bleeding in selected cases

3. Choice of operation

A. Segmental colectomy

• Resect the involved colonic segment with appropriate vascular control.
• Restore continuity with primary anastomosis only if physiology and bowel perfusion are favorable.
• In shock, gross contamination, severe coagulopathy, or high vasopressor requirement, perform resection with stoma formation rather than a risky primary anastomosis.

B. Subtotal colectomy

• Removes colon from caecum to sigmoid/upper rectum.
• Reconstruction options:
  • End ileostomy in unstable or coagulopathic patients
  • Ileorectal anastomosis in carefully selected stable patients
• Before committing to subtotal colectomy, consider on-table colonoscopy or examination of the rectosigmoid to exclude a distal source.

4. Intraoperative adjuncts

• Intraoperative colonoscopy after lavage
• Palpation and inspection of bowel
• Enterotomy with intraoperative enteroscopy if a small-bowel source is suspected
• Review preoperative CTA, angiographic images, endoscopic clips, or tattoo marks
• Examination of rectum and anus before a “blind” colectomy

5. Postoperative care

• ICU monitoring in massive-bleeding cases
• Monitor hemoglobin, hemodynamics, urine output, lactate, and evidence of recurrent hemorrhage
• Correct hypothermia, acidosis, thrombocytopenia, and coagulopathy
• Watch for anastomotic leak, bowel ischemia, abdominal compartment syndrome, renal failure, and pulmonary complications
• Restart antithrombotic therapy only after balancing rebleeding against thrombotic risk with the relevant specialists.

Exam summary

Resuscitate, localize, treat by endoscopy or embolization, then operate only for persistent or recurrent uncontrolled bleeding.
Localized lesion: segmental resection.
Unlocalized, exsanguinating presumed colonic bleed: subtotal colectomy, usually with stoma in an unstable patient.
Never perform blind segmental colectomy.