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DR. LEE KHENG HIN
NEUROSURGEON, SURGERY FOR BRAIN, SPINE & NERVES
Ahli Bedah Syaraf , Tumor Otak, Tulang Belakang & Tulang Leher
K H LEE NEUROLOGICAL SURGERY6 Napier Road, #09-10, Gleneagles Medical Centre, Singapore 258499
Ph : 6476 2889 ; Fax : 6476 2886
After Office Hours : 6535 8833
Email : clinic@khleeneurosurgery.com.sg
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“ TREATMENT FOR SWEATY PALMS - AND SCARS ARE HARDLY VISIBLE ”
Khoo Ai Ling is a happy, healthy 25-year old media executive. In the past, there was one thing that bothered and sometimes embarrassed her - that was having to shake someone’s hand. At times you would be able to see dripping beads of sweat on her palms.
For the last two years, Ai Ling had wanted to do something about her sweaty palms. In May this year, Ai Ling decided to have her condition treated. She went to see Dr Lee Kheng Hin, a consultant neurosurgeon at Gleneagles Medical Centre. Dr Lee had already earned himself a reputation for doing a minimally invasive operation to treat sweaty palms. The procedure, called video endoscopic sympathectomy, requires small cuts in the armpits so that an endoscope hooked up to a miniature video camera can be used. Ai Ling was impressed because getting rid of sweaty palms would not mean getting a massive scar.
Dr Lee had been approached by a company to design an endoscope specially for the treatment of sweaty palms. Ai Ling became Dr Lee’s first patient to have the procedure performed with a new sympathectoscope which can also be used to treat sweaty armpits and body odour.
The new sympathectoscope only gives a half centimetre scar in the armpit. Unlike the standard needlescopes which have relatively poor vision and a soft wire coagulator which makes it more difficult to stop unexpected bleeding, the sympathectoscope gives exceptional vision and has a rigid burning apparatus, both of which make the procedure safer. The sympathectoscope will be marketed by German company Zeppelin Instruments.
NEW TREATMENT FOR SWEATY PALMS
Two patients were recently treated by neurosurgeon Dr Lee Kheng Hin at Gleneagles Hospital for their sweaty palms, using endoscopic surgery. Both patients, in their early forties, had been tolerating the inconvenience of wet and clammy hands for years.
Until recently, treatments available were confined to topical medications and electrophoresis, both of which only offered temporary relief. Some patients did not react well to the topical medications and others suffered sore, dry throats from electrophoresis. These side-effects and necessity for repeated treatment often resulted in patients not completing therapy.
Another option that offered a permanent cure was conventional surgery, but this was a major procedure requiring an average hospital stay of seven days with a period in the intensive care unit. Post-operative pain was severe and the operation left long, unsightly scars.
The new minimally invasive video endoscopic technique however, addresses these difficulties. It involves a less than one centimetre incision in the armpit to destroy the T2 sympathetic chain and ganglion. The operation takes about five minutes per side. Dr Lee has performed a total of 237 procedures, one of the largest personal experiences in the region. This technique can also be used for sweaty armpits and faces. Post-operative pain is almost non-existent, the scars are not noticeable and hospitalisation is reduced to only one day without the need for intensive care.
Case 1
In July last year, Mr C H Ng consulted Dr Lee for relief from his sweaty palms. He had heard about the new technique at a talk. As a businessman, a large part of his job involved meeting clients. His sweaty palms made this very uncomfortable and he had been trying to get rid of the problem for some time. Topical drugs and electrophoresis had failed to permanently cure his condition.
After undergoing the minimally invasive procedure, Mr Ng said: “I’m so glad my problem has been eliminated. I feel more confident now.”
Case 2
Madam Chium learnt of the procedure a year ago from the newspapers. But it was only after seeing someone on television who benefited from the treatment that she decided to give it a try.
Now free from sweaty palms, she said: “Friends discouraged me from seeking treatment. To them my problem was not serious enough for surgery”. Now after surgery, she is very pleased with the result. A lifetime of inconvenience has been eradicated with this simple and relatively inexpensive technique.
SWEATY PALMS TREATMENT
Sweaty palms is an inconvenience being tolerated by many people. Before, treatments were confined to topical medications and electrophoresis, both of which offered temporary relief. Some patients did not react well to the topical medications, while others suffered sore and dry throats from the electrophoresis treatment. Such side-effects and the necessity to repeat treatment often resulted in patients not completing therapy.
Another option that was available was conventional surgery. This offered a permanent cure but because it is a major procedure, it required an average hospital stay of 7 days with a period in the intensive care unit. Many patients do not favour this option as there was severe post-operative pain and long and unsightly scars remained after the operation.
Now a new technique is available and it is known as Video Endoscopic Sympathectomy. This new minimally invasive video endoscopic technique involves a less than one centimetre incision in the armpit to destroy the T2 sympathetic chain and ganglion. The actual sympathectomy takes about five minutes per side and the whole procedure takes approximately one hour. Post-operative pain is almost non-existent and the scars are not noticeable. Hospitalisation is reduced to only one day without any need for intensive care. This technique can also be used for sweaty armpits and faces.
The first case done using this technique at our Operating Theatre was performed by Dr Lee Kheng Hin, Consultant Neurosurgeon on the patient, Ms Kong Huey Minn on 8 January 1997. Ms Kong had been tolerating this inconvenience for 24 years as topical drugs had failed to permanently cure her condition. After undergoing the minimally invasive procedure, Ms Kong remarked “I am glad this is over and I feel happier now”.
Since then, quite a number of cases were done using this technique by consultant neurosurgeons at the hospital.
" SURGERY FOR ARTERIOVENOUS MALFORMATION AND ANEURYSM "
Arteriovenous Malformation
Arteriovenous malformations are congenital lesions derived from defective formation of cerebral blood vessels during the fetal development stage. Essentially defective formation of capillaries results in high pressure arteries and arterioles shunting straight into low pressure venules and veins. Consequently the weak-walled venous part of the arteriovenous malformation eventually ruptures. This occurs at a rate of approximately four percent per year, so common ages of rupture are twenty to forty. Arteriovenous malformation must be the prime suspect in all intracerebral bleeds of the young! The two other common presentations of arteriovenous malformations are seizures from surrounding brain damage and the so-called steal syndrome where excessive shunting draws blood away from surrounding brain. This results in neurological dysfunction like speech, motor problems or general mental slowness. In children excessive shunting can lead to high output cardiac failure.
Unlike malignant lesions, however, total obliteration of the arteriovenous malformation, if achieved, results in total cure.
Surgery techniques have been defined over the last decade and the feeding arterial vessels and arteriovenous malformation nidus must be obliterated first before the draining veins. Inadvertently obliterating draining veins before feeding vessels often results in a spectacular explosion and spectacular depletion of the blood bank’s stocks. In cases of large arteriovenous malformations, a pre-operative embolisation of the feeding vessels and nidus by the interventional radiologist helps the surgeon by reducing blood loss. Also, being a stage procedure, it allows autoregulation to be regained before surgery. The arteriovenous malformation shunting over the years often results in loss of arterial autoregulation and this is thought to be responsible for the post-operative perfusion breakthrough bleeding.
Arteriovenous malformation near or within the speech area can result in speech impairment after removal. This is because brain anatomy and function do not always correlate. What is thought to be the anatomical Broca’s speech area may or may not serve the function of speech. This may be served by a nearby nonclassic anatomical area. This is because the brain is plastic below the age of five years, meaning that brain function can be transferred to a non-classic area. So if the original anatomical speech area is damaged, function can subsequently be transferred to another part of the brain so that speech can be regained. Unfortunately this does not happen beyond the age of five years and damage to the speech area in an adult is likely to cause permanent impairment of speech. In that arteriovenous malformation are congenital lesions, the speech function can be transferred elsewhere should the arteriovenous malformation be in a classic anatomical area for speech. The surgeon at surgery will have absolutely no idea where the actual area is and inadvertent damage is possible. A technique has been developed in which the patient is operated on under awake regional anaesthesia. Speech is tested throughout surgery and functional speech area is mapped out by cortical stimulation. The surgeon is thus assured that actual speech area will not be impaired during and after removal of the arteriovenous malformation.
Small or deep arteriovenous malformation within the brain can now be localised to an accuracy of 1mm or less by computer assisted minimally invasive stereotactic technique where a trajectory though unimportant brain tissue can be planned before surgery. In that the brain is so minimally disturbed, patients have gone home well on the third post-op day.
Computers can also be used to focus external radiation onto an arteriovenous malformation to destroy it. This is akin to a magnifying glass focusing the sun’s rays onto a piece of paper causing the focus point to ignite into flames. Known as radiosurgery, the surgeon with the computer’s help avoids important brain areas while focusing the external radiation onto the lesion from all angles. Consequently the arteriovenous malformation receives the full therapeutic dose from all angles and is slowly destroyed while surrounding brain, getting a small dose, is relatively unaffected. Radiosurgery can be done as an outpatient procedure and does not involve any incision so that there is no pain, infection or haemorrhage. The gold standard for radiosurgery remains the Gamma Knife at the Singapore Gamma Knife Centre.
Does radiosurgery sound like a panacea for brain arterivenous malformations and other brain lesions? Unfortunately no. Radiosurgery is limited to lesions smaller than approximately 3cm. Anything larger and the brain will not tolerate the excessive radiation. There are also complications like cerebral oedema and radionecrosis from excessive brain radiation, arising about nine months post-treatment. A knife is still a knife, whether surgical or therapeutic radiation and important structures like the eye, optic nerves, optic tract or brainstem can be inadvertently damaged. In addition, the arteriovenous malformation takes up to three years after radiosurgery to be obliterated and in the interim, can still bleed and cause death or other neurological problems. In any case, only eighty percent of all arteriovenous malformation treated will be obliterated so that either open surgery or repeat radiosurgery will have to be done.
Aneurysm
Aneurysm arise from the distal junction of the forking of cerebral vessels where the pulse wave from the heart hits before the blood is channelled to the two distal branches. Consequently the vast majority of aneurysms are degenerative in nature through vessel wall weakness from excessive smoking, alcohol or fat intake. Eventual rupture at ages fifty to seventy results in subarachnoid bleed whereby the patient experiences the worst exploding headache of his life with radiation of pain down the neck. There will be associated neck stiffness and photophobia. Eventual sciatica may occur from blood tracking down the spinal canal and irritating the nerve roots. There may or may not be subsequent loss of consciousness and hemiplegia or other neurological deficits. Unfortunately a lot of aneurysm leaks do not present with the classical picture above and patient may only complain of dizziness, weakness, grogginess or other mild symptoms. It pays to be suspicious. If the CT Scan shows subarachnoid bleed, then a cerebral angiogram is indicated. Should the CT Scan be negative, a lumbar puncture has to be done if clinical suspicion is strong. This is still the gold standard and will detect subarachnoid bleeds in the presence of a negative CT. Congenital aneurysms from congenital weakness of blood vessel walls or collagen syndromes like Ehlers-Danlos, will rupture in childhood.
Once ruptured, the aneurysm presents with three problems. There is risk of recurrent haemorrhage, vasospasm or hydrocephalus.
The majority of aneurysms will re-rupture within the first forty-eight hours so that if patient is clinically well and the vascular neurosurgeon experience, early repair is the latest trend. Should there be associated intracerebral clot or hydrocephalus early repair is also indicated even if the patient is not clinically well. The rationale is that the patient’s clinically grade may improve with evacuation of the intracerebral clot or control of hydrocephalus with either an external ventricular drainage or ventriculo-peritoneal shunt. Surgical repair is by the surgeon applying a specialised clip across the aneurysm neck while avoiding the fine perforating vessels arising nearby and supplying important brain structures. Needless to say if the perforating vessels are destroyed or occluded, severe disaster to the patient results. This is especially more likely to occur if the aneurysm ruptures in the surgeon’s face in the course of dissection or attempted clipping, a not uncommon event.
Another method of repair is by the interventional route where the radiologist inserts a special thrombogenic coil into the aneurysm through a femoral artery puncture. Early results are promising but long term results are not yet available. There are problems of the aneurysm neck not being occluded and risk of subsequent rupture. In a surgical clipping, there is intima to intima contact of the two opposing surfaces so that regrowth takes place and the parent vessel regains its structure and strength. In the aneurysm that has a coil inserted, intima may not grow across the coil to the other side so that the parent vessel is not reformed. Often the coil gets compressed against the fundus of the aneurysm exposing the lower aneurysm body and neck to the ravages of the pulse wave from the heart. A second coiling procedure or surgical clipping is indicated if this is detected post-procedure otherwise re-rupture has been known to occur. Coiling certainly has a place if the patient is medically unfit for surgery.
Vasospasm is one of the unresolved problems of neurosurgery and results when the breakdown products of haemoglobin acts on the external surfaces of the blood vessels. The exact mechanism is still to be worked out and has so far eluded the attempts of researchers. Approximately three days after rupture, when haemoglobin has broken down to its products, the blood vessels constrict resulting in cerebral ischaemia and subsequent stroke causing death, coma or hemiplegia even though the aneurysm has been successfully repaired earlier. Medically, starting nimodipine immediately after a subarachnoid bleed has been shown to improve results, not so much as to control the vasospasm but more from its calcium-channel blocking action protecting the neurons. Other medical treatment is to offer hypertension (possible only if the aneurysm has been repaired by early surgery), hypervolaemia and haemodilution, all with the purpose of pushing more blood through the constricted vessels.
Surgical measures include a bypass procedure whereby an external carotid artery is anastomosed to the cerebral artery to supply more blood. This is not commonly done. What is more common nowadays is for the interventional radiologist to give direct intra-arterial injection of papaverine. This has only temporary effects and need repeat injections, or to be followed by intra-arterial ballooning to dilate the constricted blood vessel, much like what is done for coronary artery stenosis. Results can be quite dramatic with the patient recovering from all the deficits almost immediately. Unfortunately, the blood vessel has been known to rupture from the procedure, resulting in death.
Overall, however, the modern management of arteriovenous malformation and aneurysms have resulted in a great majority of good grade patients returning to their normal lifestyle, cured.
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