463

SURGERY IN SEVERE ESSENTIAL HYPERTENSIONBy FRANK D'ABREU, CH.M., F.R.C.S.Assistant Surgeon, Westminster Hospital

Essential hypertension, according to Poppenand Lemmon (I947)1 is four times as deadly ascancer, and Lee MacGregor2, quoting thesefigures and other gloomy statistics of this disease,describes it as Public Enemy No. i. A reportfrom the Metropolitan Life Assurance Company ofNew York ten years previously, less graphic butmore chilling, states that half a million deathsoccur annually in the United States from hyper-tension, and that after the age of 45 the death ratefor this disease is four times that of cancer and20 times that of tuberculosis or diabetes.As the true cause of essential hypertension is

still unknown, treatment can only be directedtowards the effects of the disease. Surgically,attempts have been made to lower the bloodpressure by removing portions of the sympatheticchain. This has been done by operations whichhave tended, year by year, to increase in theirextent.

Sympathectomyi. Criles operation. In this, through a small in-

cision in the loin, the coeliac ganglion is removedby deep and blind dissection. This technique isa most difficult and individualistic form of re-moving only a part of what has been excised bylater methods.

2. Adson's sub-diaphragmatic approach. Inthis operation the main lumbar sympathetic chainis exposed and removed from the crus of thediaphragm to below the second lumbar ganglion.In addition, portions of the greater, lesser andleast splanchnic nerves and the coeliac ganglionare excised. This has been combined on occasionswith partial adrenalectomy.Adson has shown good results from this opera-

tion but his critics complain that the sympathec-tomy possible by this approach is not extensiveenough. A more practical objection is that theidentification of all the nerves to be removed cannot be facilitated by tracing them down from abovethe diaphragm, as is done in Smithwick's lumbo-dorsal sympathectomy.Removal of part of the adrenal has yielded

disappointing results so far as any permanenteffect in lowering the blood pressure is concerned

and is said to increase greatly the dangers of theoperation from post-operative hypotensive crises.

3. Peet's method. Here the sympathetic chainand the splanchnic nerves are exposed trans-thoracically and traced downwards.

4. Smithwick's method. This combines thethoracic and sub-diaphragmatic approaches and isdescribed in detail below.

5. In an effort to excise more and more of thesympathetic nervous system, some surgeons nowopen the chest and attack the sympathetic chaintrans-pleurally. The chain can be removed up tothe level of the second ganglion by this means andthe para-aortic sympathetic nerve excised as well asthe nerves which are removed by Smithwick'smethod. Although it is claimed that the coeliacganglion and the first lumbar ganglion can beremoved by this approach, no exploration of theadrenal gland and the kidney can be carried outand the second lumbar ganglion cannot be reachedunless the diaphragm be opened and the operationthus made more formidable. This has the advan-tage of being an easier approach, but experienceand careful assessment of mortality figures andresults, under controlled conditions, can aloneshow if this method is better than Smi'thwick's.

6. Multiple sympathectomies through separatechest and loin incisions have been advocated, butthe limit, it seems, has already been reached byGrimson3, who performs sometimes a completebilateral removal of the whole sympathetic nervoussystem.

In assessing these operations it must be re-membered that sympathectomy at its best is onlyremoving a link in the-chain of this disease. Itwill not be until the more radical sympathectomiescan show, in cases comparable in number withthose of Peet4 and Smithwick5, a longer survivalperiod and an equally low mortality rate, that theycan be deemed the better form of surgicaltreatment.There has been much discussion of recent years

concerning the selection of cases of essential hyper-tension for surgery. By means of sedation testsand by methods of epidural block anaesthesiamimicking the effects of sympathectomy, it hasbeen hoped to discover which cases are suitable for

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POST GRADUATE MEDICAL JOURNAL

removal of the pressor influence of the sympatheticnervous system. Doubt has been thrown latelyby sdme authorities, on the value of such tests andin the group of severe cases discussed in this paperthe view has been taken that as symptomatic reliefmay be attained even without permanent loweringof the blood pressure, every case should be giventhe chance of operation. The cases chosen arethose with the worst prognosis and include:

(i) Definitely ' malignant' hypertensives.(2) Those with a fixed diastolic pressure around

I50'.(3) Those with a clear history of encephalo-

pathic incidents.[Smithwick advises against operation in a male

patient with a resting diastolic pressure of 140 ormore, who has a history of an encephalopathicaccident, or has evidence of cardiac or renalimpairment.]The criterion of malignancy is not universally

clear and definite. At a meeting held in Clevelandin I942 de Takats6 and Smithwick spoke at crosspurposes until de Takats revealed that what hehad been describing as malignant hypertensionwas a case of papilloedema combined with renaland cardiac damage. Many others consider' papilloedema' as the sole criterion. Someophthalmic surgeons, however, say that the termpapilloedema should be. reserved for space-occupying lesions within the skull and considerthat papilloedema in malignant hypertension is anextension over the papilla of retinal oedema.As regards retinal classification our cases belong

to Grades III and IV, Grade III showing angio-spasm with nipping of veins at the arterio-venouscrossings With or without haemorrhages orexudates, and Grade IV definite retinal oedemaand papilloedema. Sedation tests were employedin the early cases, but when it was found that allreceived symptomatic relief in spite of unsatis-factory tests, these were abandoned.

Peet summarizes his criteria for operation asfollows:

I' A patient below 54 years of age, a more or lesscontinuously elevated blood pressure with asystolic pressure over I70 and a diastolic pressureabove I05. A non-protein nitrogen below 45 mg.,a relatively well compensated heart and a relativelynormal cerebral function.'Now many cases fulfilling all these onditions

may survive their expected span of life and it isvery understandable that physicians are oftenhesitant in advising surgery for these patients.Patients with malignant hypertension, those withGrade III retinal changes and those with a historyof definite encephalopathic attacks are, however,in a different category. In these people the prog-nosis is extremely gloomy and medical treatment

can offer little help. It is strange to find that it isthis very group of cases in which operation isdeprecated by many authorities. Here the prob-lem is akin to that of cancer. The cause is un-known, but the future, without treatment, can bepredicted with reasonable certainty. In cancer.any method of alleviation of symptoms or hope oflengthening life is rightly accepted by recognizedmedical opinion. The same should apply to hyper-tension. The strange fact that symptoms may berelieved, or cured, even when the blood pressure isnot affected for more than a period of a fewmonths, has now been noted by so many surgeonstreating hypertension, that one feels that nopatient should be denied the relief of an adequatesympathectomy, howevere severe the disease,unless he has reached the stage of advancedkidney damage where irreversible changes haveoccurred. It might be said that the indication forsurgery, above all others, is hypertension withcrippling headache and either Grade III or GradeIV retinal changes, before severe kidney damagehas set in. There are, in our opinion, certainindications for urgent surgical treatment:-

(i) A rapidly progressive hypertension. Thepatient should be submitted to surgery before theinevitable cardiac and renal changes occur.Adson7 gives a limit of i8 months' survival to arapidly progressive case.

(2) A fixed diastolic pressure above 130.(3) A history of definite encephalopathic at-

tacks, such as transient hemiparesis, markedmental changes and periods of unconsciousness.

(4) A young person with a rapidly mountingblood pressure.

In practice, in all cases at the WestminsterHospital, with one or two exceptions, operationshave only been performed on severe hypertensives.From the surgeon's point of view as well as thatof the patient, it is a great solace, after so extensivean operation that there is concrete evidence ofimprovement and that benefits are not onlytheoretical. The headache has gone and the eye-sight improves. Seven out of our first eight casesare back at full work and asymptomatic. Theeighth was a patient with advanced Grade IVretinal changes and severe renal damage who lefthospital after his operation but soon returned anddied of cardio-vascular-renal failure i i weekslater.

It is extemely important that these patientsshould be treated by a team. They should be in-vestigated, selected and assessed after operation bya physician. They are all subjected to the follow-ing routine pre-operative investigations

(i) X-ray and screening of chest.(2) Intravenous pyelography.(3) Electrocardiography.

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September I948 D'ABREU: Surgery in Severe Essential Hypertensionz 465

Vertebral Colun-in.

. ~~~~~Sympa F g|thet<uc (1-m il').

Greater Splinchnic

I I- q l 1 XNerve.

:r4-£

Alri

FIG. i.-Second stage Smithwick operation.

......>

.,...........

........

mm....

.

. .'

FIG. 2.--Case I.Before operation. After operation.

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TABLE I

T.E.(No. I)

T.G.A.(No. 2)

R.N.(No. 3)

J.H.(No. 4)

K.M.(No. 5)

TimeInterval

3months

6months

7months

Pre-operative Gphthalmic Examination

Fundi: Veins congested and comipressed byarteries at crossways. Manv soft exudatesalong course of vessels. Only a few punc-tate haemorrhages. Some retinal oedema.Well-marked hypertensive retinitis of gravegeneral significance.

Left fundus: Disc normal. Small white exud-ates between disc and macula. One cottonwool patch along left infero-temporalvessels. Right optic disc not we11 seen. Nopapilloedema.

Extensive haemorrhages and exudates in righteye. Some haemorrhages and exudates inleft eye. Marked hypertensive retinopathywith thrombosis of inferior temporal vein.

Not seen by Mr. King.

Both fundi show (a) tortuosity of vessels (b)venous congestion; (c) diffuse retinaloedema; (d) a numbei of large exudates;(e) a few small haemorrhages. There is aclassic hypertensive retinitis.

Both fundi show (a) a few soft exudates andstriate haemorrhages (b) congestion of theretinal veins (c) silver wire aiteries (d)generalized retinal oedema. A case of hyper-tensive retinopathy.

Fundi: Gross retinal oedema, exudates andhaemorrhages. Swelling of optic discs notexcessive. Arteries: Small veins congestedand irregular. Gross hypertensive retino-pathy affecting particularly the optic discs,and peri-papillary areas.

Fundi: (i) Retinal oedema particularly aroundmaculae and optic discs; (2) sclerosis ofarteries which show extreme variability incalibre; (3) veins somewhat congested andcompressed by arteries at crossing; (4) afew medium soft exudates round maculae;(5) no haemorrhages; (6) widespread an-terior choroido-retinal degeneration. Thisno doubt is partly due to retinal vascularchanges, but also to underlying sclerosis ofchoroidal vessels.

4months

months

2months

E.C(No

(No. 7)

W.D.(No. 8)

Post-operative Ophthalmic Examination

The improvement in this man's fundi isstriking :-(a) All the rec2nt soft exudateshave disappeared; (b) the few small haemor-rhages have absoibed; (c) the venous con-gestion and retinal oedema are definitelyless ; (d) the small more chronic exudatesnear the optic disc in the right eye are smallerand less numerous.

Fundi normal.

Improvement in the fundi is dramatic. On theright side there are exudates still present nearthe optic disc and one tiny haemorrhage tothe inner side of the optic disc. On the leftside there are no exudates seen but two verysmall haemorrhages along the superior tem-poral artery. There is no sclerosis of arteriesand veins.

Not seen by Mr. King.

The improvement in the fundi is striking. Theonly pathological changes remaining areslight oedema most marked at the right foveaand a few points of exudate.

The improvement in both fundi is marked. Inboth eyes all haemorrhages have disappearedand all soft exudates absorbed. There are,however, some small hard exudates above theright macula which are new. The retinaloedema is much less marked though stillvisible round the optic discs. The vesselsare unchanged.

No change. Died I i weeks after secondoperation.

There is considerable improvement. Theretinal oedema has cleared up considerablvbut still persists on the nasal side of the opticdiscs. Venous congestion and the softexudates have disappeared.

466 September I 949

I

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D'ABREU: Surgery in Severe Essential Hypertension

(4) Kidney function estimation.(5) Examination of urine.(6) Examination of fundi (and painting by

artist).(7) Serial blood pressure estimations.(8) Sedation reaction.Anaesthetization presents problems of its own.

A most alarming fall in blood pressure has beennoticed before any section or interference withsympathetic nerves has started and the pulsepressure often fades to a few millimetres of mer-cury. The cause of this is now under investigation.It may possibly be due to intense, generalizedarterio-spasm, as improvement can be attained bythe intravenous injection of Novocaine. Thatthese cases show no operative mortality is largelydue, I am sure, to careful anaesthesia.

OperationThe operative procedure in all these cases was

that of Smithwick. The patient lies with hisface downwards resting on the head-piece of thetable. A dorsal para-vertebral incision is madeIi in. lateral to the vertebral spine, starting overthe ninth rib. On reaching a point i in. belowthe 12th rib, the incision curves laterally, belowand parallel to the costal margin for a distance of3-4 in. The sheath of the erector spinae isopened and the muscle mass reflected medially.The i2th rib is now resected sub-periosteally andthe 12th nerve and sub-costal vessels excised.The renal fascia is next opened and the lower edgeof the diaphragm is identified. The anaesthetist isasked to inflate the lung and the lower limits ofthe pleural reflection are thus seen. The dia-phragm is cut parallel to this reflection and J in.below it. Its division is continued until the sideof the I2th vertebra is exposed. The kidney isdisplaced forwards after inspection of the supra-renal gland for any evidence of tumour. The tableis then tilted laterally away from the operator toan angle of 450. The sympathetic chain will thusbe exposed lying over the heads of the ribs in thethorax and inclining forwards to the first lumbarganglion. The greater splanchnic nerve isidentified and traced down to the coeliac ganglionlying on the aorta and the lesser and least splanch-nic nerves will be found lying parallel to it (Fig. I).Before removal of any part of these nerves they aretraced upwards by reflecting the pleura, which is oftissue-paper thickness here, as far as possible fromthe vertebral ends of the ribs. One should be ableto reach as high as the eighth ganglion. It mayalso be advantageous in some cases to remove theinner portion of the iith rib, to enable this levelto be reached. All these nerves and the sym-pathetic chain itself are then removed from thehighest point attained down to below the first

lumbar ganglion. The coeliac ganglion is alsoremoved completely. For some inches above thediaphragm, sympathetic filaments to the aortashould be removed, as should the pre-ganglionicnerves running from the spine to the sympatheticchain. It is recommended that the cut ends of thenerves be encased in silk sheaths turned on them-selves and embedded in neighbouring muscle todiscourage regeneration. The diaphragm is thenre-sutured and the wound closed. The left side isdone at the first stage and the right about twoweeks later.

Post-operative Complicationsi. Pleural effusion. An immediate post-opera-

tive X-ray of the chest is taken as a routine andhas shown in almost every case a pleural effusion.These, except in two cases, have been minimal,have not caused any symptoms and have clearedup in a few days. From two, a bloodstainedsterile fluid was aspirated. No further treatmentwas required.

2. Lumbar neuralgia. Two cases complainedbitterly of pain in the loin spreading down to thegroin. These pains grew gradually less and inboth cases disappeared when the patient got upfrom bed and became ambulatory, about a fort-night after the second operation.

3. Faintness and Giddiness. This occurs when avery marked fall of blood pressure is broughtabout by the sympathectomy and occurs when thepatient first gets out of his bed. In our experienceit is very uncommon in severe hypertensives buthas only occurred in the patients not discussed inthis paper, with less severe forms of essentialhypertension. If these symptoms are marked, anabdominal pad and binder plus bandaging of thelegs, will help.Every case was examined by another important

member of the team, the ophthalmic surgeon, who,in each case, provided us with a report on thefundi before and after operation. This wascombined with actual painting of the fundi by amedical artist. A summary of the ophthalmicsurgeon's reports (Mr. E. F. King) is shown inTable i. Table 2 gives some details of the eightcases treated. The pre-operative blood pressurewas taken after full pre-operative investigation hadbeen completed, while the patient was resting inbed. The post-operative blood pressure was takenat the interval stated when the patient reported forfollow-up and was also taken in the recumbentposition. It will be seen that there was no operativemortality and that all except one is now back atwork and asymptomatic. No patient was con-sidered too advanced for surgery, but it is certainthat when irreversible changes take place in thekidneys-shown by a serious deficiency in kidney

.a

September I 948 467

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468 POST GRADUATE MEDICAL JOURNAL September i 949

TABLE 2

Duration of Pre-operative Post-operative Post-operativeAge Sex Symptoms Blood Pressure Interval Blood Pressure Course

T.E. 30 M 7 months 205/135 6 months I80/135 Symptomless no evi-(No. i) dence of cardiac

failure. Doing fullwork.

T.G.A. 40 M 3 months 26o/ i 6o 5 months 170/125 Working hard-prob-(No. 2) ably too hard.

Symptomless.

R.N. 42 M 3 weeks 26o/I5O 6 months 200/130 Symptomless.(No. 3)

J.H. 48 M Hypertension known for 2 10/120 5 months iIo/8o Symptomless but tires(No. 4) 15 years. Symptoms easily.

for one year.

K.M. 25 F Headache for five years. 230/155 4 months 195/125 Vision improved. Has(No. 5) Blurring of vision for returned to work.

two months.

E.C. 29 M 5 months 210/145 3 months 200/135 Doing light duties.(No. 6) Symptoms much

improved. Occas-ional mild temporalheadache.

H.C. 47 M 6 weeks 2504/50 I month 230/I60 Died ii weeks after(No. 7) operation.

W.D 34 M 2 years 250/150 6 weeks I70/130 Residual left visual(No. 8) defect. Occasional

mild left sided head-ache.

SYMPTOMATOLOGYI

2 3 4-

5 6 7- 8

T.E. T.G.A. R.N. J.H. K.M. E.C. H.C. W.D.

Headache.. .. .. .. + + 0 + + + + +

Impairment of vision .. .. 0 0 + 0 + + + +

Dyspnoea .. .. .. .. + o 0 0 0 0 0 0

Encephalopathy .. .. .. 0 0 0 + 0 + + 0

Fatigue .. .. .. .. 0 + 0 0 0 0 0 0

Haemoptysis .. .. .. + 0 0 0 0 0 0 0

function-little improvement can be expected.Case No. 7 was a malignant hypertensive withserious kidney damage, almost blind and sufferingfrom crippling headaches. His blood pressure andeyesight were unaffected by operation but his

headaches disappeared and he left hospital twowveks after his second operation. He returnedafter seven weeks and died of cardio-vascular-renal failure.

Table No. 3 shows the symptoms with which the

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September 1948 D'ABREU: Surgery in Severe Essential Hypertension 469

30C EFFECT OF OPERATION ON B. P.

260 BAC

I Tr4.A. at'4o d'

200 200 1

lSO | 1701

100300

I.c. . 47 d'

2 230 84 2 230

200 It123160

140

* ,lOhA1 i 4.JC.L 4

100

TABLE 4

patients presented themselves. It will be seen thatheadache was present in all except one case, im-pairment of vision in five and a history of definiteencephalopathic incident in three.No case over the age of 48 appears in this small

series but recently a man aged 6o who had GradeII retinal changes only (definite arteriolar sclerosis)was sent us by a physician and has received greatbenefit from the operation.

Table 4 shows, in graphic form, the effects ofoperation on a man whose blood pressure re-acted well to operation (Case No. 2), and below itis shown a chart of the blood pressure of the patientwho received the least benefit and who eventuallydied (Case No. 7).

SummaryA series of cases-of severe types of essential

hypertension is presented and the results analysed.It is found that they all received great benefit fromthe operation except one. That this improvementis not merely functional is shown by

(i) Its effects on the blood pressure.(2) The improvement in the eyeground pictures

and, in certain cases, diminution in the size of theheart (see Fig. 2).

It is urged that every case of marked hyperten-sion should be given the chance of operation unlesssevere renal damage has set in or the patient hasadvanced arterial changes such as are present inold age. The operation is justified if symptomsare merely relieved. Its indications will be evenmore apparent if life is shown to be prolongedthereby.My thanks are due to the physicians of the

Westminster Hospital who investigated these casesand sent them to me for operation, particularly toto Sir Arnold Stott and Dr. S. P. Meadows. Alsoto Mr. E. F. King for his ophthalmic reports andto Dr. J. C. Harland and Mr. C. Drew, themedical and surgical registrars, respectively, fortheir help in preparing the data for this paper.

Since this article was submitted for publication a-further i7 cases have been submitted to operation.Of these I4 fulfilled the criteria laid down forsevere cases; 7 of these were definitely malignantcases with papilloedema. There has been onedeath and two have failed to derive any benefit,'the first having a pre-operative renal function of20 per cent., and the second advanced cardiacand pulmonary back pressure changes who hasbeen recently re-admitted to hospital with heartfailure. All the rest have benefited markedly as faras symptoms are concerned. All cases now havewound drainage for 48 hours after the operationand there has been a complete absence of thepleural effusion present in the early cases. Theoperative death occurred before drainage of thewound was instituted as a routine. At post-mortem it was found that there was a large collec-tion of blood hidden awav deeply in the operativefield. His low blood pressure post-operatively wasput down to re-active hypotension and the condi-tion not recognized. We feel that the loss of bloodwas a contributory factor to his death and wheredrainage is free and the haemoglobin concentra-tion warrants it a blood transfusion is now givenpost-operatively.

REFERENCES

I. POPPEN, J. L., and LEMMON, C. (I947), J. Am. Med. Ass.,'34, 4-

2. LEE MACGREGOR (1948), Brit. J. Surg., 139, P. 28I.3. GRIMSON, K. S. (I94I), Ann. Surg., 114, 753.4. PEET, M. M., and ISBERG, E. M\(1943), J. Am. Med. Ass.,

130, 487.5. SMITHWICK, R. H. (I945), Cleveland Clin. Quart., 12, 105.6. DE TAKATS, G., HEYER, H. E., and KEETON, R. W. (I942),

J. Am. Med. Ass., II8, 506-7.7. ADSON, A. W. (I939), Milit. Surg., 84, 537.

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