Navigation for the excessive sweat / hyperhidrosis treatment pages

Endoscopic Transthoracic Sympathectomy - ETS

Endoscopic Transthoracic Symathectomy (ETS) is a key-hole surgery technique that is 99% effective at curing palmar hyperhidrosis and, with a slight modification, can also cure axillary hyperhidrosis in 80% of people at the same time. The same technique, modified once again, can also be used for facial flushing, blushing or sweating - with a success rate of 70% for each side.  It must be noted though, that there are now much better ways of treating axillary hyperhidrosis (armpit sweating).

The sweating in the hand is controlled by the sympathetic nervous system. This system is grouped together as a "chain" in the chest, on the spinal column. 
Under a general anaesthetic, it is possible to put a keyhole telescope through a 1 cm incision in the armpit, to deflate the lung a little and to cut this chain. By doing this, the hand instantly become warmer and bone dry. If the axilla is being treated as well, removal of part of the chain can be effective at treating this in 4 out of 5 cases.
As with all surgical procedures there are side effects and complications that patients and their relatives must be aware of before going through with this operation.

Risks of Endoscopic Transthoracic Sympathectomy

1 - Compensatory Hyperhidrosis

The body needs to lose heat and so, if the arms and head are treated by ETS, the sweat that should have come from these areas is re-distributed elsewhere. This re-distribution of sweating is called Compensatory Hyperhidrosis. It can be especially noticeable in the small of the back - and some people find this unbearable. Everybody gets compensatory hyperhidrosis - but only a few find it unbearable - recent research suggests over 85% of pateints are satisfied with the results of their ETS despite some increased sweating elsewhere (see references at bottom of article).

In addition, patients who have ETS by surgeons who only perform the sympathectomy by cutting the sympathetic chain at T2 (as we do at The Whiteley Clinic) seem to get fewer problems from compensatory hyperhidrosis than those who have surgery by surgeons who remove a section of the chain (see references at the bottom of the article).  Therefore before anyone consents to have ETS, they must be certain that their symptoms are severe enough to mean that relief from them would be worth having compensatory hyperhidrosis.
(please see references at bottom of page)

2 - Damage to the Lung needing a chest drain 

In approximately 1 in 100 patients the lung can rarely get damaged during the surgery, leading to a tube called a "chest drain" having to be put in place for a couple of days to make sure that the lung re-inflates. Very rarely, the lung needs to be repaired after such an injury.

3 - Horner's Syndrome

If too much of the chain is damaged, the face become dry on the same side, the eye lid can droop a little and the eye itself can have a dilated pupil (Horner's syndrome). This used to be quite common with the older styles of surgery where the chain was approached through the neck, or was destroyed by heating at ETS. 
To reduce this risk I always cut the chain using scissors and only use any heating on the bottom part of the chain AFTER cutting it.

4 - Winging of the Scapula

There have been reports that the nerve to the muscle of the shoulder blade can be damaged leading to "winging" of the shoulder blade. This means that the shoulder blade moves out to the side and needs intensive physiotherapy to see if it can be brought back again.

In my practice, I use blunt dissection to move this nerve aside and this reduces the risks as much as is possible.

5 - Injury to a major structure in the Chest

The chest houses some of the largest and most important structures in the body - particularly the Heart, the Great Blood Vessels and the Lungs. Knowing this, we are always exceptionally careful when doing an ETS. However, there is always a very small chance that one of these structures can be damaged. If this happens then the outcome depends on which structure is damaged and how severely.

At the end of the day, it is usual to open the chest in cases of such injury, to repair the damage. In my practice I have Dr Tony Lopez, an expert interventional radiologist on stand by for each ETS that I perform. The reason for this is that if bleeding occurs, rather than open the chest to stop it, Dr Lopez is able to find the site of bleeding using X-rays and put a coil into the artery and stopping the bleeding. If this is successful, then major surgery inside the chest is avoided.

This all sounds very dire but such injury happens only in about 1 in 1000 cases.
One final thing of importance - ETS is a permanent procedure - it cannot be reversed if the patient changes their mind

Thinking about ETS?

All of the information above is here NOT to put you off ETS, but to help you realise what this operation involves.

ETS, in the right patient, can have a life changing effect. I have had people who were unable to form relationships due to excessively sweaty hands have dry hands instantly. I have had people who are unable to work due to sweating from their faces or such severe blushing that they avoid meeting people get back to normal life. For them, these risks were worth taking.

However, people with less severe symptoms will realise that these risks are not worth taking - thus most patients, if given the details as above, will know whether ETS is for them, or if one of the other treatments would suit better.

References for compensatory hyperhidrosis:
Miller DL, Bryant AS, Force SD, Miller JI Jr.
Effect of sympathectomy level on the incidence of compensatory hyperhidrosis after sympathectomy for palmar hyperhidrosis.
J Thorac Cardiovasc Surg. 2009 Sep;138(3):581-5. Epub 2009 Jun 25.

Cardoso PO, Rodrigues KC, Mendes KM, Petroianu A, Resende M, Alberti LR.
Evaluation of patients submitted to surgical treatment for palmar hyperhidrosis with regard to the quality of life and to the appearance of compensatory hyperhidrosis]
Rev Col Bras Cir. 2009 Feb;36(1):14-8.

Miller DL, Bryant AS, Force SD, Miller JI Jr.
Effect of sympathectomy level on the incidence of compensatory hyperhidrosis after sympathectomy for palmar hyperhidrosis.
J Thorac Cardiovasc Surg. 2009 Sep;138(3):581-5. Epub 2009 Jun 25.

Araújo CA, Azevedo IM, Ferreira MA, Ferreira HP, Dantas JL, Medeiros AC.
Compensatory sweating after thoracoscopic sympathectomy: characteristics, prevalence and influence on patient satisfaction.
J Bras Pneumol. 2009 Mar;35(3):213-20.

Dumont P, Denoyer A, Robin P.
Long-term results of thoracoscopic sympathectomy for hyperhidrosis.
Ann Thorac Surg. 2004 Nov;78(5):1801-7.