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).

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 becomes warmer and bone dry. If the axilla is being treated as well, removal of part of the chain can, in 4 out of 5 cases be effective at treating this.

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 the bottom of this page).

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.
(see references at the bottom of this page)

2 - Damage to the Lung needing a chest drain

Rareley, in approximately 1 in 100 patients, the lung can be 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 can 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 was 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 we 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.

At The Whiteley Clinic we 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. At The Whiteley Clinic 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 stop the bleeding. If this is successful, then major surgery inside the chest is avoided.

This all sounds very dire, but such an 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 this information above is NOT here 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. We have had people who were unable to form relationships due to excessively sweaty hands have dry hands instantly. We 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 information above, will know whether ETS is for them, or if one of the other treatments would suit better.