Endoscopic Thoracic Sympathectomy (ETS) is a minimally invasive surgical procedure that alters nerve signals to address conditions caused by an overactive sympathetic nervous system. Its primary purpose is to stop unwanted bodily responses not effectively managed by other treatments.
Mechanism and Medical Applications
ETS surgery targets the sympathetic nervous system, part of the autonomic nervous system responsible for involuntary bodily functions like sweating, blushing, and heart rate. The procedure interrupts nerve signals in the sympathetic nerve chain in the chest, preventing them from reaching specific body areas and reducing overactivity.
The surgery is performed for severe focal hyperhidrosis, characterized by excessive sweating in areas like the hands, armpits, or face. It is generally considered when other less invasive treatments have not provided sufficient relief. ETS may also manage severe facial blushing and certain forms of Raynaud’s phenomenon, which causes reduced blood flow to the fingers and toes. The procedure permanently alters nerve pathways.
Surgical Process
Before ETS surgery, patients undergo pre-operative preparations. The procedure is performed under general anesthesia, ensuring the patient is asleep and pain-free.
The surgeon makes small incisions, typically one or two, under the armpit on the side where the excessive sweating occurs. These incisions are usually between 3 to 5 millimeters. A thin tube equipped with a light and camera, known as an endoscope or thoracoscope, is inserted through one of these incisions into the chest cavity, allowing visualization on a monitor.
Other small tools are inserted through the remaining incisions. The surgeon then identifies the specific sympathetic nerves or nerve ganglia in the upper thoracic region, usually between the first and fifth thoracic vertebrae, that are responsible for the problematic symptoms. These nerves are then cut, clipped, or destroyed to interrupt the nerve signals. After one side is complete, the lung is re-inflated, incisions are closed, and the process is typically repeated on the other side. The entire surgery usually takes about one to three hours.
Recovery and Potential Effects
Following ETS surgery, patients typically experience a relatively quick recovery due to the minimally invasive nature of the procedure. Most individuals can expect to be discharged from the hospital within several hours to overnight. Soreness and bruising at the incision sites are common and usually improve within a few days, though some discomfort may persist for a couple of weeks.
Patients are generally able to return to their normal daily routines and activities within a few days to one to two weeks, with strenuous activity typically advised against for three to four weeks. While the surgery effectively stops sweating in the targeted areas, the most common and significant potential effect is compensatory sweating. This involves increased sweating in other parts of the body, such as the back, chest, abdomen, legs, or face, as the body attempts to regulate its temperature. Compensatory sweating occurs in a significant number of patients, with studies reporting rates ranging from 70% to 98%.
While many patients find compensatory sweating less bothersome than their original condition, it can be severe for some and may lead to regret about the surgery. Other less common but possible side effects include Horner’s syndrome, a neurological disorder characterized by a drooping eyelid, constricted pupil, and absence of facial sweating, though its incidence is very rare, around 0.3%. Other potential issues include pneumothorax (collapsed lung), gustatory sweating (sweating while eating certain foods), temporary nerve pain, decreased heart rate, and excessively dry hands. Some side effects, like compensatory sweating, may decrease over time for a minority of patients, but overall, the effects of ETS surgery are permanent.
Non-Surgical Options and Decision Factors
For individuals experiencing excessive sweating, several non-surgical treatments are available before considering ETS surgery. Topical antiperspirants, particularly those containing aluminum chloride, are often the first line of treatment. Iontophoresis, a procedure using a mild electrical current passed through water, can effectively reduce sweating in the hands and feet. Oral medications can also be prescribed to help manage widespread sweating. Additionally, Botox injections can block nerve signals to sweat glands and are approved for severe underarm sweating, with effects lasting several months.
ETS surgery is generally considered a treatment of last resort, typically recommended only after other less invasive methods have failed to provide adequate relief. Key factors influencing the decision to undergo ETS include the severity of the condition and its impact on a patient’s quality of life. Since the procedure is permanent and carries a high risk of compensatory sweating, a thorough discussion with a healthcare professional is important to weigh the potential benefits against the risks. Patients should be fully informed about the potential for compensatory sweating, as it can be a significant and irreversible side effect.