Endoscopic Thoracic Sympathectomy (ETS)

What is ETS?

Endoscopic thoracic sympathectomy (ETS) is mainly used as a treatment for excessive sweating (hyperhidrosis) but can also help treat extreme facial flushing.

Excessive Sweating

Sweating helps us keep our body cool and our skin moist. Sweat is produced by thousands of glands in the skin controlled by our sympathetic nervous system.

Many people suffer from excessive sweating, particularly when anxious or under stress, and this can be managed with simple measures such as strong antiperspirants. However, in some people (about 1% of the population), this nervous system is overactive and causes sweating in specific places in the body, often at inappropriate times. Excessive sweating can affect the hands, armpits, and feet, causing social embarrassment and difficulty with practical tasks such as holding a pen.

Before considering surgical treatment, it is sensible to have tried simple measures and to be clear that there is a major problem persisting despite them.

What is ETS?

ETS involves cutting the sympathetic nerves, which switches off the sweating. The sympathetic nerves that control the sweat glands of the hand and armpits run inside the rib cage near the top of the chest.

 

The Operation

A small incision is made beneath the armpit. The lung on the side being operated on is allowed to collapse a little to make room for the operation. Your other lung remains intact and is capable of doing all the work. A camera on a thin telescope is put into the chest, and the nerves to be divided are found. One other small hole may be made to insert the instruments that divide the nerves, although this can also be done using the same hole as for the camera. After the nerves are cut, the lung is re-expanded, and the instruments are removed.

Sometimes a small drain (plastic tube) is left in the chest for a few hours to ensure all the air is removed from the chest cavity. Your surgeon will discuss whether it is advisable to do both sides at once.

The operation may be done as day surgery or with an overnight stay if you need surgery on both sides.

 

How successful is it?

ETS is very effective at stopping sweating of the hands in over 95% of cases; it is slightly less effective at stopping sweating in the armpits (about 85%). Over time, sweating will recur in a few people. In a study following patients over a 15-year period, 93% reported a complete cure of sweating.

 

What are the disadvantages?

ETS is usually a very successful operation; however, it will often result in increased sweating somewhere else, known as compensatory hyperhidrosis. This usually occurs on the chest or back in almost everyone who has had ETS, although it is often much less of a problem than the original sweating in the hands or armpits. About 1% of people will have severe compensatory sweating, which can be a major problem. It is important to realize that the operation is designed to be irreversible.

 

What are the risks?

ETS is a safe operation, and usually, no problems are encountered. However, as with any operation, problems can occur, and there is a small risk of injury inside the chest. If there is air coming out of the lung or bleeding, it may be necessary to insert a drainage tube into the chest for a day or two. About 1% of ETS cases may result in a droopy eyelid (called Horner’s syndrome), which usually recovers over time but not in all cases.

 

What are the alternative treatments?

Antiperspirants: These normally have to be applied liberally and regularly.

Botox injections: Botox blocks the nerve signals to the sweat glands, stopping the sympathetic nerves from working. The effect is temporary, usually lasting about six months, but it is a good way of controlling underarm sweating. Many people do not continue with this treatment for hand sweating as it requires a large number of injections into the palms and fingers, which are unpleasant and can occasionally cause areas of temporary numbness and weakness. It is not often carried out on the NHS.

Iontophoresis: This involves using a machine that passes electric currents across the skin. Its exact method of action is not fully understood, but some people find it very helpful. The machines can be purchased for use at home.

 

Which treatment is right for me?

Before deciding to have ETS, you should try simple measures such as antiperspirants or consider iontophoresis. If simple measures have failed and it is seriously affecting your life, you should consider:

• Botox: If only your armpits are affected
• ETS: If your hands are affected

 

ETS for Facial Flushing/Blushing

Most people blush on occasions, particularly when they feel embarrassed or stressed. Blushing is caused by blood vessels in the skin opening to allow more blood to flow through, which makes the skin red. The muscles in your blood vessels are controlled by the sympathetic nervous system.

A few people find that they blush so much that it becomes a major problem in their social and work lives. ETS will help reduce facial blushing as the sympathetic nerves control the supply of extra blood to the skin. Using ETS to treat facial flushing is not as well established as its use in the treatment of excessive sweating, but it is effective. It works best for sudden surges of blushing and is not useful for people with a reddish complexion.

It is important to ensure that there is not an underlying skin condition causing the problem, such as rosacea, or that the flushing is not occurring as part of the menopause. The potential drawbacks are the same as those of ETS for excessive sweating, but in addition, it is conceivable that if the procedure works for one side and not the other, you could end up with half your face blushing.

 

Summary

It is only sensible to consider ETS if you have a major problem with sweating or flushing that is badly affecting your quality of life and if you have tried other methods of treatment and these have not worked. The operation is usually very successful, and most people are delighted. However, some degree of compensatory sweating is usual, and occasionally this is a big problem. There is inevitably some risk involved in the surgery, and although the chances of a serious problem are very small, you may be the one who develops it. You should consider your options carefully and discuss the operation with someone who performs it regularly.