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Is Endoscopic Thoracic Sympathectomy (ETS) a safe treatment for hyperhidrosis?

Date: 21th February, 2017

Hyperhidrosis or excessive sweating can be a devastating condition, causing much distress to individuals who find themselves in that situation. It is most likely to affect areas where the sweat glands are in greatest abundance; hands, underarms (axillae), feet, face and scalp.

With so much information readily available on the internet, it is often difficult to decide what is accurate and what is inaccurate.  In short there is much misinformation on many topics, including hyperhidrosis and modalities of treatment such as sympathectomy.

Hyperhidrosis occurs as the sweat glands are being “driven” by the sympathetic nerves that supply them. It is normal to sweat. Indeed it is sometimes IMPORTANT to sweat. We sweat when we get hot, either through exercise or when the temperature is high, to cool the body down. In addition it is common for some people to break out in a sweat when under stress, a so-called sympathetic response.

Individuals with hyperhidrosis find themselves sweating even on a cool day, when under no stress. For some unknown reason, the body’s thermostat has been set incorrectly, and they find themselves sweating when they shouldn’t be sweating.

Individuals bothered by hyperhidrosis need to consider non-invasive, simple, conservative measures first.  This could include choosing clothes that “breath”, spending time in cooler environments, using anti-perspirants on a regular basis.  If these measures fail other treatment options are available.

Sympathectomy, in my opinion is the best treatment option for patients with palmar (hand) hyperhidrosis, and probably the only option for patients with troublesome facial blushing.  It is the one procedure that offers a success rate as close to 100% as possible. There is however, so much misinformation about ETS on the internet, it is no wonder some patients are uncomfortable about proceeding and choose to live with hyperhidrosis or facial blushing.

Is ETS safe? Like all forms of surgery, there are risks, especially in the hands of an inexperienced surgeon. My first word of advice is seek out a surgeon with an abundance of experience in performing this operation, as things can go horribly wrong in the hands of  an inexperienced surgeon.

Thoracoscopic Sympathectomy or Endoscopic Thoracic Sympathectomy (ETS) to treat palmar (hand) hyperhidrosis is performed using minimally invasive techniques. This is performed through tiny incisions, requires less than 24 hours in hospital and is associated with a rapid return to normal activities.

Without a doubt, the main complication of this procedure is rebound sweating, often called compensatory hyperhidrosis. The incidence of this complication varies tremendously in the literature, depending to some extent on how it is defined.  Some studies say the incidence is less than 1%, whereas at the other extreme some say it occurs in all patients. In my own experience, rebound occurs in 30 to 40%, and fortunately in most it is not troublesome, however, in 2% rebound sweating can be severe. These patients find themselves sweating spontaneously on the torso, and many regret their decision to have had sympathectomy.  It is that group of patients (less than 2%) who are most likely to verbalise their opposition to the procedure.

This complication is far more likely to occur in patients for whom ETS was performed for armpit sweating or facial sweating, as compared to those undergoing the procedure for palmar (hand) sweating or facial blushing. It is for that reason I no longer offer ETS to patients with axillary sweating but rather MiraDry

Other complications of ETS include Horner’s Syndrome, which results in drooping of the eyelid. This is very rare (less than one in 1000). Chest complications such as pneumothorax (air in the chest) can occur but is usually of no clinical significance and rarely requires treatment. Gustatory sweating, which is facial sweating after meals, usually spicy meals, does occur in up to 5%, but is generally not troublesome.

I have noticed a few patients experience a very slight reduction in pulse rate, but this is never of any clinical significance and importantly does not impact upon exercise tolerance. Reports of sexual dysfunction, mood disorders, including dissociative states have nothing to do with ETS, and are more likely linked to the emotional disorder already present in the patient.

ETS is an excellent choice of treatment for patients with troublesome palmar hyperhidrosis and facial blushing.   I advise individuals to choose to a surgeon with a special interest in this field and extensive experience in performing sympathectomy.  

Roger Bell, Vascular Surgeon & Hyperhidrosis Specialist

North Western Vascular

If you’re suffering from excessive sweating,

talk to Roger Bell by calling 1800 793 289 today.