for the treatment of:
The sympathetic nervous system, part of our vegetative nervous system, sends the signals to the sweat glands of the body surface for the production and ejection of sweat. The peripheral nerve fibers start in small nodes of nerve cells (so-called ganglia) located segmentally in a chain passing along the side-walls of the spine, forming the so-called sympathetic trunk. For decades, the elimination of some of these nerve nodes has been adopted to cure certain disorders of the microcirculation of hands and feet, in some cases also for the treatment of hyperhidrosis.
Only in recent years, micro-invasive surgical techniques have been developed to access these nerve nodes in the thorax which are responsible for the innervation of the sweat glands of the upper limb and the face. This method is called Endoscopic thoracic sympathectomy. Today, this technique has become the method of choice to cure moderate and severe hyperhidrosis of the palms and the face, indicated especially if other therapies have not given an acceptable result. It is also the most efficient way to stop facial blushing which causes considerable social difficulties and embarrassment in many individuals affected by this disturbance. In the past years, this technique has been developed in Europe (much of the technical refinement and scientific work-up having been performed by the surgeons of the hospital of Boras in Sweden), superseeding definitely the conventional techniques of Open sympathectomy which implicated long periods of hospitalization and recovery. The endoscopic technique is very safe, if performed by a surgeon familiar with this type of procedure, and leads to definitive cure in nearly 100% of patients.
Total anesthesia is required. The operation consists in making a tiny incision behind the pectoralis-fold in the armpit, a small amount of CO2 is insufflated into the thoracic cavity (like in diagnostic thoracoscopy) to allow access with an endoscopic instrument, specially modified for this operation. This device has a diameter of 7.3 mm (0.3") and makes it possible for the surgeon to identify and severe the sympathetic nerve-nodes where the nervous signals to the sweat-glands in the upper limb and the face start. In facial hyperhidrosis and facial blushing, it is sufficient to sharply devide the fibers running from the 2nd thoracic ganglion upward, leaving the 2nd ganglion almost intact. Treatment of palmar hyperhidrosis requires total thermo-coagulation of the 2nd ganglion, always taking great care not to cause any spreading of thermal energy along the nervous trunk in order to avoid damage to the stellate ganglion (see below - "Horner's syndrome"). Eventually, the CO2 is re-aspirated and the incision closed. Finally, the procedure is repeated on the other side. Normally, the patient leaves the hospital the day after surgery and can resume his/her normal activity after a few days. The resulting scar in the armpit is well hidden and almost invisible.
Variations of this technique: Most surgeons who perform this operation avoid operating both thoracic halves the same day (which implies the need for 2 separate operations with total anesthesia), and most prefer the traditional technique of thoracoscopic surgery where 2 incisions (channels) per side are needed to accommodate the optical instrument in one and the electrode in the other. Some surgeons extend their action to encompass the 3rd and 4th ganglion to treat axillary hyperhidrosis; several reports and the author's experience have shown that the risk for compensatory sweating is greatly reduced, though not completely excluded, by limiting the number of ganglia treated to an absolute minimum (in practice: only 1 ganglion/side).
Sympathectomy cures palmar hyperhidrosis definitively in almost all (>99%). The effect is immediately evident, the patients awake with dry and warm hands from anaesthesia. At the same time, if present, also facial hyperhidrosis ceases. In addition, the patients become less prone to feel nervous in stressy situations, facial blushing subsides and cardiac reactions to stress (increased heart frequency) will become milder. Stage fright is substantially reduced. In many cases, even hyperhidrosis of the feet improves, but the underlying physiological mechanism is not yet understood and the outcome regarding relief of plantar hyperhidrosis is not predictable.
The rate for complete elimination of facial blushing i 95%, for facial sweating 90%.
Complications are very rare and, generally, of minor importance, requiring at most a day or two of prolonged hospital-stay.
- Horner's syndrome: This is the most feared complication, leading to a slightly smaller pupill and a dysfiguring assymmetry of the face due to a slightly drooping upper eye-lid, caused by damage the upper-most thoracic nerve-node, the so called ganglion stellatum. The risk for this event depends mainly on the surgeon's familiarity with the procedure, ranging below 0.3% in the hand of a surgeon with great experience. To correct this complication, a plastic surgery procedure (blepharoplasty = shortening of the upper eye lid) is required.
- Treatment failure: A rare occurrence as long as the patient has not had a severe pleural disease rendering access to the ganglia difficult or impossible.
- Pneumothorax: A residue of air remaining between the lung and the thoracic wall, either due to incomplete resuction of the inflated gas, or due to a minor leakage from the lung. Small amounts of air are generally reabsorbed spontaneously and need no further treatment (the patient should, however, avoid taking a flight during the next day or as long as the pneumothorax persists). Greater amounts (very infrequent) may require suction drainage for a day or two. With proper technique, when entering the thoracic cavity and when aspirating the gas at the end of the procedure, the surgeon can almost always avoid this complication. In any case, it can be easily treated.
After the operation, up to half of the patients may notice compensatory sweating in other locations (usually on the trunk or on the thighs, especially during physical exercise or high out-side tempeatures), which may range from barely noticeable to quite disturbing. Sweating in these less exposed areas is, by the vast majority of operated patients, regarded as a minor inconvenience and far more acceptable than hyperhidrosis on exposed areas (palms, face). The risk for disturbing compensatory sweating ranges around 1% (compensatory hyperhidrosis), rendering the patient very sensitive to thermal stimuli.
People with axillary hyperhidrosis, though, should be cautioned that the embarrassing wet-marks on their cloths in the underarm area may re-appear elsewhere, after the operation. In addition, compensatory sweating seems to appear more frequently in patients operated for axillary hyperhidrosis, since more ganglia have to be divided to get rid of underarm-sweating, than for the cure of palmar and facial hyperhidrosis or facial blushing. Therefore, some surgeons (including the author) do not consider isolated axillary hyperhidrosis as an indication for this procedure any more, preferring alternative methods to treat this condition.
It has to be mentioned, that compensatory sweating, secondary to the reduction of total sweating body surface, may also appear after excision of the axillary sweat glands, after iontophoresis or, even, after treatment with antitranspirants.
Up to 35% of patients may notice increased sweating while smelling or eating certain food (strong, spicy, sour) - "gustatory sweating". This phaenomenon is rarely considered a problem by the patient.
To summarize, the patient considering ETS should be well aware that
With this in mind, the patient has to decide whether to continue living with hyperhidrosis or taking the relatively small risk (around 1%) of ending up with disturbing side-effects. These figures are also reflected in the discrepancy between satisfaction rate (98.5%) and cure rate (almost 100%) of patients with palmar hyperhidrosis.
- compensatory sweating may appear after ETS
- it is usually mild to moderate and well tollerable
- it cannot be predicted by any diagnostic means whether it will show up and how intense it will manifest itself
- it often has a tendency to decrease within the first 6-12 months
- there seems to be a relationship between the number of ganglia treated and the incidence and intensity of compensatory sweating
- heavy compensatory sweating is relatively rare
- there is no reliable treatment for heavy compensatory sweating on the trunk
- it is (almost) irreversible if it persists for more than 1 year
There are no other known long-term consequences attributable to limited surgical intervention on the sympathetic trunk.
- Severe cardio-circulatory or pulmonary insufficiency
- Severe pleural diseases (TBC-pleuritis, empyema)
- Untreated hyperthyroidism
Inquiries, suggestions or communications to the author:
e-mail: firstname.lastname@example.org Ivo Tarfusser, MD
Via delle Corse, 52
39012 Merano (BZ), Italy
Tel +39 335 241686, +39 0473 237312
Fax +39 0473 236409