What is ETS?
For people with excessively sweaty hands or facial blushing, Endoscopic Thoracic Sympathectomy (ETS) is a life-altering procedure that helps them rebuild confidence and enjoy their lives again. The sweat glands responsible for perspiration are controlled by the sympathetic nerves. Over-activity of the sympathetic nerves results in excessive sweating. If these nerves are ablated or destroyed, the sweat glands will cease to function. The sweat glands in the hands, armpits, face and scalp are supplied by sympathetic nerves that originate from within the chest cavity.
The sympathetic chain from where the nerves originate can be identified clearly in the chest using a mini-scope referred to as a thoracoscope. Hence, the term thoracoscopic sympathectomy (or ETS) refers to the operation performed for hyperhidrosis and facial blushing
What Happens During ETS?
ETS surgery is performed in hospital under general anaesthesia. Two tiny incisions are made in the armpit, and 5mm ports inserted. Breathing of the lung is suspended temporarily, allowing the sympathetic nerve to be accurately identified. The relevant ganglia or nerve cell bodies are ablated, thereby drying the hands, armpits or face as required. Blood oxygen levels are continuously monitored and there is never any danger. A special endo-tracheal or breathing tube is inserted by the anaesthetist to facilitate this process. Ablation of the relevant section of the sympathetic chain can be achieved in a variety of ways, though my preference is to use diathermy or electrocautery. The small incisions are closed with a solitary stitch, and a water-proof dressing is applied. Patients are generally discharged the following morning, and most recover completely within a week.
As ETS is performed using minimally invasive techniques, recovery from the operation is usually rapid. Expect some initial chest discomfort, but this is readily brought under control with conventional pain relief. Most patients are reasonably comfortable within six hours of the procedure, though my preference is to keep patients in hospital overnight. Routine observations are undertaken by the nursing staff post-operatively. Pain relief is available to maintain comfort, and a normal diet is resumed within four hours of the operation. It is not uncommon to experience some pain between the shoulder blades 2 to 3 days after the procedure, made worse by coughing and sneezing. This usually responds to anti-inflammatories such as Nurofen.
Potential complications of ETS surgery
As with all surgical procedures, individual reactions to the operation varies. Our aim at North Western Vascular is to inform you of complications that may arise, even though the majority of patients do not experience them.
Rebound hyperhidrosis is the most feared complication. It involves an increase in sweating in areas of the body not affected by the sympathectomy, such as the lower torso, front or back. It occurs in as many as 30 – 40% of patients, but for most of these patients, it is not troublesome and settles spontaneously. However, in 2% of patients, rebound sweating can be severe, occurring spontaneously on the lower torso. Indeed, in rare cases, some patients may even regret they had the operation. Rebound hyperhidrosis, if it occurs, cannot be reversed with further surgery. In most patients but not all, rebound sweating gradually settles with time.
Pneumothorax or air around the lung may occur, but is rarely of any significance, and settles by itself. If the pneumothorax is large, it can cause breathlessness. Rarely, this may involve inserting a tube into the chest to alleviate the problem. This does not delay discharge as the tube is generally removed the following day, allowing discharge to proceed.
Horner’s syndrome is a complication which can occur if the sympathetic nerve supply to the eye is ablated. This results in drooping of the eyelid (ptosis) and constriction of the pupil. Fortunately, this is exceedingly rare, occurring in less than one in 1000 cases.
Sharp chest pain, worse with coughing or sneezing, occurs 3 to 4 days after ETS, and is due to inflammation of the lining of the lung (pleura). It may be perceived as a pulled muscle between the shoulder blades and is usually controlled with anti-inflammatories.
Dry hands – although this is the aim for many patients, those undergoing sympathectomy for other causes such as facial blushing or axillary hyperhidrosis may need to be warned of this. The problem of dry hands is generally easily remedied with hand creams and moisturisers.
Gustatory sweating or facial sweating following meals, particularly spicy foods, occurs to some extent in 5 to 10% of patients.
Bradycardia or slowing of the pulse may occur but is rarely of any clinical significance. ETS has no impact on exercise tolerance.
Mr Roger Bell at North Western Vascular specialises in performing ETS surgery. ETS is performed in a private hospital with overnight stay. Surgery offers immediate and permanent relief from hyperhidrosis or Facial Blushing, and in many cases, can be a new beginning for sufferers.