Endoscopic Thoracic Sympathectomy
What conditions are treated this way?
- Palmar/Hand sweating (hyperhidrosis)
- Blushing of the face and upper chest
Sweating (hyperhidrosis) is caused by over-stimulation of the sweat glands by the sympathetic nerves and in most cases there is no other underlying disorder. The palms of the hands and the soles of the feet have the highest concentration of sweat glands and therefore these two areas are mostly affected by hyperhidrosis. Hyperhidrosis can also involve the armpits, face, scalp and body. Certain triggers, such as emotion can influence the way these nerves behave. Sometimes for no good reason, there is over-activity of the sympathetic nerves causing debilitating sweating and/or facial blushing.
Endoscopic Thoracic Sympathectomy ETS is an operation, which involves ablation of the sympathetic chain in the chest using minimally invasive surgery. It is therefore useful for conditions in which the sympathetic nerves are over-active, as it causes a reduction in the level of sympathetic nervous activity to the upper body.
ETS is performed in hospital under general anaesthesia. Once under anaesthesia two very small ports (5mm) are inserted into the chest between the ribs in the armpit. The lung is partially collapsed thus exposing the sympathetic chain, which contains the sympathetic nerve cells. A clear, uninterrupted view of the sympathectomy chain is obtained and this is ablated.
Ablation of the sympathetic nerve is accomplished by diathermy or electro-cautery of the relevant section of the chain. Once this has been accomplished the lung is fully re-inflated and normal “breathing” restored on that side. The ports are removed and the small incisions closed with a solitary nylon stitch and water-proof dressing applied.
Complications associated with this operation are extremely uncommon, and the overwhelming majority of procedures are event-free. There are risks involved with any general anaesthetic and these can be explained by the anaesthetist.
POST OPERATIVE RISKS
Rebound hyperhidrosis. This is excessive sweating which occurs on the back and chest to some degree in about 30 to 40% of patients. Some studies suggest the incidence is higher. For most patients this is not troublesome and settles spontaneously. However in 2-5% of patients, rebound sweating can be severe and disabling. In rare cases the rebound is so severe the patient regrets the operation. Unfortunately, it cannot be reversed with further surgery. Some patients, for example those with facial/scalp sweating and older patients are at greater risk.
Pneumothorax - air around the lung. This is uncommon and when it occurs is usually small, not noticed by the patient, and does not require treatment. However, if it causes shortness of breath, the air can be allowed to escape through a small tube placed in the chest. This will delay discharge from hospital by a day or two.
Horner’s Syndrome. This occurs if there is interference of the sympathetic supply to the eye. The pupil becomes constricted and the eyelid may droop. This is extremely rare (1-2 in 1000 cases).
Pain may be experienced in the back due to inflammation in the lining of the lung, which settles with anti-inflammatories. In addition it is common for the ribs to feel sore, but this is easily controlled with simple analgesia.
Pleurisy may occur due to inflammation of the lining of the lung (pleura). This occurs commonly 2 or 3 days after the procedure. It is often perceived as a pulled muscle between the shoulder blades. It can sometimes causes severe pain, but is usually controlled with anti-inflammatories. It invariably settles spontaneously.
Dry hands! Although this is the aim for many patients, those undergoing sympathectomy for other causes such as facial blushing or axillary hyperhidrosis need to be warned of this. This problem is easily remedied with moisturisers.
Gustatory sweating involves facial sweating following meals, particular spicy foods. This occurs to some extent in 5 to 10% of patients.
Bradycardia or slowing of the pulse may occur but is never of any clinical significance.