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Endoscopic Thoracic Sympathectomy

Endoscopic Thoracic Sympathetomy (ETS) is an effective treatment of hyperhidrosis (excessive sweating) and facial blushing.

ETS EXPLAINED

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 most commonly affected by hyperhidrosis. Hyperhidrosis can also affect the armpits, face, scalp and body.

Over-stimulation of the sympathetic nerves can also cause excessive facial blushing.

ETS is an operation performed under general anaesthesia, which involves ablation of the sympathetic chain in the chest using minimally invasive surgery. It calms the sympathetic nerves of the upper body that are overactive in people with excessive hand sweating and/or facial blushing.


What does the operation involve?

Once under anaesthesia, the surgeon inserts two very small ports (5mm) into the chest, between the ribs in the armpit. The lung is partially collapsed, 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. Afterwards, the lung is fully re-inflated and normal “breathing” is restored on that side. The ports are removed and the small incisions are closed with a solitary nylon stitch and water-proof dressing is applied.


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.

Frequently Asked Questions – ETS Procedure

  • What is the success rate following sympathectomy?

    The success rate varies according to the condition for which the sympathectomy is being performed.

    In those that have the procedure for sweaty hands, the success rate (ie achieve dry hands) is very close to 100%. It is important to emphasize the benefit is permanent. Some patients (less than 5%) might experience a bout of hand sweating in the first week, but this is not an indication of a poor response, and is never sustained.

    For patients undergoing a sympathectomy for facial blushing, over 90% will no longer blush after sympathectomy. The response for blushing of the neck and upper chest is a little less predictable.

    For axillary hyperhidrosis, the success rate is about 70%. This is because the sympathetic nerve supply to the axillary sweat glands, can sometimes arise form ganglia (nerve cell bodies) well down and relatively inaccessible on the sympathetic chain. For that reason I have abandoned sympathectomy for patients with axillary sweating as miraDry is a much better option for this.

  • What are the main risks of the procedure?

    The main complication is rebound sweating or compensatory hyperhidrosis. In response to ablation of the sympathetic chain, the brain sends signals to the sympathetic nerves below to work a little harder. Indeed 30 -40% of patients experience at least some degree of rebound sweating. Fortunately in most it is very mild and of no concern. However, in one in 50 patients, the rebound can be quite severe, causing spontaneous sweating on the torso, back or front. I have had patients who regret they had the procedure because of this complication, and everyone is warned of this.

    Horner’s syndrome which results in a droopy eyelid and constricted pupil, will occur if the Stellate ganglion is ablated. This occurs rarely, one in 1000 cases, usually due to misinterpretation of the anatomy by the surgeon. I believe this is far more likely to occur if the operator is inexperienced.

    Gustatory sweating, which is facial sweating following eating, particularly in response to spicy foods is a form of rebound occurring in 5% of patients.

    Chest complications such as pneumothorax or chest infections are very rare, but can occur. It is however quite common to experience heaviness in the chest and sharp pain often at the back, particularly with coughing and sneezing, referred to as pleuritic pain in the first week.

    Some patients (less than 5%) notice a marked difference in temperature between the upper torso and lower torso. In rare cases it can become somewhat disconcerting.

  • How long will I need to stay in hospital?

    Most patients stay overnight, and are discharged the following morning. If the procedure is performed early in the day, I am happy for patients to go home the same day, as long as a responsible adult is at home to care for the patient.

  • How much time off work will I require?

    I recommend a week off work, especially if the work is of a physical nature. Sharp chest and back pain is common in the first week, and often requires anti-inflammatory medications such as Nurofen to control the pain. Having said that, a number of patients return to work earlier and seem to manage quite all right.

  • How long after the procedure can I fly?

    Particularly for my interstate patients, this is often asked. All patients have a post-operative Xray to exclude a pneumothorax (residual air in the chest cavity). This is rarely of any consequence and settles spontaneously but I caution patients against flying until the pneumothorax has resolved completely. Without a pneumothorax I usually recommend 4 to 5 days before flying.

  • If I get rebound sweating, can it be treated?

    Bad rebound, which fortunately is very uncommon (about one in 50 cases) is the complication I fear most for my patients, as it is out of my control.

    In most cases the rebound sweating does decrease with time, but this cannot be guaranteed for all.

    From a practical viewpoint, there is no surgical option for rebound sweating. Certain medications with anti-cholinergic properties (eg Ditropan) can be helpful in this setting.

  • How is the sympathectomy performed?

     

    There are many ways of performing a sympathectomy, including cutting the nerve, clamping the nerve, excising the nerve or ablating the nerve. I choose to ablate (by electro-cautery) the ganglia, which are the nerve cell bodies form where the nerves are derived. This guarantees that the objective of the procedure (ie dry hands or eliminate blushing) is far more likely to be achieved.

    I am not a proponent of clamping the nerve, as this results in an incomplete sympathectomy and does not result in reversal of rebound sweating with removal of the clamps.

  • What is the cost of the procedure?

    This is not regarded as a cosmetic procedure, and is recognised by the Medicare Benefits Schedule.

    If you have private health insurance, most of your hospital costs will be covered. Medicare and your health fund will cover you to the schedule fee, though there will be an out-of-pocket component, which does vary from fund to fund, but is in the vicinity of $1500.

    With no private health cover, it will be an expensive undertaking, costing up to $8000 out of pocket. Please download more details of prices here

  • In which hospitals is the procedure performed?

    I perform thoracic sympathectomies at 3 hospitals:

    John Fawkner Private Hospital in Moreland Road Coburg

    Monash Medical Centre (Jessie MacPherson Private Hospital)

    In Clayton Road, Clayton

    Cabrini Malvern in Wattletree Rd, Malvern

    All hospitals have State of the Art facilities with first class Nursing Care. There are minor differences with regard to fees and out-of-pocket expenses, which you should discuss with my staff.

  • Will the sympathectomy have any impact on my feet?

    It is not uncommon for patients to have the combination of sweaty hands and sweaty feet. It is more frequent for the hands to be the more problematic, though this is not always the case.

    However, almost invariably I recommend treating the hands first, as this is more often the more troublesome, but also that in two thirds of patients, there is a significant improvement in the feet following a thoracic sympathectomy.

  • Is there specific treatment for sweaty feet?

    Absolutely. A lumbar sympathectomy (performed laparoscopically or by an open procedure) will interrupt the sympathetic nerve supply to the lower limbs, thereby cutting off the nerve supply to the sweat glands in the feet. Performed as an open procedure, it involves incisions on each side of the abdomen in order to approach the sympathetic chain. The operation takes approximately one hour, is performed under general anaesthesia, requires 2 to 3 days in hospital, and a 3 to 4 week recovery. The success rate is very high (greater than 95%), and complications are rare.