Endoscopic Thoracic Sympathectomy
Endoscopic thoracic sympathectomy is used mainly as a treatment for excessive sweating (hyperhidrosis) but can also be used to help treat extreme facial flushing. The following topics are covered in this section:
What is an Endoscopic Thoracic Sympathectomy?
How successful is it?
What are the disadvantages?
What are the risks?
Which treatment is right for me?
Excessive facial flushing
Sweating is one of the ways we regulate our body temperature, it also helps to keep our skin moist. Sweat is produced by thousands of little glands in the skin. These glands are controlled by our sympathetic nervous system.
Many people suffer from occasional episodes of excessive sweating, particularly when anxious or under stress and often this can be managed with simple measures such as strong antiperspirants. However, in some people (about 1% of the population), the nervous system is overactive and causes sweating to occur in specific places in the body, often at inappropriate times. Excessive sweating (the medical term is hyperhidrosis) can affect the hands, armpits and feet. This can be a serious problem, causing social embarrassment and difficulty with practical tasks such as holding a pen.
Before considering surgical treatment it is sensible to try simple measures and be clear that there is a major problem that is persisting, despite trying to address it.
What is an endoscopic thoracic sympathectomy? (ETS)
An ETS involves cutting these sympathetic nerves which switches off the sweating. The sympathetic nerves that control the sweat glands of the hand and armpits runs inside the rib cage near the top of the chest. The development of surgical telescopes and cameras has led to the ability to divide these nerves through very small incisions, which can improve symptoms.
This operation is performed under general anaesthetic. A small incision is made beneath the armpit. The lung, on the side being operated on, is allowed to collapse a little to help make room for the operation. Your other lung remains intact and is capable of doing all the work. A camera on a thin telescope is put into the chest, and the nerves which are to be divided are found. One other small hole may be made to put in the instruments that divide the nerves, although this can also be done using the same hole as for the camera. After the nerves have been cut, the lung is re-expanded and the instruments removed. Sometimes a small drain (plastic tube) is left in the chest for a few hours to make sure all the air is removed from the chest cavity.
Your surgeon will discuss with you if it is advisable to do both sides at once. The operation may be done as a day surgery, or with an overnight stay if you need surgery on both sides.
How successful is it?
ETS is very effective at stopping sweating of the hands in over 95% of cases; it is slightly less effective at stopping sweating in the armpits (about 85%). Over time sweating will recur in a few people. In a study following patients over a 15 year period:
- 93 % reported complete cure of sweating
- 67% were fully satisfied
- 27% were partially satisfied and would have the operation again
- 7% said they would not have the operation again
What are the disadvantages?
ETS is usually very successful and most people are very pleased with their operation. However, it is very important to know that ETS will usually result in increased sweating somewhere else. This is called compensatory hyperhidrosis and usually occurs on the chest or back. This happens to some extent in almost everyone who has had ETS, although for the large majority of sufferers, it is usually much less of a problem than the original sweating in the hands or armpits. To some extent the operation can be thought of as a method of moving the sweating from the hands to somewhere else rather than stopping it altogether.
About one in a hundred people will have severe compensatory sweating which can be a major problem. It is not possible to predict who will get this and it is important to realise that the operation is designed to be irreversible. Sometimes people will notice sweating when eating spicy or hot foods (this is called gustatory sweating).
What are the risks?
ETS is a safe operation and usually no problems are encountered. As with any operation, problems can occur and there is a small risk of injury inside the chest. If there is air coming out of the lung or bleeding it may be necessary to insert a drainage tube into the chest for a day or two. Very rarely it may be necessary to do an operation on the chest to deal with any problems.
In about one in a hundred people ETS may result in a droopy eyelid (called Horner’s syndrome) which will usually recover over time, but not in all cases.
Botox injections: Botox blocks the nerve signals to the sweat glands, stopping the sympathetic nerves from working. The effect is temporary but usually lasts about six months. Treating sweating in the hands requires a large number of injections into the palms and fingers which are unpleasant and can occasionally cause areas of (temporary) numbness and weakness. Few people continue with Botox injections for sweating of the hands, although it does work. In contrast, Botox is an excellent way of treating excess sweating in the armpit. Under the arm injections do not cause as much discomfort but they do need to be repeated about once every six to nine months on average. It is not often carried out on the NHS.
Iontophoresis: This involves using a machine which passes electric currents across the skin. Its exact method of action is not fully understood but some people find it very helpful. The machines can be purchased for use at home.
1. Have you tried simple measures such as antiperspirants or considered iontophoresis?
2. Have the simple measures failed?
3. Is the extra sweating having a serious effect on your life? If the answer to all these questions is “Yes”, please go on to question 4.
4. Does the sweating involve your hands?
- If yes consider ETS
- If no consider botox
5. Does the sweating involve your armpits?
- If it involves the hands and the armpits then consider ETS
- If it only involves the armpits then consider Botox
ETS for facial flushing/blushing
Most people blush on occasions, particularly when they feel embarrassed or stressed. Blushing is caused by blood vessels in the skin opening to allow more blood to flow through, which makes the skin red. The muscles in your blood vessels are controlled by the sympathetic nervous system. A few people find that they blush so much that it becomes a major problem in their social and work lives.
ETS will help reduce facial blushing as the sympathetic nerves control the supply of extra blood to the skin. Using ETS to treat facial flushing is not as well established as its use in the treatment of excessive sweating but it is effective. It works best for sudden surges of blushing. It is not useful for people with a reddish complexion.
It is important to make sure that there is not an underlying skin condition causing the problem such as the skin condition rosacea, or that the flushing is not occurring as part of the menopause. The potential drawbacks are the same as those of ETS for excessive sweating but in addition it is conceivable that if the procedure works for one side and not the other, you could end up with half your face blushing.
It is only sensible to consider ETS if you have a major problem with sweating or flushing that is badly affecting your quality of life and if you have tried other methods of treatment and these have not worked. The operation is usually very successful and most people are delighted. However, some degree of compensatory sweating is usual and occasionally this is a big problem. There is inevitably some risk involved in the surgery and although the chances of a serious problem are very small, you may be the one who develops it. You should consider your options carefully and discuss the operation with someone who performs it regularly.
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