Surgical treatment for excessive sweating can be done with either 'open – classical technique' and 'endoscopic technique'. The open technique necessitates longer skin incisions. The endoscopic ETS procedure is well known as closed technique by the general population. Both techniques have the similar therapeutic impact on the disease. ETS procedure can be done in ANY SEASON of the year upon being suitable for the surgical intervention.
ETS procedure provides solution for the excessive facial sweating and blushing, and additionally for the excessive sweating in the palms, soles and the armpits. Sweating in the sweat glands innervated by the surgically removed sympathetic ganglions will end the excessive sweating after ETS.
ETS is not performed for 'the general sweating' of the body.
- Figure 1 - |
ETS procedure takes its name from the technique and the body region the technique used in. 'Thoracic' defines chest and chest cage including all of the organs and tissues in itself. 'Endoscopic' points to the endoscope with lighted camera to see the sympathetic ganglions and to get video records during the procedure.
In this technique, the endoscope is introduced into the thoracic cavity through a 1.0 or 1.5 cm skin incisions in the armpit. Another 1.0 cm incision is done for the surgical instruments as clips, endograsper, endohook,..etc (Figure 1-2). Thus, this kind of procedure using endoscope is named as 'closed procedure' or 'trackless procedure'. |
- Figure 2 - |
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- Figure 3 - |
In conclusion, ETS means cutting or clipping the related sympathetic ganglions at the desired level in order to stop the stimulation or the discharge of the sympathetic nerves (Figure 3). ETS should be and can be sequentially done through either side of the chest wall in the same procedure in the operating room.
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The Difference Between The Cutting And The Clipping Techniques;
ETS can be done using either cutting or clipping the sympathetic ganglions during the procedure. In the clipping method, if the compensatory sweating after the procedure gets unbearably worrying (just in 5-8% of the patients) there might have a reversal rate of 10-20% by removing the clips endoscopically. This should be described to the patient in detail before the procedure, and the patients should feel comfortable to choose either cutting or clipping techniques. Both techniques have the similar success rates in coping with the excessive sweating.
The Advantages of The ETS Over Classical Procedure (Open Surgery);
| Technique |
Skin Cut Sites |
Skin Cut Length |
Procedure Duration |
Risks |
Reversal |
Recovery Span (Getting Back to Daily Activity) |
| Classical procedure (open surgery) with clipping or cutting |
Along side the hair line in the armpit |
7-8 cm |
1.0-1.5 hr (unilateral);
NOTE - other side 2-3 wks later. |
Pain
Bleeding
Infection
Air in the chest cavity (pneumothorax)
|
10-20% in the clipping technique |
7-10 days |
| ETS - cutting |
The same or 2 suitable sites (ports) on the chest wall |
1.5 cm |
30-55 min (unilateral); the opposite side can also be sequentially done |
Less pain |
Unavailable |
2-4 days |
ETS - clipping
|
2 suitable sites (ports) on the chest wall |
1.5 cm |
30-55 min (unilateral); the opposite side can also sequentially be done |
Less pain |
10-20% in the clipping technique |
2-4 days |
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The Efficacy of The Surgery
The impact of the surgical technique can easily be detected in 10 min. after cutting or clipping the related sympathetic ganglions.
It can be seen that the hands or armpits become dry before leaving the operating room. And additionally, the hands become warm and oxygenated due to the dilatation of the vessels because of the disappearance of the sympathetic tonus (stress) on the blood vessels.
Most of the patients awake from anesthesia with having gotten rid of the excessive sweating.
Preparative Work Before Surgery;
• Examination of the respiratory and cardiovascular system
• Anamnesis of the disease process
• Laboratory study
• Plain chest radiographies – two directional (if needed, chest computerized tomography as well)
• Electrocardiogram – EKG (if needed, consultation by a cardiologist)
• Consultation by an internal medicinist (looking for the secondary causes for the excessive sweating – thyroid, ..etc.)
• Consultation by an anesthetist (the availability for the general anesthesia)
• Deciding for the date of the procedure
NOTE: Most of the patients (>95%) who have their surgery done before noon can be discharged afternoon on the same day.
Risks;
The surgical risks are almost the same in both open and closed techniques. Pain is less severe and shortermed in the ETS technique, whereas bleeding, infection, lung injury, Horner syndrome, ..etc are seen almost with the same rate in both procedures.
Another advantage of the ETS is that more than 95% of the patients can be discharged on the same day with the procedure, whereas in the open technique the patients' hospital stay is generally 3-5 days.
Recovery can be achieved in 3 days (average) and early return to daily life in the ETS group, besides in the open technique group it takes 7-10 days to regain normal daily activities.
Compensatory sweating occurs in most of the patients (40-80%) after sympathectomy. It is not a major problem for most of the patients as they usually declare it as tolerable. It is mostly seen in the anterior chest wall, back and groins. Thus, it is not a real visible problem for the patients. It is worrisome only in 5-8% of the patients who have ETS done.
Reversal;
Compensatory sweating is worrisome only for 5-8% of the patients who have ETS done. But, this compensatory sweating does not bring back the former usual complaints of the patients. It usually takes place in the anterior chest wall, back and groins.
Reversal is IMPOSSIBLE in the patients who had the sympathetic ganglions cut or ablated (burned) during the procedure. It can be POSSIBLE in the ETS group who had clipping in the sympathectomy technique (10-20%).
Even the clips are removed, most of the time (80-90%) the efficacy of the surgical procedure will continue due to the crush injury and/or scarring of the sympathetic nerves during the previous clipping.
Success Rates*
The success rates are almost the same in both ETS and open technique: 95-99% for facial sweating and/or blushing (turning red), 90-95% for palmar sweating, 90% for armpit sweating and 50% for sole sweating.
Who Does Not Fit For The ETS?
- Patients who haven't tried any treatment modality other than surgery before (iontophoresis, botox,..etc); BUT, the final choice belongs to the patient. Taking into account the expenses and time consuming of the transient therapeutic methods, surgical intervention can be suggested for all patients who fit for the surgery.
- In general, patients who had thoracic surgery previously.
- During the procedure, who has adhesion and scarring of the pleural membranes preventing the surgeon to see the surgical field clearly (previous thoracotomy, thoracoscopic procedures, inflammatory lung or heart diseases preventing single-lung ventilation and dense pleural thickening)
- Patients who can not tolerate the surgical procedure (advanced lung and/or heart diseases)
References*
1- Thorsten Walles, Geesche Somuncuoglu, Volker Steger, Stefanie Veit, Godehard Friedel, Long-term efficiency of endoscopic thoracic sympathicotomy:survey 10 years after surgery, Interactive CardioVascular and Thoracic Surgery 8, 2009, 54–57
2- Peter B. Licht, Lars Ladegaard and Hans K. Pilegaard, Thoracoscopic Sympathectomy for Isolated Facial Blushing, Ann Thorac Surg 2006;81:1863-1866
3- Johannes Schmidt, MD, PhD, Falk Georges Bechara, MD, Peter Altmeyer, MD, PhD, and Hubert Zirngibl, MD, PhD, “Endoscopic Thoracic Sympathectomy for Severe Hyperhidrosis: Impact of Restrictive Denervation on Compensatory Sweating”, Ann Thorac Surg 2006;81:1048 –55 |
