ETS Surgery

ETS surgery should be the last step that you consider.  I had the surgery in high school after trying pretty much every other treatment. Initially, I was extremely happy with the results. My hands were completely dry. Later, I had to question my decision because I was one of the few who got Compensatory sweating pretty bad. Basically sweating more in other regions, like torso armpits, thighs. In retrospect, I probably still would have gotten it done, because having sweaty hands is extremely uncomfortable. At least with the products I reviewed in my relief products section, I can hide my  compensatory sweating.

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.

The operation  


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.

RESULTS

-Benefits are seen as soon as the patient wakes up after the surgery is over.

-Palm sweating is cured instantly in almost all the patients.

-Axillary or under arm sweating in about 80% patients.

-Plantar sweating is unpredictable and gets better in about 50% of the patients.

=Facial sweating and blushing gets better in about 95% of patients, but may persist during spicy meals ( reasons unknown )

PROBLEMS

Potential problems with sympathetic surgery can be classified under

  1. Complications of surgery
  2. Side effects after surgery
  3. Reversibility of surgery
  4. Recurrence and re-do surgery

Complications:

Pneumothorax which is residual air in side the chest cavity can some times occur at the end of the procedure. This is harmless and gets absorbed naturally with no effect. What could be a problem is if the pneumothorax occurs due to lung injury at the time of surgery and is due to air coming from the lung into the chest cavity. This is a rere situation and could mean placement of a chest tube for a couple of days. Extremely rare is the situation of a re-do surgery to stitch the site of air leak in the lung.
Intercostal neuralgia can occur due to bruising of a nerve by the instruments. This can cause pain along the ribs or sometimes a numb patch of skin. It is a self limiting problem and quickly settles down with common medicines.
Pain in upper limbs: Neuralgia or pain in the limb denervated by sympathectomy occurs in up to 32% of patients some time after the procedure and is transient.
Sequelae of general anesthetic use, can occur like any other surgery and is a separate topic dealt elsewhere by experts.
Wound infection at the site of the cut ( seen in less than 1% patients ) is treated by dressings and antibiotic and settles down very rapidly.
Horner syndrome: Unilateral upper eyelid ptosis, pupil constriction, and facial anhidrosis—can occur as atemporary post-ETS complication or can be permanent. The incidence of transient Horner’s syndrome has been reported to be as high as 0.8%. Permanent Horner’s syndrome was reported in up to 0.1% of cases. Possible causes include an anatomic variation of the stellate ganglion, mistaking the stellate ganglion for the ganglion targeted by ETS, or electric current delivered to the stellate ganglion during electrocautery of the chain below.
Now hardly any incidence of Horner’s syndrome is reported when ETS was done with video assistance, presumably because of improved intraoperative visualization.
Also T1 surgery is not done any more and the stellate ganglion lies outside the vision of the telescope hence remains non reachable.

Side effects:

Compensatory sweating over chest, abdomen, back and thighs is the most common and talked about side effect. As the mechanism for this is largely unknown, it has not been satisfactorily tackled. This is the most coomon side effect that has long lasting implications. This topic needs a separate page of its own, hence please see www.hyperhidrosisindia.com/cs.html for more details on this problem.
Phantom sweating, where the patient feels the sensations of sweating but is not actually sweating, typically resolves in 1 to 3 weeks after surgery.
Excessive dryness of the hands is a possible side effect. This may require use of moisturising creams.
Dry face with T2 surgery may not be liked by some of the patients of facial hyperhidrosis. This possiblility has to be explained to all such patients. It is not a problem with palmar and axillary hyperhidrosis patients where the level of surgery is much lower at T3 or T4.
Gustatory sweating specially with T2 surgery. Gustatory sweating, which is sweating induced by smells and tastes occur in up to 1% of individuals but very few regard this as a major problem.
This is supposed to be due to new nerve fibers growing into the nerves supplying the salivary glands. One explanation for this phenomenon is that aberrant regeneration of sympathetic nerves leads to an anastomosis with the sympathetic trunk and the vagus. Another possibility is overactivity of the still-intact or regenerated sympathetic nerve fibers to the face.
There are reports of improvement with anticholinergic drugs as discussed in the medical section.
Bradycardia is a slight reduction of pulse rate (does not cause any physiological problems to the patient). There may be some reduction of systolic pressure too but the diastolic pressure remains normal. This effect is similar to the usage of beta blocker drugs as anti anxiety in these or other patients. Importantly, there are no reports of any long-term adverse effects of ETS on cardiovascular function.
Physical performance has been shown not to be reduced on stress testing despite the heart rate being reduced by 10%. It could theoretically be a problem in short distance runners or similar athletic activities. It is theoretical as there are no reports of such people having had hyperhidrosis treatment.

 

 

Reversibility

The myth about Endoscopic Thoracic Sympathectomy surgery reversal

Several surgeons have been offering an experimental nerve reconstruction surgery at the cost of $20,000 or more. This "reconstruction" surgery does not rebuild the destroyed T-2 ganglion. Rather, it is an attempt to somehow transmit signals from the lower ganglions to the palms, face and so on by bypassing the destroyed T-2 ganglion. Timo Telaranta of Finland seems to be the most experienced at this in terms of number of patients treated thus far using sural nerve graft transplant from the ankle to the sympathetic chain. Rafael Reisfeld in California is also experienced at this, but uses a different technique from Telaranta so is in effect the most experienced at his technique. Chien-Chi Lin of Taiwan also seems to have his own nerve reconstruction technique for reversal and could be more experienced than Reisfeld as far as numbers go, though its hard to tell.

According to the cigna website:

"There is no evidence in the peer-reviewed scientific literature to support that reversal or repeated sympathectomy is safe and effective in reversing compensatory sweating and other complications of ETS."

On another important note, the ETS reversal surgery involving clamp removal is also a myth (a fact supported by David Nielsen of Texas on his website with the words "reversibility questionable". Nielsen also discusses a host of other problems with clamping as opposed to his microcutting cutting). Many experienced surgeons worldwide continue to prefer electrocautery/electrocoagulation/cutting/resection over clamping to this day. In the end, not matter how the ganglion is destroyed, ETS represents permament damage to your sympathetic nevous system.


The surgeons who perform clamping ETS say that, theoretically, clamp removal very soon after surgery can lead to reversal to pre-surgical conditions in the patiet's body. However, there is no certainty about this as the nerves have been crushed (instead of cauterized, but basically still killed), and side effects typically change over the course of the first year after surgery in tandem with the weather/temperature outside and other unknown factors. You will never know your side effects until at least a year post surgery.

Recurrence of hyperhidrosis and re-do surgery:

Mild temporary (false) recurrence: Up to a third of patients have several days of increased sweating following initial dryness from day 3 to day 5 after ETS. This phenomenon is thought to be due to degeneration of the postganglionic fibers, which leads to a transient increase in activity of the sweat glands. Mechanism is unknown but it is hypothesized that this could be due to some residual chemicals from before which stops on its own. Patients should be warned in advance of this possibility. It is not been a problem as it disappears spontaneously in 2-3 days only.

True recurrence can happen in 1% of patients. Those willing to undergo re-do surgery have benefitted from division of the nerve at a new level.
Possible causes for recurrence include an inadequate ablation or resection or nerve regeneration post-ETS. Nerve regeneration has been seen at second operations. Other possible etiologies for recurrence include unrecognized anatomic variations such as residual sympathetic pathways to the affected limb, such as a C8 or T1 contribution to peripheral nerve fibers or a Kuntz nerve.

Re- do surgery is possible in some of the patients who have had limited sympathectomy. For example if someone has had T3 surgery for palmar sweating, a relook can be done to see if there were any nerve of Kuntz missed at the first surgery. Also division of the scar tissue at previous surgery site can be done along with a T2 or a T4 division. Experience is limited world over. At our centre, we have done 6 re-do surgeries with 5 getting better and 1 patient who got better again had a relapse of the symptoms.