Endoscopic thoracic sympathectomy – Cure and causes of ETS

Hyperhidrosis or excessive sweating is believed to be secondary to over activity of the sympathetic nerves located in the chest cavity. Surgical treatment of hyperhidrosis involves interrupting the sympathetic nerves.

These nerves have 12 segments in the thoracic cavity from T1 to T12. This procedure is called endoscopic thoracic sympathectomy. In its different variations it is referred to as ETS, ETS-C, or ESB.

Sympathectomy is performed through small keyhole incisions in the underarm area under general anesthesia. The sympathetic nerves are then found in the thoracic cavity and are either cut, clamped or resected. Details of this surgery are well explained at

Sympathectomy can be achieved by various methods:

Sympathectomy by clamping or clipping (ETS-C / ESB)

In this method the sympathetic nerves are interrupted but not physically cut. This is accomplished by applying a titanium clip/clamp to the nerve. The pressure from the clamp interrupts the nerve signals through the sympathetic nerves. The sympathetic ganglia are not destroyed. The advantage of the method is the theoretical possibility of reconstructing the nerves in the future by removing the clamps.

Sympathectomy by cutting

In this method the sympathetic nerves are physically cut with scissors or electrocautery. The disadvantage of this method is that it is extremely difficult to reconstruct the sympathetic nerves in the future.

Sympathectomy by resecting the sympathetic nerves

Some surgeons prefer the removal of a segment of the sympathetic nerves. This method is effective in treating various forms of hyperhidrosis. However again it is extremely to reconstruct the sympathetic chain after this procedure.

The extent of sympathectomy

The extent or level of the endoscopic sympathetic blockade, ESB, varies according to the type of hyperhidrosis or facial blushing:

ConditionLevel of ESB
Facial BlushingT2
Facial Sweating T2 or T3
Hand SweatingT3 or T4
Underarm SweatingT4 or T5

It is believed that by limiting the level of ESB to a specific segment of the sympathetic chain, compensatory sweating, the most common side effects of surgery, can be reduced.

Surgery Results

Sympathectomy is very effective in treating palmar hyperhidrosis or excessive sweating of the hands. Upon waking up from anesthesia, most patients notice having dry and warm hands. Many patients who suffer from excessive hand and feet sweating also notice some improvement in the sweating of their feet. Palpitation and trembling also improve after sympathectomy.

The results for underarm sweating are also very good. Patients notice a major improvement in the excessive perspiration of their underarm. Facial sweating also responds very well to sympathectomy. In general, patients who suffer from facial blushing also notice a significant reduction in their facial blushing.

After surgery, patients regain their confidence. Patients with hyperhidrosis regain their confidence faster than patients with facial blushing. It takes the mind some time to get used to and fully realize that one no longer suffers from hyperhidrosis or facial blushing. Gradually these people start engaging in activities, which they never did before.

Dating, socializing, shaking hands, and even public speaking can improve tremendously after surgery. However full psychological improvement may take a few months after surgery.

Side Effects

The most common side effect of sympathectomy is called compensatory sweating. This is defined as exaggerated sweating, which may occur in the lower chest, the back, abdomen, thighs, and legs. This may also be accompanied by sensitivities to heat or cold. The majority of patients undergoing sympathectomy will experience some degree of compensatory sweating. The extent of compensatory sweating is variable and unpredictable prior to surgery. It may present as very little moisture to frank sweating. It usually occurs in hot weather.

It is known that CS is related to the extent of sympathectomy. The greater the area of denervation by sympathectomy, the more severe CS. The older methods of sympathectomy involved removing or eliminating a large segment of the sympathetic nerves which would result in severe CS. Fortunately with the newer ESB methods the extent of sympathectomy is minimized and level of sympathectomy is tailored to the specific type of hyperhidrosis or facial blushing. This new technique has substantially reduced the severity of CS.

The majority of patients are content with some degree of compensatory sweating if their original condition, hyperhidrosis or facial blushing, is cured. However, a small number of patients experience extreme and troublesome compensatory sweating after having surgery. For those patients with severe CS, the titanium clamp could be removed in order to reverse the surgery. If the titanium clamp is removed soon after the surgery, there is a good chance that the surgery may be reversed and CS would be decreased or eliminated. However, this has to be done soon after surgery since after a few months, the chance of reversal diminishes.

Medications also exist to treat CS. These include Robinul and Ditropan. Both of these drugs have been used to treat CS successfully.

Other side effects and complications of the surgery include possible bleeding, infection, nerve damage, postoperative rib pain and dryness of the hand, the face and the neck. Some patient also experiences a decrease in their heart rate. Other rare complications of the surgery include damage to the lung and Horner’s syndrome. However with the new ESB technique these complications are very rare.