Endoscopic Thoracic Sympathectomy (ETS)

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"Sympathectomy"

 

What is it?

ETS is a surgical procedure that is performed under a general anaesthetic. The operation involves a camera on a telescope being inserted into the chest. This allows the surgeon to identify the sympathetic chain (the main trunk from which sympathetic nerves innervate sweat glands) and burn very small specific areas of it. This permanently removes the nerve stimulus to the relevant sweat glands so that sweating is greatly reduced.

The operation can be performed 1 side at a time or both sides in one sitting. The procedure is a “day case” if only one side is operated on but requires an overnight stay if both sides are operated on together. The operation lasts about 1 hour per side. ETS is a permanent treatment for all forms of primary focal hyperhidrosis and facial blushing. 

 

Before your Procedure

You will be admitted to the ward the day before or the morning of your surgery. As you will have a general anaesthetic, you should not eat for 6 hours prior to treatment. However, you may drink “clear fluids” like water up to 2 hours before.

Your surgeon will visit you before the operation and ask you to sign a consent form once he has explained the procedure to you.

 

How is ETS performed?

Once you are asleep, 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 small 1  2cm cut (incision) is made just beneath the armpit which allows a camera on a thin telescope to be inserted into the chest. The surgeon can then identify the sympathetic chain. A second instrument is then inserted through the same cut and depending on the type of hyperhidrosis, small sections of the sympathetic nerves are divided using “surgical diathermy” on the end of this second instrument. Once complete, the camera and instruments are removed and the lung fully reinflated. Your wound will be closed with dissolvable stitches and dressed. The effects of the operation on sweating should be immediate.

 

After the Operation

            It takes a couple of hours to recover from the anaesthetic. You will be given painkillers and anti–sickness medications if required.

            You will be given something to eat and drink soon after the operation and encouraged to get up and about when you are comfortable.

            A chest xray will be performed routinely after the operation to look for any air sitting between the lung and chest wall (a pneumothorax).

            Most patients will go home on the day of surgery or the following morning.

            The procedure causes some discomfort where incisions have been made. Most patients can get back to work 2  5 days after the procedure.

            You can shower 2 days after the procedure. If the wound is clean and dry no further dressings are required.

            Gentle exercise can be undertaken after 3  4 days or when you are comfortable.

            You can fly 2 weeks after your procedure.

 

Success rates with ETS

ETS has varying success in treating the different forms of hyperhidrosis:

 

Type of Hyperhidrosis

Success rate of ETS treatment

Palmar

95%

Facial Blushing

95%

Facial

90%

 

Axillary

70 – 80%

Plantar

 

30 – 40%

 

 

Risks of ETS

Risks that are standard for any form of surgery include post operative bleeding and wound infections which affect up to 5% of patients. These are easily treated in the vast majority of cases. Patients will also be left with a small scar in the arm pit. It is usually placed in the hairline or in a skin crease and infrequently causes cosmetic issues. Serious complications are very rare but patients should be aware of them:

 

Horner's syndrome

This is the most feared complication, leading to a slightly smaller pupil and a loss of facial symmetry due to a slight drooping of the upper eyelid. It is caused by damage to the upper–most part of the sympathetic nerves, the so called “stellate ganglion”. The Vascular Alliance surgeons have significant experience in ETS with an inherent 0.3% risk of Horner’s syndrome whilst under their care. To correct this complication, a plastic surgery procedure (blepharoplasty = shortening of the upper eye lid) is required.

 

Treatment failure

Occurs in less than 1% of cases. It is rare as long as patients have not had severe lung disease which can make the operation very technically difficult.

 

Pneumothorax

Seen in 2% of patients, a pneumothorax is a residue of air remaining between the lung and the chest wall. Small amounts of air are generally reabsorbed naturally over the following days and need no further treatment (the patient should, however, avoid taking a flight during the next day or as long as the pneumothorax persists). Greater amounts (very infrequent) may require suction drainage for a day or two. With proper technique, when entering the chest cavity and when aspirating the gas at the end of the procedure, the surgeon can almost always avoid this complication. In any case, it can be easily treated.

 

Compensatory sweating

After the operation, up to half of patients may notice compensatory sweating in other locations (usually on the trunk or on the thighs, especially during physical exercise or when out–side temperatures are high). This can range from barely noticeable to quite disturbing. Sweating in these less exposed areas is regarded as a minor inconvenience and far more acceptable than hyperhidrosis on exposed areas (palms, face) by the vast majority of operated patients. The risk of disturbing compensatory sweating known as “compensatory hyperhidrosis” is about 1%.

Compensatory sweating is more frequent in patients treated for axillary hyperhidrosis, since more nerve areas have to be divided than in procedures for other forms of hyperhidrosis. People with axillary hyperhidrosis, should be cautioned that embarrassing wet–marks on their cloths in the underarm area may re–appear elsewhere, after the operation.

 

Gustatory Sweating

Up to 35% of patients may notice increased sweating while smelling or eating certain strong or spicy foods. This phenomenon is rarely considered a problem by the patient.

How to contact us

Professor M Baguneid

Consultant Vascular Surgeon

Email: admin@vascularsurgery.org.uk

Web: www.vascularsurgery.org.uk

 

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