Hyperhidrosis Forum

Types of ETS Reversal Operations

There are two types of ETS reversal operations, and neither offers close to any kind of guarantee of a successful outcome. The first concerns the reversal of an ETS operation during which the T-2 thoracic ganglion was cut or cauterized or resected and thereby permanently destroyed. This reversal procedure is fairly complex and does not actually entail a rebuilding of the permanently destroyed T-2 ganglion since that is not feasible with current technologies. Only three surgeons around the world have sufficient experience in performing this type of reversal operation. Since all three of these surgeons have different techniques, and since two of them are probably past retirement age, the future of these reversal techniques looks bleak. This second type of ETS reversal operation involves the removal of clamps that have been used to crush a ganglion (T-2 or T-3 or T-4). Most surgeons today prefer clamping during ETS over cutting or cauterizing or resecting. Theoretically, this clamp removal reversal operation has a higher chance of success if the clamps are removed within a few months after being affixed. However, even if removed on the same day as the original ETS surgery, there is no guarantee of a successful reversal (see further below for more on that).

Cutting/Cauterizing/Resection ETS Reversal

Several surgeons have been offering an experimental nerve reconstruction ETS reversal surgery at the cost of $20,000 or more the last time I checked. 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. As of 2009, Dr. Timo Telaranta of Finland seemed 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. Dr. Rafael Reisfeld in California uses a slightly different technique from Dr. Telaranta, so is in effect the most experienced at his technique despite treating fewer patients than the latter. Dr. Chien-Chi Lin of Taiwan also has a totally different technique, and since there are so many dis-satisfied patients in Taiwan, Dr. Lin could now be more experienced than Dr. Telaranta. There are also a number of surgeons such as a Dr. Rahul Nath and teams in Korea and Japan that are trying newer reversal methods, and I recommend keeping track of developments at the following ETS reversals forum.

To me, it seems that this reversal does not work well enough to be worth it unless you really suffer from numerous side effects and are quite desperate for any small improvement. For all intents and purposes, this reversal procedure is still an experimental surgery. Some ETS patients have become miserable due to their side effects, and are willing to pay this much money and undergo the reversal surgery that is much more intensive and dangerous than the original sympathectomy. These patients then often get no benefit from the reversal surgery, or sometimes get temporary psychological satisfaction that leads them to imagine some improvements in their physical condition. The fact that patients are undergoing this crazy reconstruction surgery is the best warning of all about why it is essential to try all possible nonsurgical hyperhidrosis treatments before even thinking of getting ETS surgery in the first place.

Some very useful links to find out more about ETS reversal surgeries:

Archive of Columbian's excellent documentation of his pre-ETS, post-ETS (with Dr.Nielsen) and post-reversal (with Dr. Lin) quality of life.

Archive of testimonials from reversal patients.

Archive of reversal surgery overview.

Telaranta's page on ETS reversal. He used to have a page on his results, but it seems like a new surgeon has taken over his practice now.

Reisfeld's image of reversal surgery on his website.

Archive of Lin's nerve graft reversal surgery description with photos on bottom.

Check out the Hyperhidrosis Forum for hyperhidrosis treatments other than endoscopic thoracic sympathectomy frequently to learn about what nonsurgical treatment (or combination of treatments) other hyperhidrosis sufferers are benefiting from. Take your time and conduct ample research before deciding to get ETS surgery and then potentially having to get this expensive potentially useless reversal operation.

There is some hope that reversal surgery techniques will improve in the future. For example, a Japanese team has been doing some interesting work recently:

Repair of intra-thoracic autonomic nerves using chitosan tubes

Clamping ETS Reversal

The clamping ETS reversal surgery involving clamp removal is also somewhat of a myth, a fact supported by Dr. 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 unique "microcutting" technique, but I think he is just marketing his technique here, when it is probably no better than clamping as far as side effects and results go.

A more unbiased source, the Cigna website, stated the following when I checked it in 2006:

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.

Dr. Alan Cameron, a highly respected UK-based surgeon, also doesn't do clamping. In an e-mail to me in 2006, he said the following:

There is very little evidence of objective reversibility (but I agree some patients may feel better knowing the clamps are off which may help them). I use a single-puncture narrow instrument so I find cutting easier, but do clamp on request using two ports each side. But I emphasize that I do not believe it can be reversed (which was true for the two cases where I removed the clamps incidentally). I also think that cutting is a more effective way of doing ETS.

Dr. Ivo Tarfusser, one of the world's most experienced and respected ETS surgeons, offers both cauterization and clamping as of 2013. His main reason for still offering cauterization, however, is that some patients prefer no foreign objects in their bodies.

The surgeons who perform ETS via clamping say that, theoretically, clamp removal very soon after surgery can lead to a reversion to pre-surgical conditions in the patient's body. However, there is no certainty about this as the nerves have been crushed (which although cosmetically better than being burned via cautery, still leads to permanent destruction), 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. But than its a moot point to remove the clamps since that can only be done with some possible benefit very soon after surgery. The conclusion is that clamping, cutting, microcutting, electrocautery, electrocoagulation, resection, and ablation are all basically just ways for surgeons to differentiate themselves (often to capture market share) rather than being significantly safer or reversible techniques.

With so many medical and technological advances having occurred since the mid-1990s, I feel that this trend will only accelerate in the next decade as genetics and stem cell related research progress rapidly. This will be further bolstered by China and India producing millions of scientists as a result of rapid economic development. A nonsurgical cure for hyperhidrosis (perhaps even via basic existing laser technology as is the case for armpit sweating as of 2010) is quite possible in the next decade in my opinion, and till then, I would recommend trying iontophoresis, Botox and robinul and alternating between these solutions if necessary. As I am typing this paragraph while updating parts of this page in April 2010, Google medical news tells me that a full face transplant has just occurred, a new artificial heart is the best yet, a company has managed to grow new hair on balding people and more.