Endoscopic thoracic sympathectomy (ETS) surgery is made out to be a safe procedure on most surgeons' websites with typical short-term dissatisfaction rates quoted as being less than 5 percent. From my years of experiences of having talked to or e-mailed a large number of patients along with reading other forums on the web regarding this subject, the dissatisfaction rate is significantly higher in the long run. In addition, most surgeons do not divulge or will downplay a number of key changes to your body that often occur in the aftermath of the surgery:
Your body will lose its ability to sweat above the nipple line. Some surgeons conveniently forget to mention this, while others play it down as being nothing to worry about. How do you lose heat from your head after this happens? Are there any long term side effects? Many people have complained of a very dry face and dry scalp after surgery. Many people have major body temperature changes during times of stress as a result of an altered body "thermostat" that can not enable heat loss via sweating through the upper body after surgery (further exacerbated by the lack of heat loss via the palms).
ETS reduces the resting heart rate in a fraction of patients -- this fraction has been listed anywhere from one tenth to well over 50 percent depending on which surgeon you listen to. In my opinion, you should assume your heart rate will fall (mine fell by around ten percent). Although not dangerous, this is something to think about. Are you willing to mess with your heart rate to get rid of consistently sweaty palms? I would still say yes based on my terribly sweaty palms, but not everyone would. Some surgeons are now warning that if you are an athlete, ETS might reduce your peak performance due to this side effect. For me, a lower heart rate doesn't seem to have made any difference in athletic ability.
ETS leads to compensatory sweating (a better term is reflex sweating per Dr. Chien-Chi Lin) in almost 100 percent of patients according to some surgeons. In the past, most surgeons usually estimated a figure of around 40-60 percent, but this figure has steadily increased as more and more patients have started getting compensatory hyperhidrosis a year or two after surgery and the surgeons have realized that the problem does not necessarily start the day after the surgery (especially if the season at the time of surgery is not summer and thus does not enable a patient's compensatory sweating to be at its worst). The palms and feet house most of the body's sweat glands, so stopping sweating at either place will almost always guarantee compensatory sweating elsewhere. For me, the compensatory sweating occurred in my feet of all places. See below...
Your feet sweating (aka plantar hyperhidrosis) can become much worse than before surgery. Most people with palmar hyperhidrosis also have plantar (feet) hyperhidrosis. Surgeons typically say that there is anywhere from a 50-95 percent (again depending on which of them you listen to) chance of a reduction in feet sweating after ETS for palmar sweating (i.e, a bonus benefit). The feet sweating will remain the same as before ETS in the remaining patients according to the surgeons. However, I have experienced significantly greater feet sweating post ETS and so have many others I have talked with or read about. I haven't seen a single surgeon point out this possibility to date. Sweat signals to the feet generally come from the lumbar sympathetic chain in your lower back, so it seems that in some patients, the lumbar sympathetic chain starts transmitting more sweat signals to the feet once palmar sweating has ceased as a result of the destruction of part of the thoracic nervous system. A lumbar sympathectomy can possibly cause reverse ejaculation in men and urinary incontinence in women (among other side effects), so almost no surgeon offers this procedure for the purposes of curing feet sweating anymore.
EDIT: In May 2009, I finally got rid of my excess feet sweating using HIDREX iontophoresis. You must attempt iontophoresis therapy before looking into getting endoscopic thoracic sympathectomy surgery.
You can get extremely cold hands post ETS, and like some of the other side effects, this can show up a year or more after the surgery (so this side effect conveniently doesn't show up in most surgeons' list of potential side effects that are often based on surveys conducted in the immediate aftermath of surgery). This is also why ETS is not performed to cure Raynaud's (cold hands) syndrome by many surgeons anymore, since initially warm hands post-ETS can become extremely cold a year or two down the road. According to the "pioneers" of the endoscopic method of sympathectomy, Goran Claes and Christopher Drott (who used to practice ETS in Sweden until they were banned as a result of several patient deaths and lawsuits from several hundred of their past patients), this severely cold hands side effect happened in two percent of their patients due to "increased sensitivity to surrounding catecholamines". I get this side effect once in a while, and it seems to be positively correlated to stress levels and cold weather.
In a related side effect to the one just listed regarding cold hands, the body's thermoregulatory system or thermostat can get out of whack due to changes in sweating patterns and sympathetic innervation to the upper body after ETS. Many people have had significant problems with this side effect, although for the majority, it does not seem to be an issue or is only an issue on rare occasions.
After ETS, some patients (typically less than 5 percent in the case of ETS for palmar sweating according to most surgeons) experience a recurrence of their original symptoms. This recurrence is usually most common with regards to ETS for facial blushing, Raynaud's Syndrome and for other such non-hyperhidrosis related problems. In my own case, I had some right had sweating return a year or so after ETS while the left hand has always remained extremely dry. During intense exercise, my right hand can get very sweaty at times. It is unclear to the surgeons why this recurrence occurs, and some claim that there is no way a destroyed ganglion can regenerate, so the sweat signals must be transmitting via other pathways. Many patients need to get reoperated upon if the recurrence is significant. I am not sure how the reoperation works if the destroyed ganglion has not regenerated and hope to hear from someone with this knowledge. Does the surgeon destroy other ganglions besides the dead T-2 in the event of recurrence?
The only side effects that surgeons have discussed honestly and have quoted consistent risk percentages for are Horner's Syndrome (droopy eyelids) and Gustatory Sweating. Gustatory sweating is significant forehead sweating when eating or even smelling spicy food and can occur a year or two after ETS. Horner's Syndrome is extremely rare in the hands of an experienced surgeon. The few patients who do get permanent Horner's Syndrome have had to get cosmetic surgery to improve their appearance. Gustatory Sweating occurs in anywhere from 10-20 percent of patients, although it is unclear if this figure is higher in the long run. I got the gustatory sweating side effect a year or two after surgery, but only when eating very spicy food, which I unfortunately enjoy :-(. It is quite strange that I am unable to sweat at all from my forehead after having had endoscopic thoracic sympathectomy even while exercising during 100 degree Fahrenheit temperatures, but sweat profusely from there when eating really spicy food.
Problems that can occur during surgery include pneumothorax, intercostal neuralgia and even death on rare occasions (it seems like around ten deaths that have occurred in Western countries during ETS surgeries have been reported in the media over the past decade). Pneumothorax is some level of lung collapse after the operation. Intercostal Neuralgia is local pain in the chest wall area. Persistent or severe pain is unusual.
There are a host of other side effects that some people have complained about that are possible due to ETS such as sensitivity to light, dizziness, blood pressure changes, dry scalp, hair loss etc... If enough people complain about a specific problem and at least a few surgeons verify the problem as a side effect of ETS (as has been the case for all the side effects I listed above), I can add the problem in the above list. Otherwise, I am treating those rumored side effects as unrelated to ETS.
Curiously, people who have severe facial blushing also get the second thoracic ganglion destroyed just as most palmar and facial hyperhidrosis patients still do (although many surgeons now cut T-3 and/or T-4 to treat palmar hyperhidrosis). It seems that significant types of upper body innervation arise from the thoracic cavity and its associated ganglions, especially T-1 and T-2. That is also why injury to the first thoracic ganglion (T-1 or stellate ganglion) during surgery can cause permanent droopy eyelids and dilated pupils in the form of Horner's Syndrome.
You, the desperate patient think that you are putting your body through what you might consider a quick 1-hour (half an hour each side) minor surgical procedure. However, this can very often lead to long-term turmoil on the internal networking of your body. After all, there must be an evolutionary reason as to why the sympathetic nerve chain is in a location where it can never be damaged like virtually all other components of your body. Humans can easily damage external parts of their bodies through physical injury. In addition, most internal organs such as the brain, heart, kidney, liver, and lung can be damaged by cancer, diet, drinking, smoking and the like. However, to my knowledge, the sympathetic nervous system (or more specifically, the thoracic ganglions) can almost never be physically damaged without surgical intervention because it is deep inside the chest and made up in a rope like manner that can not break easily.
Having said all that, ETS is a last resort option that can be a very effective cure for your palmar (and facial if present at the same time) hyperhidrosis. However, I firmly believe that there is an extremely strong chance of curing hyperhidrosis using one or a combination of the numerous alternative methods available that are outlined in this website and on the hyperhidrosis forum if you are persistent.
After reading paragraphs like the one above and messages in the forums, it is easy to become a hypochondriac. I myself stopped reading and posting on message boards a few years back (around 2002) due to people with ETS-related side effects blaming every possible medical condition on ETS which can affect you mentally as you start imagining things. One has to remember that both hyperhidrosis or facial blushing and ETS are relatively minor events in comparison to other medical conditions such as AIDS, autism, cancer, paralysis and so on. Moreover, I have talked with a number of happy people who had open surgical sympathectomy many decades ago to cure hyperhidrosis, and they had numerous ganglions removed along with major bleeding and other significant trauma during and after surgery. These people are enjoying their life and old age despite the side effects they had to deal with all their lives. In the end, willpower can often overcome most side effects.
Also check out the portion of the website where I discuss the evolution of and confusion regarding ETS techniques and the way surgeons have managed to personalize their own variety of ETS at times -- i.e., cutting different ganglions for hand sweating relative to other surgeons, emphasizing/de-emphasizing kuntz nerve search and destruction, controversy about cutting the ganglion above or below each level or completely cutting it, "microcutting" versus clamping versus electrocoagulation and on and on.