ETS SURGERY EVOLUTION OVER THE YEARS

ETS surgery methods have changed a number of times over the years (with the vast majority of changes having occurred since the mid 1990s). In addition, current techniques also differ significantly depending the numerous surgeons performing the surgery worldwide -- with areas of dispute ranging from which ganglions are the most ideal to clamp (or cut or cauterize or even chemically desensitize permanently via CT fluoroscopy per the latest developments in December 2005 depending on area(s) of sweating and facial blushing, to the role of kuntz nerves in passing along sweat or blusing signals, to the morality of performing ETS for certain symptoms (i.e, ethical surgeons refuse to perform the surgery when the only symptom is armpit sweating or facial sweating, or when the symptom is something such as Raynaud's or Social Phobia -- since high reoccurrence rates and the usual side effects of ETS can make the patient even more desperate than prior to ETS).

  1. The term ETS only came into existence in the 1980s (see next paragraph). Prior to that, this surgery was an open sympathectomy (rather than an outpatient endoscopic procedure) which involved a large incision in the chest and resection (removal) of the lower portion of the T1 ganglion down to the T-4 or T-5 ganglion. The surgical procedure usually lasted for a day, with several days of extremely painful recovery in the hospital to follow. Many patients died over the years while having this open sympathectomy procedure performed. The first open sympathectomy was performed as far back as in 1889 by Dr. Alexander, with improvements by Adson in 1908 (posterior approach) and Telform in 1935 (supraclavicular approach).

  2. ETS (or endoscopic thoracic sympathectomy) was first performed/invented by the Swedish team of Goran Claes and Christopher Drott in the mid 1980s. Additionally, Claes and Drott also discovered that interrupting the signals from the second thoracic ganglion would eliminate facial blushing (though we now know that this is often only a temporary result). These guys no longer seem to perform the surgery in Sweden (or elsewhere?) due to a government ban after several patient deaths at their hospital and lawsuits from several hundred former patients and current members of the anti-ETS group called the FFSO. Nevertheless, these surgeons are largely responsible for the huge boom in ETS surgical procedures performed worldwide over the past decade. It should be mentioned that these surgeons probably have more satisfied ETS patients than dis-satisfied ones, even though virtually all patients suffer from some side effect or other after ETS. ETS represented a huge improvement over the open sympathectomy method. In ETS, the surgery is still done with the patient under general anesthesia. However, instead of opening up the chest, tiny incisions are made behind the pectoralis fold in the armpit, a small amount of CO2 is insufflated into the thoracic cavity to allow access with an specialized endoscopic instrument and video camera that makes it possible for the surgeon to identify and severe the sympathetic nerve-nodes where the nervous signals to the sweat-glands in the upper limb and the face start. Treatment of palmar hyperhidrosis requires total thermo-coagulation of the appropriate ganglion (the most popular is T-2), with the surgeon taking great care not to cause any spreading of thermal energy along the nervous trunk in order to avoid damage to the stellate ganglion that can cause Horner's Syndrome (droopy eyelid and dilated pupils). Upon completion of surgery, the CO2 is re-aspirated and the incision closed. Finally, the procedure is repeated on the other side/armpit. Normally, the patient leaves the hospital the day after surgery and can resume his/her normal activity after a few days.

  3. Most of the next improvements in ETS surgery since its invention have occurred since the late 1990s. The first of these improvements was when they started cutting or cauterizing only the T-2 and T-3 ganglions and realizing that it gave the same results with supposedly fewer side effects to cure hand sweating, facial sweating and facial blushing. I think the Swedish team of Claes and Drott also developed this improvement, although Ivo Tarfusser seems to have also been at the forefront of these changes. Perhaps him or someone knowledgeable can e-mail me at no-ets@no-ets.com or post on the forums on this site and let me know in the unlikely event of my having made any errors on this page.

  4. The second improvement in ETS occurred when surgeons (Swedish team or Tarfusser?) started cutting or cauterizing only the T-2 ganglion and realizing that it gave the same results as destroying T-2 and T-3 with supposedly fewer side effects.

  5. The third improvement (although I am not so sure this is an improvement) in ETS occurred when Chien-Chi Lin of Taiwan started clamping (with a metal clamp) instead of cutting or cauterizing or ablating the ganglion(s) with the theoretical possibility of reversal if the patient was dissatisfied with the surgery (unfortunately, this reversal seems to be a load of crap in my opinion as the ganglion is destroyed even with the clamp or else the surgery won't work. The surgeons' state that reversal can be somewhat effective if done in the first few months after surgery. However, most side effects don't show up at least a year and sometimes several years post ETS as the weather outside changes or if your weight and hormone levels change. The gustatory sweating side effect is known to occur several years after a patient undergoes ETS.

  6. The fourth improvement in ETS occurred under the auspicies of Lin and Timo Telaranta of Finland. Amazingly, these guys finally discovered that most symptoms other than Facial Blushing could be cured without touching the T-2 ganglion! They say that the main side effect of comepensatory sweating is somewhat lessened with these newer methods that are almost catered on an individual patient basis. According to this methodology the best way to treat palmar sweating is to clamp T4; to treat facial sweating and facial blushing, clamp T3; and to treat facial blushing only, clamp T2. They even recommend treating social phobia by doing the procedure only on one side (using different approaches if facial sweating and facial blushing are present at the same time). I am no doctor, but isn't it stupid to treat social phobia with this kind of surgery and instead just go get good counseling and/or join Toastmasters and/or meditate and/or...try a host of other such things? Numerous celebrities and public speakers often talk about their shyness and excessive social phobia in their childhood that went away due to certain efforts on their part (besides alcohol and dope!). Anyway, Lin and Telaranta might have truly found an improvement in this new methodology, though its too soon to tell. Most surgeon's in the world do not follow this new protocol yet and continue destroying the T-2 ganglion (some wackos still kill everything from T-2-T-5!). Rafael Reisfeld in the USA (a guy who seems very ethical as he has stopped performing ETS for facial blushing and only does it for palmar sweating now it seems) does follow this new protocol for palmar sweating, and he seems to be one of the most experienced surgeons in the US -- if not the most experienced one. I don't know if Tarfusser has changed his methodology yet.

  7. The latest change (I can't say its an improvement when it comes to side effects -- just an improvement for limiting patient discomfort levels) involves a totally different procedure that is not done endoscopically. This procedure was popularized (first done?) in December 2005. European researchers in Belgium, led by Hugues Brat, performed percutaneous sympathectomy with CT fluoroscopy in a 20-minute procedure requiring only local anesthesia on 50 patients with palmar hyperhidrosis. In this procedure, interventional radiologists make a single needle puncture through the upper back and, using CT guidance, inject a phenol-based medication that interrupts the nerve tracts and nodes that transmit signals to the sweat glands. Essentially, the ganglion is still destroyed as was the case with the open smpathectomy and ETS. The main advantage is the faster outpatient surgical procedure for which no anaesthesia is required, and the fact that your lung is not deflated as is typical in most ETS procedures (which leads to great pain upon recovery once the lung is reflated again). Besides still killing the ganglion, this new CT fluoroscopy technique could possibly kill more nerves and surrounding tissue besides the relevant ganglion if not performed with the best equipment in experienced hands (so far this one team of surgeons seems to be the only one with this level of experience). If widely adopted, this new procedure will significantly reduce patient discomfort and recovery time....but in the end you still get the same side effects as with ETS.

In the end, despite continuously evolving surgical procedures that seem to be getting safer and possibly slightly fewer side effects, this whole thing is still a shot in the dark when it comes to the main side effects (especially compensatory sweating and thermoregulatory disturbances in your body).

Putting your body through what you might think is only a quick surgical procedure can end up leading to long-term turmoil. After all, the sympathetic nerve chain was purposely placed in a location by god or chance where it can never be damaged like most other components of your body. Humans can easily damage external parts of their bodies. In addition, all internal organs such as the kidney, liver, lung, heart, brain can be damaged by diet, smoking, drinking, cancer and the like. However, none of those factors will be able to permanently alter the sympathetic nervous system via the thoracic ganglions. In effect, the thoracic ganglions are impossible to damage without surgical intervention unlike virtually all other parts of the body. Perhaps there is a strong reason for this?!

ETS should NEVER be used to treat only armpit sweating or facial sweating as some surgeons might encourage. In fact, Botox seems to ge a great cure for armpit sweating that lasts for months at a stretch. Anyway, armpit sweating is natural and its a bad idea to not sweat there at all. ETS also gets mixed results for facial blushing and is not a good idea unless your blushing is extreme as seen in the pictures on Chien-Chi Lin's website (scroll to the end for the excellent pictures).

Finally, you will notice that ALL commercial and ETS surgeons' websites undermine the value and effectiveness of alternative treatments, which is truly a shame. In addition, most surgeons do not do long-term follow ups of their patients, or else their success rates would be much lower than advertised.

Having said all that, ETS is a last resort option that can be a very effective cure for your palmar (or other) hyperhidrosis. However, I strongly beleive that there is an extremely strong chance of curing the hyperhidrosis using one of the numerous alternative methods available that will be outlined in this website and discussed on the forums.

Note that ETS is also referred to as video or video-assisted endoscopic sympathectomy and thoracoendoscopic sympathectomy.