ETS SURGERY EVOLUTION OVER THE YEARS

Modern endoscopic thoracic sympathectomy (ETS) surgery methods have changed a number of times over the decades, with the majority of changes having occurred since the mid-1990s. In addition, current techniques also differ significantly depending on the surgeon performing the surgery. Areas of dispute range from which ganglions are the most ideal to clamp (or cut or cauterize or even chemically desensitize permanently via CT fluoroscopy) depending on the area(s) of excessive sweating; to the role of kuntz nerves in passing along sweat or blushing signals; to the decision of whether or not to perform ETS for certain symptoms. Most surgeons nowadays refuse to perform the surgery when the only symptom is armpit sweating, facial sweating, facial blushing, Raynaud's syndrome or social phobia. High re-occurrence rates for such conditions and the potential side effects of ETS can make patients regret their decision to have surgery.

From Open Sympathectomy to Endoscopic Thoracic Sympathectomy: Treating Hyperhidrosis

1. The term ETS only came into existence in the 1980s. Prior to that, this surgery entailed an open sympathectomy rather than an outpatient endoscopic procedure. The former involved a large incision in the chest and resection (removal) of the lower portion of the T-1 ganglion down all the way through 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 undergoing an open sympathectomy. The first open sympathectomy was performed as far back as in 1889 by Dr. Alexander to treat an epilectic patient, with improvements by Dr. Adson in 1908 (posterior approach) and Dr. Telform in 1935 (supraclavicular approach). The first open sympathectomy to treat hyperhidrosis was performed by Dr. Kotzareff in 1920. Today, the open surgery is obsolete and has been replaced by the endoscopic approach. Note that I have had a chance to speak to several patients who underwent an open sympathectomy several decades ago, who are content despite still suffering from some side effects. Of course the oldest patients who had the worst side effects from open sympathectomy might be dead by now or not be active on the internet.


2. According to an e-mail to me from a respected surgeon "the endoscopic approach was first described by Hughes in 1942 in the Proceedings of the Royal Society of Medicine, while in his 1954 book, E. Kux claims to have started performing thoracic sympathectomies from 1940 onwards." I think that the "endoscopic" approach described here was probably very different from what I describe in the paragraph below, and for all intents and purposes, what Hughes was describing was probably still an open approach due to limited technological capabilities in the 1940s.


3. Endoscopic thoracic sympathectomy was first performed/invented by the Swedish team of Dr. Goran Claes and Dr. Christopher Drott in the mid-1980s. I went to them for my ETS surgery in 1998. Additionally, Claes and Drott also discovered that interrupting the signals from the second thoracic ganglion would eliminate facial blushing (although we now know that this is often only a temporary result). These surgeons stopped performing the surgery in Sweden due to a government ban after several patient deaths at their hospital and lawsuits from several hundred former patients and current members of the now extinct anti-ETS group called the FFSO. Nevertheless, Claes and Drott are largely responsible for the huge boom in ETS surgical procedures performed worldwide over the past several decades. It should be noted that these surgeons have far more satisfied patients than dis-satisfied ones, even though virtually all patients suffer from some side effect or other after ETS. My experiences with talking to Dr. Claes were favorable and he was a very cordial man. Endoscopic thoracic sympathectomy represented a huge improvement over the open sympathectomy method. 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 and a small amount of CO2 is insufflated into the thoracic cavity to allow access with an specialized endoscopic instrument and video camera. This makes it possible for the surgeon to identify and sever the sympathetic nerve-nodes where the nervous signals to the sweat-glands in the upper limbs and the face start. Treatment of palmar hyperhidrosis requires total thermo-coagulation of the appropriate ganglion (though most surgeons now prefer clamping to cauterizing as I discussed further below). In the past, surgeons used to destroy T-2, T-3, T-4 and T-5. Later on, they switched to T-2 and T-3. And then they realized that T-2 by itself was enough. And today, they have reached the decision that T-3 or T-4 by itself is the best option! The surgeon takes great care to not 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 eyelids 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.


4. Most of the improvements in endoscopic thoracic sympathectomy surgery (for palmar hyperhidrosis) since its invention have occurred after the late 1990s. The first of these improvements was when surgeons started cutting or cauterizing only the T-2 and T-3 ganglions (rather than T-2 through T-5) and realizing that it gave the same results with supposedly fewer side effects to cure hand sweating, facial sweating and facial blushing. The Swedish team of Claes and Drott was also responsible for this improvement due to their large caseloads, with Dr. Ivo Tarfusser of Italy also involved.


5. The second key improvement in endoscopic thoracic sympathectomy surgery occurred when some eminent surgeons 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.


6. The third improvement (although many surgeons are still not so sure whether this is an improvement) in ETS surgery occurred when Dr. Chien-Chi Lin of Taiwan started clamping the ganglion(s) with a metal clamp instead of cutting or cauterizing or ablating the appropriate ganglion(s). This allowed for the theoretical possibility of reversal if the patient was dissatisfied with the outcome. Most surgeons believe that reversal will only be effective (and even this is not a certainty) if the clamps are removed within the first few months after surgery. Unfortunately, some side effects from ETS only show up a year or later after surgery, as the weather outside changes or if a patient's underlying biology changes. The gustatory sweating side effect is known to occur several years after a patient undergoes ETS, as I learned myself when eating spicy foods. To this day, a number of eminent surgeons still prefer cauterization or cutting to clamping, although a majority of the most experienced thoracic surgeons now clamp. Note that the term sympathectomy is used to describe cutting or coagulating the nerve, while the term sympathicotomy is used to describe clipping or clamping the nerve. Also of note, ETS is variously referred to as video- or video-assisted endoscopic sympathectomy; and thoracoendoscopic sympathectomy.



7. The fourth improvement in ETS occurred under the auspices of Dr. Lin and Dr. 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 compensatory sweating is somewhat lessened with these newer methods that are often catered on an individual patient basis. According to this methodology the best way to treat palmar sweating is to clamp T3 or T4 (the latter also stops excessive armpit sweating if present). Lin/Telaranta 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). Lin and Telaranta seem to have discovered a major improvement with this new methodology since destroying the sympathectic chain at lower levels seems to lead to fewer side effects. Many surgeons in the world do not follow this new protocol yet and continue destroying the T-2 ganglion (and some lunatics still destroy everything from T-2 through T-5 as was commonly done many decades ago). One point to note is that it seems like the recurrence rate with destroying T-3 or T-4 is slightly higher than with destroying T-2 based on anecdotal evidence I have seen. If I was going for surgery today to cure hand sweating, I would prefer getting T-3 of T-4 clamped instead of T-2.


8. A more recent change involves a totally different procedure that is not done endoscopically. This procedure was first popularized 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, 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 anesthesia 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.


9. The latest development entails robotic highly selective thoracic sympathectomy. In addition to the use of a Da Vinci robot, this surgery has major differences from regular thoracic sympathectomy. Robotic selective sympathectomy (RSS) allows division of the actual branches of the sympathetic chain (preganglionic and postganglionic rami fibres) that contribute to palmar (and axillary) hyperhidrosis and facial blushing. Unlike VATS or ETS, a robotic approach allows preservation of the main sympathetic chain. This reduces the incidence of complications and side-effects (including Horner’s syndrome and compensatory hyperhidrosis).

Important New Studies

Update: April 2024 -- An interesting study from China compares radiofrequency ablation (RFA) to video-assisted thoracoscopic sympathectomy (VATS) in treating palmar hyperhidrosis. One year post surgery, 79.3% of RFA patients saw a complete remission of their hand sweating; versus 91.2% of VATS patients.

Update: March 2021 -- Yet another study from China compared the results from a

Update: March 2020 -- An excellent summary video of the current status in hyperhidrosis treatments, with a focus on the thoracoscopic sympathectomy surgical option. Increasingly, researchers are describing ETS surgery via rib location (i.e., R2, R3 and R4) rather than thoracic ganglion number (i.e., T2, T3 and T4).

Update: December 2017 -- Dr. Ivo Tarfusser has written an extremely thorough summary about the various endoscopic thoracic sympathectomy surgery techniques historically and currently in use. He describes in detail his own several decades worth of experiences with the ETS procedure, and outlines his current recommendations. An absolute must read.

Update: March 2017 -- A systemetic review of 13 studies compared the clinical outcomes of thoracoscopic sympathectomy (TS) at different denervation levels for treating palmar hyperhidrosis. While T2, T3 and T4 level surgeries all resulted in largely successful outcomes, TS at the T4 level resulted in the best best curative effect with the lowest incidence of postoperative side effects.

Should you get Modern ETS Surgery?

In the end, despite continuously evolving surgical procedures that seem to be getting safer with possibly fewer side effects, this surgery is still somewhat of a shot in the dark. Especially when it comes to the main side effects of 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 discomfort that is in some cases worse than the original symptoms. After all, the sympathetic nerve chain is located in a place where it can never be damaged, unlike 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 good reason for this?

You will notice that all ETS surgeons and surgery marketing companies' websites undermine the value and effectiveness of alternative treatments, which is 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 believe that there is an extremely strong chance of curing the hyperhidrosis using one of the numerous alternative methods available that are outlined in this website and discussed on the hyperhidrosis forum.