CHOOSING AN ETS SURGEON

So you have gone through this website and the Hyperhidrosis Forum in detail and experimented with all the various non-surgical hyperhidrosis treatments available -- but nothing has worked well. You have decided on getting endoscopic thoracic sympathectomy surgery despite understanding all the possible complications and side effects that can arise from destroying part of your sympathetic nervous system. I will now offer you advice on how to go about choosing a surgeon. Ironically, I followed almost none of this advice and just selected the most experienced surgeons in the world when I had my surgery in 1998 in Sweden. One key lesson I learned from that experience was to always try to choose a surgeon who can speak a language that I comprehend well in future! My surgeon could talk in English, but not as well as I would have liked. Some of the staff at the hospital I went to in Sweden could not talk in English at all.

Keep in mind that although your hand sweating is almost guaranteed to cease post ETS surgery, 100 percent of patients get at least one side effect (most frequently, compensatory sweating) after surgery. Additionally, regret at having the operation can arise over time based on changing body conditions and side effects. Perhaps the biggest problem with having this kind of surgery is psychological. You are manipulating a part of your body that is directly and indirectly connected to many other parts, and this can lead to confusion in the long term when you suffer any kind of ailment and are unable to decide whether it was caused or exacerbated by endoscopic thoracic sympathectomy or something that would have happened irrespective of surgery. There are numerous anti-ETS websites and organizations out there, and the owners and members tie all kind of problems besides compensatory sweating to ETS surgery, including both low and high blood pressure, heart problems, hair loss, fatigue and more. I think both the surgeon websites and these anti-ETS websites are too biased in opposite directions. My website is the least biased hyperhidrosis related site on the internet, and hopefully the most useful one too.

Having been in touch with numerous ETS patients over the years, including those who had open sympathectomy many decades ago, I feel that ETS side effects in general are not the cause of anything that endangers your life. The side effects, however, can cause a significant decline in your quality of life, but that can also depend significantly on other factors such on your genetic and nurtured ability to cope with and tolerate discomfort, your social life and family support system, your daily work environment and enjoyment of work and so on. Sometimes, your dissatisfaction with one or two aspects of life can cause symptoms to seem worse than they actually are, or weaken your immune system due to stress/tension/depression.

The Checklist

1. How experienced is the surgeon: a good place to see this is on the ETS surgeon rankings page on this site. In some surgeons' cases, this ranking doesn't mean much, since the numbers might be exaggerated and not verified by any third party (even worse is if a surgeon claims to have done over 500 ETS surgeries, but has not published the numbers in any kind of prestigious journal and never attended any international symposium on ETS). Moreover, experience does not always equate to skillfulness and ethical behavior either. Nevertheless, you still do not want to be a guinea pig and go to a surgeon who has performed less than 50 ETS surgeries. It seems that the sympathetic nervous system is located somewhat differently from person to person, and since the body is not symmetrical, the same level ganglion can be located differently on each side of the body -- so only experienced surgeons can most accurately determine the location of the stellate, T-2, T-3 and T-4 ganglions on each side of the body.
2. Is the surgeon looking out for your best long-term interests and not just focusing on his (sometimes her) short-term benefits? Call a surgeon anonymously several times and ask him the following questions: whether he will perform ETS for only armpit sweating; whether he will perform ETS for some shyness/social phobia that you may have; whether he will perform ETS for general body sweating; whether he will perform ETS for feet sweating. If the answer to any of those questions is an affirmative, choose another surgeon. Note that some well respected surgeons treat severe social phobia with ETS after lengthy patient analysis and consultation, but no ethical surgeon would make such a decision during a five minute phone conversation. Armpit sweating can easily be treated by strong antiperspirants, Botox and more recent wave and radiation based technologies. Moreover, it is natural for armpits to sweat and if you are a male you are in luck since women apparently get turned on by sweaty male armpits. If you are a woman, I can assure you that almost no man will get turned off by your sweaty armpits.
3. Surgeon reputation amongst his peers: this involves checking up on the surgeon's qualifications, the length of time the surgeon has been performing ETS, whether he has attended any of the symposiums on thoracic sympathectomy, whether he has been trained by any of the world's most experienced and respected ETS surgeons such as Claes/Drott/Lin/Tarfusser/Telaranta, whether other surgeons have positive things to say about the surgeon you are going to see, whether the surgeon has published any articles in prestigious medical journals detailing long-term results of and experience with ETS and so on.
4. Patient testimonials: all experienced surgeons should be able to provide you with a list of former patients who you can talk to. You should get a list of at least 50 patients from a surgeon and talk to a dozen patients in this list who had ETS surgery done on them at least three years ago. Their overall experiences are invaluable, especially the changes they experienced in terms of compensatory sweating and thermoregulation over the years after surgery. Did the surgeon have them fill out satisfaction surveys at least up to two years post ETS? If not, the surgeon could be exaggerating his patient satisfaction rates since some side effects appear several years post ETS. I do not know of a single surgeon who also provides a list of negative testimonials, but you can find such patients posting on online forums and you can even find consumer websites about lawsuits against ETS surgeons.
5. Basic consultation and first impressions before surgery: are you comfortable speaking with the surgeon in your first language? This is more important than one realizes, especially since some of the most experienced surgeons are not native English speakers. Many surgeons never meet the patient till the day of the operation (something to avoid if possible, or at least make sure the surgeon sees pictures of your sweaty hands to judge how bad they are), and you do not want to have language difficulties right before surgery -- especially with current trends in surgery such as the Lin-Telaranta classification making it imperative to consult with the surgeon and make sure the right ganglions are destroyed. You might be a patient who only wants hand sweating stopped and want facial sweating to continue. In that case, the surgery is less intensive and the T-2 ganglion is untouched. However, improper communication would lead to the surgeon assuming that you want to also stop facial sweating too. Did the surgeon ask and advise you about trying alternative treatments such as iontophoresis, creams, botox and so on? Does the surgeon perform numerous other oftentimes medical or cosmetic procedures besides ETS? That would be a red flag for me, especially if the procedures are cosmetic. You want to go to a surgeon who is devoted to ETS and other thoracic procedures rather than someone who is trying to do too many things at one time.
6. Clamping versus cauterization versus cutting versus microcutting versus resection versus Lin-Telaranta classification versus... There are so many techniques of doing ETS nowadays that one needs to be expeditious in doing research about which technique seems best, especially since some surgeons are just differentiating themselves in the market by variation in terminology. Some surgeons still destroy T-2 for hand sweating, but most destroy T-3 and/or T-4 per the Lin-Telaranta classification (supposedly leading to fewer side effects since innervation to the upper body from T-2 is not cut off). It is probably safe to say that a majority of surgeons around the world clamp the ganglion, but many others still cauterize or cut the ganglion. In my opinion, the effectiveness of clamping reversal is minimal at best -- although I would still prefer clamping over cauterization or cutting just due to less surrounding scar tissue and damage. Check out ETS surgery evolution and ETS reversal myth before deciding on the best technique for you.