What Is Endoscopic Thoracic Sympathectomy (ETS) Surgery?

Endoscopic Thoracic Sympathectomy (ETS) is a minimally invasive surgical procedure developed to address conditions caused by an overactive sympathetic nervous system. The technique involves a surgeon accessing the thoracic cavity to target and interrupt specific nerve signals that control various involuntary bodily functions. ETS aims to permanently modify the signals that travel from the spinal column to peripheral areas of the body. The procedure is generally reserved for patients whose conditions have not responded adequately to other, less invasive medical treatments.

Medical Conditions Treated by Sympathectomy

The primary indication for Endoscopic Thoracic Sympathectomy is primary hyperhidrosis, a condition characterized by excessive, abnormal sweating not related to heat or exercise. This procedure is most frequently used to treat palmar hyperhidrosis (excessive sweating of the hands) and axillary hyperhidrosis (affecting the armpits). ETS is considered a last resort when patients have failed to achieve satisfactory relief from conservative therapies, such as prescription antiperspirants, oral medications, or botulinum toxin injections.

The nature of palmar sweating, which can interfere with daily life, education, and occupation, often makes patients candidates for this irreversible surgery. While focused on hyperhidrosis, ETS is also sometimes applied for secondary purposes, including the treatment of facial blushing or certain vascular disorders. Raynaud’s phenomenon, a condition causing blood vessels to narrow in response to cold or stress, is an example of a vascular issue that may benefit from sympathetic nerve interruption.

The Steps of Endoscopic Thoracic Sympathectomy

The ETS procedure is performed under general anesthesia. The surgical technique is keyhole surgery, requiring the surgeon to make one or two small incisions, typically less than one centimeter, usually in the armpit area. Through these openings, a thoracoscope—a tube containing a camera and light source—is inserted into the chest cavity.

The camera allows the surgeon to visualize the sympathetic nerve chain, which runs vertically along the side of the spine. To create working space, the lung on the side of the incision is temporarily collapsed. The surgeon then locates the specific thoracic ganglion levels (often T2 to T4) that correlate to the area causing the excessive sweating.

Once the targeted nerve segment is identified, specialized instruments interrupt the signal. This interruption is achieved by cutting the nerve (sympathectomy), using electrocautery to destroy the tissue, or by placing small titanium clips on the nerve chain (sympathotomy). After the procedure is complete on one side, the lung is reinflated, instruments are removed, and the incisions are closed with sutures, followed by the same process on the opposite side.

Understanding Compensatory Hyperhidrosis and Other Risks

The most common post-operative effect of ETS is Compensatory Hyperhidrosis (CH), which is the development of excessive sweating in new areas of the body that were previously dry. CH occurs because the body’s thermoregulatory system, unable to use the treated areas for heat dissipation, attempts to compensate by increasing sweat production elsewhere. This new sweating typically affects the trunk (such as the back, chest, abdomen, or groin) and is often triggered by physical exertion or warm temperatures.

Compensatory Hyperhidrosis is considered a physiological consequence of the nerve interruption, not a typical surgical complication like infection or bleeding. While nearly all patients experience some degree of CH, its severity varies widely; studies show it can be debilitating for up to 40% of patients. For some, this new sweating can be more bothersome than the original condition, leading to long-term dissatisfaction.

In addition to CH, there are other, less common surgical risks. Horner’s syndrome, involving a drooping eyelid, constricted pupil, and decreased facial sweating, is a potential risk if the interruption affects the stellate ganglion, a nerve cluster located higher in the thoracic cavity. Other general risks include pneumothorax (a collapsed lung), which is usually managed during or immediately after the operation, and the possibility of infection or bleeding at the incision sites.

Recovery and Monitoring Long-Term Results

Following ETS, most patients experience a relatively rapid recovery due to the minimally invasive nature of the procedure. Many are discharged from the hospital on the same day or after a single overnight stay. Patients may experience localized pain or discomfort in the chest wall for the first week or two, manageable with pain medication. The immediate effect is usually noticeable, with treated areas like the hands becoming dry almost instantly.

Most individuals can return to work and resume daily activities within one to two weeks. Long-term monitoring focuses on the stability of the initial result and the patient’s adaptation to Compensatory Hyperhidrosis (CH). While relief from palmar hyperhidrosis is often durable, satisfaction rates can decline over time, primarily due to the ongoing presence of CH. Follow-up care assesses the stability of results and manages persistent effects, such as new sweating in the torso or back.