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ETS Surgery
The most invasive treatment for hyperhidrosis is the surgical
interruption of the thoracic sympathetic chain, a procedure
done with the goal of permanently stopping sweating in the area
innervated by the involved ganglia. Sympathectomy has been
shown to be very effective for palmar sweating, but is less
effective for axillary symptoms.[9]
Although now done as a minimally invasive technique using
video-assisted endoscopy, the procedure is still associated
with complications that lead most clinicians to reserve this
procedure for patients with severe symptoms who have failed
to improve with more-conservative treatment.[95,145]
History of thoracic sympathectomy
Focal hyperhidrosis was first treated by sympathectomy in
the 1920s and 1930s in several European countries,[2,72]
and over the next 50 years different surgical approaches were
advocated. These included the supraclavicular, the posterior,
the axillary transpleural, and the anterior approaches. Although
high rates of palmar anhidrosis were obtainable, there were
with each of these procedures some common complications, such
as Horner’s syndrome (ptosis, miosis, and facial anhidrosis)
and hemothorax, and specific complications, such as brachial
plexus injury and poor cosmetic outcome.[72]
Open surgery became obsolete as endoscopy was perfected.
Thoracoscopes were used as early as the 1940s and 1950s to perform
sympathectomy, and were popularized by Kux, said to be the
father of endoscopic sympathectomy. With the advent of video-assisted
endoscopy, the procedure has become increasingly popular over
the last decade.[72]
Back to top
Anatomy of the sympathetic chain
Preganglionic fibers from the spinal cord synapse in sympathetic
ganglia at the segment from which they arise travel up
or down the sympathetic chain to synapses in other ganglia.
Postganglionic fibers join peripheral nerves to innervate
the sweat glands.[106,118]
The sympathetic outflow to the arm originates from the T2
to T6 ganglia, and for some patients T1 fibers (from the stellate
ganglion, a fusion of T1 and C8) also innervate the arms.
Fibers to the face come primarily from the stellate ganglia
(C8 and T1), with some contribution from T2 and T3. Resection
of the stellate ganglion is more likely to cause Horner’s
syndrome than resection of T2 and T3 ganglia.[118]
In addition, there is an anatomical variation—the nerve of
Kuntz—seen in 10% of patients. It arises from the T2 and T3
spinal segments and bypasses the cervical chain to join the
brachial plexus.[106] The feet are innervated by L2 to L4.[106]
To affect palmar sweating, T2 and sometimes T3 ganglia must
be ablated,[106]
and for axillary sweating, at least T3 and sometimes T4 and T5(Ahn,
et al., personal communication, July 2003). For plantar sweating,
the L2 to L4 ganglia should be ablated, but, because sexual
side effects can occur with ablation at this level, sympathectomy
for plantar symptoms is rarely done.[9,106]
For facial hyperhidrosis, ablation of T2 and T3 can decrease
sweating, as can sympathectomy of the lower third of the stellate
ganglion.[26,89]
Surgical technique
The aim of surgery is to interrupt the transmission of nerve
signals from sympathetic ganglia that send fibers to the area
involved in excessive sweating. This can be done by destroying
the ganglia (sympathectomy) or by dividing the sympathetic
trunk, including the postganglionic fibers (sympathotomy or
sympathicotomy).[10,15,72]
Destruction can be done with local excision of the ganglia
or by ablation using electrocautery or laser.[72]
Sympathicotomy also can be carried out with electrocautery or laser; less frequently clipping is used.[72,151]
If present, the nerve of Kuntz also needs to be severed, excised,
or coagulated.[55,72]
When performing the procedure for palmar hyperhidrosis, many
surgeons assess the adequacy of sympathetic denervation by
measuring temperature with a fingertip temperature probe,
observing an increase in temperature after successful sympathectomy.[94,127]
Another approach is to assess microcirculation with a laser
Doppler perfusion unit, expecting an increase after the correct
ganglia are no longer functioning.[150]
Many centers perform same-day outpatient surgery, while others
keep patients overnight and discharge them the day after.[35,72,150]
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