Endoscopic thoracic sympathectomy (ETS) is a type of surgery used to treat primary focal hyperhidrosis. While hyperhidrosis itself is not dangerous, the effects of the condition can be so devastating that some people consider surgery. During an endoscopic thoracic sympathectomy a surgeon makes a small incision between a patient’s ribs and then uses a tiny camera to search for the nerves that control sweat production in the upper extremities.They then attempt to sever or destroy these nerves so that the nervous system can no longer use the neural pathways associated with creating extra sweat. This prevents the patient from sweating in specific, undesirable areas, depending on where the nerves were disabled. Usually, these areas include the palms and sometimes the axillary region. The surgery is usually very effective in alleviating sweat in these areas, however, it comes with a heavy price. There is also a type of surgical procedure called endoscopic lumbar sympathectomy that can also lead to compensatory sweating, but most doctors don't recommend getting it because of the serious adverse effects it can cause.
Between 3% and 98% of patients who have undergone ETS develop compensatory sweating. It is the most likely side effect associated with the surgery and, in some cases, its effects are so bad patients assert that it is worse than the original condition. For those with severe compensatory sweating, it can cause as much anxiety as the hyperhidrosis problem they originally had. Compensatory sweating occurs because the body is attempting to make up for the lost sweat production in the treated areas. It redirects sweating to other, broader parts of the body. These parts of the body often include the abdomen, chest, back, legs and gluteal area. In some cases excessive sweating of the groin occurs. Sweating from this side effect is more generalized and can be debilitating, depending on its severity. Besides finding ways to manage their sweat, there are medical interventions that can help those who develop compensatory sweating.
Who is At Risk of Developing Compensatory Sweating
Anyone who undergoes ETS surgery is at risk of developing compensatory sweating. However, there are some factors that make some people more prone to developing it than others. It has been shown that children undergoing a transaction not involving T2 have the lowest rates of compensatory sweating. That is why it is actually a recommended medical treatment for children with hyperhidorsis. Adults who already have a propensity to sweat in inguinal folds, buttocks, back or upper thighs are considered to be at the highest risk of developing the condition. One study showed that the higher a patient’s bmi (body mass index) the more likely they were to develop compensatory sweating. This same study also suggests that the higher the resection is performed on the sympathetic chain the more afferent fibers would be harmed and that this would increase the intensity and occurrence of compensatory sweating. Other factors like age, sex, family history and the co-occurrence of plantar hyperhidrosis are also thought to increase the likelihood of an individual developing compensatory sweating.
Compensatory Sweating Solutions
Due to the fact that compensatory sweating can be so devastating there have been multiple attempts to correct this unfortunate side effect. It has been associated with a decrease in quality of life and it is important for patients to find ways to manage their sweat and eliminate it, if possible. One easy way to manage compensatory sweating is to use antiperspirant, there are antiperspirants that can be used on the groin, and other sensitive areas that may be affected by compensatory sweating.
One way doctors have attempted to treat compensatory sweating is through the use of oral medications used to treat hyperhidrosis. The most common types of medications used are called anticholinergics. These drugs act by blocking the neurotransmitter acetylcholine in both the central and peripheral nervous systems. This is the neurotransmitter responsible communicating with sweat glands, so taking the medication reduces sweating. These drugs have a systemic effect which is desirable when treating a condition that affects multiple areas of the body like compensatory sweating does. They do have side effects, like dry mouth, among others. The most commonly prescribed anticholinergics are glycopyrrolate and oxybutynin. One study found that combining the use of oral oxybutynin while treating the affected area with Botox greatly relieved suffering.
One ways doctors seek to improve patient’s symptoms is through the use of Botox injections. Botox is used for axillary hyperhidrosis, and in many cases, botox is used for the treatment of palmar and plantar hyperhidrosis. Botox can be helpful for those suffering from compensatory sweating, especially when combined with medication. Between 60% and 90% of patients who undergo ETS for axillary hyperhidrosis will develop compensatory sweating. In these cases, Botox is especially useful. Before beginning a procedure the doctor will have a patient identify the problem areas affected by compensatory sweating. Then, the doctor will perform a starch-iodine test, a painless test that shows areas of sweat, to confirm where the problem areas are located. After an anesthetic is given and injection sites are mapped out, Botox injections will be delivered throughout the problem areas. Unfortunately, due to the large surface area that is typically affected by compensatory sweating, Botox alone is usually not enough. However, in combination with oral medication, Botox can provide much needed relief from compensatory sweating and can an important part of a patient’s treatment plan.
Some surgeons who perform ETS surgery use clips to prevent nerves from communicating, rather than destroying the pathways. They do this with the intent that if a patient does experience severe compensatory sweating, they will be able to remove the clips and reverse the surgery. In these surgeries doctors often attempt to regraft the nerve as well. In one study of patients who had clips removed due to compensatory sweating, 48% reported a large reduction in their sweating while 42% reported that their compensatory sweating remained the same. This is due to the fact that nerves may still be damaged even when clips are used. Another study done on patients who opted for a reversal of their ETS surgery found that those who had reversal procedures done were less satisfied than patients who received iontophoresis therapy for their compensatory sweating. Treatment with iontophoresis is for palmar and plantar hyperhidrosis in most situations. It is usually not an option for those with compensatory sweating due to the fact that large areas of the body are required to be submerged in water, but it is an interesting idea for the future. Overall, surgical reversal can be quite helpful for some but does not offer a consistent benefit to all patients. The outcome is prone to chance, depending on whether or not a patient’s nerve was damaged irreversibly or not.
Prevention is Key and Management is Possible
Up to 94% of patients who undergo ETS surgery say that it improved their quality of life, regardless of compensatory sweating. However, for the other 6%, compensatory sweating is the most likely reason they regretted having the procedure done. It is extremely important that patients know the risks of ETS and other similar surgical procedures so they can make an informed decision about the risks. There is a very high chance that those undergoing surgery will develop some level of compensatory sweating. If a patient has certain risk factors for developing severe compensatory sweating they need to be made aware before a procedure is performed. For those that have irreversible compensatory sweating, hyperhidrosis can be managed with a doctor and satisfactory results can be achieved.
- Karlsson-groth, A., Rystedt, A., & Swartling, C. (2015). Treatment of compensatory hyperhidrosis after sympathectomy with botulinum toxin and anticholinergics. Clinical Autonomic Research, 25(3), 161-167. doi:10.1007/s10286-015-0278-x
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