Surgical Treatments for Primary Focal Hyperhidrosis

Endoscopic thoracic sympathectomy is a surgical procedure used to manage and reduce excessive sweating caused by hyperhidrosis. It is a treatment modality that is only used once more conservative measures have been deemed unsuccessful. This is because it is more invasive and potentially risky than the other treatments available for hyperhidrosis. It has, however, been shown to have a promising success rate with over 95% of patients reporting significant relief from their symptoms.[1] There is another type of surgery called endoscopic lumbar sympathectomy which is used as a treatment for sweaty feet, however it has been shown to cause potentially severe complications and many doctors consider it to dangerous to perform.
Surgical Treatments for Primary Focal Hyperhidrosis

Who Does This Surgery Work For?

There are two types of hyperhidrosis and endoscopic thoracic sympathectomy is indicated for those who have primary focal hyperhidrosis. In other words, people who have hyperhidrosis that is not caused by another underlying condition. This type of surgery has been found to be most effective as a treatment for sweaty hands (palmar hyperhidrosis) but can also help with axillary hyperhidrosis and craniofacial hyperhidrosis. The ideal candidate for this type of surgery had an early onset of their disease, usually during adolescence, and is a young adult without other complicating health issues. Most doctors prefer to perform it on patients who are under the age of 25 and who have a body mass index within the normal or slightly overweight range.[1]

How Does This Surgery Work?

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 body from producing extra sweat because the communication network from the brain to the body has been permanently disrupted. Due to the fact that nerves are being destroyed in this surgery it cannot be reversed.[2]

To disconnect the nerves surgeons either use endoscopic resection, ablation or clipping of the nerves. The surgeon chooses which nerves to deaden depending on where the hyperhidrosis is impacting the patient most.

For example, a cut will be made higher up under the 3rd rib to treat palmar hyperhidrosis, or sweaty hands, while a lower cut under the 4th or 5th rib would be made to treat axillary hyperhidrosis. This procedure is always done under general anesthesia but most patients can go home the same day the surgery is performed.[1]

The reason a surgical procedure that disrupts nerve signals can stop excessive sweating is because hyperhidrosis is caused by an overactive sympathetic nervous system. The sympathetic nervous system is connected to sweat glands, and when the nervous system is overactive it signals sweat glands to become overactive as well. By severing that connection, surgeons prevent sweat glands from being activated and this prevents them from producing too much sweat.

Complications and Considerations of Surgery

This type of surgery is generally reserved as a last resort for people who are severely impacted by hyperhidrosis and who have not responded to over-the-counter treatments or other treatments doctors use to manage hyperhidrosis. Once done, the results are permanent. Certain complications can occur such as:

  • Development of Horner’s syndrome (nerve issues that can impact pupil size, eye drooping etc…)
  • Pneumothorax (collapsed lung)
  • Paresthesia (abnormal sensation due to damaged nerves)
  • Compensatory sweating (excessive sweating in other untreated areas of the body that were not previously impacted)
  • Hyperthermia (having a higher body temperature than normal)
  • Bradycardia (abnormally low heart rate)

Some of the possible complications listed above have a fairly high incidence of occurring, so care must be taken when making the decision to have this type of surgery.[1]

Compensatory Sweating

Compensatory sweating is considered to be one of the most likely complications of ETS and it has also been reported to be one of the most dissatisfying. The occurrence rate is anywhere from 3% to 98% of patients. Compensatory sweating is when the body overcompensates by producing too much sweat in another area of the body once the original problem area has been corrected by ETS surgery. So, for example, if palmar sweating was completely corrected by surgery a patient who suffers from compensatory sweating may then have an overabundance of sweat production on their abdomen. This can greatly affect quality of life for some, and it has the potential to make the anxiety associated with hyperhidrosis worse.

If it is going to show up, compensatory sweating usually occurs on the stomach, back, legs, groin, upper legs or gluteal area[1]. Excessive sweating of the groin and other areas can be very irritating for some. Even though many patients suffer from this complication most are still satisfied with the results of the procedure. It is an important factor for each individual to consider before undergoing such a dramatic treatment.[1] There are other options for treatment when managing hyperhidrosis with a doctor.

Long Term Outlook

The long term satisfaction associated with endoscopic thoracic sympathectomy is varied, but predominantly positive. One concurrent finding across several studies was that patients who underwent surgery as a treatment for sweaty hands were much more satisfied than those who were treated for axillary or other types of hyperhidrosis. [3]

Although patients are at a high risk of developing certain complications, such as compensatory sweating or Horner’s syndrome, ETS is still considered to be a highly effective treatment for hyperhidrosis. In many cases the benefits appear to outweigh the risks. Most patients who undergo endoscopic thoracic sympathectomy suffer from severe hyperhidrosis that greatly impacts their quality of life, and so the benefits of the surgery appear to be worth the risks.[1,3]

The decision to get endoscopic thoracic sympathectomy should not be made lightly, but it is an effective treatment for those who have tried other methods and who have not seen improvement. Some of the other treatment options that can be tried prior to surgery inlcude:

  • Topical and/or oral medications for hyperhidrosis
  • Iontophoresis for palmar hyperhidrosis
  • Botox for palmar and plantar hyperhidrosis
  • Botox for axillary hyperhidrosis
  • Local permanent treatment options for axillary hyperhidrosis
  • In many cases it can be the difference between dealing with the crippling side effects of an incurable illness or having the ability to gain control and move past it. In the end, each patient has to work with their doctor to decide what is right for their specific circumstances and create a plan that will work best for them.

    Sources
    1. Pariser, D. M. (2014). Hyperhidrosis (4th ed., Vol. 32). Amsterdam: Elsevier Pub. Co., 2014. Retrieved
    2. Endoscopic thoracic sympathectomy (ETS). (n.d.). Retrieved July 24, 2018, from https://www.sweathelp.org/hyperhidrosis-treatments/ets-surgery.html
    3. Herbst, F., MD, Plas, E. G., MD, Fugger, R., MD, & Fritsch, A., MD. (1994). Endoscopic Thoracic Sympathectomy for Primary Hyperhidrosis of the Upper Limbs. Annals of Surgery, 220(1), 86-90. Retrieved July 24, 2018, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1234291/pdf/annsurg00053-0102.pdf.
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