Endoscopic thoracic sympathectomy is a surgical procedure in which a portion of the sympathetic nerve trunk in the thoracic region is destroyed. ETS is used to treat excessive sweating in certain parts of the body, facial blushing, Raynaud's disease, and reflex sympathetic dystrophy. Sympathectomy and its variations have been performed in thoracic surgery for more than 100 years. However, its indications have undergone profound modifications in this period. Likewise, since then the surgical technique has also evolved dramatically up to the minimally invasive techniques worldwide accessible in present days. Currently, primary hyperhidrosis is, by far, the main indication for thoracic sympathectomy, and this procedure is usually carried out thoracoscopically with excellent results. However, until today, hyperhidrosis is a part of thoracic surgery still surrounded by controversy, persisting as an open field over which some confusion still resides regarding its pathophysiology, terms definitions, and operative approaches. The aim of this article is to provide a wide but easily comprehensible review of the theme, discussing and clarifying the major concepts with respect to its clinical presentation, all the presently available treatment options and strategies with their potential benefits and risks, the adequate patient selection for sympathectomy, as well as the postoperative clinical results.

In primary hyperhidrosis, the excessive sweat is usually localized and can be described mostly as palmar (hands), axillar (armpits), and/or plantar (feet). Craniofacial hyperhidrosis can also occur, alone or with facial blushing. Patients with primary hyperhidrosis classically present with sweating complaints dating from the first decade of life (remarkably in hands) and during adolescence the symptoms normally become more relevant, leading to a negative impact on the quality of life (QoL). Physical, psychological, and emotional stresses tend to worsen the symptoms, which are not related to the ambient temperature and are clearly disproportional to it. Another important aspect of primary hyperhidrosis is that sweating episodes occur only when the patient is awake.

Hyperhidrosis, or excessive sweating, can significantly impact a person’s quality of life, affecting their confidence, social interactions, and daily activities. While conservative treatments such as antiperspirants, oral medications, and Botox injections can help manage symptoms, some individuals may require a more definitive solution. Endoscopic Thoracic Sympathectomy (ETS) is a minimally invasive surgical procedure that offers long-term relief for those with severe cases of hyperhidrosis.
 
What is Endoscopic Thoracic Sympathectomy (ETS)?
ETS is a surgical procedure that interrupts the sympathetic nerve signals responsible for excessive sweating. The procedure specifically targets the sympathetic chain, which runs along the spine in the thoracic (chest) region. By selectively cutting or clamping portions of this nerve pathway, ETS effectively reduces excessive sweating in the affected areas, particularly the hands, face, and underarms.
 
Who is a Candidate for ETS?
ETS is typically recommended for individuals with severe primary hyperhidrosis that has not responded to non-surgical treatments. The most common candidates include those experiencing:
- Palmar hyperhidrosis (excessive sweating of the hands)
- Facial hyperhidrosis and blushing
- Severe axillary hyperhidrosis (underarm sweating) when other treatments fail
 
The ETS Procedure
1. Anesthesia: The procedure is performed under general anesthesia to ensure patient comfort.
2. Incision and Access: Small incisions are made in the chest to allow the insertion of a tiny camera (endoscope) and surgical instruments.
3. Sympathetic Nerve Interruption: The surgeon identifies and either cuts, clamps, or removes the targeted portion of the sympathetic nerve.
4. Closure and Recovery: The incisions are closed with sutures or adhesive strips, and the patient is monitored before being discharged, often on the same day.
 
Benefits of ETS
- Effective and Long-Lasting: Most patients experience a significant and permanent reduction in excessive sweating.
- Minimally Invasive: Small incisions mean reduced scarring, less pain, and quicker recovery.
- Improved Quality of Life: Patients report enhanced confidence and comfort in social and professional settings.
 
Risks and Considerations
While ETS is generally safe, it is important to be aware of potential risks and side effects, including:
- Compensatory Sweating: Increased sweating in other areas, such as the back or legs, is a common side effect.
- Horner’s Syndrome: If the sympathetic chain near the head is affected, it may cause drooping of the eyelid and pupil constriction.
- Dry Hands: Some patients experience overly dry hands post-surgery.
- Irreversibility: The effects of ETS are typically permanent, making it essential to consider all options before proceeding.
 
Recovery and Postoperative Care
Most patients recover quickly, resuming normal activities within a few days. Pain is generally mild and can be managed with over-the-counter medications. Follow-up appointments ensure proper healing and assess the effectiveness of the procedure.
 
Conclusion
Endoscopic Thoracic Sympathectomy (ETS) is a highly effective treatment for severe hyperhidrosis, particularly for individuals who have not found relief through non-surgical methods. While it offers significant benefits, potential risks should be carefully weighed before deciding on the procedure. Consulting with a qualified surgeon can help determine if ETS is the right option for managing hyperhidrosis.

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