E = Endoscopic, T = Thoracic, S= Sympathectomy
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Surgical Treatments

Those with the severe form of Hyperhidrosis of the underarms. Patients with this condition cannot wear certain types of fabrics (nylon or silks) or colors. Clothes become stained, fabrics are ruined and colors may run. The sweating and odor is constant and resistant to all deodorants.

What is ETS?

E = Endoscopic, means looking inside though a small scope with a camera attached
T = Thoracic, means chest cavity
S= Sympathectomy means interrupting a small nerve trunk that controls the underarm sweating. It does not affect touching or muscle function. One is not left paralyzed or numb after the procedure.

incision.gifHow is the procedure performed? The patient is sent to the operating room and undergoes general anesthesia. The patient is placed on his/her back with the arms extended. After the patient is asleep, a long-acting local anesthetic is injected into an area in the underarm and a small incision (3mm) is made in the left armpit. The lung is then gently pushed down and a small endoscope (a long narrow tube with a light source and lens) is inserted into the left chest. The scope is inserted between the ribs and the chest space is seen on a video monitor (TV screen). Another incision is made just under the underarm skin fold called the anterior axillary line and another 5mm instrument is inserted.

The next step is to accurately identify the anatomy and find the first, second, third, and fourth ribs. The sympathetic nerve trunks are then found in front of the ribs along the chest wall. Dr. Garza then performs a selective sympathectomy of specific nerve trunks. The left side takes about 5 minutes.

After the left side is completed, the same procedure is repeated on the right side. No stitches are required and the wound edges are brought together with small tapes called Steri® Strips. All together, the procedure takes about 15 minutes. The patient is sent to the recovery room where a chest x-ray is taken. Most then leave the hospital 1 hour after the operation.

The sympathetic nervous system controls sweating and does not affect touching or muscle function, thus it does not lead to numbness or paralysis.

Post Surgery

After one hour, the patient may elect to leave or to stay in the hospital. Most are ready to leave the hospital on the day of the procedure. Those who are accompanied by a friend or a family member may elect to leave the hospital after the operation. Patients who arrive alone are required to stay overnight in the hospital and may leave for the airport early in the morning.

On the day following surgery, the Band-Aids® may be removed and the patient may take a shower. Since there are no stitches to be removed, Steri® Strips (small tapes) may be removed on the fifth day. Patients are encouraged to resume full activity, which means driving a car and as much normal activity as possible. Refrain from heavy lifting for one week.

Return to work is up to each individual patient, but those that undergo the procedure on a Friday usually return to work on the following Monday.

It has been Dr. Garza's observations that women tolerate chest wall discomfort better than men do.

Is an ETS a permanent or temporary cure of the condition?

In the majority of cases, the cure is permanent. It is uncommon but possible for the nerve to grow back (regeneration).

Are blood transfusions necessary?

None of Dr. Garza's patients has required blood transfusions.

What are the side effects of a sympathectomy?

As with any surgical procedure, there are certain associated risks. However, when performed by a skilled endoscopic and experienced chest surgeon, the risks of ETS are low, and complications are rare.

Compensatory Hyperhidrosis

Compensatory Sweating (CS) is the most common side effect of ETS. This is reported to occur in all patients who undergo sympathectomy for Hyperhidrosis. Compensatory Sweating may be mild or severe. The mild form is the most common. It occurs regardless of whether the procedure is an open, Endoscopic, clamping, cutting, Micro ETS, or by Electrocautery procedure. The severity of the condition is dependent upon where the surgeon interrupts the sympathetic nerve trunk.

Compensatory Hyperhidrosis is a condition where the sweating is shifted from the hands, armpits, face and scalp to the upper and lower back, lower chest, abdomen, buttocks, groin and the backs of the thighs. The brain does this is order to get of rid excess body heat. It has recently been discovered that the 2nd or 3rd nerve trunks are responsible for the most severe forms of CS. The reason for this is because the 2nd and 3rd nerve trunks are also responsible for eliminating sweating and heat loss from the neck to the top of the head. If the 2nd or 3rd nerve trunks are cut, clamped or undergo Micro ETS, the heat loss of the head is diminished. The head alone is responsible for the elimination of 44% of all body heat. This excess body heat has to be released elsewhere, and the brain will then send the heat loss signals to the trunk, groin, buttocks and legs. This is called Compensatory Sweating.

Compensatory Sweating comes in two forms:

Mild CS: causes dampness on the trunk or the back of the legs. The sweat does not show through clothing.
Severe CS: is sweating that is profuse and leads to dripping with sweat on the trunk, groin or back of the legs.

The symptoms of CS may occur intermittently or even be constant throughout the day. What matters is the severity of the syndrome. Mild CS creates moisture on the trunk, buttocks, groin or legs but does not show through their clothes. Most people tolerate it and welcome the trade off as long as the underarms are no longer dripping with sweat. Most express the feeling, "I can tolerate it as long as my underarms don't sweat."

Severe CS causes profuse sweating between the breasts, below the breasts to the lower chest, abdomen, upper and lower back, groin, buttocks, the backs of the thighs and knees. Patients may feel cold or hot and just plain uncomfortable. It can occur after a T2, T3 or T2+T3 sympathectomy, but is rare after the updated sympathectomy. Those who develop severe CS may feel that this side effect is worse than their previous symptoms and express regret regarding their sympathectomy. Severe CS occurs in 10% of all people that under go a T2, T3 or T2+T3 sympathectomy but is rare after the updated sympathectomy. It is recommended that the T2 and T3 nerves be clamped and not cut. While removal of the clamps will not always reverse the operation, this has the highest possibility of reversal.

Who will develop Severe CS?

Of those who undergo a T2 or T2-T3 sympathectomy, 90% will develop the mild form and 10% will develop the severe form of CS. Severe CS has not been observed to occur after the updated technique.

What effect will the updated sympathectomy for Underarm Sweating have upon Compensatory Sweating?

The updated sympathectomy stops Hyperhidrosis of the underarms, but permits the face and scalp to sweat when in hot conditions; because of this, patients will develop the mild form of Compensatory Sweating, but it is rare to develop the severe form of CS. This is the procedure of choice for those with Hyperhidrosis of the underarms. A T2 or T2+T3 sympathectomy should be avoided in those with Hyperhidrosis of the underarms. Only the updated sympathectomy is recommended by Dr. Garza.

Why would one do a T2 or T2+T3 sympathectomy?

The only procedure that can cure severe Hyperhidrosis with Facial Sweating is a T2 sympathectomy, and the only procedure that can cure Facial Blushing is a T2+T3 sympathectomy. A T2, T3, T2+T3 or T4 sympathectomy is not recommended for hand or underarm sweating; the recurrence rate is too high following these techniques.

Can medications reduce the level of Compensatory Sweating?

There are some medications that may be helpful for some patients with severe Compensatory Sweating. The most useful medications for compensatory Hyperhidrosis are Robinul Forte® and Ditropan®.

Robinul Forte® is the first line of medical treatment of this condition. It causes generalized body dryness; because of this, it should be used only when necessary and should be avoided during heavy physical exercise. Side effects can include dryness of the mouth (cottonmouth), headaches or constipation. The most effective procedure is to take medication 3 hours prior to meals. This is prescription medication and can be given to you by one's personal physician.

Ditropan®, when used in low doses, has recently been found to be very effective in the treatment of severe CS.

Dr. Garza recently updated the procedure so that it is tailored specifically for the underarms. The outcome is more effective and has been found to have markedly reduced or eliminated the side-effect of severe Compensatory Sweating. He is the first surgeon in the USA to update the procedure for underarm sweating.

More information on Excessive Sweating
More information on Hyperhidrosis


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