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Endoscopic Thoracic Sympathectomy (Micro ETS) - Ganglion-Sparing, Less Traumatic Surgery Technique.


Endoscopic Thoracic Sympathectomy
Micro ETS surgery is a treatment option for Hyperhidrosis (facial, head, hands, underarms), facial blushing, vascular disorders (Raynaud's Syndrome), causalgia (RSD), and migraine headaches.

Introduction
Hyperhidrosis is present in 0.6 to 1% of the population. The sympathetic nervous system is overactive in these people at inappropriate times (low stress conditions, sitting quietly, cool surroundings, etc) causing excess sweating of the hands, armpits, face, scalp, and sometimes feet.

 
 

Today, the treatment of choice for severe hyperhidrosis is ETS. Fortunately today, for patients afflicted with excessive sweating of the hands, face, underarms, feet, Raynaud's Disease, embarrassing blushing, or Causalgia, there are a few surgeons around the world who are experienced with this minimally invasive technique.  Many individuals can now be treated surgically with improvement of symptoms from hyperactive sympathetic nerves with minimal cost and morbidity, rather than just receiving repeated life-long treatments which are palliative at best.

Micro ETS was developed by Dr. Nielson by applying new state-of-the-art technology to invasive thoracic sympathectomy of the past which has been done for decades. Now, through a single-incision ETS, what was once considered to be extremely invasive surgery reserved only for the most severe cases (severe Raynaud's or Causalgia for example), is available to and highly curative for the many individuals today who are plagued by symptoms of over-active sympathetic nerves.

Benefits of "Micro Single Incision" ETS

micro ets incisions
 
  • ETS surgery results are curative immediately.
  • Patients leave the operating room with dry scalp, face, hands, armpits.
  • Single-Micro Incision technique (1/12th Inch Incision) “Ganglion sparing, less traumatic".
  • No sutures required. 
  • Much less postop pain.
  • High success rate.
  • FDA approved instruments/equipment.
  • Same day surgery (discharged the same day means lower cost).
  • Not an experimental procedure. Latest technology applied to decades-proven invasive (open) sympathectomy.
  • Precise visual localization and transection of the ganglia of interest.  Dr. Nielson has found over the years that by sparing the ganglia, side effects may be less likely.

Less morbidity than by other approaches such as; Through the back. Above the clavicles. A long incision with rib resection. Through 3 or 4 incisions. Rapid return to full functional status usually two to three days for school/work and one week for full physical activities. Improved occupational/professional and social interactions. Sympathetic ganglia are located along both sides of the spine. The removal or destruction of some of these ganglia has been done for decades to treat micro circulation disorders of the hands and feet and hyperhidrosis. Today, Micro ETS is the method of choice to treat severe hyperhidrosis involving the scalp, face, hands, and axillae. Also, it is effective in improving facial blushing which may cause social embarrassment.

hyperhidrosis incisions  

Technique
Micro ETS is done in an ambulatory surgical center. Both sides are done at the same time. General anesthesia is required. The lungs are NOT collapsed. Only one micro incision (1/12th inch in length) is made along the outer aspect of the pectoralis major muscle in the axilla (arm pit) in the third intercostal space. A 1/12th inch endoscope is inserted through the Micro chest incision into the thoracic cavity.Identification of the sympathetic nerve and any Kuntz nerve branches is done. One thoracic ganglion level is isolated by cutting the sympathetic nerve precisely as it crosses the second rib. The divided ends are cauterized using a low current to minimize nerve reconnections. For axillary hyperhidrosis two ganglia levels are precisely isolated by cutting the sympathetic nerve and any Kuntz nerve branches as they cross the second, third and, fourth ribs for a T2-T3 sympathectomy. The nerves and ganglia are not removed with this technique. The ganglia are left attached to the spinal cord with preservation of the interganglionic connections. This helps to lessen compensatory sweating and post-op pain.

A topical skin adhesive is used to close the tiny single incision. Upon completion of the right side, the left side is then done in similar fashion. A chest X-ray is taken and the patient discharged a few hours later with a follow-up exam in the morning. The patient then returns home.

Normal activities can resume a few days later and full physical activities in one to two weeks. Whether unilateral or bilateral sympathectomy is performed depends on the patient's and surgeon's preoperative plan. Dr. Nielson usually performs bilateral sympathectomies at the same sitting.

Watch Video - Hand Sweat Treated for Young Female Patient
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Results
After the sympathetic nerve has been cut at the second rib level in the operating room, the skin of the hands, face, and scalp becomes dry. This change occurs in the operating room. While many of our patients experience continued dryness, in some instances patients report that within 3-6 months post op there is an onset of compensatory sweating. Talk to your doctor about compensatory sweating and other complications of the procedure before participating in any surgical program so that you can determine what is best for you and your condition.

Patients report that following surgery, scalp and facial blushing subside and cardiac reactions to stress (increased heart rate) is moderated but not completely eliminated. Stage fright response is substantially reduced. Hyperhidrosis of the feet even improves in some cases, but this effect is less predictable. Continued significant reduction in sweating of the hands, face and scalp has been reported but we have seen in some patients the ability of the nerve to regenerate as early as one year and as late as ten years after sympathectomy.. Some patients report a return of slight sweating during exertion one or more years after sympathectomy and often describe it as “normal” sweating. Due to anatomical differences of nerve pathways in some patients, intact nerve fibers may remain following sympathectomy which could lead to persistent symptoms.

Immediate post operative skin dryness, improvement in blushing, warming of fingers. High success rate for:

  • Palmar hyperhidrosis
  • Scalp and facial sweating
  • Facial blushing & facial hyperpyrexia
  • Raynaud's (condition recurs over time)

Dr. Nielson’s Micro ETS technique is less invasive because the T2 ganglion is not disturbed in any way. He has found over the years that by sparing the ganglia, side effects may be less likely. ETS procedures may differ in technique and invasiveness, therefore efficacy, side effects, complications and recovery time may similary vary.

Known Side Effects
Patients should be aware that compensatory sweating can and does occur.

Compensatory sweating is experienced as excessive sweating on the back, thighs, stomach, axillae, groin and/or lower legs and may range from mild to severe. Reported incidence of developing compensatory sweating in world literature range between 50% to 90% of all patients undergoing the ETS procedure. Of this group, it has been reported that about 5% - 10% of these patients experience severe compensatory sweating. Severe compensatory sweating, or severe compensatory hyperhidrosis, can be very troublesome, especially when it soaks through clothing. This can be more problematic in hot humid climates and can become more of a problem than the original problem treated.

The tolerance of compensatory sweating is patient dependent. Some patients tolerate severe sweating while others do not tolerate even mild compensatory sweating. There are medications that may help lessen the severity of compensatory sweating post operatively.

Overweight patients may experience more compensatory sweating and those who live in hot, humid climates may find it less tolerable. Compensatory sweating is the most common side effect reported by patients regardless of which surgeon is performing Micro ETS.

Gustatory Sweating, which occurs while eating or smelling certain foods, can develop post operatively in about 10 to 20% of the patients.

Phantom sweating occurs in some patients after ETS surgery (feeling the sensations of sweating but not actually sweating) and typically resolves in 1 to 3 weeks after surgery.

 

Contraindications

  • Prior thoracotomy - relative contraindication.
  • Severe cardio-circulatory or pulmonary insufficiency.
  • Severe pleural diseases (empyema, pleuritis).
  • Untreated hyperthyroidism.

Please contact us for more information on hyperhidrosis by calling 1-877-837-9379 toll free or submit a questionnaire.


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