When all else fails: Treating hyperhidrosis with endoscopic thoracic sympathectomy

Key takeaways:

• Endoscopic thoracic sympathectomy (ETs) is often avoided by dermatologists due to its risks.
• In these interviews, a patient recounts his journey with ETS and a surgeon discusses the merits of this surgery.

It was just another day at school when sophomore Cole Villaflor and his classmates were asked to write on-demand essays in class. As he approached this seemingly easy assignment, his hands began to sweat, dampening the page. Trying to ignore it,Villaflor continued to write but his perspiration caused the ink to smear and the page to tear. After struggling through his essay, Cole, embarrassed and defeated, handed his paper to the teacher explaining the reason for its battered presentation: hyperhidrosis.

Cole’s treatment journey

During elementary school, Villafor was diagnosed with palmar and plantar hyperhidrosis, and decided to seek help for his condition due to the large, negative impact that hyperhidrosis had on his life.

“It made it uncomfortable to go to school and shake hands with others because my palms were dripping with sweat,” Villafor told Healio. “It was difficult to do schoolwork as my hands would dampen the page and tear through it and ... it made gripping a basketball difficult, as it became slippery. This made me fearful of social interactions and made me anxious to participate in activities I loved.”

Although he tried many treatments to block or lessen the sweating of his hands including prescribed and over-the-counter antiperspirants such as Drysol (aluminum chloride hexahydrate, Person & Covey), glycopyrrolate pills, Qbrexza wipes (glycopyrronium, Journey Medical) and Carpe lotion (aluminum sesquichlorohydrate, Carpe), nothing worked.

“The products I tried either showed no results or only minimally lessened the volume of sweat and some made my hands swell more,” Villafor said. “My parents also spent money to do a panel of bloodwork to rule any other issues out.”

Eventually Cole turned to Botox, receiving 30 to 40 injections in each palm every 4 to 6 months.

“These painful injections showed little results and didn’t provide the relief I was looking for,” Villafor explained after enduring 4 years of failed treatments. “So, after trying just about every solution I could find, I set my sights to surgery.”

Endoscopic thoracic sympathectomy surgery process

Endoscopic thoracic sympathectomy (ETS) is a procedure that is performed to correct hyperhidrosis by interrupting the transmission of nerve signals from the spinal column to the sweat glands.

Michael Levy, MD, PhD, chief of pediatric neurosurgery at Rady Children’s Hospital-San Diego and professor at UC San Diego School of Medicine, along with Timothy Fairbanks, MD, pediatric surgeon at Rady Children’s Hospital, were the surgeons who performed Villafor’s procedure to correct his hyperhidrosis.

In an exclusive interview with Healio, Levy explained every detail of how the procedure works.

First, the patient is brought into the operating room and the anesthesiologist uses a special tube to intubate the patient. This tube goes into each side of the lung in order to deflate one side of the lung at each time.

“This must be done because the sympathetic chain travels perpendicular to the ribs and cannot be accessed otherwise,” Levy explained.

Next, three small incisions are made in the mid axillary line which allow the surgeons to safely place the endoscope, visualize and retract the lung as it is deflated and expose the sympathetic chain, which is located over the ribs at the third and fourth thoracic levels.

After initially identifying the first and second thoracic vertebrae, the surgeons mobilize the nerve in between to ensure that none of the attachments are remaining. Smaller nerve fibers may connect the chain at different levels. If these fibers are not separated, the procedure will not be successful.

“Any attachments can lead to further sweating,” Levy explained. “We operate a little lower than most surgeons. Some will operate as high as the second cervical level, but that’s riskier. Operating at the third and fourth vertebrae means that we aren’t taking any chances with regard to creating a Horner’s syndrome as a complication.”

After this is complete, the lung is reinflated, the endoscope is withdrawn to make sure the lung has expanded, and extra air is removed. This process is then repeated on the other side.

Safety concerns

While many dermatologists do not recommend this procedure due to the safety concerns surrounding the deflation and reinflation of the lungs, Levy recommends it to patients with hyperhidrosis because “it is a minimally invasive endoscopic outpatient surgery.”

According to Levy, the process of partially deflating the lung to move it off the sympathetic chain takes 7 to 10 minutes, after which the lung is reinflated. Many safety precautions are taken to ensure that no complications arise, Levy said, including a chest X-ray after surgery to confirm that the lungs are completely reinflated. Additionally, complications related to the lungs are minimal given the usual lack of pulmonary problems in children and adolescents.

The surgery is normally completed in 1 day, and less than 5% of patients require an overnight stay due to possible complications, including infection, which can be treated with oral antibiotics, or a lack of lung reinflation.

“Fortunately, most of the children and adolescents we operate on have no medical problems, so the lungs refill easily,” he said. “We haven’t had any infections or failures so far and no other complications.”

These safety findings are supported by other studies. In a retrospective study by Huang et al published in Frontiers in Surgery in 2023, of 109 patients that underwent ETS, 13 developed a slight pneumothorax resulting in less than a 30% unilateral pulmonary compression. During reexamination 1 month later, gas absorption was observed with chest radiographs despite no special treatment being pursued. In fact, no serious complication occurred in any of the patients.

Dermatologists may also be concerned with the risk for excessive compensatory sweating — a form of rebound sweating that occurs on other parts of the body that were not previously affected — that may follow ETS.

In a 2022 study published in Surgical Endoscopy, Woo et al conducted a survey-based study with 231 patients who underwent ETS for palmar and/or axillary hyperhidrosis. Of these patients, 86.1% experienced compensatory sweating following their surgery, however, 94% expressed satisfaction with the surgery. In fact, when the authors compared satisfaction ratings of the compensatory sweating group vs. the non-compensatory sweating group, there was no difference.

According to another 2018 study, published in the Journal of Thoracic Disease, Weng and colleagues surveyed data from nearly 30 randomized controlled-trials, cohort studies and case series and found that ETS performed at the fourth thoracic level was linked to a satisfaction rate of 94% to 100%. Regarding compensatory sweating, incidence ranged from 0% to 88%, but less than 1% experienced it in the severe form, indicating that this procedure is safe, effective and “could be recommended as one of the standard treatment methods” for primary palmar hyperhidrosis, according to the researchers.

According to Levy’s experience, all patients that were chosen appropriately were satisfied with the outcomes even in the presence of compensatory sweating.

“Overall, the procedure is a permanent — and the best — way to ensure you get a complete resolution of the hyperhidrosis,” Levy said.

Giving ETS a chance

It is no secret that many dermatologists are quite wary of this surgery. In fact, Villafor experienced this aversion firsthand during his treatment journey.

“After receiving Botox, I consulted with a dermatologist who told me that surgery for hyperhidrosis was outdated and ‘archaic,’” Villafor recounted. “I then went to another dermatologist for a second opinion who told me the same thing, claiming that it is harmful and not a viable solution.”

“Hearing this initially discouraged me from ever getting a permanent solution to my problems,” he added.

After conducting his own research, Villafor found Levy and Fairbanks at Rady Children’s Hospital.

“I sat down with them and they showed me that the dermatologists’ perception of the surgery was not accurate,” he said.

According to Villafor, Levy and Fairbanks described the surgery as a minimally invasive outpatient procedure that achieves high success rates. After Cole was confirmed as a viable candidate for the surgery, he received the procedure — and it has only changed his life for the better.

“Post-surgery, my life has been greatly improved,” Cole said. “My hands now sweat less than or equal to that of a normal person and I no longer have to fear the previously uncomfortable situations I had to bear.”

Is ETS worth it?

“Hyperhidrosis greatly impacted my daily life and the activities I participated in,” Villafor said, echoing the struggle of many other patients, especially those with palmar hyperhidrosis as this condition affects the constant handling of objects.

For example, musicians may not be able to pursue their musical passions due to an inability to hold the instrument, writers must wear gloves simply to grip a pencil, or, in the case of Villafor, athletes that use their hands may give up their sporting ambitions.

In fact, in the study conducted by Woo et al, 16% of the patients that underwent ETS cited “substantial inconvenience related to their jobs” as the reason for having the surgery.

Furthermore, the stigma surrounding this condition can cause sufferers to isolate themselves from social interactions for fear of having to shake hands. Many even revamp their entire wardrobe to accommodate their condition, sticking to dark or baggy clothing made of material that repels sweat.

It is clear that those suffering from hyperhidrosis deserve effective treatment options, and although Botox injections, antiperspirants and the multitude of other treatments that Villafor tried did not work for him, they may work for others.

“I do believe that there are many good options out there that others should try in order to treat their hyperhidrosis as it may work for them,” he said. “But ETS provided me the relief that I was looking for that I couldn’t find in other products.”

So, while many dermatologists may continue to disregard ETS as an “archaic” and unsafe way to resolve hyperhidrosis, to those suffering from the stigma and life-changing effects of this condition, the surgery may be worth it.

“I am extremely grateful to everyone that had a role in my surgery,” Villafor said, “and looking back, I would have definitely done it again.”

References:

• Endoscopic thoracic sympathectomy (ETS). https://www.sweathelp.org/hyperhidrosis-treatments/ets-surgery.html. Accessed Jan. 16, 2024.
• Musa AF, et al. F1000Res. 2018;doi:10.12688/f1000research.14777.1.
• Woo W, et all. Surg Endosc. 2022; doi:10.1007/s00464-022-09284-w.
• Weng W, et al. J Thorac Dis. 2018;doi:10.21037/jtd.2018.02.07.
• Frequently Asked Questions about Hyperhidrosis Treatment. https://www.mountsinai.org/care/thoracic-surgery/services/hyperhidrosis/treatment-faqs. Accessed Jan. 24, 2024.