Reversal of Thoracic Sympathectomy

Q: What is a thoracic sympathectomy, also known as an Endoscopic Thoracic Sympathectomy (ETS), and why is it performed?

A: A thoracic sympathectomy (ETS) procedure is performed for a condition called hyperhidrosis (excessive sweating), typically of the face (facial blushing), armpits, and/or palms. When antiperspirants and medications have failed, this minimally invasive surgical procedure can be effective. The surgery involves disrupting (usually by cutting or clipping) the sympathetic nerves on both sides of the body in the upper chest. The thoracic sympathetic nerves control sweat production in these areas of the body.

Q: Why would someone need a reversal of this procedure?

A: Although a thoracic sympathectomy can be effective at alleviating excessive sweating of the face, armpits, and palms, there may be side effects. At least 10% (and probably more) will experience complications from this surgery, including: uncontrolled lower body sweating or compensatory hyperhidrosis, poor control of heart rate or slow heart rate, eye dryness, gastrointestinal distress, cognitive/emotional issues, sexual dysfunction, and other problems attributable to alterations in the sympathetic nervous system. If these problems do not spontaneously improve during the first 6-12 months after surgery then reversal may be considered.

Q: How is a thoracic sympathectomy reversed?

A: Reversing a thoracic sympathectomy is most likely accomplished by performing nerve reconstruction. Although there are several descriptions of techniques, we perform nerve grafting using the sural nerve in the leg that is transplanted into the chest to restore continuity to the interrupted sympathetic nerves. We use a minimally invasive technique to facilitate recovery. Our body’s ability for nerve regeneration may permit sympathetic nerve impulses to be restored over a period of 6-12 months. The protocol we are following also includes the application of nerve growth factors to enhance the likelihood of recovery.

Q: What is the likelihood of success after ETS Reversal?

A: Nerve reconstruction for ETS reversal is an emerging technique and long term outcomes are not yet available. There are a few small series that have reported promising results. Nerve reconstruction is most successful if the following factors are in place: young age, recent injury (<2-3 years), healthy patient, and meticulous surgery performed by skilled surgeons with vast nerve reconstruction experience.
Our NJ team has performed more nerve reconstruction procedures in the chest cavity than anywhere else in the world for phrenic nerve injuries. We are adapting this experience to help patients suffering with complications after ETS and looking for reversal surgery.

Q: What are the risks of ETS reversal surgery?

A: The major risk of ETS reversal is that it will not be successful in reversing compensatory sweating and other associated symptoms. The likelihood of failure depends on the factors mentioned above. Alternatively, if the procedure is successful at reversing compensatory sweating, it may also result in recurrence of the original symptoms, such as palmar or axillary hyperhidrosis. Another potential complication includes Horner’s syndrome, which may result in a droopy eyelid and dry eye.

We have begun performing Nerve Reconstruction as part of our ETS reversal program and are actively screening candidates. Please contact us for further information.

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