Here is a list of Frequently asked Questions answered by several surgeons. Please note that Surgical Team does not endorse or favor any specific answer by a surgeon. This is only for information purpose. We suggest that you also gather information concerning ETS from other sources

Questions and Answers by Dr. Alan Cameron (London)
Questions and Answers by Dr. Chien-Chih Lin (Taiwan)
Questions and Answers by Dr. João Duarte (Brazil)

Questions and Answers by Dr. Alan Cameron (London)

What is hyperhidrosis?  Sweating in excess of that required to cool the body.

What is ETS and ETS-C?  ETS is destruction of  part of the sympathetic chain (by cautery or resection) whereas ETS-C is a technique of interrupting the nervous impulses by applying titanium clips across the nerve trunk.

How is ETS and ETS-C performed?  Both are performed under general anaesthesia and involve passing a telescope across the chest cavity from incision(s) near the armpit. The lung is depressed by passing carbon dioxide into the chest cavity to permit a good view of the sympathetic chain which is then treated as above. The CO2 is then removed from the chest and the lung re-inflated.

What is the Kuntz nerve and how does it relate to the ETS / ETS-C procedure?  The Kuntz nerve most probably has no function in man and is unrelated to the success of either ETS or ETS-C    (SEE BELOW).

Are there any negative side effects of the operation?  As with all surgery, there is a slight risk in the procedure, but the long-term side-effects include compensatory hyperhidrosis, possible excess dryness of the hands/upper body, and a slight possibility of Horner's syndrome of drooping of the eyelid (NOT the whole face as some people think).

Are there any other positive side effects of the operation?  The dry hands may be a bonus actually; also the palpitations and general anxiety in social situations may be reduced.

What complications may occur?  The risks of the procedure include damage to the structures inside the chest; the commonest is to the lung which might require temporary use of a chest drain (4%); bleeding from inside the chest is fortunately rare (0.3%) but is much more serious. There is usually a mild degree of postoperative pain for a couple of days.

What if my only condition is axillary (armpit) sweating?  ETS is not advisable as the CS is just as bad as the axillary sweat, merely moved around the body. Botox or sweat gland excision is better.

What if my facial redness is caused by rosacea or another skin condition?  ETS might affect any attacks of flushing, but not the background redness, so it is not recommended.

What is the long-term success rate?  Palmar hyperhidrosis  99% success , maintained for many years. 94% facial sweating, 90% for flushing (but the longterm effects do not seem as good as for palmar hyperhidrosis).

What is the recovery time?  Usually overnight in hospital and a couple of days off work. Sport after a week.

Questions and Answers by Dr. Chien-Chih Lin (Taiwan)

What is hyperhidrosis?  Hyperhidrosis is excessive sweating on certain parts of human body, for example, hands, feet, armpits and face. Hyperhiderosis has nothing to do with environment temperature but is influenced by emotional excitement. It possesses hereditary tendency.

What is ETS and ETS-C?  The full name of ETS is Endoscopic Transthoracic Sympathectomy (or Sympathicotomy), which means cutting sympathetic nerve (sympathicotomy) or removing a sympathetic ganglion (sympathectomy).
I designed and invented ETS-C (or ESB) to treat hyperhidrosis in 1996. The full name of ETS-C or ESB is Endoscopic Thoracic Sympathetic Block by clamping. I have used this new method to treat more than 1500 cases of sympathetic disorders with excellent operative results. ETS-C (or ESB) means interrupting sympathetic nervous conduction by clamping with a titanium clip and then therapeutic purpose is achieved. No cut of nervous trunk is performed on clamping method, for this sake, it possesses reversible potential by removal of the clip when patient can not tolerate the postoperative condition. The commonest cause of regret is reflex sweating (previously called compensatory sweating).
There are more than 30 surgeons using ETS-C or ESB in sympathetic surgery in the world now.

What is ESB-4?  I am the first person that found the mechanism of hyperhidrosis and the postoperative reflex sweating, so I designed ESB procedure in sympathetic surgery. ESB4 means block 4th segment of Thoracic Sympathetic Ganglion to treat hand and armpit sweating problems. The speciality of ESB4 is which can treat hand or armpit sweating (Bromidrosis) effectively without inducing reflex sweating. No other sympathetic procedure can treat hyperhidrosis without inducing reflex sweating.

How is ETS and ETS-C performed?  Both are performed by endoscopic method and effective to treat sympathetic disordes under general anesthesia. ETS, irreversible method, is cutting sympathetic nervous trunk to treat sympathetic disorders, but ETS-C (or ESB) without cutting nervous trunk, reversible method.

What is the Kuntz nerve and how does it relate to the ETS / ETS-C procedure?  I don't think that Kuntz's fiber plays any role in surgical failure of sympathetic surgery after my more than 5000 cases of clinical study. I don't cut Kuntz's fiber when I perform sympathetic surgery, but the operative results are the same with any other surgeons' in the world.

What about "micro-surgery"?  I don't agree with the term of Micro- or selective sympathetic surgery, because thermal or electric burn cannot be avoided if a surgeon uses electric diathermy probe to cut sympathetic nervous fibers selectively unless he uses endo-scissors to cut the nervous fibers. That means, thermal injury to nervous fibers is the reason of surgical effect, not selectively cut the nervous fibers. I don't believe it unless after a long-term follow-up.

Are there any negative side effects of the operation?  The most famous side effect of sympathetic surgery is reflex sweating (compensatory sweating is a wrong medical term). The incidence of other side effect is rare.

What complications may occur?  Complication is rare when ETS-C (ESB) is used.

What if my only condition is axillary (armpit) sweating?  Of course, armpit sweating (Bromidrosis) can be treated by sympathetic surgery. The procedure of treating armpit sweating is different from hand and facial sweating or blushing. I use different sympathetic procedures to treat different sympathetic disorders under the rule of Lin-Telaranta Classifications. Lin-Telaranta Classification emphasizes the concept of different procedures for different sympathetic disorders, then better operative results, less side effect or complication are achieved. Lin-Telaranta Classifications are the most important concept in sympathetic surgery in the world now.

What if my facial redness is caused by rosacea or another skin condition?  No, in the contrast, facial blushing induces rosacea if facial blushing is lasting longer enough.

What is the long-term success rate?  What kind of sympathetic disorders? Long term success rate is over 99% of Hyperhidrosis, but it is about 90% of cure rate for facial blushing. The older and longer the patients have facial blushing, the less cure rate is found on them.

What is the recovery time?  Patient is usually recovered on the next day after operation. Sometimes, it is not common, patients feel chest pain, tight or back sore more than one week. Resuming normal activity as soon as possible can speed recovery.

Questions and Answers by Dr. João Duarte (Brazil)

What is hyperhidrosis?  Hyperhidrosis is a dysfunction of the sudomotor center, the center in the brain that controls the body temperature, which promotes excessive stimuli to sweat glands in specific areas, independent of physiological necessity. The cause is unknown. Hyperhidrosis can occur in any part, but the hands, the feet, the underarms, and the face, in isolation or in combination, are the most affected areas.

What is ETS and ETS-C? How is ETS and ETS-C performed?  The best manner to treat hyperhidrosis is to interrupt the stimulus from the sudomotor center to the affected area. For palmar, axilar, and facial areas the stimulus is interrupted to those areas by removing or cutting the sympathetic trunk and its rami. In the past it was necessary to open the chest cavity to do this. In 1947, Dr. E. Kux and his nephew, Dr. Peter Kux, developed the endoscopic access to perform this operation- Endoscopic Thoracic Sympathicotomy (ETS) surgery, which was spread after the development of the videoendoscopic surgery. In 1997, Dr. Lin presented at the II International Symposium of ETS his experience in clipping the sympathetic trunk, instead of removing or cutting, in order to keep the possibility of reversing the surgery if strong compensatory sweating occurs.

What is the Kuntz nerve and how does it relate to the ETS / ETS-C procedure?  The Kuntz nerve is a ramus of the second and/or the third sympathetic thoracic ganglion that participates in carrying the sympathetic stimulus to the facial area. The sympathetic stimulus is responsible for the facial sweating, blushing, and rhinitis.

What about "micro-surgery"?  Micro-surgery is the ETS performed with thin surgical instruments, smaller than 5 mm.

Are there any negative side effects of the operation?  The worst side effect is the increase of sweating on the belly, back, and/or legs, known as Compensatory Sweating (CS). The characteristic of CS is different from the hyperhidrosis. Rarely does it occur in cold weather or during emotional stress. It is disproportional with the amount of exercise that is done or the temperature. A short walk or a small increase of temperature promotes excessive sweat in the above areas. The incidence of compensatory sweating depends on the surgical technique.

Care should be taken in patients with bradicardia (low heart rate below 60 beats per minutes). The areas of the sympathetic trunk that carry signals to the heart should be avoided in order not to diminish the heart rate even more.

Are there any other positive side effects of the operation?  Depending on the level of the sympathetic trunk operated and the rami cut we can diminish or sometimes cure plantar hyperhidrosis, cure facial blushing, diminished or cure acne and rhinitis. Subjective positive effect like increased self confidence, reduced anxiety, depression, and aggressiveness can also be obtained. Patients become happier after the surgery.

What if my only condition is axillary (armpit) sweating?  Like palmar and facial hyperhidrosis, axillary hyperhidrosis can be a great handicap in the patients’ lives. Using the Duarte-Kux technique, we can cure axillary sweating in 96% of the patients operated on. If you feel that your axillary sweating is a problem in your life, the most efficient, safest, and easiest solution is the Duarte-Kux technique.

What is the long-term success rate?  With the Duarte-Kux technique, the long-term success rate is:

-         Palmar hyperhidrosis: 100% of cure

-         Facial hyperhidrosis and blush: 99% of cure

-         Axillar hyperhidrosis: 96% of cure

About plantar hyperhidrosis, 94% of the patients operated on reported a reduction of the sweating in this area, allowing them to wear sandals without problem.

What is the recovery time?  With the Duarte-Kux technique, the surgery is usually performed on an outpatient basis and, if no complication occurs during the surgery, all patients are able to return to their normal activities the day after surgery (driving, working, practicing sports, dating, etc).

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