ETS – Endoscopic Thoracic Sympathectomy

Excessive sweating occurs when the sympathetic nerves become over active. These nerves can be interrupted in several ways by surgery and the procedure bears the name of endoscopic thoracic sympathectomy or ETS. The 12 segments of the sympathetic nerves that are found in the thoracic cavity play a key role in the operation and their name indicatives range from T1 to T12. Different forms of hyperhidrosis are assigned specific T indicators (facial sweating may be a T2 or T3, for example).

The ETS operation itself is performed through some small incisions located in the underarm area while the patient is under general anesthesia. The risks involved by this procedure are low and the beneficial results are usually satisfactory. There are three main methods of performing ETS sympathectomy, each with its own advantages and disadvantages:
Sympathectomy by clamping or clipping ETS (ETS -C / ESB)

This method does not involve the cutting of the sympathetic nerves. Instead, the surgeon interrupts their activity by applying a titanium clamp to the nerve, thus stopping their activity. The clamp exerts pressure on the nerve and the signals the nerve produces don’t reach the sympathetic nerve endings. This is method that has a positive effect in the sense that the sympathetic ganglia are not destroyed. This leaves the patient with the possibility of having the nerves reconstructed in the future by simply removing the titanium clamp.

Various forms of excessive sweating can be removed with this method. Selected segments of the sympathetic nerves are cut during this procedure. This leaves very little chances of a successful reconstruction of the nerves in the future.

The sympathetic nerves are surgically cut with electrocautery or surgical scissors. The difficult reconstruction of the nerves represents this method’s negative effect. ETS Insurance facts.

The variation of the levels of classification for ETS depends on the type of hyperhidrosis that the patient presents:
Facial Blushing is T2
Facial Sweating is T2 or T3
Hand Sweating is T3 or T4
Underarm Sweating is T4 or T5

Side Effects of Sympathectomy Surgery

Compensatory sweating is unpredictable and cannot be precisely identified before surgery. The intensity of this side effect varies from patient to patient. Many sympathectomy patients only experience very little moisture and sweating and hot weather seems to favor this phenomenon.

In spite of sympathectomy surgery side effects, most patients agree that they would rather experience compensatory sweating than the condition they had before surgery. Patients are willing to trade a more severe hyperhidrosis or extensive facial blushing for the effects of compensatory sweating. The number of patients experiencing aggravated forms of this side effect is low. In the cases where compensatory sweating is exceeding the expected levels, the titanium clamp may be removed. This reverses the surgery and the side effect diminishes in time. However, this operation must take place soon after the surgery, as after a few months the chances of reversing the operation are very low.

When the denervation area affected by the surgical procedure of sympathectomy is extended, the side effect of compensatory sweating also increase in intensity. The initial methods of performing sympathectomy implied that a large segment of the sympathetic nerves was cut. The side effects were also high, in accordance with the extent of the surgery. Modern methods greatly reduce the levels of compensatory sweating. The identification of specific hyperhidrosis conditions is now more accurate. By targeting the exact section of the sympathetic nerves, the surgeon doesn’t allow compensatory sweating to aggravate.

Successful treatment of compensatory sweating can also be achieved by the use of medication. Robinul and Ditropan are used to treat the side effect with good results. Several other side effects related to the sympathectomy surgery were observed with patients. Nerve damage is a possible risk, while bleeding and infection may also occur. Patients have also experienced post surgery rib pain and dryness of the hands or face. A decrease in the heart rate was also signaled by some patients. Other rare complications of sympathectomy include damage to the lungs and Horner’s syndrome. These are very rare complications as the new surgery methods have greatly improved over the years.

ETS Insurance Coverage

Some insurance companies consider treatment of intractable, disabling primary hyperhidrosis (excessive sweating) with Botox (botulinum toxin type A) or iontophoresis (electrophoresis, Drionic device) medically necessary when all of the following criteria are met:

* Topical aluminum chloride or other extra-strength antiperspirants are ineffective or result in a severe rash; and
* Member is unresponsive or unable to tolerate pharmacotherapy prescribed for excessive sweating (e.g., anti-cholinergics, beta-blockers, or benzodiazapines); and
* Significant disruption of professional and/or social life has occurred because of excessive sweating.

Insurance Coverage Beyond Botox and Iontophoresis

Insurance companies may consider the following surgical treatments for hyperhidrosis medically necessary for members who meet the above-listed criteria and have failed to adequately respond to treatment with Botox and Iontophoresis:

* Open thoracic sympathectomy
* Video-assisted endoscopic thoracic ganglionectomy (ETG)
* Endoscopic sympathetic ablation by electrocautery
* Chemical thoracic sympathectomy
* Thoracoscopic sympathectomy
* Endoscopic thoracic sympathectomy (ETS)
* Video-assisted thoracic sympathectomy (VATS)
* Excision of axillary sweat glands.
* Lumbar sympathectomy
* Tumenescent liposuction for axillary hyperhidrosis