Everyone sweats – but what if you had a condition that caused uncontrollable sweating in your hands?
Palmar hyperhidrosis is a benign condition where individuals experience uncontrollable sweating of their hands, way beyond their physiological needs. Hand sweating in such a scenario is often described as being present 24/7, may be worsened in situations of stress but also occurs out of nowhere in times of total rest and serenity. From the constant dampness the hands are exposed to, ulcerations and other skin related changes may develop. Many patients with this condition adopt a line of work and a life style that minimizes public encounters and avoid hand contact such as having to shake hands.
It has been known since the 1920s that by dividing the sympathetic chain (nerve) high up inside the chest, a procedure called thoracic sympathectomy, we can make the hands stop sweating. To achieve this surgically was quite an undertaking back then. The surgical trauma was such that historically very few individuals with hyperhidrosis opted to have corrective surgery. With the development of videoscopic surgery, however, it has become possible to perform the sympathectomy with minimal trauma to the patients. In addition, the magnification provided by the optics of videoscopic surgery has made the surgery safer.
What is involved in an ETS (Endoscopic Thoracic Sympathectomy)?
Nowadays, we offer surgery under general anesthesia as a day surgical procedure (meaning most patients are expected to go home the day of surgery). Two small incisions are needed, and we preferentially place those on your sides. At Swedish, our preferred approach is to clamp the nerve by placing titanium clips on the nerve at appropriate levels. The advantage of clipping the nerve instead of removing a segment of the nerve (as we did prior to 2005) is for possible reversal of the sympathectomy in the rare instance where a patient may be unhappy with the side effects of the surgery (see below).
What results should I expect?
In our hands, ETS will render the hands dry in 99 to 100% of cases. For many patients, their hands will become so dry that they will require the use of a moisturizing hand lotion for the rest of their life. A large number of individuals with palmar hyperhidrosis also experience excessive feet and/or armpits sweating. ETS targeting the hands will improve the feet sweating in 60% of cases, armpits sweating in up to 85%. The results are usually immediate and an eventual return of the hyperhidrosis is extremely rare.
Are there side effects?
The main side effect of ETS is a condition called “compensatory sweating” or CS where individuals may start experiencing uncontrollable sweating from other parts of their body. Most commonly, CS will affect the lower back, the lower abdomen, the groin and the back of the knees. In women, it may also develop under their breasts. One of the theories explaining the occurrence of CS is that it has been estimated that we all lose approximately 40% of our necessary body heat loss through our hands, arms and armpit areas. When one loses his or her ability to sweat from these areas, other areas have to “take over” otherwise that individual would die of “overheating”.
Though we cannot eliminate CS from happening entirely, there is evidence that by minimizing the extent of the sympathectomy performed we can lessen the severity of CS. For the rare individual who develops CS subjectively judged to be more severe than the presenting hyperhidrosis, reversal of the sympathectomy by removing the clips may be an option.
Conclusion
ETS is a minimally invasive surgical day surgery procedure where by applying titanium clips on the sympathetic nerves one can eliminate excessive hand sweating as seen in patients with palmar hyperhidrosis. In experienced hands, ETS is safe and offers great results with minimal morbidity.
