Compensatory Sweating
All patients undergoing ETS will experience some compensatory sweating. This is unavoidable because in patients with hyperhidrosis the propensity to have excessive sweating cannot be eliminated. Surgery only eliminates the pathway to the sweat glands of the hand. In the majority of patients, compensatory sweating is mild, well-tolerated and an acceptable alternative to severe palmar sweating.

Over the past several years, several different surgical procedures have evolved to treat hyperhidrosis and eliminate or reduce the risk of compensatory sweating. Patient selection is crucial. Certain patients seem to experience worse compensatory sweating. Patients who experience excessive sweating over their entire body before ETS tend to have more severe compensatory sweating. It has been our practice to avoid ETS surgery in these patients.

The surgical technique also may have an impact on both the frequency and severity of compensatory sweating. Not all patients with hyperhidrosis are the same. Some patients have predominantly hand sweating while others may also experience severe facial sweating and blushing at the same time. Since not all patients have the same symptoms, we believe the surgical procedure must be individualized to suit the symptoms. There have been several reports involving large numbers of patients from European centers that also suggest modifying the procedure depending on the dominant symptoms.

In patients with palmar sweating we isolate the T3 ganglia. This technique is equally as effective in eliminating excessive sweating as T2 sympathectomy and reduces the chances of having severe postoperative compensatory sweating. In patients who also have facial symptoms, it is necessary to isolate the T2 ganglia, and therefore there is a higher risk of developing compensatory sweating. We however have modified the T2 sympathectomy procedure in order to reduce the risk of compensatory sweating.

Gustatory Sweating
Gustatory sweating is a relatively rare side effect of sympathectomy. Patients who experience this will notice increased sweating when eating certain foods or from the smell of some foods. This side effect is quite rare. The reported incidence is less than 1% of patients having this procedure.

Cardiovascular
The sympathetic autonomic nervous system has a role in regulating cardiac function. There have been experimental reports in the literature about the effects of ETS on heart rate and the response of the heart to exercise. However, there is no reliable data that has conclusively shown a relationship between ETS and cardiac function. Based on the clinical data that has been published to date, there is no evidence that ETS surgery has any negative impact on cardiac function, or the ability to reach preoperative peak work loads.

Postoperative Pain
Although ETS is a minimally invasive procedure, there is some pain associated with it. Typically this is localized to the site of the incisions or to the nerves adjacent to the incisions and resolves within days of surgery. There is also some generalized chest discomfort that resolves in a day or two. Most patients return to full activity within several days of surgery.

Risks of Surgery
ETS is performed under general anesthesia and carries the risks of any surgical procedure, namely reactions to medications, bleeding, or infections. In order to perform ETS, the lung must be collapsed to allow visualization of the sympathetic nerve. There is no way to perform this procedure without partially collapsing the lung. There are two methods that can be used to acquire exposure to perform the procedure. Either carbon dioxide gas is pumped into the chest cavity to actively collapse the lung or a special tube is used during anesthesia that allows the lung to slowly and passively collapse. Both techniques accomplish the same result without any consequence to the patient while under anesthesia. Collapsing a lung during surgery is routine during all types of thoracic surgical procedures and has no associated risks. When the sympathectomy is completed, the lung is reinflated. Occasionally a small amount of residual air is left in the chest cavity. This is referred to as a pneumothorax. The body absorbs this air within a few days and there are no long term effects.

Horners Syndrome may occur if the sympathetic nerve near the T1 level is also disrupted. In patients who experience Horners Syndrome, the eyelid appears to droop slightly. The other manifestations such as absent facial sweating, or a sluggish pupil are rarely seen. The frequency of this is less than 1%, and in those who do experience it, it may resolve spontaneously. Careful dissection limited to the T2 level minimizes the risk of developing a droopy eyelid postoperatively. Since we now more frequently perform a T3 sympathectomy for palmar or axillary hyperhidrosis, the risk of a postoperative Horner's syndrome is much less.