ETS stands for Endoscopic Transthoracic Sympathectomy and it means cutting sympathetic nerve or removing a sympathetic ganglion. The operation interrupts the overactive sympathetic nerves that cause excessive sweating and facial blushing. These nerves are located in the chest cavity next to the spine. The operation is done under general anesthesia. The patient does not feel any pain and is asleep throughout the surgery. A small five millimeters cosmetic incision is made under the armpit, and the surgeon inserts a small telescope with a miniature camera into the chest cavity. The different surgical variations of ETS that are used today are referred to as:

Electrocautery/Micro cutting
Resecting
ETS-C
ETS-B
ESB
Graduated Clipping
ESB-4

Other names may be used for the procedures above.
Also slightly different techniques may be used.

Electrocautery/Micro cutting:
In this method the sympathetic nerves are physically cut with electrocautery or scissors.  The disadvantage of this method is that it is extremely difficult to reconstruct the sympathetic nerves in the future

Resecting (Surgically removed):
Some surgeons prefer the removal of a segment of the sympathetic nerves. This method is effective in treating various forms of hyperhidrosis. However again it is extremely to reconstruct the sympathetic chain after this procedure.

ETS-C and ETS-B (ESB):
The full name of ETS-C or ESB is Endoscopic Thoracic Sympathetic Block by clamping. It 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. Those methods do not provide for guaranteed complete reversal, but the methods give a much greater opportunity for reversal. 

Graduated Clipping

In this technique, the titanium clip is applied to the sympathetic nerve in a graduated fashion. The clip is gradually closed until the adequate amount of force is applied to the nerve and the desired effect is obtained. The neural transmissions are slowed down but the nerve is not crushed. This graduated clipping of the nerve is a very precise maneuver that is thought to theoretically decrease the chance of adverse side effects (such as compensatory sweating). By not completely crushing the nerve, it is also thought that the reversal of this procedure is more likely to occur after the removal of the clip.

ESB-4: 
Means block 4th segment of Thoracic Sympathetic Ganglion to treat hand and armpit sweating problems. The specialty of ESB4 is which can treat hand or armpit sweating, effectively without inducing reflex sweating. The Lin-Telaranta classification of symptoms: In HH, (Hyper Hydrosis) or hand sweating, only the T4 level is treated

In FS, or facial sweating, as in CH or craniofacial hyperhidrosis, only the T3 level needs to be treated. In FB, or facial blushing, T2 level needs to be treated. In SP, or social phobia, depending on the more specific examination, left sided T2 to T4 treatment may be sufficient, in some cases the surgery has to be bilateral.

The extent or level of the endoscopic sympathetic blockade, (ESB), varies according to the type of hyperhidrosis or facial blushing:

Condition                               Level of ESB
Facial Blushing                    T2
Facial Sweating                  T2 or T3
Hand Sweating                   T3 or T4
Underarm Sweating             T4 or T5

The sympathetic nerves have 12 segments in the thoracic cavity from T1 to T12.
It is believed that by limiting the level of ESB to a specific segment of the sympathetic chain, compensatory sweating, the most common side effects of surgery, can be reduced. To understand a bit more about this procedure I will explain how the nervous systems work below.

The sympathetic nervous system and the parasympathetic nervous system are parts of what is commonly called the autonomic nervous system. (Autonomic = can not be controlled by the mind).

You can say that these systems work in balance with each other and directly or indirectly affect almost every structure in the body (e.g. heart frequency, heart capacity, lumbar function, kidneys, blood vessels, stomach and intestines)

The sympathetic nervous system has an active "pushing" function.
The parasympathetic has mainly a relaxing function.

The sympathetic nervous system is located to the sympathetic chain, which connects to skin, blood vessels and organs in the body cavity. The sympathetic chain is located on both sides of the spine and consists of ganglia’s.

The autonomic nervous system is most important in two situations: emergency situations that cause stress and require us to "fight" or take "flight", and no emergency situations that allow us to "rest" and "digest". The autonomic nervous system also acts in "normal" situations to maintain normal internal functions and works with the somatic nervous system. When the body reacts to signals about e.g. danger it is the sympathetic ganglia that makes

The lungs and the bronchial tubes are widened to give us more oxygen.
The motility in the intestine is reduced - we shall not digest food - we must fight or run away!

Blood is sent to the brain while skin and internal organs get less.
Muscle tension is increased. Heart rate and force is increased.
Below you can find a summary of some of these effects: 

Sympathetic	Structure	Parasympathetic
Rate increased	Heart	Rate decreased
Force increased	Heart	Force decreased
Bronchial muscle relaxed	Lungs	Bronchial muscle contracted
Pupil dilation	Eye	Pupil constriction
Motility reduced	Intestine	Digestion increased
Sphincter closed	Bladder	Sphincter relaxed
Decreased urine secretion	Kidneys	Increased urine secretion

How is ETS performed?
This technique involves cutting or blocking (called ESB) or clamping (called ETS-C) of the sympathetic nerve. Clamping and blocking allows the procedure to be reversed as opposed to traditional ETS surgery in which the nerves are actually severed.


The reversibility of the procedures has been demonstrated to range between 3-6 months following surgery. There is no potential for reversal with the ETS cutting technique. ETS is performed under a mild, general anesthesia and requires a skilled surgeon. The surgeons enter the chest cavity through small incisions (a mere 5 mm in diameter) located on each side of the body just under the armpit.

 A small amount of carbon dioxide (a harmless gas) is introduced into the chest cavity in order to gently push the lung aside. This provides a very clear view of the sympathetic chain of nerves which is located along the spine inside the chest cavity.

The surgeons then expose the sympathetic ganglion chain and either cut or place small clamps over the nerve responsible for the sweating and/or blushing.

For hand sweating and underarm sweating, the clamps are placed over the 3rd and 4th ganglia (T3-T4) of the sympathetic nerve chain. This technique best targets hand and underarm sweating, and may also reduce facial sweating/ blushing.

For facial sweating and facial blushing, the clamps are placed over the second ganglion (T2) of the sympathetic nerve chain. This technique best targets facial sweating/blushing, as well as any hand sweating the patient may have.

After completion of the operation, the carbon dioxide gas is evacuated and the incisions are closed with an absorbable stitch which does not need removal. The procedure is then repeated on the other side. A chest X-ray is then performed to insure that the lungs are fully inflated. The patient may resume work within 48 hours and return to sports activities in 5-7 days.

ETS should only be considered as a last resort for treatment of resistant cases that don't improve significantly through conventional therapy. Some doctors no longer recommended ETS for those who suffer only from facial blushing.

Kuntz Nerve
In about 15-20% of population, the sympathetic chain is bypassed by the nerve Kuntz. During the ETS procedure, this nerve is also carefully looked for and its neural transmissions are interrupted. One of the reasons for failure of ETS procedure is not interrupting neural transmission in the nerve of Kuntz.

The risk and side effects of ETS
Below is a list of possible symptoms which you may or may not encounter. Each person reacts differently, so please do not believe that you will develop all the symptoms below.

The side effects you may get depends a lot on which T you disconnected and with what method that was done, the more aggression the surgeon used on the nerve and the tissue the more side effects. It is unclear how much the side effects differs between the commonly used ETS methods listed above.

Alertness
Because the sympathetic nervous system controls some very specific functions that tie in directly to brain function, fiddling with it can severely deplete one's ability to concentrate and general sense of mental stability and alertness. A lot of ETS:ers describe it as a feeling of fuzziness

Death
There are 2 problems here: Firstly, the small number of people who have died on the operating table. Whilst there is a risk in any surgery, ultimately this is an unnecessary surgery. There is an argument as to whether ETS should be done unilaterally (one side at a time), thus avoiding the risk of collapsing both lungs in the same operation. The tragic death of an Irishman on the operation table last year received a coroner's verdict of death by medical misadventure, and High Court action has been commenced. Secondly, death has followed ETS through consequent suicide due to side effects. Horribly, a young man in USA committed suicide in March 2003. Also around the world people have made multiple suicides and attempts, directly because of ETS side effects.

Fatigue
This loss of energy has been considerable enough to disable patients. Some degree of fatigue is not uncommon.

Flushing
Many patients find that after ETS they develop a flushing problem. There seems a lot of confusion as to why this happens, so all we can do is repeat some of the ideas which attempt to explain this. A distinction is drawn here between blushing, and flushing. Sympathectomy surgeon Telaranta describes blushing as a sympathetic mechanism, whilst flushing is a parasympathetic mechanism. One might wonder then whether removing sympathetic tone allows the parasympathetic system to take over, thus causing flushing.

Another idea is that the sympathetic system is responsible for constricting the blood vessels, whilst the parasympathetic system allows for the opposite. Thus, removal of sympathetic tone allows too much parasympathetic stimuli, engendering vasodilatation, which manifests as redness on the face. This tie in with the reason for using ETS to treat Raynauds of the hands ~ to remove sympathetic tone, thus the blood vessels dilate, so that they get warmer. Telaranta is quoted as saying that dilation of blood vessels in the peripheries due to sympathectomy is a tool for treating Raynauds, but the same action does not happen in the face because the sympathetic system works differently there.

A much simpler idea is that, where before ETS, flushing due to heat, hormones and emotion could be avoided through the natural cooling mechanism of perspiration from the head, the inability to release this heat causes flushing.

ETS surgeon Reisfeld suggests the problem is due to denervation hypersensitivity. Here, the blood vessels become very sensitive to certain circulating hormones within the blood system

Gustatory Sweating
Sweating on the forehead, face, scalp, and neck occurring soon after ingesting food. Some gustatory sweating is normal after eating hot, spicy foods. This distressing problem can be difficult to treat. Treatments used include oxybutynin chloride, propantheline bromide, and clonidine (brand name: Catapres). Recently, some success has been reported using topical applications of glycopyrrolate: the lotion was applied to the skin of the forehead and face, sparing the eyes and mouth.

Heart problems
Bradycardia is a recognized potential side effect of sympathectomy. Two American patients of surgeons who also operate in Britain advised that PET scans showed damage to the sympathetic nerves innervating the heart. One was told that he was somewhere between normal and pure autonomic failure. While it is not uncommon to complain of reduced exercise capacity, very few have complained of significant heart problems.

Horner’s syndrome
This can be brought about by both ETS and nerve graft "reversal". The low incidence of Horner's through sympathectomy possibly explains why it is always included as a possible side effect by promoters of sympathectomy. The occasional unfortunate ancillary advice that this is a condition that can be remedied by a simple operation is perhaps a little misleading.

Hyperhidrosis
The idea that post ETS hyperhidrosis is solely due to compensatory sweating is nonsense. The total body perspiration experienced after ETS is greater than the total body perspiration before ETS. This extra amount has been described as "reflex sweating". No one fully understands it, but theories advanced attribute it to bad feedback from the build up of scar around nerves, or the break in communication between the brain and the lower body sweat glands. Even using the Surgeons' vocabulary, the nonsense statistics of reported compensatory sweating are now being replaced by more realistic figures, such as Gossot et al's 2001 publication about 940 patients, which advised an incidence of 100%. A 2003 publication by Gossot et al advised that compensatory hyperhidrosis did not improve with time.

Impotence
Long recognized to be a side effect of lumbar Sympathectomy (same nerve chain, though cut lower down the trunk), there has been a surprising reticence to acknowledge impotence due to thoracic Sympathectomy. The Radisson Group contains members with greatly reduced sexual strength which can not be attributed to psychological problems in the wake of ETS. Erec dys is a recognized symptom of autonomic dysfunction. (Indeed autonomic dysfunction also has symptoms of dizziness, bladder atone, dry eyes & mouth, and pupil abnormalities.) Sympathectomy is a massive trauma to the autonomic system. This seems to affect a relatively low percentage f people.

Oversensitivity to stress, sounds and lights, smells and
Many of us now react abnormally to simple stimuli of sounds, light and touch. Whilst ETS is sometimes performed to combat social phobia, many of us now have far reduced tolerance to stress.

Pain
Sympathectomy has long been touted as a "cure" for pain syndromes, such as the particularly nasty RSD (Reflex Sympathetic Dystrophy)/CRPS (Common Regional Pain Syndrome). Long term pain which can be easily and directly traceable to ETS does not seem terribly common. There are 2 important points to make here:

1) ETS is not a valid option for pain syndrome.
2) ETS can cause pain syndrome where there was none previously.

Puffy eyes - is a common observation amongst ETS patients.
This is interesting in that it is another symptom shared by patients with thyroid problems, which are ultimately disturbances to the endocrine system. Incidence is low, an example of how we are all affected in so many different ways.

Raynaud's Disease
This condition afflicts the peripheries, and is a touted reason for ETS. Many experienced warmer hands for some extended period after the operation, only for them to become sub normally cold afterwards.
ETS corrupts peripheral blood flow and causes a condition similar to Raynaud's.

Cold extremities
ETS causes contra lateral vasoconstriction, leading to cold extremities in the areas of sympathetic denervation. Many of us found that our hands were warmer than normal after ETS, before they gradually went the opposite way, and become prone to being frighteningly cold. The interesting question here, is that this does not apply purely to the areas of sympathetic denervation (hands, fingers, ears etc), but can also affect the feet, which maintain sympathetic innervation's after ETS.

Reduced pulse 
This consequence of ETS is hailed as a positive by ETS surgeons. However, little connection is made between those patients who might benefit from a reduced pulse, and those patients who are admitted for ETS. Moreover, acceptance of the degree to which this is a problem is again disputed by ETS surgeons.

Rhinitis
Problems with nose and eyes can occur after ETS, including runny nose. This does not appear to be terribly common, but has been admitted by Gossot et al (Long-term results of Endoscopic Thoracic Sympathectomy for upper limb hyperhidrosis) as appearing in chronic form in 2.4% of their sample of 382 patients.

Skin problems
The lack of melanin, means reacting differently to sun. The skin is apparently the biggest organ in the body. Whilst the denervated top area may suffer from anhydrous and early aging due to ETS, the bottom half may be susceptible to sweat induced rashes in cleft areas, such as between the toes, or on the groin. Moreover, those who suffer permanent cold feelings may experience this all over the body, in both denervated and still innervated halves. The constant coldness suffered by some members might best be explained to those who thankfully do not suffer this, by reminding them of the feeling experienced with severe sunburn ~ the shivers, shakes and flushes. Interestingly, a praised side effect of ETS is that it can reduce acne, however, some have experienced very difficult skin conditions such as eczema. Some members also report a reduced ability to tan after ETS. it is pleasing to hear that some patients' post ETS complaint about dry skin have eased with time.

Thermoregulation
Unfortunately, it is not only the extremities which are subject to cold sensitivity. For some of us, the whole body is subject to thermoregulatory problems. Whilst the peripheral coldness described in the Raynaud's Disease section can sometimes be akin to a frozen chicken feeling, this total body thermoregulation is less severe, and can be described more as a general feeling of being cold. Whereas the peripheral problem is largely influenced by external temperatures, this total body thermoregulatory problem can be evident regardless of temperature.

Tinnitus
Medical professionals using this site will not be surprised by this result of damage to the sympathetic system. It is well documented in other syndromes. This is not terribly common.

Compensatory sweating
Everyone talks about the dreaded CS (Compensatory sweating) which almost 100% of the people will have after ETS, even the doctor's websites can't avoid mentioning it any more. But over and above the recognized side effects such as CS, fatigue or Horner’s (droopy eye), there are so many other smaller side effects that none of the websites mention, but which can make life much more uncomfortable, if not down right miserable.

Here's a list of other side effects/discomforts.
Not everyone is going to be affected by every side effect listed here, but enough of people have agreed that many of these things started happening only after having ETS. CS can get progressively worse and other problems can develop over time.

Acne
Aged Hands
Anger
Anxiety
Back Pain / Nerve Pain
Bad Circulation
Blushing
Body Odor
Brittle Nails
Burning Skin Sensation
Can't get the temp right
Chest Hair with Distinct Line of Different Colors
Chest Pain
Cracked, Dry Lips
Chronic Fatigue, Lack of Energy
Depression
Dizzy
Dry Itchy Scalp
Eczema
Excessive Dandruff
Extreme Dryness of Hands,
Hands Feel Like They Are Sunburned and Electric
Eyebrows Thinning
Face often hot
Facial Pain
Feeling Hot all the Time
Feet Sweat
Flushing
Groin Sweat
Gustatory sweating
Hair Falling/Thinning Out (even young women)
Hard, Sore & Sensitive Nipples
Headaches
Impotence
Inability to Tan
Leg Pain
Loss of Adrenalin High
Low Libido
Muscle Weakness ("lactic acid in the arms")
Nerve Pain - Intercostals neuralgia
Oily Face
Premature Grey Hair
Premature Wrinkles
Raynauds Disease
Sensitivity to Cold
Sensitivity to Heat
Sensitivity to Light
Sensitivity to Smells
Severe Compensatory Sweating
Shortness of Breathe
Slowed Reaction Time
Slowed Speech
Slow Heart Rate
Sores that don't Heal
Spacey Feeling
Stomach Problems (constipation or diarrhea)
Stuffy/Blocked Nasal Passages
Urinary Problems
Weight Gain
 
Some of the above symptoms may be the same, but are described with slightly different words.

Here are my suggestions:
When you read about what a complicated system the sympathetic chain is, you wonder how anyone can allow surgeons to perform ETS. If you are considering having ETS, I strongly recommend that you first try other remedies. However, I also understand that some people may feel surgery is the only option left. With that in mind, I've put together a suggested list of questions you should ask your doctor.

Don't rush into surgery; take your time and do as much research as possible. If you have doubts, postpone your decision until you are completely sure that surgery is the only option left. Remember, this is surgery--it can not be fully reversed (this includes early removal of clamps). Even the most experienced ETS surgeon cannot guarantee good results.

 1.) Consult at least two physicians that are familiar with the procedure but do not perform the procedure or have any financial interest in your decision. Try seeing one dermatologist and one neurologist.

 2.) Bring a family member or close friend to the consultation. Having an objective third party present will prevent you from making an emotional decision regarding the surgery.

 3.) Do not make your decision based solely on information gathered from surgeon’s websites, brochures and phone calls to the surgeon’s office.

 4.) Do not schedule a consolation that can be followed by a surgery the same day. Go to a consultation and then spend at least a few weeks considering the risks.

 5.) If you go alone to the consultation, bring a tape recorder to record the conversation. Tell the doctor you want to record the conversation. If he objects, then you have learned something about him.

 6.) Realize that testimonials from happy post-op patients are anecdotal and do not reveal anything regarding the possibility that you will regret the surgery.

 7.) Even though a minority of patients regret the surgery, regret is not at all rare. A five percent regret rate is 1 in 20 patients. A minority for sure, but it’s hardly a rare occurrence. Many studies demonstrate regret rates much higher over the long term.