Sympathectomy (e.g. ETS): when nothing else works

Blocking, transecting, or destroying parts of the sympathetic nerve trunk: nerve surgery

If noth­ing else has worked, the only remain­ing option is to block, cut off, or destroy the nerves respon­si­ble for the sweat­ing.

A last resort

If all oth­er treat­ments have failed, the last resort is to block, sev­er, or destroy the nerve trunk respon­si­ble for the sweat­ing. There are dif­fer­ent pro­ce­dures for this. Due to the many poten­tial side effects, sur­gi­cal pro­ce­dures on the sym­pa­thet­ic nerve should only be per­formed when all oth­er treat­ment options have failed.

What is the sympathetic nerve trunk?

The sym­pa­thet­ic nerve trunk is part of the auto­nom­ic ner­vous sys­tem along with its coun­ter­part, the parasym­pa­thet­ic. The sym­pa­thet­ic nerves affects the smooth mus­cles, blood ves­sels, and glands. In con­trast to the vol­un­tary con­trac­tions of skele­tal mus­cles, the reg­u­la­tion of the sym­pa­thet­ic ner­vous sys­tem can­not be con­scious­ly con­trolled by humans. One effect of the sym­pa­thet­ic nerve is the increase in sweat gland secre­tion.

The nerve cell clus­ters (gan­glia) of the sym­pa­thet­ic nerve adja­cent to the spine are inter­con­nect­ed and togeth­er form the sym­pa­thet­ic trunk. The nerve sig­nals respon­si­ble for sweat­ing on the head, hands, and under­arms are trans­mit­ted in the tho­racic part of the sym­pa­thet­ic nerve, while the sig­nals for the feet are trans­mit­ted in the lum­bar sec­tion of the sym­pa­thet­ic nerve.

Sympathectomy applications

Indi­ca­tions include pri­ma­ry (focal) hyper­hidro­sis on the hands, feet, under­arm, or face/head. The sur­gi­cal pro­ce­dures can also be applied to mor­bid blush­es (facial blush­ing, ery­thro­pho­bia).


If you are look­ing for infor­ma­tion on sur­gi­cal pro­ce­dures against exces­sive sweat­ing, you will quick­ly be con­front­ed with many abbre­vi­a­tions and tech­ni­cal terms which we will briefly explain to you below. All sur­gi­cal pro­ce­dures have a com­mon goal: to dis­rupt the trans­mis­sion of sig­nals via the sym­pa­thet­ic nerve. There are two options: Block­ing the nerve by clip­ping, sev­er­ing, or destroy­ing the gan­glia. All sur­gi­cal pro­ce­dures can be per­formed endo­scop­i­cal­ly, which means they are min­i­mal­ly inva­sive. An open sym­pa­thec­to­my, with the patient’s chest open, is no longer per­formed.

Endoscopic sympathetic block (ESB)

The endo­scop­ic sym­pa­thet­ic block (ESB) is an oper­a­tion that blocks the gan­glia of the sym­pa­thet­ic nerve. ESB is per­formed either at the tho­rax for the treat­ment of hyper­hidro­sis on the hands, armpits, head, or face, or in the lum­bar region for the feet.

One or more tita­ni­um clips are used to con­strict the sym­pa­thet­ic nerve. ESB is also some­times called endo­scop­ic transtho­racic sym­pa­thet­ic clip­ping (ETSC). In con­trast to ETS or ELS (described below), the nerve gan­glia are not sev­ered or destroyed, but are mere­ly clamped to pre­vent the trans­mis­sion of nerve impuls­es. Nev­er­the­less, ESB/ETSC is only con­di­tion­al­ly reversible for a short peri­od of time. Often, after a pro­ce­dure, the func­tion of the nerve can­not be com­plete­ly restored.

Transection or destruction of the sympathetic ganglia by endoscopy (ETS and ELS)

In a so-called endo­scop­ic transtho­racic sym­pa­thec­to­my (ETS), the gan­glia at the lev­el of the tho­rax are sur­gi­cal­ly tran­sect­ed (cut) or destroyed. Nerves can be destroyed using elec­tri­cal­ly gen­er­at­ed heat or by inject­ing chem­i­cals. The tran­sec­tion of the nerve is done with an ultra­sound. This can be used to treat hyper­hidro­sis in the area of the head, hands and, with restric­tions, the armpits.

In case of plan­tar hyper­hidro­sis, an endo­scop­ic lum­bar sym­pa­thec­to­my (ELS) is nec­es­sary. ELS uses endo­scop­ic tech­nique to reach the sym­pa­thet­ic gan­glia in the lum­bar region. The pro­ce­dure is used to treat hyper­hidro­sis of the feet. The sur­gi­cal options are the same as for ETS.


After endo­scop­ic sym­pa­thet­ic surgery, gen­er­al com­pli­ca­tions such as bleed­ing, injury to neigh­bour­ing struc­tures, nerve dam­age, infec­tion, heal­ing dis­or­ders, throm­bo­sis, and embolisms may occur.

Spe­cif­ic risks of ESB, ETS, and ELS are injury to adja­cent organs, blood ves­sels and nerves, pneu­moth­o­rax, pleurisy, and oth­er com­pli­ca­tions result­ing from dam­age to near­by gan­glia.

In addi­tion, all sur­gi­cal pro­ce­dures on the sym­pa­thet­ic ner­vous sys­tem are a major inter­ven­tion in the auto­nom­ic ner­vous sys­tem of a patient, which can have phys­i­cal as well as psy­cho­log­i­cal con­se­quences. On the phys­i­cal lev­el, risks include com­pen­sato­ry sweat­ing, sweat­ing while eat­ing, or Horner’s syn­drome. Neg­a­tive psy­cho­log­i­cal con­se­quences can include depres­sion and the loss of strong emo­tions.

Compensatory sweating after surgery

Com­pen­sato­ry sweat­ing is a very com­mon com­pli­ca­tion after oper­a­tions on the sym­pa­thet­ic nerve. Exces­sive sweat­ing is com­plete­ly pre­vent­ed by dis­rupt­ing the trans­mis­sion of nerve sig­nals to the treat­ed areas (hand, face, armpits, or feet), which affects the body’s nat­ur­al abil­i­ty to reg­u­late its tem­per­a­ture. The actu­al amount of sweat remains the same. As a result, there is often a shift of sweat pro­duc­tion to oth­er parts of the body. Typ­i­cal­ly, exces­sive sweat­ing then occurs espe­cial­ly in the groin and pubic region, on the tor­so, on the legs, and in the lum­bar region and but­tocks.

How much does such an operation cost?

The cost of a treat­ment is usu­al­ly in the mid four-dig­it range.

Will health insurance pay for this surgery?

Whether statu­to­ry health insur­ance will cov­er the treat­ment is uncer­tain. We rec­om­mend ask­ing your insur­ance com­pa­ny before begin­ning treat­ment. After evi­dence of its med­ical neces­si­ty has been sub­mit­ted, the costs will be reim­bursed on a case-by-case basis.

Benefits and risks of sympathectomy compared to HIDREX iontophoresis treatment

Even if the exces­sive sweat­ing in the treat­ment area can be stopped per­ma­nent­ly by the sur­gi­cal pro­ce­dure, the pro­ce­dure should only be con­sid­ered in excep­tion­al cas­es. The oper­a­tion can involve numer­ous risks and side effects such as com­pen­sato­ry sweat­ing. An inter­ven­tion in the auto­nom­ic ner­vous sys­tem is irre­versible. In con­trast, non-inva­sive ion­tophore­sis ther­a­py is free from neg­a­tive long-term effects, although it may cause tem­po­rary irri­ta­tion or red­ness in the treat­ment area.


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