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Endoscopic Thoracic Sympathectomy for the treatment of primary hyperhidrosis of the upper limb – Information for GPs

Background

Endoscopic thoracic Sympathectomy (ETS) is a surgical procedure in which a portion of the sympathetic nerve trunk in the thoracic region is destroyed. ETS is used to treat focal hyperhidrosis, facial blushing, Raynaud’s disease and reflex sympathetic dystrophy. By far the most common complaint treated with ETS is palmar hyperhidrosis, colloquially known as ‘sweaty palms’. The intervention is controversial and illegal in some jurisdictions. Like any surgical procedure, it has risks; the endoscopic sympathetic block (ESB) procedure and those procedures that affect fewer nerves have lower risks.

Commissioning position

NHS Scarborough and Ryedale and Vale of York CCGs do not routinely commission Endoscopic Thoracic Sympathectomy.

Applications will only be considered by the individual Funding Request Panel (IFR) where exceptional clinical circumstances are demonstrated. All cases require prior approval.

In view of the risk of side effects, this procedure should only be considered in patients suffering from severe and debilitating primary hyperhidrosis that has been refractory to other treatments. (These may include topical agents, oral medication, botulinum toxin injections and iontophoresis.)

Endoscopic Thoracic Sympathectomy does not work as well for those with excessive axillary (armpit) sweating.

Summary of evidence / rationale

Recent NICE guidance (IPG 487 May 2014) indicates that the evidence base for the efficacy and safety of this procedure is “adequate” but there is a risk of serious complications (including death from major intrathoracic bleeding); it is not always effective; and it can cause hyperhidrosis (“compensatory”) elsewhere on the body (in around 80% of cases, of whom 33% reported symptoms that were “severe‟ or “incapacitating‟).

The primary indication is palmar hyperhidrosis because it is less effective for axillary symptoms. It should only be considered in patients suffering from severe and debilitating primary hyperhidrosis that has been refractory to other treatments.

Further research is required to establish good patient selection and to identify which patient characteristics might predict severe side-effects.

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