Lecture Notes: Chronic Blushing and Endoscopic Thoracic Sympathectomy (ETS)

Introduction to Sympathectomy

• Developed in the mid-19th century.
• Aimed to affect the sympathetic nervous system, known for its role in body regulation including environmental response, exercise, and emotion.

Historical Development

• First performed by William Alexander in 1889.
• Initially aimed to treat conditions like goiter, epilepsy, glaucoma, and severe chest pain.
• Early successes included relief from intractable chest pain, uncontrollable sweating, and blushing.
• Various approaches (posterior, supraclavicular) developed over the years to reduce surgery pain and complications.
• Endoscopic version emerged in the 1980s by Goren Claes and Christer Drott in Sweden, reducing recovery time and procedure risks.

Physiology of the Sympathetic Nervous System

• Part of the autonomic nervous system, which controls involuntary functions.
• Sympathetic nervous system: increases heart rate, stimulates sweating, reduces digestion, and prepares the body for fight or flight.
• Parasympathetic nervous system: opposite functions, promoting rest and digestion.

Indications for ETS

• Treatment for idiopathic craniofacial erythema (chronic blushing), hyperhidrosis, and some pain disorders.
• Hyperhidrosis: excessive sweating, an autosomal dominant trait.
• Raynaud’s Syndrome and complex regional pain syndrome (CRPS): treated when linked to sympathetic nervous system issues.

Cognitive Behavioral Therapy (CBT)

• Effective non-invasive treatment for chronic blushing.
• Based on the principle that thoughts, not external stimuli, dictate behavior and emotions.
• Focuses on changing perceptions and behaviors to manage emotional responses.

ETS Procedure Overview

• Requires various endoscopic instruments and anesthesia.
• Procedure involves clamping or resecting sympathetic nerves to alleviate symptoms.
• Bilateral procedure with specific setups for each side of the body.

Potential Complications and Reversal

• Complications: compensatory sweating, Horner’s Syndrome, pneumothorax.
• Reversing ETS is possible but can be complex, especially if nerves were cut rather than clamped.

Related Conditions: Erythromelalgia

• Rare condition causing severe pain and redness in extremities, known as Man-on-Fire Syndrome.
• Symptoms include uncontrollable burning pain, often triggered by warmth or activity.
• Challenging to diagnose and manage due to its rarity and symptom overlap with other conditions.

Summary

• Endoscopic thoracic sympathectomy is a significant surgical option for various conditions linked to the sympathetic nervous system.
• Although effective, it should be considered a last resort due to possible severe complications.

Author Information

• Kara Showalter, CST at Willow Creek Women’s Hospital, aspiring medical student.