OBJECTIVE For many years, thoracic sympathectomy via open surgery was not used to treat Raynaud's phenomenon because of the invasiveness of this procedure and the poor long-term outcomes associated with it. However, with the introduction of endoscopic surgery, thoracic sympathectomy (or sympathicotomy) has been performed by some surgeons as a less invasive surgical option for patients with Raynaud's phenomenon. The less invasive procedure has the possibility of emphasizing merits of sympathectomy. The purpose of this study was to reevaluate the efficacy of sympathicotomy for Raynaud's phenomenon with endoscopic technique and its range of applicability. METHODS Between December 1992 and August 2001, endoscopic thoracic sympathicotomy (ETS) was performed in 28 patients with Raynaud's phenomenon (of a total of 502 patients with autonomic disorders who underwent ETS) at National Kanazawa Hospital. We considered indications for surgical treatment of Raynaud's phenomenon to include severe chronic symptoms or nonhealing digital ulceration refractory to intensive medical therapy. All patients were mailed a self-assessment questionnaire after surgery to determine the immediate and long-term results of the procedure. Data from both initial and long-term follow-up examinations were obtained. RESULTS Fifty-four ETS procedures were performed in 28 patients. No operative mortality was seen, and no occurrence of major complications necessitated open surgery. Initial resolution or improvement of symptoms was achieved in 26 of 28 patients (92.9%). However, later in the postoperative period, symptoms recurred in 23 of 28 patients (82.1%), although no recurrence of digital ulceration was seen throughout our observation. At the final follow-up examination (median follow-up period, 62.5 months), 25 patients (89.3%) reported overall improvement of the frequency and severity of their symptoms. CONCLUSIONS Despite the high rate of recurrence, ETS clearly produced a high rate of initial relief. ETS did indeed promote healing of digital ulcers, and the procedure shows potential for reducing the severity of refractory symptoms. We consider ETS to be the method of choice for treatment of severe or refractory Raynaud's phenomenon, and especially for Raynaud's involving digital ulcer, because of its safety and efficacy.