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Section 3.
Treatment of
Parathyroid Disease |
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Parathyroid
Surgery Cure Rates.
Different types of parathyroid surgeries have different cure rates.
This page of Parathyroid.com discusses parathyroid surgery outcomes.
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Different types of parathyroid operations have different cure
rates. Interestingly, the biggest parathyroid surgeries have the
lowest cure rates while mini-parathyroid surgery has the highest cure rate.
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| Different types of parathyroid operations have different
complication rates. Again, the largest, old-fashioned parathyroid
operations have the highest rate of problems and complications while
the smallest parathyroid operations have the lowest complication rate.
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The experience of the surgeon has more influence on parathyroid
surgery than any other type of surgery. There is nothing more
important than finding a surgeon who does parathyroid operations very
frequently.
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Even the New York Times
recognizes that doctors who perform only a few delicate operations per
year put patients at undue risk.
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 The
graph on the left is very important for patients with parathyroid disease
to know and understand. There is a big difference in cure rates following
parathyroid surgery depending upon which operation is performed, and the
amount of parathyroid experience the surgeon has. In fact, there is no
other type of surgery that is effected as much by surgeon experience as
parathyroid surgery. Minimally Invasive
Radioguided Parathyroid surgery (MIRP) has been reported in many medical
journals since 1997 to have the highest cure rate of all parathyroid
operations. Some extremely experienced surgeons can
perform mini parathyroid surgery on ALL patients. Other surgeons will only perform a mini parathyroid operation if your
scan is positive, while the least experienced surgeons (your typical
general surgeon or ENT surgeon) will tell you they need to do a big
operation and you have to spend the night in the hospital... because
"that is the way they do it". These are the surgeons you may
want to avoid. Look at this chart and see that the least experienced surgeon will
cure you only 85% of the time. See footnotes below for journal
citations for these statistics. [Editorial note from
Dr Norman... Obviously I can't operate on every parathyroid patient in the
US... however nearly 1/5 of my practice consists of operating on patients
that have already had an operation by an inexperienced surgeon--and they
were not cured--or worse yet, they were not cured and they can't talk.
Yep, from 1 to 3 operations that I do EVERY DAY (out of 12 or 13 that I do
every day) have had an unsuccessful parathyroid operation performed somewhere
else. I'd prefer that all those inexperienced surgeons would stop doing
this operation so we could get at least one experienced parathyroid
surgeon in every town... Find the best endocrine surgeon you can!]
Reasons Why Surgeon Experience is so Important in
Parathyroid Surgery
| The average number of parathyroid operations that surgeons
perform in the U.S. during their residency (surgical training)
is only 2 (two parathyroid operations). Data
from the American Board of Surgery, 1995 and 2002, footnote at
bottom of page. |
| The number of parathyroid operations the average general
surgeon in practice in the U.S. performs annually is less than
2. It is NOT a very common disease. |
| Parathyroid anatomy is the most variable
anatomy
in the human body. |
| The normal parathyroid is the size of a grain of rice, and
can be found anywhere in the neck from the jaw down into the
chest next to the heart. |
| Parathyroid disease can be caused by one bad parathyroid
gland, or it can be caused by 2, 3, or 4 bad parathyroid glands. |
| The complications from parathyroid surgery are serious, and
typically WORSE than the disease. Complications are MUCH more
common in general surgeons (and ENT surgeons) who do 25 or fewer
parathyroid operations per year. |
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There
are really only two potential complications possible during parathyroid surgery,
both of which are fairly uncommon but both of which are very serious. However, the type of surgery and the
experience of the surgeon affect the potential rate of both complications.
The first complication discussed is damage to the nerve to the voice box.
The second is the accidental removal of all four parathyroid glands
causing the opposite problem of too little (none) parathyroid hormone.
 Complication
Number One: Injury to the Recurrent Laryngeal Nerve. This graph shows the risk of injury to the nerve that controls the vocal
cords. Injury to this nerve during a parathyroid operation can make the
patient's voice hoarse. Sometimes the nerve can be stretched or
bruised--when this happens the voice is horse for a few weeks or even a
few months--and then it returns to normal. Sometimes, however, the nerve
is cut during the dissection needed to find or remove a parathyroid
tumor--in these cases the patients voice will remain horse (like a
whisper) for a lifetime. There are some procedures that can be done
to the vocal cord (like injection of Teflon) to make it work better, but
this can be a bad complication.
The MIRP operation often only operates on one side of the
neck and it is a much smaller operation, so the risk is the lowest for
this operation (less than 1 percent, shown in blue). The old-fashioned
standard parathyroid operation has a nerve injury risk of about 1 percent
when performed by experienced parathyroid surgeons (shown in red). When
performed by surgeons who do parathyroid surgery infrequently, the risk
can be as high as 3 or 4 percent! (shown in green). NOTE...this
may seem like a low rate for this complication, but this is a
terrible complication of parathyroid surgery, leaving the patient
with a hoarse voice (sometimes forever), and often the patient can't speak
except for a whisper. Don't take this lightly! Make sure
you discuss this with your surgeon! A parathyroid surgeon who has
done over 1000 parathyroid operations will have a risk of this
complication of less than 1 in 2,500... far less than 1%, as opposed to a
risk of 1 in 25 to 1 in 50 for a general surgeon who does this operation
less than 5 times per year.
 Complication
Number Two: Accidental Removal of All Four Parathyroid Glands Causing Permanent
Hypoparathyroidism. The second major risk from parathyroid surgery is the removal of all four
parathyroid glands (un-intentionally), leaving the patient with NO
parathyroid glands. This is called hypOparathyroidism (too little
parathyroid hormone) and it can cause some bad symptoms (We
have two complete pages on this complication, click here to read
more). This complication is also quite rare, but differs according to
surgery type and surgeon experience. The MIRP mini parathyroid surgery has
a near-zero theoretical risk of removing all four parathyroid glands since only
one side of the neck is explored (shown in blue) and typically glands that
are not radioactive do not get removed. As shown in green,
surgeons who do not perform parathyroid surgery very often have a risk of
causing hypOparathyroidism nearly double that of experienced endocrine
surgeons (shown in red) who have far less than a 1 percent chance of this
complication. Again, please note that this is a TERRIBLE complication and
will consume your life... please be careful and discuss this with your
surgeon. Ask them if it has ever happened to one of their patients and
what they will do to assure you that this will not happen to you. Also,
realize that your surgeons tells you that "you have 4 bad glands and
we have to take out 3.5 glands"...then they are 1) almost guaranteed
to be wrong, 2) inexperienced, and 3) much more likely to cause you
hyp0parathyroidism. This statement should be a big red flag to you and you
must be careful. If a surgeon says this to you based upon a sestamibi
scan, you MUST find a different surgeon.
Read more about surgeon-induced
hypoparathyroidism and a large study of these patients that was
conducted with the Hypoparathyroidism Association of America... by clicking
here.
DEAR DR. NORMAN,
Hi! and Help! My name is Mary Jo and I have been diagnosed with
hyp0parathyroidism
after my surgeon removed all my parathyroid glands when he was
trying to find the one bad one. I have been so sick, MUCH worse
than I was before the operation. They can't get my calcium to stay
in normal ranges. I have been as low as 6.5 and as high as 18.1.
When it is low, I feel worse than I ever have in my life. Is there
a test to find out if I have any parathyroid glands left? It has
been nine months since the surgery. Is it too late to do any thing
about it? Can I get a transplant? And what will be my life span if
I continue staying like this? Please any suggestions will be very
helpful... I am desperate!
Dear Mary Jo,
Regrettably, I get an email just like yours every week. Once you
have hyp0parathyroidism, there is very little that can be done...
you are simply forced to take huge amounts of calcium and vitamin
D every day, and without the parathyroid glands regulating things,
your calcium levels will fluctuate from high to very low, and your
body simply does not like that. That is the reason you feel
so bad. The only hope for patients like you is to take PTH
injections every day. This is a very new treatment, but it
requires you to inject parathyroid hormone (PTH) into your skin
every day just like a diabetic injects insulin into their skin
every day. Most people who do the daily injections will have much
better control of the calcium fluctuations, and therefore feel
significantly better. This is NOT an FDA approved application
of this drug, but it may be the only thing that makes you feel
better I wish you well!
James Norman, MD, FACS, FACE. |
Unsuccessful Parathyroid Operations.
Beside the two main potential complications of parathyroid surgery,
there is one other potential problem following parathyroid surgery: Not
fixing the problem. As discussed on other pages of this Web site,
the anatomy of the parathyroid glands
is extremely variable. The four parathyroid glands can be located all over
the neck--its the most variable anatomy in the entire human body! Thus, it
is possible for a surgeon to operate on you for several hours and NOT find
the bad parathyroid gland. Again, the chance of this happening is
EXTREMELY dependent upon the experience of the surgeon. Those that do this
operation only a few times per year have a probability of not finding the
offending parathyroid gland between 5 and 15 percent of the time. These
patients are then often referred to the experts so they can re-do the
operation. Radioguided techniques (like used in the MIRP operation) has
proven to be the best way to find these hidden parathyroid tumors.
However, do we need to say??... you would be better of going to an expert
parathyroid surgeon for the FIRST operation!
 About
one out of every ten or twelve patients operated on by an expert parathyroid surgeon
is a patient that has already been operated on by a general surgeon (or an
ENT surgeon) who did not find the bad parathyroid gland. Several clinical
studies have shown that radioguided parathyroid surgery is extremely
useful in these cases. Once again, the graph on the left shows how the
MIRP mini-parathyroid operation has about a one percent chance of not
finding the bad parathyroid gland. The standard operation is not near as
good, when performed by an endocrine surgeon (shown in red) or by a
general surgeon (shown in green). (Editorial note: we do 250 to 300 re-do
parathyroid operations per year at the Norman Parathyroid Clinic... we
wish we did not!!).
Finally,
this graph combines all of the other data into one graph to show the
chance of having a 'great' outcome (cured of the disease without any
complications from the surgery). You can easily see that an experienced
endocrine surgeon performing a MIRP mini-operation (shown in blue) has by
far the highest chance of a 'great' outcome. A standard parathyroid
operation on both sides of the neck performed by an experienced endocrine
surgeon (shown in red) should have a 'great' outcome about 94% of the
time, while a standard parathyroid operation performed by a general
surgeon (or ENT surgeon) has the lowest chance of a 'great' outcome.
What Qualifies as an "Expert Parathyroid
Surgeon" ?
A study from New York University has examined this question by
looking at complication rates and cure rates for surgeons of
different experience levels and
their answer is:
 A surgeon
who has performed less than 250 thyroid and parathyroid operations
(in their lifetime) is 'inexperienced'.
A surgeon who
has performed between 250 and 1000 thyroid and parathyroid
operations is 'experienced'.
A surgeon who
has performed more than 1000 thyroid and parathyroid operations is
called an expert.
Our studies show that surgeons that perform less
than 50 of these operations per year have a complication rate nearly
20 times higher than those that do more than 250 per year. |
 Did you know that there are only
132 practicing
endocrine surgeons in the U.S.? And, did you know that less than 20 of them fall into the "expert" category above?
Read
what the New York Times says about surgeons who do an operation only a
few times per year... "it puts people at undue risk".
Study Finds Many Doctors Performing Surgery Lack Practice
February 10, 2003
By RICHARD PÉREZ-PEÑA
A high proportion of the doctors who do delicate medical procedures
— and many of the hospitals where they are performed — have
relatively little experience at them, according to figures being
released this week. Some consumer advocates say the situation may
endanger patients.
Dozens of studies have shown that a patient has a much higher
risk of serious injury or death at the hands of a surgeon or
hospital that handles a particular procedure infrequently. Patient
advocates, including the group that is releasing the new
information, the Center for Medical Consumers, say the numbers point
to a need for the New York State Department of Health and the
hospitals themselves to limit which hospitals and doctors provide
certain services.
"It's time for the state to seriously consider applying
certificate of need to other surgeries," said Arthur Levin,
director of the Center for Medical Consumers. "The volume data
tells us that there are doctors and hospitals out there doing some
surgeries so rarely that it could put people seriously at
risk."
One of the procedures studied was thyroid/parathyroid surgery,
where 2/3 of the surgeons who performed these operations performed 3
or fewer operations per year! |
Footnotes for journal articles for statistics on this
page:
1) Chen H, Zeiger M, Gordon T, Udelsman R. Parathyriodectomy in Maryland,
Effects of an endocrine center. Surgery 1996;120:948-53.
2) Sosa JA, Powe NR, Levine MA, et al. Thresholds for surgery and surgical
outcomes for patients with primary hyperparathyroidism: A national survey
of endocrine surgeons. J Clin Endocrinol Metab 1998:83:2658-65.
3) McHenry CR. Patient volumes and complications in thyroid surgery. British
J Surgery 2002;89:821-823
4) Mittendorf EA, McHenry CR. Complications and sequelae of
parathyroidectomy and an analysis of surgeon experience and outcome. Surgical
Technology International XII. 2003:152-157.
5) Norman J, Politz D. Failed parathyroid surgery: The high personal and
financial cost of surgeon inexperience. Manuscript in press, 2007.
6) Harness JK, Organ Jr, CH, Thompson NW. Operative experience of US
general surgery residents in thyroid and parathyroid disease. Surgery
1995;118:1063-70.
7) Sosa JA, Bowman HM, Tielsch JM, et al. The importance of surgeon
experience for clinical and economic outcomes from thyroidectomy. Annals
of Surgery 1998;3:320-30.
8) Norman J. Surgeon induced hypoparathyroidism. Proceeds of the annual
meeting of the Hypoparathyroid Association. Washington, DC. 2007.
 Read
more about hypoparathyroidism caused by surgeon
inexperience and a study done in conjunction with the Hypoparathyroid
Association by clicking here.
HELPFUL
HINT: GO TO OUR TABLE OF CONTENTS TO SEE A
LISTING OF ALL OF OUR PARATHYROID PAGES AND A DESCRIPTION OF WHAT IS ON
EACH PAGE.
This page was last updated 03/26/2010
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