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Section 3.
Treatment of
Parathyroid Disease |
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Parathyroid surgery is introduced here. The
standard 'big' parathyroid operation is out of date and requires the surgeon to
"explore" most of your neck to find and examine all four parathyroid
glands. Most patients don't need this large operation!
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Surgery
is the only way to treat parathyroid disease...There are no medications or
pills that work to cure parathyroid disease. The parathyroid tumor must be
removed by a surgeon. As soon as the parathyroid tumor has been removed,
you are cured! It is very likely this will change your life. If you
have hyperparathyroidism you need to have parathyroid surgery. BUT IT IS
EASY if you have an expert surgeon!
Note:
We performed a MIRP mini parathyroid operation live on the
Internet for you to watch.
Click
Here to watch a movie of this operation as it occurred live (no
editing).

Since 1925, the standard treatment for parathyroid
disease (primary hyperparathyroidism) has been to surgically remove the
parathyroid gland (or glands) which are overproducing parathyroid hormone.
Remember, this is a
hormone problem, so the goal is to remove the source of the excess
parathyroid hormone (remove the bad parathyroid gland, leave the normal
parathyroid glands). Again, the concept is really quite simple: Find
which parathyroid gland has become a tumor and is making too much
parathyroid hormone and take it out...leaving the other normal
parathyroids alone. The normal parathyroid glands will take over and you
will be cured. You don't need all four parathyroid glands.
 The 'standard parathyroid operation' has
not changed since its invention in 1925, and is performed by putting
the patient to sleep under general anesthesia. An incision is made in the neck,
the muscles of the neck are retracted sideways and the thyroid gland is loosened
up and moved aside to allow the surgeon to identify the four parathyroid glands which reside moderately deep in the neck
behind the thyroid. Patients
having a 'standard parathyroid operation' are always hospitalized over night, and
sometimes as long as a two or even three days. The incision for the standard parathyroid operation has to be made of sufficient length to allow the surgeon adequate exposure of the numerous important structures
within both sides of the neck, and thus it is typically six or seven (and even up to 10) inches long. These wounds eventually heal
nicely but you will have a big scar on your neck forever. The picture on the left shows the incision needed to expose the
parathyroid glands on both sides of the neck when doing the old-fashioned
parathyroid surgery. This is the operation that your doctor may be reluctant
to send you for--often for good reason. The editor of this site believes this
operation should never be done in this fashion, however, this is the operation you
will probably get if you don't go to a parathyroid specialist. This
operation is a very out-dated. There is better technology available. You
can do better. Keep reading.
Because of the numerous small nerves and other important structures within the
neck which reside around the parathyroid glands, the 'standard'
parathyroid operation can be technically challenging and has the best
results when performed by experienced endocrine (parathyroid) surgeons or surgeons with extensive head and neck operative experience.
Numerous publications in medical journals have shown that the
success rate following parathyroid surgery is directly related to
the number of parathyroid operations the surgeon has performed (we
have a page devoted to cure rates).
This is what you will find when you read about parathyroid surgery in
every text book, or on any web site on the Internet...the experience of
the surgeon is more important than anything else. The cure rate
for a standard parathyroid operation performed by a general surgeon is
about 85 to 90% when performed through the big incision you see above and
at the bottom of this page. Endocrine surgeons have a cure rate between 93 and 97%. On other pages you will see that newer forms of mini
parathyroid surgery have cure rates of 99% or better in most patients.
During the standard operation, the surgeon must identify all four parathyroid glands and
remove whichever one(s) is enlarged. As covered in the section describing
hyperparathyroidism in detail, the
vast majority of time there is just one large parathyroid gland (an adenoma
which is a benign parathyroid tumor) and three normal
parathyroid glands. In this situation the one large gland (the
parathyroid adenoma) would be removed leaving the three normal
parathyroid glands to function in a normal fashion indefinitely. If the surgeon found all four
parathyroid glands to be enlarged (found in only 2-3% of patients and
called "parathyroid hyperplasia"), he/she would typically take out 3 or 3-1/2 of these glands leaving some parathyroid tissue behind to function normally in the future. In experienced
hands (endocrine surgeons who have done over 250 of these operations), this
big old-fashioned operation has a
cure rate of about
94-95 percent, but can be as low as 85% for surgeons who operate on
parathyroid patients infrequently. You MUST pick your surgeon
wisely.
To complete
a 'standard parathyroid operation' safely with a high rate of success,
the operation occurs on both sides of the neck (a standard bilateral
neck exploration), and is always performed using general
endotracheal anesthesia. Because of the concern over general
anesthesia in some elderly patients, and concerns about a 8 inch (or
larger) incision on the neck, and the risks of damage to the nerves to the voice box, some
endocrinologists and family doctors elect not to send patients for this operation until
the patients develop SEVERE hyper-parathyroid symptoms or have a significant loss of bone
density (osteoporosis). This means of management of parathyroid
disease may or may not be in the best interests of the patient based
upon the potential risks (small, but real) of the standard
parathyroid operation. You need to discuss the pros and cons of routine
parathyroid surgery with your endocrinologist and weigh the risks of surgery versus continued monitoring of your
body calcium
stores and your bone density. NOTE:
Minimal parathyroid surgery is dramatically
changing the way endocrinologists treat parathyroid disease, sending
almost all of their patients for surgery. Read a recent survey of
endocrinologists (Click Here) to see
how 98% of them would have a minimally invasive parathyroid
operation instead of a standard
parathyroid operation. The picture on the right shows how small of
an incision is made for a MIRP minimally invasive parathyroid
operation- it is a 1-inch incision (or less!) and usually takes less than 20 minutes
to perform. Again, if you can have a 20 minute out-patient procedure to
CURE your parathyroid problem, then it almost always makes sense to get
this done instead of waiting to develop kidney stones, osteoporosis, or
severe symptoms. Thus, you need to read more on this web site about your
surgery options and the difference between the old-fashioned operation and
mini-parathyroid surgery. When we do this operation, it typically takes
less than 19 minutes and has a cure rate near 100%. Patients go home
within a couple hours. Keep reading...
This
big-old-fashioned parathyroid operation typically takes 2 to 6 hours to
complete (depending on the case and the skill of the surgeon), and 5 to 15 percent of patients will not be cured after
the operation. As many as 4 percent will have a serious complication
depending on your surgeon's experience. You can expect to spend 1 to 3
nights in the hospital. This is the way they did it in 1925. FOR ALMOST
ALL PATIENTS--THIS
IS NOT THE WAY IT SHOULD BE DONE ANYMORE. THERE ARE NEW AND BETTER WAYS TO
DO THIS OPERATION! If your surgeon discusses having surgery this
way, and "exploring" for your parathyroid glands, you may want to find an expert surgeon (endocrine surgeon) who
performs parathyroid surgery on a more frequent basis. However, parathyroid disease is
an uncommon problem, so almost all surgeons only know how to do parathyroid surgery the
old-fashioned way--the way they saw it done years ago when they were
learning. Tell your endocrinologist and/or your family doctor
that you want a surgeon that is an expert in parathyroid surgery and that
you do not want the same general surgeon that they send their gallbladder
and breast biopsy surgery patients to. Ask for an endocrine surgeon.
Overview of Standard Parathyroid Surgery
For Primary Hyperparathyroidism
 | You have 4 parathyroids, so all 4 are examined to see which ones are
enlarged. |
 | If one bad (enlarged) parathyroid is found, it is removed (95%
of cases) |
 | If 4 overactive glands are found, 3 or 3 1/2 are removed (5%
of cases) |
 | Cure rate is very dependent upon the experience of the surgeon
(as high as 95% by experienced endocrine surgeons, and as low as
80% for general surgeons who perform only a few parathyroid
operations per year. VERY IMPORTANT. Often the parathyroid
glands are very hard to find, so the surgeon can't accomplish
the first item on this list. |
 | Requires general anesthesia (extremely safe these days, but
usually associated with more hospital time and bigger
operation). |
 | Risks are dependent upon surgeon experience (read more about
this on another page). |
 | Complication
rates extremely dependent upon the experience of the surgeon. |
 | Expected blood loss is low (less than 1/4 cup...no need to prepare for possible
transfusions) but depends on skill of surgeon. |
 | Standard parathyroid operation is expected to take 2.5 to 4 hours, but may take as long as
6 hours or as short as 2 hours...
depends on the skill of the surgeon. |
 | The incision is fairly big, but usually heals nicely.
Almost unheard of to get infected or have a wound problem. |
Bottom line: This is a major
operation but it is typically safe. The outcome will be
determined by the experience of the surgeon. If your surgeon only
does a few parathyroid operations per year, there is a good chance
that you will need a second operation performed by an expert
(possibly as high as 10% or more, see footnotes below). Parathyroid experts typically perform one re-do operation per week
because the previous surgeon didn't fix the problem. Dr Norman
averages one or more re-operations EVERY DAY... that should tell
you to pick your first surgeon wisely!
IMPORTANT: This is no longer the
standard way of doing parathyroid surgery--everyone should be
checked to see if they can have a minimally invasive parathyroid
operation before they elect to have the 'old-fashioned' standard
parathyroid surgery. This cannot be over-emphasized! For almost all
patients, this operation should no longer be done! We NEVER do this
operation and think it should never be done by any surgeon. |
Parathyroid.com EDITOR'S NOTE: The
standard operation for parathyroid disease as discussed on this page
can be avoided for all patients with primary hyperparathyroidism if they have a
surgeon who is an expert in parathyroid surgery. The old fashioned parathyroid
operation is a safe and
effective operation, but typically is a MUCH larger and more complex
operation than is needed. Since the
invention of Minimally Invasive Parathyroid surgery in the early and
mid 1990's, it has been documented that minimal parathyroid surgery has a cure rate that is
higher, a complication rate that is about 1/4 or less, and it can be
done with local anesthesia or "twilight anesthesia" typically in less than 20 minutes.
VIRTUALLY ALL parathyroid patients can have a MIRP mini-parathyroid operation at
some centers performed by some surgeons. NOTE: Even the
standard operation should not be done in the old fashioned way...there are
new techniques used by the best parathyroid surgeons that make this
operation smaller and more successful (measuring hormone levels during the
operation, etc). There are several pages on minimal parathyroid surgery on this web
site, including surveys from endocrinologists and summaries of
journal articles showing statistical evidence of the benefit of
minimal parathyroid surgery. Before you have surgery, make sure you
understand your options!
Dear
Dr Norman... Please put this on your Website. I had my parathyroid operation in
December 2008 by some other surgeon and not by you... and this is
what happened to me. I
first went to a surgeon that said the negative parathyroid scan meant that there
was no tumor. I am 35 years old, well educated, had major bone pain
for about 8 months, (crippling at times) and other typical symptoms.
My calcium levels were 13.6 with a PTH of 178. I'm no
doctor, but I KNOW this is severe hyperparathyroidism. I realized I
knew more about this than the first surgeon so I went to another
surgeon. I had another scan done; this time it showed a faint
object, so the surgeon decided to go in and "explore" for
my parathyroid glands.
This photo shows what the outcome was. The operation took several
hours and I spent almost 2 days in the hospital. The
incision makes me sick when I see how small and quick your
parathyroid operations are. Please put this picture on your website to show others of the "
old school" parathyroid procedure. I thought I could get a good operation
by my local "best guy". Obviously this is why people go to
Tampa.
Editors
note:
This is very typical of parathyroid surgery performed by surgeons
who don't do this operation every single day. We actually see this
every day, and quite
a few that are worse. This was done in Fort Worth, Texas... not exactly small-town
America. Parathyroid surgery performed this way is big and dangerous... and not successful at
least 5-10% of the time. The picture at the top of the page which
shows the neck cut wide open is exactly what this lady's neck looked
like during the first part of her parathyroid surgery, and what yours will
look like if you don't have an
expert. Look, we can't perform everybody's parathyroid
operation, so please, do
your homework. Do not have parathyroid surgery done by some local surgeon
because he was a great guy when he fixed your husband's hernia or
took out your gallbladder! You have a high chance of a poor
outcome. If your surgeon says he/she will "explore" to
find the parathyroid glands, then be prepared for your neck to look
like this.  This lady almost surely would have had
a 3/4 inch incision and an operation that took 16 minutes if we did
her parathyroid surgery. She would have gone home about a 1.5 hours
later, and out for dinner with her family. The picture to the right
is typical of our operations performed on the same size woman. Our
photo was taken 7 days after the operation just like the picture
above. Be
smart! Find an expert parathyroid surgeon. |

Suggested Parathyroid Pages to Read Next:

Footnotes for journal articles examining the success
rate of parathyroid operations based upon how often the surgeon does this
tricky operation:
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, 2009. |
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