Parathyroid
surgery (parathyroidectomy) can be quite simple, or it can be extremely
difficult. The approach to parathyroid surgery is extremely variable
throughout the world, based upon three factors:
-
Experience of the parathyroid surgeon. Multiple
scientific studies have shown that surgeons performing an operation
many times become better at performing it. The time it takes to
perform the operation is less, the complications become more
infrequent, and the cure rates increase. The operations become simple,
quick, and successful.
-
Technology available to the parathyroid surgeon.
Not all surgeons have all the neat new tools and devices available to
them. Some can't perform rapid parathyroid hormone assays in the
operating room. Many don't have the latest in parathyroid probes and
either don't have a probe or have to use a "breast cancer"
or "melanoma lymph-node" probe. Very few can measure the
amount of hormone being produced by each individual parathyroid gland.
-
Where and when your surgeon trained. Mini
parathyroid surgery has only been around for about a decade. Most
surgeons have never seen a mini-parathyroid operation and have never
had formal training in parathyroid surgery. Unfortunately, many places
that perform mini-parathyroid surgery also are in the business of
training young surgeons, so even though your surgeon may be
experienced, he is actually letting an inexperienced surgeon do the
operation while he assists and/or observes. Of course this is
necessary, but you may not want this arrangement.

It
is important to note that the two main tests used to "find" the
parathyroid gland are not on this list. Sestamibi scans and ultrasound
scans can be used to help a surgeon find the tumor, but under no
circumstances are positive scans required in order for a mini-parathyroid
operation to be performed.
The
only thing that determines if you can have a mini-parathyroid operation is
whether your surgeon can do it. If you are told that "only people
with a positive scan" can have a mini-parathyroid operation, then
that is true--for that surgeon. The surgeon is telling you the truth:
he/she requires a positive scan (some require several positive scans)
before they will attempt a mini-parathyroid operation. Although we cannot
operate on every parathyroid patient, we perform mini-surgery on 100% of
patients. We do not require a positive sestamibi scan. We never use
ultrasound scans. We will not stick needles into you prior to your
operation. If your surgeon requires this, then that is what they
require.
So,
why do some surgeons require all this testing prior to a parathyroid
operation, while others (like us) require ZERO scans prior to the day of
surgery? Why can some do mini-parathyroid surgery on 100% while others
will only do mini-parathyroid surgery if the scan is positive?
The answer is EXPERIENCE. Dr Norman performed
his 15,000th parathyroid operation in early 2011. There is no other human alive
that has done 1000 parathyroid operations, other than his partner Dr Doug
Politz (about 10,000) (and Dr Jose Lopez is close behind!). This doesn't mean there aren't some really good
parathyroid surgeons in the US, because there are. However when we look
back at our practice we can see the evolution of how we perform this
operation. We were the developers of mini-parathyroid surgery in the early
1990's. We invented the radioguided approach. We were the first to publish
a trial using scopes to perform parathyroid surgery. We were the driving
force behind out-patient parathyroid surgery (sending the patient home an
hour or so after the operation). We were the one of the first to use local
anesthesia (now we know this is stupid). BUT, during our first 1,500 or so
patients we required a positive scan before we would attempt a
mini-parathyroid operation. Just as nearly all surgeons currently do, we
would tell patients that if their sestamibi scan was negative they were
not a candidate for a mini-parathyroid operation. In the meantime, we
performed thousands more of these operations and by the time we had done a
little more than 3,000 we had developed more techniques and tricks that
allowed us to perform mini-parathyroid surgery on all patients except
those that weighed more than 250 pounds. A few thousand more patients and
we learned enough that we now do mini-surgery even in the biggest morbidly
obese patients. It simply doesn't matter if you have one bad gland, or 4
bad glands, we do a nearly identical operation, therefore we do NOT
require the scan to be positive. Again, we couldn't care less what
your scan shows. If you have primary hyperparathyroidism we should be able
to cure you with a near 100% cure rate and a near zero complication rate,
in about 20 minutes, through a 1 inch incision (less than 220 pounds), and
have you go home in about 1.5 hours. We average 12 parathyroid operations
daily, if even one of them took 4-5 hours we'd never get to go home.
There are some other minor issues which allow some
surgeons to perform more mini-parathyroid operations, such as anesthesia
and the nuclear medicine team. Some surgeons who work at teaching
hospitals will also have residents (student physicians) perform your
anesthesia. This isn't necessarily bad, but it is clearly not as fast and
efficient as it could be if the anesthesia was given by somebody that does
this every day. We use the same anesthesia team for thousands of cases and
they know exactly how to handle parathyroid patients. When you chose a
surgeon, you chose his entire team. Do your homework and chose a surgeon
who is confident. If you ask your surgeon how many cases he performs, and
he doesn't want to answer you, then be careful. If he combines thyroid and
parathyroid surgery together into one number, then make him break it down.
If he won't look you in the eye when you ask him tough questions, then
beware. Of course, this is not just for parathyroid surgery... but for all
surgeons.
Surgeons
are funny people. They wear their personalities on their sleeves. You
should watch your surgeon and his confidence. Does he say "this is
simple and I can fix this easily"? Or, do they want to order a
bunch of tests and scans prior to seeing you? Do they want
"another" scan? Do they want to stick needles into your neck? Do
they say they may need to make the incision bigger? Do they say you may
need to spend the night? (we haven't had somebody stay the night in well
over 8,000 cases). Do you think you know more about some aspects of this
disease than your surgeon? Pick your surgeon wisely. Some are great. Most
are not. Be smart!
The days of giving all parathyroid patients a big operation are gone! Bottom
line: Surgeons who perform only a few parathyroid operations per
year have a cure rate of approximately 85%. Surgeons who do more than
100 parathyroid operations per year have a cure rate of over 98%. We
believe there are less than 4 surgeons in the US who do this many
parathyroid operations. Complication rates are more than doubled as well for surgeons who operate
on parathyroid infrequently! Pick your surgeon
carefully! The airlines know this... they won't let every pilot fly every
type of airplane. Nope, each pilot is an expert in one plane type. Outcomes are
better this way. Just ask the people on the US Airways flight that landed
in the Hudson River. Experience is everything.
