Review of the Medical Literature About MIRP Mini Parathyroid Surgery

Before doctors send their parathyroid patients for a new type of parathyroid surgery, the "MIRP mini parathyroid operation" they often want to know what the medical literature says. MOST doctors are not up on "what's new" for the treatment of parathyroid disease because most doctors see one case of this disease every few years. Many endocrinologists will tell their patients that parathyroid surgery is dangerous and to be avoided if possible--this is true of the old fashioned operations performed by surgeons who don't do parathyroid surgery EVERY WEEK!!!  But, new techniques make mini-parathyroid surgery incredibly easy for almost all patients. A parathyroid operation performed by a parathyroid expert should take less than 35 minutes for almost ALL patients.. (often less than 16 minutes with some experts), should have a cure rate better than 97% (just over 99% with some experts), and the patient should go home in an hour or so. The days of big parathyroid surgery are gone... your doctor just may not know this yet!.  If your doctor cannot tell you that your parathyroid operation will take about a half an hour or less, and if he/she cannot tell you EXACTLY what they will be doing... then you may want to find a surgeon who is an expert in parathyroid surgery.

Physicians demand that new techniques/drugs/devices undergo scientific testing to prove their value. This keeps "junk" science from becoming common place and assures that patients are taken care of in the best possible manner. Once this testing has been completed, it is subjected to reviews at national meetings and then reviewed by experts in the field. When this is completed, the new procedure / drug / discovery is published in a reputable "peer-reviewed" medical journal. This page reviews some of the more important papers regarding minimally invasive radioguided parathyroid surgery. This page was updated January 06, 2008

The first publication regarding the safety and effectiveness of Minimally Invasive Radioguided Parathyroid Surgery was published in the journal Surgery, 1997; 122:998-1004. This paper describes Dr. Norman's first 245 patients and emphasizes the safety of the radioactivity for the surgeon and operating room personnel who will be exposed to hundreds of radioactive patients (not an issue for an individual patient since it is such a low radioactive dose and it is gone in 5-6 hours). All patients were cured. Prior to publication, it was presented at the Annual Meeting of the American Association of Endocrine Surgeons in Baltimore MD (April 1997). (Editor's note... this operation now takes Dr Norman less than 19 minutes on average, with many taking less than 15 minutes).

Another of article on Minimally Invasive parathyroid surgery examined the ability of the sestamibi scan to predict which patients need only one side of their neck operated on. The results confirmed those from other institutions and showed that a smaller operation could be done through a smaller incision under local anesthesia (i.e. Novocain) instead of general anesthesia (put to sleep). This also demonstrated a potential for fewer complications if a smaller operation is undertaken. This was published by Dr Norman's group in the journal American Surgeon 1998; 64:391-395. Prior to publication this data was presented at the Annual meeting of the Southeastern Surgical Association (February 1998).

A technical "how to" article was published by Dr Norman in Cancer Control 1997; 4:500-504. Dr Norman was invited by the editors of this journal and was published with several additional articles by experts in other areas of radio-guided surgery.  This was a "how to" article aimed at describing the technique to doctors.

An article looking at the cost savings of minimally invasive radioguided parathyroid surgery (the MIRP Operation) and the ability of nearly 100% of all patients with primary hyperparathyroidism to undergo it was published by Dr. Norman's group in the Journal of the American College of Surgeons in February, 1998; 398-405. Prior to publication, this data was presented at the Annual Meeting of the American College of Surgeons (November, 1997). This article was the first of 5 articles published by 4 different universities through December 2002 that showed mini parathyroid surgery to cost about 1/3 to 1/2 as much as standard parathyroid surgery. 

A second article regarding the dramatic reduction in cost as well as a dramatic reduction in potential complications using minimal parathyroid surgery techniques was published by Dr Norman and colleagues in the journal American Surgeon, 1999; 65:796-799. This data was also presented at the 1999 annual meeting of the Southeaster Surgical Congress where it was awarded the "most significant paper" of the meeting. There have now been over 40 articles showing MIRP is cheaper than standard parathyroid surgery.

A sixth mini-parathyroid surgery article was published in January 1999 by Dr Norman and the USF group in the journal Surgery (Surgery 1998;124:1088-1092) which examines the utility of radioguided techniques in 124 patients in whom a previous standard neck operation failed to find the bad parathyroid gland. Said differently... these patients had a standard operation that was a failure--the tumor was not found--but the MIRP parathyroid operation cured them. This study demonstrated that making the hyperactive parathyroid gland radioactive resulted in the locating of the gland 100% of the time in these "re-exploration" cases. MIRP parathyroid surgery has since become the "standard of care" for re-operations. Editorial note, November 2003: Dr Norman now performs a re-do operation between 1 and 3 times EVERY DAY for people who have had a failed operation by another surgery. Virtually all of these patients are sent home an hour or so after the procedure--just like first-time operations. 20% of the operations Dr Norman does is for patients who have already had a failed operation somewhere else.

Two more "how to" book chapters were published (Spring, 1999) by Dr Norman aimed at describing the subtle technicalities in performing this operation.  One was in a book entitled "Radioguided Surgical Techniques".  The other was an invited chapter in the Surgical Oncology Clinics of North America, a very prestigious medical journal. (Surg Ocol Clin N Am, 1999;8:555-64)

In May of 1999, Dr Norman reported on 445 consecutive minimal parathyroid operations (MIRPs) which were performed under local anesthesia with 98.9% of the patients going home immediately afterward. Everyone of these patients was followed for at least 2 years post-op so long term hormone levels have been assessed...still 100 percent cure. This was presented by Drs. Norman and Murphy at the May, 1999 meeting of the American Association of Endocrine Surgeons and was published in the journal Surgery. The real importance of this paper is that it demonstrates statistically how removing a radioactive gland proves to the surgeon during the operation that the operation is complete (proves the overactive gland has been removed) so he/she does not have to continue to dissect through other parts of the patient's neck. The 20% rule: a simple instantaneous radioactivity measurement defines cure and allows elimination of frozen sections and hormone assays during parathyroidectomy. Surgery 1999;126:1023-8.

Dr. Norman was wrote an invited editorial for the Journal of Nuclear Medicine in 1998 regarding the technique of radioguided parathyroid surgery and how surgeons need to work with their nuclear medicine doctors closely if parathyroid patients are to have a great outcome. The citation is: Minimally invasive radioguided parathyroidectomy: an endocrine surgeon's perspective. Journal of Nuclear Medicine, 1998 Oct;39(10):15N, 24N

In July 1999, Dr. Norman was issued a patent for his pioneering work and the development of minimally invasive radioguided parathyroid surgery (MIRP).  U.S. Patent 6,263,232. This patent includes the technique by which a surgeon can measure how much hormone any gland is making in less than 3 seconds. Six months later, his second patent for radioguided parathyroidectomy was issued, this one for re-operations in people who have had a failed first operation.

A very important  review article on minimal parathyroid surgery was written by Dr. Norman and published in one of the world's most premier journals, Annals of Surgery.  This article discusses the choices that surgeons make in deciding what parathyroid operation to perform for patients with parathyroid disease, and how these decisions affect patient outcomes. The citation is: The false-positive parathyroid sestamibi: a real or perceived problem and a case for radioguided parathyroidectomy. Ann Surg. 2000 Jan;231(1):31-7 

What do endocrinologists say about Minimal Parathyroid Surgery???  In March 2003, Dr. Norman and colleagues presented a paper at a major endocrine meeting that discusses how endocrinologists want their patients to have a MIRP mini-parathyroid operation and not the old fashioned parathyroid operation. Read the findings of this very important paper here. (The title of this paper is: The impact of minimally invasive parathyroidectomy on the way endocrinologists treat primary hyperparathyroidism.  "Surgery" 2003;134:910-917)

In October 2002, Dr. Norman was an invited speaker at the annual meeting of the American College of Surgeons.  The topic of this talk was long-term cure rates of MIRP (minimally invasive radioguided parathyroid surgery). The manuscript for this presentation was published in 2003 in the Journal of the American College of Surgeons.

In August 2004 there was a symposium of parathyroid articles in one of the top surgical journals "the Otolaryngology Clinics of North America". Dr Norman wrote the introductory article discussing the advances in parathyroid surgery which have come about in the past 10 years. The citation is: Norman J. Recent trends becoming standard of care yielding smaller, more successful operations at a lower cost. Otolaryngol Clin N Am 2004;37:683-688.

In August 2005 Dr Norman was a speaker at the 6th Annual Conference of Head and Neck Surgeons in Washington, DC.  He published a journal article presented at this meeting regarding outpatient parathyroid surgery in morbidly obese patients. The citation is: Outpatient parathyroid surgery and the differences seen in the morbidly obese. Otolaryngology Head Neck Surgery. 2007 Feb;136(2):282-6.

In early of 2007 Dr Norman published his results of 3000 consecutive parathyroid patients who were sent home within 2 hours of their parathyroid operation. The "Norman Calcium Protocol" is contained within this paper, describing how much calcium patients need after parathyroid surgery. The citation is: Safety of immediate discharge after parathyroidectomy: a prospective study of 3,000 consecutive patients.
Endocrine Practice. 2007 Mar-Apr;13(2):105-13.

Dr Norman's updated techniques performing MIRP mini parathyroid surgery were published in August 2006 in a textbook chapter: Minimally invasive radioguided parathyroidectomy for primary hyperparathyroidism. Mariani G, Strauss HW, Guiliano A (eds), Radioguided Surgery: A Comprehensive Team Approach. New York: Springer, 2006.

Dr Norman and Dr Poliz now operate on patients over the age of 80 virtually every day. These patients come from all over, since our techniques allow for over 99% cure rates and usually take less than 18 minutes. Dr Politz led this study showing how safe it is to operate on patients over 80 and send them home within 2 hours, since the operation was so small and simple. These older patients feel much better when the tumor has been removed. The citation is: Hyperparathyroidism in patients over 80: clinical characteristics and their ability to undergo outpatient parathyroidectomy. Thyroid. 2007 Apr:17(4):333-339.

Dr Norman recently published an article showing how it can be troubling when an endocrinologist biopsies a parathyroid tumor by sticking a needle into it. We discourage this very strongly! The citation is: Norman J, Politz D, Browarski I. Diagnostic Aspiration of Parathyroid Adenomas Causes Severe Fibrosis Complicating Surgery and Final Histologic Diagnosis. Thyroid. 2007 17:1251-1255

  Drs Norman and Politz have a full time data entry person in our office that maintains all of the data collected on thousands of parathyroid patients that we operate on yearly. We publish scientific papers every 2 months or so. Some of our latest publications coming out in 2008 are on the following topics:

1. Parathyroid disease during pregnancy (publishing in Obstetrics and Gynecology, spring 2008)

2. Parathyroid disease and how it causes flair-ups of shingles (Publishing in Journal of Infectious Diseases, Feb, 2008.

3. Parathyroid disease and how it causes kidney stones to form. (In revision for JAMA)

4. Parathyroid disease and how it can cause stones in other parts of the body (Publishing in European Journal of Endocrinology, March 2008)

5. How surgeons can tell prior to the operation if a patient has one or more than one tumor (publishing in Annals of Surgery, spring 2008).

6. How to remove thyroid nodules during a mini parathyroid operation (Publishing in Thyroid, Mid 2008)

7. How to recognize parathyroid tumors that are not in the neck

8. How symptoms of parathyroid disease do NOT correlate with how high a patient's calcium level is.

9. How MIRP techniques can allow for the measurement of INDIVIDUAL parathyroid gland hormone production in less than 3 seconds. This study was in 6000 patients we operated on over 4.5 years. (publishing in mid 2008 in Journal of Surgical Oncology)