Parathyroid
surgery can be very simple when performed by experienced endocrine
surgeons who specialize in this operation. When performed by surgeons who
don't do this operation very often, the risk of bad problems is dramatically higher.
See our page with published results and a
commentary by the New York Times. There is plenty of data published in
well over a dozen studies that shows that surgeons who perform less than
10 parathyroid operations per year have a cure rate of only 80%. That is,
one out of 5 of their operations will be unsuccessful and will require the
patient to have a second operation. The cure rate increases to about 90%
for surgeons who perform parathyroid surgery about 25 times per year,
increasing to about 95% for surgeons performing 50 or more parathyroid
operations per year. We perform about 1800 per year, which is why our cure
rate is 99.87%. The take home message, if your surgeon isn't doing AT
LEAST one parathyroid operation (not thyroid!) every week, then you have
an excellent chance that you need a second operation. You will read this
on EVERY website, and every textbook on the topic of parathyroid surgery
ever written.
Here
is the biggest issue with parathyroid surgery, and why the experience of
the surgeon is very important to the success of parathyroid operations:
When the 4 parathyroid glands are formed (before we are born), they
migrate from one part of the neck to another. THUS, they are not
always were they are supposed to be and they can potentially be high in
the neck under the jaw or all the way down into the chest next to the
heart! When you understand how the
parathyroid glands are formed, you will understand why parathyroid anatomy
is the most variable anatomy in the human body. The picture on the right
shows that the parathyroid glands can be located from just below the jaw
down to the area around the heart.
The
typical story goes like this: A well meaning surgeon operates to remove a
parathyroid tumor. The operation lasts considerably longer than expected
and afterwards he has to tell you that he couldn't find the tumor.
Remember, not finding the tumor is not malpractice. It happens. It happens
to all surgeons. Heck, it even happens to us on occasion. It just happens more often to those who don't do this
operation very often. The problem comes when an inexperienced surgeon is
so set on not failing that he performs TOO MUCH dissection and too much
operating in hopes of
finding the tumor. This almost always ends up in him removing one or more
NORMAL parathyroid glands (almost 100% of the cases that we see, which is BAD),
and in almost 80% of cases, half of your thyroid (yep, thyroid
not parathyroid). Remember, not curing a patient because the tumor
couldn't be found is OK... it happens. But when normal thyroid tissue is
removed and the good, normal parathyroid glands are removed... that is
bad. This is the EXACT story we see several times every day. This is what
you want to avoid.
"I
think this tumor is in your chest". If
your surgeon says that he/she did not find the tumor because its in your
chest--print this page and roll it up so you can hit them with it. This is
almost always a cop-out and excuse. About 99% of
"missed" parathyroid tumors are in the neck, NOT in the chest. So if he/she says that the tumor is in your chest simply because they
couldn't find it in your neck---then you should immediately become
skeptical and you MUST move on to an expert in parathyroid surgery. It is at this point that you should realize that your surgeon
is not telling the whole truth, and that he/she is not an expert at this
disease. If they can't show you the picture of it in your chest on
Sestamibi and they want to start getting all sorts of x-rays on your
chest, then you need to find another doctor. Let us say this again... if
you have an unsuccessful operation and the surgeon assumes that the tumor
is in the chest and starts getting all sorts of x-rays of the chest (CT
scans, MRI scans, Angiography, Venous Sampling)... then you need to move
on to another doctor who is a national expert. This is NOT the sort of
thing that is to be done at the local community hospital! You are soon to
spend tens of thousands of dollars on unnecessary tests!!! We have
NEVER seen a parathyroid tumor located in the chest that did not show on a
good quality sestamibi scan. Of course, most sestamibi scans (even those
done at big universities) are terrible quality. A high quality scan will
always show tumors in the chest if they are in the chest. NEVER let
anybody operate on your chest if they cannot 100% show you the tumor on a
picture!
If a doctor orders "venous sampling" or angiography, then you
need to move on to a new surgeon. This will not work. These tests are
dangerous, cost well over $20,000, and we have NEVER seen one that helped
locate the tumor. We have seen several cases where this test caused the
patient to have their chest opened to find the tumor... that wasn't there.
There is no reason to ever get one of these tests. It is wrong often, and
helpful NEVER.
When
a surgeon operates and does not find the parathyroid tumor, the adenoma is
said to be "missing". Almost all "missing" parathyroid
adenomas are in the neck and will require the second surgeon to re-operate
on your neck, almost always using the same incision that the first guy
did. (hopefully you don't let the same guy do your second operation unless
he/she is a true expert and endocrine surgeon). The tumor is almost always
located in the neck very near where the first surgeon was operating,
typically because they did not know where to look (they have not done this
enough!!!). The second surgeon--who has done lots more of these
operations--knows where to look and can go get the tumor. Second
operations take longer and have a higher complication rate because of all
the scar tissue inside--caused by the first surgeon's operation.
"I
think you must have 5 parathyroid glands". When
a surgeon operates and does not find the parathyroid tumor he/she will
often give this excuse: "you must have 5 parathyroid glands, because
I found 4 of them and couldn't find the tumor". If you are told
this, then you should feel insulted. This is a crock of crap almost 100%
of the time.... and if
you look at your pathology report you will see that he/she did NOT find 4
parathyroid glands. You don't have 5 parathyroid glands, you have 4. And,
if a surgeon tells you that you were were not cured because you have 5
parathyroid glands and
thus you have special anatomy, then you roll your eyes, get up and walk out. Find
your path report, read it, see that he is fibbing to you. Then find
yourself an expert parathyroid surgeon. If you can tell, we're tired of
hearing this BS excuse from surgeons who don't find the tumor. OK, you
didn't find the tumor, that's OK... but don't make it the patient's fault saying
God gave them 5 glands and it that is why they are not cured. This is BS.
Trust me folks, if you have had a failed parathyroid operation, its not
because you have 5 parathyroid glands.
At
the Norman Parathyroid Clinic, we operate on a parathyroid patient
who has been operated on somewhere else unsuccessfully EVERY SINGLE DAY.
Dr Norman performs between one and three re-operations every day, averaging 4-6 per
week. WE WISH WE DID NOT! WE WISH THAT THESE PATIENTS HAD A GOOD OPERATION
THE FIRST TIME! Some have been operated on 3 or 4 times previously--none
of which were successful! These patients come from all over the US. Nearly all of them are
cured of their hyperparathyroidism in less than 40 minutes (one of them took
us 6 minutes, 32 seconds total time!). Our average operating time for
re-operations for our last 500 is 25.5 minutes. The typical unsuccessful operation that these patients had
previously took over 5 hours with almost every one of them staying in the
hospital 2-4 days afterwards. There are only a handful of surgeons in the
US who can re-operate on these patients with high success. Find one! (or
better yet, find one for the FIRST operation).
There
are several keys to re-operations for hyperparathyroidism (parathyroid disease).
The most important is surgeon experience. The second is a great nuclear
medicine team... your sestamibi scan should be so clear that YOU can read
it. If it is not, it's not a good scan!!! The third key is
Intra-Operative Nuclear Mapping... using a probe to find the radioactive
parathyroid tumor. The technique that almost all experts agree should be used for re-do operations
is the MIRP (minimally invasive radioguided parathyroidectomy). The re-do operation is VERY similar to the MIRP procedure
which has a cure rate of almost 100 percent! Read
more about the MIRP procedure here.
Prior
to any re-operation, the experienced parathyroid surgeon will put lots of
thought into your case. He will review all of your pathology reports and
the operative reports to see what the previous surgeon did, and where
mistakes may have been made. Often an inexperienced surgeon will remove
your THYROID when they can't find the parathyroid. It is our opinion that
this is terrible and should almost never be done. These details must be
sorted out by your new surgeon, so expect your new expert (not the local
guy!!) to spend considerable time figuring out what operation to do... and
not to just jump in with a sharp knife. In our recent review of 500
re-operations that we performed between 1/03 and 12/07, we found that the
previous surgeon removed one half of the patient's THYROID gland in 78% of
cases, just because they couldn't find the parathyroid and thought that
removing the thyroid gland they could find it. THIS SHOULD NOT BE
DONE. Thus, almost 80% of these patients had their thyroid removed
for no reason, and most will have to be on thyroid hormone for the rest of
their lives because their surgeon couldn't find the tumor.
Note: read our page on "What
Patients Say"... there are stories there from dozens of people who
had to have a re-do operation because their first surgeon could not find
the tumor. Almost every time the story is the same... they went to a local
surgeon who somebody said was the "best in our area"... but
really is no more a parathyroid expert than my tabby cat is a lion.
Please... pick your surgeon wisely... we would love to stop hearing these
horror stories!!!
This parathyroid page was last updated 03/26/2010
Suggested Next Page to Read: Finding
the bad parathyroid BEFORE the operation.
The
inability of the surgeon to find the offending parathyroid gland
accounts for about 95 % of all cases of patients needing a second
parathyroid operation. This is called "persistent"
primary hyperparathyroidism because it persists... it was never cured.
In uncommon circumstances, the surgeon removed one tumor when the
patient had two... This is very uncommon. Almost every single time
the surgeon couldn't find the tumor and the patient needs a second
surgeon to find the tumor. We operate on these folks several times per
day because they had a surgeon who performs fewer than 50 parathyroid
operations per year do their surgery.