Picking a Surgeon

Do all surgeons perform parathyroid surgery?

No, there are actually very few surgeons who perform parathyroid surgery.  General surgeons, and some ENT surgeons have performed parathyroid surgery for many years.  However, like all other forms of surgery and medicine, the treatment of parathyroids has become very specialized. There are lots of specialized tools and tests, and there are new techniques that are difficult to learn. Most general surgeons perform breast surgery, hernias, gallbladders, and numerous intestinal/abdominal operations. The typical general surgeon performs less than 2 parathyroid operations per year. The results of this 'lack of experience' shows in multiple publications, with lesser experienced surgeons having successful outcomes after parathyroid surgery in only about 85% of cases--and that is when they chose to only operate on people with a positive scan. Yup, they only operate on people with a positive scan, and still are successful in less than 90% of cases. We operate on 2-3 people every day who have had an operation performed by a general surgeon or ENT surgeon and they are not cured, and often have had a serious complication. You must choose your surgeon wisely! The most important information we can give you is that you should pick a surgeon that performs 50 or more of these operations per year...otherwise your chance of a poor outcome or a serious complication is higher. And... if you see a surgeon that tells you he/she does 50 parathyroid operations per year, ask them if this includes thyroid operations... its NOT the same! There are only about 50 surgeons in the US who perform 50 parathyroid operations per year. We understand that we can't operate on every parathyroid patient in the US... but please pick your surgeon wisely or you will have to come here for your second operation! If your doctor sent you to a surgeon who is not performing parathyroid operations every week, then find a different surgeon. If you have to travel to another town to do so, then please do. Statistics don't lie, and experience is what really counts. Currently, 16% of our operations are on patients who let an inexperienced surgeon operate on them and they were not cured. Most of them have had their normal parathyroid glands removed and the tumor is still in their neck! IMPORTANT:  Just because your surgeon says they perform parathyroid surgery does not mean they are an expert. We wouldn't let most endocrine surgeons that we know operate on one of our family members. What you want is VOLUME. The surgeons who do the most are almost always the best.  Here is the sad part--surgeons will exaggerate their numbers and claim they do more than they do. However, as of April 2014, the US Government has begun releasing their Medicare data for all doctors. Now you can look up in the database to see how many parathyroid operations (or any kind of operation) a doctor performs. Read this important article about surgeon volume according to 2012 Medicare data. You will see that there are very few surgeons in the world that do more than 50 parathyroid operations per year, and most surgeons who are "endocrine surgeons" do not. Ask hard questions. Make your surgeon look you in the eye.  And, if your surgeon says they perform more than 120 parathyroid operations per year, simply get up and walk out. The US government data doesn't support these claims, except for our group. Get the best surgeon you can. Ask good hard questions. Make sure you like and trust your surgeon.

Don't General Surgeons get trained to perform parathyroid surgery during their residency training?

Yes, and no.  The American Board of Surgery is the group that monitors surgery residencies and certifies surgeons to perform surgery. Between the years 1990 and 2000, the average number of parathyroid operations performed by surgeons upon completion of their residency was 2.  In other words, the typical surgeon has performed only 2 parathyroid operations total when they become 'board certified' in general surgery. However, once a surgeon is board certified they are allowed to do any operation they want--even if its an operation they have never done before in their life. Unfortunately, about 1/4 of all surgery residents (surgeons in training) graduate and become board certified having done zero parathyroid operations. As you have read in other areas of this web site, the most variable anatomy in the entire human body is the anatomy of the parathyroid glands. This explains the often poor results seen with parathyroid surgery, and the reluctance of endocrinologists to send patients for parathyroid surgery.  In the February 10th, 2003 New York Times, there was an article about the dangers of having surgery for a delicate operation when the surgeon only does a few per year. Parathyroid surgery is one of those operations.  Footnote for surgery training statistics: Harness JK, et al, Surgery 1995; These same experts have suggested that thyroid and parathyroid surgery should be done at specialty centers; their conclusions: Organizing teams of specialists into thyroid centers (centers of excellence) can (1) increase efficiency; (2) increase quality of care; (3) decrease costs; (4) encourage a more individualized approach to surgery; (5) lower complication rates; and (6) foster innovation in technology and disease management.: Harness JK, et al, World Journal of Surgery 2000.

My surgeon says he does mini-parathyroid surgery. How can I tell if he really does mini-surgery?

Surgeons are typically very smart and talented individuals. They know that patients want the most advanced operation and the least invasive operation. And, almost always, surgeons want to provide this to the patients knowing it is in the best interest of the patient also. Some surgeons, however, will occasionally tell the patients what they want to hear.  So be informed and ask these few questions:

  1. Will I have to spend the night in the hospital after the operation? If the answer is "Yes", then the chances are high that the operation planned is not a mini parathyroid operation or this surgeon may not be very experienced parathyroid surgery. Of course, no surgeon can predict the future, and the primary goal of the surgeon is to take care of you safely... so it is possible that you will have to spend the night in the hospital even if you have the best parathyroid surgeon in the world. But...mini-parathyroid surgery almost never requires the patient to spend more than a couple hours in the hospital after the operation.

  2. Will you be putting a drain in my neck? If the answer to this question is "yes", then get up and walk out! There is almost never a need for a drain (to remove blood) to be left in the neck after a parathyroid operation. If your surgeon routinely puts a drain in all of his/her patients following parathyroid surgery, then you should get up and walk out. This is a huge red flag. Move on. Don't even think twice.

  3. What probe do you use a probe to help find the bad parathyroid gland? Ask which probe and if they have a probe that is specific for parathyroid surgery and not just the melanoma and breast cancer probe. Not everybody uses a probe, but if they do, it must be a probe manufactured for parathyroid surgery and not breast surgery... they are different probes.

  4. How big will the incision be?  Most surgeons who do 50 or more parathyroid operations per year (probably only about 50 of these surgeons in the US) will use a very small incision. For thin people, the incision we make is about 1 inch OR LESS. For people above 200 lbs it should be about 1.5 inches OR LESS.

  5. Will there be stitches or staples to take out? If there are, then you may want to seek out another surgeon. Those days are gone!

  6. How many parathyroid operations do you perform EACH WEEK? If your surgeon is not performing parathyroid surgery every week, then you have a significantly increased chance of NOT getting a mini-parathyroid surgery. If they are not doing parathyroid surgery weekly, then they are almost surely not a parathyroid expert, and therefore, your chances of being cured are lower. If your surgeon doesn't do parathyroid surgery every weeek, go somewhere else. It really is that simple.

  7. Will you put a breathing tube in my throat to monitor my vocal cords during surgery? If your surgeon says yes, then you may want to dig deeper. This is often associated with surgeons who don't do this operation very often. Clearly this is not minimal anesthesia, and if they need to monitor your vocal cord nerves so they don't damage them... then that could be a bad sign. Surgeons who do this operation all the time typically do not monitor the vocal cord nerves... this may be something you want to avoid. The rate of vocal cord damage can actually increase when the vocal cords are "monitored". If your surgeon says your chance of nerve injury is one percent, then find another surgeon. It should be way less than 1%. (see next question)

  8. What is the chance that you could damage my vocal cord nerve? Damage to the vocal cord nerve is one of the big risks of parathyroid surgery and what separates the experts from the non-experts. When this happens, you can barely talk and when you eat/drink you will often cough because the food can go "down the wrong pipe". The damage will almost always last 2 months, but occasionally it is forever. The rate of vocal cord damage should be far less than one percent. If your surgeon can't tell you that his/her rate of vocal cord injury is LESS than one percent, then find another surgeon. Period. Make them look you in the eye. A common answer is to say that they will use an endotracheal tube into your trachea during the operation to "monitor" your vocal cord nerves. However, you need to know that there is no published consensus data that shows this decreases the chance of vocal cord injury. In fact, almost every patient that we have seen in the past 5 years with a vocal cord injury had a nerve monitoring endotracheal tube used. This tube does not protect you--it protects the surgeon from malpractice suits. We have overwhelming evidence that nerve monitoring during parathyroid surgery can actually increase the chance of nerve injury. You need to be confident in your surgeon's skills, and you need to ask this important question. It's not a deal breaker if your surgeon uses nerve monitoring, but you must understand it does NOT protect your vocal cords from injury, makes the operation last longer, can be a big red sign of inexperience, and may actually increase your chances of nerve injury. Reference 2017 review article.

  9. If you don't find the tumor easily, will you need to make the incision larger? If your surgeon says yes, then you have a surgeon that is not as experienced as you would like. This means that there is near 100% chance you will have a big incision. Bottom line... if your surgeon isn't doing 50 parathyroid operations per year, then you want to keep looking. Would you fly on an airplane if the pilot only flew 25 times a year? Unfortunately, there are only about 50 surgeons in the US that perform 50 parathyroid operations per year. But there are about 1000 surgeons who say they do. Make them look you in the eye.

  10. Do you remove a gland and then measure the PTH level to see if the gland you removed was bad? If your surgeon says he/she will remove a parathyroid gland and then test your blood to see if the parathyroid hormone decreased, then understand you have at least a 60% chance of having one or more of your NORMAL parathyroid glands being removed. Measuring PTH in the operating room has become the worst thing to ever happen to parathyroid patients. We perform 2 or 3 operations per day on people who have had previous parathyroid surgery, and literally 100% of them have had at least one normal parathyroid gland removed (and obviously the tumor was not removed or they would't need another operation). In 2016, about 50% of the people we see with failed parathyroid surgery have had all three normal parathyroid glands removed because an inexperienced surgeon who has the ability to measure PTH in the operating room will keep removing parathyroid glands as they are found just so they can measure the PTH to see if the levels of hormone in the blood are decreasing. Be careful folks, the surgeons who rely on parathyroid hormone levels in the operating room are typically not experts. Measuring PTH in the operating room has become a crutch for people who don't do parathyroid surgery very often. Please be careful of this!

The Biggest Mistake We See: Too Much Emphasis on the Scans.

The biggest mistake we see is that surgeons put a HUGE amount of emphasis on the parathyroid scans and x-rays and ONLY operate on one side of the neck removing one bad gland and not looking at the other 3 parathyroid glands. They get CT scans (we never get CT scans), sestamibi scans, and ultrasound scans in an attempt to find the tumor. If they aren't very confident that they found your parathyroid tumor then they very often will tell you: "it isn't that bad, your numbers aren't that high, so we're gonna just watch this for a while".  This is bad advice, and what they are really saying is this: "I'm not very good at this operation and I'm not confident that I can find the bad parathyroid gland because your scans are not definitive, so I'm going to avoid operating on you at this time--maybe we can operate on you some time in the future if your scans become more positive and I'm more confident where the tumor is located."

The best way to assure that you are cured is for the surgeon to look at and examine all four parathyroid glands. If you watch our surgery video you will see why: the scan shows 1 and the patient has 2. We perform 12 or 13 parathyroid operations every day, and we look at all four glands in all patients. About 30% (4 people every day) will have more than 1 parathyroid tumor and none of them had 2 tumors show up on the scans. The scans (if they are positive) only show the biggest of the parathyroid tumors, the smaller ones are suppressed by the bigger one and don't show well. Most surgeons in the US who claim to be experts in parathyroid surgery will only look at one parathyroid gland (the one that shows on a scan) and then measure your PTH to see if it drops by 50%--which they interpret as a cure. This is NOT a cure. A drop in 50% shows that they took out a parathyroid tumor, it does NOT say anything about the status of the other three glands. Watch our video (it's only 13 minutes and there is zero blood) and you will see that a large tumor was removed and the patients' PTH fell by 88%, yet he had a second tumor on the other side of the neck that would never have been found if we didn't purposefully look at all four parathyroid glands.

If the best surgeon you can get is only going to operate on one side of your neck and simply take out the tumor that shows on a scan and then measure your parathyroid hormone to see if it falls by 50%, then know that you have a 10% chance of not being cured THAT DAY, and you have an additional 15% chance of needing a second operation within 10 years. Also, know that if you are one of these 25-30% then you will not feel better and your bones will not get better. You will have none of the benefits of the operation if your surgeon takes out one parathyroid tumor and you are one of the 25-30% that have two.  "Why don't they just look at all of them" you ask... because it is hard to do and they are not very good at it. If they were, they would. 

Example of letters that we get at the Norman Parathyroid Center almost every day: -- 

Dear Dr. Norman,

On October 31, 2010, I underwent what was supposed to be a mini-parathyroid procedure at my local hospital. Unfortunately, the surgery did not go as planned and my surgeon then opened up and took 5 hours to "search" for the adenoma. He proceeded to remove half of my thyroid and 2 of my parathyroid glands. I found out later, that he only performs a couple of parathyroid operations per year!! The trauma involved in the surgery left both of my vocal cords paralyzed and led to me having a tracheotomy performed. One vocal cord has since recovered while the other has not. I give you this history so that you may know some of the damage that occurred, however, my question is to do with my remaining 2 parathyroid glands. I am now 4 months post operative and the remaining 2 glands are not functioning, leaving me with hypoparathyroidism and I have to take several medications daily (calcium, phoslo, rocaltrol, not to mention depression medication). Do I still have hope that the remaining 2 may begin to function? Is there a window of time that I should hold out hope, or am I basically required to remain on the medications? My doctors all have different opinions. I have read your website with fascination and thank you for sharing your vast knowledge and experience. Unfortunately, I did not know about your clinic until after my surgery went awry. Thank you in advance for your time and assistance.

Sincerely,

S. H.

Response:

This is a terrible complication and it is possibly due to inexperience of the surgeon. Every possible complication occurred in this patient. She has had all four parathyroid glands destroyed (BAD!) and both nerves to the voice box were damaged... so she couldn't breath and had to get a tracheostomy. She will have a hoarse voice the rest of her life, but is lucky that she does not need a tracheostomy for the rest of her life. She will have to be on very high doses of calcium and other medications. Obviously, every patient in the world cannot come to Tampa to have parathyroid surgery. HOWEVER, please, do not have this operation performed by a surgeon that does not do it regularly! We get one or more letters like this almost every day, and it breaks our hearts. Please be wise! Do not simply go to the surgeon that your doctor sends all of his/her hernias and breast biopsies to! Please choose your surgeon wisely.

Parathyroid Sestamibi Scan

I've had an allergic reaction to x-ray dye. Can I have a Sestamibi Scan?

YES! The material that is used to perform a Sestamibi Scan is completely un-related to other types of dyes used for CAT scans, Arteriograms, and other forms of x-rays.  Having an allergy to IVP (x-ray) dye has no bearing on your ability to have a Sestamibi Scan.  We get asked this question twice a week.  Hear us well--- it is not related to any other scans, and it has no cross-reactivity.

My Sestamibi Scan doesn't show an adenoma. Does this mean I can't have a Mini Parathyroid Operation.

Well, it  depends on who your surgeon is. Most surgeons, even some very experienced ones will not do a mini operation if your scan is negative. In fact, many surgeons won't even operate on you if your scan is negative (discussed above). However, some surgeons will do mini parathyroid operations on all patients regardless of the scan results. LET US SAY THIS AGAIN CLEARLY.... We perform the exact same operation on all patients. We look at all four parathyroid glands in all our operations and we don't care if the scan is positive or negative. We perform about 4000 Sestamibi Scans per year, more than anyone else in the world. We have written journal articles and book chapters on our very specific technique that gives us such wonderful scans.  If your scans do not look clean, crisp and in focus, then your scans could probably be performed with a different technique that may show your tumor.  The difference in the quality of Sestamibi Scans is simply appalling. Patients send us their films on a daily basis (we see about 2200 per year from other hospitals), and we believe that about half are not of sufficient quality that we would rely on them for any medical decision. If your scans are not clear and crisp so that you personally can understand them then ask your doctor to find a nuclear medicine department that does these on a regular basis. And, take a copy of this technical page to give to them...its how we do it here. We show our patients their scan, and over 90% can understand it and show us the tumor without us having to explain it to them--that's how clear and crisp the scans should be.   HOWEVER, even if your scan is negative, you can STILL have mini-parathyroid surgery---this is a decision made by the SURGEON, not the endocrinologist and not the radiologist. Surgeons don't operate on x-rays... they operate on humans! There are several techniques that should be used for all patients to minimize the size of this operation and to increase cure rate!  We perform Minimally Invasive Radioguided Parathyroid surgery on ALL patients, but this is why we do more than 25 times the volume of any other surgeon. We do not choose our patients based upon scan results. We do not require a scan on our patients before they come here for surgery. We do NOT require a positive scan for you to be accepted as our patient. AGAIN---We do NOT care what your scan shows or even if you had one. All we care about is that your lab values show you have parathyroid disease. If you do, then you get a MINI-operation and we will evaluate all four parathyroid glands. This is the operation that has the highest cure rate, without exception. Watch the video and see how quick a four gland operation is--13 minutes in this man. 

My Sestamibi Scan shows a 'possible' adenoma. What does this mean?

It can mean several things.  In all of his publications, Dr Norman defines a 'positive' Sestamibi Scan as a scan that "shows a single focus of radioactivity which is distinct from the thyroid gland".  In order to do this, there are very specific maneuvers the Sestamibi technicians must perform to allow for enough detail to be achieved. A few single adenomas, and those patients with multiple bad parathyroid glands will not show a positive scan as defined above.  Thus, even at the Norman Endocrine Surgery Clinic, we can expect that about 14% of patients will not have a "positive" scan. About 5-7 percent will have a 'suggestive' scan which indicates a 'possible' adenoma. The remaining 5-7 percent will be completely negative--nothing shows up to indicate which parathyroid gland is bad. Typically these patients have 4 bad glands and not just one, so in this case the Sestamibi was CORRECT in that it did NOT show a single bad gland (a 'true negative test'). BUT DON'T WORRY!!! An experienced surgeon can still operate on you and cure you with a very safe operation. Talk to your surgeon about this. We perform MINIMAL PARATHYROID SURGERY EVERY DAY ON PATIENTS WHO HAVE "NEGATIVE" AND "SUGGESTIVE" SCANS.  ESSENTIALLY 100 PERCENT OF ALL PATIENTS GET A MINIMAL OPERATION at our center.

Am I Too Old for Parathyroid Surgery? Isn't it Too Risky?

Am I too old for parathyroid surgery?  Isn't it too risky at my age?

Surgery always has a risk associated with it. However, so does having parathyroid disease for several years. Almost always, the risk of having parathyroid disease is much higher than having surgery.  Modern anesthesia is very safe.  Most importantly, however, Mini-Parathyroid Surgery makes the entire operation safer and smaller.  The anesthesia risk is decreased on an operation that takes less than 20 minutes on average versus one that takes 2-6 hours. Local anesthesia can be use for Mini-Parathyroid Surgery and thus a general anesthesia can be avoided.  Dr Norman and his surgeons have operated on many parathyroid patients in their 80's and 90's, and one over 100! We operate on people over the age of 80 at least once per day because our operations are so quick that their doctors send them here. Bottom line: Age is NOT an issue and should not prevent a patient from having an operation--by an experienced parathyroid surgeon. Age is a reason to avoid the major parathyroid operation performed by a general surgeon who may not be very experienced at this operation. Parathyroid surgery is easy if your surgeon is an expert. One final note: In 2013 we performed 281 parathyroid operations on patients over the age of 80. Our average operating time for this group was 16.2 minutes. The shortest operation took 11 minutes while the longest took 29 minutes. 100% were cured, and 100% went home about 1.5 hours later with a Band-Aid on their neck. 100% had an incision that was 1 inch or less. This is why people seek out an expert for their parathyroid surgery.  In May 2007 we published a medial journal article showing the safety of operating on patients over 80 years of age and sending them home within 2 hours. The average operative time was under 17 minutes and everybody did great... they all went home within 2 hours. We now operate on people over the age of 80 nearly every day, sometimes 2 or 3 people over 80 in one day. The article citation is: Politz D, Norman J. Hyperparathyroidism in patients over 80: clinical characteristics and their ability to undergo outpatient parathyroidectomy. Thyroid, 2007. Apr;17(4):333-9

Anesthesia for Parathyroid Surgery

What is 'Light Anesthesia'. Why is it better than 'General Anesthesia' in many cases?

The principle requirement is that the patient must be made numb so they don't feel the tissues being cut. Another desirable effect is to make the patient 'un-aware' of what is happening so they don't worry or become too anxious (or talk too much!). Thirdly, it is often beneficial to have the patient not remember things in the operating room (give amnesia).  General Anesthesia is when you are 'put to sleep'.  General anesthesia accomplishes all of the above, but it suppresses your brain to such a degree that a tube must be put down your throat into your trachea so that a machine can breath for you. Mini parathyroid surgery can be done via 1) general endotracheal anesthesia, 2) "light" anesthetic that uses an anesthesiologist to give a mild sedative in your vein and a soft piece of plastic to hold your mouth open so you can breath on your own, 3) local anesthesia with IV sedation, or 4 via a cervical block where the nerves to the neck are numbed by an anesthesiologist prior to going to the operating room. Like most of the parathyroid experts world-wide, we have used all of these techniques at one time or another as the situation dictates. We now use the light anesthesia with an LMA airway on almost all cases. The combination of drugs that the anesthesiologist can give makes the surgery painless, and keeps the patient quiet and restful. They breath on their own, and wake up more refreshed than after general anesthesia. They can typically go home in an hour or two. Depending on the patient, light anesthesia with IV sedation can be less risky to the heart and other organs than general anesthesia. You are "asleep" enough that you don't feel or remember anything, but you are awake enough that you don't have to be put on a breathing tube that goes into your trachea. Since we tilt your head back a bit to get access to the parathyroid tumor, we typically put a small piece of soft plastic in the back of your mouth to keep your tongue out of the way so you can breath good (this is the LMA). You will NOT be aware of any of this, and you will NOT feel any of this. Bottom line, some expert parathyroid surgeons use other methods that work well for them and their patients in their hospital. Trust your surgeon on this!  However, most patients can avoid the full endotracheal general anesthesia. And... as noted above, as a general rule, avoid surgeons who use a tube to monitor your vocal cord nerves. Our data shows these surgeons have the worst complication rates... not opinion... this is factual. Vocal cord nerve monitoring is performed to protect the surgeon from a malpractice suit, it is not performed to protect the patient's vocal cord nerves.

If the parathyroid operation is performed under "Light Anesthesia", wont I be too awake and nervous?

This is an excellent question. The anesthesiologist will be giving you some sedative medication into your veins. This will make you sleepy, restful and quite peaceful. You will be awake enough to move yourself onto the operating table, but then you will just close your eyes and relax and go to sleep.  The nice thing about these new sedative medications is that they wear off quite quickly, so when the anesthesiologist turns it off, the patient typically wakes up and feels quite normal within a few minutes. All patients are monitored by the anesthesia team during the entire procedure (like a major surgery) for safety reasons. You will not know what is going on, and you will have no memory of the procedure. You will be ASLEEP, but not so much that your body functions have to be run by a machine! If your surgeon puts all of his/her patients under general endotracheal anesthesia for this operation then it may be a clue that they don't do many of these... and that their anesthesiologist doesn't do many.

Leaving the Hospital After Mini-Parathyroid Surgery

When can I go home after Mini-Parathyroid Surgery (a MIRP Procedure) ?

Mini-Parathyroid Surgery, and specifically mini-parathyroid surgery done with radioguided assistance (the MIRP Procedure) is almost always done under very mild anesthesia (the patient is given sedatives in their veins, but they are not put on a breathing machine like a full general anesthesia). They are asleep for the procedure enough that they don't feel or remember a single thing, but they are awake enough to breath for themselves. This means that the patient typically is awake and alert within minutes of the operation. Usually within 15 minutes they are drinking juice and conversing with their family. Almost all patients are discharged within 1 to 1.5 hours of the operation. Most go out for a nice dinner to celebrate!

What Happens to My Calcium, and Why do I Take Calcium Pills After Surgery?

What happens to my Calcium levels right after the surgery ?

Your blood calcium level has been high for months or years. It will start going down immediately after the operation. Your remaining parathyroid glands have been dormant (asleep) as long as your calcium has been high. It will take a week or two for these normal parathyroids to 'wake up' and start controlling your calcium like they are supposed to. If we don't give you calcium pills to take starting the evening of the operation, your calcium will go too low, and you will have symptoms of LOW Calcium. Therefore, ALL parathyroid patients are put on calcium pills after the operation. You must take the calcium pills or you will develop symptoms of low calcium during the first 1-10 days after the operation. Having a low blood calcium is more dangerous than a high calcium. 

The Symptoms of LOW calcium are:

  • Tingling around your mouth and lips
  • Tingling in your fingertips
  • Cramps in your hands/wrists
  • Feeling like 'something is wrong'... feeling poor, confused, and 'in a fog'
  • Body feels like it is "vibrating"

What should I do if I have symptoms of LOW calcium after my surgery ?

If you have symptoms of low calcium--- take 2 extra calcium pills right away. How many calcium pills can you take? Take the 2 extra pills and if you still have symptoms 2 hours later, take 2 more. You can do this until you have taken an extra 10 pills. For our patients, we ask that you call us after 10 pills. We will simply tell you to take more, but we want to know who you are so we can help. We perform 72 parathyroid operations per week, and this happens to one of our patients about once per week. We usually know who it is going to be (because they have had high calcium levels for along time and we take out a large parathyroid tumor -- or two). If you are still having symptoms, you may need to go to your local emergency room and have them check your calcium, but this is very rare in our practice because we have done this so many times. We perform about 3500 parathyroid operations per year and have only about 2 people per year go to the emergency room to get more calcium. This is because we educate our patients and give them specific written instructions at the hospital--that we talk about with them. NOTE: About 1/10 of all parathyroid patients will have some symptoms of low calcium... even if they take their pills, so you should expect it to some degree and taking more calcium pills will make the symptoms go away before you need to take 10 pills. But if you need to take more, you simply call us. All of our patients get all of our surgeons' cell phone numbers just in case they want to discuss this issue. Also remember, we are very aggressive at giving calcium to our patients--starting within minutes of the operation BECAUSE we are very confident of curing our patient because we examine all four parathyroid glands.

How Long Will You Be on Calcium Pills? All parathyroid patients that we operate on are started on 4-5 calcium pills per day. We recommend Citrical which can be bought over-the-counter at any grocery store or pharmacy. We give our patients specific instructions on what type of Citracal to buy.

Our typical Calcium dosing schedule following parathyroid surgery is:

  • 4 calcium pills per day for one week (5 if your calcium is over 12; 6 pills if your calcium is over 13)
  • 3 calcium pills per day for one week (4 if your calcium was over 12)
  • 2 calcium pills per day for a long time. (3 if you have severe osteoporosis with T-scores of -3.5 or worse)

Shouldn't patients spend the night after surgery to monitor their calcium levels?

This is a technique that was standard until the mid 1990's. If your surgeon is not very experienced with parathyroid surgery, he/she may have you spend the night (or several days!) and measure your calcium levels every 6-8 hours or so (because they are not sure if they cured you, because they did not assess all four parathyroid glands!). We have taken care of tens of thousands of these patients, so we know what to expect. We give all our patients calcium pills and full instructions on how many pills to take. This is very simple. Your calcium will drop when the bad parathyroid gland is removed, so... take some calcium pills for a couple of weeks. It is really no big deal as long as the patient takes their pills! We send about 2600 patients per year home an hour or two after the surgery. We give all of our patients their first Citracal pill about 10 minutes after the operation (most don't even remember this!)  AND... every patient gets our doctor's  home telephone number and cell phone number so they can call them directly with any questions. Make sure you know to contact at your surgeon's office if you have problems with calcium after the operation. In late 2006 we published a study in a major medical journal showing how people react to their calcium levels after their operation. Endocrine Practice. 2007 Mar-Apr;13(2):105-13. This paper includes data on 3000 patients who were sent home immediately after their operation for primary hyperparathyroidism and started on the calcium protocol listed above. On this protocol, just under 7% of people got any symptoms of low calcium and almost all of them did just fine if they simply took a few more pills (some need as many as 12 pills per day, but don't do this without talking to your surgeon!). Only 6 people out of 3000 had to go to the emergency room for IV calcium (in their veins). Not a single person had to be admitted to the hospital. A link to this very important paper will be provided here in the near future when this article is published. Bottom line, you must take calcium pills after your operation or you will almost certainly get sick... some will get extremely sick. Take your pills and chances are extremely good that you will do wonderfully!

Should I take calcium for a few years so my bones get stronger again ?

If you have decreased calcium in your bones (osteopenia or osteoporosis), then you probably need to be on calcium for years. Your body will put calcium back into your bones (reverse some or all of the osteoporosis) over several years time. You should also take Vitamin D daily, thus we recommend a calcium pill that has vitamin D already in it. Studies have shown that AFTER a parathyroid tumor has been removed, patients can expect their bone density to RISE about 6-7% per year for several years. This means that you can expect for your osteoporosis to get better and even go away after removing the parathyroid tumor. This will NEVER happen without surgery to remove the bad gland...no amount of Fosamax or any other drug will reverse the osteoporosis without surgery FIRST.

What Can I Eat After Parathyroid Surgery?

When can I eat after parathyroid surgery?

We let all of our patients eat whatever they want as soon as the operation is over. Many go out for dinner, and some of the ones that are operated on in the morning go out for lunch!  Really... the new operation is not a big deal. Talk to your doctor about this and get specific instructions.

What am I allowed to eat? Do I have to avoid Calcium in my diet?
You can eat whatever you want after your parathyroid surgery. You do not have to avoid calcium-containing foods. Your calcium problems are behind you, and you can have as much calcium in your diet as you like (see the section above...you should have lots of calcium in your diet!).

Can't I Just Wait and See What Happens? Can I Avoid Parathyroid Surgery?

Can't I just wait and see what happens? Is parathyroid disease really that bad?

Well...The problem with this type of management of parathyroid disease is that the parathyroid hormone is working 24 hours per day to take calcium out of your bones. ALL patients with hyperparathyroidism will get osteoporosis if they wait long enough. Furthermore, most patients (about 95%) claim to feel a lot better once the parathyroid tumor is removed...thus you may be cheating yourself out of a better, more healthy lifestyle. We also know that long-term exposure to high calcium in the blood increases the chance of developing breast cancer, colon cancer, and kidney cancer. It also causes significant heart problems. People with untreated hyperparathyroidism have been shown in multiple studies to die several years earlier than they would. This is all covered on our Symptoms page.

Remember, hyperparathyroidism is a slowly lethal disease. Just like high cholesterol, it causes problems over time, thus duration is the problem. A little bit if high calcium for many years is very dangerous. We have lots of information on this on our symptom page.

Bottom line, parathyroid disease causes many other problems over time, and thus the goal should be to get the parathyroid tumor out as soon as possible. Time is the enemy and with increased time there is an increased rate of: osteoporosis, kidney stones, kidney failure, high blood pressure, heart attack, stroke, atrial fibrillation (heart rhythm problems) depression, anxiety, sleep apnea, leg cramps, and many others. Waiting is always the wrong thing to do. The problem will always get worse--it will never stay the same and it will never go away.

Can I Take Fosamax Instead of Having Surgery?

My doctor put me on Fosamax. Will this drug help my bones get stronger?

NO, NO, NO. Taking Fosamax, Evista, Boniva, Actonel, Reclast, etc will NOT help bones that are being attacked by a bad parathyroid. There are two important issues here. First, none of these drugs work on bones in the same way that parathyroid hormone does. It does not block the effects of parathyroid hormone (PTH). None of these drugs is approved by the FDA for helping bones in patients with hyperparathyroidism, and it has not been shown in any clinical trial to help increase bone density in patients with parathyroid disease. It does not work! Even the makers of these drugs do not recommend using it for this purpose. Parathyroid hormone is much too powerful for Fosamax to overcome. Parathyroid patients can take Fosamax for years and their bones will continue to get thinner! Do not make this mistake! NOTE, these statements are true for Fosamax, Actonel, Evista, Boniva, Miacalcin, and others... not just Fosamax. Also, all of these drugs are GREAT drugs and they help many people with osteoporosis... but they don't work if you have a parathyroid tumor. They were not designed for this purpose or this disease.

Why did my doctor put me on Fosamax if it doesn't work?

The second issue is that a lot of endocrinologists don't want to send their patients for the big "old-fashioned" parathyroid operation... so rather than do that, they feel Fosamax "may be worth a try rather than send you for that big operation".  In a recent study (2008), 55% of endocrinologists stated that they have had at least one of their patients who was not cured after having the old-fashioned parathyroid surgery. This fuels their skepticism of parathyroid operations performed by surgeons who do not specialize in endocrine surgery. If you really want the truth, it is because most doctors are not very good, and you know it if you are reading this page. We know from experience, that 90% of patients reading parathyroid.com know more about hyperparathyroidism than their doctors. That is the sad truth.

Should I be taking calcium pills before the operation if I have osteoporosis?

Absolutely not. If you have hyperparathyroidism you should not take calcium pills. In fact, you should avoid high-calcium foods (like milk and cheese). Even if you have osteoporosis, you should not take calcium pills or a multi-vitamin if you have hyperparathyroidism. This will make you feel worse or could actually trigger a high calcium spike that can trigger a stroke. YES, we have seen people get a stroke because their doctor told them to take calcium pills for their osteoporosis even though they had hyperparathyroidism. AFTER the operation you should take lots of calcium so your bones can return to normal... but NOT BEFORE!  Similarly, you should not be taking vitamin D!  We have an entire page on Vitamin D. If your calcium is high and your vitamin D is low, then you should NOT be on vitamin D until after your parathyroid tumor is removed. Read more about Low Vitamin D here.

When do I go back to see my surgeon, endocrinologist or family doctor after mini-parathyroid surgery?

After parathyroid surgery, when do I see my surgeon again?

When to see your surgeon depends on what type of surgery you had. If you had the old-fashioned big surgery, you will probably spend a day or two in the hospital, and then will see the surgeon about one or two weeks later.  If you had a mini-parathyroid operation you will probably be sent home an hour or two after the procedure and will see the surgeon or your family doctor post op. Many times, the mini-surgery is so simple that you don't need to see the surgeon again, and can simply follow up with your family doctor or endocrinologist in a week or two. You just peel off the small Band-Aid one week after the operation. No stitches, no fuss.

After parathyroid surgery, when to I see my endocrinologist or family doctor again?

Again, the old-fashioned big parathyroid operation will often require more follow up visits. The wound is dramatically bigger and has much more potential complications, thus more visits to the doctor are often indicated. If you have the big operation, then you will see your endocrinologist or family doctor several weeks after your first visit to the surgeon after the operation.  If, however, you have a mini-parathyroid operation, you may be able to skip one or more doctor visits (mini-operation usually equals mini-problems!) and proceed directly to the endocrinologist or family doctor a week or 10 days after the mini-operation. Your surgeon will make these arrangements for you on a case-by-case basis. Of course, this is the kind of think you need to discuss with your surgeon and he/she will customize this process to what is best for you. Also, if your surgeon does not check all four parathyroid glands, you will need to be checked every 6 months for life for the return of hyperparathyroidism and a need for a second operation. About 25% of people that had a surgeon take out one parathyroid tumor and quit the operation will need a second operation. If your surgeon examined all four glands, (and you have a pathology report to prove it), and you are cured, then you can presumed to be cured for life and do not need to check calcium and PTH every 6 months forever.

What happens at this doctor visit after the parathyroid surgery? Does anything in addition to the calcium level need to be checked?  Does the patient need an endocrinologist?

How you are treated after parathyroid surgery depends on whether you had mini-surgery or the old-fashioned surgery. Those who get a mini-operation and go home an hour later can have a post op visit any time within the first 2-3 weeks. There are no stitches to take out... nothing to do except get your blood tested for calcium and PTH. It is very simple! After that, there is nothing else to be done. Once cured, almost always cured (less than 1% chance of ever getting this disease again in your lifetime IF YOUR SURGEON LOOKS AT ALL FOUR PARATHYROID GLANDS). The only issue left is deciding on how much calcium to take daily for years to help the bones get strong, and whether or not to put a patient on a bone-increasing drug. If you have an endocrinologist he/she will probably be the one that follows your osteoporosis for several years to document that your bones are getting stronger... and many family practice and internal medicine doctors know this well so you may not need the endocrinologist.  You do not have to get your calcium and PTH checked every year if your surgeon checked all four glands. However, if your surgeon did not check all four glands, then you MUST have your calcium and PTH checked every 6 months for life, because 25% chance you will need a second operation.

If I go to Tampa for my surgery, what do you do about my wound and stitches?

Our surgeons use many modern surgical techniques, including the most modern sutures. All the sutures we use are absorbable, so the body will absorb them and they disappear in about a month. For the skin, we use a suture that is thinner than a human hair, and the wound is closed in a manner that allows all the stitches to be on the INSIDE... thus there are NO stitches to take out. This is a "Plastic Surgery" type of closure and it results in a very small, often un-noticeable scar that is about 1 inch in length. You go home with a small "steri-strip" bandage as the only bandage...like a 1 inch long piece of white tape over the wound. You can get this wet and shower/swim within 24 hours. Then you simply peal it off 1 week after the surgery. If you weigh less than 120 pounds, the wound is usually about 3/4 inch. You will be amazed at how simple this can be! Please watch the movie of the MIRP operation to see more about the wound and the stitches...Click Here to watch the movie.

I have a thyroid nodule. Can my thyroid nodule be removed during a mini-parathyroid operation? Can this be done through the same small 1 inch incision?

Is it true? I can have my thyroid nodule removed at the same time as a mini-parathyroid operation?

The answer to this is YES--if you have an experienced parathyroid surgeon. The facts are that about 80% of patients will have some form of thyroid nodule by the time they are 60 years old. This number increases to about 90% when the patient is 80 years old. At least 99% of these are simple, benign nodules. However, sometimes these nodules should be biopsied or removed. Thus it only makes sense that your parathyroid surgeon should be familiar with all types of thyroid nodules and know what to do if certain types of thyroid nodules are found. During 2013, our surgeons performed 2,487 parathyroid operations. Of these, 470(19%) had a thyroid nodule removed or biopsied during the mini-parathyroid operation. None of these patients required a larger incision...this can still be done through an approx 1 inch incision if your surgeon does this type of operations all the time. On a dozen occasions, thyroid cancer was found and the patient required a complete removal of the thyroid gland (these two patients needed a larger incision to cure the thyroid cancer). Only six patients who had a thyroid nodule or a portion of one thyroid lobe were kept in the hospital overnight. Mini-surgery techniques and virtually bloodless surgery allows virtually all of these patients to go home within 2.5 hours (about 30-60 minutes longer than if they did not have a thyroid nodule removed).  The bottom line is this: the parathyroid glands are located BEHIND the thyroid gland, so it is good and acceptable practice to evaluate the thyroid at the time of parathyroid surgery. Your surgeon should be able to do this, and he/she should be able to tell you what they plan on doing about any thyroid nodule they find during your parathyroid surgery. Another problem with surgeons who are only going to look at the one bad parathyroid gland that shows on a scan and not check the others is that these surgeons do not have the opportunity to check your thyroid for problems--like thyroid cancer. The chance of cancer is very low, but these nodules should usually be evaluated and not ignored. It is simple, adds only a few minutes to the overall operation, and will allow the nodule to be removed so it doesn't have to be worried about any longer. Again, talk to your surgeon about your thyroid and figure out what he/she plans to do if they find a thyroid nodule. However, let us say this in closing... it is NORMAL to have a thyroid nodule. MOST humans with parathyroid disease have at least one thyroid nodule, thus you are not different from most patients with parathyroid disease. Do not make a big deal about your thyroid nodules. Should it be looked at?...YES.  Should it be removed?... not necessarily (most do not need to be removed).  Is it a big deal?... not really. Trust your surgeon's experience on this topic.

My doctor says I can't have a mini parathyroid operation because I have a thyroid nodule.

This is true for almost all surgeons. However, this is NOT true for some parathyroid experts. For our last 30,000 patients, about 22% have had a thyroid nodule removed during the mini parathyroid operation. This added procedure adds about 2 to 5 minutes to the typical parathyroid operation. Some peripheral nodules can be removed very quickly, while some large central nodules will take 5-10 minutes to removed. We almost never increase the size of the incision. In general, a thyroid nodule is EXPECTED in patients with parathyroid disease and thus it is so routine that it should cause your surgeon little or no concern. If your surgeon is making a big deal about your parathyroid operation because you also have a thyroid nodule, then this is a sign that they aren't as experienced as you may want. This is not a big deal, do not let your doctors make a big deal about it. Get it addressed, get the nodule removed if necessary, but geeezzze, don't let them tell you that you have to have a big old-fashioned parathyroid operation because you have a thyroid nodule!

To read more about thyroid nodules, go to our sister website ThyroidCancer.com

This page was last updated: 03/11/2022