Pre-Operative Decision Making
Who is a candidate for minimal parathyroid surgery?
It is clear that ALL patients with primary hyperparathyroidism are candidates for minimally invasive parathyroid surgery using intraoperative nuclear mapping. ALL parathyroid patients can take advantage of using a radioactive-detection probe during the surgery, and many of the other lessons that we have learned while performing mini-parathyroid surgery--even if they need all four parathyroid glands examined. Yes, Yes, Yes... ALL patients can have a mini-operation, and ALL patients can go home within hours of the operation.
Who can have the smallest of all parathyroid operations... the MIRP? -- EVERYBODY. However, we still distinguish between those found to have a single radioactive parathyroid gland on high-quality sestamibi scan and those who's scan does not show a single parathyroid tumor. Remember, about 4-5 percent of all patients with primary hyperparathyroidism will have four-gland hyperplasia (or the more rare multiple parathyroid adenoma)...they require exploration of all four parathyroid glands. Of the 95-96 percent of patients that have a single bad parathyroid gland, some will not have a sestamibi scan which shows which parathyroid gland is the bad parathyroid.
HOWEVER. EVERYBODY CAN HAVE A MINI OPERATION WHEN PERFORMED BY A FEW EXPERTS WHO DO THIS OPERATION DAILY. Somewhere between 87 and 90 percent of all patients with this disease will end up having a the smallest and quickest of all operations. As centers have gained more experience over the past year or two, this rate has climbed gradually. Editor's Note: The author's institution (Norman Parathyroid Clinic) performs a mini-parathyroid operation on ALL patients! Even those that need 4 gland parathyroid exploration avoid general anesthesia and get a 1 to 1.25 inch incision.
Localizing studies are not always required prior to the morning of the operation. Studies other than sestamibi are rarely helpful and unnecessary, and there is usually no reason to get the sestamibi prior to the day of surgery (unless you are traveling a long way for the operation, it is often helpful to get the scan ahead of time so the trip can be planned better). When the diagnosis of primary hyperparathyroidism is made, the patients are scheduled for the operating room and entered into the following protocol:
The minimally invasive approach to parathyroid surgery is performed using local anesthesia or a very "light general" anesthesia using sedation drugs given IV, and most patients are sent home an hour or two following the operation. The same-day surgery rate should average better than 98 percent of ALL parathyroid patients, with the others sent home the following morning.
Those undergoing a standard bilateral parathyroid exploration should almost always be sent home the same day as well, although some surgeons will elect to keep their patients overnight for a "23-hour stay". It is becoming quite uncommon for patients to stay longer than 23 hours following routine standard parathyroid surgery. But, underlying diseases and other conditions such as age greater than ~75 will increase the likelihood of staying longer. REMEMBER...the emphasis is on quality of care and cure of the parathyroid disease, NOT on how fast the patient is sent home!
What if your hospital doesn't have a nuclear probe? These probes have only become widely available during the late 1990's. The probes are EXPENSIVE, about $125,000. Because of this, many hospitals won't buy the probe for parathyroid exploration, because it is not worth it since their surgeons only do a couple of parathyroid operations per year. Even without a miniature probe, a number of surgeons are performing unilateral neck explorations for patients who have been identified as having a single bad parathyroid gland (as opposed to 4 gland hyperplasia). These patients are usually identified as such by a preoperative sestamibi scan. Even without the probe, the operation can be limited greatly in scope by exploring only the side of the neck which harbors the single enlarged (overactive) parathyroid gland. Not all surgeons have embraced the concept of not examining all 4 parathyroid glands. Those days are gone! To read more about the different cure rates for surgeons with different levels of experience, go to this page of Parathyroid.com.
Bottom line: Surgeons who perform only a few parathyroid operations per year have a cure rate of approximately 85 %. Those who do more than 200 parathyroid operations per year have a cure rate of over 98%. CHOOSE YOUR SURGEON CAREFULLY. The complication rate is also MUCH less for surgeons who perform this operation every week.