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What is the recommended treatment for
hyperparathyroidism?
What is the surgical procedure for treating
hyperparathyroidism?
What is MIRP (minimally invasive
parathyroidectomy)?
What type of anesthesia is used for the MIRP?
What is the difference between "general"
anesthesia and "LMA"?
Do all surgeons have training in MIRP?
What is the likelihood of a successful outcome
with MIRP?
What is the recommended treatment for
hyperparathyroidism?
Since the high calcium level is detrimental to
the body’s system over time, it is usually
recommended to fix the problem. Currently there
are no medications tor correct it. But the
abnormal parathyroid gland can easily be removed
surgically, providing an immediate cure.
In most cases, the problem is limited to just
one of the four glands.
Nothing needs to be done to the
normal glands. In fact, the less we bother
these other glands, the better off you’ll be.
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What is the surgical procedure for treating
hyperparathyroidism?
For
the past hundred years, the surgical treatment
for hyperparathyroidism involved making a long
neck incision under general anesthesia, and
searching all the nooks and crevices in the neck
around (and even inside) the thyroid gland, for
all four parathyroid glands. The surgeon would
then make a visual assessment of the four
glands, to decide which one, or more, of the
glands, looked “too big”, and presumably
overactive. Biopsies of one or more of the
glands would be done, to try to decide which
glands to completely remove. In some cases, not
all of the glands would be found, and in fact,
it might be that the abnormal gland may never be
identified.
The
traditional operation described above was
necessary in the past, because the surgeon had
no way of knowing in advance which of the four
parathyroid glands was the problem, or whether a
particular patient was one of the exceptional
cases in which there was more than one abnormal
gland. But we now have some excellent
localizing tests that can be done before surgery
that are very accurate. The most important of
these tests is the
sestamibi scan.
This test is named after the radioisotope used.
It is the same radioisotope used for patients
undergoing evaluation of their heart function.
It works in both tests for the same reason—the
isotope is taken up after injection into the
bloodstream by the most metabolically active
cells in the body. These cells are using large
amounts of energy constantly. Less active cells
do not take up much of the radioisotope. As a
result, the scan that is taken shows focal areas
or “hot spots” that show where the most active
cells are.
In the case of parathyroid glands, a single
adenoma almost always shows as a “hot spot” on
the scan, since it is a “high energy” gland.
The other glands, which are in a resting state,
will not show up. As a result, the scan can
identify the single gland that is overactive.
The surgery can then be directed toward
identification and removal of a single gland.
This is the basis for the less invasive
procedure, called a
MIRP, or “minimally invasive radioguided
parathyroidectomy”.
Another useful test for localizing a parathyroid
adenoma is an ultrasound.
This test uses the same technology as is used in
pregnancy to look at the fetus in the womb. The
ultrasound probe is placed on the neck, which
shows the internal anatomy. Normal parathyroid
glands are so small that they will not be
identified with ultrasound. But the overactive
glands will usually be large enough to be seen, as
a distinctive dark, somewhat triangular shaped
structure, just behind the thyroid gland. This
test can be helpful in knowing before the
operation what the size of the abnormal gland
is, but it does not provide the same information
as the sestamibi scan, which correlates more
closely with overactivity in an individual
gland. An ultrasound is also helpful to know if
there is anything abnormal in the thyroid
gland. If there is any abnormality in the
thyroid, it is helpful to know this in advance.
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What is MIRP (minimally invasive
parathyroidectomy)?
These new tests have given birth to a less
invasive surgical cure for hyperparathyroidism,
the
MIRP, or “minimally invasive radioguided
parathyroidectomy”.
With this technique, a small incision, only
about one inch in length, is used. A sestamibi
scan is done immediately before the surgery, so
that the abnormal glands have the high
concentration of sestamibi in them during the
surgical procedure. With
this technique, the surgical dissection is very
focused and limited. The normal glands are left
alone. As a result, the operation is usually
completed in 30-60 minutes, and can be done
without general anesthesia if desired. Patients
can usually go home the same day.
One
particularly important thing we learn when the
sestamibi scan is done is to be sure there are
no parathyroid adenomas in unusual locations,
such as up high in the neck, or down low in the
chest. Though uncommon, if you have an
overactive parathyroid gland in one of these
locations, the usual neck incision is not going
to cure you. If you have had a sestamibi
scan done already, and it was read as
"negative", that absolutely does NOT mean that
you cannot have minimally invasive surgery.
It DOES mean that, although your overactive
gland or glands are almost certainly going be in
one of the four usual locations, just behind the
thyroid gland. In other words, seeing that
there are no "hot spots" in abnormal places
means that even if not seen on the scan, they
must be hiding in the usual position behind your
thyroid, where we can find them with the usual
dissection.
Complications during the procedure are VERY uncommon,
but you should be aware of these possible
problems. Behind the thyroid, on either side is
a nerve that activates each vocal cord in your
larynx, or voice box. These nerves are quite
close to the parathyroid glands, so it is
possible for them to be injured during the
surgery. If this happens, your voice is likely
to be affected. With the traditional
parathyroid surgery, there is a lot of
dissection done very close to both of these
nerves. Fortunately, even with the traditional
operation, injuries to these nerves (recurrent
laryngeal nerves) are uncommon. But with the MIRP, the surgery is less
dissection required.
This focused procedure, which is usually almost
bloodless, does not require dissecting the
nerves, thus minimizing the risk of any injury
or bruising.
Excessive bleeding is a potential complication
of any surgery, no matter how small or large the
operation is. This problem is only very rarely
seen with the MIRP, since the dissection is
limited to finding only the involved parathyroid
gland.
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What type of anesthesia is used for the MIRP?
What is the difference between "general"
anesthesia and "LMA"?
General anesthesia is defined as a state
of unconsciousness and loss of protective
reflexes, brought about by the use of one or
more drugs or (inhalational) gases.
General anesthesia has been around for about 150
years. It has its roots in Georgia, having
first been used by Dr. Crawford Long in
1842, using ether as the inhaled gas. For
the next 120 years, ether was the only agent
used for general anesthesia. But in the
21st century, we have dozens of different agents
to choose from, both gases that are inhaled, and
drugs that are given by vein.
For the biggest operations (like in the chest or
abdomen), general anesthesia includes drugs
which temporarily paralyze the body, and your
breathing is supported during that time with a
machine. But in lesser procedures, such as
parathyroid surgery, paralysis is not necessary,
even though you are unconscious.
When we say that "protective reflexes" are lost,
one of the most important reflexes is the "gag
reflex", which you experience anytime
something makes you choke or cough, or have
something that "went down the wrong way", or
"down my windpipe". This reflex keeps us
from getting anything other than air in our
lungs. If you are given drugs or gases
that suppress your gag reflex, we say that you
cannot "protect your airway", and in that state,
you are at risk for getting stomach contents, or
oral secretions into your lungs. This is
called aspiration. In order to
avoid aspiration, some sort of tube is placed
either all the way into your airway, or directly
over the entrance to your airway in the back of
your throat.
A tube which goes all the way into the airway is
called an endotracheal tube. A tube
that fits the back of your throat is called an
LMA (which stands for "laryngeal mask airway").
Use of either of these tubes is only necessary
if your gag reflex is (or could be) impaired.
If you are given a light sedation, you can
protect your airway without a tube, but anything
deeper requires one of these tubes for safety's
sake. An LMA tube can be more easily
inserted than an endotracheal tube, particularly
since with the endotracheal tube, you have to be
given drugs that paralyze you for just a few
minutes. But the LMA does not protect your
airway as well as an endotracheal tube.
And if you have a history of reflux (GERD, GE
reflux), an LMA probably is not the better
choice.
If a surgeon says you're having LMA anesthesia
and NOT general anesthesia, it's just not
correct.
A
person who is awake enough to protect their own
airway will gag BECAUSE of the LMA, so you have
to be receiving enough drugs to suppress that
reflex.
Now there are surgical (or dental) procedures
that can be done with just local anesthesia,
like removing skin lesions, or filling cavities,
or some breast biopsies. Surgery for
heart, lung, or intestinal problems simply
cannot be done under local anesthesia, because
the pain would not be controlled with just a
local anesthetic. Parathyroid operation
involve more than removal of skin lesions, but
less than doing a heart bypass. And so,
although it IS POSSIBLE to do a parathyroid
operation with only local anesthesia, you would
probably have more pain than you want to
experience. And of course, we don't want
you to have ANY pain. For this reason,
it is usually recommended that you have at least
a light general anesthetic for the procedure.
This means that you are receiving
drugs and/or gases that lower your consciousness
and suppress your gag reflex enough to require
either an endotracheal tube, or an LMA.
And so, there is not too much difference between
what is called LMA anesthesia, and general (endotracheal)
anesthesia.
In the past, no surgeon would have considered
using anything but general anesthesia with an
endotracheal tube for a parathyroid operation.
But as experience with MIRP has been gained, the
necessary dissection has become more refined,
allowing the less "deep" levels of anesthesia to
be utilized.
In most cases, LMA (light general) anesthesia
seems to fit the bill best.
Conventional
For
many years, the surgical procedure for
parathyroid disease involved a fairly long
incision crossways on the lower part of your
neck. Through this big incision, the neck
muscles were widely mobilized, and the thyroid
gland was thoroughly dissected away from the
tissue behind it, where the parathyroid glands
lid. All 4 parathyroid glands would be
identified if possible, and one or more would be
removed if they just looked abnormal. Any normal
looking parathyroid glands would be identified
but left in place. Patient would typically be
kept in the hospital for several days afterward.
There are some surgeons who still use this
traditional operation for parathyroid disease.
But it really is much more surgery than is
needed to fix this problem. Some surgeons may
take 4 or more hours to do this operation, and
they might not have near as much success as an
experienced parathyroid surgeon using the
minimally invasive technique. Many surgeons have
very little prior experience in parathyroid
surgery, and if they choose to operate on
someone with hyperparathyroidism, they will
resort to what they know, which is the
traditional LONG incision, with tedious
exploration, looking for all 4 glands.
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Minimally invasive
We
now have some extremely valuable tests which can
help us identify where the abnormal parathyroid
gland is before the surgery is even started. The
2 most important tests are the sestamibi scan,
and ultrasound, and you can read about those
elsewhere on this website. Both of these can be
very helpful for identifying the abnormal gland,
since usually there is only one abnormal gland.
By focusing on the single abnormal gland, a very
small incision can be made, allowing the single
gland to be identified and removed. As it turns
out, even if the other parathyroid glands need
to be looked at, you still don't need the 4 inch
long incision that some surgeons still use.
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Endoscopic
There are some surgeons who have taken the
"minimally invasive" aspect to a further level.
I am not a proponent of the endoscopic methods
which have been described. These methods
involve the use of scopes and video camera
visualization projected onto a television
screen, using very small instruments. Although
the concept is attractive, it does not decrease
the operating time, and can introduce the
possibility of new complications not typically
seen with either the traditional surgery, or
with the minimally invasive parathyroidectomy
described above.
Direct
The
"direct" endoscopic procedure makes an incision
in the neck similar to what is done in the
minimally invasive radio guided parathyroid
procedure. But instead of operating directly
through this opening, a scope with an attached
video camera is inserted, and while watching the
image on a television screen, tiny instruments
are passed through the same small incision, or
through other adjacent small incisions, the
abnormal gland is identified and removed.
Although the visualization can be excellent,
there's not much difference between the size of
the incision for this procedure compared with
the minimally invasive parathyroid operation
described above. And the success rate is not
going to be any better than with the minimally
invasive technique, and possibly could be lower.
Transaxillary
Some surgeons have even developed a method of
operating through small incisions under the arm,
instead of an incision on your neck. A pathway
is dissected underneath the skin up to your
neck, behind the thyroid, and the abnormal
parathyroid gland is identified and removed. The
only reason to even consider such an indirect
approach to your parathyroid glands is to try to
avoid any scar on the neck whatsoever. However,
there will be no guarantee that a neck incision
will not be necessary after all, and it would be
difficult for this technique to have as high a
success rate as can be achieved with the
minimally invasive technique. Our first priority
is to complete a successful operation, and any
variation in the technique which threatens to
lower the rate
of success should only be considered with great
caution. At DeKalb Surgical Associates, we have
not felt it appropriate to utilize these very
indirect surgical techniques for this disease,
since our success rates are so high, and the
incisions are quite small anyway.
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Do all surgeons have training in parathyroid
surgery?
Parathyroid surgery is not a common procedure
for most surgeons, simply because
hyperparathyroidism is not nearly as common as
other things that surgeons take care of, like
hernias, gallbladder problems, and breast
problems. As a result, many surgeons either
don’t do any parathyroid surgery, or perhaps one
every year or so. In their five years of
training, they may have only actually seen just
a few cases, and may have only done just a
handful. They are likely not skilled in doing
the MIRP, and in most cases will recommend doing
the traditional bigger operation, under general
anesthesia, with a hospital stay of one or two
days. And if a surgeon only does maybe one of
these operations a year, they do not have enough
experience to know what their rate of success
is. You should probably not allow such a
surgeon to do your parathyroid surgery, when the
outcome is so unpredictable.
A
surgeon with limited experience will mistakenly
think that only patients with a "positive"
sestamibi scan are candidates for MIRP.
But nearly all patients with hyperparathyroidism
are candidates for MIRP by an experienced
surgeon.
There are also surgeons who do more parathyroid
surgery than most surgeons, but who still recommend the
bigger traditional operation. They may
have a very good success rate, using the older
techniques, typically a much larger incision,
and a hospital admission, with specific plans to
find every single gland. But the newer MIRP
technique has clearly demonstrated to be highly
successful in experienced hands, without the
need for a long incision, or a hospital
admission in most cases.
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What is the likelihood of a successful outcome
with MIRP?
The
sestamibi scan, coupled with an appropriate
pre-operative evaluation and an experienced
surgeon, will almost always lead to immediate
cure for hyperparathyroidism. At DeKalb
Surgical Associates, we track our results for
all parathyroid patients.
Over the past 10 years, our success rate is 97%.
Dr. Kennedy performs about 80-100 operations per
year. If you are seeing a surgeon for possible
parathyroid surgery, you should ask how many
procedures they do each year, and what their
success rate is.
If
you would like more information you can contact
us at 404-508-4320, or by email to
Dr. Kennedy.
There is
NO EXTRA FEE
for a consultation over and above the usual
charge. If you travel from out of town, we can
provide information of hotel accommodations.
Atlanta is a convenient hub for most airlines
from anywhere in the US. If we have information
in advance from you, which confirms the
diagnosis of hyperparathyroidism, and the
indications for surgery, we can tentatively
schedule your surgery in advance of your
arrival. Dr. Kennedy would see you in the
office on the day before the planned surgery to
review your medical history and perform a
physical exam in person, and explain the
procedure in more detail. The surgery the
next day, you will be able to return to your
hotel for just one more night in town before
returning home. There are lots of fun
things to do in and around Atlanta, so you can
combine your trip for your surgery with some
sightseeing.
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DeKalb Surgical Associates