PERFORMING MINIMALLY INVASIVE PARATHYROID SURGERY: The New Approach to Treating Hyperparathyroidism

Hyperparathyroidism is a condition causing high blood-calcium levels that afflicts about 100,000 Americans each year. It is caused by the overproduction of parathyroid hormone (PTH) by one or more of the four parathyroid glands located in the neck. This chronic condition may result in kidney stones, osteoporosis, abdominal problems, fatigue, and depression, among other illnesses. It can successfully be treated by removing the abnormal parathyroid gland(s).

At Stony Brook, Maisie L. Shindo, MD, associate professor of surgery (otolaryngology-head and neck surgery) and director of head and neck oncology, is now performing minimally invasive parathyroid surgery, and her surgical expertise in this new procedure further demonstrates our faculty's commitment to providing state-of-the-art care.

Minimally invasive parathyroid surgery — that is, parathyroidectomy (parathyroid gland removal) — can be performed in the ambulatory surgery setting, under local anesthesia, with minimal risk to the patient.

The newly developed minimally invasive approach to parathyroid surgery is well tolerated by patients, and is associated with cure rates that are at least as good as those attained through traditional bilateral neck exploration. Moreover, the complication rate is less than 1%, which is exceedingly low.

The first successful parathyroidectomy for hyperparathyroidism was performed in 1925. The four parathyroid glands were identified through a bilateral neck exploration, and an enlarged parathyroid gland was excised. The patient experienced cure with marked resolution of his symptoms and signs of hyperparathyroidism.

Thereafter, it became the standard of care in most institutions to perform bilateral neck explorations for hyperparathyroidism. The results in large series demonstrate cure rates that exceed 95%, with complication rates in the range of 1% to 2%.

WHAT IT IS

Surgery to remove abnormal parathyroid glands is indicated for moderate to severe symptoms of hyperparathyroidism. In cases where the problem is an adenoma (benign tumor), just the one gland will be removed. If all four glands are enlarged (hyperplasia), the surgeon will likely remove most (three and a half) or all of them.

Traditionally, parathyroid surgery has involved a long incision, exploration on both sides of the neck, and general anesthesia. The new technique — known in the medical literature as minimally invasive radioguided parathyroidectomy (MIRP) — offers a safer and less invasive approach. In this procedure, a radioisotope "sestamibi" scan is used to help locate a tumor or abnormal parathyroid gland prior to surgery.

For the scan, the patient is given a very small dose of a radioactive material that is absorbed only by the overactive parathyroid gland(s) — not healthy ones. During the operation, the surgeon uses the sestamibi scan results as a map to locate the abnormal gland. In some cases, a miniature hand-held probe that detects radioactivity, much as a Geiger counter does, is used to confirm the location.

The entire MIRP operation can usually be performed through a small (about 1-inch) incision in the lower neck. It takes less than an hour and generally requires local anesthesia, the use of which enables the patient to go home a few hours after surgery.

Once the problem parathyroid gland has been removed, a blood sample is drawn from the patient and sent for rapid assay of PTH. Stony Brook's special laboratory services can provide the results within half an hour. A drop in the level of the hormone to normal or near-normal range helps the surgeon be confident that the operation is complete — that is, whether or not another "normal" gland will need to be removed.

Usually it is not necessary to find any other parathyroid glands, but the experience of the surgeon will determine whether more surgery is needed.

For consultations/appointments with Dr. Shindo, please call 631-444-4121.