At Fort Lauderdale Endocrine Surgery, we are often asked if minimally invasive parathyroid surgery can be performed without the use of inhalational agents (general anaesthetic agents) and endotracheal tubes for breathing. The answer is a qualified "yes" depending on several factors.
First, the enlarged parathyroid(s) must be localizable by high resolution ultrasonography and visible relatively close to the skin surface. In shallow necks, local injection of anaesthetic agents (like lidocaine or Marcaine) can control intra-operative pain very nicely when given in combination with an intravenous twilight sleep agent (like propofol, also known as Diprivan). In addition, oral opiates should be given pre-operatively, so that the doctor has a "headstart" on controlling post-operative pain when the patient abruptly awakens as the propofol is discontinued. In general, the parathyroid glands most amenable to this kind of Minimal Anaesthesia Care (MAC) are lower pole glands in patients with thin necks. Lower pole glands are often found just below the thyroid gland and right under the skin surface in such patients, and can be removed with 15-30 minutes of gentle surgical manipulation. Occasionally, upper glands in thin necks can be removed just as easily.
Second, the patient needs to have a good airway prior to considering anaesthesia without a breathing tube (endotracheal tube). If there has been damage to the trachea from surgery, radiation or previous intubation, it is wiser to insert a breathing tube under controlled conditions before the surgery, rather than risking an emergent intubation during surgery should the patient's breathing pattern deterioriate.
Finally, MAC with local anaesthesia cannot be used if the patient is allergic to "caines" or propofol. Because propofol produces only twilight sleep, some patients have vague dream-like recollections of their surgical experience. Occasional patients dread the idea of any memory of the surgical experience and may prefer general anesthesia for this reason.
Our experience with Minimally Invasive Radioguided Parathyroid Surgery (MIRP) under MAC anesthesia has been very favorable. Appropriately selected patients avoid the potential trauma of a breathing tube (endotracheal tube) insertion and the post-operative headache and nausea that plague up to 30% of patients who elect to have general anaesthesia. Time spent in the recovery room is shorter with this technique and overall hospital time is minimized. For more information on MAC anaesthesia with MIRP, please don't hesitate to contact us at 954-267-8883.
Friday, December 11, 2009
Sunday, June 14, 2009
Do I Really Need a Neck Ultrasound Prior to Parathyroid Surgery?
At Fort Lauderdale Endocrine Surgery (FTLES), we frequently are asked to perform surgery on patients with clearcut high serum calcium levels due to overactive parathyroids (hyperparathyroidism) who have not undergone adequate neck ultrasonography. There are several reasons for this sad state of affairs.
The first is that many physicians and patients have the mistaken impression that gamma camera sestamibi parathyroid scanning is the "gold standard" radiologic procedure for parathyroid localization. Unfortunately, gamma camera scanning frequently misses upper pole parathyroids (remember that there are typically 2 upper pole glands deep in the neck below the thyroid, one on the left and one on the right) and parathyroid glands that are close to pulsatile vascular structures. Also, sestamibi does not discriminate the multi-gland parathyroid disease that is present in up to 15% of patients. In fact, out-patient sestamibi scanning may miss up to 40% of "surgical" parathyroid enlargement and occasionally incorrectly identifies thyroid nodules or lymph nodes as "parathyroids."
The second reason for ultrasound mis-utilization is that parathyroid ultrasonography is becoming a "lost" art. As a result of declining reimbursement, most hospital and out-patient radiologic facilities have handed over thyroid and parathyroid ultrasound responsibilities to radiology technicians who are not formally trained in parathyroid localization. Sure, a radiology physician eventually reviews the pictures that the technician takes, but the radiologist is only as good as the technologist. At Fort Lauderdale Endocrine Surgery (FTLES), I personally perform ALL parathyroid ultrasonography without a "middle man." In my office ultrasound suite, I find that many parathyroid adenomas require "real time" visualization. In other words, the glands are easier to "see" in real time as I actually move the ultrasound probe over them, rather than in the static pictures that I snap and review later. Patients also appreciate the fact that we take an ultrasonographic tour of the neck together, by virtue of the LG flat screen LCD panel that I have suspended over the examining table (for patient convenience and education).
Finally, when we contemplate minimally invasive parathyroid surgery at FTLES, we must be absolutely certain that there are no anatomic thyroid, parathyroid or vascular problems that will make our surgery incomplete or unsuccessful. In this regard, ultrasound is the best technology for finding small, unsuspected thyroid cancers that need to be removed along with enlarged parathyroids. The saddest outcome for a minimally invasive neck surgery occurs when an unsuspected parathyroid adenoma or a thyroid cancer is mistakenly left in the neck due to inadequate pre-operative ultrasound localization. For these reasons, we at Fort Lauderdale Endocrine Surgery require competent neck ultrasonography prior to any neck surgery. To make sure that the procedure is adequate, we do it ourselves using a state-of the art Siemens Acuson X-150 office ultrasound device.
The first is that many physicians and patients have the mistaken impression that gamma camera sestamibi parathyroid scanning is the "gold standard" radiologic procedure for parathyroid localization. Unfortunately, gamma camera scanning frequently misses upper pole parathyroids (remember that there are typically 2 upper pole glands deep in the neck below the thyroid, one on the left and one on the right) and parathyroid glands that are close to pulsatile vascular structures. Also, sestamibi does not discriminate the multi-gland parathyroid disease that is present in up to 15% of patients. In fact, out-patient sestamibi scanning may miss up to 40% of "surgical" parathyroid enlargement and occasionally incorrectly identifies thyroid nodules or lymph nodes as "parathyroids."
The second reason for ultrasound mis-utilization is that parathyroid ultrasonography is becoming a "lost" art. As a result of declining reimbursement, most hospital and out-patient radiologic facilities have handed over thyroid and parathyroid ultrasound responsibilities to radiology technicians who are not formally trained in parathyroid localization. Sure, a radiology physician eventually reviews the pictures that the technician takes, but the radiologist is only as good as the technologist. At Fort Lauderdale Endocrine Surgery (FTLES), I personally perform ALL parathyroid ultrasonography without a "middle man." In my office ultrasound suite, I find that many parathyroid adenomas require "real time" visualization. In other words, the glands are easier to "see" in real time as I actually move the ultrasound probe over them, rather than in the static pictures that I snap and review later. Patients also appreciate the fact that we take an ultrasonographic tour of the neck together, by virtue of the LG flat screen LCD panel that I have suspended over the examining table (for patient convenience and education).
Finally, when we contemplate minimally invasive parathyroid surgery at FTLES, we must be absolutely certain that there are no anatomic thyroid, parathyroid or vascular problems that will make our surgery incomplete or unsuccessful. In this regard, ultrasound is the best technology for finding small, unsuspected thyroid cancers that need to be removed along with enlarged parathyroids. The saddest outcome for a minimally invasive neck surgery occurs when an unsuspected parathyroid adenoma or a thyroid cancer is mistakenly left in the neck due to inadequate pre-operative ultrasound localization. For these reasons, we at Fort Lauderdale Endocrine Surgery require competent neck ultrasonography prior to any neck surgery. To make sure that the procedure is adequate, we do it ourselves using a state-of the art Siemens Acuson X-150 office ultrasound device.
Monday, February 16, 2009
The Plain Truth About Parathyroid Surgery
Every year 100,000 Americans discover that they have high blood calcium levels caused by overactive parathyroid glands in the neck. Surgery is necessary to cure the hypercalcemia if the blood calcium exceeds 11.0 mg/dl or if the parathyroid hormone excess is causing kidney stones, ulcer disease, pancreatitis (severe pancreatic inflammation and belly pain) or bone loss. 85-90% of the time, the enlargement involves only one out of the four parathyroids and minimally invasive removal of the enlarged gland will result in a persistent normalization of the serum calcium and clinical cure. Finding the enlarged parathyroid gland (adenoma) or glands (adenomas) can require considerable expertise from the surgeon during the surgery and from the doctor who images the parathyroids prior to the surgery. Our recent paper in the November 2008 Endocrine Practice journal suggests that pre-operative high resolution neck ultrasound performed by an ultrasound-certified endocrinologist is the best imaging technique for locating an enlarged parathyroid (adenoma). In addition, we have found that close collaboration between an ultrasound-savy endocrinologist and a minimally invasive parathyroid surgeon is the key to cure. Two intra-operative procedures turn out to be very important in maximizing surgical success. The first is the use of intra-operative sestamibi scanning using a thin surgical probe. Technetium sestamibi is given intravenously 2 hours prior to surgery and during surgery the patient's neck is scanned carefully with the probe applied directly to skin and inserted in the surgical incision. In conjunction with the pre-operative ultrasound, the sestamibi scanning locates most enlarged parathyroids (~90%). However in some cases, the enlarged glands are too deep in the chest or neck for either technology to be effective. In these cases, the patient depends on the surgeon's skill in locating deep or hidden parathyroids. In order for the surgeon to recognize the existence of unimaged enlarged glands, he must first recognize that abnormal parathyroids are still present in the neck. This final realization is achieved by the utilization of the intra-operative parathyroid hormone blood test. After the removal of an enlarged parthyroid gland and before we declare any patient cured, we test the parathyroid hormone level in blood to make sure that it has fallen at least 50% from the pre-removal level. If such a fall has not occurred, we continue to look for other enlarged glands. Without the use of PTH testing in the operating room, we estimate that as many as 10-15% of patients could undergo removal of one enlarged parathyroid adenoma without being cured. Unfortunately, the lack of cure may take 3-6 months to be recognized, as the initial post-operative blood calcium levels may drop into the normal range, only to rise again later.
Our practical advice to patients can be summed up as follows:
(1) Make sure that you get your parathyroid adenoma(s) localized by a physician with special training in parathyroid localization (many radiology ultrasound technicians do not have this training).
(2) Make sure that your surgeon does at least 50 minimally invasive parathyroidectomies a year and that he or she works closely with an endocrinologist specializing in parathyroid problems. If the endocrinologist actually does parathyroid imaging with high resolution ultrasound this will save you the trouble of finding an experienced ultrasonographer elsewhere.
(3) Demand that your parathyroid surgeon use intra-operative sestamibi scanning as well as the blood parathyroid hormone assay to make sure that you are cured while you are on the operating table.
(4) Beware of any parathyroid surgeon who demands money up front for a telephone consultation. You have a right to meet your surgeon face-to-face before any money changes hands. You should not feel locked into using a surgeon because of a telephone consultation charge. Remember, there is a reason that no insuror will pay for up front telephone consultation,
(5) Beware of any surgeon who claims more than a 99% success rate, no matter how many patients he/she claims to cure every year. It is easy to claim that a patient is cured if you never see them again after the day of surgery. Many patients with 2 gland disease will initially show normalization of calcium levels after removal of one enlarged gland, only to have hypercalcemia recur 6-12 months later.
(6) If the claims you see on a parathyroid surgical website seem like hype, they probably are. Beware of unsubstantiated internet claims.
Please feel free to navigate to our website at http://www.ftles.com/ and review all our content critically. Good luck with your parathyroid surgery!!!
Our practical advice to patients can be summed up as follows:
(1) Make sure that you get your parathyroid adenoma(s) localized by a physician with special training in parathyroid localization (many radiology ultrasound technicians do not have this training).
(2) Make sure that your surgeon does at least 50 minimally invasive parathyroidectomies a year and that he or she works closely with an endocrinologist specializing in parathyroid problems. If the endocrinologist actually does parathyroid imaging with high resolution ultrasound this will save you the trouble of finding an experienced ultrasonographer elsewhere.
(3) Demand that your parathyroid surgeon use intra-operative sestamibi scanning as well as the blood parathyroid hormone assay to make sure that you are cured while you are on the operating table.
(4) Beware of any parathyroid surgeon who demands money up front for a telephone consultation. You have a right to meet your surgeon face-to-face before any money changes hands. You should not feel locked into using a surgeon because of a telephone consultation charge. Remember, there is a reason that no insuror will pay for up front telephone consultation,
(5) Beware of any surgeon who claims more than a 99% success rate, no matter how many patients he/she claims to cure every year. It is easy to claim that a patient is cured if you never see them again after the day of surgery. Many patients with 2 gland disease will initially show normalization of calcium levels after removal of one enlarged gland, only to have hypercalcemia recur 6-12 months later.
(6) If the claims you see on a parathyroid surgical website seem like hype, they probably are. Beware of unsubstantiated internet claims.
Please feel free to navigate to our website at http://www.ftles.com/ and review all our content critically. Good luck with your parathyroid surgery!!!
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