December 2, 1999
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Minimally invasive outpatient surgery to remove tumors of the parathyroid glands is safe for most patients and far more cost-effective than traditional open surgery, a Johns Hopkins study shows.
The parathyroid glands, located in the neck behind the thyroid, control calcium and bone metabolism. When the glands are overactive, usually because of benign tumors, patients can suffer from osteoporosis, peptic ulcers or kidney stones. About 100,000 new cases of hyperparathyroidism occur each year; women are more susceptible. Surgery is the favored treatment.
Reporting in the December issue of the journal Surgery, endocrine surgeon Robert Udelsman, M.D., notes that his patients treated with minimally invasive surgery had a significantly shorter length of hospital stay than their inpatient counterparts (½ day or less vs. up to two days) and about half of the hospital charges -- an average of $3,174 vs. $6,328. Patients receiving the minimally invasive procedure also had a 100 percent cure rate and zero deaths, compared to a 97 percent cure rate among those undergoing the open procedure.
The outpatient procedure has another significant benefit as well, according to Udelsman, director of endocrine and oncologic surgery at Hopkins. Injury to the vocal nerve is an occasional complication that can occur during the open procedure. "But in the outpatient procedure, the patient is awake and can talk. The surgeon can assess the patient's voice during manipulation of the vocal cord nerve. This information helps the surgeon protect the nerve from injury."
Parathyroid glands make parathyroid hormone, which helps the body regulate calcium levels. But if one of the glands enlarges (a condition called hyperparathyroidism), generally due to the development of a benign tumor, it can make and release too much, inducing an abnormally high level of calcium in the blood.
For the Hopkins study, Udelsman compared results of 33 of his patients who received the minimally invasive procedure between March and November 1998 with those of 184 of his patients treated with open surgery between August 1990 and May 1996. Both groups ranged from 59 to 63 years of age and had similar preoperative calcium and parathyroid levels.
During the standard two-hour procedure done under general anesthesia, the surgeon makes a three- to four-inch incision in the neck and removes those of the four glands that are enlarged.
Unlike the traditional surgery, which relies upon the surgeon's direct exam of the glands during the operation, the minimally invasive technique uses radioactive scanning prior to surgery to pinpoint the exact location of the diseased gland. A mild radioactive agent, sestamibi, is injected into the veins of a patient with hyperparathyroidism and is absorbed by the overactive gland. A gamma camera placed over the patient's neck picks up the location of the overactive gland. The scan paints an accurate picture in about 90 percent of patients.
Then, using the scan as a guide, doctors remove the diseased gland through a one- to two-inch incision. The half-hour procedure is done under local anesthesia. Measures of parathyroid hormone are taken before tumor extraction and again five minutes later to ensure the problem has been corrected.
The study's other authors were Herbert Chen, M.D., and Lori J. Sokoll, Ph.D.
Related Web sites:
Endocrine Surgery at Johns Hopkins
Endocrine Disorders Web site
The Thyroid Foundation of America