DESTINATION: SURGERY

By Doug Politz, MD & Jose Lopez, MD

Having surgery would hardly have been considered a reason for a road trip a few short years ago. But sometimes different worlds intersect, and the consumer (in this case the patient) benefits. The 21stcentury has seen countless advances across every field of human activity. The internet, along with its cousins in social media, have become digital travel agents in the field of medical tourism, providing easy access to necessary information. Patients can research the most advanced techniques for parathyroidectomy, share their experiences at different centers, and help unite each other with surgeons who have expertise in performing parathyroid surgery. 

Dr. Doug Politz and Dr. Jose Lopez, former senior surgeons at the Norman Parathyroid Center in Tampa for 25 combined years, have spent the majority of their careers caring for patients who have traveled long distances to see them. No pair of surgeons in the world has performed more parathyroid operations in the last decade than these two. They have learned what makes it efficient and safe and how to guide and prepare patients for a smooth journey through surgery and the recovery that follows, while avoiding pitfalls with well-researched planning.

Now as Co-Founders of the Tampa General Hospital Parathyroid & Thyroid Institute, Drs. Politz and Lopez enjoy bringing their experience and expertise to patients who seek it. Below these two world leaders answer some of the most common questions patients ask about traveling for parathyroid surgery.

Do I need to stay in the area for a week after surgery in case any problems come up?

This is a perfectly reasonable question. When you plan your surgery, the surgeon (or the office staff) can let you know the follow-up protocols for that particular practice. Some have you stay in town a few days so they can personally see you before you return home, while others may keep you in the hospital overnight only, perhaps to check blood tests again. Some simply contact you by phone or telehealth later that evening or once you have returned home. Any number of factors can influence each surgeon’s routine and comfort with the timing of your departure. These may include: experience with the procedure, findings in your particular operation, length of the procedure, years in practice, call coverage by surgical partners (what the on-call partners are comfortable with), difficulty waking from anesthesia, other medical problems that require additional care, and of course COVID-19 testing (although that is more likely to impact your arrival plans rather than your departure.)

While minimally invasive parathyroidectomy in the hands of expert surgeons is extremely safe, nothing in medicine is perfect. If you have traveled a considerable distance and are being released from the surgery center or hospital the same day as the procedure, staying in the area until at least the next morning is certainly a safe choice. Particular surgeons can let you know what they are comfortable with, and you can plan accordingly.

Our experience has taught us that most anything that happens after surgery that would require our in-person attention is exceedingly rare (well under 1%). Also, anything that requires our bedside attention after parathyroidectomy is almost always apparent in the recovery room. That’s why we have our patients stay for an hour and a half or so afterward–so we can check on them a few times. Our routine is to call and check on them again that evening to review the details of their operation (now that the anesthesia has had more time to wear off) and make sure they are recovering appropriately. We recommend patients stay somewhere in the area if they are flying out the next day. Experience has taught us that the day after surgery is the best day to fly home. We have learned that once a patient gets to the next morning uneventfully, the chance that in-person attention is needed from us falls to near zero. We can troubleshoot virtually anything that comes up from that point forward by phone. Bottom line: safety! The destination is safety, and there are multiple routes to get there. The best route is where the surgeon and the patient are both comfortable and confident with the plan.

I won’t have access to my surgeon after I leave town.

You will want to find out how you will contact your surgeon (or your surgeon’s office) after you leave the hospital in case something comes up. Your surgeon may want you to stay in town for a week and come to the office for an in-person follow-up visit. You might be given a number for the answering service for your surgeon’s group. There are some surgeons who will want to arrange your follow-up care with a local surgeon in your hometown, to whom you would direct any questions. There is no right or wrong answer, just differences in style of practice, experience, and comfort with troubleshooting questions and problems remotely.

Our routine is to provide patients with our personal cell phone numbers to reach us once they leave the hospital. We are the ones most familiar with the details of the case, and we are directing that patient’s care. We prefer to know personally if any issues arise, and patients usually appreciate the access—and not having to tell their story to multiple individuals before speaking to the doctor. We don’t use an answering service. Our patients are able to text message us, call us, call our office to speak with our nurse, or message us through the hospital’s electronic medical record system. We have heard of a number of different arrangements in this regard, all of which are perfectly safe and can be easily learned by asking the staff at the surgeon’s office. This just happens to be a system that has worked well for us and for our patients.

What if I get there, and the scan shows the tumor in my chest?

You will want to find this out since it can affect travel arrangements, extent of surgery, expense, and the medical complexity of your case. Thankfully, this is not very common. Some surgeons may want you to arrive in town a couple of days early to get a scan to rule this out and then meet with them prior to the date of surgery. Still others may want you to have scans done at home and send them the films so they can review them ahead of time before any definitive travel arrangements are made.

If a scan shows a tumor in the chest, some parathyroid surgeons will want you to meet with a chest surgeon (thoracic surgeon) ahead of time or even undergo a chest operation and not a neck operation. This would, of course, depend upon the specific location of the tumor, the coordination of schedules between surgeons, and the experience of the parathyroid surgeon with tumors in this location. There’s no question that a parathyroid tumor seen in the chest adds some challenge and complexity to the situation.

We don’t require a scan ahead of time. After doing thousands and thousands of parathyroid operations, we’ve learned some pretty handy techniques to reach parathyroid tumors in unusual locations….

Our particular approach to this issue has evolved over the years, as we have encountered this time and time again. Our current approach reflects this experience. We don’t require a scan ahead of time. After doing thousands and thousands of parathyroid operations, we’ve learned some pretty handy techniques to reach parathyroid tumors in unusual locations…like the upper chest behind the breastbone. In our experience, over half of parathyroid tumors that are seen in the upper mediastinum (in the chest above the heart) end up being within our reach by using these advanced techniques and specific knowledge of anatomy and embryology (human development before birth). One advantage we have found in approaching these tumors through the neck is that the other three parathyroid glands in the neck can be examined in addition to removing the tumor out of the upper chest. Valuable information is gained by seeing those other three parathyroid glands (about 20-30% of patients have a second abnormal parathyroid gland that is not seen on a scan and needs to be removed.) In other words, the trip is not for nothing! Even if we see a parathyroid tumor in the chest that is out of our reach, this is important information for any thoracic surgeon who will be planning to remove that tumor.

Take-home point: no doctor can hand you a script of exactly how every situation is going to be handled when unexpected findings occur. But sometimes a surgeon has had an experience with a situation like this one and has made a policy for how it will be handled in the future. That’s good information for you to know when you’re trying to plan hotel nights, plane flights, expenses, insurance coverage, time off work, childcare, etc.

I haven’t met my surgeon yet.

Actually, with the technology of telehealth visits, and its proliferation across the healthcare landscape throughout the recent pandemic, physicians are able to carry out “office visits” in exactly the same way as if they were sitting across the table from the patient. Recent experience tells us that most insurance plans cover these virtual visits. They have some important advantages. Patients are in the comfort of their own home, so it’s far more convenient than fighting traffic, finding a parking place, walking a quarter of a mile, sitting in the waiting room with ill patients, etc.…you get the idea. Obviously, while COVID precautions are in place, it minimizes the risk to everyone involved to interact remotely. On a more personal note, we really enjoy visiting on screen because we get to interact without the barrier of a mask. We get to see our patients smile, a most basic human joy that the pandemic has eliminated from face-to-face encounters.

If you really think about the science of parathyroid disease in particular, these remote visits are ideal. We have found that we could sit with a potential parathyroid patient for an hour, or two hours, and still not know whether that patient has hyperparathyroidism until we get a chance to look at blood test results. Some patients really don’t feel comfortable proceeding unless they sit down in a traditional office setting to talk things over with the surgeon, and some surgeons (as mentioned above) will want you to arrive in town a few days early for an office visit anyway, as they are also more comfortable with this approach. So while we have found no particular advantage to an in-person meeting before the day of surgery, we (and just about any surgeon we know of) would gladly arrange for traditional office visits for those patients who desire it. The office staff answering the phone would almost certainly be able to provide this information.

It’s going to be more expensive to travel so far for surgery, isn’t it?

Maybe not! Here’s where you want to check with your local doctors to see what they require. They may require very few tests and visits before having surgery; whereas, some surgeons and endocrinologists may want CT scans, MRIs, ultrasounds, and sestamibi scans. Additional office visits to review these results can add more time (and sometimes anxiety). These can really start to fill up the ledger. Some surgeons will evaluate you remotely for an out-of-pocket fee that your insurance company won’t cover, while others may simply use telehealth and accept your insurance company’s reimbursement. Still others may evaluate your records remotely but ask that you arrive a few days early to meet with them in person and then remain in town for surgery.  Hotel nights, meals, and transportation costs then come into play. These are all considerations that can impact whether traveling a long-distance for surgery is cost-effective. 

If I need something done to my thyroid gland during my surgery, won’t I have to stay longer?

While most parathyroid operations will not need anything done with the thyroid gland at the same time, some of them do. In fact, up to 20-25% of parathyroid operations in some series can discover an issue with the thyroid that needs to be addressed. This is a straightforward question to ask the surgeon. Removing part of the thyroid gland will prompt some surgeons to keep the patient overnight for observation or ask that they stay in town a few days for a follow-up visit. You may want to plan for this as a contingency by booking an extra night in the hotel or scheduling a flight a day later if this is your surgeon’s routine. Of course, removing part of the thyroid gland can be as simple as taking out a small nodule or as extensive as removing the whole thyroid gland, although unexpected total thyroidectomy in a patient having a parathyroidectomy is indeed a rarity.

Over the years we have run into parathyroid patients needing a thyroid nodule removed fairly commonly, and just about any patient undergoing parathyroidectomy with us who ends up needing a portion of the thyroid gland removed can plan on the same discharge and travel accommodations as someone who needed nothing done with the thyroid. 

What if I get symptoms of low calcium and I’ve already left town?

Quite honestly, this was the overarching reason why patients were kept in the hospital for extended periods of time for decades until outpatient parathyroidectomy came along. The safety of having parathyroidectomy and returning home afterward while taking oral calcium supplements has since been shown in tens of thousands of patients.  Some surgeons will still keep patients overnight in the hospital with this problem in mind. Others have embraced outpatient parathyroidectomy and have grown comfortable managing this issue outside of the hospital. 

An important point to remember is that symptoms of low calcium do not typically occur, even in the subset of patients who experience them, until the second or third day after surgery. This again is why we encourage parathyroid patients who are flying in for surgery to fly out the day after surgery. Even when these symptoms occur, they are mild and easily managed with supplemental oral calcium intake in the overwhelming majority of patients. This is a sign that the problem of hyperparathyroidism has been cured, and it is a development that can be managed quite easily by phone in our experience. If you should be one of those exceptionally rare individuals in whom oral calcium supplements just aren’t enough to control the symptoms, and you need to be seen at a hospital and get the calcium through an IV, we feel that patients are best off near their home for that…in familiar surroundings with family and friends nearby who can help with all kinds of issues like child and pet care, running errands, etc. Everything that is needed to address these issues is available in your hometown. There’s nothing special about the oral calcium pills at a pharmacy near your surgeon (or the bags of IV calcium in your surgeon’s hospital for the exceedingly rare patient that may need them). Trying to rearrange flights, babysitters, and work meetings from a hotel room in another city away from home while recovering from surgery just adds unnecessary stress.

What if I get there, and my COVID test is positive?

Not much anyone can do about this. The good news is: as more people get vaccinated, and more restrictions get lifted, things are drifting back toward normal. How long until we get there? No one knows, but for now we have to follow public policy guidelines. 

In many ways, traveling long distances to reach expertise in the field of surgery has become commonplace. Social media and online patient forums put patients in touch with each other, spreading information about centers of expertise worth seeking out. Minimally invasive parathyroidectomy allows small incisions, quick procedures, outpatient discharge the same day, and speedy recovery. This formula has seen tens of thousands of patients undergo parathyroidectomy over the last 20 years, and we have learned how safely it can be done. Not everyone is in a situation to fly across the country for a quick, 20-30 minute procedure, but for those who can, rest assured that it is available, affordable, and safe.

Dr. Douglas Politz

Douglas E. Politz, MD, FACS, FACE, is one of the most experienced parathyroid surgeons in the world, having performed over 8,000 parathyroidectomies. He has dedicated his career to parathyroid disease, combining enormous experience with superior knowledge and skill to compliment his warm, engaging manner. Having seen the simplest and the most challenging scenarios in which parathyroid disease can present, Dr. Politz welcomes those patients who have been diagnosed for the first time and those with prior attempts at surgical cure. Patients whose parathyroid disease is associated with thyroid cancer or kidney disease also benefit from his decades of experience. Dr. Politz has helped refine the advanced techniques of minimally invasive parathyroidectomy used to quickly identify the four parathyroid glands in surgery. He has examined over 25,000 parathyroid glands and has helped to train the most experienced parathyroid surgeons worldwide who have followed him in this field. Dr. Politz has operated on patients from every US state and multiple continents.

Dr. Politz together with his partner and friend of over 20 years, Dr. Jose Lopez, are the two most experienced parathyroid surgeons in the world in the last 10 years. In addition to their impressive operative volume as primary surgeons, their expertise has been utilized in a supervisory role for the cure of thousands more patients as these two surgeon-leaders guided the efforts of colleagues they trained. Their combined 25 years of experience in parathyroid surgery have been spent almost exclusively at Tampa General Hospital, a medical center which has seen more parathyroid patients than any other facility in the world by far.

Dr. Politz’s video introduction: https://doctors.tgh.org/doctor/npi_1194746966/General+Surgery/Douglas+Edwin+Politz

Dr. Jose Lopez

José A. Lopez, MD, FACS, is one of the most experienced parathyroid surgeons in the world today, having performed over 5,000 parathyroidectomies. He has dedicated the last 10 years of his career to the exclusive pursuit of parathyroid disease with particular focus on patients whose disease is complicated by scar tissue from prior surgeries and patients with coexisting thyroid tumors. Known for his upbeat manner and superior surgical skill, Dr. Lopez has helped perfect the advanced techniques of minimally invasive parathyroidectomy used to quickly identify the four parathyroid glands in surgery. He has examined over 20,000 parathyroid glands and has played a pivotal role in training the five most experienced parathyroid surgeons worldwide who have followed him in this field. Dr. Lopez, a native of Puerto Rico who is fluent in Spanish and English, has operated on patients from nearly every US state and multiple continents.

Dr. Lopez together with his partner and friend of over 20 years, Dr. Douglas Politz, represent the two most experienced parathyroid surgeons in the world in the last 10 years. In addition to their impressive operative volume as primary surgeons, their expertise has been utilized in a supervisory role for the cure of thousands more patients as these two surgeon-leaders guided the efforts of colleagues they trained. Their combined 25 years of experience in parathyroid surgery have been spent almost exclusively at Tampa General Hospital, a medical center which has seen more parathyroid patients than any other facility in the world by far.

Dr. Lopez’s video introduction: https://doctors.tgh.org/doctor/npi_1396854329/General+Surgery/Jose+Abraham+Lopez

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