Primary Hyperparathyroidism – Surgery is the cure but how does one avoid the pitfalls of a failed parathyroid surgery?

You’ve been diagnosed with primary hyperparathyroidism, perhaps after struggling with various symptoms for many years, with this being the root cause that perplexed your medical professionals. Maybe you joined a social media platform to compare notes with others who have been on a similar journey. After hearing other patient stories, you might be feeling more confused than ever. A few mention having had failed surgeries and are now suffering the consequences. That’s scary and now you have doubts and questions. You want to understand why this happens and want reassurance that this doesn’t happen in your case. Don’t all surgeons perform the surgery in a similar way? What questions should be asked to help ensure a surgery is successful?

To help answer these questions and concerns, we asked parathyroid experts Dr. Jose Lopez and Dr. Doug Politz, who have performed surgeries on thousands of patients and helped cure many whose first surgeries were not successful, for guidance on this topic. We hope this information is helpful to you as you journey onward.

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By Dr. José Lopez and Dr. Doug Politz

Top 3 reasons the first operation fails. 

1. Deep upper tumor.

This is definitely the most common scenario we have seen over the years. The upper parathyroid glands can lie farther back in the neck. Surgeons who don’t do this all of the time will get nervous to work back in that area because that’s where the nerve to the voice box runs. It’s a healthy fear! Voice issues can be life-changing for the patient. Having been in that area so many times over the years, we are very comfortable working around this nerve and performing re-operations to fix this problem for patients while preserving their voices.

2.  Second adenoma.

Just took out the one on the scan and a second one is still in the neck. As long as the first surgeon didn’t spend hours and hours looking for it, stirring up a lifetime of scar tissue, this is not such an awful thing. It’s not a character flaw to take out what is on the scan and stop there if you don’t have a lot of experience day in and day out in doing parathyroid surgery. You’re going to cure 70-75% of the patients with this disease by doing just that!

3.  Looked but didn’t find all four. (Only found 3 and called it hyperplasia). 

Surgeons whose experience is limited and is still growing don’t always find all four glands. They may find 2 or 3 and not the fourth and figure it must be hyperplasia. It’s hard to find these tiny little things. The subtle differences between parathyroid and other tissues in the neck can be hard to appreciate. And then the subtle differences between normal and diseased glands can be challenging. It takes thousands of these to notice that a diseased gland is sometimes just a little bit larger than a normal one, but it’s a little bit redder, a little bit firmer, a little bit chunkier, gets angry immediately when you barely touch it with a cotton ball. We’ve seen tens of thousands of these glands. So the first surgeon may have only found 2 or 3 normal glands, and the tumor is still in there!

All 3 reasons above can reflect limited experience, and it is this one factor that accounts for the overwhelming majority of surgical failures!

Some questions you may want to ask your surgeon during your consultation and prior to your procedure:

1. How many of these parathyroid operations have you done in your lifetime or in the last year?

Most surgeons will not have a problem answering this. If they cannot give you an approximate number, it’s probably because they don’t know offhand or they would rather not share. On the contrary, if they have done many parathyroid surgeries, they will be happy to share it with you. In order to have good outcomes doing parathyroid surgery, it is generally accepted that at least 50 PARAthyroid operations should be undertaken per surgeon per year. Although this number is not a rule, it is the consensus of most experts in order to have good outcomes. As you see we didn’t say great outcomes or perfect operations. In our opinion you should be doing at least two parathyroid operations a week in order to consider yourself an expert with high success rates and minimal complications.

2. What is your cure rate?

We all understand that nobody is perfect. We also understand that it is impossible to cure every patient that we touch. But cure rates below 90-95% probably signal that the surgeon has not yet reached the desired level of expertise most patients should seek, that would allow them to feel comfortable going “under the knife.” The best chance to cure somebody is during their first operation.

Any reoperation runs the risk of failing, especially if the surgeon creates a fair amount of scar tissue during the first surgery. Unless the surgeon has the expertise to locate and examine all four glands without exploration as we do, it is best to remove the tumor that can be identified on a scan prior to surgery and avoid an extensive operation, thus avoiding excessive scar tissue.

We do not have a problem with surgeons using this focused approach. It is a lot easier to re-operate if a focused operation was done first. It is also important that the surgeon knows if someone is cured the day of surgery. It is a lot easier to re-operate in the first week after a failed operation than 6 months later. Despite scar tissue we do re-operations every week with excellent results and outcomes.

3. What will you do if you cannot find the tumor? This is the question that determines if we would let somebody operate on us or not. Anybody can find a tumor that shows up on preoperative scans, although their accuracy is not as high as most people think. For example, we know that about 50% of the patients we operate on, have negative sestamibi scans. 

So, it is advisable to surgeons that don’t do this operation often, to just remove the tumor found on preoperative imaging and if not, to quit the operation. If a surgeon goes into an operation and he/she is not able to find a tumor, they should be able to find the other parathyroid glands and create a map, but this takes knowledge and experience. That way you know what gland is missing. This ensures that at least you can gather information and center your efforts in finding the missing tumor. The other thing you do not want happening is a 2-hour operation, and no other parathyroid glands identified.

In conclusion, the list of questions above is provided just so you can get a feel for your surgeon and get acquainted with their surgical expertise, it is not meant to be taken as the only source to determine if your surgeon is the right one for you. That is a very personal decision, but our hope is that it helps you start a meaningful conversation during your consultation.

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. Jose Lopez together with his partner and friend of over 20 years, Dr. Douglas Politz (below), 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

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

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