Surgeons in the Division of Endocrine Surgery at the University of Michigan are among leading health care providers for treatment of parathyroid disease, having performed over 3,500 parathyroid operations since 2000. Both in and out of the operating room, our treatments are based on years of research and personal experience. We are constantly evaluating new methods and therapies to provide patients with parathyroid disorders with best, and most up-to-date care available.
Our surgeons offer treatments for both routine cases and most advanced types of parathyroid disease. We are often referred patients with highly complex issues requiring state-of-the-art surgical care not available elsewhere. We offer inpatient and outpatient services, utilizing both minimally invasive and traditional surgical techniques.
When is Parathyroid Surgery Needed?
Parathyroid glands make parathyroid hormone (PTH) to regulate the level of calcium in the blood. Other cells in the body, especially cells of the bones, kidneys, and small intestine, respond to PTH by increasing the calcium level in the blood. Under normal conditions, this control is quite accurate. If one or more parathyroid glands enlarge and produce too much PTH, the calcium level in the blood will increase. When the calcium level in the bloodstream is higher than normal and the parathyroid glands stop responding appropriately to this elevation by shutting down production of PTH, this leads to the condition called primary hyperparathyroidism. Surgery is the only way to cure this problem. This condition is rarely due to cancer (<1%).
While many patients elect to undergo surgery so that they do not develop complications from their parathyroid disease, some patients may have mildly elevated calcium levels and mild complications from their disease. Some patients may decide not to have surgery in this situation, which is acceptable. These patients need to be followed closely for the rest of their life.
If patients have any of the following, they should undergo surgery:
- Osteoporosis or fractures due to decreased bone density
- Kidney stones
- Decreased kidney function with a GFR <60
- 24 hour urine calcium >400mg
- Age less than 50
- Calcium levels greater than 1 above the upper limit of normal
How is Parathyroid Surgery Usually Performed?
Parathyroid surgery takes place in the operating room. Most operations are done under general anesthesia, although local anesthesia with I.V. sedation can be used in many cases.
Protecting the nerves that cause movement of the vocal cords and the remaining parathyroid glands so they will function normally is an important part of your surgery. It is not uncommon to have a low calcium level after a successful surgery. That situation is nearly always temporary and normal function is restored in over 98% of people in just a few weeks.
You may have read about minimally invasive, or "keyhole" parathyroid surgery. This is the preferred approach by endocrine surgeons at the University of Michigan, but requires identification of an abnormal parathyroid gland prior to surgery. Most patients go home within 2 hours after surgery.
Four Gland Parathyroid Exploration
The "gold standard" operation for primary hyperparathyroidism for almost 100 years has been the four gland parathyroid exploration. This involves making a small incision in the lower neck and examining all parathyroid glands. Abnormally enlarged parathyroid glands are removed, and the wound is closed with sutures, a substance similar to super glue, and/or steri-strips. This operation has a cure rate of ~98% when performed by an experienced parathyroid surgeon.
Minimally Invasive Parathyroidectomy
Endocrine surgeons at the University of Michigan have been performing minimally invasive parathyroid surgery for nearly 20 years. This approach to parathyroid surgery was developed in the late 1980's and gained acceptance during the 1990's.
The technique offers advantages over conventional open surgery, including:
- less pain
- reduced scarring
- most patients discharged within hours following surgery
- performed under general anesthesia or local anesthesia with IV sedation
During minimally invasive parathyroid surgery, the surgeon makes a small incision at the base of the neck. The surgeon then removes the enlarged gland that had been identified by imaging studies performed prior to surgery. Instead of looking at all four parathyroid glands, parathyroid hormone levels are measured just before removal of the enlarged gland and several times after removal of the abnormal gland. If the PTH levels decrease appropriately suggesting that the other three glands are functioning normally, then the operation is concluded. If the PTH levels do not decrease appropriately suggesting cure, then the surgeon goes on to look at the remaining parathyroid glands and removes any additional abnormal tissue.
Currently, the success rate for minimally invasive parathyroidectomy equals that of the more conventional four gland exploration when performed appropriately. If there is any concern for multigland disease identified during a minimally invasive procedure, all four parathyroid glands will be examined. All monitoring of PTH levels is done while the patient is in the operating room.
Endocrine surgeons at the University of Michigan have developed more advanced techniques for monitoring parathyroid hormone production during parathyroid surgery. Our techniques lead to higher cure rates than techniques used in other centers.
Parathyroid Surgery for Primary Hyperparathyroidism
Surgery is the only cure for primary hyperparathyroidism. It has a high success rate, is low risk, and very well tolerated. It can even be done under local anesthetic (numbing medicine) with intravenous medication for sedation. Parathyroid surgery has been shown to be very safe, even in patients into their 80's and beyond.
Parathyroid Surgery for Secondary and Tertiary Hyperparathyroidism
In general, all four parathyroid glands are affected and must be examined using the traditional four gland parathyroid exploration. A four gland exploration involves making a small incision in the lower neck and examining all the parathyroid glands. Abnormally enlarged parathyroid glands are removed while the equivalent of one, normal-size parathyroid gland, must be left somewhere in the body. In some patients, one of the abnormal parathyroid glands can be trimmed down to a normal-size gland using clips, as the rest of the abnormal parathyroid tissue is removed. In other patients, all parathyroid tissue in the neck is removed and the equivalent of one normal-size parathyroid gland is re-implanted into the muscle in the forearm, chest wall, or another site. The blood supply from the muscle grows into the parathyroid tissue and the parathyroid tissue begins functioning 6-10 weeks later.
Patients with secondary and tertiary hyperparathyroidism are more prone to have extra parathyroid glands. We search for these extra glands at the time of surgery as well. Once the abnormal parathyroid has been removed, the incision is closed with sutures, a substance similar to super glue, and/or steri-strips.
What Can I Expect After My Parathyroid Surgery?
Parathyroid surgery, regardless of type, is very well tolerated. Pain is relatively mild, and many patients complain more about a sore throat from the breathing tube (if surgery was performed under general anesthesia) than they do about pain from their incision.
In cases with primary hyperparathyroidism, if only one gland is removed, as is the case 80-85% of the time, most patients are discharged home the same day. If more than one parathyroid gland is removed, or you have other specific medical conditions requiring observation, you will be kept in the hospital overnight.
Patients with secondary hyperparathyroidism may spend more time in the hospital than those patients who have surgery for other types of hyperparathyroidism. This is because it takes some time for the calcium level in the bloodstream to stabilize. Patients are usually placed on high doses of oral or intravenous calcium and oral Vitamin D. Patients will be dialyzed in the hospital if necessary. Dialysis can also help regulate the calcium level. Once the calcium level has stabilized and patients are not having symptoms of low calcium levels, they are discharged home. Patients with tertiary hyperparathyroidism are usually kept in the hospital overnight after their operation, and are generally sent home the next day, after ensuring their calcium levels are at an appropriate level for discharge.
Patients are asked to take calcium supplements in the form of CitraCal Maximum with Vitamin D while at home. The appropriate dose will be written down for you and included in your discharge paperwork. CitraCal Maxiumum with Vitamin D is available at most drugstores and grocery stores and does not require a prescription. We ask all of our patients to use this brand of calcium after their operation so that we can more easily and uniformly manage your calcium level.
The pain associated with the incision is not particularly great, and is commonly controlled with over-the-counter pain medications. Stronger pain medication is rarely required at home, but if so, it is usually only necessary for a day or two.
You may eat and drink whatever you choose after surgery and may resume your normal daily activities as soon as you like. However, we ask that you refrain from any strenuous physical activity, heavy lifting, or exercise until you return to the office for your postoperative visit in the early postoperative period.
You may shower 24 hours after your surgery and gently wash the incision with soap and water. Patients are discharged home with steri-strips in place over their incision. You can, and should, wash gently over these in the shower; however, do not submerge them in a bathtub, hot tub, or pool. Allow the steri-strips to remain in place until they fall off on their own.
If You are Scheduled for Parathyroid Surgery
For more information about parathyroid surgery, including information about what to expect before and after your operation, visit the About Your Parathyroid Surgery page on the Division of Endocrine Surgery website.
Make an Appointment
To schedule an appointment to discuss parathyroid surgery, please call us at (734) 936-5738, or visit our online appointment request page. For more appointment information, including information about insurance, visit our Endocrine Surgery Appointments page.