For Referring Physicians - Parathyroid disease Treatment
Parathyroid Disease Treatment - UCLA Endocrine Surgical Unit Brings Unrivaled Experience, Methods and Tools
The UCLA Endocrine Surgical Unit is the only surgical program in
Southern California dedicated exclusively to thyroid, parathyroid and adrenal disease, offering an unrivaled level of experience
and excellence along with the latest diagnostic and surgical methods and equipment.
Research confirms that experience counts when it comes to surgical treatment of parathyroid
disease, with success rates of approximately 97 percent among experienced surgeons like those
at UCLA, who perform in excess of 100 procedures annually, compared with rates of only 70
percent among less experienced surgeons (1, 2). Similarly, diagnostic tests to locate diseased
parathyroid glands are 90 percent sensitive when performed by experienced multidisciplinary
teams such as those at UCLA, compared to 30 to 70 percent in less experienced hands (3, 4).
The parathyroid glands — four sunflower seed-sized
glands located behind the thyroid gland — control the body’s calcium levels.
Primary hyperparathyroidism is characterized by inappropriate parathyroid hormone (PTH) excess,
that is, high PTH levels in the presence of high or high-normal calcium levels. This ongoing
pathologic process causes the net loss of calcium from the skeleton into the bloodstream
and urine. Complications include kidney stones, osteoporosis, musculoskeletal pain, possible
cardiovascular disease, and neuropsychiatric symptoms such as fatigue, anxiety, memory loss
and depression (5).
The disease affects approximately 1 percent of the adult population, and occurs three
times more often in women than men. The risk of parathyroid disease increases with age, particularly
after age 55. About 3 percent of postmenopausal women have the disorder, often complicating
bone density loss related to menopause (6).
Diagnosis and Treatment of Parathyroid Disease
Elevated calcium levels related to parathyroid
disease are typically detected during routine blood testing. Among outpatients, primary hyperparathyroidism
is the leading cause of hypercalcemia, and can generally be diagnosed if calcium and intact
PTH levels are simultaneously elevated. Parathyroid sestamibi scan and ultrasound are the
two most useful tests in localizing parathyroid adenomas, though the sensitivities of both
are highly operator-dependent (7).
Increased understanding of the multiple adverse health effects of primary hyperparathyroidism
has prompted national expert groups to recommend parathyroid surgery for all patients in
whom the biochemical diagnosis has been established (8). About 85 percent of patients suffer
from single-gland parathyroid disease, and up to 90 percent of those are eligible for minimally
invasive parathyroid surgery, which is associated with faster recovery and less scarring.
At UCLA, a minimally invasive procedure typically lasts less than 30 minutes and involves
a scar measuring 1.5 centimeters – the diameter of a penny – that is hidden within
natural skin folds. Intraoperative PTH measurements can determine success of the procedure
within minutes of removal of the diseased gland. Virtually all patients are discharged from
the hospital within 23 hours of admission.
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Myths About Parathyroid Surgery
- Myth: Radio-guided parathyroid surgery improves outcomes. Multiple
independent studies have demonstrated no benefit from usage of the gamma probe, leading to
abandonment of the technique by nearly all expert centers (9-11). UCLA surgeons do not use
gamma probes to locate parathyroid tumors during surgery.
- Myth: Technologists and radiologists and are most expert
at administering and interpreting ultrasound tests for parathyroid disease. Surgeon-performed
ultrasound has emerged as a first-line localization study (12-14). Endocrine surgeons at
UCLA personally conduct and interpret diagnostic ultrasound tests for parathyroid disease
using the most advanced equipment available. The study is repeated immediately prior to surgery
to guide incision placement and operative strategy.
- Myth: Many patients are too elderly and/or
frail to be candidates for parathyroid surgery. In its modern form, parathyroid
surgery is very well tolerated and carries few complications. Studies show that elderly patients
enjoy the same benefits from successful parathyroid surgery that younger individuals do (15).
There is no standard definition of “minimally invasive” parathyroid surgery. Though
many centers may claim to offer minimally invasive procedures, only a minority truly meet
objective criteria for the technique, as defined by researchers at the University of California
at San Francisco (16). The term “minimally invasive” is reserved for
parathyroid surgery involving an incision measuring less than 2.5 cm in length. At UCLA,
an incision length of 1.5 centimeters is used. To our knowledge, this is the least invasive
parathyroid operation offered worldwide (17-19).
For more information, for consultation, or to refer
a patient, call 310-206-0585 (primary line)
or 310-825-8340 (secondary line) or fax to 310-825-0189.
Additional information is available at our website:
Michael Yeh, M.D. – Endocrine Surgery,
Christiann Schiepers, MD – Nuclear Medicine
1. Shen W, Duren, M, Morita, E, Higgins, C, Duh, QY, Siperstein, AE, and Clark, OH. Reoperation
for persistent or recurrent primary hyperparathyroidism. Arch Surg, 131: 861-867; discussion
2. Soon PS, Yeh, MW, Sywak, MS, Roach, P, Delbridge, LW, and Sidhu, SB. Minimally invasive
parathyroidectomy using the lateral focused miniincision approach: is there a learning curve
for surgeons experienced in the open procedure? J Am Coll Surg, 204: 91-95, 2007.
3. Clark PB, Case, D, Watson, NE, Morton, KA, and Perrier, ND. Experienced scintigraphers
contribute to success of minimally invasive parathyroidectomy by skilled endocrine surgeons.
Am Surg, 69: 478-483; discussion 483-474, 2003.
4. Yeh MW, Barraclough, BM, Sidhu, SB, Sywak, MS, Barraclough, BH, and Delbridge, LW. Two
hundred consecutive parathyroid ultrasound studies by a single clinician: the impact of experience.
Endocr Pract, 12: 257-263, 2006.
5. Bilezikian JP, Brandi, ML, Rubin, M, and Silverberg, SJ. Primary hyperparathyroidism:
new concepts in clinical, densitometric and biochemical features. J Intern Med, 257: 6-17,
6. Coker LH, Rorie, K, Cantley, L, Kirkland, K, Stump, D, Burbank, N, Tembreull, T, Williamson,
J, and Perrier, N. Primary hyperparathyroidism, cognition, and health-related quality of
life. Ann Surg, 242: 642-650, 2005.
7. Arici C, Cheah, WK, Ituarte, PH, Morita, E, Lynch, TC, Siperstein, AE, Duh, QY, and Clark,
OH. Can localization studies be used to direct focused parathyroid operations? Surgery, 129:
8. The American Association of Clinical Endocrinologists and the American Association of
Endocrine Surgeons position statement on the diagnosis and management of primary hyperparathyroidism.
Endocr Pract, 11: 49-54, 2005.
9. Duh QY. Presidential Address: Minimally invasive endocrine surgery--standard of treatment
or hype? Surgery, 134: 849-857, 2003.
10. Inabnet WB, 3rd, Kim, CK, Haber, RS, and Lopchinsky, RA. Radioguidance is not necessary
during parathyroidectomy. Arch Surg, 137: 967-970, 2002.
11. Kell MR, Sweeney, KJ, Moran, CJ, Flanagan, F, Kerin, MJ, and Gorey, TF. Minimally invasive
parathyroidectomy with operative ultrasound localization of the adenoma. Surg Endosc, 18:
12. Solorzano CC, Carneiro-Pla, DM, and Irvin, GL, 3rd. Surgeon-performed ultrasonography
as the initial and only localizing study in sporadic primary hyperparathyroidism. J Am Coll
Surg, 202: 18-24, 2006.
13. Van Husen R and Kim, LT. Accuracy of surgeon-performed ultrasound in parathyroid localization.
World J Surg, 28: 1122-1126, 2004.
14. Kairys JC, Daskalakis, C, and Weigel, RJ. Surgeon-performed ultrasound for preoperative
localization of abnormal parathyroid glands in patients with primary hyperparathyroidism.
World J Surg, 30: 1658-1663; discussion 1664, 2006.
15. Kebebew E, Duh, QY, and Clark, OH. Parathyroidectomy for primary hyperparathyroidism
in octogenarians and nonagenarians: a plea for early surgical referral. Arch Surg, 138: 867-871,
16. Brunaud L, Zarnegar, R, Wada, N, Ituarte, P, Clark, OH, and Duh, QY. Incision length
for standard thyroidectomy and parathyroidectomy: when is it minimally invasive? Arch Surg,
138: 1140-1143, 2003.
17. Henry JF, Sebag, F, Tamagnini, P, Forman, C, and Silaghi, H. Endoscopic parathyroid surgery:
results of 365 consecutive procedures. World J Surg, 28: 1219-1223, 2004.
18. Miccoli P, Berti, P, Materazzi, G, and Donatini, G. Minimally invasive video assisted
parathyroidectomy (MIVAP). Eur J Surg Oncol, 29: 188-190, 2003.
19. Palazzo FF and Delbridge, LW. Minimal-access/minimally invasive parathyroidectomy for
primary hyperparathyroidism. Surg Clin North Am, 84: 717-734, 2004.