It was a pleasure to share in the care of your patient who has completed a parathyroid operation with us. We perform 15 or more parathyroid surgeries per day (over 3700 per year) on patients with simple and very complex disease from around the world. Our mini-operation typically examines all four glands and takes about 20 minutes total time–this will be described in the reports you should already have. We evaluate and address all thyroid issues at the same time–complex cases are our specialty. Importantly, patients with positive and negative scans get the exact same mini-4-gland operation.
Records of the operation
You should already have received from our office: 1) the dictated operative report, 2) a personal letter from us explaining what has taken place and what needs to be done, 3) a photo of the tumor and 4) hormone measures 1 hour post surgery (a white sticker on the photo; the level will be quite low because the remaining glands are dormant). The normal glands will awaken and produce normal PTH levels within a few days of the operation.
There are no stitches to remove. Some wounds have a little swelling, but this will go away. Obtain serum calcium and PTH levels (note that patient is currently taking calcium pills, but this should not affect results).
You may choose to put patients with osteoporosis on a bone-enhancing drug of your choice. Although none of these drugs will have any beneficial effect while the patient has hyperparathyroidism, and thus are not a substitute for removing the offending parathyroid tumor, they may be helpful after this disease has been cured. A number of good studies have demonstrated that the vast majority of patients will show significant increase in bone density for several years after curative parathyroid surgery if given calcium / Vitamin-D supplementation only. We leave these decisions up to your good judgment.
DEXA scans are recommended every 2 years for patients with osteoporosis to document the expected increases in bone density following removal of a parathyroid tumor. Often the increase in the bone density is dramatic!
If your patient did not have a DEXA scan prior to surgery, then it is typically appropriate. The amount and duration of calcium supplementation (and potential use of Bisphosphonates) will depend on the amount of bone destruction that has occurred. Importantly, it is the duration of the disease that causes osteoporosis–the height of the calcium has no correlation with the degree of osteoporosis.
Most important teaching point
Thank you for reading this far! The number one teaching point we try to make is that the height of the calcium elevation has no correlation to any symptom or complication of this disease. Like all endocrine diseases, it is the duration that causes secondary health problems. Complications such as kidney stones, osteoporosis, fractures, renal failure, atrial fibrillation, hypertension, and stroke are all related to the duration of calcium over 10.0 mg/dl (2.5 mmol/l) (the upper limit of normal for adults). A calcium level of 12.0 does not have a higher incidence of any of these factors than a calcium of 10.6. Thus, the take home message is simple: Bad things always occur with primary hyperparathyroidism and they occur with time. Time is the enemy. It is almost never appropriate to “watch” or “monitor” high calcium because it is “just a little bit high”. A little bit high is deadly with time.
Removing parathyroid tumors has an amazing positive effect on how patient’s feel and their overall health. This is a slow, chronic, deadly disease that makes people miserable as it destroys their body. It is almost never asymptomatic–just ask this patient how they feel now compared to preoperatively!
The second most important teaching point
Since you are still reading, (thanks!), the second most important teaching point is that the upper limit of normal calcium for adults over 35 is 10.0 mg/dl (2.5 mmol/L). Many labs show the upper limit of normal being 10.5 mg/dl (2.7 mmol/L). This is the upper limit for teenagers (who are building bone) and the lab is not adjusting the upper limit for the patient’s age. Take a look at your own labs, and those of all your healthy patients — we all have calcium levels in the mid 9’s. It really is that simple: adults have calcium levels in the 9’s, not the 10’s.
Referring patients to us
Call our main number 813-972-0000 (a human will answer) and ask for “new patient referrals”. If you have a specific question for one of our doctors, we have a doctor in the office every day to take your call. As noted above, we perform the same 4-gland mini operation regardless of scan results. A positive scan doesn’t save us even 1 minute in the operating room; the only way to have very high cure rates that are durable for decades is to examine all four glands. We prefer patients do not have localizing scans prior to being referred. This is all we do, and we’re happy to help.