Parathyroid Surgery Made Easier

t 23, Steven Oritt was on a roll. A recent film-school graduate, he was pegged to do his first short film in L.A., but all the excitement had left him a bit fatigued. Then a routine medical checkup caught an excessively high blood calcium level, and ultrasound scans and other tests revealed a growth on one of Oritt’s parathyroid glands. Suddenly the young man’s professional plans were thrown askew, as he faced surgery under a general anesthetic and a lengthy recovery. But Oritt’s physician had heard that an easier approach to the complex operation was available. Johns Hopkins was offering outpatient parathyroid surgery. Since the young man’s parents lived nearby, he headed for Baltimore.

The key to the outpatient procedure is good pre-op mapping of the abnormal parathyroid tissue, says surgeon Robert Udelsman, M.D., because its position can be anything but stereotyped. Oritt’s abnormal parathyroid, for example, was hidden well behind his esophagus, far from the position touching the thyroid where the parathyroid glands usually reside. Using an agent called sestamibi, which homes in on abnormal parathyroid tissue, in combination with single photon emission computed tomography (SPECT), Hopkins nuclear-medicine specialists produced a clear 3-D image of the abnormal parathyroid in relation to the thyroid gland. “The combination of the two techniques is unique,” says Udelsman. “Having such an image greatly simplifies the surgery.”

With the patient under local anesthesia, Udelsman made an inch-or-so incision in the neck above the target parathyroid. Five minutes after he extracted the offending tissue, pathologists did an on-site radioimmunometric assay of the patient’s blood to measure parathyroid hormone. “If we have a 50 percent drop from baseline within five minutes of surgery,” says Udelsman, “we know the surgery’s successful.” Two hours later, patients can go home. The surgery would have taken four times longer with conventional techniques. Oritt, who played golf two days later, announced, “It’s the only way to go.”

--MC