Patients come to Yale from around the world to have parathyroid surgery done in a way that is quicker and safer than traditional methods.
[September 2008] Sometimes a small change can make a big difference.
Such is the case with an innovative technique for performing parathyroid operations developed by Robert Udelsman, MD, MBA, chair and William H. Carmalt Professor of Surgery.
Since 2001, when Udelsman arrived at Yale and began treating patients with his new procedure, the number of parathyroid operations he and his colleagues have done at Yale-New Haven Hospital (YNHH) has gone up from 91 to more than 300 annually. Many patients come from out of state and as far away as Canada, Italy and Greece.
Udelsman’s technique is used for patients with primary hyperparathyroidism (PHP), an uncommon disease in which enlarged parathyroid glands, called adenomas, in the neck start over-producing parathyroid hormone (PTH). Too much parathyroid hormone causes bone loss, kidney stones and other health problems.
To treat this condition, the adenoma is surgically removed, which in most centers requires general anesthesia and several nights in the hospital. Not so at YNHH.
Udelsman, who came to Yale from The Johns Hopkins School of Medicine to head the surgery department, combines established methods with a radical but simple innovation—the placement of a technician and laboratory machine in the operating room to take a blood test that provides immediate hormone level readings. This creates a quicker and safer surgical experience and has made Yale a worldwide destination for PHP patients.
“Patients can fly in Sunday, stay at a hotel and see us on Monday morning. Tuesday morning they have the surgery,” says Patricia Donovan, RN, MBA, Udelsman’s nurse coordinator and director of strategic operations. Patients return three days later for a follow-up examination and to get their stitches removed.
Coordinated front-end planning is a key element of Udelsman’s method, which has been adopted by the other three endocrine surgeons on the team: Sanziana A. Roman, MD, chief and assistant professor of surgery (endocrine); Julie Ann Sosa, MD, associate professor of surgery; and Tobias Carling, MD, PhD, assistant professor of surgery.
Before the patients arrive for surgery, Donovan gathers all relevant records, medical information and scan results, talking by phone with patients and their doctors as needed.
Then the team gets to work identifying the location of the offending adenoma. Since most people have four or more parathyroid glands, figuring out which is the overactive one—or whether there is more than one—is a challenge. Imaging studies, such as sestamibi scans or ultrasounds, are used.
During surgery, Udelsman and his colleagues don’t use general anesthesia; they prefer to numb the neck with a local anesthesia. The offending adenoma is removed through a small incision, followed by a blood test to check PTH levels.
This is where Udelsman’s innovation comes into play. Instead of sending the blood sample to another part of the hospital, the on-site lab technician immediately tests hormone levels. If PTH levels have dropped sufficiently, the surgeons know they got the right adenoma and have removed it completely. Then it’s time to sew up.
The whole procedure typically takes only half an hour. That’s because the surgical team gets the blood test results in 12 minutes —about a quarter of the time needed at other institutions, where waiting for results can take longer than the operation itself.
Other benefits of Udelsman’s innovation include:
“Putting the lab technician in the operating room is what made us, I think, the premier parathyroid center in the world,” says Udelsman.
Robert Udelsman (left) consults with a patient.
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