On-the-spot blood tests make surgery quicker

Ever take a medical vacation? Stay in a hotel, take in the sights and fit in some surgery? That’s a reality for some of the hundreds of patients each year who come to Yale-New Haven Hospital (YNHH) for parathyroid operations by endocrine surgeon Robert Udelsman, M.D., M.B.A., chair and William H. Carmalt Professor of Surgery. Since Udelsman’s arrival at Yale in 2001, the number of such operations has risen steadily from 91 to more than 300 annually. Many of his patients are from out of state, and some fly in from Canada and as far away as Italy and Greece.

Most of these patients have primary hyperparathyroidism (PHP), an uncommon disease in which one of the parathyroid glands in the neck begins to enlarge and produce too much hormone. These enlarged glands are called adenomas. Too much parathyroid hormone, or PTH, causes bone loss, kidney stones and other health problems. The adenoma needs to be removed, and in most centers that 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 in 2001 to head the surgery department, combines already existing techniques with a radical but simple innovation—placing a laboratory machine to measure hormone levels, along with a technician, inside the operating room—to create the safe, quick approach to adenoma removal that has made Yale a worldwide destination for PHP patients. “They can fly in Sunday, stay at the hotel and see us on Monday morning. Tuesday morning they have surgery,” says Patricia Donovan, R.N., M.B.A., director of strategic operations and Udelsman’s nurse coordinator. “They return Friday that same week—they might explore New Haven in the meantime—get their stitches removed . . . and fly back.”

Udelsman’s approach, which has been adopted by the other three endocrine surgeons on the team—Sanziana A. Roman, M.D., chief and assistant professor of surgery (endocrine); Julie Ann Sosa, M.D., associate professor of surgery; and Tobias Carling, M.D., Ph.D., assistant professor of surgery—involves several coordinated steps.

First comes pre-op preparation. Besides the patient’s medical background, the team needs to know where the offending adenoma is located. With most people having four or more parathyroid glands, figuring out which is the overactive one—or whether there is more than one—can be a challenge. Imaging studies such as sestamibi scans or ultrasounds help localize it. Before the patients arrive for surgery, Donovan gathers all relevant records, medical information and scan results, talking by phone with patients and their doctors to make sure that the surgery is appropriate for them.

But it is in the operating room that the uniqueness of Yale’s approach is most evident. For one thing, Udelsman and his colleagues do not routinely place patients under general anesthesia. Instead, the patient receives a series of injections of local anesthetics in the neck to block pain. A small incision is made, the offending adenoma is removed and a blood test is done to check levels of PTH. But rather than having to send the blood sample to another part of the hospital, the lab technician in the operating room tests hormone levels immediately, an innovation that greatly speeds up the operation. The surgical team needs to wait only 12 minutes for the blood test results—about a quarter of the time needed at other institutions, where waiting for results can take longer than the operation itself. If PTH levels have dropped sufficiently, the surgeons can be confident that they removed the adenoma completely. Then it’s time to sew up.

The entire procedure typically takes half an hour, and the patient goes home—or back to the hotel—a few hours later, returning to the clinic in three days for a final follow-up visit. Complication rates are low, cure rates are about 98 percent and the surgery is cost-effective. But most of all, patients are satisfied. According to Udelsman, “Putting the lab technician in the operating room is what made us, I think, the premier parathyroid center in the world.” The patients who keep checking into New Haven’s hotels would no doubt agree.