Factors influencing the length of the incision and the operating time for total thyroidectomy.

BACKGROUND: The incision used for thyroid surgery has become shorter over time, from the classical 10 cm long Kocher incision to the shortest 15 mm access achieved with Minimally Invasive Video-Assisted Thyroidectomy. This rather large interval encompasses many different possible technical choices, even if we just consider open surgery.The aim of the study was to assess the correlation between incision length and operation duration with a set of biometric and clinical factors and establish a rationale for the decision on the length of incision in open surgery. METHODS: Ninety-seven consecutive patients scheduled for total thyroidectomy were prospectively evaluated. All operations were performed by the same team and the surgeon decided the length of the incision according to his personal judgement. Patients who had previously undergone neck surgery were excluded. RESULTS: The length of the incision was strongly correlated with gender, thyroid volume, neck circumference and clinical diagnosis and weakly correlated with the body mass index. Operation duration was only weakly correlated with gender and neck circumference. Multiple linear regression revealed that the set of factors assessed explained almost 60 % of the variance in incision length but only 20 % of the variance in operation duration. When patients were classified according to the distribution of their thyroid volume, cases within one standard deviation of the mean did not show a significant difference in terms of operation duration with incisions of various lengths. CONCLUSIONS: Although thyroid volume was a major factor in driving the decision with respect to the length of the incision, our study shows that it had only minor effect on the duration of the operation. Many more open thyroidectomies could therefore be safely performed with shorter incisions, especially in women. Duration of the operation is probably more closely linked to the inherent technical difficulty of each case.

Spleen dimensions are inversely associated with lysosomal acid lipase activity in patients with non-alcoholic fatty liver disease.

Fatty liver and splenomegaly are typical features of genetic lysosomal acid lipase (LAL) deficiency. No data in adult patients with non-genetic reduction of LAL activity are available. We investigate the association between spleen dimensions and LAL activity in non-alcoholic fatty liver disease (NAFLD) patients, in whom a reduced LAL activity has been reported. We include 425 consecutive patients who underwent abdominal ultrasound to evaluate hepatic steatosis and spleen dimensions. LAL activity was measured with dried blood spot method (Lalistat2). NAFLD was present in 74.1% of screened patients. Higher median spleen longitudinal diameter (10.6 vs. 9.9 cm; p < 0.001) and spleen area (SA) (32.7 vs. 27.7 cm2; p < 0.001), together with a higher and proportion of splenomegaly (17.8 vs. 5.5%, p = 0.001), are present in patients with NAFLD compared to those without. In NAFLD patients, median LAL activity is 0.9 nmol/spot/h. LAL activity is lower in 56 patients with splenomegaly, as compared to those without (p = 0.009). At multivariable logistic regression analysis, age (above median, OR 0.344; p = 0.003), LAL activity (below median, OR 2.206, p = 0.028), and platelets (OR 0.101, p = 0.002) are significantly associated with splenomegaly. NAFLD patients disclose a relatively high prevalence of spleen enlargement and splenomegaly, which are significantly associated with a reduced LAL activity, suggesting that LAL may contribute to spleen enlargement in this setting.

Relation of nonalcoholic fatty liver disease and Framingham Risk Score to flow-mediated dilation in patients with cardiometabolic risk factors.

Nonalcoholic fatty liver disease (NAFLD) has a high prevalence in the general population. Brachial artery flow-mediated dilation (FMD) is a surrogated marker of early atherosclerosis. Few data investigating the relation between FMD, NAFLD, and cardiovascular (CV) risk are available. We recruited 367 consecutive outpatients with cardiometabolic risk factors who underwent ultrasound scanning for liver steatosis and FMD. Mean age was 54.2 ± 12.2 years, and 37% were women. NAFLD was present in 281 patients (77%). Median FMD was 5.1%. FMD was significantly reduced in patients with NAFLD (p <0.001), diabetes (p = 0.001), history of coronary heart disease (p = 0.034), and metabolic syndrome (p = 0.050) and in those taking antihypertensive drugs (p = 0.022). Women disclosed greater FMD than males (p = 0.033). Moreover, FMD inversely correlated with age (Spearman rank correlation test [Rs], -0.171; p = 0.001), waist circumference (Rs, -0.127; p = 0.016), fasting blood glucose (Rs, -0.204; p <0.001), and gamma-glutamyl transpeptidase (Rs, -0.064; p = 0.234). At multivariate regression analysis, fasting blood glucose (ß, -0.148; p = 0.008), age (ß, -0.158; p = 0.005), and the presence of NAFLD (ß, -0.132; p = 0.016) inversely correlated with FMD, whereas female gender predicted a better FMD (ß, 0.125; p = 0.022). FMD and Framingham Risk Score (FRS) were inversely correlated (Rs, -0.183; p <0.001). After dividing patients into low (FRS <10; FMD, 5.5% [3.1% to 8.9%]), intermediate (FRS 10 to 20; FMD, 4.9% [2.7% to 7.5%]), and high (FRS >20; FMD, 3.3% [1.7% to 4.5%]) risk, FMD significantly decreased across risk classes of FRS (p = 0.003). At multivariate regression analysis, both FRS (ß, -0.129; p = 0.016) and NAFLD (ß, -0.218; p <0.001) were variables independently associated with FMD. In conclusion, the presence of NAFLD and FRS inversely correlated with FMD.

Similar Reduction of Cholesterol-Adjusted Vitamin E Serum Levels in Simple Steatosis and Non-Alcoholic Steatohepatitis.

OBJECTIVES: Reduced vitamin E levels have been reported in patients with non-alcoholic steatohepatitis (NASH), but no conclusive data on patients with simple steatosis (SS) are available. Aim of this study was to investigate the association between serum vitamin E levels and SS. METHODS: A cohort of 312 patients with cardio-metabolic risk factors was screened for liver steatosis by ultrasonography (US). We reasonably classified as SS patients with US-fatty liver, normal liver function tests (LFTs) and with Cytokeratin 18 <246 mIU/ml. Liver biopsy was performed in 41 patients with US-fatty liver and persistent elevation of LFTs (>6 months). Serum cholesterol-adjusted vitamin E (Vit E/chol) levels were measured. RESULTS: Mean age was 53.9±12.5 years and 38.4% were women. Non-alcoholic fatty liver disease (NAFLD) was detected at US in 244 patients; of those 39 had biopsy-proven NASH and 2 borderline NASH. Vit E/chol was reduced in both SS (3.4±2.0, P<0.001), and NASH (3.5±2.1, P=0.006) compared with non-NAFLD patients (4.8±2.0 µmol/mmol chol). No difference was found between SS and NASH (P=0.785). After excluding patients with NASH, a multivariable logistic regression analysis found that Vit E/chol (odds ratio (OR): 0.716, 95% confidence interval (CI) 0.602-0.851, P<0.001), alanine aminotransferase (ALT, OR: 1.093, 95% CI 1.029-1.161, P=0.004), body mass index (OR: 1.162, 95% CI 1.055-1.279, P=0.002) and metabolic syndrome (OR: 5.725, 95% CI 2.247-14.591, P<0.001) were factors independently associated with the presence of SS. CONCLUSIONS: Reduced vitamin E serum levels are associated with SS, with a similar reduction between patients with SS and NASH, compared with non-NAFLD patients. Our findings suggest that the potential benefit of vitamin E supplementation should be investigated also in patients with SS.

Clinical value of calcifications in thyroid carcinoma and multinodular goiter.

BACKGROUND: To confirm the predictive value of calcifications in thyroid nodules as a risk factor for malignancy and to detect aspects specific for tumours. MATERIALS AND METHODS: In a set of 196 patients (33 differentiated thyroid carcinoma, 9 follicular adenomas and 154 multinodular goiters with dominant nodule) calcifications were detected by ultrasound scan. RESULTS: Calcifications were significantly more frequent in differentiated thyroid carcinoma (DTC) than in benign diseases (DTC 39.4%, adenoma 11.1%, goiter 20.1%) but their considered characteristics (size, number, position, location in the gland, sonographic features of the nodule) did not show any particular difference between DTC and benign diseases. The frequency of calcifications in our series was higher in older patients (mean age 59.4 +/- 13.7 vs. 52.1 +/- 13.1 in patients without calcifications, p < 0.001) and this could imply that their onset is time-dependent. CONCLUSION: Calcifications can be a useful indicator of enhanced risk, to be considered in the overall diagnostic process.

[Vascular malformations: the need for a multidisciplinary treatment. Considerations on a clinical case]. / Le malformazioni vascolari: necessità di un trattamento multidisciplinare. Considerazioni su di un caso clinico.

The case reported here is a paradigm of a complex vascular malformation with a therapeutic approach which involved both vascular radiology and surgery. The case came to our attention in 1999 and consisted in a tumefaction of the left gluteal region in a 14-year-old female. The lesion had previously been evaluated by ultrasonography and magnetic resonance imaging. The lesion was described as a dysplastic malformation with a high vascular factor. After angiography, we decided to embolize the mass. A second embolization also yielded no result, and therefore we decided to remove the dysplasia surgically. The dysplasia, however, was resolved only in 2001 after a third embolization. Because of the multiple types of symptoms, a multidisciplinary approach is required to obtain both a correct classification and treatment of the vascular malformations.