Outpatient management of proctologic disease. Which techniques for local anesthesia? The experience of a single center.

INTRODUCTION: Since 1899 outpatient management of surgical patients had been increasing, becoming the best option when possible. In 1988 was described the first experience of outpatient management of proctologic disease. Advances in local anesthesia techniques have improved the outpatient approach to surgical disease, particularly in patients with proctological diseases. METHODS: From 2010 to 2016, 1160 patients who needed surgery for proctologic disease have been recruited: 239 hemorrhoidectomies using the variant of Milligan Morgan technique described by Phillips, 45 trans-anal hemorrhoidal DE-arterialization (THD), 315 sphincterotomies, 12 anal polypectomies, 230 loop seton positions, 65 cone-like fistulectomies and 254 fistulotomies for perianal fistulas. In 329 cases, we used the posterior perineal block, 603 local perineal blocks, and 228 tumescent anesthesia. RESULTS: On a total of 1160 procedure failure rate was of 4.7% (55 cases). Urinary retention (69% 38 cases); bleeding 18% (10 cases), uncontrolled pain 12% of cases (7 cases). The chi-square test demonstrates (p<0.01) that the failure rate of the three types of anesthesia is very different with high statistical significance. The failure rate in patient underwent Posterior Perineal Block was 27/329 cases (8.2%), 8/228 (3.5%) in patients who underwent Tumescent Anesthesia and 20/603 (3.3%) in who underwent Local Perineal Block. CONCLUSIONS: Outpatient protocols represent the most common approach to minor proctologic disease that needs a good local block, with a good analgesic and sedative assistance, the different local block seems to be the same concerning the pain control, but presents some little, not relevant difference concerning urinary retention rate.

Targeted therapies in hepatocellular carcinoma.

The onset of hepatocellular carcinoma (HCC) is related to the development of non-neoplastic liver disease, such as viral infections and cirrhosis. Even though patients with chronic liver diseases undergo clinical surveillance for early diagnosis of HCC, this cancer is often diagnosed in advanced stage. In this case locoregional treatment is not possible and systemic therapies are the best way to control it. Until now sorafenib, a Raf and multi-kinase inhibitor has been the best, choice to treat HCC systemically. It showed a survival benefit in multicenter phase III trials. However the proper patient setting to treat is not well defined, since the results in Child-Pugh B patients are conflicting. To date various new target drugs are under developed and other biological treatments normally indicated in other malignancies are under investigation also for HCC. These strategies aim to target the different biological pathways implicated in HCC development and progression. The target drugs studied in HCC include anti-VEGF and anti-EGFR monoclonal antibodies, tyrosine kinase inhibitors and mTOR inhibitors. The most important challenge is represented by the best integration of these drugs with standard treatments to achieve improvement in overall survival and quality of life.