BACKGROUND: Enhanced recovery programs (ERPs) are associated with a lower morbidity rate and a shorter length of stay. The present study’s objective was to determine whether an ERP is feasible and effective for patients undergoing early cholecystectomy for grade I or II acute calculous cholecystitis. STUDY DESIGN: A 2-step multicenter study was performed. In the first step (the feasibility study), patients were consecutively included in a dedicated, prospective database from March 2019 until January 2020. The primary endpoint was the ERP’s feasibility, evaluated in terms of the number and nature of the ERP components applied. During the second step, the ERP’s effectiveness in acute calculous cholecystitis was evaluated in a case-control study. The ERP+ group comprised consecutive patients who were prospectively included from March 2019 to November 2020 and compared with a control (ERP–) group of patients extracted from the ABCAL randomized controlled trial treated between May 2010 and August 2012 and who had not participated in a dedicated ERP. RESULTS: During the feasibility study, 101 consecutive patients entered the ERP with 17 of the 20 ERP components applied. During the effectiveness study, 209 patients (ERP+ group) were compared with 414 patients (ERP– group). The median length of stay was significantly shorter in the ERP+ group (3.1 vs 5 days; p < 0.001). There were no intergroup differences in the severe morbidity rate, mortality rate, readmission rate, and reoperation rate. CONCLUSIONS: Implementation of an ERP after early cholecystectomy for acute calculous cholecystitis appeared to be feasible, effective, and safe for patients. The ERP significantly decreased the length of stay and did not increase the morbidity rate.

Background: The feasibility of day case surgery (DCS) appendectomy for uncomplicated acute appendicitis (UCAA) was evaluated by the prospective AppendAmbu study (NCT01839435). The aim of this study was to evaluate the real-life feasibility of DCS for UCAA.Study design: This single-center, retrospective, non-interventional study was conducted after the AppendAmbu study and only included UCAA. The primary endpoint was the DCS success rate (LOS less than 12 hours) in the intention-to-treat (ITT) population (all patients with UCAA) and in the per protocol (PP) population (population with UCAA and no preoperative and intraoperative exclusion criteria). The secondary endpoints were to determine the DCS quality criteria to evaluate and compare the morbidity and mortality of DCS and conventional hospitalization for UCAA (Clavien, CCI) and to externally validate the St Antoine criteria for the selection of patients for DCS. Results:From January 2016 to September 2017, 296 patients were operated for acute appendicitis.The proportion of patients with successful DCS management was 27% in the ITT population and 95% in the PP population. The unplanned consultation rate was 15%, the unplanned hospitalization rate was 4% and the unplanned reoperation rate was 0%. The postoperative morbidity of patients managed by DCS was not different from that of patients managed in conventional hospitalization. The DCS success rate was 0% with a St Antoine score of 0 and 80% of patients had a St Antoine score of 5 (p<0.0001).Conclusion: DCS constitutes progress in surgery as a result of enhanced recovery programs. It avoids unnecessary prolonged hospitalization.

Approximately 10% of patients with ascites associated with cirrhosis fail to respond to dietary rules and diuretic treatment and therefore present with refractory ascites. In order to avoid iterative large-volume paracentesis in patients with contraindication to TIPS, the automated low flow ascites pump system (Alfapump) was developed to pump ascites from the peritoneal cavity into the urinary bladder, where it is eliminated spontaneously by normal micturition. This manuscript reports the surgical technique for placement of the Alfapump.

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Background: There is a level-1 evidence indicating that postoperative antibiotics are unnecessary following cholecystectomy for grade I or II acute calculous cholecystitis (ACC). We wanted to evaluate the applications of this recommendation in clinical practice four years after the original publication in ABCAL-participating centers.Methods: A retrospective analysis of patients operated for grade I or II ACC from January to December 2016 in ABCAL-participating centers was performed. Inclusion criteria were the same as for the ABCALstudy. The primary endpoint was the postoperative antibiotic administration rate. The secondary endpoints were postoperative outcomes.Results: Of the 283 patients included, 64% received postoperative antibiotics. Only 19% received antibiotics after POD1. The perioperative outcomes were similar between those that did or did not receive antibiotics after POD1. The median [range] length of stay was significantly shorter in patients who did not receive postoperative antibiotics (4 days [1-20]) compared to the others (6 days [1-50], p > 0.001). Conclusion:Despite strong recommendations included in the Tokyo 2018 guidelines, the results of the ABCAL-study are poorly applied even if the absence of postoperative antibiotics has no impact on morbidity. It is important to stress that postoperative antibiotics are not necessary after cholecystectomy for grade I or II ACC.

Glissonian approach has been described as a selective vascular clamping procedure during hepatectomy based on external anatomical landmarks. Anatomical variations of the right Glissonian pedicle have been identified with an increased risk of clamping failure during Glissonian approach. The objective of this study was to characterize the anatomical variations of the right Glissonian pedicle at risk of clamping failure during right hepatectomy. This was a retrospective analysis of abdominal multiphasic CT and routine 3D reconstruction (n = 346). Anatomical variations at risk of clamping failure were Types 1 to 3 (Madoff's classification) and an angle of less than 50 between the portal vein and the left portal vein. Primary objective was the risk of right Glissonian pedicle clamping failure. Secondary objectives were the rate of normal anatomy, the rate of variations, and the rate of incomplete or extended clamping. Normal anatomy was found in 245 patients (71%). Anatomical variations were as follows: Type 1: 11%, Type 2: 17%, Type 3: 0.8%, Type 4: 0%. Angle variation less than 50 was observed in 4.5%. The risk of selective clamping failure was 34%. Extension of clamping was observed in 16%, while incomplete clamping was observed in 17.8%. Failure of right Glissonian pedicle clamping was predictable in 34% of cases while 71% of patients presented normal portal vein anatomy. Clin. Anat. 32:328-336, 2019.

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