[Introduction] Ultraviolet rays are used for environmental disinfection. We evaluated the bactericidal effect of ultraviolet irradiation on microorganisms that may be present at the high contact surface in the hospital room. [Material and methods] A medium coated with Clostridioides difficile, carbapenem resistant Enterobacteriaceae (CRE) and multidrug resistant Acinetobacter (MDRA) in the model room was used as an alternative carrier. Multiple alternative carriers were installed and irradiated with UV–C UV irradiation system, yielding the median number of bacteria decrease (log) before and after irradiation. [Results] In C. difficile, the decrease in bacterial load varied. At a bed height of 40 cm, 10–minute 2 cycles significantly decreased compared to 10–minute 1–cycle (P=0.03). At a bed height of 60 cm, the amount of bacteria decreased significantly in 10 minutes and 2 cycles compared to 5 minutes and 2 cycles (P = 0.03). CRE decreased by 3 logs or more, MDRA decreased by 4 logs or more. [Conclusion] This suggests that the UV–C UV irradiation system may be useful for environmental cleaning of rooms where multi–drug–resistant bacteria are present.

International practice guidelines on antimicrobial therapy for acute cholangitis and cholecystitis have been developed and released since 2007 (Tokyo Guidelines 2007, TG 07). Since then the revisions of TG 07 were performed twice and those were TG 13, and TG 18. After TG 18 became available, related clinical studies were published. In developing TG 18, the areas with few evidence and challenges have become more evident. Accordingly, there were limitations in TG 18. Given this, required evidence and the areas for future research were discussed.

We exposited revision of initial management of acute biliary infection and flowchart for acute cholangitis of TG18 and performed literature–based evaluation of those. A meta–analysis of randomized controlled trials revealed that analgesic agent could be used safely for acute abdominal pain without risk of impairment of diagnostic accuracy. Two case series studies reported that recombinant human soluble thrombomodulin had been effective for severe acute cholangitis and cholecystitis. A case series study revealed that elective biliary drainage (≥12 hours of admission）had not been associated with worse clinical outcomes of non–severe acute cholangitis as compared to urgent drainage (<12 hours of admission). The result indicates that appropriate timing and indication for the early biliary drainage in patients with moderate acute cholangitis should be re–considered.

Early drainage is required for moderate or severe acute cholangitis, and the first choice of biliary drainage is endoscopic transpapillary drainage. If difficult, percutaneous transhepatic biliary drainage or endosonography–guided biliary drainage is used as a useful alternative drainage technique. In the treatment of bile duct stone, stone removal at a single session may be considered in patients with mild or moderate acute cholangitis according to Tokyo Guidelines 2018. However, if patients have coagulopathy or take anticoagulant therapy, stone removal at a second session is recommended. Balloon enteroscopy–assisted endoscopic retrograde cholangiopancreatography is recommended in patients with surgically altered anatomy, but the technical success rate is not always high. With the diversification of drainage procedures, the technical difference between facilities is increasing, and it is necessary to respond flexibly according to the situation of the facilities and the cases.

I explained diagnositic criteria and severity of acute cholecystitis according to Tokyo Guidelines 2018. And I evaluated results of strict treatment policy in my department. Following revision of Tokyo Guidelines, safer management of acute cholecystitis would be done.

The Tokyo Guidelines 2018 (TG18) proposed the safe steps of laparoscopic cholecystectomy for acute cholecystitis. In these guidelines, “difficult gallbladder” was defined as the presence of severe fibrosis or scarring in the Calot’s triangle, which may result in bile duct injury (BDI) and vasculobiliary injury (VBI); for these patients, TG18 proposed a bailout procedure, which includes conversion to open surgery, subtotal cholecystectomy, and fundus first technique. Our recent therapeutic results demonstrated a significant performed bailout procedures, decreased rates of conversion to open surgery and postoperative complications, significantly decreased duration of hospital stay. Appropriate definition of the “difficult gallbladder” is important. In addition, appropriate performance of a bailout procedure is important for the prevention of BDI and VBI. These management strategies may lead to better surgical outcomes for patients with acute cholecystitis.

Purpose: The Tokyo Guidelines 2018 (TG18) recommends conversion of laparoscopic cholecystectomy (LC) to open cholecystectomy (OC) as a bailout procedure (BOP) for patients in whom LC cannot be performed safely. However, the treatment results of OC are reported to be poorer than those of LC. Herein, we investigated the treatment results in patients with acute cholecystitis who required conversion to OC from LC and the factors involved in the conversion to OC. In addition, we also evaluated the outcomes of laparoscopic subtotal cholecystectomy (LSC), which is another BOP for LC. Methods: We investigated the following items in 418 patients with acute cholecystitis who underwent LC at our institution between January 2001 and September 2019: age, sex, severity of acute cholecystitis, presence/absence of gallstones, white blood cell(WBC) count and serum C–reactive protein(CRP) immediately before the surgery, use of preoperative drainage and the type of drainage, operation time, blood loss, total length of hospital stay, length of postoperative hospital stay, complication rate, and results of histopathology. Results: All of the items investigated were significantly worse in the patients who required conversion of LC to OC as compared to those in the patients treated by LC: operation time(151 min. vs. 254 min., P＜0.001), intraoperative blood loss(26.2 mL vs. 348.8 mL, P＜0.001), complication rate (3.8％ vs. 19.0％, P＜0.001), total length of hospital stay(21 days vs. 38 days, P＜0.001) and length of postoperative hospital stay(9 days vs. 22 days, P＜0.001). In addition, the operation time and total length of hospital stay were also worse in the patients who required conversion to OC from LC as compared to those who were treated by LSC. Factors involved in the conversion to OC included intraperitoneal factors, gallbladder bed fibrosis, and fibrosis in Calot’s triangle. The latter two factors were the causes for the prolongation of the operation time and increase of the blood loss. In consideration of the patients’ safety, it seems desirable to complete cholecystectomy using a laparoscopic technique, including LSC, as needed.

The Tokyo Guidelines (TG) was launched in 2003 under the Project for assessing Medical technology sponsored by the Japanese Ministry of Health, Labour, and Welfare(H–15–Medicine–30), Labour and Welfare, and published with the support of the co–organizing societies and supporting organizations. After successful publication of the first edition in 2005, we organized an International Consensus Conference to step up this guidelines toward the Global one for global validation of the guideline. After this conference, we published TG07 (English version) in The Journal of Hepato–Biliary–Pancreatic Surgery (JHBPS). Subsequently, TG13 and TG18 were developed and published in 2013 and 2018, respectively, in collaboration with the committee members abroad. In line with the more evolved publishing methods of the times, Evidence–Practice–Cycle was adopted. Two international collaborative researches, namely, Lap–C (laparoscopic cholecystectomy)’s “Road to Safety” and the results of an epidemiological study on acute biliary infection are described in TG18.