Acute cholangitis and cholecystitis are diseases importantly requiring to decide a treatment policy with careful consideration of the time from onset to diagnosis before the pathological conditions become severe. The principles of treatment are local control of infection focus by cholecystectomy or biliary drainage and antimicrobial therapy. Antimicrobial therapy has also been changing due to the spread of multiple drug-resistant Gram-negative bacteria. According to Tokyo Guidelines 2018 (TG18), it proposes recommended medication for initial treatment on the basis of the classification as community-acquired infection (by severity) or healthcare associated infection while selecting antibacterial drug in consideration of susceptibility pattern (antibiogram) at each institution. In addition, it is important to de-escalate the empirically-administered initial drug to an optimal drug when proving susceptivity results with the identification of microorganism in blood culture/bile culture test. In this article, we describe antimicrobial therapy for acute cholangitis and cholecystitis on the basis of TG18.

Case1: A 82-year-old man had undergone endoscopic stenting for biliary stenosis caused by autoimmune pancreatitis. At follow-up 51 months after stent placement, Type A stent-stone complex (SSC) was formed around the plastic stent. Since endoscopic choledocholithiasis lithotripsy failed due to impacted stone, we removed the SSC by peroral cholangioscopy-directed lithotripsy (POCSL).

Case2: A 87-year-old man had undergone endoscopic stenting for distal bile duct benign stenosis. At follow-up 23 months after stent placement, the Type B stent-stone complex (SSC) was formed into the inward migrated metalic stent. Since the SSC was large and impacted to the bile duct, we crushed the SSC by POCSL and removed the metallic stent.

SSC is one of the complications related long term bilialy stent placement, but there are still few reports of SSC. We report two cases, one for each of Type A and Type B SSC, treated by POCSL successfully.

Fishbones that have migrated into the bile duct are a rare cause of bile duct stones. Even after pancreaticoduodenectomy, fishbones can migrate into the bile duct and act as a nidus for stone formation. We experienced three cases of bile duct stones formed around fishbones after pancreaticoduodenectomy for pancreatic cancer treated with endoscopic retrograde cholangiography (ERC) using a balloon endoscope. Case 1 was an 80-year-old male, the time between the surgery and the diagnosis of bile duct stones was 46.5 months, and the bile duct stones were found due to elevated hepatobiliary enzymes. Case 2 was a 72-year-old male, the time between the surgery and the diagnosis of bile duct stones was 70.5 months, and the bile duct stones were found due to cholangitis. Case 3 was an 83-year-old man with a 10.3-month interval between the surgery and the diagnosis of bile duct stones, which was detected by a follow-up CT scan, which also revealed a postoperative recurrence of pancreatic cancer. In all cases, the stones were successfully removed by ERC using a balloon endoscope. Since fish-eating habits are common in Japan and the number of cases with surgically altered anatomy increases along with the rising incidence of pancreatic cancer, careful attention should be paid to the risk of bile duct stones formed around fishbones.

A 67-year-old man underwent laparoscopic cholecystectomy for acute cholecystitis. On the 15th postoperative day, CT scan revealed an intra-abdominal mass on the ventral side of the ascending colon. Four months later, the mass increased in size. Needle biopsy revealed xanthogranulomatous inflammation (XGI). Two months later, CT showed the mass had further increased in size and the boundary between the mass and nearby organs was unclear. In laparotomy, it was suggested the mass invaded the ascending colon, abdominal wall, and omentum, therefore right hemicolectomy with combined resection of these organs was performed. Abscess and a small stone were inside the mass, and had penetrated into the ascending colon. Analysis of the stone revealed that it was derived from bile. Histopathological examination indicated the abscess formation with XGI resulted from the spilled gallstone. This is the first report of a penetration of abscess formed by spilled gallstone into the intestine.

A 47-year-old man took ERCP for common bile duct stones. Although the endoscopic sphincterotomy (EST) was performed, it was difficult to grasp and crush the stones. Five hours after the ERCP, his abdominal pain worsened, and then duodenal perforation was recognized by computer tomography. Naso-drainage tubes were inserted into the bile tract and pancreatic duct by urgent ERCP. Since then, the inflammation induced by perforation has gradually improved, and he was discharged 20 days after the procedure. In our hospital, we experienced 2 cases of perforation associated with EST and 2 cases of perforation associated with endoscopic papillectomy. In these cases, biliary and pancreatic drainage was performed for 3 cases, while 1 case who did not undergo drainage finally required surgery. We experienced a case that urgent drainage for biliary and pancreatic duct might be effective for cases with perforation around Vater's papilla.

The primary diseases of the three cases of periampullary perforation associated with ERCP were left intrahepatic bile duct stone, extrahepatic cholangiocarcinoma, and benign intrahepatic bile duct stricture, all of which were normal anatomies. The causes of perforation were guidewire manipulation after precutting, exceeded sphicnteretomy, and cholangioscopy manipulation in the bile duct, respectively. In one case, the perforation was diagnosed immediately after ERCP, and in the other two cases, one day and two days after ERCP, respectively, and all of them could be treated non-surgically, which includes endoscopic naso-biliary drainage, biliary metal stent placement, percutaneous drainage, and endoscopic ultrasound-guided transmural drainage.

Hepatolithiasis is characterized by its intractable nature and frequent recurrence. National multi-institutional surveys have been conducted for 40 years or over. The treatment outcomes including residual stones and recurrence are not improved, even treatment techniques are advanced. Non-surgical procedures such as percutaneous transhepatic cholangioscopic lithotripsy (PTCSL), ERC, balloon ERC, and peroral cholangioscopy (POCS) and surgical treatment such as hepatectomy, choledocho-enterostomy, cholecystectomy with stone removal, and papilloplasty were performed for the treatment of hepatolithiasis. Recently, treatment by ERC and Balloon ERC are frequently performed because of increasing of secondary hepatolithiasis and the advance of the endoscopic techniques. For the large stones, combination treatments with ESWL or EHL are performed. Hepatectomy is the most frequently performed as a surgical procedure, and reports of laparoscopic hepatectomy are increasing. The risk of development of cholangiocarcinoma is high, even if complete stone removal is performed. In particular, long-term and strict follow-up is required for patients with risk factors of cholangiocarcinoma.