TOKYO GUIDELINES

2018

For management of Acute Cholecystitis & Acute Cholangitis

Dr Sushil Gyawali
MS resident
SURGICAL GASTROENTEROLOGY UNIT II
 TG07 / TG13 /TG18
• The diagnostic rate of AC :TG13 diagnostic criteria was higher than that based on the
TG07 criteria

• The TG13 severity grading : useful as an indicator for biliary drainage as well as a
predictive factor.

• TG07 severity grading criteria were found to be of limited use due to the ambiguous
definition of moderate cholangitis as “not responding to initial treatment”

• In TG07, Acute Cholecystitis : the use of two categories for deciding a definitive
diagnosis led to ambiguity in clinical practice, and criteria for suspected diagnosis
were not specified;;;; severity assessment criteria were adopted unchanged in TG13
 Diagnostic Criteria (TG18/TG13 )
Acute cholecystitis Acute Cholangitis
A. Local signs of inflammation A. Systemic Inflammation
1 Murphys sign 1. Fever or
2. Inflammatory response
2 RUQ mass/pain/tenderness
B. Cholestasis
B. Systemic signs
1. Jaundice or
1 Fever
2. Abnormal LFT
2 CRP elevation
C. Imaging
3 WBC elevation
1. Biliary dilatation or
C. Imaging
TG13/18 Suspected: A+B Definite: A+B+C 2. Evidence of etiology
TG07: One item in A and one item in B are positive
Suspected: A + B/C Definite: A+B+C
Diagnostic Criteria of Acute cholangitis
(TG07)
 Diagnostic rate
Charcoat’s triad:
• Low sensitivity (21-
50%), High specificity
• not applicable in using
as diagnosis criteria for
acute cholangitis.

TG13 severity grade was an

independent predictor of
both length of hospital stay
and conversion to open
surgery
Severity : Grade III (severe
Cholecystitis/Cholagitis)
At least one organ dysfunction
1. CVS : hypotension requiring dopamine ≥5 lg/kg per min, or any dose
of norepinephrine
2. Neurological: disturbance of consciousness
3. Respiratory: PaO2/FiO2 ratio <300
4. Renal: oliguria, serum creatinine >2.0 mg/dl
5. Hepatic: PT-INR >1.5
6. Hematological: platelet count <100,000/mm

Procalcitonin is suggested as a useful parameter for the severity assessment of acute cholangitis. (Level D)
Grade II (Moderate) and I (mild )
 Severity Criteria: Cholangitis (TG07)

Mild (grade I): Moderate (grade II)

• acute cholangitis which responds • acute cholangitis which does not
to the initial medical treatment respond to the initial medical
treatment and is not accompanied
by organ dysfunction

Severe (GradeIII)
same as TG13/TG18
 Imaging for Diagnosis of acute cholecystitis
• USG: first-choice imaging method for the morphological diagnosis
• Non-invasiveness, widespread availability, ease of use, and cost-effectiveness
make it recommended as the (Recommendation 1, level C)

• MRI/MRCP are recommended, when diagnosing the cause of acute cholangitis

and evaluating inflammation. (Recommendation 2,level C

CECT or contrast-enhanced MRI is recommended for diagnosing gangrenous cholecystitis.

1. irregular thickening of the gallbladder wall, poor contrast enhancement of the gallbladder wall (interrupted rim
sign),
2. increased density of fatty tissue around the gallbladder, gas in the gallbladder lumen or wall,
3. membranous structures within the lumen fever >38°C, distention of gallbladder,
4. wall edema, and preoperative adverse events (intraluminal flap or intraluminal membrane), and perigallbladder
abscess
Initial management of acute biliary infection
Flowchart for Acute Cholecystitis
• Flowcharts for the management were presented in the Tokyo Guidelines 2007 (TG07)
and the Tokyo Guidelines 2013 (TG13)
• The flowchart for the management of acute cholecystitis, however, has undergone
major revisions compared with TG13.
• The Tokyo Guidelines flowchart: recommended treatments according to the severity.
Flowchart for acute cholangitis

In TG18, part of the flowchart for moderate acute cholangitis has been somewhat revised fromTG13.
Transfer criteria
 Antimicrobial therapy
Prophylactic antimicrobial usage for elective endoscopic
retrograde cholangiopancreatography is no longer

• Antimicrobial therapy : mainstay

• In the TG18 guidelines, empiric therapy first later specific therapy
• antimicrobial therapy should be adjusted to specific antimicrobial agents
targeting the organisms.
• This process is defined as de-escalation of antimicrobial therapy in the
TG18 guidelines

• For patients with septic shock, administered within an hour.

• For other, less acutely ill patients, administered within 6 h of diagnosis.
• Duration: Once the source of infection is controlled, antimicrobial therapy for patients with acute
cholangitis is recommended for the duration of 4 to 7 days.
Community Aquired and Healthcare Associated biliary Infections
GB DRAINAGE IN ACUTE
CHOLECYSTITIS
• TG18: standard drainage method & endoscopic gallbladder drainage
techniques
• Percutaneous transhepatic gallbladder drainage/Cholecystostomy
(TG13/18) should be considered the first alternative to surgical
intervention in surgically high-risk patients.
• Endoscopic transpapillary gallbladder drainage (ETGBD)or EUS
guided gallbladder drainage: in high-volume institutes by skilled
endoscopists.
• In case of coagulopathy: INR<1.5, can continue Aspirin; hold
Cloidogrel.
When is the optimal timing for cholecystectomy following PTHBD
(biliary drainage/Cholecystostomy) ?
 

• No best timing
1. In high risk patients, CCI ≥6 or body mass index (BMI) ≤20 if they
had Grade I or II AC and
2. With jaundice (TBil ≥2.0 mg/dl), cranial neuropathy, or respiratory
dysfunction if they had Grade III AC ;
• early/urgent surgery is not recommended and PTGBD is indicated
 Optimal timing of cholecystectomy for acute
cholecystitis?
• If surgically fit, regardless of time passed since onset. (Recommendation
2, level B)
•  TG07 : performed soon after hospital admission, whereas
• TG13 : soon after admission and within 72 h after onset.
• Therefore, for AC patients for whom more than 72 h has passed since
symptom onset, there still are benefits to performing surgery early.
• Compared with delayed cholecystectomy, early cholecystectomy < 72h
if possible and even within 1 week may reduce costs, as the overall hospital
stays are shorter and there is less chance the patient will require additional
treatments or emergency surgery due to symptoms suddenly recurring during the
waiting period.
BILIARY DRAINAGE: ACUTE
CHOLANGITIS
TG07 -first described biliary drainage for acute cholangitis

 TG13 - indications and procedures of biliary drainage techniques –

 Endoscopic ultrasonography‐guided biliary drainage (EUS‐BD) and
Balloon enteroscope‐assisted bile duct drainage in patients with surgically altered anatomy

 New :In TG18, biliary drainage is recommended for acute cholangitis

regardless of the degree of severity except in some cases of mild acute cholangitis in which
antibiotics and general supportive care are effective
 Indications and techniques of biliary drainage for acute cholangitis
 

• Endoscopic transpapillary biliary drainage (ERCP): first-line therapy for

acute cholangitis.
• Endoscopic sphincterotomy (EST) is not routinely done alone because
of the concern of post-EST bleeding.
• In case of concomitant bile duct stones, stone removal following EST at
a single session may be considered in mild or moderate acute
cholangitis except in patients under anticoagulant therapy or with coagulopathy.
• We recommend the removal of difficult stones at two sessions after
drainage in pt with a large stone or multiple stones
Biliary drainage in difficult situations

• In patients with potential coagulopathy, endoscopic papillary dilation

can be a better technique than EST for stone removal.
• BE-ERCP: used as the first-line therapy with surgically altered
anatomy where BE-ERCP expertise is present.

• Thus, several studies have revealed that EUS-BD can be one of the
second-line therapies in failed BE-ERCP as an alternative to PTBD
where EUS-BD expertise is present
Biliary drainage… contd
• External drainage: PTBD can be used as a salvage therapy when conventional endoscopic
transpapillary drainage has failed owing to difficult selective biliary cannulation.

• Recently, EUS-BD has been developed and reported as a novel useful alternative drainage
technique when standard endoscopic transpapillary drainage has failed

 Surgical drainage
• Open drainage for decompression of the bile duct : surgical intervention.

• When surgical drainage in critically ill patients with bile duct stones is performed, prolonged
operations should be avoided and simple procedures, such as T-tube placement without
choledocholithotomy, are recommended
Indicators of surgical difficulty in Lap C for
acute cholecystitis
 Difficult Laparoscopic cholecystectomy

• Bail-out procedures to
prevent BDI according to
the intraoperative findings.
(Recommendation 1, level C)

Delphi Conseusus: A bail-out procedure

should be chosen if a CVS cannot be
achieved because of scarring or severe
fibrosis, as long as the
Calot’s triangle is appropriately retracted
and is recognized as a landmark
 Points to avoid biliary injury in laparoscopic cholecystectomy

1. Early LC before fibrosis: at an early stage before florid inflammation and fibrosis
develop in order to avoid BDI.
2. Creation of the CVS: CVS be achieved and noted in a “time-out” before clipping or
cutting structures.
3. Dissection along the GB surface with the following landmarks: If GB surface is difficult
to identify, an attempt should first be made to identify the GB surface from the dorsal
side of the neck of the GB, still difficult to identify, bail-out procedures should be
considered. Roof of Rouviere’s sulcus should be used as anatomical landmarks.

4. Bail-out procedures:
5. Perioperative imaging: Although there is no evidence for the value of intraoperative
cholangiography, preoperative MRCP, intraoperative fluorescence cholangiography,
and intraoperative ultrasound may reduce BDI.
SIX STEPS: DELPHI CONSESUS
Based on the recent Delphi consensus, we propose the following safe steps in LC for AC.
• Step 1: If a distended GB interferes with the field of view, it should be decompressed
by needle aspiration
• Step 2: Effective retraction of the GB to develop a plane in the Calot’s triangle area
and identify its boundaries (countertraction)
• Step 3: Starting dissection from the posterior leaf of the peritoneum covering the neck
of the GB and exposing the GB surface above Rouviere’s sulcus
• Step 4: Maintaining the plane of dissection on the GB surface throughout LC
• Step 5: Dissecting the lower part of the GB bed (at least one-third) to obtain the
critical view of safety
• Step 6: Creating the critical view of safety
Is one-stage management for acute cholecystitis associated
with CBD stone more effective than two-stage management?

Either approach is acceptable.

• one- (laparoscopic CBD exploration plus LC or intraoperative

laparoendoscopic rendezvous technique) and two-stage (ERCP
followed by sequential LC) approaches are equally safe and feasible.

• METANALYSIS found no significant difference in the success rate of

CBD removal , complication rate, and in-hospital mortality.
` Table 2. Management bundle for acute cholecystitis

1. When suspected, perform a diagnostic assessment every 6 to 12 h until a diagnosis reached.

2. US, followed by a CT scan or HIDA scan if needed
3. Assess severity at diagnosis, within 24 h s, and from 24 to 48 h after diagnosis. Evaluate the
surgical risk (e.g. local inflammation, CCI, ASA, PS, predictive factors).
4. initiate treatment,sufficient fluid , electrolyte, fasting, and analgesics and full‐dose
antimicrobial agents.
5. In Grade I (mild) patients, Lap‐C at an early stage, i.e. within 7 days (within 72 h is better
6. If conservative with Grade I (mild) disease and no within 24 h, reconsider early Lap‐C if fewer
than 7 days since symptom onset or biliary tract drainage.
7. In Grade II (moderate) patients, consider urgent/early Lap‐C if patient performance status is
good and the advanced Lap‐C technique is available. If not , urgent/early biliary drainage, or
delayed/elective Lap‐C, can be selected.
8. In Grade III (severe) patients with high surgical risk, perform urgent/early biliary drainage. If
there are neither negative predictive factors nor FOSF and the patient has good PS, early Lap‐C
at an advanced center can be chosen.
9. Perform blood, bile culture, or both, in Grade II and III patients.
10.Consider transferring if urgent/emergency Lap‐C, biliary drainage, and intensive care - not
available.
 • Table 1. Management bundle for acute cholangitis

1. perform a diagnostic assessment every 6 to 12 h until a diagnosis.

Added in 2. abdominal US, followed by a CT scan, MRI, MRCP, and HIDA scan as required.
TG13
3. Use the severity assessment repeatedly: at diagnosis, within 24 h, and 24 to 48 h after diagnosis.
4. provide initial treatment. -sufficient fluid replacement, electrolyte compensation, and intravenous
administration of analgesics and full‐dose antimicrobial agents.
5. In patients with Grade I (mild) disease, if no response to the initial treatment is observed within 24
h, perform biliary tract drainage immediately.
6. In patients with Grade II (moderate) disease, perform biliary tract drainage immediately
along with the initial treatment. If not, transferring the patient.
7. In patients with Grade III (severe) disease, perform urgent biliary tract drainage .if not ,consider
transferring the patient.
8. In patients with Grade III (severe) disease, supply organ support (e.g. noninvasive/invasive
positive pressure ventilation, use of vasopressors and antimicrobial agents) immediately.
9. blood culture or bile culture, or both, in Grade II (moderate) and III (severe) patients.
10.Consider treating the etiology of acute cholangitis with endoscopic, percutaneous, or operative
intervention once the acute illness has resolved. Cholecystectomy after the acute cholangitis has
resolved.
11.If the hospital is not equipped to perform endoscopic or percutaneous transhepatic biliary drainage
or provide intensive care, transfer patient with moderate or severe cholangitis
THANK YOU