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Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos)

Authors:	Seiki Kiriyama Kazuto Kozaka Tadahiro Takada Steven M Strasberg Henry A Pitt Toshifumi Gabata Jiro Hata Kui‐Hin Liau Fumihiko Miura Akihiko Horiguchi Keng‐Hao Liu Cheng‐Hsi Su Keita Wada Palepu Jagannath Takao Itoi Dirk J Gouma Yasuhisa Mori Shuntaro Mukai Mariano Eduardo Giménez Wayne Shih‐Wei Huang Myung‐Hwan Kim Kohji Okamoto Giulio Belli Christos Dervenis Angus C W Chan Wan Yee Lau Itaru Endo Harumi Gomi Masahiro Yoshida Toshihiko Mayumi Todd H Baron Eduardo de Santibañes Anthony Yuen Bun Teoh Tsann‐Long Hwang Chen‐Guo Ker Miin‐Fu Chen Ho‐Seong Han Yoo‐Seok Yoon In‐Seok Choi Dong‐Sup Yoon Ryota Higuchi Seigo Kitano Masafumi Inomata Daniel J Deziel Eduard Jonas Koichi Hirata Yoshinobu Sumiyama Kazuo Inui Masakazu Yamamoto

Institution:	1. Department of Gastroenterology, Ogaki Municipal Hospital, Gifu, Japan;2. Department of Radiology, Kanazawa University Graduate School of Medical Sciences, Ishikawa, Japan;3. Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan;4. Section of Hepato‐Pancreato‐Biliary Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO, USA;5. Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA;6. Kanazawa University Hospital, Ishikawa, Japan;7. Department of Endoscopy and Ultrasound, Kawasaki Medical School, Okayama, Japan;8. Mt Elizabeth Novena Hospital Singapore and Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore;9. Department of Gastroenterological Surgery, Fujita Health University School of Medicine, Aichi, Japan;10. Division of General Surgery, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan;11. Department of Surgery, Cheng Hsin General Hospital, Taipei, Taiwan;12. Department of Surgical Oncology, Lilavati Hospital and Research Centre, Mumbai, India;13. Department of Gastroenterology and Hepatology, Tokyo Medical University Hospital, Tokyo, Japan;14. Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands;15. Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan;16. General Surgery and Minimal Invasive Surgery “Taquini”, University of Buenos Aires, Buenos Aires, Argentina;17. DAICIM Foundation, Buenos Aires, Argentina;18. Department of Surgery, Show Chwan Memorial Hospital, Changhua, Taiwan;19. Department of Gastroenterology, University of Ulsan College of Medicine, Seoul, Korea;20. Department of Surgery, Center for Gastroenterology and Liver Disease, Kitakyushu City Yahata Hospital, Fukuoka, Japan;21. Department of General and HPB Surgery, Loreto Nuovo Hospital, Naples, Italy;22. First Department of Surgery, Agia Olga Hospital, Athens, Greece;23. Surgery Centre, Department of Surgery, Hong Kong Sanatorium and Hospital, Hong Kong, Hong Kong;24. Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong;25. Department of Gastroenterological Surgery, Yokohama City University Graduate School of Medicine, Kanagawa, Japan;26. Center for Global Health, Mito Kyodo General Hospital, University of Tsukuba, Ibaraki, Japan;27. Department of Hemodialysis and Surgery, Ichikawa Hospital, International University of Health and Welfare, Chiba, Japan;28. Department of EBM and Guidelines, Japan Council for Quality Health Care, Tokyo, Japan;29. Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan;30. Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA;31. Department of Surgery, Hospital Italiano, University of Buenos Aires, Buenos Aires, Argentina;32. Department of Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong;33. Department of Surgery, Yuan's General Hospital, Kaohsiung, Taiwan;34. Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, Korea;35. Department of Surgery, Konyang University Hospital, Daejeon, Korea;36. Department of Surgery, Yonsei University Gangnam Severance Hospital, Seoul, Korea;37. Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, Tokyo, Japan;38. Oita University, Oita, Japan;39. Department of Gastroenterolgical and Pediatric Surgery, Oita University, Faculty of Medicine, Oita, Japan;40. Department of Surgery, Rush University Medical Center, Chicago, USA;41. Surgical Gastroenterology /Hepatopancreatobiliary Unit, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa;42. Department of Surgery, JR Sapporo Hospital, Hokkaido, Japan;43. Toho University, Tokyo, Japan;44. Department of Gastroenterology, Second Teaching Hospital, Fujita Health University, Aichi, Japan

Abstract:	Although the diagnostic and severity grading criteria on the 2013 Tokyo Guidelines (TG13) are used worldwide as the primary standard for management of acute cholangitis (AC), they need to be validated through implementation and assessment in actual clinical practice. Here, we conduct a systematic review of the literature to validate the TG13 diagnostic and severity grading criteria for AC and propose TG18 criteria. While there is little evidence evaluating the TG13 criteria, they were validated through a large‐scale case series study in Japan and Taiwan. Analyzing big data from this study confirmed that the diagnostic rate of AC based on the TG13 diagnostic criteria was higher than that based on the TG07 criteria, and that 30‐day mortality in patients with a higher severity based on the TG13 severity grading criteria was significantly higher. Furthermore, a comparison of patients treated with early or urgent biliary drainage versus patients not treated this way showed no difference in 30‐day mortality among patients with Grade I or Grade III AC, but significantly lower 30‐day mortality in patients with Grade II AC who were treated with early or urgent biliary drainage. This suggests that the TG13 severity grading criteria can be used to identify Grade II patients whose prognoses may be improved through biliary drainage. The TG13 severity grading criteria may therefore be useful as an indicator for biliary drainage as well as a predictive factor when assessing the patient's prognosis. The TG13 diagnostic and severity grading criteria for AC can provide results quickly, are minimally invasive for the patients, and are inexpensive. We recommend that the TG13 criteria be adopted in the TG18 guidelines and used as standard practice in the clinical setting. Free full articles and mobile app of TG18 are available at: http://www.jshbps.jp/modules/en/index.php?content_id=47 . Related clinical questions and references are also included.

Keywords:	Acute cholangitis Diagnostic criteria Diagnostic imaging Guidelines Severity grading

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