TOKYO GUIDELINES: TG 18 MANAGEMENT OF ACUTE CHOLECYSTITIS AND ACUTE CHOLANGITIS ( TG18), Comparison among other editions TG 07 vs TG13 vs TG18

1. TOKYO GUIDELINES 2018
For management of Acute Cholecystitis & Acute Cholangitis
Dr Sushil Gyawali
MS resident
SURGICAL GASTROENTEROLOGY UNIT II

2. 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

3. Diagnostic Criteria (TG18/TG13 )
Acute cholecystitis
A. Local signs of inflammation
1 Murphys sign
2 RUQ mass/pain/tenderness
B. Systemic signs
1 Fever
2 CRP elevation
3 WBC elevation
C. Imaging
Acute Cholangitis
A. Systemic Inflammation
1. Fever or
2. Inflammatory response
B. Cholestasis
1. Jaundice or
2. Abnormal LFT
C. Imaging
1. Biliary dilatation or
2. Evidence of etiology
Suspected: A + B/C Definite: A+B+C
TG13/18 Suspected: A+B Definite: A+B+C
TG07: One item in A and one item in B are positive

4. Diagnostic Criteria of Acute cholangitis (TG07)

5. 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

6. 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)

7. Grade II (Moderate) and I (mild )

8. Severity Criteria: Cholangitis (TG07)
Mild (grade I):
• acute cholangitis which responds
to the initial medical treatment
Moderate (grade II)
• acute cholangitis which does not
respond to the initial medical
treatment and is not accompanied
by organ dysfunction
Severe (GradeIII)
same as TG13/TG18

9. 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

10. Initial management of acute biliary infection

11. 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.

13. Flowchart for acute cholangitis
In TG18, part of the flowchart for moderate acute cholangitis has been somewhat revised fromTG13.

14. Transfer criteria

15. Antimicrobial therapy
• 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.
Prophylactic antimicrobial usage for elective endoscopic
retrograde cholangiopancreatography is no longer

17. Community Aquired and Healthcare Associated biliary Infections

18. 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.

19. 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

20. 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.

21. 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

22. 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

23. 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

24. 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

25. Indicators of surgical difficulty in Lap C for
acute cholecystitis

26. 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

27. 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.

28. 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

30. 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.

31. ` 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.

32. • Table 1. Management bundle for acute cholangitis
1. perform a diagnostic assessment every 6 to 12 h until a diagnosis.
2. abdominal US, followed by a CT scan, MRI, MRCP, and HIDA scan as required.
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
Added in
TG13

33. THANK YOU