Clinical appraisal of the validity of tokyo guidelines for management of acute cholangitis and cholecystitis

Abstract

Background: Before the 1970s, the mortality rate of acute cholangitis was as high as >50%, and was significantly improved to < 7% in the '90s. However, in cases of severe acute cholangitis, the mortality rate remains high (20-28%). In cases of severe acute cholangitis, prompt & appropriate clinical management is required. However, no standard criteria of diagnosis, severity assessment and clinical management guidelines for acute cholangitis have been established yet. There is some evidence that Charcot's triad (fever, jaundice, right upper quadrant pain) could diagnose only 50-70% cases of all acute cholangitis Introduction: International consensus meeting (Tokyo) was held, 29 panelists from abroad, 30 panelists from Japan and 200 audience members participated on 1 st - 2 nd April 2006 to develop the standard criteria of diagnosis, severity assessment and clinical management guidelines for patients with acute cholangitis and cholecystitis. There were first guidelines that defined diagnostic and severity criteria, management for biliary tract infection. Here we evaluated these guidelines for the councilmen of related academic societies for these revisions. Method 1 (Survey): For Japanese doctors, the unsigned mail questionnaire survey was sent to all meeting committees of Japan Society for Surgical Infection, Japanese Society for Abdominal Emergency Medicine, Japan Biliary Association, and Japanese Society for Hepato Biliary Pancreatic Surgery (1,234 medical doctors). The survey asked to the clinical practitioners about the changes of assessment and management of these diseases in antibiotics, biliary drainage, and timing and methods of operation. And next, we will find the international assessment for the guidelines. Method 2 (Prospective cohort study): For Japanese doctors, we started a prospective cohort study to evaluate differences between the Guidelines and clinical practices of diagnostic criteria and the severity assessment. To evaluate the Tokyo guidelines, we will also start a prospective cohort study to find a international tendency for the management of acute cholangitis and cholecystitis. Result (Survey): 367 (29.7%) doctors replied. Ninety-six percent of them checked Japanese version guidelines, for the management of acute biliary tract infection. Sixty-eight percent of them changed management of these diseases after guidelines. In diagnosis for acute cholangitis and cholecysytitis, 70% of them used Japanese criteria. In severity assessment for these diseases, 60% of them used Japanese criteria. In severe acute cholangitis, doctors that use 2nd-generation cephalosporin decreased (19% to 13%), and those that use carbapenem or quinolone increased from 30% to 37%. After the guidelines, more endoscopic procedure and less percutaneous procedure were performed for biliary drainage for acute cholangitis. On the other hand, earlier laparoscopic cholecystectomy was done in acute cholecystitis. Conclusion: Japanese Guidelines for Management of acute cholangitis and cholecystitis became widely used in Japan. More than 70% doctors used diagnostic criteria and severity criteria for acute cholangitis and cholecystitis. To evaluate the Tokyo guidelines, we will start a questionnaire survey and a prospective cohort study to find some international tendency for the management of acute cholangitis and cholecystitis. And we will evaluate the validity of Tokyo Guidelines for Management of Acute Cholangitis and Cholecystitis for revision.