Tokyo Guidelines 2018 – What’s new? (and what’s not)

Introduction

The Tokyo Guidelines are the main recommendations regarding Acute Cholangitis and Acute Cholecystitis. The guidelines have been updated every 5 years, taking into consideration the most valuable studies published in between – the Tokyo Guidelines 2013 and more recently, the Tokyo Guidelines 2018.

The 2018 guidelines comprise 9 articles, each one about a specific aspect of the conditions, all published in the Journal of Hepatobiliary and Pancreatic Sciences of the Japanese Society of Hepato-biliary-pancreatic Surgery.

Tokyo Guidelines 2018 – what’s not new

The 2018 revision of the 2013 guidelines maintained a few aspects. The diagnostic criteria and Severity grading of acute cholangitis and acute cholecystitis were validated in the studies published since 2013 and have not been changed.

Acute cholangitis is defined as an acute biliary infection with signs of systemic inflammation, signs of cholestasis and imaging findings compatible with biliary obstruction.

Acute cholecystitis is acute biliary inflammation with signs of local inflammation, systemic inflammation and imaging findings compatible with gallbladder inflammation.

Any of the conditions varies in severity from mild, to moderate to severe disease, depending on the presence of organ dysfunction or specific laboratory or clinical alterations.

Tokyo Guidelines 2018 – what’s new

The 2018 revision resulted in changes in the management of both acute cholangitis and acute cholecystitis, with the last one undergoing the most significant modifications.

For acute cholangitis, the most important aspect is the relevance of biliary drainage, which can be done by endoscopy, percutaneously, or though or surgery.

The flowchart for the management of acute cholecystitis re-enforces the role of laparoscopic cholecystectomy and the patient’s general status in the choice of treatment path. For patients with good general status and no negative predictive factors, even in higher grade disease, laparoscopic cholecystectomy can be performed safely when done by an expert surgeon.

Other minor changes occurred in the antimicrobial therapy, gallbladder drainage and management bundles.