What are the surgical standards for managing acute cholangitis and cholecystitis according to the Tokyo Guidelines 2018?

Tokyo Guidelines 2018: Surgical Standards for Acute Cholangitis and Cholecystitis

Acute Cholangitis Management

For mild (Grade I) acute cholangitis, initial medical treatment with broad-spectrum antibiotics may be sufficient, but early biliary drainage is mandatory for moderate (Grade II) and severe (Grade III) cases, with endoscopic retrograde cholangiography being the preferred drainage method. 1, 2

Severity-Based Treatment Algorithm

Grade I (Mild) Acute Cholangitis:

• Initial medical treatment with antimicrobial agents is appropriate for most cases 2, 3
• If patients fail to respond to initial medical treatment, biliary drainage should be performed 2
• Treatment for underlying etiology (e.g., endoscopic sphincterotomy for choledocholithiasis) may be performed simultaneously with biliary drainage when feasible 2

Grade II (Moderate) Acute Cholangitis:

• Early biliary drainage must be performed along with antibiotic administration 1, 2
• After the patient's general condition improves, definitive treatment for the underlying etiology should be performed 2, 3

Grade III (Severe) Acute Cholangitis:

• Appropriate organ support (ventilatory/circulatory management) is required first 2, 3
• After hemodynamic stabilization, urgent endoscopic or percutaneous transhepatic biliary drainage must be performed 1, 2
• Definitive treatment for etiology is performed after clinical improvement 2

Antibiotic Therapy Standards

• Empiric broad-spectrum antibiotics should include piperacillin/tazobactam, imipenem/cilastatin, meropenem, ertapenem, or aztreonam 1
• Duration should be at least 4 days after successful biliary drainage 4, 1
• Treatment must be extended to 2 weeks if Enterococcus or Streptococcus is present to prevent infectious endocarditis 4, 1
• Bile cultures should be obtained during drainage procedures to guide antibiotic therapy 1

Surgical Considerations for Stone-Related Cholangitis

Early laparoscopic common bile duct exploration (LCBDE) is suitable for mild and moderate acute cholangitis but should be avoided in severe acute cholangitis due to high mortality rates, particularly in patients over 80 years old. 4

• Early LCBDE (within 72 hours) versus delayed LCBDE showed no significant difference in complication rates for mild-moderate disease 4
• However, three deaths occurred in early LCBDE groups, all in patients >80 years with severe cholangitis 4
• LCBDE has comparable stone clearance rates to endoscopic approaches (91.7% vs 88.1%) 4
• LCBDE offers shorter hospital stays and lower recurrence rates (2.06% vs 9.47%) compared to ERCP + LC 4

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Acute Cholecystitis Management

Early laparoscopic cholecystectomy is the first-line treatment for Grade I (mild) acute cholecystitis in patients with Charlson comorbidity index ≤5 and ASA-PS ≤2, while gallbladder drainage should be considered for moderate to severe disease in high-risk patients. 1, 2

Severity-Based Surgical Algorithm

Grade I (Mild) Acute Cholecystitis:

• Early laparoscopic cholecystectomy is the preferred first-line treatment 1, 2, 3
• This applies to patients with CCI ≤5 and ASA-PS ≤2 1
• Laparoscopic approach is superior to open cholecystectomy with lower complications, shorter hospital stay, and quicker recovery 5

Grade II (Moderate) Acute Cholecystitis:

• Delayed/elective laparoscopic cholecystectomy after initial medical treatment with antimicrobials is first-line 2
• For non-responders to initial medical treatment, gallbladder drainage should be performed 2
• In patients with extensive local inflammation, elective cholecystectomy is recommended after percutaneous gallbladder drainage 3

Grade III (Severe) Acute Cholecystitis:

• Appropriate organ support plus initial medical treatment is necessary 2
• Urgent or early gallbladder drainage is recommended 1, 2
• Biliary peritonitis due to gallbladder perforation requires urgent cholecystectomy and/or drainage 3
• Elective cholecystectomy should be performed after improvement of the acute inflammatory process 2, 3

Gallbladder Drainage Techniques for High-Risk Patients

Percutaneous transhepatic gallbladder drainage (PTGBD) should be considered the first alternative to surgical intervention in surgically high-risk patients with acute cholecystitis. 6

• Endoscopic transpapillary gallbladder drainage or EUS-guided gallbladder drainage can be considered in high-volume centers by skilled endoscopists 6
• For endoscopic transpapillary approach, either endoscopic naso-gallbladder drainage or gallbladder stenting can be used 6

Timing of Intervention

• Outcomes are similar regardless of timing of intervention (< 1 week, 2-5 weeks, or ≥6 weeks from symptom onset) when proper protocols are followed 7
• The critical factor is achieving critical view of safety (CVS) during surgery, which was achieved in 97.2% of complex cases using standardized safety steps 7

Surgical Outcomes with Tokyo Guidelines Protocol

When following Tokyo Guidelines assessment and using intraoperative safety steps:

• CVS achieved in 97.2% of cases 7
• Conversion rate of only 1.4% 7
• Major complications (Clavien-Dindo Grade IIIa/IIIb) in 4.1% 7
• No bile duct injuries and mortality of 0.7% 7
• Subtotal cholecystectomy required in only 2.8% 7

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Critical Pitfalls to Avoid

The most dangerous error is delaying biliary drainage in moderate to severe cholangitis, which significantly worsens outcomes and increases mortality. 1

• Failure to initiate early antibiotic therapy in suspected cholangitis leads to increased mortality 1
• Attempting early LCBDE in severe cholangitis, especially in elderly patients (>80 years), carries unacceptable mortality risk 4
• Performing laparoscopic cholecystectomy after ERCP is more difficult due to severe adhesions (33.4% of cases) and inflammation around Calot's triangle 4
• ERCP-induced sphincter dysfunction causes permanent damage and increases CBD stone recurrence rates 4