Results of the Tokyo Consensus Meeting Tokyo Guidelines

Department of Surgery, Teikyo University, Edo, Tōkyō, Japan
Journal of Hepato-Biliary-Pancreatic Surgery (Impact Factor: 1.6). 02/2007; 14(1):114-21. DOI: 10.1007/s00534-006-1163-8
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A systematic review of references conducted in the process of developing the Guidelines for the Management of Acute Cholangitis and Cholecystitis did not find many high-quality research reports. There were no criteria for diagnosis, severity assessment, or patient transfer, and no established principles of clinical practice guidelines for acute cholangitis and cholecystitis. In order to develop guidelines that would be useful in clinical practice, an understanding of the current status of clinical practice for acute cholangitis and cholecystitis was considered essential. After several open symposia and a survey of these two diseases, we developed and published a Japanese-language version of Evidence-Based Practice Guidelines for the Management of Acute Cholangitis and Cholecystitis. In order to prepare international Guidelines, we had repeated discussions about the draft Guidelines together with international experts, and, following the Consensus Meeting, held on April 1-2, 2006, in Tokyo, with the attendance of 300 world experts in the field, the International Guidelines for the Management of Acute Cholangitis and Cholecystitis were developed. In this article, we outline the comments and opinions given at the International Meeting and how they are reflected in the final version of the Guidelines.

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    • "In addition, supportive and antibiotic therapies are also necessary. The effectiveness of antibiotics increases with the drainage [1] [5] [8]. In obstructive jaundice, adjustment of the dose of antibiotics and application of a careful supportive treatment become necessary due to renal impairment (in the excretion of antibiotics) [2] [5]. "
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    ABSTRACT: Objective: The objective of this study was to evaluate the serum and bile concentrations of cefazolin and ceftriaxone at the third and sixth hours in an experimental obstructive jaundice model and to identify the rate of excretion of these antibiotics into the bile. Material and methods: Thirty-two Wistar albino rats were used in this study. The bile and serum levels of cefazolin were measured at the third hour in the A1 group and at the sixth hour in the A2 group, with cefazolin administered as 5 mg/rat; while the bile and serum levels of ceftriaxone were studied at the third hour in the B1 group and at the sixth hour in the B2 group, with ceftriaxone administered as 5 mg/rat. Results: After 3 hr of cefazolin administration, the serum concentration in the A1 group reached a mean of 1.8 μg/ml, while the bile concentration was 90% of the serum concentration, with a mean of 1.6 μg/ml; whereas in the B1 group, the third-hour serum concentration of ceftriaxone was 18.6 μg/ml, while the bile concentration was found to be as high as 330% of this level, i.e., 56 μg/ml. The serum value of cefazolin decreased to 1.4 μg/ml in the A2 group and ceftriaxone decreased to 3.7 μg/ml in the B2 group at the sixth hour. Conclusions: Although the excretory level of cefazolin and ceftriaxone into the bile reaches therapeutic doses, the duration for which these levels are above those required for bactericidal activity is short. Ceftriaxone is better concentrated in the serum and bile than cefazolin.
    Journal of Investigative Surgery 12/2012; 26(1). DOI:10.3109/08941939.2012.687433 · 1.16 Impact Factor
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    • "The most important role of diagnostic criteria and severity assessment is to allow early diagnosis and to provide the most appropriate treatment for the disease depending on its severity. TG07 of acute cholecystitis aimed at this by systematic literature search and integration of expert opinions through a consensus conference held in Tokyo in 2006 [27]. The guidelines should reflect the current clinical practice but they need periodic assessment and revision. "
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    ABSTRACT: The Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07) were published in 2007 as the world's first guidelines for acute cholangitis and cholecystitis. The diagnostic criteria and severity assessment of acute cholecystitis have since been widely used all over the world. A validation study of TG07 has shown that the diagnostic criteria for acute cholecystitis are highly reliable but that the definition of definite diagnosis is ambiguous. In addition, considerable new evidence referring to acute cholecystitis as well as evaluations of TG07 have been published. Consequently, we organized the Tokyo Guidelines Revision Committee to evaluate TG07, recognize new evidence, and conduct a multi-center analysis to revise the guidelines (TG13). We retrospectively analyzed 451 patients with acute cholecystitis from multiple tertiary care centers in Japan. All 451 patients were first evaluated using the criteria in TG07. The "gold standard" for acute cholecystitis in this study was a diagnosis by pathology. The validity of TG07 diagnostic criteria was investigated by comparing clinical with pathological diagnosis. Of 451 patients evaluated, a total of 227 patients were given a diagnosis of acute cholecystitis by pathological examination (prevalence 50.3 %). TG07 criteria provided a definite diagnosis of acute cholecystitis in 224 patients. The sensitivity of TG07 diagnostic criteria for acute cholecystitis was 92.1 %, and the specificity was 93.3 %. Based on the preliminary results, new diagnostic criteria for acute cholecystitis were proposed. Using the new criteria, the sensitivity of definite diagnosis was 91.2 %, and the specificity was 96.9 %. The accuracy rate was improved from 92.7 to 94.0 %. In regard to severity grading among 227 patients, 111 patients were classified as Mild (Grade I), 104 as Moderate (Grade II), and 12 as Severe (Grade III). The proposed new diagnostic criteria achieved better performance than the diagnostic criteria in TG07. Therefore, the proposed criteria have been adopted as new diagnostic criteria for acute cholecystitis and are referred to as the 2013 Tokyo Guidelines (TG13). Regarding severity assessment, no new evidence was found to suggest that the criteria in TG07 needed major adjustment. As a result, TG07 severity assessment criteria have been adopted in TG13 with minor changes.
    Journal of Hepato-Biliary-Pancreatic Sciences 08/2012; 19(5):578-85. DOI:10.1007/s00534-012-0548-0 · 2.99 Impact Factor
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    • "A limitation of this study also warrants mention. The CPGs determine the severity of acute cholecystitis based on the laboratory data and imaging findings of patients (Mayumi et al. 2007). Regrettably, laboratory and imaging data are not recorded in the Japanese administrative database (Murata et al. 2010, 2011, 2012). "
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    ABSTRACT: Acute cholecystitis is one of the most frequently encountered conditions in daily practice in Japan. However, there is a shortage of detailed data about treatments that have been performed according to the clinical practice guidelines (CPGs) for acute cholecystitis. We therefore examined the management of acute cholecystitis for adherence to the appropriate CPGs using the Japanese administrative database associated with the Diagnosis Procedure Combination (DPC) system. We collected data from 6,070 patients with acute cholecystitis, examining for the application of four recommended treatments (administration of antimicrobial drugs and nonsteroidal anti-inflammatory drugs (NSAIDs) and performance of early and laparoscopic cholecystectomy). The patients were classified according to the procedures documented for each case: no gallbladder drainage (n = 4,333), gallbladder drainage without supportive care (ventilation or hemodiafiltration or the use of vasopressor) (n = 1,591) and gallbladder drainage and supportive care (n = 146). Multiple logistic regression models revealed that patients with gallbladder drainage without supportive care and those with gallbladder drainage and supportive care significantly higher received administration of antimicrobial drugs and NSAIDs, while these patients underwent less early or laparoscopic cholecystectomy than did patients without gallbladder drainage, after adjusting for potential confounding effects of the clinical variables. This study demonstrated that there were various differences with regard to the performance of recommended treatments between the levels of procedures required for acute cholecystitis. In addition, this administrative database was a feasible tool for the evaluation of care processes and will provide useful information contributing to improved quality of medical care.
    The Tohoku Journal of Experimental Medicine 08/2012; 227(4):237-44. DOI:10.1620/tjem.227.237 · 1.35 Impact Factor
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