Results of the Tokyo Consensus Meeting Tokyo Guidelines

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1 J Heptobiliry Pncret Surg (2007) 14: DOI /s Results of the Tokyo Consensus Meeting Tokyo Guidelines Toshihiko Myumi 1, Tdhiro Tkd 2, Yoshifumi Kwrd 3, Yuji Nimur 4, Mshiro Yoshid 2, Miho Sekimoto 5, Fumihiko Miur 2, Keit Wd 2, Mshiko Hirot 6, Yuichi Ymshit 7, Msto Ngino 4, Toshio Tsuyuguchi 8, Atsushi Tnk 9, Hrumi Gomi 10, nd Henry A. Pitt 11 1 Deprtment of Emergency nd Criticl Cre Medicine, Ngoy University Grdute School of Medicine, 65 Tsurumi-cho, Show-ku, Ngoy , Jpn 2 Deprtment of Surgery, Teikyo University School of Medicine, Tokyo, Jpn 3 Mie University School of Medicine, Mie, Jpn 4 Division of Surgicl Oncology, Deprtment of Surgery, Ngoy University Grdute School of Medicine, Ngoy, Jpn 5 Deprtment of Helthcre Economics nd Qulity Mngement, Kyoto University Grdute School of Medicine, School of Public Helth, Kyoto, Jpn 6 Deprtment of Gstroenterologicl Surgery, Kummoto University Grdute School of Medicl Science, Kummoto, Jpn 7 Deprtment of Surgery, Fukuok University Hospitl, Fukuok, Jpn 8 Deprtment of Medicine nd Clinicl Oncology, Grdute School of Medicine Chib University, Chib, Jpn 9 Deprtment of Medicine, Teikyo University School of Medicine, Tokyo, Jpn 10 Division of Infection Control nd Prevention, Jichi Medicl University Hospitl, Tochigi, Jpn 11 Deprtment of Surgery, Indin University School of Medicine, Indinpolis, USA Abstrct A systemtic review of references conducted in the process of developing the Guidelines for the Mngement of Acute Cholngitis nd Cholecystitis did not find mny high-qulity reserch reports. There were no criteri for dignosis, severity ssessment, or ptient trnsfer, nd no estblished principles of clinicl prctice guidelines for cute cholngitis nd cholecystitis. In order to develop guidelines tht would be useful in clinicl prctice, n understnding of the current sttus of clinicl prctice for cute cholngitis nd cholecystitis ws considered essentil. After severl open symposi nd survey of these two diseses, we developed nd published Jpnese-lnguge version of Evidence-Bsed Prctice Guidelines for the Mngement of Acute Cholngitis nd Cholecystitis. In order to prepre interntionl Guidelines, we hd repeted discussions bout the drft Guidelines together with interntionl experts, nd, following the Consensus Meeting, held on April 1 2, 2006, in Tokyo, with the ttendnce of 300 world experts in the field, the Interntionl Guidelines for the Mngement of Acute Cholngitis nd Cholecystitis were developed. In this rticle, we outline the comments nd opinions given t the Interntionl Meeting nd how they re reflected in the finl version of the Guidelines. Key words Guidelines Consensus development meeting Evidence-bsed medicine Cholngitis Acute cholecystitis Introduction Guidelines should not only be bsed on evidence but should lso meet the needs of current medicl prctice. We thought tht dequte discussion, to receive feed- Offprint requests to: T. Myumi Received: My 31, 2006 / Accepted: August 6, 2006 bck t open symposi nd conferences, ws essentil during the development of the Guidelines. As one of the Integrted Reserch Projects for Assessing Medicl Technology, sponsored by the Jpnese Ministry of Helth, Lbour, nd Welfre, Reserch Group for the Preprtion nd Diffusion of Guidelines for the Mngement of Acute Biliry Trct Infection ws estblished. With support from the Jpnese Society for Abdominl Emergency Medicine, the Jpn Biliry Assocition, nd the Jpnese Society of Hepto- Biliry-Pncretic Surgery, development of the Guidelines for the Mngement of Acute Cholngitis nd Cholecystitis hs been underwy since After severl open consensus conferences nd open symposi to obtin feedbck from members of these societies, Jpnese-lnguge version of Evidence- Bsed Prctice Guidelines for the Mngement of Acute Cholngitis nd Cholecystitis ws prepred nd published. An English-lnguge version of these Guidelines (drft) ws discussed, vi e-mil, with worldwide experts on cute cholngitis nd cholecystitis, with the im of publishing Interntionl Guidelines for the Mngement of Acute Cholngitis nd Cholecystitis. Much spirited debte, which chnged mny res of dignosis criteri, severity ssessment, etc, then took plce t the Interntionl Consensus Meeting, held in Tokyo on April 1 nd 2, 2006, ttended by experts from Jpn nd mny other prts of the world. After severl modifictions by the Orgnizing Committee, the finl version is published here s the Interntionl Guidelines for the Mngement of Acute Cholngitis nd Cholecystitis. In this rticle, we outlined comments nd opinions given t the Interntionl Consensus Meeting,

2 T. Myumi et l.: Results of the Tokyo Consensus Meeting 115 nd how they re reflected in finl version of the Guidelines. Chnges mde in the Guidelines t the Interntionl Consensus Meeting for the Mngement of Acute Cholngitis nd Cholecystitis (Tokyo, April 1 2, 2006) In order to prepre interntionl guidelines bsed on the Evidence-Bsed Prctice Guidelines for the Mngement of Acute Cholngitis nd Cholecystitis, drft guidelines were modified severl times by the Orgnizing Committee, nd discussion ws crried out, vi e- mil, with worldwide experts on cute cholngitis nd cute cholecystitis before the Interntionl Consensus Meeting. The discussions were followed by the 2-dy Interntionl Consensus Meeting, held in Tokyo on April 1 2, 2006, with the ttendnce of bout 300 world experts specilizing in cute cholngitis nd cute cholecystitis, in order to prepre evidence-bsed guidelines. Attendees from brod re listed (Pge 8 10). Discussions t the Meeting re outlined below. Dignostic criteri for cute cholngitis Some pnelists proposed tht History of biliry disese should be included in the dignostic criteri for cute cholngitis (Tble 1B). A history of biliry disese, such s gllstones, history of previous biliry surgery, nd hving n indwelling biliry stent ply n importnt role in mking the dignosis, s greed upon by mny prticipnts t the Consensus Meeting. But other pnelists disgreed nd proposed different criteri (Tble 1C). Becuse not only n increse but lso decrese in the WBC count indictes inflmmtion, leukocytosis ws chnged to bnorml WBC count. Becuse C- rective protein (CRP) is sometimes not elevted, or other evidence of inflmmtory response ws dded. WBC count nd elevtion of CRP level or other evidence of inflmmtory response re seprte items. As sprtte minotrnsferse (AST) nd lnine minotrnsferse (ALT) sometimes increse in cute cholngitis, bnorml liver function tests, lkline phosphtse (ALP), γ-gtp, AST, ALT) ws dded. Imging findings of inflmmtory chnges in cute cholngitis re lso useful for dignosis. Biliry dilttion or etiology (stricture, tumor, stones) (Tble 1A) ws chnged to biliry dilttion, inflmmtory findings, or etiology (stricture, tumor, stones) (Tble 1B, C). Two wys of mking definite dignosis were proposed; in revision 1 (Tble 1B), these were: (1) three or four items in A (Chrcot s trid) nd (2) ny item in A + two items in B + C, nd in Revision 2 (Tble 1C), these were: Any item in A + two items in B + C. As more thn 90% of the prticipnts t the Tokyo Consensus Meeting greed on four criteri in revision 1 (Tble 1B), history of biliry disese ws included, nd bnorml WBC count nd elevtion of CRP or other evidence of inflmmtory response were included in the finl version of the dignostic criteri for cute cholngitis (Tble 1D). In Tble 1D, two or more items in A were defined s suspected dignosis, nd either: (1) Chrcot s trid (items in A) or (2) two or more items in A plus both items in B + C, were defined s definite dignosis of cute cholngitis. Severity ssessment criteri for cute cholngitis (Tble 2) More thn 70% of the prticipnts t the Tokyo Consensus Meeting greed tht the severity of cute cholngitis should be divided into three grdes, severe (grde III), moderte (grde II), nd mild (grde I). To strtify cute cholngitis into three grdes, two different criteri were necessry, nd it ws decided to use onset of orgn dysfunction nd response to the initil medicl tretment s criteri for the severity ssessment of cute cholngitis. Severe (grde III) cute cholngitis ws defined s tht ssocited with ny one of the ctegories of orgn/ system dysfunction or severe locl inflmmtion listed in Tble 2. This ws supported by more thn 90% of the pnelists t the Interntionl Consensus Meeting. But the thresholds of these ctegories were not discussed t the Summry session. There ws some rgument bout whether the score on n cute physiology scoring system, such s cute physiology nd chronic helth evlution (APACHE) II, or multiple orgn dysfunction scoring system, such s Mrshll s system or the sepsis-relted orgn filure ssessment (SOFA) system should be used s criterion for severe (grde III) cute cholngitis. The principl dvntge of these scoring systems is tht they provide grdtions of severity. The APACHE II system hs been vlidted, especilly for criticl cre ptients, including ptients with sepsis, nd cute cholngitis cn be interpreted s subset of sepsis. The disdvntge of these scoring systems is tht the scores re sometimes troublesome to clculte, nd criticlly speking, they hve not been stisfctory vlidted in ptients with cute cholngitis. The vote on this rgument showed tht 37.8% of the pnelists supported the use of APACHE II nd 62.2% did not. As result of this vote, the chirmen of this session, Drs. Yoshifumi Kwrd (Jpn) nd Henry Pitt (United Sttes), hd proposed to remit the finl decision of whether or

3 116 T. Myumi et l.: Results of the Tokyo Consensus Meeting Tble 1. Dignostic criteri for cute cholngitis (A) Originl A. Clinicl signs 1. Fever nd/or chills 2. Jundice 3. Abd. pin (RUQ, epigstric) B. Lbortory dt 4. Leukocytosis or elevtion of CRP level 5. Elevtion of ALP or γ-gtp level C. Imging findings 6. Biliry dilttion or etiology (stricture, tumor, stones) Definite dignosis (1) All items in A (Chrcot s trid) (2) One or two items in A + ll items in B + C Note: cute heptitis nd other cuses of cute bdomen should be excluded (B) Proposed revision 1 t Interntionl Meeting A. Clinicl context nd mnifesttions 1. History of biliry disese 2. Fever nd/or chills 3. Jundice 4. Abd. pin (RUQ, epigstric) B. Lbortory dt 5. Abnorml WBC count 6. Elevtion of CRP level or other evidence of inflmmtory response 7. Abnorml liver function tests (ALP, γ-gtp, AST, ALT) C. Imging findings 8. Biliry dilttion, inflmmtory findings, or etiology (stricture, tumor, stones) Definite dignosis (1) Three or 4 items in A (Chrcot s trid) (2) Any item in A + 2 items in B + C Note: cute heptitis nd other cuses of cute bdomen should be excluded (C) Proposed revision 2 t Interntionl Meeting A. Clinicl context nd mnifesttions 1. Fever nd/or chills 2. Jundice 3. Abd. pin (RUQ, epigstric) B. Lbortory dt 4. Abnorml WBC count 5. Elevtion of CRP level or other evidence of inflmmtory response 6. Abnorml liver function tests (ALP, γ-gtp, AST, ALT) C. Imging findings 7. Biliry dilttion, inflmmtory findings, or etiology (stricture, tumor, stones) Definite dignosis (1) Any item in A + 2 items in B + C Note: cute heptitis nd other cuses of cute bdomen should be excluded (D) Finl version of dignostic criteri for cute cholngitis A. Clinicl context nd clinicl 1. History of biliry disese mnifesttions 2. Fever nd/or chills 3. Jundice 4. Abdominl pin (RUQ or upper bdominl) B. Lbortory dt 5. Evidence of inflmmtory response 6. Abnorml liver function tests b C. Imging findings 7. Biliry dilttion, or evidence of n etiology (stricture, stone, stent, etc) Suspected dignosis Two or more items in A Definite dignosis (1) Chrcot s trid ( ) (2) Two or more items in A + both items in B + C Abnorml WBC count, incresed serum CRP level, nd other chnges indicting inflmmtion b Incresed serum ALP, γ-gtp (GGT), AST, nd ALT levels not APACHE II should be included s criterion for severe (grde III) cute cholngitis to the Orgnizing Committee, nd this proposl ws pproved by the udience. Neither recurrent symptom nor mlignncy s etiology lwys shows moderte (grde II) cute cholngitis. Therefore, both of these were deleted from the criteri for moderte (grde II) cute cholngitis. The thresholds of high fever nd WBC counts were not decided. After the Interntionl Meeting, ll the criteri nd thresholds of severity of cute cholngitis were dis-

4 T. Myumi et l.: Results of the Tokyo Consensus Meeting 117 Tble 2. Severity ssess ment criteri for cute cholngitis (A) Proposed severity ssessment criteri t Interntionl Meeting Severe (grde III) cute cholngitis Severe (grde III) cute cholngitis is tht ssocited with dysfunctions of t lest one of the following orgns/systems 1. Crdiovsculr Hypotension 2. Neurologic Disturbnce of consciousness 3. Respirtory PO 2 /FiO 2 rtio <300, SpO 2 decrese: (not decided) 4. Renl Oliguri, cretinine >2.0 mg/dl 5. Heptic PT > 15?, 20? Seconds? or INR > 1.5?, or PT prolongtion?: (not decided) 6. Hemtologic Pltelets < /mm 3? 7. APACHE II? To be included or not included? If yes, Score? Moderte (grde II) cute cholngitis Moderte (grde II) cute cholngitis is tht ssocited with t lest one of the following fctors High fever >39 C?: (threshold level ws not decided) WBC > 20000/mm 3? (threshold level ws not decided) No remission for h Recurrent symptom Mlignncy s etiology Note: elderly ptients (>75 yers) nd ptients with medicl comorbidities should be closely monitored Mild (grde I) cute cholngitis Mild (grde I) cute cholngitis is tht which does not meet the criteri for severe or moderte cute cholngitis. (i.e., neither orgn dysfunction nor risk fctors) (B) Finl version of severity ssessment criteri for cute cholngitis Mild (grde I) cute cholngitis Mild (grde I) cute cholngitis is defined s cute cholngitis tht responds to the initil medicl tretment Moderte (grde II) cute cholngitis Moderte (grde II) cute cholngitis is defined s cute cholngitis tht does not respond to the initil medicl tretment nd is not ssocited with orgn dysfunction Severe (grde III) cute cholngitis Severe (grde III) cute cholngitis is defined s cute cholngitis tht is ssocited with the onset of dysfunction t lest in ny one of the following orgns/systems: 1. Crdiovsculr system Hypotension requiring dopmine 5 µg/kg per min, or ny dose of dobutmine 2. Nervous system Disturbnce of consciousness 3. Respirtory system PO 2 /FiO 2 rtio < Kidney Serum cretinine >2.0 mg/dl 5. Liver PT-INR > Hemtologicl system Pltelet count < /µl Note: compromised ptients, e.g., elderly (>75 yers old) nd ptients with medicl comorbidities, should be closely monitored Generl supportive cre nd ntibiotics cussed nd decided or by the Orgnizing Committee (Tble 2B). The definition of moderte (grde II) cute cholngitis ws chnged to: cute cholngitis tht does not respond to the initil medicl tretment nd is not ssocited with orgn dysfunction (Tble 2B). Dignostic criteri for cute cholecystitis (Tble 3) After the discussion during the Tokyo Interntionl Consensus Meeting, lmost unnimous greement ws chieved (Tble 3B). However, 19% of the pnelists from brod expressed the necessity for minor modifictions, becuse the dignostic criteri did not include technetium heptobiliry iminodicetic cid (Tc-HIDA) scns s n item in the provisionl version. Some pnelists insisted tht suspected dignosis ws not necessry, nd tht only definite dignosis should be included in the dignostic criteri for cute cholecystitis. There ws no discussion on whether, if suspected dignosis ws deleted, how the definition of definite dignosis should be modified. After the Interntionl Meeting, A. Locl signs of inflmmtion ; B. Systemic signs of inflmmtion nd C. Imging findings were clerly specified in the dignostic criteri for cute cholecystitis (Tble 3B). Tc- HIDA scn ws included in C. Imging findings. Suspected dignosis ws deleted from the criteri. Severity ssessment criteri for cute cholecystitis (Tble 4) Before the Interntionl Meeting, Severe (grde III) cute cholecystitis ws defined s tht ssocited with dysfunction in ny one of the orgns/systems or ny one of the severe locl inflmmtion ctegories listed in Tble 4A.

5 118 T. Myumi et l.: Results of the Tokyo Consensus Meeting Tble 3. Dignostic criteri for cute cholecystitis (A) Proposed t Interntionl Meeting 1. (1) Murphy s sign, (2) RUQ, mss/pin/tenderness, (3) rigidity/muscle gurding, (4) rebound tenderness 2. (1) Fever, (2) bnorml WBC count, (3) elevted CRP 3. Imging findings chrcteristic of cute cholecystitis Suspected dignosis: one item in 1. nd one item in 2. re positive. (Suspected dignosis my be deleted? If so, definition of definite dignosis?) Definite dignosis: 3. is positive in ptients who fulfill the criteri for suspected dignosis Note: cute heptitis, other cuses of cute bdomen, nd chronic cholecystitis should be excluded (B) Finl version of dignostic criteri for cute cholecystitis A. Locl signs of inflmmtion (1) Murphy s sign, (2) RUQ mss/pin/tenderness B. Systemic signs of inflmmtion (1) Fever, (2) elevted CRP, (3) elevted WBC count C. Imging findings Imging findings chrcteristic of cute cholecystitis Definite dignosis (1) One item in A nd one item in B re positive (2) C confirms the dignosis when cute cholecystitis is suspected cliniclly Note: cute heptitis, other cute bdominl disese, nd chronic cholecystitis should be excluded Imging findings of cute cholecystitis Ultrsonogrphy Sonogrphic Murphy sign (tenderness elicited by pressing the gllbldder with the ultrsound probe) Thickened gllbldder wll (>4 mm, if the ptient does not hve chronic liver disese nd/or scites or right hert filure) Enlrged gllbldder (long xis dimeter >8 cm, short xis dimeter >4 cm) Incrcerted gllstone, debris echo, pericholecystic fluid collection Sonolucent lyer in the gllbldder wll, strited intrmurl lucencies, nd Doppler signls MRI Pericholecystic high signl Enlrged gllbldder Thickened gllbldder wll CT Thickened gllbldder wll Pericholecystic fluid collection Enlrged gllbldder Liner high-density res in the pericholecystic ft tissue Tc-HIDA scn (technetium heptobiliry iminodicetic cid scn) Non-visulized gllbldder with norml uptke nd excretion of rdioctivity Rim sign (ugmenttion of rdioctivity round the gllbldder foss) At the Meeting, concepts of the severity of cute cholecystitis were discussed nd chnged s shown below. The concept of the finl version of the severity ssessment of cute cholecystitis, severe (grde III) cute cholecystitis ws defined s tht ssocited with orgn dysfunction, moderte (grde II) cute cholecystitis ws defined s tht ssocited with difficulty to perform due to locl inflmmtion, nd mild (grde I) cute cholecystitis ws defined s tht which does not meet the criteri of severe or moderte cute cholecystitis. In the severity ssessment initilly proposed t the Meeting moderte (grde II) cute cholecystitis ws ssocited with ny of the following conditions: (1) bnorml WBC (>15 000, >18 000? threshold ws not decided), (2) plpble inflmmtory mss, (3) onset more thn h nd (4) Serious wll thickening nd fluid collection round the gllbldder. Some pnelists insisted tht serious should be chnged to thickening or deleted. Whether threshold of wll thickening should be included ws not discussed. If included, the extent of the thickness, whether 6 7 mm or 8 mm, or twice tht of the norml gllbldder wll, lso remined s questions. Also, it ws queried whether both the thickness of the gllbldder wll nd fluid collection round the gllbldder were necessry for the dignosis of moderte cute cholecystitis? Pnelists suggested tht liver cirrhosis should be described in Note. After the Interntionl Meeting, ech item nd its threshold were discussed nd decided on by the Orgnizing Committee. Severe locl inflmmtion ws deleted from the criteri for severe (grde III) cute cholecystitis (Tble 4B). Onset more thn h ws chnged to prolonged locl signs of inflmmtion in the criteri for moderte (grde II) cute cholngitis. Flowchrts Flow chrts for the mngement of cute cholngitis nd cute cholecystitis ccording to severity were lso discussed nd modified t the Meeting.

6 T. Myumi et l.: Results of the Tokyo Consensus Meeting 119 Tble 4. Severity ssessment criteri for cute cholecystitis (A) Proposed t Interntionl Meeting Severe (grde III) cute cholecystitis Severe (grde III) cute cholecystitis is ssocited with ny one of the following ctegories. Orgn/System dysfunction (Note: Thresholds were not discussed t the Summry session) Crdiovsculr Hypotension Neurologic (Disturbnce of consciousness) Respirtory (PO 2 /FiO 2 rtio <300) Renl (Oliguri, cretinine >2.0 mg/dl) Heptic (T. bilirubin >5.0 mg/dl) DIC (Pltelets < /mm 3 ) Severe locl inflmmtion Biliry peritonitis, pericholecystic bscess, heptic bscess, gngrenous cholecystitis, emphysemtous cholecystitis Moderte (grde II) cute cholecystitis Moderte (grde II) cute cholecystitis is ssocited with ny of the following conditions. WBC > 15000, (Threshold?) Plpble inflmmtory mss Onset > h Serious thickening? (or serious deleted?), thickening of wll (include threshold?, if so, wht thickness 6 7 mm or 8 mm? or twice norml gllbldder wll?) nd fluid collection round the gllbldder. (Is both thickness of gllbldder wll nd fluid collection round the gllbldder necessry?) Liver cirrhosis should be described in Note. Mild (grde I) cute cholecystitis Mild (grde I) cute cholecystitis does not meet the criteri of severe or moderte cute cholecystitis (B) Finl version of severity ssessment criteri for cute cholecystitis Mild (grde I) cute cholecystitis Mild (grde I) cute cholecystitis does not meet the criteri of severe (grde III) or moderte (grde II) cute cholecystitis. It cn lso be defined s cute cholecystitis in helthy ptient with no orgn dysfunction nd mild inflmmtory chnges in the gllbldder, mking sfe nd low-risk opertive procedure. Moderte (grde II) cute cholecystitis Moderte cute cholecystitis is ssocited with ny one of the following conditions: 1. Elevted WBC count (>18000/mm 3 ) 2. Plpble tender mss in the right upper bdominl qudrnt 3. Durtion of complints >72 h 4. Mrked locl inflmmtion (biliry peritonitis, pericholecystic bscess, heptic bscess, gngrenous cholecystitis, emphysemtous cholecystitis) Lproscopic surgery should be performed within 96 h of the onset of cute cholecystitis Severe (grde III) cute cholecystitis Severe cute cholecystitis is ssocited with dysfunction of ny one of the following orgns/systems 1. Crdiovsculr dysfunction (hypotension requiring tretment with dopmine 5 µg/kg per min, or ny dose of dobutmine) 2. Neurologicl dysfunction (decresed level of consciousness) 3. Respirtory dysfunction (PO 2 /FiO 2 rtio <300) 4. Renl dysfunction (oliguri, cretinine >2.0 mg/dl) 5. Heptic dysfunction (PT-INR > 1.5) 6. Hemtologicl dysfunction (pltelet count < /mm 3 ) Almost ll pnelists greed with the flowchrt for Generl guidnce for the mngement of cute biliry infection (Fig. 1). But in the flowchrt for the mngement of cute cholngitis (Fig. 2), pnelists suggested tht medicl tretment should be begun before ssessment of the severity of cute cholngitis. Therefore, the flowchrt ws chnged, s shown in Fig. 2b. In the flowchrt for the mngement of cute cholecystitis (Fig. 3), becuse the concept of severity of cholecystitis ws chnged, this flowchrt ws lso modified (Fig. 3b). As severe (grde III) cute cholecystitis is ssocited with orgn dysfunction, urgent/erly dringe ws preferred to urgent/erly for severe (grde III) cholecystitis. Similrly, s moderte (grde II) cute cholecystitis is ssocited with difficulty to perform due to locl inflmmtion, urgent/erly dringe ws preferred to erly/elective for moderte (grde II) cholecystitis lso. Definitions of severity: mild to severe (grdes I III) Before the Meeting, the severity of both cute cholngitis nd cute cholecystitis ws clssified s mild,

7 Suspicion of cute biliry infection Clinicl presenttions, blood test, dignostic imging Dignostic criteri Differentil dignosis Other diseses Acute cholngitis Acute cholecystitis Fig. 1. Flowchrt for generl guidnce for the mngement of cute biliry infection Dignosis of cute cholngitis Severity ssessment Medicl tretment Observtion Mild (Grde I) Moderte (Grde II) Erly biliry dringe Severe (Grde III) Urgent biliry dringe Orgn support for severe cses Tretment for etiology (Endoscopic tretment nd surgery) Dignosis of cute cholngitis Lunch of medicl tretment Medicl tretment Observtion Mild (Grde I) Severity ssessment Moderte (Grde II) Erly biliry dringe Severe (Grde III) Urgent biliry dringe Orgn support for severe cses b Tretment for etiology (Endoscopic tretment, percutneous tretment, or surgery) Fig. 2,b. Flowchrts for the mngement of cute cholngitis. Originl; b modified t the Meeting

8 T. Myumi et l.: Results of the Tokyo Consensus Meeting 121 Dignosis of cute cholecystitis Medicl tretment Mild (Grde I) Erly/elective Severity ssessment Moderte (Grde II) Urgent/ erly GB dringe Severe (Grde III) Urgent/ erly Orgn support for severe cses Observtion Erly/elective Observtion Dignosis of cute cholecystitis b Medicl tretment Observtion moderte, nd severe. But, with these criteri, even moderte cute cholngitis nd moderte cute cholecystitis sometimes cuse orgn filure nd even deth. This definition could hve confused users of these Guidelines, s moderte diseses re usully regrded s those hving good course without high morbidity or mortlity. Therefore, insted of using the ctegories mild, moderte, nd severe, the ctegories grdes I, II, nd III were used s the severity clssifictions for both cute cholngitis nd cute cholecystitis. Conclusion Mild (Grde I) Erly LC Severity ssessment Moderte (Grde II) Urgent/ erly GB dringe Erly/ elective Severe (Grde III) Observtion In the preprtion of the Guidelines for Acute Biliry Trct Infections (Acute Cholngitis nd Cholecystitis), we found tht there ws not sufficient volume of highqulity reserch. In this rticle, we hve reported the process of developing the Guidelines, rnging from the identifiction of current clinicl prctice for cute biliry trct infection, to the proposls for the Guidelines nd the improvements bsed on consensus. The Guidelines re the world s first interntionl guidelines for the Urgent/ erly Orgn support for severe cses Fig. 3,b. Flowchrts for the mngement of cute cholecystitis. Originl; b modified t the Meeting. GB, gllbldder; LC, lproscopic clinicl mngement of cute biliry trct infections (cute cholngitis nd cholecystitis), nd it is strongly expected tht they my be used brodly in everydy medicl prctice throughout the world s Guidelines tht fully reflect locl nd regionl conditions. Acknowledgments. We would like to express our deep grtitude to the Jpnese Society for Abdominl Emergency Medicine, the Jpn Biliry Assocition, nd the Jpnese Society of Hepto-Biliry-Pncretic Surgery, who provided us with gret support nd guidnce in the preprtion of the Guidelines. This process ws conducted s prt of the Project on the Preprtion nd Diffusion of Guidelines for the Mngement of Acute Cholngitis (H-15-Medicine-30), with reserch subsidy for fiscl 2003 nd 2004 (Integrted Reserch Project for Assessing Medicl Technology) sponsored by the Jpnese Ministry of Helth, Lbour, nd Welfre. We lso truly pprecite the pnelists who cooperted with nd contributed significntly to the Interntionl Consensus Meeting, held in Tokyo on April 1 nd 2, 2006.