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  • Indications and techniques of biliary drainage for acute cholangitis inupdated Tokyo Guidelines 2018

    Shuntaro Mukai Takao Itoi Todd H. Baron Tadahiro Takada Steven M. Strasberg Henry A. Pitt

    Tomohiko Ukai Satoru Shikata Anthony Yuen Bun Teoh Myung-Hwan Kim Seiki Kiriyama

    Yasuhisa Mori Fumihiko Miura Miin-Fu Chen Wan Yee Lau Keita Wada Avinash Nivritti Supe

    Mariano Eduardo Gimenez Masahiro Yoshida Toshihiko Mayumi Koichi Hirata Yoshinobu Sumiyama

    Kazuo Inui Masakazu Yamamoto

    Published online: 5 October 2017

    2017 Japanese Society of Hepato-Biliary-Pancreatic Surgery

    The authors affiliations are listedin the Appendix.

    Correspondence to: TadahiroTakada, Department of Surgery,Teikyo University School ofMedicine, 2-11-1 Kaga, Itabashi-ku,Tokyo 173-8605, Japane-mail:

    DOI: 10.1002/jhbp.496

    Abstract The Tokyo Guidelines 2013 (TG13) include new topics in the biliarydrainage section. From these topics, we describe the indications and new techniques ofbiliary drainage for acute cholangitis with videos. Recently, many novel studies andcase series have been published across the world, thus TG13 need to be updatedregarding the indications and selection of biliary drainage based on published data.Herein, we describe the latest updated TG13 on biliary drainage in acute cholangitiswith meta-analysis. The present study showed that endoscopic transpapillary biliarydrainage regardless of the use of nasobiliary drainage or biliary stenting, should beselected as the first-line therapy for acute cholangitis. In acute cholangitis, endoscopicsphincterotomy (EST) is not routinely required for biliary drainage alone because ofthe concern of post-EST bleeding. In case of concomitant bile duct stones, stoneremoval following EST at a single session may be considered in patients with mild ormoderate acute cholangitis except in patients under anticoagulant therapy or withcoagulopathy. We recommend the removal of difficult stones at two sessions afterdrainage in patients with a large stone or multiple stones. In patients with potentialcoagulopathy, endoscopic papillary dilation can be a better technique than EST forstone removal. Presently, balloon enteroscopy-assisted endoscopic retrogradecholangiopancreatography (BE-ERCP) is used as the first-line therapy for biliarydrainage in patients with surgically altered anatomy where BE-ERCP expertise ispresent. However, the technical success rate is not always high. Thus, several studieshave revealed that endoscopic ultrasonography-guided biliary drainage (EUS-BD) canbe one of the second-line therapies in failed BE-ERCP as an alternative topercutaneous transhepatic biliary drainage where EUS-BD expertise is present.

    Keywords Cholangitis Drainage Endoscopic retrogradecholangiopancreatography Endoscopic sphincterotomy Gallstones


    Acute cholangitis varies in severity, ranging from a mild form which can be treated byconservative therapy to a severe form which leads to a life-threatening state (e.g. shockstate and altered sensorium). In particular, the severe form often causes mortality inthe elderly [1]. Early biliary drainage should be performed for Grade II (moderate) andGrade III (severe) cases according to the severity grading of the updated Tokyo

    J Hepatobiliary Pancreat Sci (2017) 24:537549DOI: 10.1002/jhbp.496


  • Guidelines of 2013 (TG13) [24]. Biliary drainage, whichis the most essential therapy for acute cholangitis, is tradi-tionally divided into three types: (1) surgical, (2) percuta-neous transhepatic, and (3) endoscopic transpapillarydrainage. Of these therapies, surgical intervention causesthe highest mortality rate [1]. Recently, mortality due toacute cholangitis has decreased owing to the developmentof percutaneous transhepatic cholangial drainage (PTCD)[5] and endoscopic transpapillary biliary drainage [6, 7].Nevertheless, acute cholangitis can still be fatal unless itis treated early and properly.

    The Tokyo Guidelines of 2007 (TG07) was the firstglobal guidelines in which fundamental biliary drainagetechniques for acute cholangitis were described [8]. Sub-sequently, TG07 was revised to TG13, which include theindications and procedures of newly developed biliarydrainage techniques such as endoscopic ultrasonography-guided biliary drainage (EUS-BD) and balloon entero-scope-assisted bile duct drainage in patients with surgi-cally altered anatomy [9]. As several reports of thesenewly developed biliary drainage techniques or the meth-ods and timing of stone removal after or simultaneouslywith drainage have been published, TG13 needs to beupdated. Thus, the Tokyo Guidelines Revision Committeewas assembled and the committee discussed six argumentpoints on biliary drainage for acute cholangitis as men-tioned below. In this article, we describe the latest drai-nage techniques for acute cholangitis and the treatmentmethods for stone removal in the updated Tokyo Guideli-nes 2018 (TG18).

    Indications and techniques of biliary drainage

    In the updated TG18, biliary drainage is recommended foracute cholangitis regardless of the degree of severityexcept in some cases of mild acute cholangitis in whichantibiotics and general supportive care are effective [10].

    Q1. What is the most preferable biliary drainage foracute cholangitis? (Surgical vs. endoscopic transpapillaryvs. EUS-guided vs. percutaneous transhepatic biliarydrainage?)

    We recommend endoscopic transpapillary biliarydrainage for acute cholangitis (recommendation 1,level B).

    *Refer to Q6 in acute cholangitis patients with sur-gically altered anatomy.

    Endoscopic transpapillary biliary drainage should beconsidered as the first-line drainage procedure because ofits less invasiveness and lower risk of adverse events thanother drainage techniques despite the risk of post-endoscopic retrograde cholangiopancreatography (ERCP)

    pancreatitis [1114]. The internal drainage by endoscopictranspapillary biliary drainage produces less pain after theprocedures than the external drainage by percutaneoustranshepatic biliary drainage (PTBD), also known as per-cutaneous transhepatic cholangial drainage (PTCD) [15].PTCD places more burden on patients owing to cosmeticproblems, skin inflammation, or bile leakage, compromis-ing the patients quality of life. A single treatment sessionfor a bile duct stone is possible with the endoscopictranspapillary approach, making the hospitalization dura-tion shorter. However, in patients with an inaccessiblepapilla due to upper gastrointestinal tract obstruction, orwhen skilled pancreaticobiliary endoscopists are not avail-able in the institution, PTCD is a useful alternative drai-nage procedure [5, 16]. Furthermore, PTCD can be usedas a salvage therapy when conventional endoscopictranspapillary drainage has failed owing to difficult selec-tive biliary cannulation. Recently, EUS-BD has beendeveloped and reported as a novel useful alternative drai-nage technique when standard endoscopic transpapillarydrainage has failed [17, 18].

    From the results of a randomized controlled trial(RCT) and meta-analysis that compared EUS-BD withPTCD as an alternative drainage technique after failedendoscopic transpapillary biliary drainage, the technicalsuccess and clinical success rates were approximately thesame at 90100%, but the rates of PTCD adverse eventssuch as post-procedure bleeding, cholangitis, and bileleakage were higher than those of EUS-BD adverse events(Table 1) [1924]. However, almost all reports aboutEUS-BD come from high-volume centers and performedby skilled pancreaticobiliary endoscopists. A national sur-vey in Spain wherein most of the institutions involvedwere not high-volume centers reported a technical successrate of only 67.2% from 106 patients [25]. Their dataindicated that EUS-BD remains an unestablished proce-dure and is not an easy technique to perform. Therefore,when skilled pancreaticobiliary endoscopists are availablein an institution, EUS-BD is recommended as an alterna-tive drainage procedure. Otherwise, PTCD should beselected, or transfer of the patient to a high-volume centershould be considered.

    Percutaneous transhepatic cholangial drainage

    Before the widespread use of transabdominal ultrasonog-raphy, needle puncture of the bile duct was conductedunder fluoroscopy [5]. Currently, needle puncture is safelyperformed under ultrasonography to avoid interveningblood vessels [16]. Therefore, in the current PTCD proce-dure, operators should continuously observe the bile ductby ultrasonography regardless of the presence of dilation.

    538 J Hepatobiliary Pancreat Sci (2017) 24:537549

  • PTCD is performed as previously described [5]. In brief,ultrasonography-guided transhepatic puncture of the intra-hepatic bile duct is initially performed using an 18-G to22-G needle. After confirming the backflow of bile, aguidewire is advanced into the bile duct. Finally, a 7-Fr to10-Fr catheter is placed in the bile duct under fluoroscopiccontrol over the guidewire. Puncture using a small-gauge(22-G) needle is safer in patients without biliary dilationthan in patients with biliary dilation. According to theQuality Improvement Guidelines developed by Americanradiologists, the success rates of drainage are 86% inpatients with biliary dilation and 63% in patients withoutbiliary dilation [16].

    Surgical drainage

    Open drainage for decompression of the bile duct is per-formed as a surgical intervention. When surgical drainagein critically ill patients with bile duct stones is performed,prolonged operations should be avoided and simple proce-dures, such as T-tube placement without choledocholitho-tomy, are recommended [26]. At present, surgicaldrainage is extremely rare because of the widespread useof endoscopic drainage or PTCD for acute cholangitistherapy.