Indications and techniques of biliary drainage for acute cholangitis in updated 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 Giménez, Masahiro Yoshida, Toshihiko MayumiKoichi Hirata, Yoshinobu Sumiyama, Kazuo Inui, Masakazu Yamamoto

Research output: Contribution to journalArticlepeer-review

106 Citations (Scopus)


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

Original languageEnglish
Pages (from-to)537-549
Number of pages13
JournalJournal of Hepato-Biliary-Pancreatic Sciences
Issue number10
Publication statusPublished - Oct 2017

All Science Journal Classification (ASJC) codes

  • Surgery
  • Hepatology


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