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      TG13: Updated Tokyo Guidelines for the management of acute cholangitis and cholecystitis

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          Abstract

          In 2007, the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07) were first published in the Journal of Hepato-Biliary-Pancreatic Surgery. The fundamental policy of TG07 was to achieve the objectives of TG07 through the development of consensus among specialists in this field throughout the world. Considering such a situation, validation and feedback from the clinicians' viewpoints were indispensable. What had been pointed out from clinical practice was the low diagnostic sensitivity of TG07 for acute cholangitis and the presence of divergence between severity assessment and clinical judgment for acute cholangitis. In June 2010, we set up the Tokyo Guidelines Revision Committee for the revision of TG07 (TGRC) and started the validation of TG07. We also set up new diagnostic criteria and severity assessment criteria by retrospectively analyzing cases of acute cholangitis and cholecystitis, including cases of non-inflammatory biliary disease, collected from multiple institutions. TGRC held meetings a total of 35 times as well as international email exchanges with co-authors abroad. On June 9 and September 6, 2011, and on April 11, 2012, we held three International Meetings for the Clinical Assessment and Revision of Tokyo Guidelines. Through these meetings, the final draft of the updated Tokyo Guidelines (TG13) was prepared on the basis of the evidence from retrospective multi-center analyses. To be specific, discussion took place involving the revised new diagnostic criteria, and the new severity assessment criteria, new flowcharts of the management of acute cholangitis and cholecystitis, recommended medical care for which new evidence had been added, new recommendations for gallbladder drainage and antimicrobial therapy, and the role of surgical intervention. Management bundles for acute cholangitis and cholecystitis were introduced for effective dissemination with the level of evidence and the grade of recommendations. GRADE systems were utilized to provide the level of evidence and the grade of recommendations. TG13 improved the diagnostic sensitivity for acute cholangitis and cholecystitis, and presented criteria with extremely low false positive rates adapted for clinical practice. Furthermore, severity assessment criteria adapted for clinical use, flowcharts, and many new diagnostic and therapeutic modalities were presented. The bundles for the management of acute cholangitis and cholecystitis are presented in a separate section in TG13. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

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          GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.

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            What is "quality of evidence" and why is it important to clinicians?

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              Is Open Access

              Systems for grading the quality of evidence and the strength of recommendations I: Critical appraisal of existing approaches The GRADE Working Group

              Background A number of approaches have been used to grade levels of evidence and the strength of recommendations. The use of many different approaches detracts from one of the main reasons for having explicit approaches: to concisely characterise and communicate this information so that it can easily be understood and thereby help people make well-informed decisions. Our objective was to critically appraise six prominent systems for grading levels of evidence and the strength of recommendations as a basis for agreeing on characteristics of a common, sensible approach to grading levels of evidence and the strength of recommendations. Methods Six prominent systems for grading levels of evidence and strength of recommendations were selected and someone familiar with each system prepared a description of each of these. Twelve assessors independently evaluated each system based on twelve criteria to assess the sensibility of the different approaches. Systems used by 51 organisations were compared with these six approaches. Results There was poor agreement about the sensibility of the six systems. Only one of the systems was suitable for all four types of questions we considered (effectiveness, harm, diagnosis and prognosis). None of the systems was considered usable for all of the target groups we considered (professionals, patients and policy makers). The raters found low reproducibility of judgements made using all six systems. Systems used by 51 organisations that sponsor clinical practice guidelines included a number of minor variations of the six systems that we critically appraised. Conclusions All of the currently used approaches to grading levels of evidence and the strength of recommendations have important shortcomings.
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                Author and article information

                Journal
                Journal of Hepato-Biliary-Pancreatic Sciences
                Journal of Hepato-Biliary-Pancreatic Sciences
                Springer Science and Business Media LLC
                18686974
                January 2013
                January 2013
                January 11 2013
                : 20
                : 1
                : 1-7
                Affiliations
                [1 ]Department of Surgery; Teikyo University School of Medicine; 2-11-1 Kaga, Itabashi-ku Tokyo 173-8605 Japan
                [2 ]Section of Hepatobiliary and Pancreatic Surgery; Washington University in Saint Louis School of Medicine; Saint Louis MO USA
                [3 ]Department of Surgery; University of Cincinnati College of Medicine; Cincinnati OH USA
                [4 ]Department of Surgery; Indiana University School of Medicine; Indianapolis IN USA
                [5 ]Center for Clinical Infectious Diseases; Jichi Medical University; Tochigi Japan
                [6 ]Clinical Research Center Kaken Hospital; International University of Health and Welfare; Ichikawa Japan
                [7 ]Department of Emergency and Critical Care Medicine; Ichinomiya Municipal Hospital; Ichinomiya Japan
                [8 ]Department of Surgery; Academic Medical Center; Amsterdam The Netherlands
                [9 ]Clinical Surgery; The University of Edinburgh; Edinburgh UK
                [10 ]Department of Surgery; University of Heidelberg; Heidelberg Germany
                [11 ]Department of Gastroenterology; Ogaki Municipal Hospital; Ogaki Japan
                [12 ]General Internal Medicine; Nagoya Daini Red Cross Hospital; Nagoya Japan
                [13 ]Department of Surgical Oncology and Gastroenterological Surgery; Sapporo Medical University School of Medicine; Sapporo Japan
                [14 ]Department of Medicine and Clinical Oncology; Graduate School of Medicine Chiba University; Chiba Japan
                [15 ]Department of Gastroenterology and Hepatology; Tokyo Medical University; Tokyo Japan
                [16 ]Department of Radiology; Kanazawa University Graduate School of Medical Science; Kanazawa Japan
                [17 ]Department of Surgery, Institute of Gastroenterology; Tokyo Women's Medical University; Tokyo Japan
                [18 ]Department of Surgery; Kitakyushu Municipal Yahata Hospital; Kitakyushu Japan
                [19 ]Department of Endoscopy and Ultrasound; Kawasaki Medical School; Okayama Japan
                [20 ]Department of Preventive Medicine and Community Health, School of Medicine; University of Occupational and Environmental Health; Kitakyushu Japan
                [21 ]Department of Surgery; Toho University Medical Center Ohashi Hospital; Tokyo Japan
                [22 ]Department of Surgery; The University of Auckland; Auckland New Zealand
                [23 ]Department of Surgical Gastroenterology; Seth G S Medical College and K E M Hospital; Mumbai India
                [24 ]HepatoBiliary Surgery and Liver Transplantation, Asan Medical Center; Ulsan University; Seoul Korea
                [25 ]Department of Surgery, Hepatic Surgery Centre, Tongji Hospital, Tongi Medical College; Huazhong Universty of Science & Technology; Wuhan China
                [26 ]Department of Gastroenterological Surgery; Fukuoka University School of Medicine; Fukuoka Japan
                [27 ]Department of Internal Medicine, Second Teaching Hospital; Fujita Health University School of Medicine; Nagoya Aichi Japan
                [28 ]Department of Surgery I; Sapporo Medical University Hospital; Sapporo Hokkaido Japan
                [29 ]Toho University School of Medicine; Tokyo Japan
                Article
                10.1007/s00534-012-0566-y
                23307006
                a010cc4f-b2bd-4d18-9d24-dbe72474878d
                © 2013

                http://doi.wiley.com/10.1002/tdm_license_1.1

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