BackgroundThe Tokyo Guidelines for the management of acute cholangitis and cholecystitis were published in 2007 (TG07) and have been widely cited in the world literature. Because of new information that has been published since 2007, we organized the Tokyo Guidelines Revision Committee to conduct a multicenter analysis to develop the updated Tokyo Guidelines (TG13).Methods/materials We retrospectively analyzed 1,432 biliary disease cases where acute cholangitis was suspected. The cases were collected from multiple tertiary care centers in Japan. The ‘gold standard’ for acute cholangitis in this study was that one of the three following conditions was present: (1) purulent bile was observed; (2) clinical remission following bile duct drainage; or (3) remission was achieved by antibacterial therapy alone, in patients in whom the only site of infection was the biliary tree. Comparisons were made for the validity of each diagnostic criterion among TG13, TG07 and Charcot’s triad.ResultsThe major changes in diagnostic criteria of TG07 were re-arrangement of the diagnostic items and exclusion of abdominal pain from the diagnostic list. The sensitivity improved from 82.8 % (TG07) to 91.8 % (TG13). While the specificity was similar to TG07, the false positive rate in cases of acute cholecystitis was reduced from 15.5 to 5.9 %. The sensitivity of Charcot’s triad was only 26.4 % but the specificity was 95.6 %. However, the false positive rate in cases of acute cholecystitis was 11.9 % and not negligible. As for severity grading, Grade II (moderate) acute cholangitis is defined as being associated with any two of the significant prognostic factors which were derived from evidence presented recently in the literature. The factors chosen allow severity assessment to be performed soon after diagnosis of acute cholangitis.ConclusionTG13 present a new standard for the diagnosis, severity grading, and management of acute cholangitis.

We describe a case of giant cavernous haemangioma of the liver with disseminated intravascular coagulopathy (Kasabach-Merritt syndrome) which was cured by orthotopic liver transplant.A 47 year old man presented with bleeding and tender massive hepatomegaly after tooth extraction.Investigations showed disseminated intravascular coagulopathy and a giant hepatic haemangioma involving both lobes of the liver. Initial treatment failed to resolve the coagulopathy and liver resection was attempted. At laparotomy the turnout was unresectable and the only option for cure was to offer a liver transplantation. The orthotopic liver transplant was performed 20 days after initial laparotomy. Subsequently, all coagulation parameters returned to normal and the patient remains well after 12 months. Orthotopic liver transplant can be considered for giant hepatic haemangioma with Kasabach-Merritt syndrome when resection is necessary and a partial hepatectomy is not technically feasible.

There is significant heterogeneity in the use of anticoagulation after PV resection. Overall morbidity, mortality and EPVT in both groups were similar. EPVT has a high associated mortality. While we have been unable to demonstrate a benefit for anticoagulation, the incidence of EPVT is low in the absence of prosthetic grafts.

BACKGROUND. Life expectancy is increasing, and more patients are presenting with cancer at an advanced age (≥80 years). Optimal management for this group of patients has not been well defined. METHODS. The South Australian Clinical Registry for Metastatic Colorectal Cancer (mCRC) collects data on all patients diagnosed since February 2006 in South Australia. The authors examined cancer characteristics, treatments administered, and outcomes for patients aged ≥80 years compared with patients aged <80 years. RESULTS Data from 2314 patients were evaluable, and 29.2% of these patients were aged ≥80 years. The majority had moderately differentiated tumors. Poorly differentiated tumors were reported in fewer patients aged ≥80 years (20.1% vs 26.1%; P < .005). Overall, 28.1% of patients aged ≥80 years received chemotherapy, and 74.2% received single‐agent fluoropyrimidines as first‐line treatment. By comparison, 68.2% of patients aged <80 years received chemotherapy, 74.3% received combination chemotherapy, and 25.7% received single‐agent fluoropyrimidine as first‐line treatment. No treatment was received by 38.2% of patients aged ≥80 years compared with 11.4% of those aged <80 years. Participation in clinical trials was lower in patients aged ≥80 years (2% vs 13%). The median survival was worse for patients aged ≥80 years (8.2 months vs 19.2 months; P < .001), and the median survival of patients who received chemotherapy was 19.0 months for those aged ≥80 years and 22.3 months for those aged <80 years (P = .139). Patients who did not receive treatment had a poor median survival regardless of age (2.6 months for patients aged ≥80 years vs 2.7 months for patients aged <80 years). CONCLUSIONS. Patients aged ≥80 years were less likely to receive intervention for their metastatic colorectal cancer and had poorer survival. The survival of selected patients aged ≥80 years who received chemotherapy was similar to the survival of those aged <80 years despite the receipt of single‐agent therapy. Patients aged ≥80 years with metastatic colorectal cancer are less likely to receive intervention for their disease and have poorer survival. Survival for selected patients aged ≥80 years who receive chemotherapy is similar to the survival of patients aged <80 years despite the receipt of single‐agent therapy. Cancer 2013. © 2012 American Cancer Society.