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

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.

TG13 guidelines for diagnosis and severity grading of acute cholangitis (with videos)

Since the publication of the Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07), diagnostic criteria and severity assessment criteria for acute cholangitis have been presented and extensively used as the primary standard all over the world. However, it has been found that there are crucial limitations in these criteria. The diagnostic criteria of TG07 do not have enough sensitivity and specificity, and its severity assessment criteria are unsuitable for clinical use. A working team for the revision of TG07 was organized in June, 2010, and these criteria have been updated through clinical implementation and its assessment by means of multi-center analysis. The diagnostic criteria of acute cholangitis have been revised as criteria to establish the diagnosis where cholestasis and inflammation demonstrated by clinical signs or blood test in addition to biliary manifestations demonstrated by imaging are present. The diagnostic criteria of the updated Tokyo Guidelines (TG13) have high sensitivity (87.6 %) and high specificity (77.7 %). TG13 has better diagnostic capacity than TG07. Severity assessment is classified as follows: Grade III: associated with organ failure; Grade II: early biliary drainage should be conducted; Grade1: others. As for the severity assessment criteria of TG07, separating Grade II and Grade I at the time of diagnosis was impossible, so they were unsuitable for clinical practice. Therefore, the severity assessment criteria of TG13 have been revised so as not to lose the timing of biliary drainage or treatment for etiology. Based on evidence, five predictive factors for poor prognosis in acute cholangitis--hyperbilirubinemia, high fever, leukocytosis, elderly patient and hypoalbuminemia--have been extracted. Grade II can be diagnosed if two of these five factors are present. Free full-text articles and a mobile application of TG13 are available via http://www.jshbps.jp/en/guideline/tg13.html.

New diagnostic criteria and severity assessment of acute cholecystitis in revised Tokyo Guidelines

BACKGROUND

The Tokyo Guidelines for the management of acute cholangitis and cholecystitis (TG07) were published in 2007 as the world's first guidelines for acute cholangitis and cholecystitis. The diagnostic criteria and severity assessment of acute cholecystitis have since been widely used all over the world. A validation study of TG07 has shown that the diagnostic criteria for acute cholecystitis are highly reliable but that the definition of definite diagnosis is ambiguous. In addition, considerable new evidence referring to acute cholecystitis as well as evaluations of TG07 have been published. Consequently, we organized the Tokyo Guidelines Revision Committee to evaluate TG07, recognize new evidence, and conduct a multi-center analysis to revise the guidelines (TG13).

METHODS AND MATERIALS

We retrospectively analyzed 451 patients with acute cholecystitis from multiple tertiary care centers in Japan. All 451 patients were first evaluated using the criteria in TG07. The "gold standard" for acute cholecystitis in this study was a diagnosis by pathology. The validity of TG07 diagnostic criteria was investigated by comparing clinical with pathological diagnosis.

RESULTS

Of 451 patients evaluated, a total of 227 patients were given a diagnosis of acute cholecystitis by pathological examination (prevalence 50.3 %). TG07 criteria provided a definite diagnosis of acute cholecystitis in 224 patients. The sensitivity of TG07 diagnostic criteria for acute cholecystitis was 92.1 %, and the specificity was 93.3 %. Based on the preliminary results, new diagnostic criteria for acute cholecystitis were proposed. Using the new criteria, the sensitivity of definite diagnosis was 91.2 %, and the specificity was 96.9 %. The accuracy rate was improved from 92.7 to 94.0 %. In regard to severity grading among 227 patients, 111 patients were classified as Mild (Grade I), 104 as Moderate (Grade II), and 12 as Severe (Grade III).

CONCLUSION

The proposed new diagnostic criteria achieved better performance than the diagnostic criteria in TG07. Therefore, the proposed criteria have been adopted as new diagnostic criteria for acute cholecystitis and are referred to as the 2013 Tokyo Guidelines (TG13). Regarding severity assessment, no new evidence was found to suggest that the criteria in TG07 needed major adjustment. As a result, TG07 severity assessment criteria have been adopted in TG13 with minor changes.

New diagnostic criteria and severity assessment of acute cholangitis in revised Tokyo Guidelines

BACKGROUND

The 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.

RESULTS

The 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.

CONCLUSION

TG13 present a new standard for the diagnosis, severity grading, and management of acute cholangitis.

Prospective randomized trial of transnasal versus peroral endoscopy using an ultrathin videoendoscope in unsedated patients

AIM

The aim of this study was to compare the acceptance and tolerance of transnasal and peroral esophagogastroduodenoscopy (EGD) using an ultrathin videoendoscope in unsedated patients.

METHODS

A total of 124 patients referred for diagnostic endoscopy were assigned randomly to have an unsedated transnasal EGD (n = 64) or peroral EGD (n = 60) with local anesthesia. An ultrathin videoendoscope with a diameter of 5.9 mm was used in this study. A questionnaire for tolerance was completed by the patient (a validated 0-10 scale where '0' represents no discomfort/well tolerated and '10' represents severe discomfort/poorly tolerated).

RESULTS

Of the 64 transnasal EGD patients, 60 patients (94%) had a complete examination. Four transnasal EGD examinations failed for anatomical reasons; all four patients were successfully examined when switched to the peroral EGD. All 60 peroral EGD patients had a complete examination. Between the transnasal and peroral groups, there was a statistically significant difference in scores for discomfort during local anesthesia (1.5 +/- 0.2 vs 2.6 +/- 0.3, P = 0.003), discomfort during insertion (2.3 +/- 0.3 vs 4.3 +/- 0.3, P = 0.001), and overall tolerance during procedure (1.6 +/- 0.2 vs 3.8 +/- 0.2, P = 0.001). In all, 95% of transnasal EGD patients and 75% of peroral EGD patients (P = 0.002) were willing to undergo the same procedure in the future. Four patients in the transnasal EGD group experienced mild epistaxis.

CONCLUSION

For unsedated endoscopy using an ultrathin videoendoscope, transnasal EGD is well tolerated and considerably reduces patient discomfort compared with peroral EGD.

Endoscopic submucosal dissection using a novel grasping type scissors forceps

Endoscopic submucosal dissection (ESD) with a knife is a technically demanding procedure that is associated with a high complication rate. The shortcoming of this method is the difficulty in fixing the knife to the target lesion. This difficulty can lead to unexpected incision, resulting in major complications such as perforation and bleeding. To reduce the risk of complications related to ESD, we developed a new grasping type scissors forceps (GSF), which can grasp and incise the targeted tissue using an electrosurgical current. The ESD procedure using the GSF was carried out in an animal model (resected porcine stomachs in vitro). After marking the lesion and injecting a solution into the submucosa, the lesion was separated from the surrounding normal mucosa following complete incision around the lesion using the GSF. A piece of submucosal tissue was grasped and cut with the GSF using an electrosurgical current to achieve submucosal exfoliation. ESD using the GSF was carried out safely and easily without unintentional incision. ESD using GSF appears to be an easy, safe, and technically efficient method for resecting gastrointestinal neoplasms.

Multivariate analysis of factors influencing medical costs of acute pancreatitis hospitalizations based on a national administrative database

BACKGROUND

Little information is available on the analysis of medical costs of acute pancreatitis hospitalizations.

AIM

This study aimed to determine the factors affecting medical costs of patients with acute pancreatitis during hospitalization using a Japanese administrative database.

METHODS

A total of 7193 patients with acute pancreatitis were referred to 776 hospitals. We defined "patients with high medical costs" as patients whose medical costs exceeded the 90th percentile in medical costs during hospitalization and identified the independent factors for patients with high medical costs with and without controlling for length of stay.

RESULTS

Multiple logistic regression analysis demonstrated that necrosectomy was the most significant factor for medical costs of acute pancreatitis during hospitalization. The odds ratio of necrosectomy was 33.64 (95% confidence interval, 14.14-80.03; p<0.001). Use of an intensive care unit was the most significant factor for medical costs after controlling for LOS. The OR of an ICU was 6.44 (95% CI, 4.72-8.81; p<0.001).

CONCLUSION

This study demonstrated that necrosectomy and use of an ICU significantly affected the medical costs of acute pancreatitis hospitalization. These results highlight the need for health care implementations to reduce medical costs whilst maintaining the quality of patient care, and targeting patients with severe acute pancreatitis.

Effect of hospital volume on clinical outcome in patients with acute pancreatitis, based on a national administrative database

OBJECTIVE

This study aimed to investigate the relationship between hospital volume and clinical outcome in patients with acute pancreatitis, using a Japanese national administrative database.

METHODS

A total of 7007 patients with acute pancreatitis were referred to776 hospitals in Japan. Patient data were corrected according to the severity of acute pancreatitis to allow the comparison of risk-adjusted in-hospital mortality and length of stay in relation to hospital volume. Hospital volume was categorized based on the number of cases during the study period into low-volume (<10 cases), medium-volume (10-16 cases), and high-volume hospitals (HVHs, >16 cases).

RESULTS

Increased hospital volume was significantly associated with decreased relative risk of in-hospital mortality in both patients with mild and those with severe acute pancreatitis. The odds ratios for HVHs were 0.424 (95% confidence interval [CI], 0.228-0.787; P = 0.007) and 0.338 (95% CI, 0.138-0.826; P = 0.017), respectively. Hospital volume was also significantly associated with shorter length of stay in patients with mild acute pancreatitis. The unstandardized coefficient for HVHs was -0.978 days (95% CI, -1.909 to -0.048; P = 0.039).

CONCLUSIONS

This study demonstrated that hospital volume influences the clinical outcome in both patients with mild and those with severe acute pancreatitis.

Double-balloon endoscopy in the diagnosis and management of GI tract diseases: Methodology, indications, safety, and clinical impact

AIM

To prospectively evaluate the indications, methodology, safety, and clinical impact of double-balloon endoscopy.

METHODS

A total of 60 patients with suspected or documented small- or large-bowel diseases were investigated by double balloon endoscopy. A total of 103 procedures were performed (42 from the oral route, 60 from the anal route, and 1 from the stoma route). The main outcome measurements were the time of insertion and the entire examination, complications, diagnostic yields, and the ability to successfully perform treatment.

RESULTS

Observation of the entire small intestine was possible in 10 (40%) of 25 patients with total enteroscopy. The median insertion time was 122 min (range, 74-199 min). Observation of the entire colon was possible in 13 (93%) of 14 patients after failure of total colonoscopy using a conventional colonoscope. Small-intestine abnormalities were found in 20 (43%) of 46 patients with indications of suspected or documented small bowel diseases, obscure GI tract bleeding, or a history of ileus. Endoscopic procedures including tattooing (n = 33), bite biopsy (n = 17), radiographic examination (n = 7), EUS (n = 5), hemostasis (n = 1), polypectomy (n = 5), balloon dilatation (n = 1), endoscopic mucosal resection (n = 1) and lithotripsy (n = 1) were all successfully performed. No relevant technical problems or severe complications were encountered.

CONCLUSION

Double balloon endoscopy is a feasible technique that allows adequate small and large bowel examination and potentially various endoscopic procedures of small-intestinal lesions. It is safe, useful, and also provides a high clinical impact.

An observational study using a national administrative database to determine the impact of hospital volume on compliance with clinical practice guidelines

BACKGROUND

Little information is available on the relationship between hospital volume and compliance with clinical practice guidelines (CPGs).

OBJECTIVES

To investigate the relationship between hospital volume and compliance with CPGs using a Japanese administrative database.

DESIGN AND SUBJECTS

This was an observational study that included 60,842 patients with acute cholangitis from 829 hospitals in Japan.

MEASURES

Hospital volume was categorized into the following 3 groups based on the number of cases of acute cholangitis during the study period: low-volume hospitals (LVHs; n = 20,869), medium-volume hospitals (MVHs; n = 18,387), and high-volume hospitals (HVHs; n = 21,586). We further collected patient data with regard to CPGs for acute cholangitis, and counted the number of recommendations that had been complied with for each patient. CPGs compliance score was defined as the rate of compliance with these recommendations for each patient (range, 0-10). Aggregated CPGs compliance score was measured according to hospital volume.

RESULTS

Mean CPGs compliance score in HVHs was significantly higher than that in MVHs and LVHs (6.8 ± 1.6 vs. 5.6 ± 1.5 vs. 3.9 ± 1.4, respectively; P < 0.001). Multiple linear regression analysis revealed that hospital volume was most significantly associated with CPGs compliance score. The standardized coefficient for CPGs compliance score in HVHs was 0.689, whereas that of MVHs was 0.366 (P < 0.001).

CONCLUSIONS

This study demonstrated that hospital volume was significantly associated with compliance with CPGs and that the Japanese administrative database was a viable tool for the monitoring of compliance with CPGs.

Endoscopic submucosal dissection for gastric cancer in elderly Japanese patients: an observational study of financial costs of treatment based on a national administrative database

OBJECTIVE

There is currently little information on the medical economic outcomes of endoscopic submucosal dissection (ESD) for gastric cancer (GC) in elderly patients. This study therefore aimed to investigate the medical economic outcomes of ESD in elderly patients with GC using a national administrative database.

METHODS

A total of 27 385 patients treated with ESD for GC were referred to 867 hospitals in Japan from 2009 to 2011. We collected data from the national administrative database and divided them into two groups according to age: elderly patients (≥80 years; n = 5525) and non-elderly patients (<80 years; n = 21 860). We compared ESD-related complications, risk-adjusted length of stay (LOS) and medical costs during hospitalization between elderly and non-elderly patients.

RESULTS

There was no significant difference in ESD-related complications between elderly and non-elderly patients (4.3% vs 3.9%, P = 0.152). However, significant differences were observed in mean LOS and medical costs during hospitalization between the two groups (P < 0.001). Multiple linear regression analysis showed that elderly patients experienced a significantly longer LOS and higher medical costs. The unstandardized coefficient for LOS in elderly patients was 2.71 days (95% confidence interval [CI] 2.59-2.84, P < 0.001), while that for medical costs during hospitalization was USD952.1 (95% CI 847.7-1056.5, P < 0.001).

CONCLUSIONS

LOS and medical costs during hospitalization were significantly higher in elderly patients undergoing ESD for GC than in non-elderly patients, although there was no difference in the incidence of ESD-related complications.

Age-related differences in outcomes and etiologies of acute abdominal pain based on a national administrative database

Acute abdominal pain is one of the most frequent causes of admission to emergency departments. However, there is a shortage of detail information showing the difference of outcomes or etiology of acute abdominal pain according to age. We therefore conducted an epidemiological analysis to reveal the difference between age on outcomes and etiology of acute abdominal pain using an administrative database associated with the Diagnosis Procedure Combination (DPC) system. We obtained discharge data relating to 12,209 patients with acute abdominal pain from 931 DPC participation hospitals between 2009 and 2011 in Japan. We compared length of hospital stay (LOS), in-hospital mortality, and etiology of acute abdominal pain between age categories. Patients were divided into five age groups as follows: < 20 (n = 1,106), 20-39 (n = 3,353), 40-59 (n = 2,925), 60-79 (n = 3,144), and ≥ 80 years (n = 1,681). Longer LOS and higher in-hospital mortality were observed in patients aged ≥ 80 years (p < 0.001). Regarding etiologies of acute abdominal pain, intestinal infection or acute appendicitis were more frequent in patients aged < 20 or 20-39 years, while ileus or cholelithiasis were more frequent in patients aged 60-79 or ≥ 80 years in both male and female patients (p < 0.001). This study demonstrated the significant differences between age with regard to the patient outcomes and etiology of acute abdominal pain. The current findings highlight the importance of improving the quality of medical care for patients with acute abdominal pain.

Endoscopic submucosal dissection for gastric cancer: the influence of hospital volume on complications and length of stay

BACKGROUND

Little information is available about the relationship between hospital volume and the clinical outcome of endoscopic submucosal dissection (ESD) for gastric cancer. The purpose of this study was to investigate the influence of hospital volume on clinical outcomes of ESD using a national administrative database.

METHODS

A total of 27,385 patients treated with ESD for gastric cancer were referred to 867 hospitals between 2009 and 2011 in Japan. We collected patients' data from the administrative database to compare ESD-related complications and length of stay (LOS) in relation to hospital volume. Hospital volume was categorized into three groups based on the number of cases treated over the study period: low-volume hospitals (LVHs, <50 cases), medium-volume hospitals (MVHs, 50-100 cases), and high-volume hospitals (HVHs, >100 cases). These analyses were performed for each location of gastric cancer [upper (cardia and fundus), middle (body), and lower third (antrum and pylorus)].

RESULTS

Significant differences in ESD-related complications among the three hospital volume categories were observed for upper gastric cancer (6.5 % in LVHs vs. 5.2 % in MVHs vs. 3.4 % in HVHs; p = 0.017). Multiple logistic regression revealed that HVHs were significantly associated with decreased relative risk of ESD-related complications in upper gastric cancer (odds ratio for HVHs 0.51; 95 % confidence interval, 0.31-0.83, p = 0.007). However, no significant differences for ESD-related complications were seen for middle and lower gastric cancers among the different hospital volume categories (p > 0.05). Additionally, hospital volume was significantly associated with a decreasing LOS for all locations of gastric cancers (p < 0.001).

CONCLUSIONS

The present study has demonstrated that hospital volume was mainly associated with clinical outcome in patients with ESD for upper gastric cancer. Further studies for successive monitoring of outcomes of ESD should be conducted in the near future.

A descriptive study evaluating the circumstances of medical treatment for acute pancreatitis before publication of the new JPN guidelines based on the Japanese administrative database associated with the Diagnosis Procedure Combination system

PURPOSE

To examine the circumstances of medical treatment for acute pancreatitis before publication of the new Japanese (JPN) guidelines using the Japanese administrative database associated with the Diagnosis Procedure Combination system.

METHODS

We collected data from 7,193 patients with acute pancreatitis in 2008 and examined the recommended medical treatment in the new JPN guidelines [from recommendations B (considered to be recommended treatments) to D (considered to be unacceptable treatments)] according to severity of acute pancreatitis. Patients were divided into two groups: mild cases (n = 6,520) and severe cases (n = 673).

RESULTS

Enteral nutrition for severe cases without ileus (recommendation B) was uncommon (13.5%). In contrast, prophylactic antibiotics were administered in a large number (80.4%) of mild cases without acute cholangitis (recommendation D). Furthermore, administration of H(2) receptor antagonists, except for cases of upper gastrointestinal bleeding (recommendation D), were performed in many patients with both mild and severe cases (66.8 vs. 78.6%).

CONCLUSIONS

This study demonstrated a discrepancy between actual medical treatment performed and the new JPN guidelines with regard to some of the medical treatments. Future studies are required after publication of the new JPN guidelines to determine how they affect medical treatments.

The recent time trend of outcomes of disseminated intravascular coagulation in Japan: an observational study based on a national administrative database

The aim of this study is to investigate the recent trend over time of outcomes of patients with disseminated intravascular coagulation (DIC) based on the Japanese administrative database. A total of 34,711 patients with DIC had been referred to 1,092 hospitals from 2010 to 2012 in Japan. We collected patients' data from the administrative database to compare in-hospital mortality within 14 and 28 days between periods. The study periods were categorized into three groups: 2010 (n = 8,382), 2011 (n = 13,372), and 2012 (n = 12,957). These analyses were performed according to the underlying diseases associated with DIC. The in-hospital mortality within 14 or 28 days of DIC patients with infectious diseases decreased between 2010 and 2012 (within 14 days: 20.4 vs. 18.1 vs. 17.9 %, P = 0.009; within 28 days: 31.1 vs. 28.7 vs. 27.7%, P = 0.003; respectively). Multiple logistic regressions also showed that the period was associated with in-hospital mortality of DIC patients with infectious diseases. The odds ratios of 2011 and 2012 for in-hospital mortality within 14 days were 0.86 [95% confidence intervals (CI) 0.77-0.97] and 0.84 (95% CI 0.75-0.94) whereas those for in-hospital mortality within 28 days were 0.89 (95% CI 0.81-0.98) and 0.83 (95% CI 0.76-0.92), respectively. However, there were no significant differences in mortality of patients with DIC associated with other underlying diseases between 2010 and 2012. This study demonstrated that in-hospital mortality of DIC patients with infectious diseases gradually improved between 2010 and 2012 in Japan.

Impact of hospital volume on clinical outcomes of endoscopic biliary drainage for acute cholangitis based on the Japanese administrative database associated with the diagnosis procedure combination system

BACKGROUND

We aimed to determine the relationship between hospital volume and the clinical outcomes of endoscopic biliary drainage for acute cholangitis, using the Japanese administrative database associated with the diagnosis procedure combination (DPC) system.

METHODS

A total of 8698 patients with endoscopic biliary drainage were referred to 654 hospitals. We corrected patients' data from the database to compare risk-adjusted length of stay (LOS) and drainage-related complications in relation to the hospital volume. Hospital volume was categorized into three groups based on number of cases during the study period: low-volume hospitals (LVHs; <16 cases), medium-volume hospitals (MVHs; 16-32 cases), and high-volume hospitals (HVHs; >32 cases).

RESULTS

Significant variation in mean LOS was observed between hospital volume categories (26.8 ± 22.6 days in LVHs vs. 23.3 ± 21.5 days in MVHs vs. 19.7 ± 17.2 days in HVHs, P < 0.001). There was a significant difference with regard to complications of endoscopic biliary drainage (5.6% in LVHs vs. 4.3% in MVHs vs. 3.2% in HVHs, P < 0.001). Multiple linear regression analysis revealed that hospital volume was most significantly associated with a decrease in risk-adjusted LOS. The standardized coefficient of MVHs was -0.155, whereas that of HVHs was -0.802. Multiple logistic regression analysis showed that hospital volume decreased the relative risk of drainage-related complications. The odds ratio (OR) of MVHs was 0.764 [95% confidence interval (CI), 0.604-0.965], whereas the OR of HVHs was 0.561 (95% CI, 0.434-0.725).

CONCLUSIONS

There was a significant association between hospital volume and the clinical outcomes of endoscopic biliary drainage for acute cholangitis.

Portal vein thrombosis associated with antiphospholipid syndrome

Portal vein thrombosis is a rare occurrence, and often an underlying hypercoagulable state can be found. Recently, there has been growing interest and recognition of the antiphospholipid syndrome in association with acquired hypercoagulable state. This syndrome consists of the association of lupus anticoagulant or antiphospholipid antibodies with arterial or venous thrombosis, thrombocytopenia, and spontaneous abortion. We report a case of portal vein thrombosis associated with the antiphospholipid syndrome. In our patient, chronic liver disease, hepatobiliary infection, abdominal malignancies, myeloproliferative disorders, and inherited coagulation disorders were excluded. This case report suggests that serum antiphospholipid antibodies should be investigated in patients with portal vein thrombosis of unexplained etiology.

Evaluation of compliance with the Tokyo Guidelines for the management of acute cholangitis based on the Japanese administrative database associated with the Diagnosis Procedure Combination system

BACKGROUND/PURPOSE

We aimed to evaluate compliance with the clinical practice guidelines for acute cholangitis (Tokyo Guidelines) using the Japanese administrative database associated with the Diagnosis Procedure Combination (DPC) system.

METHODS

We collected database data from 60,842 acute cholangitis patients, examining 10 recommendations in the Tokyo Guidelines. We counted how many recommendations had been complied with for every patient. The patient compliance score was defined as the rate of compliance with these recommendations (score 0 = 0% to score 10 = 100%). An aggregated patient compliance score was measured according to the severity of acute cholangitis. Severity was categorized as grade I (mild cholangitis; n = 49,630), grade II (moderate cholangitis; n = 10,444), and grade III (severe cholangitis; n = 768).

RESULTS

The mean patient compliance score was significantly higher for patients with grade III than for those with grades II and I (7.6 ± 2.1 vs. 6.5 ± 3.0 vs. 2.9 ± 0.9, p < 0.001, respectively). Multiple linear regression analysis revealed that the severity of acute cholangitis was the parameter most significantly associated with the patient compliance score. The standardized coefficient of grade III was higher than that of grade II (0.657 vs. 0.248, p < 0.001).

CONCLUSIONS

Compliance with the Tokyo Guidelines became higher in accordance with the severity of acute cholangitis.

Effects of additional laparoscopic cholecystectomy on outcomes of laparoscopic gastrectomy in patients with gastric cancer based on a national administrative database

BACKGROUND

Little information is available on the effects of adding laparoscopic cholecystectomy to laparoscopic gastrectomy on outcomes of patients with gastric cancer. The aim of this study is to investigate the effects of adding laparoscopic cholecystectomy to laparoscopic gastrectomy on outcomes in patients with gastric cancer using a national administrative database.

METHODS

A total of 14,006 patients treated with laparoscopic gastrectomy for gastric cancer were referred to 744 hospitals in Japan between 2009 and 2011. Patients were divided into two groups, those who also underwent simultaneous laparoscopic cholecystectomy for gallbladder stones (n = 1484) and those who underwent laparoscopic gastrectomy alone (n = 12,522). Laparoscopy-related complications, in-hospital mortality, length of stay, and medical costs during hospitalization were compared in the patient groups.

RESULTS

Multiple logistic regression analysis revealed that adding laparoscopic cholecystectomy did not affect laparoscopy-related complications (odds ratio, 1.02; 95% confidence interval [CI], 0.84-1.24; P = 0.788) or in-hospital mortality (odds ratio, 1.16; 95% CI, 0.49-2.76; P = 0.727). Multiple linear regression analysis also showed that adding laparoscopic cholecystectomy did not affect the length of stay (unstandardized coefficient, 0.37 d; 95% CI, -0.47 to 1.22 d; P = 0.389). However, adding laparoscopic cholecystectomy was associated with significantly increased medical costs during hospitalization (unstandardized coefficient, $1256.0 (95% CI, $806.2-$1705.9; P < 0.001).

CONCLUSIONS

This study demonstrated that adding laparoscopic cholecystectomy did not affect outcomes of patients undergoing laparoscopic gastrectomy for gastric cancer, although medical costs during hospitalization were significantly increased.

Time trend of medical economic outcomes of endoscopic submucosal dissection for gastric cancer in Japan: a national database analysis

BACKGROUND

Little information is available on the analysis of chronological changes in medical economic outcomes of endoscopic submucosal dissection (ESD) for gastric cancer. This study aimed to investigate the recent time trend of medical economic outcomes of ESD for gastric cancer based on the Japanese administrative database.

METHODS

A total of 32,943 patients treated with ESD for gastric cancer were referred to 907 hospitals from 2009 to 2011 in Japan. We collected patients' data from the administrative database to compare ESD-related complications, risk-adjusted length of stay (LOS), and medical costs during hospitalization. The study periods were categorized into three groups: 2009 (n = 9,727), 2010 (n = 11,052), and 2011 (n = 12,164).

RESULTS

No significant difference was observed in ESD-related complications between three study periods (p = 0.496). However, mean LOS and medical costs during hospitalization of patients with ESD were significantly lower in 2011 than in 2009 and 2010 (p < 0.001). Multiple linear regression analysis showed that patients who received ESD in 2011 had a significantly shorter LOS and lower medical costs during hospitalization compared with those in 2009. The unstandardized coefficient of patients with ESD in 2011 for LOS was -0.78 days [95 % confidence interval (CI), -0.89 to -0.65; p ≤ 0.001], while that of those for medical costs during hospitalization was -290.5 US dollars (95 % CI, -392.3 to -188.8; p ≤ 0.001).

CONCLUSIONS

This study showed that the complication rate of ESD was stable, whereas the LOS and medical costs of patients were significantly reduced from 2009 to 2011.

Prevalence of type 2 diabetes among acute inpatients and its impact on length of hospital stay in Japan

OBJECTIVE

The goal of this study was to determine the prevalence of type 2 diabetes among acute inpatients and evaluate its impact on the length of hospital stay in Japan.

RESEARCH DESIGN AND METHODS

The discharge records of 2,120,170 acute inpatients who were 30 years old or older and discharged between July and December of 2008 were obtained from the Japanese administrative case-mix system, Diagnosis Procedure Combination (DPC), and allocated for analysis. Type 2 diabetes was defined by E11 of the ICD-10 coding system on patient records. Other types of diabetes, including type 1 diabetes and diabetes in pregnancy (defined by ICD-10 codes E10 E12-14 and O24, respectively) were excluded from the analyses.

RESULTS

Type 2 diabetes was observed among 11.4% of the records, 9.9% of which were cases of diabetes as a comorbidity. Total length of hospital stay was 33,468,152 days, with diabetes patients occupying 13.9% of the total bed days. Patients with type 2 diabetes as a comorbidity had prolonged lengths of hospital stay compared to patients free from diabetes, and stratification by sex, age, surgical treatment, and disease category did not alter these results. The median length of hospital stay was 9 days among patients without diabetes and 13 days among patients with diabetes.

CONCLUSION

Japanese acute health care is experiencing an epidemic of type 2 diabetes, with 1 out of 10 acute inpatients suffering from the disease. Complication of type 2 diabetes is associated with prolonged length of hospital stay.

Influence of comorbidity on outcomes of older patients with acute pancreatitis based on a national administrative database

BACKGROUND

Little information is available on the influence of comorbidities on outcomes of older patients with acute pancreatitis. This study aimed to investigate the influence of comorbidities on outcomes of older patients with acute pancreatitis using data from a national Japanese administrative database.

METHODS

A total of 14 322 older patients (≥70 years) with acute pancreatitis were referred to 1090 hospitals between 2010 and 2012 in Japan. We collected patients' data from the administrative database to compare the in-hospital mortality and length of stay of older patients with acute pancreatitis. The patients were categorized into four groups according to comorbidity level using the Charlson Comorbidity Index (CCI): none (CCI score=0; n=6890); mild (1; n=3874); moderate (2; n=2192) and severe (≥3; n=1366).

RESULTS

Multiple logistic and linear regression analyses revealed that severe comorbidity was significantly associated with higher in-hospital mortality and longer length of stay [odds ratio (OR)=2.26; 95% confidence interval (CI): 1.75-2.92, P<0.001 and coefficient 4.37 days; 95% CI: 2.89-5.85, P<0.001, respectively]. In addition, cardiovascular and renal diseases were the most significant comorbidities affecting outcomes of the older patients. ORs of cardiovascular and renal diseases for mortality were 1.44 (95% CI: 1.13-1.85, P=0.003) and 2.69 (95% CI: 1.88-3.85, P<0.001), respectively, and coefficients for length of stay were 3.01 days (95% CI: 1.34-4.67, P<0.001) and 3.72 days (95% CI: 1.01-6.42, P=0.007), respectively.

CONCLUSION

This study demonstrated that comorbidities significantly influenced outcomes of older patients with acute pancreatitis and cardiovascular and renal comorbidities were significant factors affecting outcomes.

Effects of proton pump inhibitor on outcomes of patients with severe acute pancreatitis based on a national administrative database

OBJECTIVE

This study aimed to investigate whether proton pump inhibitors (PPIs) affect the outcomes of patients with severe acute pancreatitis based on a national administrative database.

METHODS

A total of 10,400 patients with severe acute pancreatitis were referred to 1021 hospitals between 2010 and 2012 in Japan. Patients were divided into two groups: patients who used PPIs (n = 3879) and those without PPIs (n = 6521). We collected patients' data from the administrative database to compare in-hospital mortality within 7, 14, and 28 days, and overall in-hospital mortality between groups, using propensity score analysis to adjust for treatment selection bias.

RESULTS

Multiple logistic regression showed that use of PPIs did not affect in-hospital mortality within 7 and 14 days. The odds ratio (OR) for mortality within 7 days was 1.14 (95% confidence interval [CI]: 0.91-1.42, p = 0.236) while that within 14 days was 1.10 (95% CI: 0.89-1.35, p = 0.349). No significant association was observed for in-hospital mortality within 28 days and overall in-hospital mortality (OR for within 28 days: 1.12, 95% CI: 0.92-1.37, p = 0.224; OR for overall in-hospital mortality: 1.42, 95% CI: 0.97-1.87, p = 0.065).

CONCLUSIONS

This study shows that use of PPIs does not affect clinical outcomes of patients with severe acute pancreatitis. Prospective or randomized studies are needed to confirm the efficacy of PPIs on outcomes of patients with severe acute pancreatitis in the future.

Recent Change in Treatment of Disseminated Intravascular Coagulation in Japan: An Epidemiological Study Based on a National Administrative Database

This study investigated the time trends and hospital factors affecting the use of drugs for infectious disease-associated disseminated intravascular coagulation (DIC) based on a national administrative database. A total of 14 324 patients with infectious disease-associated DIC were referred to 1041 hospitals from 2010 to 2012 in Japan. Patients' data were collected from the administrative database to determine time trends and hospital factors affecting the use of drugs for DIC. Three study periods were established, namely, the fiscal years 2010 (n = 3308), 2011 (n = 5403), and 2012 (n = 5613). The use of antithrombin, heparin, protease inhibitors, and recombinant human soluble thrombomodulin (rhs-TM) for DIC was evaluated. The frequency of use of antithrombin, heparin, and protease inhibitors decreased while that of rhs-TM significantly increased from 2010 to 2012 in Japan (25.1% in 2010, 43.1% in 2011, and 56.8% in 2012; P < .001, respectively). Logistic regression showed that the study period was associated with the use of rhs-TM in patients with DIC. The odds ratio (OR) for 2011 was 2.34 (95% confidence interval [CI], 2.12-2.58; P < .001) whereas that for 2012 was 4.34 (95% CI, 3.94-4.79; P < .001). A large hospital size was the most significant factor associated with the use of rhs-TM in patients with DIC (OR, 3.14; 95% CI, 2.68-3.66; P < .001). The use of rhs-TM has dramatically increased. A large hospital size was significantly associated with the increased use of rhs-TM in patients with DIC from 2010 to 2012 in Japan.

Impact of regional clinical pathways on the length of stay in hospital among stroke patients in Japan

BACKGROUND

Clinical pathways are care plans used by health providers to describe essential steps in the care of patients with specific medical conditions. Clinical implementation of the regional clinical pathways in Japan has spread, and the 2008 fee schedule included a new "regional inter-provider care planning fee" for stroke. However, no evidence regarding the efficacy of the regional clinical pathways for stroke has appeared.

OBJECTIVES

We examined the association of regional clinical pathways on the length of in-hospital stay in patients with stroke. We also examined whether a variation in the length of in-hospital stay for stroke patients between hospitals exists, and if so, the impact of regional clinical pathways on this variation.

RESEARCH DESIGN

Cross-sectional analysis using the Diagnosis Procedure Combination database for the period April 2011 to March of 2012.

SUBJECTS

A total of 117,180 patients with the diagnosis "cerebral infarction," coded as I63 in ICD10.

MEASURES

Associations of the use of a regional clinical pathway with the length of in-hospital stay (LOS) were estimated by multilevel regression models using a 2-level structure of individuals nested within the 1011 hospitals. The models added both patient-level factors and hospital-level factors that are potentially associated with LOS.

RESULTS

Hospitals administering a regional clinical pathway had a significantly shorter LOS (9.1 d) than hospitals that did not. Approximately 12% of the variation in LOS between hospitals is possibly explained by whether hospitals implement regional clinical pathways. Application of regional clinical pathways at the individual level is associated with a 7.2-day decrease in LOS at the individual level.

CONCLUSIONS

These findings suggest that the regional clinical pathways are potentially effective in improving the management of stroke patients and in promoting the consistency of care between hospitals.