Bile duct injuries: classification & repair

One discussion last week included classification of bile duct injuries.

Seeras K, Kalani AD. Bile Duct Repair. 2018 Nov 24. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-.

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Clinical Significance: “Many major bile duct injuries will require surgical repair. There are many described techniques for complex biliary injury repairs including primary repair or primary end to end anastomosis of bile ducts, choledochoduodenostomy, and cholecystojejunostomy. The most popular surgical repair is the Roux-en-Y hepaticojejunostomy. This operation has been consistently superior to the other methods when considering long-term outcomes. There are many different techniques described to perform an RYHJ, and the operating surgeon should choose the method with which he or she is most comfortable or experienced.”


Chun K. Recent classifications of the common bile duct injury. Korean J Hepatobiliary Pancreat Surg. 2014 Aug;18(3):69-72.

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Bismuth classification: The first classification of bile duct injury is authored by H. Bismuth in 1982. Up to now, a number of classifications have been proposed by different authors. The Bismuth classification is a simple classification based on the location of the injury in the biliary tract. This classification is very helpful in prognosis after repair. This classification included five types of bile duct injuries according to the distance from the hilar structure especially bile duct bifurcation, the level of injury, the involvement of bile duct bifurcation, and individual right sectoral duct.14 Type I involves the common bile duct and low common hepatic duct (CHD) >2 cm from the hepatic duct confluence. Type II involves the proximal CHD <2 cm from the confluence. Type IIIis hilar injury with no residual CHD confluence intact. Type IV is destruction of the confluence when the right and left hepatic ducts become separate. Type Vinvolves the aberrant right sectoral hepatic duct alone or with concomitant injury of CHD. However, the Bismuth classification does not include the wide spectrum of possible biliary injuries.

Strasberg classification: The Strasberg classification is a modification of the Bismuth classification, but allows differentiation between small (bile leakage from the cystic duct or aberrant right sectoral branch) and serious injuries performed during laparoscopic cholecystectomy as type A to D. Type E of the Strasberg classification is an analogue of the Bismuth classification.3 The Strasberg classification, summarized in Fig. 1, is very simple which can be easily applied to bile duct injuries. The major disadvantage of the Strasberg classification is that it does not describe additional vascular involvement at all. For this reason, the Strasberg classification could not demonstrate a significant association between the discrimination of specific injury patterns and the resection of liver tissues.


Strasberg SM, Helton WS. An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy. HPB (Oxford). 2011 Jan;13(1):1-14.

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Vasculobiliary injuries: spectrum of clinical effects and time of onset

1 Artery
1.1 Pseudoaneurysm with intraperitoneal or intrabiliary haemorrhage (haematobilia) (presentation: hours to weeks)

2 Bile duct
2.1 Necrosis of bile duct with generalized peritonitis. When an anastomosis has been performed, this will be manifested as an early breakdown of the anastomosis with fistula, intraperitoneal abscess or generalized peritonitis (presentation: days)
2.2 Stenosis of the bile duct or of an anastomosis to the bile duct leading to hepatic atrophy or cholangitis with or without hepatic abscess (presentation: weeks to years)
2.3 Untreated or unsuccessfully treated stenosis leading to recurrent cholangitis, intrahepatic stones and secondary biliary stenosis (presentation: months to years)

3 Liver
3.1 Rapid hepatic necrosis with haemodynamic instability (presentation: hours)
3.2 Slow hepatic necrosis with abscess formation (presentation: days to weeks)
3.3 Hepatic atrophy (presentation: months to years; usually asymptomatic)


Myburgh JA. The Hepp-Couinaud approach to strictures of the bile ducts. I. Injuries, choledochal cysts, and pancreatitis. Ann Surg. 1993 Nov;218(5):615-20.

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“The results of this personal series over a 14-year period indicate that the Hepp-Couinaud approach provides a safe, durable, and effective solution to the problem of benign bile duct strictures. The major impact is on the high strictures where a 2.5- to 3.5-cm, accurate, mucosa-tomucosa, side-to-side anastomosis can be effected between a jejunal Roux loop and healthy ductal tissue by preplacement of sutures and a railroading technique. In the patient with a Bismuth type IV stricture, after mobilization and approximation of the posterior half of the circumferences of the right and left ducts, a similar anastomosis could be done with longitudinal incisions in the partially joined ducts. The same principle of a wide side-to-side anastomosis was applied in most of the lower strictures.”


More PubMed results on management of biliary injuries.

 

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