What is the management approach for bile duct injuries classified using the Strassburg classification?

Strasberg Classification and Management of Bile Duct Injuries

Overview of the Strasberg Classification

The Strasberg classification remains the most commonly used system for categorizing bile duct injuries during cholecystectomy, though the ATOM classification represents the most comprehensive modern approach and should be increasingly adopted in clinical practice. 1

The Strasberg system categorizes injuries into five main types based on anatomical location and severity:

Type A Injuries

• Bile leak from minor ducts still in continuity with the common bile duct, such as cystic duct stump or small ducts in the liver bed 2
• Management: Endoscopic therapy with ERCP and stent placement achieves 96% success rates 3, 4
• These represent minor injuries without tissue loss 1

Type B Injuries

• Complete occlusion of part of the biliary tree, typically an aberrant right hepatic duct that has been divided and excluded from the main biliary drainage system 2
• Critical diagnostic pitfall: ERCP appears normal because the injured duct is not in communication with the main system 2
• Requires MRCP, PTC, or CT scan to identify the isolated occluded segment 2
• Management approach depends on segment size:
  • Small segments: Conservative management as the affected liver may atrophy over time 2
  • Larger segments: Surgical reconstruction with hepaticojejunostomy to prevent progressive liver damage 2

Type C Injuries

• Bile leak from a duct not in communication with the main duct system 2
• Management similar to Type B, requiring surgical intervention rather than endoscopic techniques 2

Type D Injuries

• Lateral injuries to extrahepatic bile ducts without complete transection 2
• Can be managed with T-tube placement in selected cases 4, 5
• Primary repair over T-tube is an option for partial injuries without tissue loss 6

Type E Injuries (Major Injuries)

• Circumferential injuries to major bile ducts with tissue loss, subdivided by Bismuth levels (E1-E5) based on injury height 2
• These are major injuries requiring Roux-en-Y hepaticojejunostomy as definitive treatment 1, 6
• Surgical management achieves 88-95% success rates when performed by experienced surgeons 3, 4

Management Algorithm Based on Injury Type

Immediate Intraoperative Recognition

• Only experienced hepatopancreatobiliary (HPB) surgeons should attempt immediate repair 6, 7
• For complex vasculobiliary injuries, delayed repair is preferred even by expert surgeons 6, 7
• Remove all clips and scar tissue from bile duct stumps before reconstruction 6

Early Postoperative Detection (Within 72 Hours)

• Start broad-spectrum antibiotics immediately (piperacillin/tazobactam, imipenem/cilastatin, or meropenem) for biliary fistula, biloma, or bile peritonitis 7
• Complete biliary tree imaging is essential using PTC, MRCP, or other appropriate modalities before definitive repair 7
• Early repair possible if no inflammation present and appropriate surgical expertise available 6

Delayed Detection (With Inflammation/Infection)

• Definitive repair should be performed 4-6 weeks after effective control of inflammation and infection, not the previously recommended 3 months 6, 7
• Control bile leakage and infection first with drainage procedures 7

Technical Principles for Surgical Reconstruction

Hepaticojejunostomy Technique

• Fundamental principle: Anastomosis must use healthy, non-ischemic, non-inflamed, and non-scarred bile duct tissue 7
• Remove all scar tissue from proximal bile duct stump after full exposure 6
• Use fine suture technique (5-0 or 6-0) with single-layer stitching, uniform margins, and tension-free anastomosis 6
• Stenting for more than 6 months improves outcomes significantly 3

Management of Vascular Injuries

• Systematic immediate repair of isolated right hepatic artery injuries is not recommended; evaluate benefit/risk ratio case-by-case 6, 7
• Portal vein injuries should be primarily repaired 5
• Vascular injury presence (VBI+) should be documented and influences timing of repair 6

Critical Pitfalls to Avoid

• Never attempt end-to-end anastomosis for major injuries with tissue loss or when clips have been placed - this leads to high stricture rates 6
• Failure to use healthy tissue for reconstruction is the most common cause of repair failure 7
• Thermal injury boundaries are unclear early on, leading to anastomotic leakage if not properly addressed 7
• Missing Type B injuries on ERCP because the occluded segment doesn't communicate with the main system 2
• Using scarred bile duct wall or surrounding tissue inevitably leads to surgical failure 7

Outcomes and Follow-up

• Surgical management achieves best outcomes (88-95% success) compared to endoscopic (76%) or interventional radiology (50%) for major injuries 3
• Outcomes have improved significantly in recent years (95% vs 80% in earlier era) 3
• Two common complications requiring intervention: bile leak after hepaticojejunostomy (managed with percutaneous drainage) and anastomotic stricture (requiring balloon dilation and stenting) 4
• Median follow-up should extend at least 36 months to identify late complications 4