What is the Strassberg classification of bile duct injury?

Strasberg Classification of Bile Duct Injury

The Strasberg classification, proposed in 1995, is the most commonly used system for categorizing bile duct injuries during cholecystectomy, dividing injuries into five types (A through E) based on anatomical location and injury pattern. 1, 2

Classification Types

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 (ducts of Luschka) 2, 3
• These injuries do not involve the main biliary tree and represent minor injuries without tissue loss 1
• Managed almost exclusively by endoscopists with 96% success rate using ERCP and stent placement 4, 3

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, 3
• Will appear normal on ERCP because the occluded segment doesn't communicate with the main biliary system 2
• Patients may present with persistent bile leak or segmental liver atrophy despite normal-appearing ERCP 2
• Require additional imaging (MRCP, PTC, or CT) to identify the isolated occluded segment 2

Type C Injuries

• Bile leak from a duct that is not in communication with the main duct system 2
• Represents a lateral injury to an aberrant duct with leakage but without complete transection of the main system 2

Type D Injuries

• Lateral injuries to the extrahepatic bile ducts without complete transection 2
• Partial injury to the main biliary system with preserved continuity 2

Type E Injuries (Major Injuries)

• Circumferential injuries to major bile ducts with tissue loss, subdivided according to the Bismuth classification (E1-E5) based on the level of injury 2, 3
• Associated with tissue loss (e.g., common bile duct clipped and transected) and require complex reconstruction 1
• Require Roux-en-Y hepaticojejunostomy as definitive treatment, with surgical management achieving 88-95% success rates when performed by experienced surgeons 3, 4
• E1: >2 cm from hepatic duct bifurcation
• E2: <2 cm from bifurcation
• E3: At the bifurcation
• E4: Involvement of right hepatic duct confluence
• E5: Involvement of aberrant right sectoral duct with concomitant injury to common hepatic duct 5

Clinical Categorization

Minor versus major injuries represent the most clinically relevant distinction:

• Minor BDIs (Type A): Caused by electrocautery burns or partial cuts without tissue loss, typically repaired primarily with sutures and abdominal drain placement 1, 6
• Major BDIs (Type E): Associated with tissue loss requiring complex reconstruction with Roux-en-Y hepaticojejunostomy 1, 6

Management Implications by Type

Type A Management

• Endoscopic therapy with ERCP and biliary stenting 3
• Success rate of 96% with endoscopic management 4

Type B Management

• Small segments: Conservative management as the affected liver segment may atrophy over time 2
• Larger segments: Surgical reconstruction with hepaticojejunostomy to prevent progressive liver damage 2, 3

Type E Management

• Roux-en-Y hepaticojejunostomy is the treatment of choice 6, 3
• Outcomes are best with surgical management (88-95% success) when performed by experienced surgeons 4, 3
• Patients stented for more than 6 months have superior outcomes 4

Critical Pitfalls

• Type B injuries are easily missed on ERCP because the occluded segment doesn't fill with contrast—always obtain cross-sectional imaging (MRCP or CT) if clinical suspicion persists despite normal ERCP 2
• Never attempt end-to-end anastomosis for Type E injuries with tissue loss or when clips have been placed, as this leads to high stricture rates 3
• The Strasberg classification does not account for vascular injuries, which occur in approximately 19% of cases and significantly impact surgical complexity and outcomes 5

Evolution and Alternatives

While the Strasberg classification remains most commonly used, the ATOM classification (2013) represents the most comprehensive modern approach, integrating anatomical damage, vascular injury, timing of detection, and mechanism of injury 1, 6. The World Society of Emergency Surgery guidelines recommend knowing both systems, with ATOM classification promoted for future standardization 6.