What is the Strassberg classification used for in bile duct injuries?

Strasberg Classification for Bile Duct Injuries

The Strasberg classification is the most commonly used system for categorizing bile duct injuries during cholecystectomy, dividing injuries into five main types (A through E) based on anatomical location and injury pattern to guide treatment decisions. 1

Classification System Structure

The Strasberg classification organizes bile duct injuries into distinct categories that directly inform management:

Type A Injuries

• Bile leak from minor ducts (cystic duct stump or small liver bed ducts) that remain in continuity with the common bile duct 1
• No involvement of the main biliary tree and no tissue loss 1
• Represent the most common injury type, accounting for approximately 46% of cases 2

Type B Injuries

• Complete occlusion of part of the biliary tree, typically an aberrant right hepatic duct that has been divided and excluded from main biliary drainage 1
• Critical pitfall: These injuries appear normal on ERCP because the occluded segment doesn't communicate with the main biliary system 1

Type C Injuries

• Bile leak from ducts not in continuity with the common bile duct 3

Type D Injuries

• Lateral injury to major bile ducts without complete transection 3

Type E Injuries (Major Injuries)

• Circumferential injuries to major bile ducts with tissue loss, subdivided by Bismuth levels (E1-E5) based on the height of injury 1
• E1: Common hepatic duct injury >2 cm from bifurcation
• E2: Common hepatic duct injury <2 cm from bifurcation
• E3: Injury at the hilum with intact confluence
• E4: Injury involving the confluence with separation of right and left ducts
• E5: Injury involving aberrant right sectoral duct plus common hepatic duct 4

Clinical Management Based on Classification

Type A Injuries (Minor)

• Endoscopic therapy with ERCP and biliary stenting achieves 96% success rate 1
• First-line treatment for these minor leaks without main duct involvement 2

Type B Injuries

• Small segments may be managed conservatively 1
• Larger segments require surgical reconstruction with hepaticojejunostomy to prevent progressive liver damage 1

Type E Injuries (Major)

• Require Roux-en-Y hepaticojejunostomy as definitive treatment, achieving 88-95% success rates when performed by experienced surgeons 1
• Surgical management is superior to endoscopic or interventional approaches for these complex injuries (88% success vs 76% for endoscopy vs 50% for interventional radiology) 5
• Repair should be delayed 4-6 weeks after controlling infection and inflammation 6

Critical Technical Principles

Never attempt end-to-end anastomosis for major injuries with tissue loss, as this leads to high stricture rates 7

Key surgical principles for hepaticojejunostomy include:

• Remove all scar tissue from the proximal bile duct stump 7
• Use only healthy, non-ischemic, non-inflamed bile duct tissue for anastomosis 7
• Fine suture technique (5-0 or 6-0) with tension-free anastomosis 6

Diagnostic Approach

• ERCP is most useful for bile leak scenarios (Type A injuries) 2
• CT, MRCP, and PTC are more useful for biliary obstruction scenarios (Type B-E injuries) 2
• Most injuries (89%) are diagnosed postoperatively rather than intraoperatively 2

Evolution and Alternative Systems

While the Strasberg classification remains most commonly used, the ATOM classification represents the most comprehensive modern approach and should be increasingly adopted, as it integrates anatomical damage, timing of detection, mechanism of injury, and vascular involvement 6, 7