Strasberg Classification Of Bile Duct Damage : Affect And Administration Challenges


Antonio Pesce, Stefano Palmucci, Gaetano La Greca, Stefano Puleo Division of Medical, Surgical Sciences and Superior Applied sciences “G.F. Ingrassia”, College of Catania, Catania, Italy Summary: Iatrogenic bile duct accidents (BDIs) after laparoscopic cholecystectomy, being one of the vital widespread carried out surgical procedures, stay a considerable downside in gastrointestinal surgical procedure with a major influence on affected person’s high quality of life. The first goal of this evaluation was to debate the classification of BDIs, the proposed strategies to stop biliary lesions, the related threat components, and the administration challenges relying on the timing of recognition of the damage, its extension, the affected person’s medical situation, and the supply of skilled hepatobiliary surgeons. Early recognition of BDI is of paramount significance and limiting the analysis delay is essential for an optimum postoperative consequence. The therapeutic administration is determined by the kind and gravity of the biliary lesion, and consists of endoscopic, radiologic, and surgical approaches. Key phrases: bile duct damage, laparoscopic cholecystectomy, biliary anatomy, early recognition, administration problem, endoscopic therapy, surgical restore


Laparoscopic cholecystectomy (LC) is among the most incessantly carried out procedures worldwide typically surgical procedure.1 Yearly, greater than 750,000 procedures are carried out within the US.2 Bile duct damage (BDI) represents essentially the most critical complication of LC, with an incidence of 0.3%–0.7%, leading to a major influence on high quality of life (QoL), general survival, and frequent medico-legal liabilities.1–4 The incidence of iatrogenic BDI has considerably gone up since LC grew to become the “gold commonplace” within the therapy of symptomatic cholelithiasis. It has been demonstrated that the first explanation for BDI is the misinterpretation of biliary anatomy in 71%–97% of all circumstances.1 Through the years, varied classifications of biliary accidents have been proposed and totally different strategies have been described to stop iatrogenic biliary tract lesions. Early recognition of BDI is of paramount significance. The optimum therapy is influenced by the timing of recognition of the damage, the extent of BDI, the affected person’s medical situation, and the supply of skilled hepatobiliary surgeons. This text goals to debate the classification and administration challenges of iatrogenic BDIs after cholecystectomy.

Đang xem: Strasberg classification of bile duct damage

Classification of BDIs

Earlier than the arrival of LC, essentially the most frequent lesion to biliary tract was represented by bile duct stricture, and biliary accidents had been categorized utilizing the “Bismuth classification”5 in line with the extent of biliary damage. This classification consists of 5 forms of bile duct lesions in line with the gap from the hepatic hilus, the extent of damage, the involvement of bile duct bifurcation, and particular person proper sectoral duct. Few years later, Strasberg et al6 proposed a brand new classification, just like the Bismuth, however incorporating extra biliary accidents seen extra generally within the laparoscopic period, particularly biliary leaks. Within the “Strasberg classification”, biliary accidents had been stratified type kind A to kind E, as summarized in Desk 1. McMahon et al7 proposed one other classification by distinguishing main and minor biliary accidents: lacerations underneath 25% of the widespread bile duct (CBD) diameter or cystic duct-common hepatic duct (CD-CHD) junction had been thought-about as minor damage, whereas transection or laceration over 25% of CBD diameter and postoperative bile duct stricture had been categorized as main damage. The “Stewart-Method classification”8 concerned 4 lessons primarily based on the mechanism and anatomy of biliary damage, as proven in Determine 1. This classification arose from the evaluation of operative stories, offering the human errors and cognitive processes concerned within the mechanisms of BDIs. Class I damage happens in two methods: 1) both the CBD is mistaken for the cystic duct, however the error is acknowledged earlier than CBD is split in 72% of circumstances, or 2) an incision made within the cystic duct for the cholangiogram catheter is unintentionally prolonged into the CBD (28% of circumstances). Class II accidents encompass lateral harm to the CHD with resultant stricture and/or leak. The sort of damage happens when clips or electro-cautery are used too near the CBD, primarily in circumstances the place visibility is restricted as a consequence of extreme irritation or extreme bleeding. Class III accidents are the commonest (about 60% of circumstances) and contain full transection of the principle bile duct, which all the time consists of the CD-CHD junction. Class IV accidents embody transection or leak of the precise hepatic duct (RHD) or posterolateral sectoral duct, usually mixed with damage to the precise hepatic artery.


Desk 1 Bismuth and Strasberg classification

Abbreviations: –, not relevant; RHD, proper hepatic duct; CBD, widespread bile duct; CHD, widespread hepatic duct.


Determine 1 Stewart-Method classification of bile duct accidents.

The “Amsterdam classification” proposed by Bergman et al in 19969 can be very generally utilized in many articles, particularly amongst endoscopists. This classification consists of 4 forms of ductal damage: kind A with leakage from cystic ducts or peripheral hepatic radicles, kind B presenting as main bile duct leakage, kind C displaying an remoted ductal stricture, and sort D with full transection of the bile duct.

For a simple studying, we have now chosen the Stewart-Method classification system on this manuscript, because it higher describes the mechanisms of biliary lesion throughout LC, together with additionally concomitant vascular accidents.

Prevention of iatrogenic BDI

Through the years, varied strategies have been proposed and described within the scientific literature to stop iatrogenic biliary tract lesions. They’re summarized in Desk 2. The “crucial view of security (CVS)” method was launched by Strasberg in 199510 and it’s thought-about the gold commonplace to carry out a protected cholecystectomy with identification of biliary buildings throughout dissection. Three standards are required to attain the CVS: 1) the hepatocystic triangle should be cleared of adipose and fibrotic tissues; the CBD and CHD should not be uncovered; 2) the decrease third of the gallbladder should be separated from the liver mattress to show the cystic plate; and three) two and solely two buildings ought to be seen getting into the gallbladder. CVS was conceived not as a technique to do LC however as a technique to keep away from biliary damage.


Desk 2 Abstract of proposed strategies to stop bile duct accidents

Observe: B-SAFE: B, bile duct; S, sulcus of Rouvière; A, hepatic artery; F, umbilical fissure; E, enteric/duodenum.

In such circumstances, some surgeons favor performing the infundibular methodology so as to work very near gallbladder infundibulum, lowering the danger of biliary accidents, however care ought to be taken with “hidden cystic duct” syndrome which presents a misleading look of a false infundibulum that misleads the surgeon into figuring out the CBD because the cystic duct.11 The “antegrade dissection or fundus first/dome-down method” represents a manner of dissection from the gallbladder fundus as much as the infundibulum away from Calot’s triangle.12 On this manner, the gallbladder is left pedunculated by the cystic artery and cystic duct, which will be clipped and divided in flip, lowering the danger of biliary lesions. One other simple, protected, and definitive operation for the “tough gallbladder” is described and has been termed “subtotal or partial cholecystectomy”,13 consisting in leaving the posterior wall of the gallbladder connected to the liver and securing the cystic duct at its origin from throughout the gallbladder.

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Totally different anatomic landmarks have been described: amongst them, in 1924, Henri Rouvière, a French surgeon, described a 2–5 cm sulcus working to the precise of liver hilum, anterior to the caudate lobe, and often containing the precise portal triad or its branches.14 It may be thought-about a helpful landmark web site to start out dissection of the hepatocystic triangle throughout LC.15 The “Rouvière’s sulcus” is current within the majority of sufferers, starting from 68% to 90%,16 and is clearly seen throughout laparoscopy, being seen in a single type or the opposite (a sulcus, a slit, or a scar). One other anatomic landmark to information gallbladder dissection is represented by the “cystic lymph node” or Mascagni’s node, which all the time lies lateral to the biliary tree and will type the medial finish level of dissection.17

Some authors proposed a mnemonic “B-SAFE methodology”, through the use of 5 anatomic landmarks (B, bile duct; S, sulcus of Rouvière; A, hepatic artery; F, umbilical fissure; E, enteric/duodenum) to appropriately place their cognitive map throughout dissection.18

The routine use of “intra-operative cholangiography (IOC)” has been proposed for the higher declaration of biliary anatomy, detection of silent CBD stones, and discount of incidence of BDIs, however it’s burdened by morbidity and mortality and therefore ought to be carried out in services the place the required tools and expertise can be found.1,19,20 The opinions concerning the “routine” or “selective” use of IOC nonetheless signify a matter of debate.1,19

“Laparoscopic ultrasound (LUS)” was proven to offer extremely delicate mapping of the extra-hepatic biliary anatomy however the tough studying curve and the dearth of randomized managed trials have lowered its use in medical observe.21,22

One of many newest improvements in minimally invasive expertise is fluorescence image-guided surgical procedure; “near-infrared fluorescent cholangiography (NIRF-C)” represents a novel intra-operative imaging method that permits a real-time enhanced visualization of the extrahepatic biliary tree by fluorescence.23–25 NIRF-C properly represents a helpful methodology to establish the CVS with assistance from real-time fluorescent imaginative and prescient with an ideal mixture between surgical anatomy and technical innovation, as proven in Determine 2.26


Determine 2 Intra-operative real-time identification of biliary buildings with seen gentle (VL) on left and by fluorescence (NIRF-C) on proper.

Observe: Cystic duct (CD) working parallel to the widespread hepatic duct (CHD).

Abbreviation: NIRF-C, near-infrared fluorescent cholangiography.

In some tough conditions, the opinion of a surgical colleague in neighborhood throughout operation might also signify a sound different, the so-called “colleaguography”, instead of IOC or different strategies, as proposed by some authors.27

Regardless of the plethora of publications and debates, there may be nonetheless no consensus as to which methodology is one of the best to stop BDIs throughout LC. Not too long ago, highest consensus was achieved on the significance of the CVS and NIRF-C, in addition to antegrade dissection or fundus first/dome-down method and partial cholecystectomy as different strategies.28,29

A basic advice is that in all circumstances of difficult cholecystectomies, the surgeon should not hesitate when contemplating conversion to open strategy as a result of there isn’t any substitute for expertise and warning in biliary surgical procedure.

Threat components

There are a number of threat components which may contribute to the iatrogenic damage of the biliary tract: anatomical components; patient-related components; and components associated to the gallbladder illness, the surgical method, and the surgeon. Among the many anatomical components, the quite a few anatomical variants of the biliary tract signify a potential explanation for iatrogenic lesion, for instance, the totally different variants of the cystic duct, resembling brief cystic duct, cystic duct working parallel to the CBD, anomalies of the CD-CHD junction, presence of the hepatocystic duct, accent cystic duct, the existence of aberrant bile ducts (eg, Luschka duct).30 Among the many patient-related components, extreme weight problems, earlier surgical procedure on the biliary tract, and underlying liver illness appear to be predisposing components for peri-operative issues.

Nevertheless, acute cholecystitis causes a collection of modifications of the native anatomy (adhesions, thickening of the tissues, irritation, bleeding) which can be related to an elevated threat of iatrogenic lesion.31,32 Among the many components associated to the method, the laparoscopic strategy itself represents a threat issue, therefore the significance of an accurate “studying curve” for younger surgeons.33,34 The human components additionally play an important function within the pathophysiology of the iatrogenic bile lesion: the extreme security of the surgeon, the push to complete the intervention, the fatigue and private considerations of the surgeon, the efficiency nervousness, the superficiality of the surgical act, and the dearth of humility in changing to open surgical procedure in uncertain circumstances might decide a related harm to the biliary tree.8–35

LC will be seen as a trivial intervention but it surely may conceal many difficulties with dramatic penalties. For these causes, warning and expertise are important in biliary surgical procedure.

Scientific presentation

Scientific presentation relies upon basically on the extent and sort of iatrogenic lesion, if this isn’t found intra-operatively. The presence of a potential biliary leak can begin with non-specific signs, resembling nausea, vomiting, bloating, widespread stomach ache, basic discomfort, and anorexia. Not often, the affected person presents the medical image of biliary peritonitis, regardless of massive quantities of bile within the stomach. The evolution of biliary leak could be very delicate, due to the presence of those obscure signs. Sufferers with stricture at stage of the CBD, in circumstances the place the CBD is mistaken for the cystic duct, will current the basic Charcot’s triad with ache in the precise hypochondrium, fever, and jaundice. A basic advice is that any alteration within the regular postoperative course after LC should counsel a potential harm to the biliary tract. For these causes, a cautious medical analysis of sufferers is important. A delay within the analysis is essential for the postoperative consequence.

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Timing of recognition

Early recognition of BDI is of paramount significance. Intra-operative recognition ought to sometimes immediate speedy surgical restore as this confers one of the best outcomes; nevertheless, 36,37 If the surgeon is inexperienced, an intra-abdominal drain ought to be positioned, and the affected person ought to be instantly transferred to a high-volume hepatobiliary middle. There are a number of knowledge suggesting that these accidents are greatest managed by a surgeon with experience in biliary reconstruction with higher outcomes.37–39 There are a number of components that result in a recognition of intra-operative lesion, however a very powerful is the surgeon’s consciousness to suspect and/or consider for a BDI. Analysis usually happens within the speedy postoperative interval (inside 6 weeks post-intervention) or, in some circumstances, later (over 6 weeks). A cautious medical analysis helps for an accurate analysis. The looks of persistent or irregular stomach ache in the precise hypochondrium, the leakage of bile from drainage (if positioned throughout surgical procedure), an image of biliary peritonitis, and the looks of fever and jaundice with elevated liver operate exams are all components supporting a analysis of any iatrogenic lesion of the biliary tree. Radiologic investigations ought to be obtained for the right identification of the harm, its extension, and gravity and to plan therapeutic methods. Stomach ultrasound represents the primary diagnostic software aimed toward discovering any liver collections, dilatation of the CBD, and any related vascular lesions.40 The stomach computed tomography (CT) scan is the principal investigation that permits to outline the potential presence of focal intra- or peri-hepatic fluid collections, ascites, biliary obstruction with upstream dilatation, or long-term sequelae of a long-standing bile stricture, resembling lobar hepatic atrophy or indicators of secondary biliary cirrhosis. The CT scan additionally permits to establish any related vascular lesions, resembling to the precise hepatic artery.

Magnetic resonance cholangio-pancreatography (MRCP) represents the “gold commonplace” for the whole morphological analysis of the biliary tree because it presents detailed details about the integrity of the biliary tract.41,42 MRCP may also be executed with a distinction agent (a gadolinium-based distinction agent, the gadoxetic acid and its salt, gadoxetate disodium), and it’s rather more informative in bile leaks than plain MRCP.42 Using a distinction agent throughout MRCP permits detection of energetic bile leakage by direct visualization of distinction materials extravasation into fluid collections along with demonstrating the anatomical web site of the leakage and the kind of BDI. For instance, in Determine 3 cystic duct leak was demonstrated at MRCP after gadoxetic acid injection. In the identical manner, hepatobiliary scintigraphy might affirm the presence of an energetic biliary leak with the progressive accumulation of the radiotracer contained in the peritoneal cavity, however this examination is way much less dependable. Nevertheless, if fluid assortment is present in ultrasound, CT, or MRCP, an stomach drain ought to be positioned straight away underneath radiological steering so as to enhance affected person’s medical situation (peritonitis, sepsis, tissue repairing). If there’s a delay of greater than every week in operative therapy of Stewart-Method Class III or IV accidents, there ought to be a timeout for two–3 months earlier than operation. On this time-frame, the affected person must be stabilized and optimized for surgical procedure. An optimum management of any intra-abdominal fluid assortment, irritation, and an infection is important, and is greatest achieved with percutaneous drainage.37