**7. Treatment of iatrogenic bile duct injuries**

#### **7.1 Non-invasive treatment of iatrogenic bile duct injuries**

Non-invasive, percutaneous radiological end endoscopic techniques are recommended as initial treatment of IBDI. When these techniques are not effective, surgical management is considered.

Recontructive Biliary Surgery in the Treatment of Iatrogenic Bile Duct Injuries 483

Peripheal bile leakage (in communication with main biliary system).

CHD or CBD stricture without damage (eg caused by a clip).

Large injury (> 5 mm) below the hepatic ducts confluence. Large injury at the level of the hepatic ducts confluence. Large injury above the hepatic ducts confluence.

Without ductal loss below the hepatic ducts confluence. With ductal loss below the hepatic ducts confluence.

Above the hepatic ducts confluence. (with or without ductal loss).

The complete closure of all the bile ducts, including sectoral bile ducts.

The effectiveness of percutaneous diltatation of biliary strictures with transhepatic insertion of the stent under radiological control is 40-85%. The main treatment-related complications associated with the liver puncture include haemorrhage, bile leakage and cholangitis. The other less common complications include pneumothorax which is the result of damage to the pleura, biliary-pleural fistula and perforation of adjacent organs, including the colon. Percutaneous technique is less effective (52%) than surgical therapy (89%). Also frequently than post-surgical complications observed (35% and 25% of complications). It is also associated with the higher number of complications (35%) than surgery (25%). The most frequently, it is recommended in very difficult cases of very high, hilar biliary strictures or

Endoscopic dilatation associated with insertion of biliary prosthesis during ERCP investigation is the most frequently used non-surgical method in the treatment of IBDI. The effectiveness of endoscopic (72%) and surgical (83%) treatment is comparable. Incidence of complications in both methods of treatment is also comparable (35% vs. 26%). The common complications of endoscopic techniques regarding placement of biliary prosthesis include cholangitis, pancreatitis, prosthesis occlusion, migration, dislodgement and perforation of the bile duct.

**Type Injury type** 

Bile leakage from the cystic duct. Bile leakage from the gallbalder fossa.

Lateral CHD or CBD injury. Small spot injury (< 5 mm).

CHD or CBD stricture.

Table 7. Hannover classification of IBDI.

Total transsection of CHD Or CBD.

Longitudinal CBD stricture (>5 mm).

At the level of the hepatic ducts confluence.

Short, circular (< 5 mm) CHD or CBD stricture.

**7.1.1 Percutaneous dilatation under radiological control** 

in the treatment of very small bile ducts in the diameter.

**7.1.2 Endoscopic dilatation during ERCP** 

Stricture at the level of the hepatic ducts confluence Stricture of the right hepatic duct / sectorral hepatic duct.

**A A1 A2** 

**B B1 B2** 

**C C1 C2 C3 C4** 

**D D1 D2 D3 D4** 

**E E1 E2 E3 E4 E5**  Incomplete. Complete.


Table 3. Strasberg classification of IBDI.


Table 4. Mattox classification of IBDI.


Table 5. Steward i Way classification of IBDI.


Table 6. Schmidt classification of IBDI.

A Injury of small bile ducts in communication with the main biliary system, with

B Injury of the sectoral bile duct, with subsequent obstruction of the main biliary

C Injury of the sectoral bile duct with bile leakage of bile from bile duct, without

E1 CBD or CHD stricture at a distance> 2 cm from the hepatic duct confluence.

**V** CBD or CHD transsection> 50% and injury of intrapancreatic or intraduodenal part of

III Total transsection or excision of the or CBD, CHD or the right or left hepatic ducts. IV Resection of the right hepatic cord erroneously recognized as the cystic duct.

A Leak from the cystic duct (A1) or an accessory hepatic duct within gallbladder fossa

C Side injury of CBD or CHD over a distance of up to 5 mm (C1) or more than 5 mm

E Stricture of CBD or CHD over a distance of up to 5 mm (E1),> 5 mm (E2) or the

E2 CHD stricture at a distance< 2 cm from the hepatic duct confluence.

E4 Stricture involving the right and left hepatic ducts separately. E5 Complete closure of all the bile ducts, including sectoral bile ducts.

**Type Injury type** 

system.

bile ducts.

(A2).

(C2).

leakage of bile from the Luschka's or cystic ducts.

communication with the main biliary system.

E3 CHD stricture within the hepatic duct confluence.

**Type Injury type I** Contusion of the gallbladder or hepatic triad. **II** Jagged or perforation of the gallbladder.

**Type Injury type**  I Small incisions or incomplete intersections of CBD.

**Type Injury type** 

B Clip closure of CBD or CHD incomplete (B1) or complete (B2).

D Transsection of CBD or CHD without loss (D1) or loss (D2) of bile duct.

hepatic ducts confluence (E3) or only the right hepatic duct (E4).

II Stricture caused by thermal injury or clips.

Table 5. Steward i Way classification of IBDI.

Table 6. Schmidt classification of IBDI.

**III** The total separation of the gallbladder from the liver. **IV** CBD or CHD partial <50% CBD or CHD laceration or CSF.

D Side extrahepatic bile duct injury.

Table 3. Strasberg classification of IBDI.

Table 4. Mattox classification of IBDI.


Table 7. Hannover classification of IBDI.
