Bile Duct Injury Classification & Management - Strasberg

Algorithm Steps

1. ▶

   Start

   Suspected Bile Duct Injury

   Post-cholecystectomy bilious drainage, jaundice, sepsis

   1. ●

      Action

      Diagnostic Workup

      Labs, imaging, cholangiography

      • LFTs, WBC, bili trend
      • CT abdomen for collections
      • MRCP or ERCP for anatomy
      1. ◆

         Decision

         Strasberg Classification

         • A: Cystic duct leak or minor duct injury
         • B: Occlusion of aberrant right hepatic duct
         • C: Transection of aberrant duct without occlusion
         • D: Lateral CBD injury (<50%)
         • E1-E5: CBD transection at various levels
         1. ●

            Action

            Type A: Cystic Duct Leak

            Minor injury, usually ERCP manageable

            1. ●

               Action

               ERCP + Stent/Sphincterotomy

               First-line for Type A

               • Biliary sphincterotomy
               • Temporary biliary stent
               • Percutaneous drain if collection
               1. ■

                  End

                  Long-term Surveillance

                  LFTs, imaging for stricture, quality of life assessment

         2. ●

            Action

            Type B-D: Partial/Aberrant Duct

            Variable management

            1. ●

               Action

               Conservative/Endoscopic

               Depends on specific injury

               • Type B: may atrophy, observe
               • Type C: ERCP if accessible
               • Type D: ERCP stent if <50%
               1. ●

                  Action

                  HPB Center Referral

                  Essential for major injuries

                  • Control sepsis first
                  • Establish biliary drainage (PTC/ERCP)
                  • Delay definitive repair 6-12 weeks if inflamed
                  1. ●

                     Action

                     Surgical Repair

                     Hepaticojejunostomy (Roux-en-Y)

                     • After inflammation resolves
                     • High (proximal) repair if possible
                     • Meticulous technique, experienced surgeon
         3. ●

            Action

            Type E: Major CBD Injury

            Requires surgical repair

            1. ◆

               Decision

               Associated Vascular Injury?

               • Right hepatic artery injury
               • Portal vein injury
               • Affects repair planning