Endoscopic management of bile duct leaks: Current strategies and controversies

Table 1 Bile duct injury classification

Classification, year	Study objective	Type/grade	Practical implication
Bismuth[13], 1982	To classify post-cholecystectomy biliary strictures for surgical planning and prognosis	Type I: Injury > 2 cm below confluence; Type II: < 2 cm; Type III: Hilar with no confluence; Type IV: Complete separation of right and left ducts; Type V: Aberrant right sectoral duct ± CHD injury	Designed for strictures, not leaks. Offers limited guidance for endoscopic management of BDLs such as cystic duct or Luschka leaks
Strasberg[15], 1995	To classify bile duct injuries after cholecystectomy for treatment planning	Type A: Cystic duct/Luschka leak; B: Occluded right posterior duct; C: Leaking posterior duct; D: Lateral injury (< 50%); E1-E5: Strictures (Bismuth I-V).	Most widely adopted. Types A, C, D may be endoscopically managed; B and E often require surgery. Useful for guiding endoscopic decisions
Amsterdam[61], 1996	To guide endoscopic management of bile duct injuries	Type A: Cystic duct/peripheral leak; B: Major duct leak; C: Stricture; D: Complete transection	Types A and B can be managed endoscopically; C and D generally need surgical repair. Aids decision-making for endoscopic vs surgical management
Stewart-Way[22], 2004	To evaluate the mechanism and impact of RHAI in laparoscopic bile duct injury	Class I: CBD mistaken for cystic duct, recognized pre-transection; Class II: CHD injured by clip/cautery; Class III: CBD transected due to misidentification (most common); Class IV: RHD injured during dissection	Highlights the high RHAI incidence in severe injuries, especially Class III (35%) and IV (64%). Important for surgical planning; limited relevance for endoscopic strategies
Hannover[23], 2007	To guide surgical strategies for bile duct and vascular injuries	Type A: Peripheral leaks (A1: Cystic duct; A2: Gallbladder bed); Type B: Strictures without injury (B1-B2); Type C: Tangential injuries (C1-C4); Type D: Complete transections (D1-D4); Type E: Strictures (E1-E4); Vascular injury suffixes: D, s, p, com, c, pv	Provides comprehensive anatomical and vascular classification, aiding surgical decision-making. Limited utility for endoscopic management
McMahon[24], 1995	To classify bile duct injury severity and guide surgical repair	Minor: Laceration < 25% or cystic-CBD tear; Major: Laceration > 25%, CBD/CHD transection, postoperative stricture	Minor injuries often amenable to T-tube or suture repair; major injuries typically require hepaticojejunostomy. Endoscopy plays a limited role
Neuhaus[25], 2000	To guide surgical/endoscopic management of post-cholecystectomy injuries	Type A (Peripheral leaks): A1, cystic duct leak; A2, gallbladder bed leak. Type B (Occlusion): B1, incomplete (e.g., clip); B2, complete. Type C (Lateral CBD injury): C1, lesion < 5 mm; C2, > 5 mm. Type D (Transection): D1, without tissue defect; D2, with tissue defect. Type E (Stricture): E1, < 5 mm; E2, > 5 mm; E3, confluence; E4, right hepatic/segmental duct	Type A: Sphincterotomy ± stent; percutaneous drainage if needed. Type B1: Endoscopic dilation + stent; B2: Surgery (clip removal) + long-term stenting. Type C1: Sphincterotomy or stent; C2: Surgery + stent ≥ 12 months. Type D: Surgical reconstruction (e.g., hepaticojejunostomy). Type E1: Stenting ≥ 12 months; E2-E4: Surgical resection + hepaticojejunostomy; extended hepatectomy if ischemic cholangiopathy
Siewert[26], 1994	To stratify bile duct injuries for surgical planning	Type I: Immediate biliary fistula; Type II: Late stricture; Type IIIa/IIIb: Tangential lesion ± vascular injury; Type IVa/IVb: Duct disruption ± vascular injury	Type I may be endoscopically treated; Types II-IV typically require surgical reconstruction, especially with vascular involvement
Csencdes[27], 2001	To guide surgical/endoscopic treatment of bile duct injuries	Type I: Small tear of hepatic duct or right hepatic branch. Type II: Injury at cysticocholedochal junction (e.g., from traction, catheter, electrocautery, or close transection). Type III: Partial or complete CBD section. Type IV: Resection of > 10 mm of CBD	Type I/II: May be managed with endoscopic stenting; Type III/IV: Typically require surgical repair (e.g., hepaticojejunostomy)

CBD: Common bile duct; CHD: Common hepatic duct; RHD: Right hepatic duct; RHAI: Right hepatic artery injury; Com: Common hepatic artery involvement; c: Coeliac trunk injury; d: Right hepatic artery injury; p: Portal vein injury; pv: Portal vein branch injury; s: Left hepatic artery injury.