[The new classifications of biliary tract diseases based on actual anatomy].

In order to facilitate the treatment strategies for biliary tract injury, hilar cholangiocarcinoma, bile duct tumor thrombus, cholangiocellular carcinoma and bile duct cystic dilatation, many classifications have been made, even more than 10 types for one disease. Each type is represented by numbers or English alphabet, which are not only confusing but also difficult to remember. The Academician Mengchao Wu divided the liver into five sections and four segments base on its anatomy, this classification is very direct and visual, thus had been using till now. In order to overcome those complicated problems, it is considered to develop a new classification based on actual anatomic location similar to that for liver cancer, which is easy to remember and to directly determine the treatment strategy. All kinds of classifications have their own characteristics and advantages and disadvantages. This practical classifications avoid the complexity and may be useful for clinicians.

Reliability and accuracy of a novel classification system using peroral cholangioscopy for the diagnosis of bile duct lesions.

BACKGROUND: The aim of this study was to propose a novel, comprehensive, macroscopic classification for bile duct lesions. METHODS: A two-stage protocol was designed. In Stage I, a retrospective study (September 2013 to September 2015) of patients with bile duct lesions detected by peroral cholangioscopy (POCS) was performed. A total of 315 images with at least 6 months of follow-up were recorded, analyzed, and correlated to histology, and were classified as non-neoplastic (one of three types, 1 - 3) or neoplastic (one of four types, 1 - 4) based on morphological and vascular patterns. In Stage II, a prospective, nonrandomized, double-blind study was performed from December 2015 to December 2016 to validate the proposed classification. Sensitivity, specificity, positive and negative predictive values (PPV and NPV, respectively), and positive and negative likelihood ratios (LR + and LR - , respectively) were calculated (gold standard: 6-month follow-up). Inter- and intraobserver agreement (kappa value, κ) among experts and non-experts were calculated. RESULTS: 171 patients were included (65 retrospective; 106 prospective). In Stage I, 28/65 cases were neoplastic and 37 /65 were non-neoplastic, according to the final diagnosis. In Stage II, 56/106 were neoplastic with a sensitivity, specificity, PPV, NPV, LR + , and LR - for neoplastic diagnosis of 96.3 %, 92.3 %, 92.9 %, 96 %, 12.52, and 0.04, respectively. The proposed classification presented high reproducibility among observers, for both neoplastic and subtypes categories. However, it was better for experts (κ > 80 %) than non-experts (κ 64.7 % - 81.9 %). CONCLUSION: The novel classification system could help physicians to distinguish non-neoplastic from neoplastic bile duct lesions.

Controversies in choledochal malformation.

Choledochal malformations (some of which are choledochal cysts) may be characterised as an abnormal dilatation of the biliary tract in the absence of acute obstruction. Most appear to be of congenital origin, probably related to distal bile duct stenosis, and almost 15% can now be detected antenatally. Excision and biliary reconstruction using a Roux loop as an open operation is still the standard to compare against, although laparoscopic reconstruction is increasingly reported. This article discusses recent advances in the understanding of choledochal malformation aetiology and classification, together with the role of newer modalites of surgical treatment such as laparoscopic excision and biliary reconstruction. Although these are definitely feasible, care should be taken before dispensing with standard open techniques that have minimal complications and proven long-term benefit.

ATOM, the all-inclusive, nominal EAES classification of bile duct injuries during cholecystectomy.

BACKGROUND: Several studies seem to indicate at least a 2-fold increase in bile duct injuries (BDI) since the inception of laparoscopic cholecystectomy. Moreover, injuries seem to be more proximal, seem to be revealed earlier, are expressed by leaks more often than by strictures, are repaired more frequently by nonspecialists (either during the index operation or soon after), and appear to be more often associated with loss of substance and ischemia. The plethora of prior classifications probably attests to the evolving clinical spectrum, the mounting wealth of ever-increasing diagnostic methods, and an acknowledgment of insufficiencies or lack of data in earlier classification reports. Previous attempts at uniformity remain incomplete. The purpose of this study was to devise a nominal classification, combining all existing classification items, taking into account the changing pattern of BDI. METHODS: Extensive bibliographic research, analysis of each category within the individual classifications combined into one uniform classification. RESULTS: Fifteen classifications were retained. All items were integrated into the European Association for Endoscopic Surgery (EAES) classification, using semantic connotations, grouped in three easy-to-remember categories, A (for anatomy), To (for time of), M (for mechanism): (1) the anatomic characteristics of the injury: NMBD for non-main bile duct or MBD for main bile duct (followed by a number 1-6, corresponding to the anatomic level on the MBD), followed by Oc (for occlusion) or D (division), P (partial) or C (complete), LS (loss of substance), VBI (vasculobiliary injury in general), and whenever known, the vessel; (2) time of detection: Ei (early intraoperative), Ep (early postoperative) or L (late); and (3) mechanism of injury: Me (mechanical) or ED (energy-driven). CONCLUSIONS: The EAES composite, all-inclusive, nominal classification ATOM (anatomic, time of detection, mechanism) should allow combination of all information on BDI, irrespective of the original classification used, and thus facilitate epidemiologic and comparative studies; indicate simple, appropriate preventive measures; and better guide therapeutic indications for iatrogenic BDI occurring during cholecystectomy.

Classification of probe-based confocal laser endomicroscopy findings in pancreaticobiliary strictures.

BACKGROUND AND STUDY AIMS: The accurate diagnosis of indeterminate pancreaticobiliary strictures presents a clinical dilemma. Probe-based confocal laser endomicroscopy (pCLE) offers real-time in vivo microscopic tissue examination that may increase sensitivity for the detection of malignancy. the objective of this study was to develop and validate a standard descriptive classification of pcle in the pancreaticobiliary system. PATIENTS AND METHODS: A total of 102 patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) with pCLE to assess indeterminate pancreaticobiliary strictures were enrolled in a multicenter registry; 89 of these patients were evaluable. Information and data on the following were collected prospectively: clinical, ERCP, tissue sampling, pCLE, and follow-up. A uniform classification of pCLE findings ("Miami Classification") was developed, consisting of a set of image interpretation criteria. Thereafter, these criteria were tested through blinded consensus review of 112 randomized pCLE videos from 47 patients, and inter-observer variability was assessed in 42 patients . RESULTS: A consensus definition of the specific criteria of biliary and pancreatic pCLE findings for indeterminate strictures was developed. Single-image interpretation criteria did not have a high enough sensitivity for predicting malignancy. However, combining two or more criteria significantly increased the sensitivity and predictive values. The characteristics most suggestive of malignancy included the following: thick white bands (>20 µm), or thick dark bands (>40 µm), or dark clumps or epithelial structures. These provided sensitivity, specificity, positive predictive value, and negative predictive value of 97%, 33%, 80%, and 80% compared with 48%, 100%, 100%, and 41% for standard tissue sampling methods. Inter-observer variability was moderate for most criteria. CONCLUSION: The Miami Classification enables a structured, uniform, and reproducible description of pancreaticobiliary pCLE. Combining individual characteristics improves the sensitivity for the detection of malignancy.

Portal ductopathy: clinical importance and nomenclature.

Non-cirrhotic portal hypertension (PHT) accounts for about 20% of all PHT cases, portal vein thrombosis (PVT) resulting in cavernous transformation being the most common cause. All known complications of PHT may be encountered in patients with chronic PVT. However, the effect of this entity on the biliary tree and pancreatic duct has not yet been fully established. Additionally, a dispute remains regarding the nomenclature of common bile duct abnormalities which occur as a result of chronic PVT. Although many clinical reports have focused on biliary abnormalities, only a few have evaluated both the biliary and pancreatic ductal systems. In this review the relevant literature evaluating the effect of PVT on both ductal systems is discussed, and findings are considered with reference to results of a prominent center in Turkey, from which the term "portal ductopathy" has been put forth to replace "portal biliopathy".

[Some aspects of classification and treatment strategy of iatrogenic bile duct injury].

Iatrogenic bile duct injury continues to be an important clinical problem, resulting in serious morbidity, and occasional mortality, to patients. None of the classification system is universally accepted and worldwide used as each has its own limitation. This article reviews the various classification systems of bile duct injury. Traditionally, biliary injuries have been classified using the Bismuth's classification. This classification does not encompass the whole spectrum of injuries during laparoscopic cholecystectomy. Strasberg's classification made Bismuth's classification much more comprehensive by including various other types of extrahepatic bile duct injuries. Our own classification is simple enough, embraces the majority possible variants of bile duct injuries and convenient in clinical use.

Management of bile duct injury after laparoscopic cholecystectomy: a review.

BACKGROUND: Bile duct injury following cholecystectomy is an iatrogenic catastrophe which is associated with significant perioperative morbidity and mortality, reduced long-term survival and quality of life, and high rates of subsequent litigation. The aim of this article was to review the management of bile duct injury after cholecystectomy. METHODS: Medline and PubMed database search was undertaken to identify articles in English from 1970 to 2008 using the key words 'bile duct injury', 'cholecystectomy' and 'classification'. Additional papers were identified by a manual search of the references from the key articles. Case report was excluded. RESULTS: Early recognition of bile duct injury is of paramount importance. Only 25%-32.4% of injuries are recognized during operation. The majority of patients present initially with non-specific symptoms. Management depends on the timing of recognition, the type, extent and level of the injury. Immediate recognition and repair are associated with improved outcome, and the minimum standard of care after recognition of bile duct injury is immediate referral to a surgeon experienced in bile duct injury repair. There is a growing body of literature supporting the importance of early referral to a tertiary care hospital which can provide a multidisciplinary approach to treat bile duct injury. Inadequate management may lead to severe complications. CONCLUSIONS: None of the classification system is universally accepted as each has its own limitation. The optimal management depends on the timing of recognition of injury, the extent of bile duct injury, the patient's condition and the availability of experienced hepatobiliary surgeons.

Iatrogenic biliary injuries: classification, identification, and management.

Iatrogenic biliary injuries most commonly occur during laparoscopic cholecystectomy. Biliary injuries are complex problems requiring a multidisciplinary approach with surgeons, radiologists, and gastroenterologists knowledgeable in hepatobiliary disease. Mismanagement can result in lifelong disability and chronic liver disease. Given the unforgiving nature of the biliary tree, favorable outcome requires a well-thought-out strategy and attention to detail.

[Bile duct involvement in autoimmune pancreatitis: classification and treatment]. / Atteinte biliaire au cours d'une pancréatite auto-immune: quel cadre nosologique et quel traitement?

Autoimmune pancreatitis is a rare disease characterized by inflammation of the pancreatic parenchyma, irregular narrowing of the pancreatic duct, periductal lymphoplasmacytic infiltration and fibrosis at histological examination, the presence of autoantibodies and hypergammaglobulinemia, as well as the possible association of cholangitis and other autoimmune diseases. There is a favorable response to steroid therapy. We report the case of a patient with autoimmune pancreatitis with bile duct involvement and peripheral eosinophilia, requiring long-term immunosuppressant treatment. The diagnosis of a diffuse form of AIP was made without direct histological evidence and based on indirect imaging, clinical and laboratory findings in an autoimmune context. The histological and imaging studies of bile duct involvement and the favourable response to steroids were additional arguments.

[Classification of iatrogenic damages of biliary ducts in cholecystectomy].

While introduction of laparoscopic technologies into clinical practice the extrahepatic bile--efferent ways damages during cholecystectomy performance had increased from 0.1-0.2 to 0.4-0.7%. The necessity of elaboration of a simple and mostly complete classification of such damages had occurred. The advantages and faults of the main world-wide now existing classifications of the extrahepatic biliary ducts damages were analyzed. Classification of their own, reflecting, without unnecessary details, the majority of possible variants of the biliary ducts damages, was proposed, making it convenient for practical application.

Classification and prognosis of intrahepatic biliary stricture after liver transplantation.

Intrahepatic biliary stricture (IHBS) after liver transplantation (LT) may develop in patients with hepatic artery thrombosis, chronic rejection, or ABO incompatibility, as well as in patients with prolonged warm ischemia in non-heart-beating donor (NHBD) LT. However, the clinical course and methods of management have not been well defined for IHBSs to date. Thus, the purpose of this study was to provide a classification of post-LT IHBS and to investigate patient prognosis. Forty-four patients who developed IHBS after NHBD LT were enrolled. On the basis of the cholangiographic appearance, patients were classified into 4 groups: unilateral focal (UF, n=8), confluence (CO, n=10), bilateral multifocal (BM, n=21), and diffuse necrosis (DN, n=5). The UF type was defined as cases with stricture only in the segmental branch of the unilateral hemiliver; the CO type in cases with several strictures at confluence level; and the BM type in cases with multiple strictures bilaterally. Cases with diffuse obliteration of peripheral ducts or destruction of the central architectural integrity, over a long segment, were classified as the DN type. Five patients with the CO type required several interventions requiring biliary dilatation, yet all patients with the UF or CO type had a good prognosis. Among the patients with the BM type, 3 patients (14.3%) died or underwent retransplantation due to biliary complications, and 7 (33.3%) required repeated interventions for >1 year without improvement. Moreover, among 5 patients classified as the DN type, 1 (20%) died of biliary sepsis, 2 (40%) underwent retransplantation, and the remaining 2 (40%) did not recover from persistent jaundice and life-threatening cholangitis despite multiple interventions. In conclusion, all patients classified as UF or CO had a good outcome with or without additional interventions. However, all patients with the DN type and about half the patients with the BM type did not recover from life-threatening complications, despite repeated aggressive interventions; early retransplantation was therefore the only treatment option for these patients.

Classification of iatrogenic bile duct injury.

BACKGROUND: Iatrogenic bile duct injury continues to be an important clinical problem, resulting in serious morbidity, and occasional mortality, to patients. The ease of management, operative risk, and outcome of bile duct injuries vary considerably, and are highly dependent on the type of injury and its location. This article reviews the various classification systems of bile duct injury. DATA SOURCES: A Medline, PubMed database search was performed to identify relevant articles using the keywords "bile duct injury", "cholecystectomy", and "classification". Additional papers were identified by a manual search of the references from the key articles. RESULTS: Traditionally, biliary injuries have been classified using the Bismuth's classification. This classification, which originated from the era of open surgery, is intended to help the surgeons to choose the appropriate technique for the repair, and it has a good correlation with the final outcome after surgical repair. However, the Bismuth's classification does not encompass the whole spectrum of injuries that are possible. Bile duct injury during laparoscopic cholecystectomy tends to be more severe than those with open cholecystectomy. Strasberg's classification made Bismuth's classification much more comprehensive by including various other types of extrahepatic bile duct injuries. Our group, Bergman et al, Neuhaus et al, Csendes et al, and Stewart et al have also proposed other classification systems to complement the Bismuth's classification. CONCLUSIONS: None of the classification system is universally accepted as each has its own limitation. Hopefully, a universally accepted comprehensive classification system will be published in the near future.

Outcome of hepaticojejunostomy without access loop for repair of iatrogenic bile duct injury at laparoscopic cholecystectomy.

BACKGROUND PURPOSE: Roux-en-Y hepaticojejunostomy is the accepted treatment for transectional biliary injury at cholecystectomy. Many authors advocate leaving a long redundant jejunal access loop to facilitate subsequent access. Reasoning that percutaneous access can be achieved transhepatically in patients with stenosis, this study reports the outcome of a policy of biliary repair without the use of a jejunal access loop. METHODS: Eleven patients undergoing biliary reconstruction over a 5-year period constituted the study population. Three (27%) were male, and the median (range) age at injury was 53 (26-75) years. Median delay from injury to repair was 2 (1-48) months. Bismuth stage was: stage I, 4; stage II, 5; and stage III, 2. Four patients had concomitant arterial injury. All underwent surgical repair by Roux-en-Y hepaticojejunostomy without an access loop. RESULTS: The median follow-up was 13 (1-64) months. The principal postoperative complication was a hepatic abscess in one patient. There was one death during follow-up, from acute myeloid leukemia. One patient (9%) with a type III injury presented with a symptomatic recurrent biliary stricture 6 months after repair, and was successfully managed by percutaneous biliary dilatation, using a combination of transhepatic and jejunal loop puncture. CONCLUSIONS: Successful biliary reconstruction can be performed without a routine jejunal access loop.

Endoscopic therapy of benign biliary strictures.

Benign biliary strictures are being increasingly treated with endoscopic techniques. The benign nature of the stricture should be first confirmed in order to ensure appropriate therapy. Surgery has been the traditional treatment, but there is increasing desire for minimally invasive endoscopic therapy. At present, endoscopy has become the first line approach for the therapy of post-liver transplant anastomotic strictures and distal (Bismuth I and II) post-operative strictures. Strictures related to chronic pancreatitis have proven more difficult to treat, and endoscopic therapy is reserved for patients who are not surgical candidates. The preferred endoscopic approach is aggressive treatment with gradual dilation of the stricture and insertion of multiple plastic stents. The use of uncovered self expandable metal stents should be discouraged due to poor long-term results. Treatment with covered metal stents or bioabsorbable stents warrants further evaluation. This area of therapeutic endoscopy provides an ongoing opportunity for fresh research and innovation.

Primary sclerosing cholangitis--the arteriosclerosis of the bile duct?

Primary sclerosing cholangitis (PSC) is a chronic inflammatory disease of unknown aetiology affecting the large bile ducts and characterized by periductal fibrosis and stricture formation, which ultimately result in biliary cirrhosis and liver failure. Arteriosclerosis involves the accumulation of altered lipids and lipoproteins in large arteries; this drives inflammation and fibrosis and ultimately leads to narrowing of the arteries and hypoperfusion of dependent organs and tissues. Knowledge of the causative factors is crucial to the understanding of disease mechanisms and the development of specific treatment. Based on pathogenetic similarities between PSC and arteriosclerosis, we hypothesize that PSC represents "arteriosclerosis of the bile duct" initiated by toxic biliary lipids. This hypothesis is based on common molecular, cellular, and morphological features providing the conceptual framework for a deeper understanding of their pathogenesis. This hypothesis should stimulate translational research to facilitate the search for novel treatment strategies for both diseases.