Advertisement

Surgical Endoscopy

, Volume 27, Issue 12, pp 4608–4619 | Cite as

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

  • A. FingerhutEmail author
  • C. Dziri
  • O. J. Garden
  • D. Gouma
  • B. Millat
  • E. Neugebauer
  • A. Paganini
  • E. Targarona
Article

Abstract

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.

Keywords

Bile duct injury Biliary injuries Cholecystectomy Classification Laparoscopic cholecystectomy Laparoscopy Vasculobiliary injury 

Notes

Disclosures

A. Fingerhut, C. Dziri, O. J. Garden, D. Gouma, B. Millat, E. Neugebauer, A. Paganini, and E. Targarona have no conflicts of interest or financial ties to disclose.

Supplementary material

464_2013_3081_MOESM1_ESM.docx (120 kb)
Supplementary material 1 (DOCX 121 kb)

References

  1. 1.
    Cannon RM, Brock G, Buell JF (2011) A novel classification system to address financial impact and referral decisions for bile duct injury in laparoscopic cholecystectomy. HPB Surg 2011:371245PubMedCrossRefGoogle Scholar
  2. 2.
    Flum DR, Cheadle A, Prela C, Dellinger EP, Chan L (2003) Bile duct injury during cholecystectomy and survival in medicare beneficiaries. JAMA 290:2168–2173PubMedCrossRefGoogle Scholar
  3. 3.
    Karvonen J, Salminen P, Grönroos JM (2011) Bile duct injuries during open and laparoscopic cholecystectomy in the laparoscopic era: alarming trends. Surg Endosc 25:2906–2910PubMedCrossRefGoogle Scholar
  4. 4.
    Chuang KI, Corley D, Postlewaite DA, Merchant M, Harris HW (2012) Does increased experience with laparoscopic cholecystectomy yield more complex bile duct injuries? Am J Surg 203:480–487PubMedCrossRefGoogle Scholar
  5. 5.
    Lau WY, Lai EC, Lau SH (2010) Management of bile duct injury after laparoscopic cholecystectomy: a review. ANZ J Surg 80:75–81PubMedCrossRefGoogle Scholar
  6. 6.
    Connor S, Garden OJ (2006) Bile duct injury in the era of laparoscopic cholecystectomy. Br J Surg 93:158–168PubMedCrossRefGoogle Scholar
  7. 7.
    Lillemoe KD, Melton GB, Cameron JL, Pitt HA, Campbell KA, Talamini MA, Sauter PA, Coleman J, Yeo CJ (2000) Postoperative bile duct strictures: management and outcome in the 1990s. Ann Surg 232:430–441PubMedCrossRefGoogle Scholar
  8. 8.
    McMahon AJ, Fullarton G, Baxter JN, O’Dwyer PJ (1995) Bile duct injury and bile leakage in laparoscopic cholecystectomy. Br J Surg 82:307–313PubMedCrossRefGoogle Scholar
  9. 9.
    Neuhaus P, Schmidt SC, Hintze RE, Adler A, Veltzke W, Raakow R, Langrehr JM, Bechstein WO (2000) Classification and treatment of bile duct injuries after laparoscopic cholecystectomy. Chirurg 71:166–173PubMedCrossRefGoogle Scholar
  10. 10.
    Siewert JR, Ungeheuer A, Feussner H (1994) Bile duct lesions in laparoscopic cholecystectomy. Chirurg 65:748–757PubMedGoogle Scholar
  11. 11.
    Stewart L, Robinson TN, Lee CM, Liu K, Whang K, Way LW (2004) Right hepatic artery injury associated with laparoscopic bile duct injury: incidence, mechanism, and consequences. J Gastrointest Surg 8:523–531PubMedCrossRefGoogle Scholar
  12. 12.
    Strasberg SM, Helton WS (2011) An analytical review of vasculobiliary injury in laparoscopic and open cholecystectomy. HPB 13:1–14PubMedCrossRefGoogle Scholar
  13. 13.
    Bismuth H, Majno PE (2001) Biliary strictures: classification based on the principles of surgical treatment. World J Surg 25:1241–1242PubMedCrossRefGoogle Scholar
  14. 14.
    Koffron A, Ferrario M, Parsons W, Nemcek A, Saker M, Abecassis M (2001) Failed primary management of iatrogenic biliary injury: incidence and significance of concomitant hepatic arterial disruption. Surgery 130:722–731PubMedCrossRefGoogle Scholar
  15. 15.
    Lau WY, Lai EC (2007) Classification of iatrogenic bile duct injury. Hepatobiliary Pancreat Dis Int 6:459–463PubMedGoogle Scholar
  16. 16.
    Bektas H, Kleine M, Tamac A, Klempnauer J, Schrem H (2011) Clinical application of the Hanover classification for iatrogenic bile duct lesions. HPB Surg 2011:612384PubMedCrossRefGoogle Scholar
  17. 17.
    Bergman JJ, van den Brink GR, Rauws EA, de Wit L, Obertop H, Huibregtse K, Tytgat GN, Gouma DJ (1996) Treatment of bile duct lesions after laparoscopic cholecystectomy. Gut 38:141–147PubMedCrossRefGoogle Scholar
  18. 18.
    Bismuth H (1982) Postoperative strictures of the bile duct. In: Blumgart LH (ed) The biliary tract. Churchill Livingstone, Edinburgh, pp 209–218Google Scholar
  19. 19.
    Bismuth H, Lazorthes F (1981) Les traumatismes opératoires de la voie biliaire principale. Masson, ParisGoogle Scholar
  20. 20.
    Csendes A, Navarrete C, Burdiles P, Yarmuch J (2001) Treatment of common bile duct injuries during laparoscopic cholecystectomy: endoscopic and surgical management. World J Surg 25:1346–1351PubMedCrossRefGoogle Scholar
  21. 21.
    Kapoor VK (2008) New classification of acute bile duct injuries. Hepatobiliary Pancreat Dis Int 7:555–556PubMedGoogle Scholar
  22. 22.
    Li J, Frilling A, Nadalin S, Radunz S, Treckmann J, Lang H, Malago M, Broelsch CE (2010) Surgical management of segmental and sectoral bile duct injury after laparoscopic cholecystectomy: a challenging situation. J Gastrointest Surg 14:344–351PubMedCrossRefGoogle Scholar
  23. 23.
    Sandha G, Bourke MJ, Haber GB, Kortan PP (2004) Endoscopic therapy for bile leak based on a new classification: results in 207 patients. Gastrointest Endosc 60:567–574PubMedCrossRefGoogle Scholar
  24. 24.
    Strasberg SM, Hertl M, Soper NJ (1995) An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 180:101–125PubMedGoogle Scholar
  25. 25.
  26. 26.
    Eikermann M, Siegel R, Broeders I, Dziri C, Fingerhut A, Gutt C, Jaschinski T, Nassar A, Paganini AM, Pieper D, Targarona E, Schrewe M, Shamiyeh A, Strik M, Neugebauer EA, European Association for Endoscopic Surgery (2012) Prevention and treatment of bile duct injuries during laparoscopic cholecystectomy: the clinical practice guidelines of the European Association for Endoscopic Surgery (EAES). Surg Endosc 26:3003–3039PubMedCrossRefGoogle Scholar
  27. 27.
    Bektas H, Schrem H, Winny M, Klempnauer J (2007) Surgical treatment and outcome of iatrogenic bile duct lesions after cholecystectomy and the impact of different clinical classification systems. Br J Surg 94:1119–1127PubMedCrossRefGoogle Scholar
  28. 28.
    Keulemans YC, Bergman JJ, de Wit LT, Rauws EA, Huibregtse K, Tytgat GN, Gouma DJ (1998) Improvement in the management of bile duct injuries? J Am Coll Surg 187:246–254PubMedCrossRefGoogle Scholar
  29. 29.
    Schmidt SC, Settmacher U, Langrehr JM, Neuhaus P (1994) Management and outcome of patients with combined bile duct and hepatic arterial injuries after laparoscopic cholecystectomy. Surgery 135:613–618CrossRefGoogle Scholar
  30. 30.
    Weber A, Feussner H, Winkelmann F, Siewert JR, Schmid RM, Prinz C (2009) Long-term outcome of endoscopic therapy in patients with bile duct injury after cholecystectomy. J Gastroenterol Hepatol 24:762–769PubMedCrossRefGoogle Scholar
  31. 31.
    Lillemoe KD (2008) Current management of bile duct injury. Br J Surg 95:403–405PubMedCrossRefGoogle Scholar
  32. 32.
    Pulitano C, Parks RW, Ireland H, Wigmore SJ, Garden OJ (2011) Impact of concomitant arterial injury on the outcome of laparoscopic bile duct injury. Am J Surg 201:238–244PubMedCrossRefGoogle Scholar
  33. 33.
    Buanes T, Waage A, Mjaland O, Solheim K (1996) Bile leak after cholecystectomy: significance and treatment. Results from the National Norwegian Cholecystectomy Registry. Int Surg 81:276–279PubMedGoogle Scholar
  34. 34.
    Davidoff AM, Pappas TN, Murray EA, Hilleren DJ, Johnson RD, Baker ME, Newman GE, Cotton PB, Meyers WC (1992) Mechanisms of major biliary injury during laparoscopic cholecystectomy. Ann Surg 215:198–202Google Scholar
  35. 35.
    Nenner RP, Imperato PJ, Alcorn CM (1992) Serious complications of laparoscopic cholecystectomy in New York State. N Y State J Med 92:179–181PubMedGoogle Scholar
  36. 36.
    Schwartz SI (2005) Schwartz’s principles of surgery, 8th edn. McGraw-Hill, New YorkGoogle Scholar
  37. 37.
    Bonnel DH, Fingerhut AL (2012) Percutaneous transhepatic balloon dilatation of benign bilioenteric strictures: long term results in 110 patients. Am J Surg 203:675–683PubMedCrossRefGoogle Scholar
  38. 38.
    Pekolj J, Alvarez FA, Palavecino M, Sanchez Claria R, Mazza O, de Santibanes E (2013) Intraoperative management and repair of bile duct injuries sustained during 10,123 laparoscopic cholecystectomies in a high-volume referral center. J Am Coll Surg 216:894–901PubMedCrossRefGoogle Scholar
  39. 39.
    Ausania F, Holmes LR, Ausania F, Iype S, Ricci P, White SA (2012) Intraoperative cholangiography in the laparoscopic cholecystectomy era: why are we still debating? Surg Endosc 26:1193–1200PubMedCrossRefGoogle Scholar
  40. 40.
    Millat B, Deleuze A, de Saxce B, de Seguin C, Fingerhut A (1997) Routine intraoperative cholangiography is feasible and efficient during laparoscopic cholecystectomy. Hepatogastroenterology 44:22–27PubMedGoogle Scholar
  41. 41.
    Christensen RA, van Sonnenberg E, Nemcek AA, D’Agostino HB (1992) Inadvertent ligation of the aberrant right hepatic duct at cholecystectomy: radiologic diagnosis and therapy. Radiology 183:549–553PubMedGoogle Scholar
  42. 42.
    Mercado LMA, Domínguez I (2011) Classification and management of bile duct injuries. World J Gastrointest Surg 3:43–48PubMedCrossRefGoogle Scholar
  43. 43.
    Way LW, Stewart L, Gantert W, Liu K, Lee CM, Whang K, Hunter JG (2003) Causes and prevention of laparoscopic bile duct injuries. Analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg 237:460–469PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • A. Fingerhut
    • 1
    • 2
    Email author
  • C. Dziri
    • 3
  • O. J. Garden
    • 4
  • D. Gouma
    • 5
  • B. Millat
    • 6
  • E. Neugebauer
    • 7
  • A. Paganini
    • 8
  • E. Targarona
    • 9
  1. 1.First Department of Surgery, Hippokration HospitalUniversity of Athens Medical SchoolAthensGreece
  2. 2.Section for Surgical Research, Department of SurgeryMedical University of GrazGrazAustria
  3. 3.Surgical Department BCharles Nicolle University HospitalTunisTunisia
  4. 4.Clinical Surgery, Royal InfirmaryUniversity of EdinburghEdinburghUK
  5. 5.Surgical DepartmentAcademic Medical CenterAmsterdamThe Netherlands
  6. 6.Surgical Department, Hôpital St EloiUniversity of MontpellierMontpellierFrance
  7. 7.IFOM FOM–Institut für Forschung in der Operativen Medizin Lehrstuhl für Chirurgische Forschung Private Universität Witten/HerdeckeCologneGermany
  8. 8.Divisione de II Clinica ChirurgicaDipartemento de RomeRomeItaly
  9. 9.Surgical DepartmentSant Pau University HospitalBarcelonaSpain

Personalised recommendations