Biliary strictures: classification based on the principles of surgical treatment.

The classification of biliary strictures used at Hopital Paul Brousse is based on the lowest level at which healthy biliary mucosa is available for anastomosis. The classification is intended to help the surgeon choose the appropriate technique for the repair. Type I strictures, with a common duct stump longer than 2 cm, can be repaired without opening the left duct and without lowering the hilar plate. Type II strictures, with a stump shorter than 2 cm, require opening the left duct for a satisfactory anastomosis. Lowering the hilar plate is not always necessary but may improve the exposure. Type III lesions, in which only the ceiling of the biliary confluence is intact, require lowering the hilar plate and anastomosis on the left ductal system. There is no need to open the right duct if the communication between the ducts is wide. With type IV lesions the biliary confluence is interrupted and requires either reconstruction or two or more anastomoses. Type V lesions are strictures of the hepatic duct associated with a stricture on a separate right branch, and the branch must be included in the repair. Although this classification is intended for established strictures, it is commonly used to describe acute bile duct injuries. The surgeon must be aware, however, that the established stricture is generally one level higher than the level of the injury at the original operation.