A retrospective analysis of bile duct injuries treated in a tertiary center: the utility of a universal classification-the ATOM classification.

Abstract

Bile duct injuries (BDI) are the most feared complications that can occur after laparoscopic cholecystectomy (LC). BDI have a high variability and complexity, several classifications being developed along the years in order to correctly assess and divide BDI. The EAES ATOM classification encompasses all the important details of a BDI: A (for anatomy), To (for time of), and M (for mechanism) but have not gained universal acceptance yet. Our study intents to analyze the cases of BDI treated in our institution with a focus on the clinical utility of the ATOM classification. We conducted a retrospective study, on a 10-year period (2011-2020), including patients diagnosed with BDI after LC, with their definitive treatment performed in our tertiary center. All injuries were retrospectively classified using the Strasberg, Hannover, and ATOM classifications. We included in our study 100 patients; 15% of the BDI occurred in our center. No classification system was used in 73% of patients; 23% of the BDI were classified by the Strasberg system, 3% were classified by the Bismuth classification, 1% being classified by the ATOM classification. After retrospectively assessing all BDI, we observed that especially the Strasberg classification, as well as Hannover, over-simplifies the characteristics of the injury, many types of BDI according to ATOM being included in the same Strasberg or Hannover category. Most main bile duct injuries underwent a bilio-digestive anastomosis (60%), as a definitive treatment. An important percentage of cases (31%) underwent a primary treatment in the hospital of origin, reintervention with definitive treatment being done in our department. The ATOM classification is the best suited for accurately describing the complexity of a BDI, serving as a template for discussing the correct management for each lesion. Efforts should be made toward increasing the use of this classification in day-to-day clinical practice.