Background: A uniformly accepted classification allows an accurate comparison of results and formulation of a standardized treatment plan. Suggested herein is a subclassification of Bismuth type III post-cholecystectomy benign biliary strictures (BBS).
Methods: Fifty-seven patients (41%) with Bismuth type III and eight patients (6%) with type IV BBS out of a total of 139 patients with BBS were analysed retrospectively. Strictures were subclassified as type IIIA where the confluence was healthy and type III B where the roof of the confluence was healthy and right and left ductal continuity was maintained, although the floor of the confluence was scarred.
Results: Of 57 patients with type III BBS, 44 were subclassified as type IIIA and 13 as type IIIB. Statistically significant differences were observed in the mean operative blood loss (317 vs 635 mL, P = 0.004; 317 vs 606 mL, P = 0.006), blood transfused (0.8 vs 2.2 units, P = 0.0007; 0.8 vs 2.0 units, P = 0.0008), and duration of surgery (3.8 vs 5.1 h, P = 0.002; 3.8 vs 5.6 h; P = 0.0004) between type IIIA and IIIB, and between type IIIA and IV strictures, respectively. There were no differences in the operative parameters between type IIIB and IV strictures. There was no difference in the overall morbidity (18% vs 15% vs 25%) and septic complications among the three groups. At a mean follow up of 36.4 months, 87%, 91% and 100% of patients had excellent/good outcome in type IIIA, IIIB and IV, respectively.
Conclusions: Type III biliary strictures need to be subclassified, based on whether the floor of the confluence is healthy or scarred because it influences the degree of operative difficulty and morbidity. Type IIIB BBS behave like and should be classified with type IV strictures for uniformity of result evaluation.