Online Submissions: http://www.wjgnet.
com/1948-9366office World J Gastrointest Surg 2011 April 27; 3(4): 43-48
wjgs@wjgnet.com
doi:10.4240/wjgs.v3.i4.43
Classification and management of bile duct injuries
Miguel Angel Mercado, Ismael Domínguez
Miguel Angel Mercado, Ismael Domínguez, Department of
Surgery, Instituto Nacional de Ciencias Médicas y Nutrición
“Salvador Zubirán”, P.C.14000 México, DF, Mexico
Author contributions: Mercado MA and Domínguez I were
both responsible for the design, conception, drafting and final ap-
proval of this paper.
Correspondence to: Miguel Angel Mercado, MD, Department
of Surgery, Instituto Nacional de Ciencias Médicas y Nutrición
“Salvador Zubirán”, Vasco de Quiroga 15 Colonia Sección XVI
Tlalpan, P.C.14000 México, DF,
Mexico. miguel.mercadod@quetzal.innsz.mx
Telephone: +52-55-739321 Fax: +52-55-739321
Received: February 23, 2011 Revised: March 25, 2011
Accepted: April 1, 2011
Published online: April 27, 2011
Abstract
To review the classification and general guidelines for
treatment of bile duct injury patients and their long term
results. In a 20-year period, 510 complex circumferen-
tial injuries have been referred to our team for repair at
the Instituto Nacional de Ciencias Médicas y Nutrición
“Salvador Zubirán” hospital in Mexico City and 198 else-
where (private practice). The records at the third level
Academic University Hospital were analyzed and divided
into three periods of time: GⅠ-1990-99 (33 cases), G
Ⅱ- 2000-2004 (139 cases) and GⅢ- 2004-2008 (140
cases). All patients were treated with a Roux en Y hepa-
tojejunostomy. A decrease in using transanastomotic
stents was observed (78% vs 2%, P = 0.0001). Partial
segment Ⅳ and Ⅴ resection was more frequently car-
ried out (45% vs 75%, P = 0.2) (to obtain a high bilio-
enteric anastomosis). Operative mortality (3% vs 0.7%,
P = 0.09), postoperative cholangitis (54% vs 13%, P
= 0.0001), anastomosis strictures (30% vs 5%, P =
0.0001), short and long term complications and need
for reoperation (surgical or radiological) (45% vs 11%,
P = 0.0001) were significantly less in the last period.
The authors concluded that transition to a high volume
center has improved long term results for bile duct inju-
ry repair. Even interested and tertiary care centers have
a learning curve.
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ISSN 1948-9366 (online)
© 2011 Baishideng. All rights reserved.
EDITORIAL
© 2011 Baishideng. All rights reserved.
Key words: Bile duct injury; Hepatojejunoanastomosis;
Biliary repair; Hepatectomy; Cholangitis
Peer reviewers: Grigory G Karmazanovsky, Professor, Depart-
ment of Radiology, Vishnevsky Istitute of Surgery, B Serpuk-
hovskaya street 27, Moscow 117997, Russia; Imtiaz Ahmed
Wani, PhD, Shodi Gali, Amira Kadal, Srinagar, India
Mercado MA, Domínguez I. Classification and management of
bile duct injuries. World J Gastrointest Surg 2011; 3(4): 43-48
Available from: URL: http://www.wjgnet.com/1948-9366/full/
v3/i4/43.htm DOI: http://dx.doi.org/10.4240/wjgs.v3.i4.43
INTRODUCTION
Bile duct injuries (BDI) take place in a wide spectrum
of clinical settings. The mechanisms of injury, previ-
ous attempts of repair, surgical risk and general health
status importantly influence the diagnostic and thera-
peutic decision-making pathway of every single case. A
multidisciplinary approach including internal medicine,
surgery, endoscopy and interventional radiology special-
ists is required to properly manage this complex disease.
BDI may occur after gallbladder, pancreas and gastric
surgery, with laparoscopic cholecystectomy responsible
for 80%-85% of them[1-3]. Although not statistically sig-
nificant, BDI during laparoscopic cholecystectomy is
twice as frequent compared to injuries during an open
procedure (0.3% open vs 0.6% laparoscopic)[4]. BDIs are a
complex health problem and, although they usually occur
in healthy young people, the effect on the patient’s quality
of life and overall survival is substantial[5]. The two most
frequent scenarios are bile leak and bile duct obstruction.
Most of BDIs after laparoscopic cholecystectomy are
recognized transoperatively or in the immediate postop-
erative period[6,7]. Bile leak scenario is easily recognized
during the first postoperative week. Constant bile ef-
fusion is documented through surgical drains, surgical
wounds or laparoscopic ports. Patients usually complain
43 April 27, 2011|Volume 3|Issue 4|
 Mercado MA et al . Bile duct injury classification and management
of diffuse abdominal pain, nausea, fever and impaired
intestinal motility. In addition, bile collections, peritonitis,
leukocytosis and mixed hyperbilirubinemia may be part
of the clinical setting[8,9]. An obstructive pattern in liver
function tests accompanied by jaundice is frequent in the
biliary obstruction scenario. Most of these patients have
a complex Strasberg E injury recognized in the transop-
erative period. However, if not identified during the first
postoperative week, patients have an insidious evolution
with relapsing abdominal pain and cholangitis as well as
bile collections. Jaundice is not always present immediate-
ly after bile duct injury. Some partial stenosis and isolated
sectorial right duct lesions (Strasberg B and C) present
with abdominal pain, pruritus, general weakness, fever
and intermittent alteration of liver function tests.
Unfortunately, late diagnosis, multiple repair attempts
and neglected medical care in order to avoid legal entan-
glements result in extension and increased complexity of
bile duct repair. The late clinical course of bile duct injury
leads to chronic liver disease, cirrhosis and portal hyper-
tension, with liver transplantation the last hope of cure.
BILE DUCT INJURY CLASSIFICATION
Bismuth-Corlette
Multiple classifications have been developed before and
after the laparoscopic era. The Bismuth-Corlette classi-
fication was introduced before laparoscopy. It is difficult
to apply in laparoscopic cholecystectomy as most of the
technical factors and lesion mechanisms are completely
different to open surgery. It considers the complete sec-
tion of the common bile duct and the length of the
proximal bile duct stump[10]. Nevertheless, most cases
have late stenosis or bile duct obstruction which may
be included in this classification, representing a subtype
Strasberg E and Stewart-Way Ⅲ-Ⅳ lesions.
Type Ⅰ is a low injury with a stump length more than
2 cm. Type Ⅱ is a middle level injury with a stump length
less than 2 cm. Type Ⅲ is a high level injury without
common hepatic duct available but preserved confluence.
Type Ⅳ involves loss of hepatic confluence with no
communication between right and left ducts.
Stewart-Way classification
This classification involves four strata based on the mech-
anism and anatomy of injury.
Class Ⅰ refers to the incomplete section of bile duct
with no loss of tissue. It has a prevalence rate of 7%.
The first mechanism of injury is a misleading recognition
of the common hepatic duct with the cystic duct but is
rectified and results in only a small loss of tissue with no
complete section of the bile duct. The second mecha-
nism refers to the lateral injury of the common hepatic
duct which results from the cystic duct opening extension
during cholangiography. The former represents 72% and
the latter 28% of class Ⅰ cases.
Class Ⅱ is a lateral injury of the common hepatic duct
that leads to stenosis or bile leak. It is the consequence
of thermal damage and clamping the duct with surgical
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staples. It has a prevalence of 2% with a concomitant he-
patic artery injury in 18% of cases. T-tube related injuries
are included within this class.
Class Ⅲ is the most common (61% of cases) and rep-
resents the complete section of the common hepatic duct.
It is subdivided in to type Ⅲa, remnant common hepatic
duct; type Ⅲb, section at the confluence; type Ⅲc, loss of
confluence; and type Ⅲd, injuries higher than confluence
with section of secondary bile ducts. It occurs when the
common hepatic duct is confounded with the cystic duct,
leading to a complete section of the common hepatic
duct when resecting the gallbladder. A concomitant injury
of right hepatic artery occurs in 27% of cases.
Class Ⅳ describes the right (68%) and accessory right
(28%) hepatic duct injuries with concomitant injury of
the right hepatic artery (60%). Occasionally it includes
the common hepatic duct injury at the confluence (4%)
besides the accessory right hepatic duct lesion. Class Ⅳ
has a prevalence of 10%[11,12].
Strasberg classification
To our knowledge, the Strasberg classification of BDI is
the most complete and easy to understand. It divides in
to five groups (A to E) where the E class is analog to the
Bismuth classification, a complex bile duct injury with a
complete section of the duct.
Only right and left partial injuries are not included
in this classification. Despite the fact that the latter are
infrequent injuries (8% and 4% respectively in our series),
it is important for the surgeon to be aware of them in
order to make a proper diagnosis and timely referral.
Class A represents a bile leak from the cystic duct or
an accessory duct. In both conditions there is continuity
with the common bile duct. Class B is the section of an
accessory duct with no continuity with the common bile
duct. Class C represents a leak from a bile duct with no
continuity with the common bile duct. Class D is a partial
section of a bile duct with no complete loss of continuity
with the rest of the bile duct system. Class E is a com-
plete section of the bile duct with subtypes according to
the length of the stump (E1-E5). It also includes the loss
of confluence and injury to accessory ducts[13].
Hannover classification
This was published in 2007 but is poorly known in the
world literature. It classifies injuries in relationship to the
confluence and also includes vascular injuries. It has five
subtypes. Type A refers to cystic and/or gallbladder bed
leaks. Type B is a complete or incomplete stenosis caused
by a surgical staple. Type C represents lateral tangential in-
juries. Type D refers to complete section of the common
bile duct emphasizing their distance to the confluence as
well as the hepatic artery and portal vein concomitant in-
juries. Type E is late bile duct stenosis at different lengths
to the confluence[12].
MANAGEMENT
BDI must be treated according to the type of injury. The
44 April 27, 2011|Volume 3|Issue 4|
 Mercado MA et al . Bile duct injury classification and management
Strasberg classification is a helpful tool to decide the best
intervention for each case according to etiological mecha-
nism of injury.
Strasberg A injury
As Strasberg A injuries maintain continuity with the rest
of the bile ducts, they are easily treated through endo-
scopic intervention. The objective is to decrease intra-
ductal pressure distal to the bile duct leak. If endoscopy
is not available, a T tube could be useful.
The last resource is to control the bile leak through
subhepatic drains and refer to a specialized center with
enough experience to treat BDI[14].
It is difficult to prevent Strasberg A injury, except
when the common bile duct obstruction is documented
and properly treated before surgery.
Strasberg B injury
Segmentary bile duct occlusion is the etiological factor
in this type of injury. If mild pain and elevation of liver
function tests are present with no clinical impairment,
conservative management is followed. The presence of
moderate and severe cholangitis makes the drainage of
the occluded liver segment necessary. Percutaneous drain-
age or surgical resections can be performed when cholan-
gitis is not controlled with medical treatment.
Biliodigestive derivation of segmentary bile ducts is
technically hard to perform with only anecdotal cases be-
ing reported[15]. Long term prognosis is poor and there is a
higher probability of bile colonization and cholangitis[16].
Strasberg C injury
As in Strasberg B injury, an accessory right duct is sec-
tioned but the proximal stump is not detected and oc-
cluded, with an unnoticed bile leak as a consequence. No
continuity exists with the rest of the bile duct system,
leaving endoscopy out of the therapeutic options.
Subhepatic collections are frequent in the postopera-
tive setting. These must be drained in order to avoid bili-
ary peritonitis and septic shock.
It is common that the bile leak is occluded spontane-
ously with no other intervention maintaining a controlled
bile leak through external drains. If this does not happen,
therapeutic options are the same that Strasberg B injury,
biliodigestive derivation to segmentary ducts (also with
poor long term prognosis), percutaneous drainage and
hepatectomy.
Strasberg D injury
A partial injury of the common bile duct in its medial
side characterizes this type. No complete loss of bile
duct continuity is present. If a small injury with no de-
vascularization is present, a 5-0 absorbable monofilament
suture to close the defect is adequate. In these rare cases,
external drainage must be left in place and mandatory
endoscopic sphincterotomy and endoprothesis should be
performed.
In the setting of a devascularized duct, even if small
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5-0 absorbable stitches are used, a bile leak will develop
during the first postoperative week with concomitant bile
collections. Management of these cases requires a mul-
tidisciplinary approach with endoscopy and radiological-
guided drainage as the first therapeutic options. Surgery
is the last resource of treatment when a loss of bile duct
tissue is present and migration of a Strasberg D to E in-
jury has taken place.
Strasberg E injury
This injury is defined by a complete loss of common
and/or hepatic bile duct continuity. Devascularization
and loss of bile duct tissue obliges the surgeon to per-
form a high-quality hepatojejunal anastomosis. The lat-
ter procedure guarantees well-perfused bile ducts and a
low tension anastomosis. The opposite is obtained when
choledoco-choledoco or hepato-duodenum anastomosis
are performed as devascularized ducts are used for the
reconstruction and the duodenum tends to move down-
wards, increasing anastomotic tension, even if a Kocher
maneuver is performed well in advance[17].
The best postoperative outcomes are obtained when
the hepatic confluence is preserved, allowing a high-
quality, wide, well vascularized hepatojejunal anastomosis.
Partial resection of Ⅳ and Ⅴ segments facilitates iden-
tification of bile ducts and proper settling of the jejunal
loop[17,18].
In the unfortunate situation of inadequate ducts to
perform a hepatojejunoanastomosis, the jejunal loop
must be sutured to the liver parenchyma including feru-
lized bile ducts within the anastomosis similarly to a Ka-
zai portoenterostomy[19]. Most of these cases are consid-
ered for liver transplant as postoperative outcomes after
portoenterostomy are disappointing[20].
INSTITUTIONAL EXPERIENCE
A retrospective review of the database of patients who
have had bile duct reconstruction at our hospital from
1991 to 2008 was conducted. The protocol was approved
by the Institutional Committee for Human Investigation
at our hospital. All patients referred to our hospital are
evaluated by a multidisciplinary team and the best option
available is chosen for each individual patient. In this re-
port only cases that were treated by means of surgery are
included. All cases were treated by means of Roux en Y
hepatojejunostomy, whose technical aspect has evolved in
the last years[17,21]. Almost all the cases were performed by
one surgeon (MAM).
Based on Strasberg’s definition, some cases were re-
paired at the index operation (when the injury occurred,
early primary repair), other cases with delayed primary
repair (6 wk or more after the injury) and, in the great
majority of cases (more than 90%), secondary repairs
(patients who had a prior attempt of reconstruction)[22].
At the beginning of our experience, the Bismuth clas-
sification was used[10]. From 1997 until now, the Strasberg
classification has been used more frequently[13]. In the
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 Mercado MA et al . Bile duct injury classification and management
1990s, ultrasound was used as the main imaging method
with all the inherent limitations. Percutaneous cholangi-
ography was used selectively and MR cholangiography
has been used in the last decade as the most effective tool
of visualizing the biliary tree.
Although a Roux en Y hepatojejunostomy has been
used in every single case, the operative technique has
evolved greatly. At the beginning of our experience, an
end to side anastomosis with a transanastomotic stent
was used for E1-E3 injuries[16]. In cases with E-4 or E-5
injuries, a porto enterostomy was done with transhepatic
stents placed through the intestinal lumen. As we real-
ized that the end to side anastomosis was sometimes
jeopardized because of devascularization[4], we started to
perform the anastomosis at the confluence level where
well vascularized ducts were usually found. In order to
reach the confluence, the anastomosis was always done in
the anterior aspect of the ducts on order to preserve the
circulation. In some cases lowering the hilar plate pro-
vided adequate ducts exposition for the anastomosis. In
order to obtain a tension free, wide anastomosis (and as
a result having more room for the intestinal loop) partial
resection of segments Ⅳ and Ⅴ was done[23]. Routine ex-
tension of the anterior opening of the common bile duct
with direction to the left duct was done, particularly for
thin ducts[24].
The utilization of transhepatic and transanastomotic
stent decreased progressively so that they are placed only
for cases in which a porto enterostomy has to be done.
Major hepatectomy was done in some cases in which a
duct was found with irreversible damage and/or the in-
trahepatic biliary tree was affected because of major arte-
rial injury (right hepatic artery)[25].
In the last years, patients are scheduled for endoscopi-
cal or radiological treatment, mainly done when conti-
nuity of the bile ducts is shown and in some cases with
stenosed bilio enteric anastomosis that can be dilated
by percutaneous intervention. We use MRI routinely to
evaluate the biliary tree and, seldom, we use percutaneous
cholangiography, mainly indicated in patients with chol-
angitis, providing drainage and anatomical information.
Through a subcostal incision the porta hepatis is
selectively dissected, preserving all the arterial branches
found and the anterior aspect of the ducts is dissected
free. This is enhanced with partial resection of segment
Ⅳ and Ⅴ parenchyma. The jejunal limb is anastomosed
side to side with interrupted everted sutures of 5-0 hy-
drolysable monofilament suture (Figure 1).
Table 1 summarizes the results of the cohort divided
in three periods. No differences were found in gender, age
and type of operation (open or laparoscopic) in which the
injury occurred. Most of the cases were secondary repairs
and no differences were found for a given period of time.
Partial segment Ⅳ and Ⅴ resection had a significant in-
crease. Usage of biliary transanastomotic stents decreased
significantly. In the last period of time, only 2% of the
cases had a stent placed at the time of repair. The rate of
major hepatectomy remained without significant change.
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Figure 1 Side to side hepatojejunoanastomosis. An absorbable 5-0 mono-
filament interrupted stitches leaving the knots outside the anastomotic lumen.
Post operative complications also had significant
changes. The rate of post operative long term cholangitis
dropped to 13% and the rate of stenosis of the anasto-
mosis to 5%. Although less frequent, no significant differ-
ences were found in the rate of postoperative abscesses,
fistula or biloma. Need for reoperation (surgical or radio-
logical) also dropped to 11%. Operation-related mortality
decreased to less than 1% in the last period of time.
This study demonstrates that referral centers for bile
duct injury repair, transitioning from low to high volume
of cases, have a learning curve. Combining a high volume
of cases with team experience, low mortality, acceptable
peri and post operative morbidity and good long term re-
sults can be achieved.
Winslow and Strasberg have recently stated that tech-
nical aspects of repair are essential for early and long
term success[22]. If the repair is done in well vascularized
ducts, is done without tension and with the largest diam-
eter possible (achieved with the anterior opening of the
duct), with epithelium to mucosa apposition using sutures
that produce minimum reaction and complete biliary tree
drainage, good long term results can be achieved.
In the three periods analyzed, no differences were
found in the general characteristics of the patients. In our
center, secondary repair is the most frequent scenario that
we face. In many centers, patients with history of bilioen-
teric anastomosis are treated radiologically with percutane-
ous dilation and/or transhepatic transanastomotic stent
placement for subsequent dilation. Most of the cases with
a stenosed bilioenteric anastomosis are surgically treated.
Indeed, the repair at the time of injury has not in-
creased since our report about the repair in the acute
setting. Only 1-2 cases per year are repaired by our team
at the index operation. Some cases are referred after con-
version, drainage and attempt of repair. These numbers
certainly have a high variation according to the center, city
and country analyzed. The best advice given to a surgeon
for a laparoscopic injury is that if he/she is not able to
do the repair and/or no interested experienced surgeon
is available, it is better not to convert and only place sev-
eral silastic drains though the laparoscopic ports before
referring the patient to an interested center. Nevertheless,
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 Mercado MA et al . Bile duct injury classification and management

Table 1 Summary the results of the cohort divided in three periods

1990-1999 2000-2004 2004-2008

N % N % N %
Total 33 100 139 100 140 100
Male 6 18 39 28 31 22
Female 27 82 100 72 109 78
Age (yr) 38 ± 11 43 ± 15 40 ± 13
Type of cholecystectomy - - - - - -
Open 27 82 104 75 89 63
Lap 6 18 35 25 51 36
Previous repair
0 17 51 72 52 71 51
1 13 39 58 41 60 42
2 2 6 8 6 10 7
3 1 3 3 2 1 0.7
>6 1 3 . . 1 0.7
SEG Ⅳ-Ⅴ resection 15 45 57 41 99 71
Transanastomotic stent 26 78 46 33 3 2
Hepatectomy at repair 1 3 3 2 1 0.7
Post op complications
Cholangitis 18 54 35 25 19 13
Stenosis 10 30 13 9 7 5
Abscesses 5 15 7 5 8 6
Fístula 3 9 6 4 4 3
Biloma 4 12 10 7 18 13
Reoperation 15 45 25 18 16 11
Hepatectomy post repair 1 3 2 1.5
Operative mortality 3 9 6 4 1 0.7

conversion is necessary in some cases in which bleed-
ing control is mandatory and cannot be achieved though
the laparoscope. In some instances, after conversion, the
injury is produced with the maneuvers related to achieve
hemostasis unfortunately.
The technical evolution of the repair has had a sub-
stantial variation through time. Nevertheless, in all our ex-
perience, we have always done Roux en Y hepatojejunos-
tomy. No end to end anastomosis of the transected duct
or hepatoduodenostomy has been done. Although several
reports have good outcomes with this type of procedures,
we do not favor them. Most of the injuries (result of the
combination of ischemic injury and/or loss of substance)
do not allow a tension free, well vascularized anastomosis
(as is the case of liver transplantation). The result is early
dehiscence and/or fistulization with late stenosis that in
some cases in experienced groups has a good long term
outcome[26]. Hepatoduodenostomy also has the same
disadvantages. Although a wide Kocher maneuver, the
anastomosis is not tension free. In these cases, when de-
hiscence or fistulization occurs, it results in a catastrophic
outcome (biliary + duodenal fistula). In addition, direct
contact with gastric contents and food (vegetables and
other fibers) can result in anastomotic dysfunction.
At the beginning of our experience, we used to place
transhepatic transanastomotic stents[16]. We agreed that
leaks of a small bilioenteric anastomosis promote steno-
sis and that low pressure of the bile ducts were desirable
and a flow through the anastomosis was warranted by the
stents.
The opportunity to obtain a wide, non ischemic anas-
tomosis at the hilar level began to restrict the usage of
stents. A wide anastomosis allows free flow of the pro-
ducing low duct pressure and less opportunity of leak. It
also minimizes the risk of stricture and the need of sub-
sequent instrumentation. Nevertheless, some cases with
loss of confluence and complete destruction of the iso-
lated right and left hepatic duct need a portoenterostomy,
with no probability of obtaining a wide, tension free non
ischemic anastomosis that need ferulization of the ducts,
they obtain long term patency.
These types of anastomosis have the worst long term
prognosis in our experience.
In the last period, the anastomosis was routinely done
high in the hilum with the final goal of obtaining a high
quality bilioenteric anastomosis with all the above ex-
plained requirements, particularly the circulatory status of
the ducts.
This goal is obtained by removing the segments Ⅳ
and Ⅴ (a small wedge at its base) that also allow the low-
ering of the hilar plate when the parenchyma is retracted
cephalically. Tissue resection is individually shaped ac-
cording to the anatomical condition of the liver. Some
cases have a well developed segment Ⅳ that not only
obstructs the dissection of the left duct but also does not
allow the placement of the jejunal limb. The resection is
easy to achieve, allowing an anteroposterior view of the
confluence (instead of a caudocephalic view) that permit
a wide opening of a healthy left hepatic duct with well
circulatory status suitable for a high quality anastomosis.
In cases with isolated right and left hepatic ducts,
neoconfluence is built and the hepatojejunoanastomosis
is done.
The better results obtained in the last period of time

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 Mercado MA et al . Bile duct injury classification and management
are related to refinement in the technical aspects of re-
construction but other issues have also been improved.
Classification of the injury nowadays is done initially
with MRI cholangiography and in selected cases with
ERCP and/or percutaneous radiology. These two op-
tions are used when continuity of the ducts (lateral in-
jury) is suspected. Cases resolved by means of endoscopy
and/or radiology are not included in this analysis. The
failure of these methods, including the development of
late stenosis of the duct (although patent), also indicated
the need of reconstruction. Selection and timing of the
operation has also been improved. Patients with active
sepsis and multiple organ failure are not included for sur-
gical repair until these issues are resolved. Some patients
with these negative conditions were operated on early in
our experience, explaining the higher mortality rate of
the initial period.
The number of cases referred to our unit has been
growing in the last years. There were 33 cases repaired
in the first period of 10 years (all the cases done at other
hospitals were excluded) and they have grown to 140
cases in the last 4 years. The total of repairs done by our
team in the 19-year period is 510. The transition to a high
volume center with the refinement in technical aspects al-
lows better long and short term results.
In conclusion, this study shows that referral centers
also have a learning curve and that a high volume of
cases has repercussions in long term results due to refine-
ment in technical aspects and selection of patients. It can
also be advised that not only surgeons with low volume
of repair but also centers with a low volume of repair
should redirect these cases to interested facilities.
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S- Editor Wang JL L- Editor Roemmele A E- Editor Zheng XM
48 April 27, 2011|Volume 3|Issue 4|