Bile Leakage After T-tube Removal: Report of 3 Cases
Abstract
Introduction: It is a common practice to drain common bile duct (CBD) by the use of T-tube after supraduodenal choledocholithotomy. The T-tube is removed on the 10th -14th post-operative day following normal findings of post-operative T-tube cholangiogram. Small amount of bile leakage from T-tube tract usually ceases within a few days. In rare instance, persistent biliary leakage may cause bile ascites or bile peritonitis, intraperitoneal collection or biloma and prolonged external biliary drainage or biliary fistula.
Case Reports: We reported our experiences of bile leakage following T-tube removal in three patients who underwent cholecystectomy and exploration of the CBD for gallstones and CBD stones. T-tubes were removed within the 14t-16t post-operative day after normal T-tube cholangiogram findings. One patient was treated simply by percutaneous drainage, the other two patients required endoscopic sphincterotomy and insertion of biliary stent for 3-7 weeks.
Conclusions: Percutaneus drainage and endoscopic procedure are effective treatment in most cases of bile leakage following T-tube removal. Open surgery is needed in bile ascites or bile peritonitis. Bile out flow obstruction should be recognized and managed for the prevention of serious complications from persistent bile leakage.
References
2. Neoptolemos JP, Davison BR, Lloyd D, Shaw DE, Carr-Lock DL, Fossard DP. Study of common bile duct exploration and endoscopic sphincterotomy in a consecutive series of 438 patients. Br J Surg 1987; 74: 916-21.
3. Ihse I, Borch K, Carlsson P, Lindstrom E, Tiseliys HG. Extracorporeal shock wave lithotripsy of bile duct stones. Acta Chir Scand 1990; 156: 87-90.
4. Hotta T, Taniguchi K, Kobayashi Y, Johata K, Sahara M, Naka H, et al. Biliary drainage tube evaluation after common bile duct exploration for choledocholithiasis. Hepato- Gastroenterology 2003; 50: 315-21.
5. Chen SMS, Chou FF. Choledochotomy for biliary lithiasis: Is routine T-tube drainage necessary. Acta Chir Scand 1990;156:387-390.
6. Mihmanli M, Isgor A, Erzurmlu K, Kabukcuoglu F, Mihmalli I. Long term results of choledochoduodenostomy and T-tube drainage. Hepato-Gastroenterology 1996; 43: 1480-3.
7. Uchiyama K, Onishi H, Tani M, Kinishita H, Kawai M, Ueno M, et al. Long term prognosis after treatment of patient with Choledocholithiasis. Ann Surg 2003; 238: 97-102.
8. Keighley MRB, Burdon DW, Baddeley RM, Dorricot NJ, Oates GD, Watts GT, et al. Complication of supraduodenal choledochotomy: a comparison of three methods of management, Br J Surg 1976; 63: 745-58.
9. Gillatt DA, May RE, Kenedy R, Longstaff AJ, Complications of T-tube drainage of common bile duct. Ann R Coll Surg Engl 1985; 67: 370-1.
10. Neoptolemos JP. Complications of T-tube draiage the common bile duct. Ann R Coll Surg Engl 1986;68: 326
11. Lygidakis NJ. Incidence of bile infection in biliary lithiasis. Effect on postoperative bacteremia of choledochoduodenostomy, T-tube drainage, and primary closure of the common bile duct after choledochotomy - a prospective clinical trial. Am Surg 1984;50: 236-40.
12. Watanabe H, Iwase H, Sugitani M. Inflammatory polyp in common bile duct cause by T-tube. Hepato-Gastroenterology 2002; 49: 894-6.
13. Thors H, Gudjonsson H, Oddsson E, Cariglia N, Endoscopic retrieval of a biliary T-tube remnant. Gastrointest Endosc 1994;40:241-2.
14. Fulham SB, Pritchard GA. Internal hernia following T-tube drainage. Br J Surg 1985; 72: 519.
15. Lykidakis NJ. Hazard following T-tube removal after choledochotomy. Surg Gynaecol Obstet 1986; 163: 153-5.
16. Gharaibeh KIA, Heiss HA. Biliary leakage following T-tube removal. Int Surg 2000; 85: 57-63.
17. Galan CP, Alonso AC. Bile leakage after removal of T-tube from common bile duct. Br J Surg 1990; 77: 1075.
18. Horgan PG, Campbell AC, Gray GR, Gillespie G. Biliary leakage and peritonitis following removal of T-tube after bile duct exploration. Br J Surg 1989;76: 1296-7.
19. Corbett CRR, Fyfe NCM, Nichol RJ, Jackson BT. Bile peritonitis after removal of T-tube from the common bile duct. Br J Surg 1986; 73: 641-3.
20. Kacker LK, Mittal BR, Sikora SS, Ali W, Kapoor VK, Saxena R, et al. Bile leak after T-tube removal - a scintigraphic study. Hepato-gastroenterology 1995; 42: 975-8.
21. Ryttov N, Rasmussen L, Pedersen SA, Oster-Jorgensen E. 99m Tc-labelled HIDA scintigraphy in assessment of bile leakage after removal of T-tube from the common bile duct. Br J Surg 1989; 76:1319.
22. Demellof L, Rydh A, Truedson H. Leakage from T-tube tracts as determined by contrast radiology. Br J Surg 1977:64: 862-3.
23. Norrby S, Heuman R, Anderberg B, Sjodahl R. Duration of T- tube drainage after exploration of the common bile duct. Acta Chir Scand 1988; 154:113-5.
24. Mosley JG, Barron JA, Holbrook MC, Desai A. An association between leakage of contrast seen on T-tube cholangiogram and subsequent biliary peritonitis. Br J Radiol 1992;65:185-6.
25. Crnojevic L, Thompson JN, Dudley HAF. T-tube: a comparison of virgin, slit guttered sculpted design. Br J Surg 1989;76:342-3.
26. Neoptolemos JP. Scupted T-tubes. Br J Surg 1989; 76: 102.
27. Dawyer JL. T-tubes: Virgin, slit, guttered or sculpted. Br J Surg 1988; 75: 932.
28. Coelho JCU, Wiederkehr JC. Motility of Oddi's sphincter: recent development and clinical applications. Am J Surg 1996;172: 48-51.
29. Tzovaras G, Rowlands BJ. Diagnosis and treatment of sphincter of Oddi dysfunction. Br J Surg 1998; 85: 588-95.
30. Rolny P, Geenen JE, Hogan WJ. Post-cholecystectomy patients with "objective sign" of partial bile outflow obstruction: clinical characteristics, sphincter of Oddi manometry findings, and results of therapy. Gastrointest Endosc 1993; 39:778-81.
31. Chuttani R, Carr-Locke DL. Pathophysiology of the sphincter of Oddi. Surg Clin N Am 1993; 73:13 11-22.
32. Hogan WJ, Geenen JE. Biliary dyskinesia. Endoscopy 1988;20:179-83.
33. Moody FG, Calabuig R, Vecchio R, Runkel N. Stenosis of the sphincter of Oddi. Surg Clin N Am 1990; 70: 1341-54.
34. Ackerman NB, Silin LF, Suresh K. Consequences of intraperitoneal bile: Bile ascites versus bile peritonitis. Am J Surg 1985;149:244-6.
35. Jacobs LK, Shayani V, Sackier JM. Common bile duct T-tube; a caveat and recommendations for management. Surg Endosc 1998; 12: 60-2.
36. Hartle RJ, Mc Garrity TJ, Conter RL. Treatment of a giant biloma and bile leak by ERCP stent placement. Am J Gastroenterol 1993;88: 2117-2118.
37. Sugawa C, Park DH, Lucas CE, Higuchi D, Ukawa K. Endoscopic sphincterotomy for stenosis of sphincter of Oddi. Surg Endosc 2001; 15: 1004-7.
38. Weitemeyer R. The treatment of ampullary stenosis by endoscopic sphincteromy (EST), Am J Surg 1994; 167: 493-6
39. Nussbaum MS, Warner BW, Sax hc, Fischer JE. Transduodenal sphincteroplasty and trans ampullary sepotomy for primary sphincter of Oddi dysfunction. Am J Surg 1989; 157: 38-43.
40. Watanapa P, Williamson RCN. Pancreatic sphincterotomy and sphincteroplasty. Gut 1992; 33: 865-7.
41. Martin DF. Biopsies of the ampullary region in sphincter of Oddi dysfunction. Gastrointest Endosc 1996; 2:208-9.
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