Overview
Definition:
A T-tube, also known as a Kehr's T-tube, is a pliable rubber or silicone tube inserted into the common bile duct during biliary surgery
It serves multiple purposes: to drain bile externally, to decompress the biliary tree, to facilitate contrast injection for postoperative cholangiography, and to maintain patency of the duct while it heals
It is typically inserted following choledochotomy for stone removal, stricture repair, or in liver transplantation.
Epidemiology:
T-tube use is primarily indicated in complex biliary reconstructions and after common bile duct exploration
The incidence varies based on surgical indications, with its use becoming less frequent with advancements in laparoscopic techniques and choledochoscopic stone extraction
Common indications include impacted stones, proximal strictures, and iatrogenic injuries to the common bile duct.
Clinical Significance:
Proper T-tube placement and management are crucial for preventing postoperative complications such as bile leaks, cholangitis, and retained stones
It allows for diagnostic imaging of the biliary tree to ensure ductal patency and absence of stones before definitive removal
It is a vital tool for optimizing outcomes in challenging biliary surgical cases, directly impacting patient recovery and reducing re-intervention rates.
Indications
Absolute Indications:
Common bile duct exploration with choledochotomy
Repair of common bile duct strictures or injuries
Biliary reconstruction following pancreaticoduodenectomy (Whipple procedure)
Liver transplantation (occasionally, as part of biliary reconstruction).
Relative Indications:
Prophylactic drainage in cases of suspected residual stones or difficult anatomy
To provide a route for long-term drainage in palliative settings for unresectable tumors obstructing the biliary tree.
Contraindications:
Absence of a clear indication for drainage or decompression
Known allergies to latex or silicone (for specific tube materials)
Active cholangitis that cannot be controlled preoperatively (may necessitate prompt drainage)
Patients with coagulopathy that cannot be corrected.
Procedure Steps
Tube Selection:
Tubes are typically made of soft, pliable material (silicone or latex) in sizes ranging from 10 to 20 French
The limb lengths should be appropriate to traverse the common bile duct and exit the abdominal wall comfortably.
Placement Technique:
After performing a choledochotomy, the duct is meticulously explored for stones and debris
The T-tube is then carefully introduced, with the longer limb placed within the common bile duct and the shorter limb extending into the duodenum (if applicable and feasible) or simply exiting the duct
The T-shaped configuration anchors the tube in place
The choledochotomy incision is then closed around the tube, ensuring a watertight seal.
Abdominal Wall Exit:
The T-tube is brought out through a separate stab incision in the abdominal wall, typically in the right upper quadrant
This exit site is secured with sutures and a dressing is applied
The tube is connected to a drainage bag.
Confirmation:
Intraoperative cholangiography is usually performed through the T-tube to confirm patency of the common bile duct, absence of retained stones, and appropriate placement of the tube with drainage into the duodenum (if intended).
Postoperative Care
Drainage Monitoring:
Bile output is monitored hourly for the first 24-48 hours
Initially, the output may be serosanguinous, progressing to bile-stained fluid
Significant amounts of bile (e.g., > 400-500 mL/day) with a dark color indicate patency and drainage.
Pain Management:
Adequate analgesia is provided to manage incisional pain and discomfort related to the T-tube
Opioids are often used initially, transitioning to non-opioid analgesics as tolerated.
Fluid And Electrolyte Balance:
Aggressive fluid resuscitation is crucial, especially if there is significant bile loss
Electrolyte levels (sodium, potassium, chloride, bicarbonate) are monitored and corrected as needed
Bile loss can lead to significant electrolyte imbalance, particularly hyponatremia and hypochloremia.
Antibiotic Prophylaxis:
Prophylactic antibiotics are typically continued postoperatively for a defined period, especially in patients with a history of cholangitis or those undergoing extensive biliary manipulation
Monitoring for signs of cholangitis is essential.
Cholangiography And Removal
Timing Of Cholangiography:
Postoperative cholangiography is usually performed between postoperative day 5 and 7, or when drainage output has significantly decreased and the patient is clinically stable
This allows the duct to heal and reduces the risk of extravasation during imaging.
Cholangiography Procedure:
A contrast agent is gently injected through the T-tube, and serial X-rays are taken
The goal is to visualize the entire biliary tree, confirm ductal patency, identify any residual stones, and ensure free flow of contrast into the duodenum
If significant filling defects (stones) or obstruction are noted, further intervention may be required.
Tube Removal Criteria:
The T-tube is typically removed after a successful cholangiogram demonstrating a clear biliary tree and unobstructed flow into the duodenum
Other criteria include minimal bile output from the T-tube (e.g., < 20 mL/day), absence of abdominal pain, and patient tolerance.
Removal Technique:
Tube removal is usually a simple bedside procedure
The tube is gently pulled straight out after ensuring the tract is patent
A sterile dressing is applied to the exit site
A small amount of bile leakage may occur initially but usually resolves spontaneously
A formal cholangiogram may be performed a few days post-removal to ensure continued patency.
Complications
Early Complications:
Bile leak: Can occur from the choledochotomy closure or the T-tube tract
Signs include increasing abdominal pain, fever, and bile-stained drainage from wound sites
Cholangitis: Infection of the biliary tree, presenting with fever, jaundice, and right upper quadrant pain (Charcot's triad)
Retained common bile duct stones: May cause pain, jaundice, or cholangitis
Tube obstruction: Can be due to blood clots or inspissated bile.
Late Complications:
Biliary stricture: Formation of a stricture at the site of T-tube removal or at the previous choledochotomy
T-tube sinus tract: Failure of the tract to close after tube removal, leading to persistent bile drainage
Stone formation within the T-tube or biliary tree
Hernia at the T-tube exit site.
Prevention Strategies:
Meticulous surgical technique during placement and closure
Gentle handling of the tube and surrounding tissues
Adequate choledochotomy closure
Careful selection of T-tube material and size
Prompt and thorough postoperative cholangiography to identify residual stones
Appropriate timing of tube removal based on radiographic evidence and clinical status.
Key Points
Exam Focus:
Indications for T-tube placement in specific scenarios (e.g., choledochotomy, stricture repair)
Complications associated with T-tube use and their management
Criteria for successful postoperative cholangiography and tube removal
Understanding the physiological role of T-tube drainage.
Clinical Pearls:
Always confirm T-tube patency by aspirating bile before injecting contrast during cholangiography
Gentle injection of contrast is paramount to avoid avulsion or rupture
Observe the patient closely for signs of cholangitis, especially if delayed cholangiography is performed
Secure the T-tube well to prevent accidental dislodgement
If the T-tube tract fails to close post-removal, consider Endoscopic Retrograde Cholangiopancreatography (ERCP) or further surgical intervention.
Common Mistakes:
Premature removal of the T-tube before adequate ductal healing or successful cholangiography
Inadequate closure of the choledochotomy around the T-tube, leading to bile leaks
Failure to monitor bile output and electrolyte balance diligently
Aggressive injection of contrast during cholangiography, causing complications
Dislodging the T-tube during dressing changes or patient mobilization.