T Tube


Article Author:
Ghaith Al-Qudah


Article Editor:
Faiz Tuma


Editors In Chief:
Kranthi Sitammagari
Mayank Singhal


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
5/15/2019 10:28:17 PM

Introduction

T Tube is a draining tube placed in the common bile duct after Common Bile Duct (CBD) exploration with supra-duodenal choledochotomy. It provides external drainage of bile into a controlled route while the healing process of choledochotomy is maturing and the original pathology is resolving. T tub is named to reflect the shape of the tube used for the CBD drainage. It is not be confused with the Tracheal tube or Tympanoplasty tube.

Other options of managing CBD exploration are stenting, or primary closure in selected patients have been used[1][2]. The idea and procedure was introduced and used for decades by surgeons around the world. It was the standard of care for CBD exploration until a couple of decades ago[3][4][5]

Anatomy

The CBD is the continuation of the hepatic duct after the cystic duct joins it[6]. The CBD then runs medially and inferiorly until it reaches the second part of the duodenum[7]. T tube is usually inserted at the choledochotomy site. It is part of the closure of the choledochotomy. The chosen site of choledochotomy is the common bile duct segment between the cystic duct junction and the duodenal lateral border. This is the accessible site of surgery. Upon T tube placement and closure of the choledochotomy, the tube is passed in the shortest distance to the anterior abdominal wall, then through the abdominal to the skin surface in the right upper quadrant.

Indications

Indications of T Tube can be summarized in one concept that is to stent and drain the common bile duct after choledochotomy[8]. The most common reason for performing choledochotomy is extraction of biliary stones[1]. Choledochotomy, stone extraction and T Tube placement was common procedure for intractable stones before the ERCP era. Since ERCP became available and expertise were developed, it became the common and less aggressive approach to CBD stones extractions[9][3]. The number of choledochotomies became much less common and not familiar procedure to many surgeons trained and practiced after 2000.

Another less common reason is repairing limited injury of the CBD over a T tube. Simple closure of the CBD injury without stenting and draining is associated with a high rate of stricture and or leak. T tube placement may also be used for CBD drainage when ERCP and PTC fail to clear the CBD intraluminal non-malignant obstruction. This is a rare indication, but it is an option to relieve the obstruction and prevent further complications.

A common misconception is using the word T tube interchangeably with different tubes such as Cholecystostomy tube and PTC drain. The Cholecystostomy tube is a tube that is inserted by interventional radiology method through the abdominal wall into the gallbladder, and serves as a drain to an inflamed gallbladder in patients with acute cholecystitis who are otherwise at high risk to undergo formal cholecystectomy. On the other hand, Percutaneous Transhepatic Cholangiogram (PTC) is a drain that is inserted through the abdominal wall into a major hepatic duct, also by interventional radiology method, and serves as an external drain for bile in patients with bile duct obstruction until the underlying pathology is treated.

Equipment

The special part of the equipment is the T tube itself. As the name refers, it is a special tube in the shape of T with a shorter transverse part (20 cm) that stays inside the CBD (after trimming) and a long longitudinal part (60 cm) that extends from the middle of the transverse part to an end that connects with a drainage bag. This portion extends from the CBD to outside the abdominal cavity when applied. It comes with different circumference sizes (10, 12, 14, 16, 18 Fr). T tube can be made of different materials like latex, silicone, red rubber and polyvinyl chloride (PVC)[10]. PVC is very inert causing the least tissue reaction with lack of tissue tract formation making it the least favorable material for T tube placement purposes. Silicon has many favorable physical properties, but it can disintegrate with poor handling making it not a practical option for long-term placement. Latex has the desired properties to be the most commonly used. Red rubber is an alternative if latex can not be used or is not available[10].

Technique

Placing T tube in the CBD after choledochotomy is technically challenging[11]. It should be done with several precautions in mind to achieve the purpose and cause no complications[12]. The technical concept is to keep the draining (transverse) end of the T tube inside the CBD. Before placement, the segment is trimmed to a short length of 2-4 cm and cut longitudinally to remove half of the circumference. Additional wedge cut at the point where this segment meets the main long segment is made. The idea of trimming is to facilitate tube removal with minimal risk of leak or other complications.  This trimmed transverse segment of the tube placed in the CBD provides stenting support for the CBD and anchors the tube in place. Caution should be taken to keep the tube lumen patent without pressure. Bile should easily pass through the tube lumen otherwise the likelihood of a leak from the choledochotomy site will significantly increase[13]. Choledochotomy closure around the tube exit should be done meticulously in a tension free fashion. A fine ( 3-0 or 4-0) monofilament absorbable suture should be used. Non-absorbable suture can be a nidus for stone formation or infection. Closure is fashioned longitudinally with the direction of the incision and CBD. Choledochotomy direction and site should be placed longitudinal in the anterior portion of the duct to avoid interrupting the blood supply.

Flushing the tube at this stage is important to ensure tube patency and absence of leakage. The tube is then exteriorized through the abdominal wall in the shortest and most straight possible distance. This will facilitate easier possible intervention through the T tube and formation of short and straight tissue tract that can also be used for intervention. Deflation of the pneumoperitoneum at the end of the procedure is helpful to adjust the intra-abdominal needed length of the tube. Flushing and irrigation is important at this stage too to ensure continued patency and absence of a leak. Jackson Prat draining tube should be placed nearby the choledochotomy area. This is a very important supportive measure to provide both continuous monitoring of a possible leak and drain the leak if it happens. A controlled and drained leak is much easier to handle than undrained leak. The JP drain should be left in place until after removal of the T tube.

Different surgeons may have different approaches depending on their experiences. But these the important principles that should be considered in T tube placement[14].

Complications

Complication of T tube placement can be due to the procedure technique, the nature of the disease, or patients' reasons. T tube placement demands high skills. Optimal techniques may reduce complications. Leak around the tube, tight closure of the choledochotomy, the inclusion of the T tube in the suturing are the possible technique complications.

Bile leak is the most common complication with T tube placement and the following period. This could be immediate, delayed, or after removal.

Clinical Significance

The clinical use of T tube has been significantly decreased in the last two decades due to the availability of less invasive alternatives of removing CBD stones. Because placement and removal of T tube is technically demanding and the complication rate and complexity are high, it should not be routinely performed. Less aggressive alternatives should be considered first.

Enhancing Healthcare Team Outcomes

CBD exploration can be managed with other non-T tube options. CBD stenting or primary closure can be used in selected patients. Stenting may provide better length of stay and hospitalization cost when appropriately and selectively used[1]. It is very important clinicians and nurses work together to manage and maintain T-tubes.


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T Tube - Questions

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A 76-year-old male presented with obstructive jaundice. US showed a 12 mm impacted stone in the distal common bile duct (CBD). Endoscopic retrograde cholangiopancreatography (ERCP) failed to extract the stone safely. The surgery team performed minimally invasive cholecystectomy and CBD through a choledochotomy. The team considered T tube placement for which of the following reasons?



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A 57-year-old male had T Tube after common bile duct (CBD) exploration for impacted stone. He recovered well from the surgery and is ready for discharge. Which one of the following is recommended?



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A 62-year-old female has a T tube for common bile duct (CBD) exploration placed four days ago without complications. The serum bilirubin level is trending down to a normal value. The amount of bile drained in through the tube is decreasing. What is the next step?



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A 62-year-old female with clinical and biochemical findings of obstructive choledocholithiasis was admitted for management. She has moderate right upper quadrant pain with no fever. Biliary ultrasound showed distal common bile duct stone of 8 mm. What is the best management approach?



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A 57-year-old male with T tube placed after common bile duct (CBD) exploration. On the 6th postoperative week, his serum bilirubin level is normal while the T tube is capped. The nearby Jackson Pratt (JP) is draining a small amount of serous fluid. What is the best next step?



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A 75-year-old female presents with acute cholangitis secondary to a 10 mm stone obstructing her common bile duct (CBD). Endoscopic retrograde cholangiopancreatography (ERCP) fails to retrieve the stone, so CBD exploration is performed. What is the appropriate site for choledochotomy?



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A 32-year-old male with a history of recurrent biliary colic presents for an elective laparoscopic cholecystectomy. Intraoperatively, a cholangiogram is performed and shows a filling defect in the common bile duct (CBD) suggestive of a stone. What is the best next step?



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T Tube - References

References

Xiao LK,Xiang JF,Wu K,Fu X,Zheng MY,Song XX,Xie W, The reasonable drainage option after laparoscopic common bile duct exploration for the treatment of choledocholithiasis. Clinics and research in hepatology and gastroenterology. 2018 Aug 22     [PubMed]
Abdelkader AM,Zidan AM,Younis MT, Temporary CBD Stenting with a Nelaton Tube Is a More Practical and Safer Option Than T-Tube Drainage after Conventional CBD Exploration for Choledocholithiasis. HPB surgery : a world journal of hepatic, pancreatic and biliary surgery. 2018     [PubMed]
Hundt M,Bhimji SS, Anatomy, Abdomen and Pelvis, Biliary Ducts null. 2018 Jan     [PubMed]
Apalakis A, An experimental evaluation of the types of material used for bile duct drainage tubes. The British journal of surgery. 1976 Jun     [PubMed]
Hakuta R,Kawahata S,Kogure H,Nakai Y,Saito K,Saito T,Hamada T,Takahara N,Uchino R,Mizuno S,Tsujino T,Tada M,Sakamoto N,Isayama H,Koike K, Endoscopic papillary large balloon dilation and endoscopic papillary balloon dilation both without sphincterotomy for removal of large bile duct stones: A propensity-matched analysis. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society. 2018 Jun 26     [PubMed]
Park CH, [The Management of Common Bile Duct Stones]. The Korean journal of gastroenterology = Taehan Sohwagi Hakhoe chi. 2018 May 25     [PubMed]
Espinel Díez J,Pinedo ME,Bernad B, MRCP before ERCP: the added value in the management of common bile duct stones. Revista espanola de enfermedades digestivas : organo oficial de la Sociedad Espanola de Patologia Digestiva. 2018 Jul     [PubMed]
Sherifi F,Bexheti S,Gashi Z,Bajraktari I,Shatri J,Lahu A, Anatomic Variations of Pancreaticobiliary Union. Open access Macedonian journal of medical sciences. 2018 Jun 20     [PubMed]
Ivanov D,Milosević P, Primary closure of the common bile duct in the treatment of choledocholithiasis. Medicinski pregled. 2010 Jan-Feb     [PubMed]
Baiu I,Hawn MT, Choledocholithiasis. JAMA. 2018 Oct 9     [PubMed]
Saeed N,Nasir MT,Khan MI,Channa GA, Choledochorraphy (primary repair) versus t-tube drainage after open choledochotomy. Journal of Ayub Medical College, Abbottabad : JAMC. 2012 Jan-Mar     [PubMed]
Deo KB,Adhikary S,Khaniya S,Shakya VC,Agrawal CS, Laparoscopic Choledochotomy in a Solitary Common Duct Stone: A Prospective Study. Minimally invasive surgery. 2018     [PubMed]
He MY,Zhou XD,Chen H,Zheng P,Zhang FZ,Ren WW, Various approaches of laparoscopic common bile duct exploration plus primary duct closure for choledocholithiasis: A systematic review and meta-analysis. Hepatobiliary     [PubMed]
Zhu H,Wu L,Yuan R,Wang Y,Liao W,Lei J,Shao J, Learning curve for performing choledochotomy bile duct exploration with primary closure after laparoscopic cholecystectomy. Surgical endoscopy. 2018 Oct     [PubMed]

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