Biliary T-tube Research Articles

328 Local Delays in Tubogram Completion for Biliary Patency – Why the Wait?

Abstract Aim Despite the CHOCOLATE Study (CS Loozen et al 2018) recommending laparoscopic cholecystectomy even in high-risk patients, we are completing more cholecystostomies than ever to manage acute cholecystitis, particularly during the COVID pandemic. Fluoroscopic tubogram can be performed to check biliary patency post intervention, this can potentially definitive treatment or discharge. We locally assessed the time delay in accessing tubograms. Method Audit of all local tubograms completed of the biliary system (September 2020-2022). All tubogram procedures (not just biliary) within the North West Mersey Region over the same period also quantified. Results 397 tubograms were conducted in the NW; 51 locally. 26/51 were for post IR drain & 1 for biliary t-tube assessment from 26 patients (av. age 73, range 59-90yrs). 19 were as inpatient, 8 outpatients. Assessing working days between expected completion and actual completion in both groups: 73.7% of inpatient tubograms were completed within 3 or less days (av. 3.6, range 0-17 days). 37.5% of outpatient tubograms were completed within 5 days of less (av. 7.9, range 0-23 days). There was 1 true complication (tube slippage & removal), 3 extravasations & 1 abandoned procedure. 4 (15%) patients had died at the time of data assessment. Conclusions With the rise of cholecystostomy, there has been an increase in biliary tubograms. These are a specialist procedure; there is a time delay in obtaining them and they do not come without risk. Provision of tubograms needs to be assessed, or a move back to traditional initial surgical management considered.

Short-term efficacy of cholecystectomy plus bile duct T-tube drainage or choledochojejunostomy in the treatment of gallbladder cancer and its effects on median survival time and postoperative complications.

To explore the short-term efficacy of cholecystectomy plus bile duct T-tube drainage or choledochojejunostomy (CJ) in the treatment of gallbladder cancer (GC) and its effects on the median survival time and postoperative complications. The clinical data of 121 patients who underwent laparoscopic cholecystectomy (LC) in department of hepatobiliary surgery of the hospital from January 2018 to December 2018 were retrospectively analyzed. According to the adjuvant treatment methods, the patients were divided into 2 groups: the control group (n = 61, LC + bile duct T-tube drainage) and experimental group (n = 60, LC + CJ). The perioperative indicators, short-term efficacy, median survival time, postoperative complications and immune stress response were compared between the 2 groups of patients before and after propensity score matching. The surgical time, postoperative anal first exhaust time, and intraoperative blood loss in the experimental group were no different from those in the control group (P > .05), but the hospital stay was shorter than that in the control group (P < .05). There was no difference in the effective rate of treatment and median survival time between the 2 groups (P > .05). The total incidence rate of complications in the experimental group at 14 days after surgery was lower than that in the control group (P < .05). Day 3 after surgery, the levels of immunoglobulin M (IgM) and immunoglobulin G (IgG) of the experimental group were higher than those of the control group (P < .05), while the level of C-reactive protein (CRP) was lower than that of the control group (P < .05). Compared with bile duct T-tube drainage, LC + CJ in the treatment of GC can better shorten the postoperative hospital stay and reduce the postoperative complications and immune stress response, but and the median survival time of the 2 is similar, which can be promoted in clinical practice.

The ART and Craft of Biliary T-Tube Use

Introduction: Biliary surgery has matured substantially over recent decades. The use of Hans Kehr’s universally adopted T-tube in the early twentieth century, has shifted from ‘routine’ in frequent bile duct explorations to highly selective and occasional. This evolution is primarily a consequence of improved interventional endoscopy, interventional radiology and hepato-pancreato-biliary (HPB) surgery. Unfortunately, it has also resulted in far less exposure to this technique for surgical trainees.

The art and craft of biliary T-tube Use.

Since the universal adoption of Hans Kehr's biliary T-tube in the early twentieth century, use has shifted from routine towards highly selective. Improved interventional endoscopy, percutaneous techniques, and hepato-pancreato-biliary (HPB) training have resulted in less T-tube experience within general surgery. The aim of this technical review is to discuss T-tube indications, technical nuances, and management. Peer-reviewed literature, combined with high volume HPB experience by the authors, was utilized to construct a 10-step conceptual pathway for safe T-tube usage. Essential concepts surrounding T-tube use include: 1. Contemporary indications for T-tube insertion (disease-, patient-, and anatomy-based); 2. Correct instrument availability (open and laparoscopic); 3. T-tube selection and mechanical preparation; 4. Atraumatic T-tube insertion and security; 5. Immediate postoperative management and meticulous T-tube care; 6. Imaging biliary T-tubes; 7. Optimal timing of T-tube removal; 8. Technical aspects of T-tube removal; 9. Management of potential T-tube inpatient complications; and 10. Management of T-tube complications in the outpatient setting. Although their use has decreased substantially, the role of biliary T-tubes in some patients is essential. Given the reality of less frequent experience with T-tube insertion and management, this 10-step pathway will provide an adequate mental and technical framework for safe biliary T-tube use. Expert opinion, level V.

The art and craft of biliary t-tube use

Introduction Since the universal adoption of Hans Kehr's biliary T-tube in the early twentieth century, use has shifted from routine towards highly selective. Improved interventional endoscopy, percutaneous techniques, and hepato-pancreato-biliary (HPB) training have resulted in less T-tube experience within general surgery. The aim of this technical review is to discuss T-tube indications, technical nuances, and management. Methods Peer-reviewed literature, combined with high volume HPB experience by the authors, was utilized to construct a 10-step conceptual pathway for safe T-tube usage. Results Essential concepts surrounding T-tube use include: 1. Contemporary indications for T-tube insertion (disease-, patient-, and anatomy-based); 2. Correct instrument availability (open and laparoscopic); 3. T-tube selection and mechanical preparation; 4. Atraumatic T-tube insertion and security; 5. Immediate postoperative management and meticulous T-tube care; 6. Imaging biliary T-tubes; 7. Optimal timing of T-tube removal; 8. Technical aspects of T-tube removal; 9. Management of potential T-tube inpatient complications; and 10. Management of T-tube complications in the outpatient setting. Conclusions Although their use has decreased substantially, the role of biliary T-tubes in some patients is essential. Given the reality of less frequent experience with T-tube insertion and management, this 10-step pathway will provide an adequate mental and technical framework for safe biliary T-tube use. Level of evidence Expert opinion, level V.

English

English

The role of biliary T-tubes in contemporary hepatobiliary and emergency surgery: Has their time passed?

The role of biliary T-tubes in contemporary hepatobiliary and emergency surgery: Has their time passed?

胆总管探查改良自行脱落胆管支架引流与T管引流的比较

胆总管探查改良自行脱落胆管支架引流与T管引流的比较

Development of a novel T-tube frontal sinus irrigation catheter.

The problem of postoperative management after frontal sinus surgery remains a challenge. The bilateral opening created in the Draf III procedure does not fit any currently available stent, and patients find rinsing the frontal sinus difficult, which thus decreases compliance. The objective of this study was to demonstrate the successful use of a novel frontal sinus catheter fashioned from a biliary T tube by addressing these issues in patients with complicated sinus disease. This was a review of 30 patients who underwent a Draf III procedure between January and October 2014, and who had a T-tube stent inserted at the end of the procedure. Patient charts were analyzed for complications such as bleeding, infection, and restenosis as well as indications of ease of rinsing ability after surgery. From the chart data, there was only one intraoperative bleed and only one postoperative bleed that required packing. Four patients had infections that required antibiotics after surgery. At the time of data collection, only one patient had signs of restenosis as judged by the operating surgeon. Patients reported an ease of rinsing ability with the T-tube stent. The novel biliary T-tube stent use presented in this article is a promising future direction for postoperative care after extended frontal sinus surgery.

Comparison of the disposable bag replacement time of biliary T-tube drainage

Objective To compare the replacement time of normal and anti-reflux disposable drainage bag for the risk of infection in patients with biliary T-tube drainage, and to explore the most suitable frequency which patients can get the most benefits.Methods Totals of 144 patients with routine T-tube drainage and the negative culture results of biliary bile were randomly divided into three groups by random number table method. Group A and group B used ordinary disposable drainage bag, while group A changed it every day and group B changed it once a week.Group C used the disposable anti-reflux drainage bag and replaced it once a week.The extraction of bile from drainage bag was used to do the bacteriological monitoring and the results were compared among the three groups.Results There was no significant difference in the bacterial culture among the three groups at the 5th day and 10th day after the drainage （χ2 =0.51, 1.64, respectively;P 〉0.05）.The replacement frequency of the three groups were statistically significant （F=1 379.17,P〈0.01）.The cost of changing drainage bag in three groups had statistically significant difference （ F =229.19, P 〈0.01 ）. Conclusions Patients with biliary T-tube, who use the ordinary disposable bags and change it weekly have similar infection rate as the anti-reflux drainage bag, what’ s more, it can reduce the costs of patients and the workload of nurses. Key words: Biliary track; T-tube drainage; Disposable drainage bag; Replacement time

How do we manage post-OLT redundant bile duct?

To address endoscopic outcomes of post-Orthotopic liver transplantation (OLT) patients diagnosed with a "redundant bile duct" (RBD). Medical records of patients who underwent OLT at the Liver Transplant Center, University Texas Health Science Center at San Antonio Texas were retrospectively analyzed. Patients with suspected biliary tract complications (BTC) underwent endoscopic retrograde cholangiopancreatography (ERCP). All ERCP were performed by experienced biliary endoscopist. RBD was defined as a looped, sigmoid-shaped bile duct on cholangiogram with associated cholestatic liver biomarkers. Patients with biliary T-tube placement, biliary anastomotic strictures, bile leaks, bile-duct stones-sludge and suspected sphincter of oddi dysfunction were excluded. Therapy included single or multiple biliary stents with or without sphincterotomy. The incidence of RBD, the number of ERCP corrective sessions, and the type of endoscopic interventions were recorded. Successful response to endoscopic therapy was defined as resolution of RBD with normalization of associated cholestasis. Laboratory data and pertinent radiographic imaging noted included the pre-ERCP period and a follow up period of 6-12 mo after the last ERCP intervention. One thousand two hundred and eighty-two patient records who received OLT from 1992 through 2011 were reviewed. Two hundred and twenty-four patients underwent ERCP for suspected BTC. RBD was reported in each of the initial cholangiograms. Twenty-one out of 1282 (1.6%) were identified as having RBD. There were 12 men and 9 women, average age of 59.6 years. Primary indication for ERCP was cholestatic pattern of liver associated biomarkers. Nineteen out of 21 patients underwent endoscopic therapy and 2/21 required immediate surgical intervention. In the endoscopically managed group: 65 ERCP procedures were performed with an average of 3.4 per patient and 1.1 stent per session. Fifteen out of 19 (78.9%) patients were successfully managed with biliary stenting. All stents were plastic. Selection of stent size and length were based upon endoscopist preference. Stent size ranged from 7 to 11.5 Fr (average stent size 10 Fr); Stent length ranged from 6 to 15 cm (average length 9 cm). Concurrent biliary sphincterotomy was performed in 10/19 patients. Single ERCP session was sufficient in 6/15 (40.0%) patients, whereas 4/15 (26.7%) patients needed two ERCP sessions and 5/15 (33.3%) patients required more than two (average of 5.4 ERCP procedures). Single biliary stent was sufficient in 5 patients; the remaining patients required an average of 4.9 stents. Four out of 19 (21.1%) patients failed endotherapy (lack of resolution of RBD and recurrent cholestasis in the absence of biliary stent) and required either choledocojejunostomy (2/4) or percutaneous biliary drainage (2/4). Endoscopic complications included: 2/65 (3%) post-ERCP pancreatitis and 2/10 (20%) non-complicated post-sphincterotomy bleeding. No endoscopic related mortality was found. The medical records of the 15 successful endoscopically managed patients were reviewed for a period of one year after removal of all biliary stents. Eleven patients had continued resolution of cholestatic biomarkers (73%). One patient had recurrent hepatitis C, 2 patients suffered septic shock which was not associated with ERCP and 1 patient was transferred care to an outside provider and records were not available for our review. Although surgical biliary reconstruction techniques have improved, RBD represents a post-OLT complication. This entity is rare however, endoscopic management of RBD represents a reasonable initial approach.

Endoscopic trans(naso)orbital management of supraorbital mucoceles with biliary T‐tube stenting

The objective of this article is to describe our surgical technique for accessing orbital and supraorbital ethmoid sinus mucoceles and the novel application of a biliary T-tube to stent and redirect mucociliary flow into the frontal recess. We describe in technical terms our surgical approach and the use of an 8-Fr pediatric biliary T-tube as a paranasal sinus stent with demonstrative case reports. Four patients have been successfully managed employing the endoscopic trans(naso)orbital approach to access and marsupialize supraorbital and superiorly located orbital mucoceles without egress to the frontal recess. Patency of drainage was maintained by utilizing a flexible, pediatric, biliary T-tube that is inserted via an above (trephination) and below (endoscopic) approach in three patients, and without the need for stenting in one patient (median follow-up, 14.5 months). The presented surgical strategy is safe and effective in accessing and maintaining long-term patency of problematic supraorbital and superiorly located intraorbital mucoceles without communication to the frontal recess.

A feasible and effective method for restoring patency of a biliary T-tube sinus tract

A feasible and effective method for restoring patency of a biliary T-tube sinus tract

A feasible and effective method for restoring patency of a biliary T-tube sinus tract

A feasible and effective method for restoring patency of a biliary T-tube sinus tract

Endoscopic management of a migrated biliary T-tube

Endoscopic management of a migrated biliary T-tube

A novel technique for biliary T-tube fixation

A novel technique for biliary T-tube fixation

PROSPECTIVE ASSESSMENT OF HEPATIC FUNCTION AND MECHANISMS OF DYSFUNCTION IN THE CRITICALLY ILL

Liver dysfunction affects a variety of metabolic pathways in the critically ill, but mechanisms remain poorly understood. We prospectively assessed markers of hepatic injury and function in sepsis and I/R injury in vivo and molecular mechanisms in human liver tissue ex vivo. Markers of hepatocellular injury, synthesis, and excretion, including plasma disappearance rate of indocyanine green (ICG), were measured in 48 patients with severe sepsis. Incidence of liver dysfunction was 42% as assessed by hyperbilirubinemia but 74% by impaired dye excretion. Conventional markers for liver injury failed to predict outcome, whereas dye excretion of less than 8% per minute predicted death with high sensitivity and specificity. Potential mechanisms were assessed via (a) gene expression analysis of transporter proteins for bilirubin and ICG in cultured human liver tissue, and (b) monitoring uptake and excretion of the dye after I/R injury in 12 patients receiving a biliary T-tube during liver transplantation. Ex vivo gene expression of transporters was differentially affected for bilirubin and ICG with upregulation of basolateral and downregulation of canalicular ICG transporters. Consistently, patients with unfavorable course after liver transplantation displayed almost complete cessation of biliary dye excretion, whereas uptake into the hepatocyte was reduced by only 40%. In conclusion, standard liver tests lack the required sensitivity to assess hepatic injury and function in the critically ill. Dye excretion better reflects excretory and/or microvascular dysfunction but still underestimates impaired canalicular transport. The observed differential susceptibility of the polar surfaces of human hepatocytes has potential implications for monitoring liver function and drug-induced liver injury.

Orthotopic Liver Transplantation: T-Tube or Not T-Tube? Systematic Review and Meta-Analysis of Results

The purpose of this study was to compare outcomes after duct-to-duct anastomoses with or without biliary T-tube in orthotopic liver transplantation. We pooled the outcomes of 1027 patients undergoing choledocho-choledochostomy with or without T-tube in 9 of 46 screened trials by means of fixed or random effects models. The "without T-tube" and "with T-tube" groups had equivalent outcomes for: anastomotic bile leaks or fistulas, choledocho-jejunostomy revisions, dilatation and stenting, hepatic artery thromboses, retransplantation, and mortality due to biliary complications. The "without T-tube" group had better outcomes when considering "fewer episodes of cholangitis," "fewer episodes of peritonitis," and showed a favorable trend for "overall biliary complications." Although the "with T-tube" group showed superior result for "anastomotic and nonanastomotic strictures," the incidence of interventions was not diminished. Our systematic review and meta analysis favor the abandonment of T-tubes in orthotopic liver transplantation.

Management of postoperative complications in patients with biliary tract exploration and T-tube drainage

目的 探讨胆道探查T管引流术后并发症发生的原因及其防治措施.方法 对1986年至2002年间该院行972例胆道探查T管引流术后发生并发症的36例临床资料作回顾性分析.结果 36例并发症中胆漏或胆汁性腹膜炎20例,胆道出血3例,胆道蛔虫症2例,T管压迫胃十二指肠致不全梗阻1例,T管拔断遗留胆总管内1例,术后胆汁引流量异常2例,术后黄疸急剧加深1例,并发急性胰腺炎2例,T管不能夹闭(胆道结石残留)3例,T管致胆道结石形成1例.本组保守治疗21例(58%),再手术治疗15例(42%).除1例并发急性坏死性胰腺炎死亡,1例并发低渗性脱水、营养不良自动出院外,其余均痊愈出院.结论 发生并发症的原因主要与手术操作技术、术后处理以及患者本身疾病、机体状况等有关.恰当的术中操作与术后处理是预防术后并发症发生的主要措施。

Biliary T-Tube Remnant As the Cause of Microlithiasis and Recurrent Acute Pancreatitis, Detected By a New Per Oral Cholangioscopy System (SpyGlass)

A 62 year old female s/p cholecystectomy for cholelithiasis a year ago, with recurrent acute pancreatitis and mildly elevated LFTs with dilated biliary tree underwent ERCP that showed long cystic duct stump and dilated biliary tree without filling defects. Balloon sweep of CBD after sphinterotomy yielded only sludge. She developed another attack of acute pancreatitis after few months. MRCP showed a filling defect in the distal CBD. Repeat ERCP was done with sludge extraction. After few months, she had acute pancreatitis again and MRCP showed new distal CBD stone. An ERCP with cholangioscopy using the new per oral cholangioscopy system (SpyGlass) was done. Cholangiogram showed a filling defect in distal CBD but no filling defects in the cystic duct stump. Cholangioscopy confirmed the presence of the filling defect in distal CBD as microlithiasis, and in addition showed a tubular structure covered with sludge in the cystic duct. Balloon sweep of the cystic duct yielded a foreign body that was found to be remnant of a T-tube used during patient's cholecystectomy (picture). Presence of a foreign body in biliary tree is known to act as a nidus for sludge and microlithiasis formation. Recurrent attacks of acute pancreatitis in our patient were attributed to microlithiasis and sludge as a result of presence of T-tube remnant. Due to its hollow structure, the tube would fill with contrast and could not be visualized during ERCP. Filling with bile prevented visualization on MRCP. Being made up of radiolucent plastic material it also had evaded detection on CT scan. Direct cholangioscopy was the only diagnostic technique that enabled the detection of T-tube remnant in the cystic duct stump and subsequent removal.