INTRODUCTION: Operations on the common bile duct may lead to potentially serious complications such as biliary peritonitis. T-tube insertion is performed to reduce the risk of this occurring postoperatively. Biliary leakage at the point of insertion into the common bile duct, or along the fistula, can sometimes occur after T-tube removal and this has been reported extensively in the literature. We report a case where the site at which the T-tube fistula leaked proved to be the point of contact between the fistula and the anterior abdominal wall, a previously unreported complication. CASE PRESENTATION: A 36-year-old sub-Saharan African woman presented with gallstone-induced pancreatitis and, once her symptoms settled, laparoscopic cholecystectomy was performed, common bile duct stones were removed and a T-tube was inserted. Three weeks later, T-tube removal led to biliary peritonitis due to the disconnection of the T-tube fistula which was recannulated laparoscopically using a Latex drain. CONCLUSION: This case highlights a previously unreported mechanism for bile leak following T-tube removal caused by detachment of a fistula tract at its contact point with the anterior abdominal wall. Hepatobiliary surgeons should be aware of this mechanism of biliary leakage and the use of laparoscopy to recannulate the fistula.RIGHTS : This article is licensed under the BioMed Central licence at http://www.biomedcentral.com/about/license which is similar to the 'Creative Commons Attribution Licence'. In brief you may : copy, distribute, and display the work; make derivative works; or make commercial use of the work - under the following conditions: the original author must be given credit; for any reuse or distribution, it must be made clear to others what the license terms of this work are

Harris, Adrian M

Karthikesalingam, Alan

Nachimuthu, Senthil

Nikolić, Marko

Tang, Tjun Y

Journal of Medical Case Reports

PubMed

INTRODUCTION: Operations on the common bile duct may lead to potentially serious complications such as biliary peritonitis. T-tube insertion is performed to reduce the risk of this occurring postoperatively. Biliary leakage at the point of insertion into the common bile duct, or along the fistula, can sometimes occur after T-tube removal and this has been reported extensively in the literature. We report a case where the site at which the T-tube fistula leaked proved to be the point of contact between the fistula and the anterior abdominal wall, a previously unreported complication. CASE PRESENTATION: A 36-year-old sub-Saharan African woman presented with gallstone-induced pancreatitis and, once her symptoms settled, laparoscopic cholecystectomy was performed, common bile duct stones were removed and a T-tube was inserted. Three weeks later, T-tube removal led to biliary peritonitis due to the disconnection of the T-tube fistula which was recannulated laparoscopically using a Latex drain. CONCLUSION: This case highlights a previously unreported mechanism for bile leak following T-tube removal caused by detachment of a fistula tract at its contact point with the anterior abdominal wall. Hepatobiliary surgeons should be aware of this mechanism of biliary leakage and the use of laparoscopy to recannulate the fistula

Apollo (Cambridge)

BioMed CentralJournal of Medical Case ReportsssOpen AcceCase reportBiliary peritonitis caused by a leaking T-tube fistula disconnected at the point of contact with the anterior abdominal wall: a case reportMarko Nikolić1, Alan Karthikesalingam1, Senthil Nachimuthu2, Tjun Y Tang2 and Adrian M Harris*2Address: 1Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 2QQ, UK and 2Department of General Surgery, Hinchingbrooke Hospital NHS Trust, Hinchingbrooke Park, Huntingdon PE29 6NT, UKEmail: Marko Nikolić - mzn@cantab.net; Alan Karthikesalingam - alankarthi@googlemail.com; Senthil Nachimuthu - senthil.nachimuthu@hinchingbrooke.nhs.uk; Tjun Y Tang - tt279@cam.ac.uk; Adrian M Harris* - adrian.harris@hinchingbrooke.nhs.uk* Corresponding author    AbstractIntroduction: Operations on the common bile duct may lead to potentially serious complicationssuch as biliary peritonitis. T-tube insertion is performed to reduce the risk of this occurringpostoperatively. Biliary leakage at the point of insertion into the common bile duct, or along thefistula, can sometimes occur after T-tube removal and this has been reported extensively in theliterature. We report a case where the site at which the T-tube fistula leaked proved to be thepoint of contact between the fistula and the anterior abdominal wall, a previously unreportedcomplication.Case presentation: A 36-year-old sub-Saharan African woman presented with gallstone-inducedpancreatitis and, once her symptoms settled, laparoscopic cholecystectomy was performed,common bile duct stones were removed and a T-tube was inserted. Three weeks later, T-tuberemoval led to biliary peritonitis due to the disconnection of the T-tube fistula which wasrecannulated laparoscopically using a Latex drain.Conclusion: This case highlights a previously unreported mechanism for bile leak following T-tuberemoval caused by detachment of a fistula tract at its contact point with the anterior abdominalwall. Hepatobiliary surgeons should be aware of this mechanism of biliary leakage and the use oflaparoscopy to recannulate the fistula.IntroductionThe placement of a T-tube to drain the biliary system is awidely used alternative to primary closure of choledochot-omy following Common Bile Duct (CBD) exploration,especially in a non-dilated system. T-tubes are used toensure decompression of the biliary tree by creating afibrous fistula to the anterior abdominal wall. This per-mits healing of the choledochotomy incision and reducesthe risk of bile leak and stricture formation [1,2]. A smallbile discharge from the dermal ostium of the fistula maystill be observed but usually stops within 24 hours afterremoval of the tube without causing biliary peritonitis [3].As long as there is no distal CBD obstruction, normalintra-abdominal pressure will cause compression andPublished: 16 September 2008Journal of Medical Case Reports 2008, 2:302 doi:10.1186/1752-1947-2-302Received: 27 March 2008Accepted: 16 September 2008This article is available from: http://www.jmedicalcasereports.com/content/2/1/302© 2008 Nikolić et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4(page number not for citation purposes)Journal of Medical Case Reports 2008, 2:302 http://www.jmedicalcasereports.com/content/2/1/302obliteration of the fistula lumen. We describe a case wherethe fistula tract failed to adhere to the anterior abdominalwall, causing a leak after removal of the T-tube.Case presentationA 36-year-old sub-Saharan African woman presented tothe Accident and Emergency department with a 7-hourhistory of vomiting and central abdominal pain radiatingto the back. There were no respiratory, cardiovascular orurinary symptoms, and past medical history was unre-markable. The blood results included an amylase of 3070U/litre and an abdominal ultrasound showed multipletiny gallstones confined to a thin-walled gallbladder withnormal pancreas, liver, kidneys and spleen. A diagnosis ofgallstone-induced pancreatitis was made and laparo-scopic cholecystectomy was performed 5 days later, onceher symptoms had settled. An on-table cholangiogramdemonstrated a filling defect at the distal end of the CBDwith no duodenal filling. Laparoscopic CBD explorationwas undertaken and two stones were removed from thedistal CBD using a Dormia basket through the choledo-choscope. A Latex 12-Fr T-tube was inserted into the CBDat the end of the procedure. The patient made an unevent-ful recovery postoperatively and was discharged with theT-tube spigotted and left in situ.A T-tube cholangiogram 3 weeks later excluded any bileduct obstruction or leakage and the T-tube was thereforeremoved without difficulty. However, the patient soonstarted vomiting and complained of increasingly severeright upper quadrant abdominal pain. Following over-night observation, ultrasonography for suspected bile leakwas inconclusive. Biliary peritonitis was clinically sus-pected and an emergency diagnostic laparoscopy was per-formed. This revealed that the fistula had becomedisconnected at the point of contact with the anteriorabdominal wall (Fig. 1a,b). Bile was clearly visible drain-ing from the fistula opening (arrowed). The whole lengthof the fistula was inspected and no other leak was found;the proximal junction with the CBD was intact. The distalfistula was recannulated with a 10 Fr Latex drain (Fig. 2)and bile was observed to be draining freely from it. Fol-lowing an uneventful recovery, cholangiography of thecannulated tract with the Latex drain in-situ was repeatedafter 5 weeks and no dye was able to pass down it. Thetract was therefore presumed to have closed. The Latexdrain was removed 24 hours later with good recovery todate and no further complications.DiscussionBiliary peritonitis is regarded as a rare but serious compli-cation of elective T-tube removal after CBD exploration.Incidence reported in the literature varies from 0.8 to 5%in elective removal of T-tubes, rising to 24% in cases ofliver transplants [3].Historically, a latex T-tube has always been used duringopen exploration, specifically to encourage a vigorousinflammatory reaction around it causing formation of abiliary fistula. This makes T-tube removal much safer byreducing the potential for intraperitoneal bile leak. Thefistula closes rapidly after removal of the T-tube as long asthere is no distal CBD obstruction. More recently, sili-cone-coated or polyethylene T-tubes have become availa-ble, but these are less irritant and the resulting fistulatends to be less mature, increasing the risk of a leak afterT-tube removal. We do not recommend use of these newerT-tubes after CBD exploration unless the patient has alatex allergy.This case is novel since the site of the bile leak was distal,at the point of contact between fistula and anteriorabdominal wall. Usually biliary leakage occurs through(a) T-tube fistula tract openingFigure 1(a) T-tube fistula tract opening. Intraoperative laparo-scopic photograph illustrating opening to T-tube fistula tract (arrow) with diagrammatic representation of relation to bil-iary anatomy. (b) Diagram of fistula pathway and leak mecha-nism.a  b  Page 2 of 4(page number not for citation purposes)Journal of Medical Case Reports 2008, 2:302 http://www.jmedicalcasereports.com/content/2/1/302lack of complete fibrous T-tube fistula formation orthrough proximal fistula disruption during the removalprocess [4]. Identification of the location of the leak asdescribed was important for three reasons: first, it pro-vided an accurate diagnosis; second, it confirmed that theusual leak point (i.e. the junction between fistula andCBD) was intact and did not therefore require a further T-tube placement, and third, it allowed a simple therapeuticmanoeuvre by re-intubating the fistula opening.It may be suggested that the fistula was disrupted from theabdominal wall during insufflation at the time of laparos-copy. However, this does not explain the clinical presen-tation before laparoscopy. We knew there was no leakbefore T-tube removal because of a normal T-tube cholan-giogram and lack of abdominal symptoms. The patientsuffered upper abdominal pain soon after removal of theT-tube, developing biliary peritonitis along with raisedinflammatory markers (white cell count and C-reactiveprotein). This indicates a leak at the time of T-tuberemoval which was subsequently confirmed at laparos-copy with a pool of bile on the surface of the abdominalviscera. Bile was clearly observed emanating directly fromthe distal fistula opening.The literature has been reviewed in view of factors whichaffect the risk of biliary leakage.T-tubes versus choledochorrhaphyThe first option is to avoid T-tube insertion altogether andperform a choledochorrhaphy (primary closure of thecholedochotomy). In the past, this was rarely advised as itwas thought to increase the risk of stricture formation andprevent postoperative CBD decompression. However,research has recently suggested that primary closure maybe as safe as T-tube usage [5], although it should beavoided if the CBD is not significantly dilated. The otherbenefit of T-tubes is the ease of postoperative visualisationof retained CBD stones (T-tube cholangiogram).Duration of T-tube insertionMany factors may affect the risk of symptomatic bile leak-age following T-tube removal. Ellis [2] originally sug-gested that T-tubes should be removed 10 days afteroperation. It has been suggested that leaving T-tubes insitu for longer periods allows maturation of the temporarybiliary cutaneous fistula, thus potentially reducing the riskof leakage [4]. However, there is no experimental evidenceto prove this hypothesis. Indeed, one study has shownthat leaving T-tubes in situ for longer periods, such as 1month postoperatively does not provide protectionagainst increased rates of bile leakage [1]. In this case, theT-tube was removed after 3 weeks, in line with commonpractice in the UK.T-tube materialExperimental evidence demonstrates that the materialused for manufacturing T-tubes affects the quality offibrous fistula formed [6,7]. This finding is supported byclinical evidence that polyvinyl chloride (PVC) or hypoal-lergenic latex T-tubes (such as those coated with silicon)increase rates of biliary peritonitis compared to red rubberor normal latex T-tubes, as the former take longer to forma mature tract [8]. In our case, therefore, the standard latexT-tube used is unlikely to be of aetiological significance.Immune systemThe hypothesis that an increased inflammatory responseleads to the formation of a stronger fistulous tract mayexplain the increased rates of symptomatic bile leaks inimmunocompromised patients, such as those undergoingliver transplantation [3]. In our case, there was no pastmedical history of diabetes or steroid use and no medicalevidence of occult immunosuppressive pathologies,although an HIV test was not performed.T-tube morphologyIt has been suggested that the morphology of the T-tube orits placement could reduce leakage [2], although otherauthors have pointed out that there is no experimentalevidence for this theory. Figure 3 illustrates the morphol-ogy of the T-tube used in this patient, designed to mini-mise trauma during T-tube removal and thus potentiallythe risk of biliary leakage [9]. Some authorities recom-mend cutting a notch in the short 'crossbar', opposite thedrainage tube, to further facilitate removal by allowing thetwo 'wings' to fold more easily. If this is done, care mustbe taken not to make the resulting bridge of material tooCannulation of T-tube fistulaFigure 2Cannulation of T-tube fistula. Intraoperative laparo-scopic photograph illustrating cannulation of T-tube fistula tract with 10-Fr Latex drain.Page 3 of 4(page number not for citation purposes)Journal of Medical Case Reports 2008, 2:302 http://www.jmedicalcasereports.com/content/2/1/302Publish with BioMed Central   and  every scientist can read your work free of charge"BioMed Central will be the most significant development for disseminating the results of biomedical research in our lifetime."Sir Paul Nurse, Cancer Research UKYour research papers will be:available free of charge to the entire biomedical communitypeer reviewed and published immediately upon acceptancecited in PubMed and archived on PubMed Central yours — you keep the copyrightSubmit your manuscript here:http://www.biomedcentral.com/info/publishing_adv.aspBioMedcentralthin as the wings may then detach during the removalprocess.T-tube removal techniqueGoodwin et al. [10] reported a significant reduction in bileleakage and subsequent biliary peritonitis after T-tuberemoval in liver transplant patients when the tube wasremoved along a wire (Seldinger method). This techniqueis generally only recommended in high-risk patients inwhom bile leakage is anticipated following T-tuberemoval, especially in immunocompromised patients fol-lowing liver transplantation.ConclusionThis case and our review of the literature highlight a pre-viously unreported mechanism for bile leak following T-tube removal caused by dehiscence of a fistula tract at itscontact point with the anterior abdominal wall. Hepato-biliary surgeons should be aware of this mechanism ofbiliary leakage and the use of laparoscopy to recannulatethe fistula with a satisfactory outcome.ConsentWritten informed consent was obtained from the patientfor publication of this case report and any accompanyingimages. A copy of the written consent is available forreview by the Editor-in-Chief of this journal.Competing interestsThe authors declare that they have no competing interests.Authors' contributionsMN and AK were involved in design of the case report,drafted the manuscript and performed critical literaturereview. AH, SN and TT conceived the original idea of thecase report, conducted the operations detailed and havebeen involved in critically revising the manuscript.References1. Wills VL, Gibson K, Karihaloot C, Jorgensen JO: Complications ofbiliary T-tubes after choledochotomy.  ANZ J Surg 2002,72(3):177-180.2. Ellis H: Choledocholithiasis.  In Maingot's Abdominal OperationsEdited by: Schwartz S, Ellis H. Norwalk, CT: Appleton-Century-Crofts; 1985:1883-1907. 3. Lazaridis C, Papaziogas B, Patsas A, Galanis I, Paraskevas G, Argiria-dou H, Papaziogas T: Detection of tract formation for preven-tion of bile peritonitis after T-tube removal. Case report.Acta Chir Belg 2005, 105(2):210-212.4. Maghsoudi H, Garadaghi A, Jafary GA: Biliary peritonitis requiringreoperation after removal of T-tubes from the common bileduct.  Am J Surg 2005, 190(3):430-433.5. Gurusamy KS, Samraj K: Primary closure versus T-tube drain-age after open common bile duct exploration.  Cochrane Data-base Syst Rev 2007.6. Koivusalo A, Eskelinen M, Wolff H, Talva M, Mäkisalo H: Develop-ment of T-tube tracts in piglets: effect of insertion methodand material of T-tubes.  Res Exp Med (Berl) 1997, 197(1):53-56.7. Apalakis A: An experimental evaluation of the types of mate-rial used for bile duct drainage tubes.  Br J Surg 1976,63(6):440-445.8. Winstone NE, Golby MG, Lawson LJ, Windsor CW: Biliary perito-nitis: a hazard of polyvinyl chloride T-tubes.  Lancet 1965,1:843-844.9. Sakorafas GH, Stafyla V, Tsiotos GG: Biliary peritonitis due to fis-tulous tract rupture following a T-tube removal.  N Z Med J2005, 118(1217):U1522.10. Goodwin SC, Bittner CA, Patel MC, Noronha MA, Chao K, Sayre JW:Technique for reduction of bile peritonitis after T-tuberemoval in liver transplant patients.  J Vasc Interv Radiol 1998,9:986-990.T-tube morphologyFig r  3T-tube morphology. A gutter is cut out of the cross arm to lower resistance during T-tube removal and thus reduce the risk of traumatic fistula disruption.Page 4 of 4(page number not for citation purposes)

English

Biliary peritonitis caused by a leaking T-tube fistula disconnected at the point of contact with the anterior abdominal wall: a case report.

Marko Nikolić

Alan Karthikesalingam

Senthil Nachimuthu

Tjun Y Tang

Adrian M Harris

Springer - Publisher Connector

Biliary peritonitis caused by a leaking T-tube fistula disconnected at the point of contact with the anterior abdominal wall: a case report

An experimental evaluation of the types of material used for bile duct drainage tubes.

Choledocholithiasis. I n Maingot's Abdominal Operations Edited by: Schwartz

Complications of biliary T-tubes after choledochotomy.

CW: Biliary peritonitis: a hazard of polyvinyl chloride T-tubes. Lancet

GA: Biliary peritonitis requiring reoperation after removal of T-tubes from the common bile duct.

JW: Technique for reduction of bile peritonitis after T-tube removal in liver transplant patients. J Vasc Interv Radiol

Mäkisalo H: Development of T-tube tracts in piglets: effect of insertion method and material of T-tubes. Res Exp Med (Berl)

Papaziogas T: Detection of tract formation for prevention of bile peritonitis after T-tube removal. Case report. Acta Chir Belg

Samraj K: Primary closure versus T-tube drainage after open common bile duct exploration. Cochrane Database Syst Rev

Tsiotos GG: Biliary peritonitis due to fistulous tract rupture following a T-tube removal.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2557018

Biliary peritonitis caused by a leaking T-tube fistula disconnected at the point of contact with the anterior abdominal wall: a case report.

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