World J. Surg.

6, 610-615, 1982
World Journal
of Sdr ry

Adverse Reactions Following T-Tube Removal

E. Patchen Dellinger, M.D., Michael Steer, M.D., Mark Weinstein, M.D., and Gerald Kirshenbaum, M.D.

Departments of Surgery, Harborview Medical Center, Universityof Washington Schoolof Medicine, Seattle, Washington and Beth
Israel Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A.

Six of 139 (4.3%) patients experienced adverse reactions ing tube removal were noted. These data, suggest-
following the postoperative removal of a T-tube. Five ing that T-tube removal may not always be benign,
(3.6%) were severe enough to require readmission to the form the basis for the subsequent report.
hospital or to delay discharge. All had had normal T-tube
cholangiograms and the T-tube had been clamped without
problem prior to tube removal. Signs and symptoms in- Materials and Methods
cluded abdominal pain (6 of 6), chills (3 of 6), tenderness (4
of 6), fever (5 of 6), and increased bilirubin (3 of 4). The charts of 141 patients who had undergone
Symptoms resolved between 4 hours and 8 days following common duct exploration at the Beth Israel Hospi-
removal without operative intervention. Adverse reaction
tal between January 1975 and June 1977 were
following T-tube removal may be related to disruption of
reviewed. Two patients had complications of intra-
the fibrous tract and extravasation of infected bile into the
abdominal or abdominal wall abscesses in associa-
surrounding tissues.
tion with their T-tubes, making evaluation of bacte-
riologic data or possible reaction to T-tube removal
Although some [1-5] have advocated primary com- unclear, and so were excluded from the study.
mon bile duct closure following common duct ex-
ploration, most surgeons recommend the use of a
tube to drain the common duct following choledo- Results
chotomy [6-9]. Abbe [10, 11] first reported this
technique in 1892, and later Kehr [12] and Robson Six patients experienced marked reactions shortly
[13] recommended its use whenever distal obstruc- after the removal of their T-tubes in the postopera-
tion was suspected or "stinking muddy bile" was tive period. A representative patient is presented.
encountered. Deaver [14] first described the T-tube
that is commonly used today. Removal of the T-
tube is usually performed 10-14 days postoperative- Case Report
ly and is considered to be a benign maneuver [6, 7,
15]. However, reports of problems without details J.D., a 45-year-old male, underwent cholecystecto-
or incidences have appeared from time to time [1, my, common bile duct exploration, and sphinctero-
16, 17], and several authors have suggested alter- plasty for acute cholecystitis with choledocholithia-
ations of the standard tubes to reduce the likelihood sis and distal common bile duct stricture and had a n
of problems [7, 16, 18-21]. In a review of 139 unremarkable postoperative course. He was treated
consecutive common duct explorations [22] with T- with intravenous ampicillin intraoperatively and for
tube placement, a total of 6 (4.3%) reactions follow- two additional days, although bile cultures obtained
in the operating room showed no growth. Serum
bilirubin was 1.5 mg/100 ml on the first postopera-
tive day, falling to 1.1 mg/100 ml on the eighth
Reprint requests: E. Patchen Dellinger, M.D., Depart- postoperative day. A T-tube bile culture on the
ment of Surgery, ZA-16, Harborview Medical Center, 325 seventh postoperative day grew Staphylococcus
9th Ave., Seattle, WA 98104, U.S.A. epidermidis, Candida species, and Haemophilus

0364-2313/82/0006-0610 $01.20
9 1982 Socidt6 Internationale de Chirurgie
E.P. Dellinger et al.: Reaction to T-Tube Removal 611

parainfluenzae. A cholangiogram on the ninth post- duct exploration and tube removal. All patients
operative day was normal and the T-tube was were well at the time of follow-up without sequelae
clamped without incident 2 days later at the time of related to the biliary tract.
discharge. On the fifteenth postoperative day, his The frequency of reactions following tube remov-
T-tube was removed without difficulty in the outpa- al [6 in 139 patients (4.3%)] noted in this report may
tient clinic. One hour after the tube was removed, be a minimal figure, since specific information
he noted severe right upper quadrant pain and regarding tube removal was not available on a
reported to the emergency room, where he was significant number of the charts. These patients
found to have marked right upper quadrant tender- were discharged with their tubes in place and had
ness and guarding and a temperature of 101~ them removed in the office of their private surgeon.
Three blood cultures were obtained, all of which It is likely, however, that all reactions severe
were negative. The patient was admitted to the enough to prompt readmission have been docu-
hospital and treated with kanamycin and ampicillin mented.
for 5 days. His temperature peaked at 101.8~ on
the day following admission and slowly returned to
normal over the next 7 days~ Serum bilirubin was Discussion
0.4 mg/100 ml when he presented to the emergency
room and increased to 1.8 mg/100 ml 2 days later, Passing mention of problems at the time of tube
then fell to 0.5 mg/100 ml 7 days after the tube had removal has been made in reports of large series of
been removed. Serum amylase was elevated to 314 common bile duct explorations [5, 21] or in books
(normal, <150) in the emergency room and fell to devoted to biliary tract surgery [8, 9]. McKenzie
128 two days later. The right upper quadrant pain [23] and Ellis [24] reported series of 20 and 22
and tenderness resolved over 4 days. patients with bile peritonitis, respectively, of which
Five patients (3.6%) experienced a reaction se- one in each series followed postoperative T-tube
vere enough to provoke readmission to the hospital removal. Wolfson [25] reported 3 cases of "sponta-
or to delay discharge. One additional patient experi- neous rupture" of the common bile duct, but each
enced right upper quadrant discomfort similar to his case followed a common duct exploration with tube
previous gallbladder attacks but which lasted for drainage and in all probability represented delayed
only 4 hours and was not associated with a change diagnosis of bile leakage with subhepatic abscess
in temperature. All 6 patients reported severe right formation following tube removal. One of these
upper quadrant pain. Other common findings in- patients had retained stones, but this information is
cluded abdominal tenderness, fever, and chills (Ta- not recorded for the other 2 patients.
ble 1). Serum bilirubin was elevated in 3 of the 5 The major focus of literature dealing with T-tube
patients in whom it was measured. Seven blood problems has been the effect of different materials
cultures were obtained from 4 patients and all from which the T-tube may be made. It is well
showed no growth. The 5 patients with temperature known that tubes within the biliary system are
elevations were all treated with antibiotics and none subject to encrustation, obstruction, and inflamma-
required reoperation. Resolution of symptoms and tory reactions. Experiments performed in dogs [26,
fever occurred between 4 hours and 8 days after 27] have documented an inflammatory reaction
their onset (average, 3.4 days). around rubber T-tubes within the common bile
The average age of the 6 patients was 48 years duct, and concern regarding the possible contribu-
(range, 25-81 years) as compared to an average of tion of this reaction to postoperative bile duct
62 years (range, 17-98 years) in the 133 patients stricture formation led to the development of T-
who did not experience a reaction. Four of the 6 tubes made from less reactive materials such as
patients (67%) had documented bactobilia before silicone rubber and polyvinyl chloride. The fact that
tube removal, as compared to 114 of 133 (86%) of these materials evoke less inflammation in the bile
the remaining patients. All 6 patients had normal ducts and elsewhere has been noted [28-31]. How-
cholangiograms in the postoperative period and ever, this favorable property is accompanied by a
prior to tube removal. In addition, all 6 patients had new problem, since the inflammatory reaction ap-
their tubes clamped between 3 and 12 days prior to pears necessary for adequate formation of a sinus
tube removal. The interval between operation and tract around the tube. Under the usual circum-
tube removal varied from 13 to 20 days, with an stances, T-tube removal in the postoperative period
average interval of 16 days. is associated with a very brief period of bile drain-
Follow-up information on 5 of the 6 patients who age to the skin, provided that the common duct is
experienced reactions has been obtained by con- free of retained stones or other distal obstruction.
tacting the patients or their private surgeons at When bile drainage persists, this fibrous sinus tract
intervals ranging from 3 to 5 years after common leads the bile out to the skin, preventing its intra-
612 World J. Surg. Vol. 6, No. 5, September 1982

Table 1. Presentation of reactions following removal of T-tubes.

Abdominal Peak Bilirubin
Patient pain temperature initial/peak Blood cultures Antibiotics
number Age Sex duration Chills ~ rag/100 ml (Number done) used
1 45 M 4 days No 101.8 0.4/1.8 NG b (3) Yes
2 56 M 4 hrs No 98.6 ND c ND No
3 28 F 1 day Yes 102 0.6/1.7 NG (1) Yes
4 54 M 5 days Yes 103 1.7/3.2 NG (2) Yes
5 81 F 2 days No 102.6 -/1.0 NG (1) Yes
6 25 F 1 day Yes 100 -/0.8 ND Yes
aAll patients were afebrile prior to removal of T-tube.
bNG: no growth.
' N D : not done.

abdominal accumulation and the subsequent devel- placement of the duct during tube removal varied
opment of intra-abdominal abscess or bile peritoni- between 0.5 and 2.0 cm, and the duct returned
tis [7-9]. quickly to its normal position. No extravasation of
Shortly after the introduction of polyvinyl chlo- contrast material outside of the tube sinus tract
ride (PVC) T-tubes, several authors reported diffuse occurred in these 6 patients. There is no record of
bile peritonitis immediately following the removal the tube materials or any alteration or trimming of
of these tubes [32, 33]. They attributed this to the the T-tubes. Domell6f et al. [40] performed contrast
poor quality tract formed about these tubes, as well radiography with fluoroscopic control during T-
as to the stiffness that the tubes develop after tube removal in 51 patients. They did not mention
incubating for a short period of time in bile [30, 32, movement of the common duct, but in contrast to
34]. A search of the medical literature has revealed Scatliff, observed contrast extravasation out of the
no further reports regarding the use of PVC T-tubes tube tract in 25 of the 51 patients. In II instances
for biliary drainage. Early reports of the use of this resulted in a localized collection of dye adjacent
silicone rubber T-tubes emphasized the lesser de- to the sinus tract. In 7 patients the extravasated dye
gree of inflammation within the bile duct and the drained along the penrose drain tract, and in one of
longer period of time they could be used for before these and in 7 of the other patients the dye was
encrustation and occlusion by biliary precipitates noted in the free peritoneal cavity. Ten of their
[31, 35]. However, Osborne [36] reported 3 closely patients (20%) experienced marked right upper
spaced cases of diffuse biliary peritonitis following quadrant pain; 6 had a demonstrated dye extravasa-
T-tube removal which occurred after the manufac- tion and 4 did not. Four patients experienced fever
ture of the latex rubber T-tubes used in his hospital within the 24 hours following tube removal; all of
had been changed to include a silicone outer wash. these had bactobilia. The T-tubes were all rubber
Work examining the use of silicone rubber T-tubes and had been modified by removal of the back wall
in animals confirmed that the fibrous tract that of the short arm.
forms around these tubes is weak and occurs only It seems clear that drainage of the common bile
after a prolonged period of time in situ [29, 30, 37]. duct following choledochotomy is not free of mor-
Accordingly, silicone rubber T-tubes are not in bidity. We [22] have previously reported I 1 adverse
common use in biliary tract surgery. On the other reactions following postoperative T-tube cholangio-
hand, silicone rubber tubes have been used increas- grams in the same 139 patients discussed in this
ingly in complex biliary reconstructive procedures paper. We now report an additional 6 reactions
and in cases of bile duct carcinoma which require following removal of the T-tube for a combined
long-term transhepatic stenting. In these cases, morbidity rate of 12%. Domell6f [40] reported a
prolonged freedom from tube obstruction is desired 20% incidence of pain and/or fever following T-tube
and the tubes will be left long enough to develop a removal and numerous other reports of isolated
tract or may not be removed at all [38]. instances of bile peritonitis have been cited above.
While many authors have examined T-tube tract This report will not settle the argument between
formation in animals, until recently no reports di- advocates of primary common duct closure and
rectly examined the role of these tracts in humans. those who drain all common duct explorations. It
Scatliff et al. [39] monitored T-tube removal with does, however, document the morbidity of common
cinefluorography in 6 patients between 9 and 64 bile duct drainage. It seems logical that a policy
days following common bile duct exploration. Dis- designed to minimize bacterial contamination of the
E.P. Dellinger et al.: Reaction to T-Tube Removal 613

bile and to ensure a secure tube sinus tract would be duct following its exploration. Ann. Surg. 145:153,
beneficial. A longer duration of tube drainage 1957
should increase the security of the tract; however, 2. Collins, P.G., Redwood, C.R.M., Wynne-Jones, G.:
Common bile-duct suture without intraductal drain-
neither this report nor that of Domell6f d o c u m e n t s age following choledochotomy. Br. J. Surg. 47:661,
an advantage of any particular postoperative inter- 1960
val for tube removal. In c o m m o n practice this 3. Collins, P.G.: Further experience with common bile-
period varies between 1 and 3 weeks. Alteration of duct suture without intraductal drainage following
the tube shape is another factor that might influence choledochotomy. Br. J. Surg. 54:854, 1967
tube reactions. Surgeons c o m m o n l y alter T-tubes at 4. Krauss, H., Kern, E.: Some current problems of
the time of placement by cutting notches, removing biliary tract surgery: Indications and technique of
choledochotomy, intraoperative cholangiomanome-
the back wall of the horizontal limb, or other try, primary closure of the common bile duct. Sur-
maneuvers designed to facilitate removal of the gery 62:983, 1967
tube and minimize disruption of the tract. These all 5. Chande, S., Devitte, J.E.: T tubes, the surgical
seem logical and are practiced by the authors but amulet after choledochotomy. Surg. Gynecol. Ob-
have not been p r o v e n to be beneficial by this report stet. 136:100, 1973
or that of Domell6f. We and others have reported 6. Waugh, J.M., Walters, W., Gray, H.K., Priestley,
J.T.: Annual report on surgery of the biliary system
that 85% or more of all T-tubes will be associated and pancreas for 1951. Staff Meet. Mayo Clin. 27:578,
with bactobilia at the time of their removal [22, 41], 1952
but many of these patients already have contam- 7. Maingot, R.: The technique of operations upon the
inated bile at the time of operation and that inci- gallbladder and bile ducts for gallstones. In Abdomi-
dence cannot be significantly reduced. Silen [41] nal Operations, fourth edition, New York, Appleton-
has advocated antibiotic treatment of bactobilia Century-Crofts, Inc., 1961, pp. 696-726
following T-tube removal in order to prevent subse- 8. Schein, C.J., Stern, W.Z., Jacobson, H.G.: The T-
tube and its management. In The Common Bile Duct,
quent bacterial stone formation. If antibiotics are to Springfield, Ill., Charles C Thomas, 1966, pp. 245-
be administered, it would seem logical to begin such 251.
treatment shortly prior to tube removal so as to 9. Glenn, F.: Management of common duct drainage
reduce the concentrations of bacteria in the bile and and decompression. In Common Duct Stones,
thus possibly reduce the morbidity associated with Springfield, Ill., Charles C Thomas, 1975, pp. 59-76
bile extravasation at the time of T-tube removal. 10. Abbe, R.: Cases of gall-bladder surgery. N.Y. Med.
J. 55:120, 1892
11. Abbe, R.: The surgery of gall stone obstruction. Med.
R6sum6 Rec. 43:548, 1893
12. Kehr, H.: Introduction to the differential diagnosis of
Six malades sur 139 (4,3%) ont pr6sent6 des r6ac- the separate forms of gallstone disease, W.W. Sey-
mour, translator, Philadelphia, P. Blakiston's Son &
tions d6favorables apr~s l'ablation post-op6ratoire Co., 1901
d'un tube en T drainant la voi biliaire principale. 5 13. Robson, M.: The surgical treatment of obstruction in
(3,6%) d'entre eux durent rester & l'hopital plus the common bile-duct by concretions. Lancet 1:1023,
longtemps que n o r m a l e m e n t ou 6tre r6admis. Tous 1902
pr6sentaient une cholangiographie post-op~ratoire 14. Dearer, J.B.: Hepatic drainage. Br. Med. J. 2:821,
normale et le tube en T avait 6t6 clamp6 sans 1904
15. Way, L.W., Admirand, W.H., Dunphy, J.E.: Man-
r6action anormale avant son ablation.
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la palpation (4 cas), fi6vre (5 cas), augmentation du biliary tract surgery. Surg. Clin. North Am. 44:431,
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drain. I1 ne fut pas n6cessaire d'intervenir chirurgi- tract operations. Arch. Surg. 98:428, 1969
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evaluation of primary closure of the common bile Steer, M.: Determinants of adverse reaction follow-
614 World J. Surg. Vol. 6, No. 5, September 1982

ing postoperative T-tube cholangiogram. Ann. Surg. 32. Winstone, N.E., Golby, M.G.S., Lawson, L.J.,
191:397, 1979 Windsor, C.W.O.: Biliary peritonitis: A hazard of
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39. Scatliff, J.H., Mark, J.B.D., Simarak, S.: Cineflu-
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1963
30. Apalakis, A.: An experimental evaluation of the
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Br. J. Surg. 63:440, 1976 T-tube tracts as determined by contrast radiology.
31. Nundy, S., Bell, G.D., Cowley, D.J., Melrose, D.G.: Br. J. Surg. 64:862, 1977
Are silicone rubber T-tubes better than latex rubber 41. Silen, W., Wertheimer, M., Kirshenbaum, G.: Bacte-
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Invited Commentary ever, in the latter group, leakage was o b s e r v e d

around the tract of the tube and even into the
peritoneal cavity in 25 of the 51 patients studied.
Joaquin S. Aldrete Interestingly, only l0 of the patients with demon-
strated leakage felt abdominal pain; 4 had fever, but
Department of Surgery, University of Alabama, Birmingham, 11 experienced no difficulties.
Alabama, U.S.A. Although this investigation d o c u m e n t s the inci-
dence of adverse reactions to pulling out the T-tube,
The study by Dellinger et al. d o c u m e n t s that the many questions remain unanswered. Undeniably,
t e m p o r a r y insertion of a T-tube into the c o m m o n other factors such as the size of the T-tube used, the
bile duct and its subsequent removal are not innocu- material of the T-tube, the size of the c o m m o n bile
ous. Six (4.3%) of 139 patients studied had adverse duct in which the T-tube was inserted, the tech-
reactions, most of them severe enough to require nique of closure of the exploratory choledochoto-
readmission to the hospital. I am certain that e v e r y my, the manner in which the T-tube was cut to
surgeon who has taken great care to a p p r o x i m a t e facilitate its exit from the c o m m o n bile duct, and the
accurately the edges of the c h o l e d o c h o t o m y around presence and type of drains used along with the T-
the T-tube and a few days later to r e m o v e it by tube are not even mentioned in the study of Dellin-
simply pulling on it until it c o m e s out, observing the ger et al., or in those previously mentioned [1, 2].
bile that leaks f r o m the opening, has to think of this Some allusions have been made in these papers as
gross m a n e u v e r for pulling the T-tube out as a to the day the T-tube was r e m o v e d , which varied
"surgical p a r a d o x . " Despite the extensive use of T- from the fifth to the 24th postoperative day. The
tubes, there is surprisingly scant information as to presence of bacteria in the bile has also been
what happens after the T-tube is abruptly removed. discussed in these 3 papers and " b a c t o b i l i a " ap-
The authors in their thorough search of the litera- pears to be relevant in the w a y that the presence of
ture accurately describe the studies of Scatliff et al. infection seems to increase the risk of adverse
[1] and those of Domell6f et al. [2]. The observa- reactions after r e m o v a l of the T-tube. In order to
tions of these 2 groups are s o m e w h a t contradictory analyze this problem completely and objectively, all
in that the f o r m e r o b s e r v e d no leakage of contrast the above-mentioned factors would have to be
material outside the sinus tract of the T-tube. H o w - taken into consideration.