Primary Duct Closure Versus T‐tube Drainage Following Exploration of the Common Bile Duct

Abstract

T‐tube drainage of the common bile duct (CBD) following duct exploration has become standard surgical practice. This randomized prospective study has compared primary closure versus T‐tube drainage of the CBD following exploration for calculous disease. Thirty‐seven patients underwent primary closure and 26 underwent closure over T‐tube. Both groups were comparable in terms of age, indications for surgery, associated illnesses, pre‐operative bilirubin, amylase and white cell count. Forty‐three per cent of operations were performed by a consultant in the primary closure group and 65% in the T‐tube group. There was no significant difference in the duration of operation, incidence of wound infection, surgical or other complications following operation between the two groups. However, the postoperative stay was significantly prolonged in the T‐tube group, to a median of 11 days, compared to 8 days in the primary closure group (P= 0.0001). This prolongation in stay was unrelated to whether admission was as an emergency or elective. T‐tube drainage of the bile continued for a median of 7 days postoperative, whereas the bile drained via a wound drain in only 13 (35%) of the primary closure group, for a median of 5 days in these 13 patients. Long‐term follow up was achieved in 48 patients, by a questionnaire sent at a median of 2.8 years following operation. Abdominal pains following recovery from the operation were experienced by 18% of the primary closure group and 20% of the T‐tube group. No patient developed jaundice or pancreatitis, nor needed further biliary surgery following operation. Primary closure of the CBD following exploration for calculous disease significantly reduces hospital stay, and is as safe as closure with T‐tube, in both the short and long‐term.

Closure of the Common Duct -Endonasobiliary Drainage Tubes vs. T Tube: A Comparative Study

“…In the recent study conducted by Yamazaki and colleagues (2006) the postoperative hospital stay in the primary closure group was reported at 18.3 days [41]. In a study by De Roover and [3]. However, they reported 13 patients of the 37 who had undergone primary closure to drain bile through the wound drain for a median of 5 days (2-7 days).…”

“…Complications are known to be associated with the use of T tubes. These may be displacement, biliary sepsis, thromboembolism, electrolyte and fluid losses, wound infections, pancreatitis and obstructive jaundice [1][2][3][4][5][6]. Biliary leaks have been shown to occur at the time of tube removal or at cholangiography [8] which may progress to intraperitoneal collections, external fistulae or even peritonitis [9][10][11].…”

“…This instrumentation is no longer routinely needed and therefore many consider primary closure of the duct without intraductal drainage as a safe procedure. However drainage of the common bile duct using a T tube has been standard practice following choledochotomy for choledocholithiasis [3]. The T tube vents the biliary tree and prevents extravasation of bile through the choledochotomy incision in the immediate postoperative period.…”

Primary Closure of CBD With Antegrade Stenting for Choledocholithiasis

“…These complications outweigh the benefits offered by the Ttube, especially because the short-and long-term results of primary closure or closure over a stent are favourable. [9][10][11][12][13][14][15][16][17][18][19][20][21] The T-tube does have a role in select patients in those with altered anatomy, such as after a Billroth II reconstruction where endoscopic access to the papilla is not possible. In patients with a failed pre-operative ERCP or when a stone clearance cannot be confirmed per operatively, placement of an indwelling tube (T-tube) is mandatory.…”

Primary Closure Following Common Bile Duct Exploration for Choledocholithiases

“…Choledocholithiases have been managed traditionally with Ttube closure or more recently with minimally invasive procedure like laparoscopic CBD exploration or with help of ERCP. T-tube drainage of the common bile duct is performed for the following reasons (Williams 1994) (a) Post-operative decompression of the common bile duct (If outflow obstruction occurs) (b) Post-operative visualization of common bile duct (c) Availability of a T-tube to extract common bile duct stones with a Burhenne steerable catheter (Burhenne 1973). 8,9 However, the use of T-tube is not without complications.…”