Journal of Visceral Surgery (2012) 149, e172—e178

Available online at

www.sciencedirect.com

REVIEW

T-tube drainage of the common bile duct

choleperitoneum: Etiology and management
S. Daldoul a,∗,b, A. Moussi a,b, A. Zaouche a,b

a
Service de chirurgie générale A, hôpital Charles-Nicolle, boulevard 9-Avril-1938, 1006 Tunis,
Tunisia
b
Université de Tunis El Manar, Faculté de Médecine de Tunis, Tunisia

KEYWORDS Summary External drainage of the common bile duct by placement of a T-tube is a com-
T-tube; mon practice after choledochotomy. This practice may result in the specific complication of
Common bile duct; bile peritonitis due to leakage after removal of the T-tube. This complication has multiple
Choleperitoneum causes: some are patient-related (corticotherapy, chemotherapy, ascites), and others are due
to technical factors (inappropriate suturing of the drain to the ductal wall, minimal inflam-
matory reaction related to some drain materials). The clinical presentation is quite variable
depending on the amount and rapidity of intra-peritoneal spread of of bile leakage. Abdominal
ultrasound (US), with US-guided needle aspiration and occasionally Technetium99 scintigraphy
are useful for diagnosis. Traditional therapy consists of surgical intervention including peri-
toneal lavage and re-intubation of the choledochal fistulous tract to allow for a further period
of external drainage. When leakage is walled off and well-tolerated, a more nuanced and less
invasive conservative therapy may combine percutaneous drainage with endoscopic placement
of a trans-ampullary biliary drainage.
© 2012 Elsevier Masson SAS. All rights reserved.

Introduction
Various strategies have been proposed for patients with common bile duct (CBD) stones:
surgical cholecystectomy with open CBD exploration, or cholecystectomy combined with
endoscopic clearing of the CBD lithiasis by endoscopic sphincterotomy (ES). Even though
the diagnosis of choledocholithiasis may be suspected pre-operatively on the basis of the
clinical history, abnormal liver function tests, imaging studies (US, CT, echo-endoscopy
(EES), ERCP, or biliary MRI), the diagnosis of choledocholithiais is often made only at surgery
by intra-operative cholangiography (IOC). After common duct exploration, the surgeon has
five different options for closure of the choledochotomy:

∗ Corresponding author. Tel.: +216 98 53 10 15.

E-mail address: samidaldoul@yahoo.fr (S. Daldoul).

1878-7886/$ — see front matter © 2012 Elsevier Masson SAS. All rights reserved.
doi:10.1016/j.jviscsurg.2012.03.008
T-tube drainage of the common bile duct choleperitoneum: Etiology and management
• primary suture closure of the CBD without drainage (so-
called ideal choledochotomy);
• CBD suture closure with internal drainage via an endo-
prosthesis;
• CBD suture closure with transcystic ductal drainage;
• CBD suture closure with external drainage via T-tube;
• choledocho-enteric anastomosis [1—3].
T-tube placement allows passive decompression and
drainage of the biliary tract and also post-operative access
to the CBD for T-tube cholangiography or further stone
extraction through the matured drain tract [3,4]. T-tube
drainage is widely used but routine use is much debated
since it appears to prolong hospital stay and to be associated
with increased cost of care [5]. In addition, the use of T-tube
drainage has been associated with specific complications,
particularly choleperitoneum occurring at the time of T-tube
removal and requiring urgent surgical management.
The goal of this topical review is to define the indications
for T-tube placement, the technique for insertion and the
timing and technique of removal, and to identify risk fac-
tors for the development of choleperitoneum after T-tube
removal.
History
External biliary drainage initially consisted of the place-
ment of wick drains adjacent to the CBD, which was left
open. A later approach was the placement of a Nelaton drain
beneath the liver surrounded by wick drains [4]. In Berlin in
1897, Hans Kehr placed the horizontal limbs of a T-shaped
rubber drain in the CBD and exteriorized the vertical limb
through the abdominal wall [4,6]. Initially, the descending
limb of the T was left long to pass through the papilla into
the duodenum. Subsequently, transpapillary placement of
the tube was abandoned because it could result in acute
pancreatitis and resulted in the functional equivalent of an
external duodenal fistula for as long as the tube was left
unclamped.
The role of materials
Like any foreign body, the T-tube results in an inflamma-
tory response along the entire length of the drainage tract.
The composition of the tube influences the intensity of this
inflammatory reaction [6—9]. This reaction is characterized
by infiltration of lymphocytes, plasma cells, and histiocytes,
fibrin deposition and collagen formation around the tract.
This reaction results in the formation of a fibrous ‘‘chimney’’
along the intra-peritoneal trajectory of the T-tube and a true
bilio-cutaneous fistula; the tract formation prevents leakage
of bile into the free peritoneal cavity. When the T-tube is
removed, this tract will ideally remain leakproof and subse-
quently close down under the influence of intra-abdominal
pressure.
Four types of material have been used in the fabrication
of T-tubes; polyvinyl chloride (PVC), red rubber, silicone,
and latex.
PVC [6,8,10—15], which is very inert, requires 3 months
for the development of a fibrous tract; PVC becomes very
rigid and loses its elasticity when left in contact with bile
and the peritoneal surfaces within the abdominal cavity. This
may result in intra-peritoneal rupture of the T-tube or tract
leakage when the drain is removed. In the series reported by
e173
Winstone et al. [16], there was an increased incidence of bile
peritonitis with PCV T-tubes (4% vs. 0% for latex T-tubes).
Michotey et al. also noted at re-operative surgery that there
was an absence of fibrosis along the tract when removal of
a PVC T-tube on the 16th post-operative day resulted in bile
peritonitis [17].
Red rubber is a very irritating material that rapidly (in
7 to 10 days) induces an inflammatory reaction around the
drain. However, prolonged exposure to bile results in stiffen-
ing of the T-tube with risk of fracture; this has considerably
decreased interest in the use of this material.
The inflammatory reaction induced by silicone [7,10] is
very muted and 2 to 3 months are required before a mature
drainage tract is formed. The drain remains supple and
is generally well tolerated clinically, but the slowness of
inflammatory reaction with this material makes it a poor
choice for short-duration biliary drainage.
In current practice, latex T-tubes are most commonly
used in biliary tract surgery. Several older experimental
studies (including animal experiments) have suggested that
latex is superior to silicone in terms of inflammatory reac-
tion, rate of development of a fibrous tract, and absence of
bile precipitation within the lumen [8,9,15,18].
Method of placement
As its name implies, Kehr’s T-tube is shaped like a ‘‘T’’ with
variable calibers of tubing adaptable to the actual diameter
of the CBD. The horizontal branch should be incised to form
a gutter allowing better flow of bile within the CBD and facil-
itating the folding of the arms when the tube is extracted.
The two intraductal arms should be trimmed to a length that
avoids obstruction of the biliary bifurcation or exclusion of
either the right or left hepatic duct proximally and that does
not extend to or through the papilla distally. A V-excision
of the transverse branch opposite the long arm facilitates
flexion of the tube at the time of extraction (Fig. 1).
A T-tude of appropriate caliber to adapt to the diameter
of the CBD should be chosen. If the caliber is too small, the
Figure 1. Crnojevic’s method of trimming a T-tube [35]: the hor-
izontal branch is shortened and incised to form a gutter, and a
V-notch is cut out at the junction of the two arms.
e174
endoluminal branches can kink and obstruct flow within the
drain; if the caliber is too large, the tube will exert pressure
on the bile duct wall causing tension on the suture closure
of the choledochotomy. Once the two arms of the ‘‘T’’ have
been inserted, they should slide easily back and forth along
the axis of the CBD to confirm correct positioning. After the
T-tube is positioned, the choledochotomy incision is closed
with slowly-resorbable suture using either a running closure
or interrupted sutures place at intervals of 1 to 2 mm to avoid
ischemia of the CBD wall. No study has been performed to
compare running versus interrupted suture closure of the
choledochotomy. A low pressure injection of saline through
the T-tube should be performed to check that the closure
is water tight, and contrast can be injected to assess distal
flow and test for leaks radiographically [2,4,19]. The long
arm of the T-tube is then led out through the abdominal
wall along the shortest and most direct course. The T-tube is
fixed to the skin with two non-absorbable sutures taking care
to avoid occlusion or angulation of the lumen. At the end
of surgery, the tube is connected to a water-tight drainage
system to collect the free flow of bile.
Post-operative management and
surveillance
The amount of biliary drainage should be measured daily
and replaced volume for volume with bicarbonated saline
either parenterally or orally [4,19]. In older patients or those
with altered renal function pre-operatively, a high volume of
biliary drainage (> 500 mL/24 h) requires close surveillance
to maintain adequate hydration and renal function, and may
require ongoing IV fluid administration. T-tube output may
be slowed by raising the level of the collection system from
floor level up to bed level.
Cholangiography with injection through the T-tube is
usually performed on the 7th post-operative day to
check that there is no endoluminal obstacle to flow, no
stenosis of the CBD, and free flow into the duodenum
[4,6,10,11,16,20—23]. The T-tube can then be clamped if
the cholangiography results are normal. If there is evidence
of residual CBD lithiasis (beware factitious images due to air
introduced through the T-tube), treatment with endoscopic
sphincterotomy or, more rarely, direct extraction through
the T-tube tract may be indicated. If there is obstruction
of flow at the papilla with no image of obstructing stone,
this may be due to post-traumatic edema resulting from
efforts to extract stones during CBD exploration. In such
cases, the T-tube can be left open for several days before
repeat cholangiography. Some authors have described cases
of ‘‘sclero-inflammatory odditis’’; in such cases, free bile
flow into the duodenum may be delayed by as much as 4
weeks [2]; the T-tube must be left open to drainage through-
out this period.
T-tube removal
Latex T-tubes may be removed at 7 to 10 days after place-
ment if all clinical factors are favorable [1,16]. Other
authors prefer to leave a latex T-tube in place for 21 days
[10]. It is not generally recommended to leave a T-tube in
place for longer periods. Thus, Hertzer et al. [8] found no
benefit with regard to fibrosis along the tract if the T-tube
was left in place for 6 to 12 weeks. These findings have been
confirmed by several other authors [6,11,12,24,25].
S. Daldoul et al.
Most authors prefer a technique of simple gentle trac-
tion on the long arm of the T-tube. Jacobs et al. [26] and
Lazaridis et al. [7], have proposed withdrawal of the tube
under direct fluoroscopic visualization; after removal of the
T-tube, a low-pressure injection of 5 to 10 cm3 of gastro-
grafin through the cutaneous orifice will confirm the absence
of any leakage along the tract. If there is evidence of leak-
age, a multi-perforated drainage tube can be placed in the
tract to guarantee ongoing external drainage and prevent
intra-peritoneal bile leakage.
The patient may experience moderate but transient pain
at the time of T-tube removal. A small amount of bile leak-
age will continue to exit along the tract for 24 to 48 hours.
The development of sudden intense pain with attendant
tachycardia several minutes after T-tube removal should
lead to suspicion of choleperitoneum.
T-tube complications
Non-peritoneal complications
Complications directly related to the T-tube arise in 2% to
6% of cases [20]. Dehydration due to excessive bile flow
may be the cause of prolonged hospitalization in older
patients and those with impaired renal or cardiac function
[2,4,19,22—24].
Inability to remove the drain is a rare complication.
This is usually due to a technical error during the closure
of the choledochotomy (suture transfixion of the tube),
or to the maintenance of a T-tube for a prolonged period
resulting in the development of a rigid tract; surgical re-
intervention is often necessary to remove the tube [4,27].
In certain patients, applying gentle traction on the tube
with a hemostat for 48 hours (to prevent scar formation)
may allow T-tube removal without the need for surgical
re-intervention.
The development of a persistent external biliary fistula
after T-tube removal should cause suspicion of a distal CBD
obstruction that was not evident on post-operative cholan-
giography, such as ‘‘sclero-inflammatory odditis’’ [2]. Under
these circumstances, an endoscopic or radiologic interven-
tion may be considered.
General considerations-pathophysiology
Choleperitoneum is the most serious complication of T-tube
removal, occurring in from 0.8% to 6.1% of cases (Table 1).
If an intact fibrous tract from the CBD to the cutaneous ori-
fice has not formed, this can lead to free leakage of bile
into the peritoneal cavity. This bile results in a peritoneal
inflammatory reaction, even when there is no co-incident
infection. The bile leakage may be generalized through-
out the peritoneal cavity or walled off; this accounts for
the variable interval between leakage and diagnosis of
choleperitoneum (within minutes or after an interval of
days or even weeks) [4,25,26,28—31]. The consequences of
choleperitoneum may be serious due to:
• the irritant nature of bile (resulting in mucosal edema and
alterations of the reticulo-endothelial system);
• diminution of immune response caused by bile exposure
[28,32];
• the local necrosing effect on adjacent organs, particularly
when the bile is infected (lysis of mesothelial cells from
prolonged exposure to bile salts) [28,30,32];
T-tube drainage of the common bile duct choleperitoneum: Etiology and management
Table 1 Incidence of choleperitoneum after removal of T-tube.
Author, year (ref) Number of cases of
choleperitoneum per number
of T-tubes placed
Winstone et al., 1965 [16] 4 cases in 100
Michotey et al., 1981 [17] 1 case in 112
Gauchet et al., 1982 [4] 3 cases in 139
Corbett et al., 1986 [36] 1 case in 119
Gharaibeh et al., 2000 [31] 6 cases in 97
Wills et al., 2002 [38] 7 cases in 274
Maghsoudi et al., 2005 [6] 34 cases in 1375
Personal series, 2011 9 cases in 573
PVC: polyvinyl chloride.
• the potential for multi-system failure due to peritoneal
re-absorption of toxins and bile salts [25,28—30,32].
Risk factors for development of
choleperitoneum
Several factors that account for failure to develop a fibrous
‘‘chimney’’ of adhesions around the T-tube have been iden-
tified; these may be tied to patient-specific factors or to
errors in surgical technique.
Factors related to failure to develop a fibrous
‘‘chimney’’ of adhésions
The formation of the fibrous ‘‘chimney’’ around the T-tube
depends on the composition of the drain (see above), the
duration of contact between this foreign body and the sur-
rounding tissues, and the individual host reaction to the
foreign body.
Patient-related factors
Corticosteroid therapy and chemotherapy both reduce the
inflammatory reaction around the T-tube and alter the
quality of the fibrous tract [6,11,16]. Other authors have
suggested that obesity, hypoproteinemia, anemia, and dia-
betes may also be responsible for poor quality of the
peri-tubular fibrous tract [22,26,33].
In the case of hepatic transplantation, post-operative
ascites and corticotherapy impair the ability to wall off the
long limb of the T-tube [34]. In this setting, it is therefore
preferable to wait several weeks after resolution of ascites
before removing the T-tube.
If there is residual lithiasis or a stenosis of the CBD, the
increased intraductal pressure increases the risk of rupture
and leakage from the tract when the T-tube is removed
[6,7,11,16,24,33,35]. In the series of Ellis et al. [29] and
Corbett et al. [36], the incidence of residual CBD lithiasis in
patients presenting with choleperitoneum was 20% and 33%
respectively.
Factors related to operative technique
Inadvertant transfixion of the horizontal branch of the T-
tube during choledochotomy closure can result in a tear of
the CBD during T-tube extraction [7,35]. In the series of
Maghsoudi et al. [6], this technical error was found in 9 cases
(26.4%).
e175
Incidence (%) Type of drain
4 PVC
0.9 PVC
2.2 2 latex, 1
silicone
0.8 Latex
6.1 Latex
2.6 Latex
2.5 Latex
1.6 Latex
Clinical presentation
The clinical presentation of choleperitoneum is highly vari-
able. The classical picture is one of sharp upper abdominal
pain developing within minutes of T-tube removal. Signs
of tachycardia, fever, abdominal distention and peritoneal
irritation develop secondarily [7,11,13,16,26,30,31]. Mild
jaundice visible on scleral examination may develop within
hours due to transperitoneal re-absorption of bile [26,28].
Shock occurs if there is a delay in management.
At times, the clinical picture develops more insidiously;
abdominal pain may be mild to moderate, and abdominal
distention with evidence of ascites and jaundice due to re-
absorption of bile may develop slowly. This is often the case
when there is a slow leak of non-infected bile through a
small defect in the tract [25,26,29]. If the biliary fistula
is walled off resulting in a biloma, the clinical picture can
be even more deceptive. The patient usually complains of
malaise, anorexia, and low-grade fever. There is little or
no abdominal distention and the physical findings are sub-
tle [25]. Such findings should raise suspicion of bile leak and
lead to performance of complementary studies.
Diagnostic methods
In cases of generalized choleperitoneum, abdominal ultra-
sound reveals free peritoneal fluid that increases in volume
on successive studies [7,22]. When bile leakage is localized
and physical findings are minimal, ultrasound may show only
a localized peri-hepatic fluid collection without specifically
identifying a biloma [11,25]. Ultrasound-guided needle aspi-
ration is then helpful; the diagnosis depends on a higher
level of conjugated bilirubin in the aspirated fluid com-
pared to serum levels. Laboratory analysis of the aspirated
fluid is not even necessary if the liquid is frankly bilious.
CT will specifically confirm the presence and localization
of a fluid collection and its relation to adjacent structures.
Percutaneous drainage can be performed under CT guid-
ance [22,25]. Other than image-guided aspiration, the best
test to distinguish between a walled off fluid collection and
a biloma is biliary scintigraphy using technetium-labelled
derivatives of iminodiacetic acid (HIDA, PAPIDA, DISIDA).
This will confirm the biliary leak and define the volume and
anatomic location of the fistula [22,25,37]. The prospec-
tive study of Kacker et al. [12] described 6 out of 37
patients in whom scintigraphy revealed internal biliary fis-
tula. Scintigraphy was successful in diagnosing minimal
e176
Figure 2. A. There is a leak from the T-tube tract at some distance from the common bile duct (CBD). This was inaccessible due to severe
sub-hepatic inflammatory adhesions. B. The old tract was re-intubated with a multi-fenestrated drain. C. Intra-operative cholangiography
through the drain opacifies the entire biliary tree and shows no obstruction within the CBD.
internal biliary fistulas in four patients who were completely
asymptomatic.
These findings suggest that internal biliary fistula after
T-tube removal occurs more commonly than clinical studies
suggest, since subclinical leaks often remain undiagnosed
[24]. Ryttov et al. [37] do not propose surgical re-
intervention except in cases with scintigraphic evidence of
extravasation from the CBD and no evidence of Tc99 signal
in the duodenum; this suggests a massive bile leak into the
peritoneal cavity. In practice, the lack of ready access to
biliary scintigraphy for emergencies limits the utility of this
technique; the diagnosis more often rests on the combi-
nation of clinical suspicion with ultrasound-guided needle
aspiration.
Management
There is no consensual agreement in the literature regard-
ing management of patients with choleperitoneum after
T-tube removal. Conservative management is appropriate
for patients with a minimal leak and low-grade symptoms;
this consists of analgesics and antibiotic therapy to cover
probable pathogens [7,12,20,31]. Other authors propose an
endoscopic sphincterotomy with transpapillary placement
of an endoprosthesis to reduce peritoneal contamination by
lowering pressure within the CBD [7,25,26,38,39]. If there
is generalized bile peritonitis, fluid and electrolyte replace-
ment plus broad spectrum antibiotic coverage to correct
multi-organ failure should be followed by urgent surgical
re-intervention. Surgery should include, at a minimum, peri-
toneal lavage and placement of drains adjacent to the
fistula; if possible, a new cholangiography should be per-
formed to rule out obstruction of the CBD, and to allow for
external drainage, either with a new T-tube or a cystic duct
drain [6,7,12,28,29]. Extensive sub-hepatic inflammatory
S. Daldoul et al.
adhesions may render exposure of the CBD impossible; this
has led some authors to limit their re-intervention to lavage
combined with sub-hepatic drainage or simple re-intubation
of the leaking T-tube tract at a distance from the CBD
[6,11,29] (Fig. 2). This simple procedure can be performed
laparoscopically, even after hepatic transplantation [40].
CT-guided percutaneous aspiration [12,25,26,33,41], with
or without associated endoscopic treatment, has been pro-
posed by other authors [20,31,42]. Zhang et al. have thus
reported 11 cases of local re-positioning of the drain with
endoscopic assistance.
Finally, some authors propose techniques to prevent
choleperitoneum with T-tube removal under fluoroscopic
control in the radiology suite; opacification of the intra-
peritoneal tract through the cutaneous exit site verifies the
absence of leak and, if a leak is present, a multi-perforated
drain is placed to assure external drainage of the bile [7,26].
Prognosis
The mortality rate for choleperitoneum after T-tube removal
has rarely been reported in the literature; it was 6% in the
series of Corbett et al. [36] and 5.9% in the series of Magh-
soudi et al. [6]. The mortality rate varies depending on
whether the choleperitoneum is localized or generalized.
In particular, the mortality rate is much higher (20% vs. 8%)
when the bile is infected [25,31,42].
Conclusions
Kehr’s T-tube is a very old drainage technique. In the era
of mini-invasive surgery, T-tube use is rarely described in
the recent literature. The development of choleperitoneum
after T-tube removal can adversely affect patient progno-
sis and mortality, especially if diagnosis and management
T-tube drainage of the common bile duct choleperitoneum: Etiology and management
are delayed. The dianosis should be considered whenever
abdominal pain develops concurrent with T-tube removal.
The origins of this complication are multifactorial and bet-
ter understanding of these factors may permit a reduction
in the incidence.
KEY POINTS
• Because of specific morbidity, the indications for
T-tube placement should always be carefully
weighed, taking into account the risk of
choleperitoneum after T-tube removal.
• Latex is the ideal material for fabrication
of T-tubes, offering the best combination of
patency, solidity, tolerance, and induction of a
prompt intra-peritoneal inflammatory response
and development of a leak-proof fibrous tract.
• Risk factors for development of choleperitoneum
after T-tube removal are patient-related
(corticotherapy, chemotherapy, ascites) and
technique-related (T-tube material, inadvertent
transfixion of the drain during choledochotomy
closure).
• The diagnosis of choleperitoneum depends chiefly
on clinical and ultrasound findings, with eventual
diagnostic needle aspiration and measurement of
bilirubin level.
• The treatment of diffuse choleperitoneum
involving the entire abdominal cavity or resulting
in bile peritonitis requires surgical re-intervention
(often via laparoscopy) with peritoneal toilet
and lavage, contact drainage, focussed antibiotic
therapy, and, if possible, external biliary drainage
by placement of a new drain.
• The treatment of minimally symptomatic localized
choleperitoneum that is well-tolerated can be
exclusively medical (analgesics, antibiotics) or can
rely on percutaneous drainage with or without
endoscopic sphincterotomy or internal drainage of
the CBD.
Disclosure of interest
The authors declare that they have no conflicts of interest
concerning this article.
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