World J. Surg.
6, 610-615, 1982
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
following the postoperative removal of a T-tube. Five
(3.6%) were severe enough to require readmission to the
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-
cluded abdominal pain (6 of 6), chills (3 of 6), tenderness (4
of 6), fever (5 of 6), and increased bilirubin (3 of 4).
Symptoms resolved between 4 hours and 8 days following
removal without operative intervention. Adverse reaction
following T-tube removal may be related to disruption of
the fibrous tract and extravasation of infected bile into the
surrounding tissues.
Although some [1-5] have advocated primary com-
mon bile duct closure following common duct ex-
ploration, most surgeons recommend the use of a
tube to drain the common duct following choledo-
chotomy [6-9]. Abbe [10, 11] first reported this
technique in 1892, and later Kehr [12] and Robson
[13] recommended its use whenever distal obstruc-
tion was suspected or "stinking muddy bile" was
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-
ly and is considered to be a benign maneuver [6, 7,
15]. However, reports of problems without details
or incidences have appeared from time to time [1,
16, 17], and several authors have suggested alter-
ations of the standard tubes to reduce the likelihood
of problems [7, 16, 18-21]. In a review of 139
consecutive common duct explorations [22] with T-
tube placement, a total of 6 (4.3%) reactions follow-
Reprint requests: E. Patchen Dellinger, M.D., Depart-
ment of Surgery, ZA-16, Harborview Medical Center, 325
9th Ave., Seattle, WA 98104, U.S.A.
0364-2313/82/0006-0610 $01.20
9 1982 Socidt6 Internationale de Chirurgie
World Journal
of Sdr ry
ing tube removal were noted. These data, suggest-
ing that T-tube removal may not always be benign,
form the basis for the subsequent report.
Materials and Methods
The charts of 141 patients who had undergone
common duct exploration at the Beth Israel Hospi-
tal between January 1975 and June 1977 were
reviewed. Two patients had complications of intra-
abdominal or abdominal wall abscesses in associa-
tion with their T-tubes, making evaluation of bacte-
riologic data or possible reaction to T-tube removal
unclear, and so were excluded from the study.
Results
Six patients experienced marked reactions shortly
after the removal of their T-tubes in the postopera-
tive period. A representative patient is presented.
Case Report
J.D., a 45-year-old male, underwent cholecystecto-
my, common bile duct exploration, and sphinctero-
plasty for acute cholecystitis with choledocholithia-
sis and distal common bile duct stricture and had a n
unremarkable postoperative course. He was treated
with intravenous ampicillin intraoperatively and for
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
postoperative day. A T-tube bile culture on the
seventh postoperative day grew Staphylococcus
epidermidis, Candida species, and Haemophilus
E.P. Dellinger et al.: Reaction to T-Tube Removal
parainfluenzae. A cholangiogram on the ninth post-
operative day was normal and the T-tube was
clamped without incident 2 days later at the time of
discharge. On the fifteenth postoperative day, his
T-tube was removed without difficulty in the outpa-
tient clinic. One hour after the tube was removed,
he noted severe right upper quadrant pain and
reported to the emergency room, where he was
found to have marked right upper quadrant tender-
ness and guarding and a temperature of 101~
Three blood cultures were obtained, all of which
were negative. The patient was admitted to the
hospital and treated with kanamycin and ampicillin
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
0.4 mg/100 ml when he presented to the emergency
room and increased to 1.8 mg/100 ml 2 days later,
then fell to 0.5 mg/100 ml 7 days after the tube had
been removed. Serum amylase was elevated to 314
(normal, <150) in the emergency room and fell to
128 two days later. The right upper quadrant pain
and tenderness resolved over 4 days.
Five patients (3.6%) experienced a reaction se-
vere enough to provoke readmission to the hospital
or to delay discharge. One additional patient experi-
enced right upper quadrant discomfort similar to his
previous gallbladder attacks but which lasted for
only 4 hours and was not associated with a change
in temperature. All 6 patients reported severe right
upper quadrant pain. Other common findings in-
cluded abdominal tenderness, fever, and chills (Ta-
ble 1). Serum bilirubin was elevated in 3 of the 5
patients in whom it was measured. Seven blood
cultures were obtained from 4 patients and all
showed no growth. The 5 patients with temperature
elevations were all treated with antibiotics and none
required reoperation. Resolution of symptoms and
fever occurred between 4 hours and 8 days after
their onset (average, 3.4 days).
The average age of the 6 patients was 48 years
(range, 25-81 years) as compared to an average of
62 years (range, 17-98 years) in the 133 patients
who did not experience a reaction. Four of the 6
patients (67%) had documented bactobilia before
tube removal, as compared to 114 of 133 (86%) of
the remaining patients. All 6 patients had normal
cholangiograms in the postoperative period and
prior to tube removal. In addition, all 6 patients had
their tubes clamped between 3 and 12 days prior to
tube removal. The interval between operation and
tube removal varied from 13 to 20 days, with an
average interval of 16 days.
Follow-up information on 5 of the 6 patients who
experienced reactions has been obtained by con-
tacting the patients or their private surgeons at
intervals ranging from 3 to 5 years after common
611
duct exploration and tube removal. All patients
were well at the time of follow-up without sequelae
related to the biliary tract.
The frequency of reactions following tube remov-
al [6 in 139 patients (4.3%)] noted in this report may
be a minimal figure, since specific information
regarding tube removal was not available on a
significant number of the charts. These patients
were discharged with their tubes in place and had
them removed in the office of their private surgeon.
It is likely, however, that all reactions severe
enough to prompt readmission have been docu-
mented.
Discussion
Passing mention of problems at the time of tube
removal has been made in reports of large series of
common bile duct explorations [5, 21] or in books
devoted to biliary tract surgery [8, 9]. McKenzie
[23] and Ellis [24] reported series of 20 and 22
patients with bile peritonitis, respectively, of which
one in each series followed postoperative T-tube
removal. Wolfson [25] reported 3 cases of "sponta-
neous rupture" of the common bile duct, but each
case followed a common duct exploration with tube
drainage and in all probability represented delayed
diagnosis of bile leakage with subhepatic abscess
formation following tube removal. One of these
patients had retained stones, but this information is
not recorded for the other 2 patients.
The major focus of literature dealing with T-tube
problems has been the effect of different materials
from which the T-tube may be made. It is well
known that tubes within the biliary system are
subject to encrustation, obstruction, and inflamma-
tory reactions. Experiments performed in dogs [26,
27] have documented an inflammatory reaction
around rubber T-tubes within the common bile
duct, and concern regarding the possible contribu-
tion of this reaction to postoperative bile duct
stricture formation led to the development of T-
tubes made from less reactive materials such as
silicone rubber and polyvinyl chloride. The fact that
these materials evoke less inflammation in the bile
ducts and elsewhere has been noted [28-31]. How-
ever, this favorable property is accompanied by a
new problem, since the inflammatory reaction ap-
pears necessary for adequate formation of a sinus
tract around the tube. Under the usual circum-
stances, T-tube removal in the postoperative period
is associated with a very brief period of bile drain-
age to the skin, provided that the common duct is
free of retained stones or other distal obstruction.
When bile drainage persists, this fibrous sinus tract
leads the bile out to the skin, preventing its intra-
612
Table 1. Presentation of reactions following removal of T-tubes.
Abdominal
Patient pain
number Age Sex duration Chills
1 45 M 4 days No
2 56 M 4 hrs No
3 28 F 1 day Yes
4 54 M 5 days Yes
5 81 F 2 days No
6 25 F 1 day Yes
aAll patients were afebrile prior to removal of T-tube.
bNG: no growth.
' N D : not done.
abdominal accumulation and the subsequent devel-
opment of intra-abdominal abscess or bile peritoni-
tis [7-9].
Shortly after the introduction of polyvinyl chlo-
ride (PVC) T-tubes, several authors reported diffuse
bile peritonitis immediately following the removal
of these tubes [32, 33]. They attributed this to the
poor quality tract formed about these tubes, as well
as to the stiffness that the tubes develop after
incubating for a short period of time in bile [30, 32,
34]. A search of the medical literature has revealed
no further reports regarding the use of PVC T-tubes
for biliary drainage. Early reports of the use of
silicone rubber T-tubes emphasized the lesser de-
gree of inflammation within the bile duct and the
longer period of time they could be used for before
encrustation and occlusion by biliary precipitates
[31, 35]. However, Osborne [36] reported 3 closely
spaced cases of diffuse biliary peritonitis following
T-tube removal which occurred after the manufac-
ture of the latex rubber T-tubes used in his hospital
had been changed to include a silicone outer wash.
Work examining the use of silicone rubber T-tubes
in animals confirmed that the fibrous tract that
forms around these tubes is weak and occurs only
after a prolonged period of time in situ [29, 30, 37].
Accordingly, silicone rubber T-tubes are not in
common use in biliary tract surgery. On the other
hand, silicone rubber tubes have been used increas-
ingly in complex biliary reconstructive procedures
and in cases of bile duct carcinoma which require
long-term transhepatic stenting. In these cases,
prolonged freedom from tube obstruction is desired
and the tubes will be left long enough to develop a
tract or may not be removed at all [38].
While many authors have examined T-tube tract
formation in animals, until recently no reports di-
rectly examined the role of these tracts in humans.
Scatliff et al. [39] monitored T-tube removal with
cinefluorography in 6 patients between 9 and 64
days following common bile duct exploration. Dis-
World J. Surg. Vol. 6, No. 5, September 1982
Peak Bilirubin
temperature initial/peak Blood cultures Antibiotics
~ rag/100 ml (Number done) used
101.8 0.4/1.8 NG b (3) Yes
98.6 ND c ND No
102 0.6/1.7 NG (1) Yes
103 1.7/3.2 NG (2) Yes
102.6 -/1.0 NG (1) Yes
100 -/0.8 ND Yes
placement of the duct during tube removal varied
between 0.5 and 2.0 cm, and the duct returned
quickly to its normal position. No extravasation of
contrast material outside of the tube sinus tract
occurred in these 6 patients. There is no record of
the tube materials or any alteration or trimming of
the T-tubes. Domell6f et al. [40] performed contrast
radiography with fluoroscopic control during T-
tube removal in 51 patients. They did not mention
movement of the common duct, but in contrast to
Scatliff, observed contrast extravasation out of the
tube tract in 25 of the 51 patients. In II instances
this resulted in a localized collection of dye adjacent
to the sinus tract. In 7 patients the extravasated dye
drained along the penrose drain tract, and in one of
these and in 7 of the other patients the dye was
noted in the free peritoneal cavity. Ten of their
patients (20%) experienced marked right upper
quadrant pain; 6 had a demonstrated dye extravasa-
tion and 4 did not. Four patients experienced fever
within the 24 hours following tube removal; all of
these had bactobilia. The T-tubes were all rubber
and had been modified by removal of the back wall
of the short arm.
It seems clear that drainage of the common bile
duct following choledochotomy is not free of mor-
bidity. We [22] have previously reported I 1 adverse
reactions following postoperative T-tube cholangio-
grams in the same 139 patients discussed in this
paper. We now report an additional 6 reactions
following removal of the T-tube for a combined
morbidity rate of 12%. Domell6f [40] reported a
20% incidence of pain and/or fever following T-tube
removal and numerous other reports of isolated
instances of bile peritonitis have been cited above.
This report will not settle the argument between
advocates of primary common duct closure and
those who drain all common duct explorations. It
does, however, document the morbidity of common
bile duct drainage. It seems logical that a policy
designed to minimize bacterial contamination of the
E.P. Dellinger et al.: Reaction to T-Tube Removal
bile and to ensure a secure tube sinus tract would be
beneficial. A longer duration of tube drainage
should increase the security of the tract; however,
neither this report nor that of Domell6f d o c u m e n t s
an advantage of any particular postoperative inter-
val for tube removal. In c o m m o n practice this
period varies between 1 and 3 weeks. Alteration of
the tube shape is another factor that might influence
tube reactions. Surgeons c o m m o n l y alter T-tubes at
the time of placement by cutting notches, removing
the back wall of the horizontal limb, or other
maneuvers designed to facilitate removal of the
tube and minimize disruption of the tract. These all
seem logical and are practiced by the authors but
have not been p r o v e n to be beneficial by this report
or that of Domell6f. We and others have reported
that 85% or more of all T-tubes will be associated
with bactobilia at the time of their removal [22, 41],
but many of these patients already have contam-
inated bile at the time of operation and that inci-
dence cannot be significantly reduced. Silen [41]
has advocated antibiotic treatment of bactobilia
following T-tube removal in order to prevent subse-
quent bacterial stone formation. If antibiotics are to
be administered, it would seem logical to begin such
treatment shortly prior to tube removal so as to
reduce the concentrations of bacteria in the bile and
thus possibly reduce the morbidity associated with
bile extravasation at the time of T-tube removal.
R6sum6
Six malades sur 139 (4,3%) ont pr6sent6 des r6ac-
tions d6favorables apr~s l'ablation post-op6ratoire
d'un tube en T drainant la voi biliaire principale. 5
(3,6%) d'entre eux durent rester & l'hopital plus
longtemps que n o r m a l e m e n t ou 6tre r6admis. Tous
pr6sentaient une cholangiographie post-op~ratoire
normale et le tube en T avait 6t6 clamp6 sans
r6action anormale avant son ablation.
Les signes et s y m p t 6 m e s suivant furent con-
stat6s: douleur (6 cas), frissons (3 cas), sensibilit6
la palpation (4 cas), fi6vre (5 cas), augmentation du
taux de la bilirubine (3 cas). Les s y m p t o m e s s'effa-
c6rent de 4 heures & 8 jours apr6s l'ablation du
drain. I1 ne fut pas n6cessaire d'intervenir chirurgi-
calement.
Ces r6actions anormales apr6s ablation du drain-
age biliaire p e u v e n t etre attribu6 ~ la rupture du
tractus fibreux constitu6 autour du drain et & l'6pan-
chement de la bile infect6e dans les tissus voisins.
References
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613
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Invited Commentary
Joaquin S. Aldrete
Department of Surgery, University of Alabama, Birmingham,
Alabama, U.S.A.
The study by Dellinger et al. d o c u m e n t s that the
t e m p o r a r y insertion of a T-tube into the c o m m o n
bile duct and its subsequent removal are not innocu-
ous. Six (4.3%) of 139 patients studied had adverse
reactions, most of them severe enough to require
readmission to the hospital. I am certain that e v e r y
surgeon who has taken great care to a p p r o x i m a t e
accurately the edges of the c h o l e d o c h o t o m y around
the T-tube and a few days later to r e m o v e it by
simply pulling on it until it c o m e s out, observing the
bile that leaks f r o m the opening, has to think of this
gross m a n e u v e r for pulling the T-tube out as a
"surgical p a r a d o x . " Despite the extensive use of T-
tubes, there is surprisingly scant information as to
what happens after the T-tube is abruptly removed.
The authors in their thorough search of the litera-
ture accurately describe the studies of Scatliff et al.
[1] and those of Domell6f et al. [2]. The observa-
tions of these 2 groups are s o m e w h a t contradictory
in that the f o r m e r o b s e r v e d no leakage of contrast
material outside the sinus tract of the T-tube. H o w -
World J. Surg. Vol. 6, No. 5, September 1982
32. Winstone, N.E., Golby, M.G.S., Lawson, L.J.,
Windsor, C.W.O.: Biliary peritonitis: A hazard of
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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.
Interestingly, only l0 of the patients with demon-
strated leakage felt abdominal pain; 4 had fever, but
11 experienced no difficulties.
Although this investigation d o c u m e n t s the inci-
dence of adverse reactions to pulling out the T-tube,
many questions remain unanswered. Undeniably,
other factors such as the size of the T-tube used, the
material of the T-tube, the size of the c o m m o n bile
duct in which the T-tube was inserted, the tech-
nique of closure of the exploratory choledochoto-
my, the manner in which the T-tube was cut to
facilitate its exit from the c o m m o n bile duct, and the
presence and type of drains used along with the T-
tube are not even mentioned in the study of Dellin-
ger et al., or in those previously mentioned [1, 2].
Some allusions have been made in these papers as
to the day the T-tube was r e m o v e d , which varied
from the fifth to the 24th postoperative day. The
presence of bacteria in the bile has also been
discussed in these 3 papers and " b a c t o b i l i a " ap-
pears to be relevant in the w a y that the presence of
infection seems to increase the risk of adverse
reactions after r e m o v a l of the T-tube. In order to
analyze this problem completely and objectively, all
the above-mentioned factors would have to be
taken into consideration.