T-tube vs Primary Common Bile Duct Closure

Results: There were total 71 cases included in the study. Thirty one in T-tube group and 40 in primary closure group. T-tube was removed in most of the cases after three weeks where as average time of drain removal in primary closure group is 5.79±1.79 days. Incidence of retained stone was equal in each group. Major complication in T-tube group is biliary peritonitis in four patients at the time of T-tube removal whereas none of the patient from primary closure group suffered from such major complication.


INTRODUCTION
Common bile duct (CBD) stones have been managed historically by supraduodenal choledochotomy, stone removal and the duct repair around T-tube.As the incidence of retained stone was more than 10%, T-tube tract was used for per-cutaneous stone removal postoperatively. 1 The problems related to T-tube are a longer hospital stay, higher cost of hospitalization 2 and serious morbidity if the T-tube is dislodged or removed before the tract is developed.So, the T-tube is kept for 3-4 weeks before removal. 3The most frequent complication of T-tube removal is bile leakage in 1-19% of cases. 4imary closure of the CBD was fi rst described by Halstead in 1917. 5Mayo, 6 Kirschner, 7 Mirrizzi, 8 Edward and Herrington, 9 and Herrington et al 10 are the proponent of the primary closure.Recently, with the availability of per-operative cholangiography, choledochoscopy and per-operative ultrasonography, incidence of retained stone is very low.So, there is increasing trend towards the primary closure.We have compared the two groups.

METHODS
A prospective, comparative study carried out at department of general surgery, Kathmandu Medical College during the period 2006 to 2009.Permission of ethical committee and informed consent of patient was taken.We included all the patients who underwent common bile duct exploration for choledocholithiasis.The study is carried out since the time when we started primary closure of the CBD inspite of closing it with T-tube.We have tried to compare the advantage and disadvantages of the procedure during this period with the group of patients who have undergone the conventional method of using T-tube due to various reasons.The patients who had acute severe infl ammation, acute obstructive suppurative cholangitis, acute pancreatitis and patients with sand like stones are excluded from the study as these patients need decompression of the CBD so they need T-tube invariably.Primary closure is not done in the cases where the stone clearance is doubtful and excessive instrumentation had been done for dilatation of papilla and stone removal.
The patients included in study were the patients having common bile duct stones larger than 5mm and multiple stones detected during ultrasonography as an investigation either for obstructive jaundice or abdominal pain.All patients were reconfi rmed for the CBD stone by repeating the ultrasonography at our centre.Some of the cases where the fi ndings are doubtful, patients have undergone Magnetic resonance cholangiopancreatography (MRCP).We have also included the patients who are asymptomatic and unable to pass CBD stones despite of conservative treatment with antispasmodics for one week.
All patients included in study had undergone preoperative investigation complete blood count (CBC), Renal function test (RFT), Liver function test (LFT), Chest X-ray and repeat Ultrasonography before surgery.Informed consent is taken by surgeon himself and surgical resident.Patients who have been planned for primary closure were explained about the surgical plan and procedures, probability of prolonged postoperative bile leak, chance of retained stone and possibility of Endoscopic Sphincterotomy and stenting in postoperative period.
After pre-operative workups, patients were subjected for surgery.Cholecystectomy is done as standard.CBD dissected, incision given in between two stay sutures.Stones are removed.Choledochoscopy was performed by either fl exible bronchoscope or semi rigid ureterorenoscope.Once the stone clearance is assured, common bile duct is closed with 4-0 polyglactin with round body needle taking interrupted sutures.Drain is kept in Morrison's pouch.In post operative period, drain is kept till there is bile stained fl uid in drain.Once the drain is nil, ultrasonography is done to make sure that there is no collection in and around common bile duct.
In T-tube group, after the stone clearance is assured during surgery, dilatation of the papilla is done in some cases, depending upon the surgeon's choice.Appropriate sized polythene T-tube was used and duct is closed over T-tube.Drain is kept in right sub-hepatic space.Drain is removed once there is no fl uid.T-tube is removed after seven days to four weeks.The data collected was compiled and analyzed using statistical package for social sciences (SPSS) version 16 for windows.

RESULTS
Seventy one patients had undergone open Common bile duct exploration.Forty cases were managed with primary closure whereas in 31 cases common bile duct was closed over T-tube.Majority 49(69.01%)had multiple stones.Numbers of stones are comparable between two groups and method of choledochoscopy (Ureterorenoscope or bronchoscope) is also comparable.In most of cases, semirigid ureterorenoscope (58%) was used to visualize and removal of the common bile duct stones.
Out of 31 patients, who had undergone T-tube placement, T-tube was dislodged in three patients, three developed electrolyte disturbances and one suffered from T-tube related biliary colic.Major complication that occurred was post T-tube removal biliary peritonitis in four (12.9%) (Figure2).Average age of the patient in this age group is 45 yrs and male:female is 1:2.
In primary closure group, majority were females, (1:2).Mean age group was 40 (Figure 1).In eight (20%) patients, there was bile leak from closure site.Most of them leaked for 3-6 days (80%).Only three cases had prolonged leak for more than six days.Mean time of drain removal is 5.79±1.793days and mean hospital stay time is 6.76±1.914days.None of them developed biliary peritonitis and none of them required further intervention.Post operative ultrasonography done in all patients before drain removal was normal.
On comparison between two groups, numbers of stones, co-morbid medical conditions and method of stone clearance are comparable.There is no signifi cant difference regarding minor complications and retained stones.But there is obvious advantage in primary closure group over T-tube group in relation to prolonged T-tube placement and T-tube related complications like electrolyte disturbances, T-tube colic and post T-tube removal bile leakage (Table 1).

DISCUSSION
When the common bile duct surgery was started by Halsted in 1921, it was the primary closure of the duct.This technique was continued for many years.Later due to high incidence of retained stones in common bile duct, T-tube was used so that different technique can be applied for removal of retained stones through the matured T-tube tract post-operatively.Another rationale of using T-tube is with the belief that the T-tube helps to decompress the common bile duct and prevents the biliary leak due to post-traumatic edema of sphincter in post-operative period.T-tube was removed on 12 th day and there was no more pain.Most probably the size of T-tube (14fr) was larger for small sized common bile duct.The most diffi cult complication to handle had been post T-tube removal bile leakage.Out of three patients who had this problem, one had to stay for 1month and two others stayed around 20 days in hospital for repeated aspiration of bile although none of them required the re-laparotomy or ERCP and stenting.These results are comparable with other similar observations.T-tube has been found to be associated with many complications by many authors.Marwah S has observed the increased biliary infection and wound infection associated with T-tube. 14Moreux suggests the external loss of bile through T-tube may lead slow wound healing, anorexia and constipation (Post-choledochotomy acidotic syndrome). 18 In primary closure group, although the drain was kept in every case, bile was seen in drain tube only in eight patients out of total 40 patients.Most of the patients (approx.80 %) had drain tube in situ for 3-6 days.In our series, Mean time of drain removal is 5.79±1.793days and mean hospital stay time is 6.76±1.914days.Three patients had biliary leakage for more than six days but the drain stopped uneventfully with conservative treatment.None of the patient suffered the drain block and other major complications and none of them required any further intervention like re-exploration, ERCP and stenting.The result of the present study are quite comparable with similar other studies.Gigot reported median hospital stays of 7.7 days with and 4.7 days without biliary drainage. 21Slight longer hospital stay is seen in our series because we tend to keep patients for slightly longer period as it is our early experience.
In overall, In T-tube group, there is longer hospital stay and prolonged morbidity related to T-tube in situ for more than three weeks whereas the patients of primary closure group are ready for daily household work within 10-14 days.This has shown the great benefi t for the patient in primary closure group.
Whatever the technique used for common bile duct exploration, external biliary drainage, either transcystic or via T-tube carries a specifi c morbidity ranging from 0 to 6.3% in series of open Common bile duct exploration. 22It has been shown that CBD exploration may be performed safely without biliary drainage even in cases of cholangitis. 23 our observation, we have found that bile leakage occurs in cases where the common bile duct is thin, non infl amed and non edematous.Most of the cases of common bile duct stone have thick edematous two layered bile duct which is less likely to leak through the needle prick site.Residual stone in our series has been nil despite of more than six month observation in most of the cases.Direct choledochoscopy had been used in all cases and primary closure was done only when the Common bile duct was considered to be stone free by all the operating team members watching choledocoscopy in monitor.In this study we have excluded the cases where there were multiple uncountable stones including in intrahepatic ducts.This might be the cause of the low residual stone incidence.
For the primary closure of the common bile duct, stone free common bile duct must be ensured. 246][27] In our institute we did not have the proper choledochoscope but for this purpose we had been using the fl exible bronchoscope until the author started using semirigid ureterorenoscope.Semirigid ureterorenoscope has the added advantage of using the stone holding forceps and intracorporeal pneumatic lithotripsy which we had to use in few occasions.

CONCLUSIONS
Primary closure of the common bile duct is safe and effective method and it helps to reduce the morbidity related to T-tube use.It reduces the hospital stay and overall cost and it can be done in most of the cases.

Figure 1 .
Figure 1.Number of cases in different T-tube related complications.

Table 1 . Comparison between two groups for biliary peritonitis in post op period.
17[12][13][14]tube vs Primary Common Bile Duct Closureperitubal cellulitis, sepsis, necrotizing fasciitis, post T-tube removal bile leakage etc.8,[12][13][14]Hence, recently the invariable use of T-tube is being challenged.The three randomized controlled trials by De-Roover et al,15Sheen-Chen et al16and Williams et al17found no difference in outcome between primary closure and T-tube groups except the longer hospital stay in T-tube group.
11But the use of T-tube is not without complications.It is associated with peritubal leakage, excess bile drainage and electrolyte imbalance, T-tube was dislodged causing the prolonged bile leakage in drain.None of these suffered the peritonitis.They were managed conservatively.One patient had suffered recurrent colicky pain in post-operative period although the T-tube cholangiogram was normal.