Retrospective Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Dec 27, 2021; 13(12): 1628-1637
Published online Dec 27, 2021. doi: 10.4240/wjgs.v13.i12.1628
Pediatric T-tube in adult liver transplantation: Technical refinements of insertion and removal
Gabriele Spoletini, Giuseppe Bianco, Antonio Franco, Francesco Frongillo, Erida Nure, Francesco Giovinazzo, Federica Galiandro, Andrea Tringali, Vincenzo Perri, Guido Costamagna, Alfonso Wolfango Avolio, Salvatore Agnes
Gabriele Spoletini, Giuseppe Bianco, Antonio Franco, Francesco Frongillo, Erida Nure, Francesco Giovinazzo, Federica Galiandro, Alfonso Wolfango Avolio, Salvatore Agnes, General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
Andrea Tringali, Vincenzo Perri, Guido Costamagna, Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
Author contributions: Spoletini G and Bianco G were responsible for the conception, design, data analysis and drafting the article; Franco A and Tringali A were responsible for the acquisition of data and provided important intellectual content of the manuscript; Frongillo F, Nure E, Giovinazzo F, Galiandro F, Perri V, Costamagna G, Avolio AW and Agnes S provided substantial contributions to analysis and interpretation of data and made critical revisions of the manuscript; all authors approved the final version submitted.
Institutional review board statement: The Institutional Review Board of Fondazione Policlinico Universitario A Gemelli IRCCS provided approval for this study (IRB No. 3796).
Conflict-of-interest statement: The authors declare no conflicts of interest.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Gabriele Spoletini, FEBS, MD, PhD, Doctor, General Surgery and Liver Transplantation Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Largo Agostino Gemelli 8, Rome 00168, Italy. gabriele.spoletini@policlinicogemelli.it
Received: March 17, 2021
Peer-review started: March 17, 2021
First decision: May 4, 2021
Revised: May 17, 2021
Accepted: November 24, 2021
Article in press: November 24, 2021
Published online: December 27, 2021
Processing time: 281 Days and 11.1 Hours
ARTICLE HIGHLIGHTS
Research background

The use of T-tube in liver transplantation (LT) remains controversial despite being the objective of randomized trials and meta-analyses. Since the 90’s many centers stopped using T-tubes in LT. More recently, the increasing use of extended-criteria organs has revived the interest around the usefulness of T-tube in LT.

Research motivation

In our center, we maintained our T-tube policy refining the T-tube insertion and removal techniques continuously. Since March 2017, we have adopted a pediatric rubber 5-French T-tube for splinting the biliary duct-to-duct anastomosis in adult LT recipients.

Research objectives

To describe the insertion and removal protocols implemented at our institution for the safe use of pediatric rubber 5-French T-tubes and the subsequent outcomes in a consecutive series of adult patients.

Research methods

We retrospectively analyzed data of consecutive adult LT recipients from brain-dead-donors, treated from March 2017 to December 2019, regarding biliary complications, adverse events, and treatment required after T-tube removal. Patients with upfront hepatico-jejunostomy, endoscopically removed T-tubes, those who died or received retransplantation before T-tube removal were excluded.

Research results

Out of 72 patients who had the T-tube removed, 68 (94.4%) had per-protocol Nelaton drain insertion through the T-tube exit site. Of these, biliary output was observed in 18 (25%) patients. The Nelaton drain was removed after 2 d (median; IQR 1-4 d). Three (4%) patients required endoscopic retrograde cholangiopancreatography (ERCP) due to persistent Nelaton drain biliary output. Three (4%) patients developed suspected biliary peritonitis, requiring ERCP with sphincterotomy and nasobiliary drain insertion (only one revealing contrast extravasation). No patients required percutaneous drainage of bile collections or emergency surgery after T-tube removal. In four (5.6%) patients accidental T-tube removal occurred, none requiring active treatment. There was no mortality associated with T-tube removal.

Research conclusions

In our series of adult LT recipients, the use of a pediatric T-tube was safe with insertion and removal technique refinements, resulting in minor morbidity and no mortality after T-tube removal.

Research perspectives

With the increasing use of extended-criteria donor grafts in LT, the use of T-tubes is regaining interest, regarding bile output and quality measure and for bile duct protection purposes to reduce the risk of stenosis and leaks. In this perspective, refined insertion and removal techniques are pivotal to ensure low morbidity associated with the use of the T-tube.