Published online Dec 27, 2021. doi: 10.4240/wjgs.v13.i12.1628
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
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.
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.
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.
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.
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.
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.
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.