Overview of T-Tube
Cholelithiasis refers to the formation of stones in the gall bladder. These stones can sometimes block the flow of bile (a digestive fluid) into the small intestine. Sometimes, these stones can move into a duct called the choledochal, causing a patient to show symptoms of jaundice (yellowing of the skin and eyes). Various surgical methods can be adopted to treat this condition. This may include techniques like endoscopic retrograde cholangiopancreatography (ERCP), a procedure that involves using a flexible tube to examine the gallbladder and related ducts, followed by surgery to remove the gallbladder (cholecystectomy). It could also include laparoscopic choledocotomy, this is a lawsuit to make a small opening in the gall bladder and the removal of the stones. This surgical procedure is often carried out in specialized medical centers.
After the gallstones are removed, the opened duct is stitched with dissolvable sutures. To prevent narrowing of the duct and help with the flow of bile, surgeons often insert a T-Tube, a tube that is shaped like the letter ‘T’. This tube is made from materials like latex or silicone and goes through the abdominal wall and is connected to a bag that collects the drained bile. This T-Tube can also be used to check whether any bile stones have been left behind by injecting a dye and taking an X-ray. The T-Tube is different from and should not be confused with tubes used in throat treatments (tracheal tube) or ear surgeries (tympanoplasty tube).
There are other treatment options which include using a stent (small tube) to keep the bile duct open, or closing the bile duct only in selected patients. These methods have been in use for many years and were once considered the standard treatment for this condition. Some medical centers also use a procedure called postoperative percutaneous choledochoscopy. This involves using the pathway created by the T-Tube to look inside the gall bladder or duct and remove any remaining stones.
Anatomy and Physiology of T-Tube
The biliary system, which is involved in the digestion and absorption of fats in the body, has a high chance of having different shapes and structures in different people. This is why there are various ways to categorise the possible shapes and structures of the biliary system, including categories by people like Couinaud, Huang, Karakas, Choi, Champetier, and Ohkubo.
According to Couinaud’s system, the most common shape of the biliary system is known as type A, which is found in nearly 58% of people. In this type, the common bile duct (CBD) is the part of the biliary system that the cystic duct joins. The CBD then goes downward and toward the center of the body until it reaches the second part of the small intestine, which is called the duodenum.
A T tube is a tube that doctors insert into the CBD during a surgical procedure. It helps to keep the duct open, allowing bile to drain out. The best place to insert the T tube is the part of the CBD between where the cystic duct joins it and the edge of the small intestine. It is easy for the surgeons to reach this place. After the T tube is inserted and the surgical incision (choledochotomy) is closed, the tube is routed through the shortest path to the front wall of the abdomen, passing through the abdomen and coming out to the surface at the right upper part of the belly.
Why do People Need T-Tube
The main use of a T Tube is to keep the common bile duct open and drain it after a surgical procedure called choledochotomy. This procedure is most often performed to remove stones blocking the flow of bile, a digestive fluid. In the past, this was a common method for dealing with problematic stones. However, with the introduction of a procedure called Endoscopic Retrograde Cholangiopancreatography (ERCP), which is less invasive, the need for choledochotomies has significantly reduced. This means that new surgeons may not be as familiar with the procedure.
A less frequent use for a T Tube is to aid in repairing minor damage to the common bile duct. Without the help of a T Tube, simply closing the wound can lead to issues such as strictures (narrowing of the duct) and leaks. In rare instances, a T Tube might be used to drain the common bile duct if the ERCP procedure or a process called Percutaneous Transhepatic Cholangiography (PTC) fails to resolve a non-cancerous obstruction, providing relief and reducing potential complications.
Sometimes people can confuse using a T Tube with other types of tubes like a Cholecystostomy tube and PTC drain. The Cholecystostomy tube is a drain inserted through the abdomen into the gallbladder to relieve inflammation in patients at high risk for gallbladder surgery. Meanwhile, a Percutaneous Transhepatic Cholangiogram (PTC) is a tube that goes through the abdominal wall into a major liver duct. It is used to drain bile externally from patients with a bile duct obstruction until the root cause of the problem is treated. It should be noted that these tubes are used for different purposes and cannot be used interchangeably.
Equipment used for T-Tube
The unique aspect of the apparatus is the T tube itself. As hinted by its name, it is a distinct tube in the shape of a “T”. This particular tube has a shorter section (20 cm) that remains within your common bile duct (CBD)—this is the tube that conveys bile from the liver and gallbladder to the small intestine. This section is adjusted to fit perfectly. There is also a longer part (60 cm) that reaches from the middle of the short section and connects to a bag that helps drain the bile. This part of the tube projects from the common bile duct to outside of the abdominal cavity.
The T tubes come in different circumferences or sizes (10, 12, 14, 16, 18 Fr) to match the varying sizes of patients’ ducts. They can be made of various materials such as latex, silicone, red rubber, and polyvinyl chloride, best known as PVC. PVC is often rejected as a choice because it reacts the least with human tissues, which means it wouldn’t form a secure fit within the duct. Silicone is often avoided for long-term use as it can break apart with rough handling.
Latex is usually the preferred choice, as it has the favorable properties of being flexible and durable. However, if a patient is allergic to latex or latex is not available, red rubber is a suitable alternative.
Preparing for T-Tube
There are various elements, like low levels of albumin in the blood (hypoalbuminemia), that may suggest potential issues after surgery when a T tube is used. For example, one possible issue could be the formation of an abnormal connection between the T-tube sinus and the duodenum (a part of the gut), known as a T-tube sinus duodenal fistula. To prevent these types of health problems, it is crucial to improve a patient’s overall health before the surgery.
How is T-Tube performed
If you have been diagnosed with both gallstones (cholelithiasis) and bile duct stones (choledocholithiasis), your doctor might recommend a procedure to clear the common bile duct (CBD) and remove the gallbladder. There are two main ways to achieve this: First is to perform a procedure called endoscopic retrograde cholangiopancreatography (ERCP) and follow it up with surgery. The second way is to do both things at the same time during an open or laparoscopic surgery. Studies have not found a lot of differences between these two approaches.
If it is decided that you should have a laparoscopic gallbladder surgery, the doctor will need to confirm the presence of bile duct stones and their successful removal. This is typically done through methods such as a cystic duct approach (going through the small tube that drains bile from the gallbladder) or a direct cut into the bile duct (choledochotomy), confirmed by an X-ray procedure using dye (contrast cholangiogram). Both these techniques require specialized tools. If these tools are not available, an ERCP may be scheduled afterward.
When a cut is made in the bile duct, the doctor will evaluate the size of the bile duct. If the bile duct is large, stitching it up might be enough. But if it’s small, the doctor might use a T-tube (a tube shaped like the letter ‘T’) to fix it. The T-tube size varies and can be adjusted according to the specific length of the bile duct.
A few weeks after placing the T-tube, your doctor will check the condition of the bile duct. If they can’t remove the stones endoscopically (possibly due to large, impacted stones), they might suggest a surgical procedure to make a new route for the bile to travel from the liver to the intestine (a choledochoduodenostomy or a Roux-en-Y choledochojejunostomy).
Placing a T tube in the CBD is technically complex and should be carried out very accurately to avoid complications. The aim is to successfully place the horizontal part of the T tube inside the bile duct. They’ll cut it to a shorter length to minimize the risk of leakage. The tube is then cut in a particular way to have a semi-circular shape, an additional cut is made at the point where the horizontal and vertical parts of the tube meet.
When closing the cut made in biliary duct (choledochotomy) where the tube exits, it should be done carefully to avoid creating tension. A suture is used to close the site, with absorbable sutures preferred because non-absorbable ones can cause problems like stone formation and infection. The closure is done along the incision and the bile duct, which should be made lengthwise on the front side of the duct to avoid damaging blood vessels. Then, the T-tube is flushed to ensure it is patent (open), and to check that there isn’t any leakage. The T-tube is then fixed in place and the route it takes through the abdominal wall is chosen to be the shortest one.
Possible Complications of T-Tube
Getting a T tube placed in your body can lead to some potential risks. These risks can be due to how the procedure is done, the type of disease being treated, or individual factors about the patient. Placing a T tube is a complex procedure that requires a high level of skill from the surgeon. Using the right techniques can help lower the chance of problems.
The main issue that can arise after T tube placement is bile leaking from the tube. Bile is a liquid made by the liver that helps with digestion. The leak can happen right after the surgery, a while later, or even after the tube has been removed.
In around 1.5% of people who have small stones stuck in their liver’s bile ducts and get a T tube and percutaneous cholecystoscopy (a type of surgery to remove the stones), a problem called a duodenal fistula might happen. This is an abnormal connection between the path of the T tube and the duodenum, the first part of the small intestine.
What Else Should I Know About T-Tube?
The use of T tubes in medical practice has considerably reduced over the past twenty years. This is largely due to the development of less invasive methods for removing CBD stones, which are hard deposits that form in your common bile duct (CBD). The common bile duct is a small, tube-like structure that carries bile from your liver and gallbladder to the small intestine, helping in the process of digestion.
T tubes are devices used to drain bile, but they can be difficult to place and remove, and can sometimes lead to complications. Because of these reasons, the use of T tubes is not commonly recommended anymore. Instead, doctors usually opt for less aggressive alternatives when they can.
