Eur Radiol (2005) 15: 2200–2202DOI 10.1007/s00330-004-2489-8 TIPS AND TRICKS

Antonio BasileAntonio MacrìAntonio BottariTommaso LupattelliGiuseppe ScuderiCiro FamulariAntonio Certo

Received: 18 March 2004Revised: 21 June 2004Accepted: 10 August 2004Published online: 20 November 2004# Springer-Verlag 2004

Novel use of a T-tube access to perform

an internal/external biliary drainage

Abstract We report a case of post-surgical temporary functional stenosisof the sphincter of Oddi and biliaryleak in a patient with a previousBillroth II reconstruction who hadundergone cholecystectomy, surgicalcholedocotomy and sphincterotomyfor biliary calculi. The patient wastreated by creation of an internal/

external biliary drainage using theT-tube access with an unreportedtechnique.

Keywords Cholangiography . Bileducts . Cholecystectomy . BiliarydrainageA. Basile

Department of InterventionalRadiology, Ospedale Ferrarotto,Catania, Italy

A. Basile . A. Bottari . A. CertoDepartment of Radiology,Policlinico G. Martino,University of Messina,Messina, Italy

A. Basile (*)Via Papa Giovanni XXIII n. 166,98051 Barcellona P.G. (Me), Italye-mail: antodoc@yahoo.comTel.: +39-090-9762324

Introduction

Post-surgical biliary complications are related to persistentrecurrent calculi and iatrogenic biliary duct trauma [1]. Thelatter may occur either at intra- or extra-hepatic sites andmay be related to inadvertent ligation or transection of abiliary duct. This may lead to functional or organic ductstenosis and to obstructive jaundice or bile leakage [2].

In such cases, the role of interventional radiology is veryimportant, mostly when ERCP has been unsuccessful, toassess the nature of bile duct injury, to drain bile collectionsand to divert bile if obstruction or leaks are present [3]. Thepurpose of this article is to present a case of internal/externaldrainage performed with a new technique using a T-tubeaccess in a patient with a post-surgical (cholecystectomy,choledocotomy and sphinterotomy) temporary functionaldysfunction of the sphincter of Oddi and biliary leak, andwith a previous Billroth II reconstruction.

Case report

A 67-year-old male was admitted with abdominal pain,vomiting and increasing blood chemistry indices of bili-ary stasis (total serum bilirubin 2.1 mg/dl; direct bilirubin1.6 mg/dl; GGT 253 U/l; alkaline phosphatase 489 U/l;white cell count 15,840 mm−3). The past medical historyconsisted of gastric neoplasm treated with hemigastrectomy(Billroth II reconstruction) 5 years previously. An abdom-inal ultrasound (US) and a magnetic resonance cholangi-ography (MRCP) examination showed a dilated commonbiliary duct (CBD) with multiple calculi in the gallblad-der and in the CBD. Because of the anatomical changessecondary to the Billroth II reconstruction, the attempt toperform an ERCP failed. Thus, the patient underwent sur-gical cholecystectomy, choledocotomy and sphincterotomyusing forceps inserted via the choledocotomy. A sub-he-patic surgical draining tube and a 12 French T tube were

A. Macrì . G. Scuderi . C. FamulariDepartment of Emergency Surgery,Policlinico G. Martino,University of Messina,Messina, Italy

T. LupattelliDepartment of Radiology,Policlinico Monteluce,University of Perugia,Perugia, Italy

then left in the CBD; the former began to drain on the 3rdpost-surgical day with increasing cholestatic laboratoryfindings. The patient presented with abdominal pain andfever, and a surgical drainage was performed. The symp-toms persisted, and 2 days later an US examination showeda persistent fluid collection at the same site. A cholangi-ography performed via the T tube demonstrated a leak fromthe distal portion of the CBD and a critical stenosis of thesphincter of Oddi that we assumed to be related to aniatrogenic injury (likely as a result of sphincterotomy). Inview of the absence of dilatation of the intra-hepatic biliarytree, the percutaneous trans-hepatic approach was thoughtto be inappropriate. Thus, once we obtained informed con-sent, we decided to use the T-tube access with the intent toperform a sphincteroplasty. First, we inserted a 0.035-inJ-tip heavy-duty wire (William Cook Europe, DK-4632,Bjaeverskov) through the lumen of the T tube, directedproximally towards the biliary bifurcation; then, a 0.035-incurved-tip glidewire (Terumo Europe NV, Leuven, Bel-gium), directed distally towards the duodenum, was ad-vanced negotiating the sphincteric stenosis (Fig. 1A,B).The T tube was then retrieved, and a six French pig-tail

catheter (Flexima, Meditech, USA) was advanced coaxi-ally over the 0.035 heavy-duty wire towards the proximalcommon bile duct to ensure a proximal biliary drainage.However, clinical conditions of the patient deteriorated,and he needed to be transferred immediately to the in-tensive care unit because of a cardiac block. We did notperform the sphincteroplasty; we had only time to insert anangiographic diagnostic five French pig-tail catheter (Cor-dis Europa, Roden, The Netherlands) placed with its distaltip into the duodenum. By means of a multipurpose adapt-er (20.0–40.0 French, William Cook Europe, DK-4632,Bjaeverskov) and a low pressure polyvinylchloride con-necting tube (14 French ×30 cm, William Cook Europe,DK-4632 Bjaeverskov), we connected the hubs of the cath-eters to each other in such away as to create an “extra-body”internal/external biliary drainage (Figs. 1, 2); in this way, wewere able to change the distal catheter for a balloon catheterlater to perform a sphincteroplasty while we ensured anantegrade flow of bile towards the duodenum. The patient’sconditions improved in the following days, and the bilirubinlevel decreased up to normal values 5 days after our in-tervention. The drainage from the surgical catheter pro-

Fig. 1 A The graphic displays the two wires inserted through theproximal tip of the T tube and directed, respectively, proximallytowards the biliary bifurcation and distally towards the duodenum,negotiating the sphincter. B The T tube was then removed, and the

wires left in place. C Two pig-tail catheters were inserted on the twowires andD their proximal hubs connected by using a combination ofadapters, a multipurpose adapter 20/40 French (black arrow), and alow pressure polyvinylchloride connecting tube (white arrow)

2201

gressively decreased, and an injection of contrast mediumthrough the six French catheter showed no evidence ofleakage and a normal morphology of the sphincter of Oddi.Given that no changes in the analytical data were noted, weretrieved both catheters 7 days later. The patient is currentlydoing well after the 9-month follow-up.

Discussion

Fluid collections in the sub-hepatic space are a commonfinding during the 1st week following cholecystectomy andare usually small (10–20 ml), asymptomatic and self-lim-iting [2, 4]. However, major leaks can lead to intra-peri-toneal collection of bile that, because of its irritant effects,may cause abdominal pain, tenderness, jaundice, low gradefever and leukocytosis. In such cases, the leak could besecondary to a slipped ligature of the cystic duct stump, Ttube misplacement or dislodgement, stenoses or occlusions

of the distal common bile duct because of retained calculi,blood clots or iatrogenic injuries [4]. The insertion of a Ttube in the common bile duct is a frequently usedmaneuvre,and it allows ductal decompression and provides access forpostoperative cholangiography or interventions.

In our patient, the cholangiography via the T tube dem-onstrated a biliary leak in the distal portion of the CBD,close to the sphincteric stenosis, that was likely the result ofiatrogenic etiology. We planned to insert an external biliarydrainage from the proximal portion of the CBD and to ne-gotiate the CBD stenosis performing a sphincteroplasty.However, due to the patient’s condition, we had only time toinsert a five French catheter on the glidewire negotiating thesphincter into the duodenum and to connect the proximal tipof the catheters performing an extrabody internal/externaldrainage (Figs. 1, 2). Our thinking was at least to ensure anantegrade biliary flow through the sphincteric stenosis andto allow us to perform a sphincteroplasty, whenever thepatient’s clinical condition improved, by only changing thedistal catheter for an angioplasty balloon.

We used the T tube access to reach the biliary tree, thusavoiding a percutaneous puncture of the nondilated biliarysystem. We opted for this technique because of the clinicalcondition of the patient and the anatomical changes sec-ondary to Billroth II reconstruction, which did not allow usto perform either an endoscopic or a percutaneous sphinc-teroplasty to re-establish an antegrade biliary flow. The totalresolution of the occlusion less than 15 days following sur-gery suggested a temporary functional dysfunction of thesphincter as the main cause of the obstruction, and the pa-tient did not need sphincteroplasty.

The use of a T tube access to extract retained stones in thebiliary ducts was first described in 1978 by Burhenne [5]and is still performed. However, the T-tube approach tocreate an internal-external biliary drainage has not beenpreviously reported.

In our case, this technique, even if not previously planned,has proven to be effective and relatively easy to perform andrepresents a good option for those patients with particularpostoperative duct injuries with an unsuccessful or impos-sible endoscopic approach.

Fig. 2 Control radiogram shows the six French catheter in the VBDand the other one negotiating the sphincter stenosis (white arrows);biliary fistula from the distal part of the choledocus was demon-strated (black arrow)

References

1. Glenn F (1974) Retained calculi withinthe biliary ductal system. Ann Surg179:528–537

2. Targarona EM, Marco C, Balague Cet al (1998) How, when, and why bileduct injury occurs: a comparison be-tween open and laparoscopic chole-cystectomy. Surg Endosc 12:322–326

3. Civelli EM, Meroni R, Cozzi G, MilellaM, Suman L, Vercelli R, Severini A(2004) The role of interventional radi-ology in biliary complications afterorthotopic liver transplantation: a sin-gle-center experience. Eur Radiol14:579–582

4. Elboim CM, Goldman L, Hann L et al(1983) Significance of postcholecys-tectomy subhepatic fluid collections.Ann Surg 198:137–141

5. Burhenne HJ (1978) Nonoperative in-strument extraction of retained bileducts stones. World J Surg 2(4):439–445

2202