Cholestatic peritonitis after T-tube extraction is a rare but serious complication after common bile duct exploration, with an incidence of 0.66%-0.98% and an increasing trend in recent years. In order to raise awareness of this complication, we analyzed and summarized the clinical data of 144 cases of cholestatic peritonitis after T-tube extraction admitted to two hospitals from June 1995 to February 2004.
1.Clinical data
1.1 General information
There were 144 cases in this group, 81 males and 63 females, aged 12-74 years, average 46 years, 78 cases of chronic calculous cholecystitis, common bile duct stones, 30 cases of residual stones in the common bile duct, 12 cases of intrahepatic bile duct stones, and 24 cases of medical biliary stenosis. Among them, there were 12 cases with history of cirrhosis and portal hypertension and 30 cases with diabetes mellitus.
The T-tube was withdrawn 2-4 weeks after biliary surgery in 114 cases and 5-7 weeks in 30 cases, and the T-tube was clamped before withdrawal. The T-tube was removed 2 hours after the T-tube was opened for drainage.
All patients in this group had epigastric colic immediately after T-tube extraction, which spread rapidly to the whole abdomen and increased progressively, with varying degrees of abdominal pain. It was followed by nausea, vomiting, fever and chills of different degrees. Physical examination showed acute painful face, generalized cold sweat, inability to lie down, total abdominal pressure, muscle tension and rebound pain.
1.2 Results
In 114 patients, the symptoms were significantly relieved after drainage by T-tube sinus cannula, and the hospital stay was 1-2 weeks. 24 patients were discharged from the hospital after 4-6 weeks due to the accumulation of fluid in the abdominal cavity, which was repeatedly drained by ultrasound-guided puncture. 6 patients with residual bile duct stones were surgically drained due to multiple accumulations of fluid in the abdominal cavity. They were discharged after 6 weeks of hospitalization. The operation rate was 4.1%, and 144 patients were discharged from the hospital with 100% cure rate.
2, Discussion
2.1 Reasons for occurrence
2.1.1 Patient’s physical factors: T-tube sinus tract formation is a kind of proliferative tissue repair process, and under the stimulation of T-tube material, a large amount of surrounding fibrous collagen is formed, and the dirty layer of peritoneum or large omentum wraps around the T-tube to form a fibrous tissue adhesion tube. If the patient is in poor physical condition, such as combined with hypoproteinemia, anemia, cirrhosis, advanced age, diabetes mellitus or postoperative glucocorticoid use, it will affect the collagen fiber formation leading to incomplete sinus tract formation, thus leading to bile leak and biliary peritonitis after T-tube extraction. In our group, 52/144 (29.2%) cases were accompanied by cirrhosis and diabetes mellitus. Poor bile duct outlet drainage caused by various causes, such as: residual stones, oddi sphincter stenosis, papillary tumors, etc., increased biliary tract pressure and easy leakage of bile after extraction led to biliary peritonitis.
2.1.2 Surgical factors
The short arm of the T-tube is roughly trimmed during surgery, and due to improper handling of the short arm, the short arm is pulled out from the sinus tract with great resistance and easy to cause damage to the sinus tract wall during extraction. the long arm of the T-tube is excessively bent or folded, and may cut the sinus tract during extraction. The sinus tract formation may be affected by improper filling of the large omentum around the T-tube due to the short length of the omentum after multiple operations or due to the inexperience of the surgeon. Excessive dissection during intraoperative search for the common bile duct, which damages the trophoblastic vessels on both walls of the bile duct, or too close suture spacing resulting in local ischemic necrosis (2). Or the short arm of the T duct was mistakenly sutured when the common bile duct incision was closed, and the wall of the bile duct was torn when the duct was removed.
2.1.3 Extraction factors
Due to the improvement of T-tube material and reduced tissue irritation, the traditional 2-4 week extubation time makes it difficult to allow complete formation of the sinus wall. The short time between surgery and extubation is another reason that predisposes to the formation of cholestatic peritonitis. Failure to open the T-tube before extubation, high pressure in the T-tube or excessive force during extubation or rotation of the T-tube can predispose to biliary peritonitis.
2.1.4 T-tube material factors
After Deaver made the first T-tube with natural rubber for common bile duct drainage in 1904, complications of biliary peritonitis during T-tube extraction were extremely rare. Nowadays, T-tubes are made of silicone or latex, and there is no reaction or very little reaction around the T-tube, and a solid fibrous tube cannot be formed or the formation of fibrous tube is incomplete, so bilious peritonitis is easily formed after T-tube extraction. All the data in this group use latex tubes. To prevent the occurrence of cholestatic peritonitis, further contact with the manufacturer and experimental studies on T-tube materials must be conducted if necessary.
2.2 Prevention and treatment
Postoperative supportive therapy should be strengthened for patients with poor physical fitness such as anemia, hypoproteinemia, and advanced age, supplemented with fat emulsion, amino acids, vitamins, and albumin, etc. Postoperative glucocorticoid use should be avoided as much as possible, and extubation time should be extended to more than 6 weeks for patients who must use glucocorticoids postoperatively.
Intraoperatively, cut off more than 1/2 of the diameter of the short arm tube with neat edges, and cut off a triangle of appropriate size on the opposite side of the long arm to reduce the resistance to postoperative extubation, while keeping the placement of the T-tube slightly curved to avoid excessive bending or folding, and filling the greater omentum, if the greater omentum is very short for various reasons, the greater omentum needs to be further freed so that the exact area around the T-tube is filled with the free greater omentum to help the early establishment of the fibrous tube. The postoperative extubation time should not be shorter than 4 weeks, and 114/144 (79.2%) of our group occurred 2-4 weeks after biliary surgery.
The diagnosis of cholestatic peritonitis after T-tube extraction is not difficult. The presence of cholestatic peritonitis should be considered in those with severe abdominal pain with signs of peritonitis immediately after T-tube removal. At this time, a suitable catheter (of comparable thickness to the T-tube) should be immediately inserted along the sinus tract of the T-tube after cutting the lateral hole at the tip, and the insertion depth should be consistent with the depth of the T-tube in the abdominal cavity, and after seeing the smooth flow of bile, the catheter should be fixed and continuous low negative pressure suction should be applied. At the same time, general treatment such as semi-recumbent position, oxygen administration, gastrointestinal decompression, antispasmodic and analgesic, anti-inflammatory, fasting and fluid replacement was given. The catheter can be removed after 2 weeks if no abdominal fluid is found.
If the ultrasound reveals a fluid in the abdominal cavity, puncture and drainage can be performed under ultrasound guidance until the straight symptoms and signs disappear and the ultrasound does not reveal a fluid in the abdominal cavity. It usually takes 2-3 weeks to cure. All 138 cases in our group were successfully treated by conservative treatment. Surgical treatment is based on the principle of removing and draining the abdominal fluid and reestablishing external bile drainage. The surgical operation is as simple as possible, and the drainage tube can be inserted directly from the original T-tube sinus tract to drain the bile, so that the common bile duct does not need to be cut again to reset the T-tube drainage. In this group, 6 cases (3 cases of medical biliary stricture) were discharged from the hospital 6 weeks after surgery because of the poor effect of conservative treatment due to multiple fluid accumulation in the abdominal cavity. In this group of 144 cases, all of them were cured.