Clinical

T-tubes useful in liver transplants, especially with small common bile ducts

Last Updated: 2013-03-06 18:05:06 -0400 (Reuters Health)

By James E. Barone MD

NEW YORK (Reuters Health) - A randomized trial from Valencia, Spain of patients undergoing liver transplantation found that while overall biliary complication rates were similar, patients who had T-tubes placed had significantly fewer major complications and bile duct strictures.

While several previous papers have addressed the issue of T-tube use, results have been conflicting. Dr. Rafael Lopez-Andujar, who headed the new study, told Reuters Health by email he believes his paper settles the issue of whether or not a T-tube should be used, and in whom.

Dr. Cristiano Quintini, a liver and intestinal transplant surgeon at the Cleveland Clinic who was not an author of the study, said it was very well designed. But he said his group has not used T-tubes for at least the past 10 years. They perform roux-en-y hepatico-jejunostomies whenever they identify a patient or situation in which the risk of a biliary complication is high.

The Spanish study was done at a single hospital, and all operations were performed by four experienced liver transplant surgeons. T-tubes were left in place for a minimum of 12 weeks.

All anastomoses were end-to-end choledocho-choledochostomies. After randomization, 95 patients received a T-tube and 92 did not. About midway through the study, the type of T-tube was changed from latex to rubber.

Baseline demographic and surgical variables were similar for both groups.

Biliary complications occurred in 24 T-tube patients and 18 of the no T-tube group (25.5% vs 19.6%; p=0.35).

However, when rated for severity using a standard classification system, 66.7% of the complications in the T-tube cohort were relatively minor, while 94% of the no T-tube patients required another procedure to correct their complications (p<0.0001).

Thirteen patients without T-tubes developed anastomotic biliary stenosis vs only two of those with T-tubes (14.1% vs 2.1%; p=0.002). The relative risk reduction for T-tube placement was 85%, and the number needed to treat was eight.

Rates of bile leaks and common duct stone formation were low and not significantly different in the two groups.

Complications specific to T-tube use, such as cholangitis and bile leaks at the insertion site and after removal, were significantly more common with latex vs rubber tubes.

Using logistic regression, a median donor or recipient bile duct diameter of <7 mm was a significant predictor of anastomotic stenosis, and insertion of a T-tube was significantly associated with decreased odds of that complication.

Patient and graft survival rates for the two groups did not differ significantly at one, two, or three years after transplant.

Dr. Lopez-Andujar said the most important findings of this research were that latex tubes led to more complications and that "T-tube use prevents stenosis of the common bile duct anastomosis in liver transplantation."

The 12-week duration of T-tube placement was chosen empirically based on common practice in Spain. Dr. Lopez-Andujar said his group now leaves them in for only eight weeks, and uses only rubber T-tubes.

Dr. Quintini said that while his group in Cleveland isn't using T-tubes, "definitely the authors are presenting a convincing argument that favors the use of rubber T-tubes and this may be an important learning point of this article."

Dr. Lopez-Andujar said his group uses them for anastomoses <7 mm in diameter, discrepancy of donor and recipient duct diameters, retransplants and if the donor was in asystole.

Dr. Quintini said he thinks the verdict on T-tubes isn't in yet, "although this article offers some valid practical points that could benefit in many ways transplant programs around the world." He feels the use of T-tubes is a complex issue that involves a more detailed costs analysis, the access to therapeutic endoscopy in different institutions, and postoperative follow-up.

SOURCE: http://bit.ly/YtvRrq

Ann Surg 2013.