Syed Razi Muhammad ( Departments of Surgery, Baqai Medical University, Super High Way, Karachi. )
David Gatehouse ( Shotley Bridge General Hospital, Conset, Co Durham, England DH8 ONB. )
In 1972, Ban1 published his paper about foreign bodies of the billiaiy tract and advocated theiropen surgical removal. Since then, techniques have been described for their endoscopic removal2-4. We report acaseof removal ofaT-tube which was caught in a suture while closing the anterior abdominal wall.
A44yearoldwomanwas referredfromanotherhospital with a retained T-tube, She had an open cholecystectomy during which common bile duct was divided, This was recognised and an end-to-end anastomosis was performed about a number 12 T-tube, Post- operative recovery was uneventful and an early T-tube cholangiogram indicated satisfactory alignment without significant leak out of the ductal system. T tube was left in for six weeks during which time she had occasional episodes of cholangitis. The patient was admitted for the removal of the T tube after a further satisfactory cholangiogram. When the tube was pulled, it broke. She was then left with a portion of T tube presumably lying within the duct. An attempt to pass fibroptic cystoscope through the billiary fistula was unsuccessful, She was then referred for retrieval of T-tube using lateral duodenoscope.
At the X-ray department of Shotley Bridge General Hospital, a 5F catheterwas introduced into the T-tube tract and contrast injected. It did not reach the biliary tree. A side view duodenoscope was then introduced and the papilla was visualised. Billiary duct was canulated. After injecting the contrast, it was clearly seen that the cross limb of the T tube was lying in the bile duct. Contrast was running down the T-tube laterally anda considerable part of the T-tube was seen towards the anterior abdominal wall. After the passage of guide wire up in the common bile duct, an endoscopic sphincterotomy was performed. After the serial passage of baloon catheters, the cross limb of T-tube was pulled down into the duodenum. This was then caught using a snare and an attempt was made to pull it out. However, the traction on the T tube did not cause any further displacement and itwas felt that the long arm of the T-tube was probably caught in a suture at the level of pentoneurn or anterior abdominal wall. The procedure was abandoned. Two days later, the patient was taken to theatre. The side viewing duodenoscope was passed and the T-tube was grasped using alligator forceps. While an assistant was holding the duodenoscope and the alligator forceps, the drain site opening and the T-tract opening on skin were joined together with an incision. Digital exploration of the wound revealed any lon suture, whichwas dividedandwas removed in part. Following this the retained T-tube was easily removed with the endoscope and alligatorforceps. The patient was discharged home three days later and was reviewed in the outpatient department after six weeks when she was found to be totally asymptomatic.
Exogenous billiary tract foreign bodies can predispose to stone formation and inflammation1. Re-exploration of the billiary tract increases the risk of stricture fommtion4. Despite the advances achieved in endoscopic therapy of bile duct pathology, scant infommtion exists about the best technique for their removals2. We believe that the case reported above, illustrates the fact that foreignbodies of the billiary tract canbe removed without an open exploration of the common bile duct.
1. Ban, J.K., Hlirose, F.M. and Benfield,J,R. Foreign bodies of the biliary tract: Report ofthe patients and a review ofthe literature. Ann. Surg., 1912; 176:102-106.
2. Cardin, F., Fritach, J., Aubert, A. et a!. Two stage endoacopic removal of a foreign body from the common bile duct. Surg. Endoac., 19915:94-95.
3. Marahal, L.Z.,Gilliam, J.H.,Dyer,R. etal. Dormiabasketentanglementwitha T-tube management with interventional radiologic technique. Gaatrointest. Endoac., 1993;39: 196-98.
4. O’Regan, P.F.B., Shanahan, F, Jennon, JR. et al. Successful endoscopic removal of a common bile duct foreign body. Endoscopy, 1982; 14:26-27