Primary Closure or T-Tube Drainage After Open or Laparoscopic Common Bile Duct Exploration?

Abstract

Common bile duct exploration (CBDE) is an operation that can be performed either laparoscopically or open in order to treat choledocholithiasis by removing stones from the common bile duct. CBDE can be performing via either a transcystic approach or a transcholedochal one, in which an incision (or choledochotomy) is made directly into the common bile duct in order to access the stones within it. Traditionally this cholecdochotomy have been closed around an external drain, or “T-tube”, at the end of CBDE operations, in order to drain the biliary system and allow access for future interventions should the need arise. However, recent data suggesting that primary closure of the choledochotomy may in fact be a superior technique have challenged the surgical dogma of routine T-tube placement after CBDE.

In this chapter we summarize and evaluate the available evidence comparing T-tube drainage with primary choledochotomy closure after CBDE. Six randomized trials have compared these strategies after open CBDE, and four such trials have been performed for laparoscopic CBDE. The existing literature mostly examines perioperative and short-term postoperative outcomes, such as operative time, 30-day postoperative morbidity and mortality, hospital length of stay, and need for re-interventions during the immediate postoperative period. Long-term implications of using or foregoing T-tube drainage have not been as well studied.

Based on these studies, there is a high level of evidence that primary choledochotomy closure after CBDE (both open and laparoscopic) results in shorter operative times and shorter hospital length of stay when compared with t-tube drainage. There is moderate evidence that primary closure and t-tube drainage after CBDE result in equivalent rates of serious complications in the perioperative period. Due to insufficient data, there is a very low level of evidence that the two techniques result in equivalent rates of long-term recurrent choledocholithiasis and biliary stricture. Based on the sum of this evidence, we make a moderate strength recommendation that primary choledochotomy closure should be the preferred technique in uncomplicated cases of both open and laparoscopic CBDE.