Biliary Duct-to-Duct Reconstruction with a Tunneled Retroperitoneal T-Tube During Liver Transplantation: a Novel Approach to Decrease Biliary Leaks After T-Tube Removal

  • 216 Accesses


The benefit of placing a T-tube for duct-to-duct biliary reconstruction during orthotopic liver transplantation (OLT) remains controversial because it could be associated with specific complications, especially at the time of T-tube removal. While the utility of T-tube during OLT represents an eternal debate, only a few technical refinements of T-tube placement have been described since the report of the original technique by Starzl and colleagues. Herein, we present a novel technique of T-tube placement for duct-to-duct biliary reconstruction during OLT, using a tunneled retroperitoneal route. On the basis of our experience of 305 patients who benefitted from the reported technique, the placement of a tunneled retroperitoneal biliary T-tube appears to be safe and results in a low rate of biliary complications, especially at the time of T-tube removal.

This is a preview of subscription content, log in to check access.

Access options

Buy single article

Instant unlimited access to the full article PDF.

US$ 39.95

Price includes VAT for USA

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6



Biliary complication




Hepatocellular carcinoma


Intensive care unit


Model for end-stage liver disease


Non-alcoholic steatohepatitis


Orthotopic liver transplantation


Radiofrequency ablation


Transarterial chemoembolization


Transjugular intrahepatic porto-systemic shunt


Tunneled retroperitoneal biliary T-tube


  1. 1.

    Welling TH, Heidt DG, Englesbe MJ, Magee JC, Annich GM. Biliary complications following liver transplantation in the model for end-stage liver disease era: effect of donor, recipient and technical factors. Liver Transpl 2008;14:73–80.

  2. 2.

    Lerut J, Gordon RD, Iwatsuki S, et al. Biliary tract complications in human orthotopic liver transplantation. Transplantation 1987;43:47–51.

  3. 3.

    Rabkin JM, Orloff SL, Reed MH, et al. Biliary tract complications of side-to-side without T tube versus end-to-end with or without T tube choledochocholedochostomy in liver transplant recipients. Transplantation 1998;65:193–199.

  4. 4.

    Weiss S, Schmidt SC, Ulrich F, et al. Biliary reconstruction using a side-to-side choledochocholedochostomy with or without T-tube in deceased donor liver transplantation: a prospective randomized trial. Ann Surg 2009;250:766–771.

  5. 5.

    López-Andújar R, Orón EM, Carregnato AF, et al. T-tube or no T-tube in cadaveric orthotopic liver transplantation: the eternal dilemma: results of a prospective and randomized clinical trial. Ann Surg 2013;258:21–29.

  6. 6.

    Vougas V, Rela M, Gane E, et al. A prospective randomised trial of bile duct reconstruction at liver transplantation: T tube or no T tube? Transpl Int 1996;9:392–395.

  7. 7.

    Amador A, Charco R, Martí J, et al. Clinical trial on the cost-effectiveness of T-tube use in an established deceased donor liver transplantation program. Clin Transplant 2007.21:548–553.

  8. 8.

    Shuhart MC, Kowdley KV, McVicar JP, et al. Predictors of bile leaks after T-tube removal in orthotopic liver transplant recipients. Liver Transpl Surg 1998;4:62–70.

  9. 9.

    Riediger C, Müller MW, Michalski CW, et al. T-Tube or no T-tube in the reconstruction of the biliary tract during orthotopic liver transplantation: systematic review and meta-analysis. Liver Transpl 2010;16:705–717.

  10. 10.

    Sotiropoulos GC, Sgourakis G, Radtke A, et al. Orthotopic liver transplantation: T-tube or not T-tube? Systematic review and meta-analysis of results. Transplantation 2009;87:1672–1680.

  11. 11.

    Goodwin SC, Bittner CA, Patel MC, Noronha MA, Chao K, Sayre JW. Technique for reduction of bile peritonitis after T-tube removal in liver transplant patients. J Vasc Interv Radiol 1998;9:986–990.

  12. 12.

    Urbani L, Campatelli A, Romagnoli J, et al. T-tube removal after liver transplantation: a new technique that reduces biliary complications. Transplantation 2002;74:410–413.

  13. 13.

    [Cozzi G, Colella G, Bellomi M, et al. Use of safety catheter after of removal Kehr’s tube in liver transplant patients]. Radiol Med 1995;89:91.

  14. 14.

    Mohkam K, Fanget F, Darnis B, et al. Use of systemic vasodilators for the management of Doppler ultrasound arterial abnormalities after orthotopic liver transplantation. Transplantation. In press 2016.

  15. 15.

    Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–213.

  16. 16.

    Daldoul S, Moussi A, Zaouche A. T-tube drainage of the common bile duct choleperitoneum: etiology and management. J Visc Surg. 2012;149:e172-178.

  17. 17.

    Ferraz-Neto BH, Mirza DF, Gunson BK, et al. Bile duct splintage in liver transplantation: is it necessary? Transpl Int 1996;9(Suppl 1):S185-187.

  18. 18.

    Scatton O, Meunier B, Cherqui D, et al. Randomized trial of choledochocholedochostomy with or without a T tube in orthotopic liver transplantation. Ann Surg 2001;233:432–437.

  19. 19.

    Koivusalo A, Eskelinen M, Wolff H, Talva M, Mäkisalo H. Development of T-tube tracts in piglets: effect of insertion method and material of T-tubes. Res Exp Med (Berl) 1997;197:53–61.

  20. 20.

    Apalakis A. An experimental evaluation of the types of material used for bile duct drainage tubes. Br J Surg 1976;63:440–445.

  21. 21.

    Thethy S, Thomson BN, Pleass H, et al. Management of biliary tract complications after orthotopic liver transplantation. Clin Transplant 2004;18:647–653.

  22. 22.

    Saab S, Martin P, Soliman GY, et al. Endoscopic management of biliary leaks after T-tube removal in liver transplant recipients: nasobiliary drainage versus biliary stenting. Liver Transpl 2000;6:627–632.

Download references

Authors’ Contribution

JN and KM collected and analyzed the data and wrote the manuscript.

BD and JBC interpreted the data and critically revised the manuscript.

CD and JYM designed the study and critically revised the manuscript.

Author information

Correspondence to Kayvan Mohkam.

Ethics declarations

Source of Funding

The authors have no source of funding to disclose for the present work.

Conflict of Interest

The authors declare that they have no conflict of interest.

Electronic supplementary material

Below is the link to the electronic supplementary material.

(MOV 171887 kb)

(MOV 171887 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Navez, J., Mohkam, K., Darnis, B. et al. Biliary Duct-to-Duct Reconstruction with a Tunneled Retroperitoneal T-Tube During Liver Transplantation: a Novel Approach to Decrease Biliary Leaks After T-Tube Removal. J Gastrointest Surg 21, 723–730 (2017) doi:10.1007/s11605-016-3313-x

Download citation


  • Liver transplantation
  • Biliary reconstruction
  • T-tube
  • Bile leakage
  • Peritonitis