Delayed cholangitis resulting from a retained T-tube fragment encased within a stone: a rare complication

Inserting a T-tube after choledochotomy for the removal of bile duct stones remains a time-honored practice. Biliary drainage after bile duct exploration has some advantages. It minimizes bile leakage, provides access for cholangiography, and removes occasional retained stones. The use of T-tubes also has been associated with significant complications. Biliary sepsis, bile duct trauma during removal, bile leakage leading to peritonitis, retention of a fragment, stricture formation after removal have been reported. We report an unusual case of cholangitis caused by a T-tube fragment within a large stone, occurring 11 years after bile duct exploration. A 39-year-old woman underwent common bile duct exploration with insertion of a T-tube. Cholangiography was normal, but as the T-tube was removed, its horizontal limb was missing. The patient failed to present for endoscopic removal a few weeks after surgery Five years later, she presented with recurrent biliary pains and a mild episode of cholangitis. This last episode was associated with severe pain and jaundice. After initial conservative treatment, endoscopic retrograde cholangiopancreatography was performed, and endoscopic removal of the fragment and stone material was successful. Despite the declining numbers of bile duct explorations in the laparoscopic era and the tendency to use transcystic drainage or primary closure of a choledochotomy, the T-tube will continue to be a useful tool in biliary surgery, subject to consideration of the indications and the available alternatives. The reported case highlights the importance of careful tube preparation to prevent partial separation at removal, and early removal of a missing fragment to avoid potential serious complications.