Difference of Fistula Maturation Degree and Physical Property by the Types of Tube Material: An Experimental Study Sang Koo Kang, M.D. 1, Hee Chul Yu, M.D. 1,4, Woo Sung Moon, M.D. 2,4, Ju Hyoung Lee, M.D. 3, Ju Sin Kim 5 and Bak Hwan Cho, M.D. 1,4 Departments of 1 Surgery, 2 Pathology and 3 Preventive Medicine, 4 Research Institute of Clinical Medicine, Chonbuk National University Medical School, Jeonju and 5 College of Pharmacy, Woosuk University, Jeonbuk, Korea Purpose: We recently experienced 3 consecutive cases of bile peritonitis due to tract rupture following T-tube removal at about 6 weeks after choledocholithotomy with using a new tube (1.1% silica-filled rubber). These unexpected cases of bile peritonitis have raised questions related to the tube material factor for the rupture. The aim of this study was to compare three kinds of T-tubes [(100% silicone (SIL), 1.1% silica-filled rubber (SFR), and 100% rubber (RUB)] from the point of view of fistula maturation as is related to the physicochemical properties of the tube materials. Methods: SIL, SFR and RUB tubes were implanted into the subcutaneous space in rats. Histologically, the degree of fistula maturation was estimated by an inflammation score, the thickness of inflammation and the fibrosis. The physical properties of the tube materials were estimated by their modulus and elasticity. Results: SFR and RUB tube had no statistically significant difference for the thickness of the inflammation and fibrosis. Yet there were difference in their modulus and elasticity. The modulus, elasticity, thickness of the inflammation and the fibrosis were difference in the SIL versus SFR and the SIL versus RUB. Conclusion: There were no statistically significant differences in the degree of fistula maturation between the SFR and RUB tubes. The rubber tube tended to show a more severe inflammatory reaction and better maturation of the fistula. Moreover, the flexibleness of the RUB tube make easy to experience collapse of the tube. The degree of maturation mostly depends upon the chemical property of the tube materials. However, the tract rupture that happens is due to the physical properties rather than the chemical properties of the tube. We recommend RUB for the T-tube to prevent the tube related complication such as tract rupture. (Korean J HBP Surg 2005;9:128-133) Key Words: Rats Silicones Latex Choledochostomy Fistula Peritonitis :,,,, T-
a b c
130 한국간담췌외과학회지 제 9 권 제 3 호 2005 ꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏꠏ a b c d Fig. 3. Rat tissue reaction to a tube implant; (a) There is no inflammatory infiltration around a 100% silicon tube (H&E stain, 400). (b) Narrow and mature fibrosis is formed around a silicon tube (Masson trichrome stain, 400). (c) There is severe inflammatory infiltration around a 1.1% silica-filled rubber tube (H&E stain, 400). (d) Wide and immature fibrosis is formed around a 100% rubber tube (Masson trichrome stain, 400). 결 과 1. T관 재질과 염증 점수 재질에 따른 염증 점수를 비교한 결과, 실리콘관에서는 0점이 11건(91.7%), 1점인 경우는 1건(8.3%)이었고, 실리카 충진 고무관은 0점인 경우는 없었으며, 1점인 경우 4건 (33.3%), 2점인 경우는 8건(66.7%)이었다. 고무관 역시 0점 인 경우는 없었고, 1점인 경우 7건(58.3%), 2점인 경우는 5 건(41.7%)이었다. 관찰 수가 적어 통계학적 분석기법을 이 용할 수 없었으나, 실리콘관의 경우보다 실리카 충진 고무 관과 고무관의 염증 점수가 더 높았다(Table 1). 2. T관 재질과 염증 두께 삽입 주수와 재질에 따른 염증 두께의 차이를 확인하기 위해 이원배치 분산분석을 실시한 결과 삽입 주수에 따른 염증 두께의 차이는 관찰되지 않았다(p=0.945). 반면 재질 에 따른 염증부위 두께 차이는 관찰(p 0.001)되어 튜키 방 법에 의한 사후검정을 실시한 결과 실리카 충진 고무관과 고무관의 염증 두께는 차이를 보이지 않았고(p=0.827), 실 리콘관은 실리카 충진 고무관(p 0.001), 고무관(p 0.001) 과 유의한 차이가 관찰되었다(Table 2). 3. T관 재질과 섬유화 두께 삽입주수와 재질에 따른 섬유화 두께의 차이를 확인하기 위해 이원배치 분산분석을 실시한 결과 삽입 주수(p=0.003) 와 재질(p=0.005)에 따른 섬유화 두께 차이가 관찰되었다. 사후 검정을 실시한 결과 삽입 5주째와 6주째 간에는 차이 를 보이지 않았으나(p=0.980), 삽입 4주째와 5주(p=0.007), 6 주(p=0.011)째 간에는 유의한 차이를 보였다. 재질에 따른 섬유화 두께차이는 사후 검정을 실시한 결과 실리카 충진 고무관과 고무관이 섬유화 두께 차이를 보이지 않았고