Letter to the Editor: T-tubes in modern biliary surgery - selective use must be matched by postoperative stewardship

Abstract

This correspondence discusses the opinion review by Nizar and Shelat on the evolving role of T-tubes in biliary surgery. We agree that routine use should not be revived. The practical issue is how a selective indication is defined and then managed, especially in hepatobiliary surgery and liver transplantation. We propose that T-tube placement and the subsequent postoperative stewardship pathway should be reported as a single intervention. This includes output monitoring, clamping strategy, cholangiography or equivalent imaging, removal criteria, patient education, post-removal surveillance, and outcome reporting. We also separate three situations: Drainage after common bile duct exploration, temporary externalized support across high-risk biliary-enteric reconstruction, and biliary damage-control when definitive repair is unsafe. Such a framework may make future reports easier to interpret and may avoid a simplistic T-tube vs no T-tube debate.

Key Words: Biliary surgery; T-tube; Bile leak; Liver transplantation; Hepaticojejunostomy; Postoperative care; Biliary drainage; Stewardship

Core Tip: Selective T-tube use should be judged together with the postoperative pathway, not as an isolated intraoperative decision. In hepatobiliary surgery and liver transplantation, indication, monitoring, clamping, pre-removal imaging, removal criteria, patient education, and early surveillance after removal are part of the same intervention. This practical point is the main contribution of this correspondence.

TO THE EDITOR

We read with interest the opinion review by Nizar and Shelat[1] on the past, present, and future role of T-tubes in biliary surgery. The article revisits a device that many surgeons now see as belonging to an earlier surgical era, although it still appears in selected complex biliary situations. We agree with the authors that the T-tube should no longer be considered a routine postoperative drain. Its remaining role, when present, is as a selective tool for temporary decompression, access, and control in carefully chosen high-risk cases.

The aim of this correspondence is not to repeat the argument against routine use. Our additional point is practical: The indication for a T-tube and its postoperative management should be judged together. A T-tube is not only a device placed during the operation. It creates a period of externalized biliary management, during which the surgical team must monitor the patient, provide clear instructions, have access to rescue pathways, and remove the tube safely. The decision to use a T-tube should therefore consider not only duct diameter and technical difficulty, but also patient condition, local resources, and the reliability of follow-up.

This issue is particularly relevant in hepatobiliary surgery and liver transplantation. In these settings, biliary risk may be influenced by immunosuppression, malnutrition, previous cholangitis, ischemia, reoperation, small ducts, or poor tissue quality. Complications are not necessarily confined to the anastomosis. In our previous experience with adult right-lobe split liver transplantation, most bile leaks originated from the cut surface rather than from the biliary anastomosis[2]. This observation is illustrative, not definitive, and should not be interpreted as evidence in favour of T-tube placement. It does, however, support the broader point that biliary risk in complex transplant surgery is multifactorial and cannot be reduced to duct diameter alone.

These possible benefits must be balanced against the burdens of an external biliary tube. A T-tube may provide temporary control and postoperative access, but it may also cause infection, fluid and electrolyte loss, discomfort, accidental dislodgement, complications related to cholangiography, and bile leak after removal. The review appropriately highlights these risks, including leakage after T-tube removal and the specific concerns reported in liver transplant recipients[1,3-5].

INDICATIONS SHOULD BE SEPARATED

The discussion is clearer when three clinical settings are kept distinct. In common bile duct exploration, evidence from open and laparoscopic surgery has moved practice toward primary closure or internal stenting when duct patency is secure and endoscopic or radiological rescue is available[6,7]. In this setting, routine T-tube placement is difficult to justify.

A different issue is temporary externalized support or access across a high-risk biliary-enteric anastomosis. In small ducts, inflamed tissues, hilar reconstructions, or complex hepaticojejunostomies, externalized access may still have a role. Its value, however, depends on the setting. A centre with experienced nursing support, interventional radiology, endoscopy, and planned outpatient review may not achieve the same results as a centre where post-discharge tube care is less standardized.

The third setting is biliary damage-control. In selected hepatobiliary cases, controlled external biliary drainage may be preferable while sepsis is treated and tissues recover, rather than insisting on definitive repair in unfavourable conditions. This concept should remain focused on biliary and hepatobiliary surgery in the present correspondence. Wider gastrointestinal analogies may be conceptually useful, but they risk moving the discussion away from the point at issue.

POSTOPERATIVE STEWARDSHIP

Selective use will be difficult to compare unless future studies and clinical reports describe not only whether a T-tube was placed, but also how it was managed. Table 1 outlines a practical stewardship framework. Without this information, it is difficult to know whether outcomes reflect the tube itself, the indication, or the postoperative pathway around it. A well-managed T-tube and a poorly managed T-tube are not the same intervention.

Table 1 Key elements of postoperative T-tube stewardship.

Domain	Practical element	Purpose
Before placement	Define the indication, duct size, tissue quality, type of reconstruction, and expected role of the tube	Avoids nonspecific use and makes high-risk indications easier to compare
Early postoperative phase	Record bile output and colour, abdominal drain output, liver tests, inflammatory markers, fluid balance, and electrolytes	Allows early recognition of leak, obstruction, cholangitis, dehydration, and electrolyte loss
Clamping strategy	Use a predefined clamping plan only when the patient is clinically stable and bile flow is considered adequate	Avoids premature functional closure and makes assessment of tolerance more consistent
Imaging before removal	Perform cholangiography or other appropriate imaging to confirm free flow, absence of obstruction, and no relevant leak	Reduces the risk of removing the tube in an unsafe condition
Removal criteria	Combine time from surgery with clinical status, laboratory trend, imaging findings, and tract maturity before extraction	Recognizes that timing alone is not enough to decide safe removal
Patient education	Provide written instructions on tube fixation, bag emptying, output recording, dressing care, and warning signs	Reduces anxiety, dislodgement, infection, delayed presentation, and avoidable readmission
Post-removal surveillance	Define who the patient should contact, when urgent review is needed, and how early abdominal pain, fever, or suspected bile leak will be assessed	Allows rapid treatment of post-removal bile leak or sepsis
Outcome reporting	Report readmissions, cholangitis, dislodgement, electrolyte problems, removal-related leak, interventions, and patient burden	Makes future series more interpretable and clinically comparable

The patient’s perspective should also be considered. For the surgeon, a T-tube may look familiar and simple. For the patient, it may mean weeks of anxiety, dependence on a drainage bag, fear of dislodgement, dressing changes, and uncertainty about returning to normal daily life. Any decision to externalize bile should therefore be accompanied by written instructions, a clear contact pathway, and a planned removal strategy. These are part of treatment, not administrative details.

We agree with Nizar and Shelat[1] that the future will not be a return to routine T-tube use. Indications are likely to narrow further with better intraoperative imaging, choledochoscopy, internal stenting, and biodegradable biliary support[8,9]. Until these alternatives are properly validated in high-risk biliary reconstruction, however, the T-tube will probably remain useful in selected cases. Its role should be neither romanticized nor dismissed.

CONCLUSION

Nizar and Shelat remind us that an old surgical tool may still have value when used with judgment. The T-tube is not obsolete, but it should not be routine. Its contemporary role should be selective, clearly justified, and closely linked to postoperative stewardship.