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

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