Toti L, Pedini D, Manzia TM, Angelico R. Letter to the Editor: T-tubes in modern biliary surgery - selective use must be matched by postoperative stewardship. World J Hepatol 2026; 18(9): 125414 [DOI: 10.4254/wjh.125414]
Corresponding Author of This Article
Luca Toti, MD, PhD, Assistant Professor, HPB and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, Viale Oxford, 81, Rome 00133, Italy. toti@med.uniroma2.it
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Surgery
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letter
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Toti L, Pedini D, Manzia TM, Angelico R. Letter to the Editor: T-tubes in modern biliary surgery - selective use must be matched by postoperative stewardship. World J Hepatol 2026; 18(9): 125414 [DOI: 10.4254/wjh.125414]
World J Hepatol. Sep 27, 2026; 18(9): 125414 Published online Sep 27, 2026. doi: 10.4254/wjh.125414
Letter to the Editor: T-tubes in modern biliary surgery - selective use must be matched by postoperative stewardship
Luca Toti, Domiziana Pedini, Tommaso Maria Manzia, Roberta Angelico
Luca Toti, Domiziana Pedini, Tommaso Maria Manzia, Roberta Angelico, HPB and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, Rome 00133, Italy
Author contributions: Toti L conceived the correspondence and drafted the manuscript; Angelico R contributed to conceptualization and critical revision of the intellectual content; Pedini D contributed to literature interpretation and critical revision of the intellectual content; Manzia TM contributed to critical revision and supervision; and all authors have read and approved the final manuscript.
AI contribution statement: The authors used ChatGPT (OpenAI) only after the scientific content had been drafted, for English language editing and proofreading. The tool was not used to generate original data, analyse data, select references, or formulate clinical recommendations. All authors reviewed and revised the final manuscript and remain fully responsible for its scientific content.
Conflict-of-interest statement: All authors report no relevant conflicts of interest for this article.
Corresponding author: Luca Toti, MD, PhD, Assistant Professor, HPB and Transplant Unit, Department of Surgical Sciences, University of Rome Tor Vergata, Viale Oxford, 81, Rome 00133, Italy. toti@med.uniroma2.it
Received: July 7, 2026 Revised: July 24, 2026 Accepted: August 5, 2026 Published online: September 27, 2026 Processing time: 73 Days and 8.4 Hours
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.
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.
