THE PAST
The biliary T-tube is associated with Hans Kehr and common bile duct drainage (CBD) after choledochotomy. Historically, T-tubes were not deployed simply to drain bile. They enabled a workflow that combined decompression, ductal protection, postoperative cholangiography, and a route for subsequent interventions. Early descriptions of CBD exploration and postoperative duct imaging strongly normalized T-tube drainage as a pragmatic solution to retained stones and postoperative duct assessment. As described by Smyth[2], the T-tube was not positioned as an afterthought, but as an integral component of duct exploration strategy explicitly pairing drainage with T-tube and cholangiography as a deliberate postoperative extension of operative management, reflecting how surgeons conceptualized verification and rescue long before endoscopic retrograde cholangio-pancreaography was routine. Over time, the T-tube tract became an access route for therapy, including chemical dissolution approaches for retained ductal stones. In a classic series, Lansford et al[3] treated retained CBD stones by intraductal sodium cholate infusion via the postoperative access route; success was most apparent when stones lay between the T-tube and the duodenum. The same access value underpinned iterative engineering of the device itself. Baker[4] described a modified T-tube geometry (outer limb angled rather than right-angled) explicitly to permit passing a catheter into the CBD—notably to enable targeted instillation (e.g., solvents) and irrigation directly upon a retained stone. This detail matters conceptually: Even in 1941, surgeons were already thinking of the T-tube not only as a drain, but for intraductal intervention. In parallel, the push toward intraoperative duct visualization sought to reduce reliance on postoperative rescue. Ashby[5] highlighted how fibreoptic choledochoscopy could reduce retained stones before placing a T-tube and closing the duct, thereby shifting the T-tube from being the primary solution to being a secondary safeguard in an improved operative workflow. But the historical record also documents why the T-tube gradually lost favour: It is a foreign body, it is management-intensive, and it can fail at the most consequential moment, i.e., removal.
The other use of T-tube was bile sampling of the medications with biliary excretions to determine their concentrations for antimicrobial treatment. In 12 patients with T-tube drainage after cholecystectomy, Brogard et al[6] demonstrated that ciprofloxacin achieved bile concentrations substantially exceeding serum levels after a single oral dose, supporting the concept that bile sampling can inform antimicrobial choices for biliary infection. In 10 post-cholecystectomy patients with T-tube drainage, Westphal et al[7] showed that a single 200-mg oral dose of cefixime produced bile concentrations far higher than serum (peak bile 56.9 ± 70 mg/L vs peak serum 2.3 ± 0.85 mg/L), and levels remained measurable even 20 hours after dosing—illustrating how T-tube access enabled direct quantification of biliary antibiotic exposure.
As bile sodium concentration approximates plasma, high-output external drainage is not physiologically neutral and can become a clinically important source of sodium and fluid loss. In a 208-patient series, Furey[8] reported postoperative hyponatraemia in 46 patients (22.1%), with clinical evidence of electrolyte depletion in 30 (14.4%); risk increased with higher and more prolonged biliary drainage and was accentuated by renal impairment, low-salt diet, or diuretic exposure. Classical physiologic work also reminds us that external T-tube output should not be equated simplistically with pure biliary loss. De Palma et al[9] showed that T-tube drainage creates an abnormal low-pressure state in which a proportion of bile that would normally reach the duodenum is diverted externally, and that bile volume may vary inversely with bile acid concentration; when the tube side arm was elevated, external volume fell while bile acid concentration rose, suggesting that drainage volume alone is an imperfect surrogate for physiologic loss. A clinical observation further suggested that drainage exceeding 1000 mL/24 hours may sometimes reflect reflux of pancreatic or duodenal secretions into the common duct rather than bile alone, particularly with a short-arm T-tube or altered sphincter of Oddi physiology[10]. In such situations, amylase testing of the effluent may help distinguish true high-output biliary loss from mixed pancreaticoduodenal reflux.
In selected patients with unavoidable prolonged external biliary drainage, one supportive strategy is enteral bile reinfusion, including oral refeeding of drained bile or reinfusion via a feeding tube. Recycling bile may mitigate malabsorption, dehydration, and electrolyte loss, and in refractory high-output drainage has even been used to correct severe hyponatraemia. Bile refeeding can also serve as a cost-free alternative to oral bile salts[11]. This is not a routine solution and may be burdensome or unpalatable, but it underscores an important principle: When bile must be externalized, surgeons should think not only about drainage, but also about physiological replacement. To improve patient acceptance for bile recycling, various authors have reported recycling via nasoduodenal tube[12], nasojejunal tube[13], and percutaneous gastrostomy tube feeding[14].
THE PRESENT
Modern biliary surgery has increasingly embraced primary closure and internal stenting strategies after choledochotomy, supported by improved flexible choledochoscopy and ductal clearance. CBD exploration can be performed with acceptable outcomes, with laparoscopic approach showing shorter length of stay and lower complication rates compared with open surgery[15]. In an early 50-case institutional LCBDE series, Tan et al[16] showed that even among laparoscopic choledochotomies, closure strategy was already selective rather than routine, with T-tube insertion in 8 patients, internal biliary stenting in 4, and primary closure in 6 of 18 cases. They further concluded that, where feasible, transcystic extraction is preferred because it obviates the need for biliary diversion. Contemporary bile duct surgery has increasingly favoured primary closure or internal stenting after choledochotomy when duct clearance is secure and endoscopic or radiologic rescue is available. This shift is easier to justify when rescue pathways are mature: In a salvage LCBDE series after failed endoscopic stone extraction, 14 of 15 patients who failed endoscopic clearance subsequently achieved successful laparoscopic duct clearance, reinforcing that postoperative dependence on a T-tube tract is less compelling when operative and endoscopic rescue remain available[17]. A recent propensity-matched retrospective cohort study (118 cases after matching) comparing primary closure + double-J stent vs T-tube drainage after laparoscopic CBD exploration found higher overall clinical efficacy and lower complication rates with internal stenting with shorter hospital stay, and lower cost in the primary closure group[18]. Similarly, Wang et al[19] evaluated primary duct closure supported by a self-dislodging biliary stent vs T-tube drainage (n = 112) and reported shorter time to first defecation and shorter hospital stay with the primary closure/stent approach, with a lower overall complication burden. Randomized data also show that primary duct closure after laparoscopic choledochotomy achieved a shorter postoperative stay and earlier return to work than T-tube drainage, with biliary complications numerically lower in the primary closure arm[20,21]. These studies reinforce a modern consensus: Where safe primary closure is feasible and rescue options are strong, the routine T-tube is often unnecessary in experienced units. Meta-analytic synthesis of randomized trials has shown primary closure to be associated with fewer biliary complications and fewer major complications, with shorter operating time and shorter hospital stay compared with T-tube drainage, without differences in mortality or retained stones[22]. Focused on laparoscopic choledochotomy, a systematic review/meta-analysis (12 studies; 956 patients) found postoperative complications lower with ‘T-tube-free’ strategies and demonstrated reductions in operative time and length of stay compared with T-tube drainage[23]. Thus, what is already known is that routine T-tube use has declined in standard bile duct exploration; what Liu et al[1] adds is the suggestion that, in selected small-duct biliary-enteric reconstruction, temporary externalized stenting may still have value. Technical advances such as three-dimensional laparoscopy and absorbable barbed sutures have further strengthened the case for one-stage laparoscopic CBD exploration with primary closure, reducing reliance on external drainage[24]. More recently, a prospective single-center randomized trial by Niu et al[25] involving 45 patients found that primary barbed suture closure after LCBDE was associated with shorter operative time, lower postoperative drainage volume, shorter hospital stays, and lower hospitalization cost than T-tube drainage, without an observed increase in early postoperative complications. Notably, no bile leak or biliary stricture was observed in either arm during follow-up, so the study strengthens the case for selective T-tube-free primary closure while still warranting caution because of its small sample size and single-center design. With widespread adoption of single-stage therapy it is increasingly important for biliary surgeons to overcome the learning curve of LCBDE[26].
Alongside the advances in biliary surgical techniques, T-tube-associated morbidity should be also considered as a reason for decline in its use. A recent case report described life-threatening biliary peritonitis following T-tube removal, where required emergency surgery ultimately requiring re-placement of a T-tube to control the leak[27]. This risk is also seen in larger surgical cohorts: In 97 patients undergoing open CBD exploration, Gharaibeh and Heiss[28] reported clinically significant biliary leakage after T-tube removal with substantial morbidity including collections requiring drainage and a death from biliary peritonitis.
The report reframes risk as patient biology (e.g., malnutrition) and lack of T-tube tract maturity, rather than time alone. At the population level, Gillatt et al[29] prospectively studied T-tube drainage complications and found a high complication rate especially around removal, with biliary leakage and bacteremia being key problems and proposing broad-spectrum antibiotic cover at removal. Likewise, the act of check postoperative T-tube cholangiography is not without risk. Dellinger et al[30] reported adverse reactions following 6.5% of postoperative T-tube cholangiograms (11/170), including severe reactions, and observed that gravity infusion techniques that limit pressure may reduce risk—an early caution against iatrogenic cholangiovenous reflux. In an orthotopic liver transplant cohort, symptomatic bile leaks occurred in roughly one-third after T-tube removal and many required endoscopic or operative intervention; duct mural irregularities on the final cholangiogram were strongly associated with leak[31]. These data establish the inherent morbidity potential of T-tube placements and hence the declining use considering patient safety and healthcare quality metrics.
Risk, however, is only one side of postoperative T-tube cholangiography; interpretive quality is the other. Authors have emphasized that this is a dynamic examination in which rotational spot filming, multiple oblique views, and careful assessment of the cystic duct remnant are essential to distinguish true calculi from artifacts[32]. Furthermore, radiologic literature highlighted the “pseudocalculus sign” and air bubbles as important causes of false-positive distal duct filling defects[33,34]. The pseudocalculus sign is a false cholangiographic filling defect in the distal common bile duct, usually produced by transient sphincteric contraction rather than a true stone, and recognition of it is important to avoid unnecessary duct instrumentation or reoperation[35]. More recently, substantial agreement has been reported between T-tube cholangiography and choledochoscopy for residual stones, but both false positives and false negatives still occur, reinforcing that the value of cholangiography depends on low-pressure technique plus disciplined interpretation rather than contrast injection alone.
Non-biliary surgery use
T-tubes are also used in non-biliary foregut surgeries for luminal patency, drainage, and sepsis control strategies. In foregut emergencies, T-tube strategies have also been used to convert uncontrolled leaks into controlled fistulae. In a thoracic surgery series, delayed intrathoracic esophageal perforations were frequently managed with T-tube repair to create a controlled fistula with low mortality, despite high morbidity[36]. Fujikuni et al[37] described a novel “triple-tube-ostomy” approach for difficult iatrogenic duodenal perforation, applied in three cases. The technique is built around three principles—biliary diversion, duodenal decompression, and early enteral nutrition—and all three patients reportedly had good postoperative courses with few complications. Do et al[38] reported successful management of late-diagnosed Boerhaave syndrome using T-tube drainage with video-assisted thoracoscopic surgery. This supports the “T-tube principle” beyond the biliary tree—creating controlled drainage and a healing interface when primary repair is high-risk. Similarly, tube duodenostomy using a trimmed T-tube has been described as a decompressive option for the “difficult duodenum” (e.g., duodenal stump compromise/perforation), aiming to prevent blowout while healing occurs[39]. An additional foregut variant is transampullary T-tube duodenocholangiostomy, proposed to decompress the duodenum while avoiding further disruption of an already fragile bowel wall; in a 16-patient series, outcomes were favorable, enteral feeding began early, and mean hospital stay was 19 days, although septic events still occurred in 30% and the authors appropriately called for further study[40]. Even when a T-tube strategy is technically successful, removal is not always benign; in an early series, 6 of 139 patients (4.3%) developed adverse reactions after postoperative T-tube removal, with 5 severe enough to delay discharge or require readmission despite a normal cholangiogram and uneventful clamping trial[41]. Complementing this, Isik et al[42] showed in 31 patients that tube duodenostomy can function as a rescue strategy for insecure duodenal closure or postoperative leakage, but only within a disciplined postoperative pathway that allows tract maturation and verifies integrity before removal, underscoring that benefit depends as much on stewardship as on insertion.
Biliary surgery use
Biliary reconstruction encounters scenarios where the anastomosis is vulnerable: Small duct diameter, inflammation or ischemia, unhealthy tissue quality for suture placement, difficult angles for needle driving, or re-operative fields. Liu et al[1] investigated the role of external stent across the biliary-enteric anastomosis in reducing bile leak, stricture, or re-intervention while remaining acceptable in terms of patient burden. Even if individual units differ in their threshold for external stenting, the results suggest that device minimalism should not become device dogma. A further practical modifier is institutional availability and familiarity with T-tube placement, postoperative cholangiography, and outpatient tube care. In centers where these resources and follow-up pathways are limited, the apparent benefit of externalized stenting may not be reproducible. Conversely, units with established protocols may derive greater benefit, suggesting that effectiveness is context-dependent rather than device-intrinsic. In their single-center retrospective series (n = 68), 32 patients underwent T-tube stent external drainage at the choledochojejunostomy site and 36 underwent conventional internal drainage. They report no biliary stricture and no biliary leakage in the T-tube group, compared with eight strictures and nine bile leaks in the non-T-tube group. However, I wish to highlight four issues in particular. Firstly, the cohort appears to represent a heterogeneous biliary reconstruction population including both benign and malignant disease in patients with small, non-dilated ducts; and therefore the most appropriate inference is that externalized stenting may be most relevant when small duct diameter is the dominant risk, rather than advocating T-tube placement as a universal adjunct across all biliary-enteric reconstructions. Secondly, the abstract’s suggestion of shorter operative time should be interpreted cautiously. In the main results, operative duration was numerically lower in the T-tube group but not significantly different (189.94 ± 48.67 minutes vs 197.44 ± 20.72 minutes, P > 0.05). Operative time therefore does not appear to be the primary differentiator between strategies in this cohort. Thirdly, the described technique appears closer to a hilar/common hepatic duct or hepaticojejunostomy-level reconstruction in many cases than to a distal choledochojejunostomy; readers should therefore interpret applicability accordingly, particularly for small-caliber hilar biliary-enteric anastomoses. Fourthly, they kept the tube for three months and performed imaging prior to removal, reporting no catheter breakage or dislodgement during indwelling suggesting that their workflow emphasized device stewardship rather than mere placement.
This externalized stent framing also has historical precedent beyond simple choledochotomy drainage. Cattell and Braasch[43] evaluated a long T-tube concept explicitly to maintain luminal patency after sphincteroplasty/transduodenal sphincter procedures and to deliver bile distally across more complex tissue planes. That earlier long-arm design underscores a continuity of logic with Liu et al[1] when luminal narrowing is the feared endpoint, the T-tube may function as a temporary scaffold rather than a passive drain.
The patient
One reason T-tubes fell out of favour is not purely technical but human: Living with a tube changes discharge readiness, self-care demands, anxiety, and follow-up intensity. A 2025 review on discharge readiness among patients discharged with T-tubes summarized factors influencing preparedness and proposed interventions, reflecting the growing recognition that T-tube care is a postoperative program, not a simple surgical endpoint[44]. Another quasi-experimental nursing study in CBD exploration patients (n = 60) showed that structured high-quality nursing care was associated with fewer wound infections and fewer T-tube problems, and improved postoperative quality-of-life scores emphasizing that when T-tubes are used, outcomes depend on the system around them, not the latex alone[45]. For surgical readership, this matters: Any advocacy for liberal T-tube use must account for the downstream burden especially when alternatives are increasingly shown to be safe and effective. Electrolyte imbalance and patient inconvenience or discomfort can partly be mitigated by active management. For example, per oral bile recycling requires patient persuasion and strategies such as mixing bile with fruit juices or cold drinks may improve compliance. Similarly nudging the relatives may enhance the compliance and not unethical considering best interest principles and reversible or transient nature of the intervention[46].
Patients discharged with a T-tube should receive structured verbal and written instructions on tube care, drainage monitoring, diet, and warning signs that warrant urgent review. The T-tube, inserted into the bile duct to allow external drainage during postoperative healing, may remain in situ for approximately 4-6 weeks, and tube removal is typically preceded by radiographic assessment to confirm ductal healing and the absence of obstruction. Patients should be advised to keep the exit site clean and dry, change the dressing at least weekly or whenever it becomes wet, and avoid vigorous movements that may dislodge or damage the tube. They should also be taught to empty the drainage bag when it is about one-third full and to document the date, time, volume, and colour of bile output, with 24-hour totals brought to follow-up review. Dietary advice should include small frequent meals, temporary adherence to a low-fat diet, and replacement of fluid losses in proportion to biliary drainage output, with isotonic fluids preferred to help replenish electrolyte losses. Clear escalation advice is equally important: Patients should seek prompt medical attention for suture breakage, tube slippage, increasing redness, warmth, pain or tenderness at the exit site, blistering, bile leakage around the wound, fever or chills, bloody drainage, or excessive bile output exceeding 1 L per day. Local follow-up pathways should also be specified, including contact with the surgical team during office hours and emergency department review after hours. The criteria for T-tube removal are both time dependent and clinical situation. T-tube track maturation requires time, and this is determined by the material of the tube. In general, the tube has to be retained for few weeks prior to consideration of its removal. The clinical situation is determined by history and physical examination, serum biochemistry and the cholangiogram images. Absence of acholic stools, tea-coloured urine, fever, and abdominal pain can indicate that bile flows unobstructively downstream through the tube[47]. Serum biochemistry should demonstrate normalization or downtrending of the liver enzymes. The cholangiogram images show free flow of the dye distal into the intestine, proximally into intrahepatic biliary ducts, as well as absence of filling defects. When these criteria are met, it is safe to consider removal advising the patient to report to healthcare facility if there is abdominal pain or fever following removal.
THE FUTURE
We suggest that the most constructive way is to treat the T-tube as a selective adjunct in high-risk biliary-enteric reconstruction, not as a default after every duct exploration or repair. In practice, the question becomes: Which patient benefits from temporary externalization and who is better served without a T-tube? It may help to conceptualize indications in three buckets (Figure 1). The system factors are often under-discussed in technical papers but matters enormously: The decline of the T-tube is partly a triumph of minimally invasive culture, but also a recognition that external drains export complexity to the ward and home with burdensome issues such as education, dressing, infection, blockage, accidental dislodgement[48], and readmission. Modern enhanced recovery after surgery pathways have therefore indirectly pushed many teams away from routine externalization. Notably, a contemporary nursing and discharge-readiness literature has begun to treat discharge with a T-tube as a distinct transitional-care problem, reinforcing that if we use T-tubes selectively, we must also operationalize safe outpatient management. Thus, the utility of selective T-tube use depends not only on anatomy and operative difficulty, but also on institutional capability for tube stewardship after discharge. Importantly, the move away from routine T-tube drainage is not confined to laparoscopic surgery; a Cochrane review of randomized trials in open CBD exploration found longer operating time and hospital stay with T-tube drainage, without apparent evidence of clinically important benefit, supporting selective rather than routine use even in open surgery[49]. At the same time, improved real-time biliary mapping may continue to narrow indications for routine externalization; a randomized control trial comparing indocyanine green fluorescence cholangiography with intraoperative cholangiography found the technique safe and associated with satisfactory extrahepatic biliary visualization during elective laparoscopic cholecystectomy[50]. Importantly, modern choledochoscopy has evolved beyond residual stone detection alone to include optical-guided biopsy, lithotripsy or other ablative therapies, biliary stenting, and retrieval of migrated stents, further weakening the historical dependence on a T-tube tract for postoperative reassessment[51]. This broader shift away from routine external drainage is also supported by Cochrane-level evidence in laparoscopic common bile duct exploration, which found longer operating time and hospital stay with T-tube drainage, without evidence of benefit sufficient to justify its routine use over primary closure[52]. More broadly, the recent World Society of Emergency Surgery consensus on indocyanine green fluorescence-guided emergency surgery argues that fluorescence-based cholangiography and angiography can improve intraoperative decision-making and may reduce complications and hospital stay, while also emphasizing that benefit depends on training, equipment availability, and standardized protocols[53]. While resorbable technology is already being explored in other luminal settings, translating it to biliary reconstruction will require careful attention to: Predictable degradation kinetics in bile, biofilm resistance, inflammatory response, and avoidance of fragment obstruction. In selected high-risk or immunocompromised patients, pre-removal fistulography can help confirm tract maturation before tube extraction and may reduce the risk of post-removal biliary leakage[54]. Fluoroscopically guided T-tube removal with immediate tract visualization may allow prompt detection of tract disruption and early management before intraperitoneal bile accumulation becomes clinically significant[55].
Figure 1
Indications and implications of T-tube.
Biodegradable biliary support is already moving beyond concept into translational and early clinical use. Early review data suggested favorable biocompatibility and the practical advantage of avoiding mandatory stent removal, and subsequent human series reported feasible implantation, acceptable safety, and encouraging medium- to long-term patency in benign biliary strictures and related bilio-pancreatic indications[56,57]. Preclinical work has further shown that degradable biliary stents can maintain temporary radial support long enough to aid healing and may reduce postoperative fibrosis and stricture after biliary anastomosis[58]. More recently, data in high-risk pancreaticoduodenectomy and a 2026 systematic review suggest that biodegradable stents may become particularly relevant for small-caliber or high-risk biliary reconstructions, although longer comparative studies are still needed before broader routine adoption[59,60].
