A Question Seeking for an Answer: Use of T-tube in the Era of Liver Transplantation With Grafts From Extended Criteria Donors and Donors After Cardiac Death.

To the Editor: W e read with great interest the recent publication of López-Andújar et al1 presenting their results of a prospective and randomized clinical trial referring to the incidence and severity of biliary complications due to liver transplantation (LT) after choledochocholedochostomy for the biliary reconstruction with or without a temporary T-tube. Biliary complications including leaks; strictures; and ischemic-type biliary lesions, stones, and sphincter of Oddi dysfunction still remain the Achilles’ heel of the procedure because they contribute to its morbidity and mortality. There is still controversy about the usefulness of T-tube for end-to-end biliary anastomosis to reduce the incidence of biliary complications. More specifically, there is ongoing debate regarding the use of a T-tube for biliary reconstruction in LT. There is emerging literature that suggests the application of T-tube because it provides easy access to the biliary tree, lowers the pressure in the biliary system, aids in monitoring the quality and output of bile, and might reduce the incidence of anastomotic stricture2 without the increased rate of complications compared with the non–T-tube approach.3 Moreover, a previous meta-analysis conducted by our group on this subject4 evaluated the outcomes after duct-to-duct biliary reconstruction with or without T-tube in LT. We demonstrated nonsuperiority of performing duct-to-duct anastomoses with T-tube as far as anastomotic bile leaks or fistulas, need for postoperative choledochojejunostomies, and need for dilatation and stenting of anastomotic strictures is concerned. The evidence gathered in our study discourages the routine use of T-tubes in biliary reconstruction in LT.2