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Summary Experience with closure of the common duct after exploration for removal of calenli has been reviewed. The postoperative morbidity was less in the 250 patients having primary common duct closure than in a similar group of 250 patients subjected to T tube drainage. The conditions necessary for closure of the common bile duct after surgical exploration have been outlined. The indications for drainage of the common duct are also discussed. In the usual case primary closure of the common duct incision may be safely performed following exploration for calculi, but drainage is preferred in the presence of intensive inflammatory reaction involving the duct system and adjacent structures.

THE value of coumarin anticoagulant therapy in both the prevention and the treatment of postoperative thromboembolic disease is well established.1 Patients who have external (T-tube) drainage of the common bile duct present a risk, theoretically at least, of bleeding associated with the use of coumarin anticoagulant therapy. The presence of a drainage tube sometimes aggravates bleeding, but perhaps even more important in these patients is the external drainage of bile. It has been amply demonstrated that the presence of bile salts in the gastrointestinal tract is necessary for the absorption of natural vitamin K, and it is also well recognized . . .

A high incidence of infective complications followed choledochotomy and T-tube drainage when compared with closed biliary-tract procedures. Organisms cultured from infective sites were identical to those isolated from the T-tube in the postoperative period. Postoperative infection was associated with an increased morbidity in terms of length of hospital stay. As infection in these sites was independent of the presence of stones in the common bile-duct, complications would have been reduced if unnecessary exploration had been avoided. The routine use of operative cholangiography in the avoidance of these complications is discussed.

A patient is described who had acute perforation of a duodenal diverticulum and survived after surgical intervention. Various technics for the surgical management of perforated duodenal diverticula are detailed. Choledochotomy, with passage of a catheter or sound into the duodenum, permits identification of the ampulla and safe excision and closure of the diverticulum. T tube drainage seems to be useful, and postoperative cholangiography confirms the integrity of the duodenum prior to feeding. Drainage of the retroduodenal area is recommended.

The incidence of hyponatremia in a study of 208 patients with common duct exploration was determined. The total amount and the daily average biliary drainage were calculated on all patients. The importance of the amount of daily biliary drainage, the total amount of biliary drainage, and the effect of prolonged drainage are discussed as factors in the development of hyponatremia. The causative factors for increased drainage volumes in the patients in whom hyponatremia developed are analyzed. The additional effects of pre-existing adrenocortical or renal disease or the treatment of cardiac disease are discussed as factors in the development of hyponatremia.

To the Editor:— I would like to comment on the question and answer to the letter regarding excessive t-tube drainage following cholecystectomy ( 208: 541, 1969). The most common cause of t-tube drainage in excess of 1,000 cc/24 hr is reflux of pancreatic or duodenal secretions into the common duct. I have seen this commonly in patients with a "short" arm t-tube that does not enter the duodenum. Obviously, one may have a "tight" sphincter of Oddi with a common channel of bile and pancreatic juice or patulous sphincter with duodenal contents refluxing up the common duct. The diagnosis is easily confirmed by testing the "bile" for the presence of amylase.

Primary sclerosing cholangitis is an uncommon condition of unknown etiology, presenting extrahepatic biliary obstruction due to a chronic inflammatory obliterative process. Criteria for diagnosis include progressive biliary obstruction due to a chronic inflammatory fibrous process, absence of biliary stones, absence of biliary surgery prior to onset of symptoms, and a follow-up period long enough to exclude sclerosing carcinoma of the biliary tree. Long-term prognosis is generally considered to be poor. Our patient was treated by resection of the hyperplastic fibrous inner wall making possible T tube drainage. Steroids and antibiotics were given, and the patient is alive and well three years later.

BLOCH and his co-workers1first demonstrated the biological conversion of cholesterol to cholic acid in 1943. Siperstein and Murray,2in 1955, demonstrated that the major metabolic pathway of cholesterol catabolism is its conversion to bile acids in man. These workers collected bile during a 50-hour period of total biliary drainage using a T tube with an inflatable balloon. Of intravenously administered cholesterol-4-14C, 98% of the14C excreted in this period appeared in the bile; 90% was recovered as bile acids. While it has been shown that increased catabolism of cholesterol to bile acids is a major mechanism for the control of the serum cholesterol concentration in the rat,3such a mechanism has not yet been clearly established in man. Our purpose, in this study, was to observe in a more complete manner, the overall pattern of bile acid excretion in man and the response

Traumatic hemobilia is a major complication of liver trauma which is being recognized with increasing frequency. Prevention of hemobilia of intrahepatic origin would appear to depend upon thorough exploration and debridement of major hepatic injuries as well as provision for the external drainage of bile. Controlled biliary decompression utilizing T tube drainage of the common duct is recommended as a major adjuvant in the management of severe liver injuries. The progressively decreasing morbidity and mortality of traumatic hemobilia is the result of more aggressive surgical management. Hemobilia originating with one lobe is best treated by excision of the involved hepatic segment or lobectomy when necessary. Hemobilia originating from a central hepatic cavity is best treated by wide exposure of the cavity and direct ligation of the bleeding vessels. A patient with traumatic hemobilia of central hepatic origin is presented in detail. The surgical management of previously reported cases of intrahepatic traumatic hemobilia is reviewed and summarized.

Any system that provides for drainage of the common bile duct consists of two essential parts; a catheter or T-tube to be placed in the duct and a receptacle for collecting the bile, which is attached to the dressing on the abdominal wall. I have used a number of devices for the receptacle, none of which have ever been completely satisfactory to either the patients or the attending nurses. Any unexpected change in position on the part of the patient would be apt to cause spillage of bile on the dressing and the bed. Recently, after having inserted a T-tube in the common duct of an obese patient and having applied the dressing, I was confronted with a T-tube that was too short to reach the 8 oz. (250 cc.) pharmacy bottle and nipple that I usually used for the receptacle. The nursing supervisor, Miss Catherine Marburger, speedily remedied the

To the Editor: —A very recent personal experience with a cholecystectomy and choledochotomy followed by T tube drainage of the common duct leads me to make some comments on the experience for the benefit of those practicing this procedure. The most annoying symptoms following the operation, aside from the pain produced by coughing, sneezing and the like, were those referred to the stomach. These symptoms were similar to those experienced at intervals for years prior to the operation, and consisted of an almost continuous nausea accompanied by a terrific burning in the epigastrium. After a time vomiting would occur followed by a period of relief of the burning and nausea; but the act itself, which was resisted as long as possible, was accompanied by excruciating pain in the wound, and the muscular effort involved was sufficient to break one of the silkworm-gut stitches. It was found that a quarter grain