Search

OBJECTIVE: To compare the safety and feasibility of T-tube drainage and primary suture after laparoscopy combined with choledochoscopy in the treatment of secondary choledocholithiasis. METHODS: The clinical data of patients who underwent laparoscopic choledochoscopy combined with choledochoscopic common bile duct exploration (LCBDE) for secondary choledocholithiasis from June 2015 to June 2020 were analyzed retrospectively. According to the different treatment method of common bile duct (CBD) incision, the patients were divided into a T-tube drainage group and a primary suture group. The preoperative clinical characteristics, results of preoperative liver function tests (LFTs), LFTs on the first day after the operation and the fourth day after the operation, operation time, intraoperative bleeding, postoperative complications, and times of postoperative hospital stay were compared between the two groups. RESULTS: There was no significant difference in preoperative clinical data, preoperative LFTs, and postoperative complications between the two groups (P > .05). However, primary suture demonstrated significant advantages (P

Background Residual and recurrent stones remain one of the most important challenges of hepatolithiasis and are reported in 20 to 50% of patients treated for this condition. To date, the two most common surgical procedures performed for hepatolithiasis are choledochojejunostomy and T-tube drainage for biliary drainage. The goal of the present study was to evaluate the therapeutic safety and perioperative and long-term outcomes of choledochojejunostomy versus T-tube drainage for hepatolithiasis patients with sphincter of Oddi laxity (SOL). Methods/design In total, 210 patients who met the following eligibility criteria were included and were randomized to the choledochojejunostomy arm or T-tube drainage arm in a 1:1 ratio: (1) diagnosed with hepatolithiasis with SOL during surgery; (2) underwent foci removal, stone extraction and stricture correction during the operation; (3) provided written informed consent; (4) was willing to complete a 3-year follow-up; and (5) aged between 18 and 70 years. The primary efficacy endpoint of the trial will be the incidence of biliary complications (stone recurrence, biliary stricture, cholangitis) during the 3 years after surgery. The secondary outcomes will be the surgical, perioperative and long-term follow-up outcomes. Discussion This is a prospective, single-centre and randomized controlled two-group parallel trial designed to demonstrate which drainage method (Roux-en-Y hepaticojejunostomy or T-tube drainage) can better reduce biliary complications (stone recurrence, biliary stricture, cholangitis) in hepatolithiasis patients with SOL. Trial registration Clinical Trials.gov: NCT04218669. Registered on 6 January 2020.

We compared the post-operative course and final outcome of primary duct closure combined with transcystic drainage with those of T-tube drainage.We retrospectively analysed 112 consecutive patients treated with laparoscopic choledochotomy for common bile duct stones between February 2014 and December 2017. Primary closure with transcystic drainage was performed in 59 patients (group A), and laparoscopic choledochotomy with T-tube drainage was performed in 53 (group B). The primary endpoints were morbidity, the bile drainage quantity, operative time, post-operative stay, time until return to work and post-operative complications.The operation was successfully completed in all patients. The return to work period in group A was significantly shorter than that in group B (7.25 ± 1.27 versus 46.47 ± 3.86 days, P 0.05). The average daily drainage was not significantly different between the two groups (P 0.05). There was no significant difference in the operation time (133.75 ± 14.51 versus 132.21 ± 12.71 min) and duration of hospital stay (5.15 ± 1.23 versus 5.94 ± 0.95 days) between the two groups (P 0.05). Bile leakage was seen in one T-tube removal patient. No complications were reported in group A. The patients were followed for 2 to 29 months (average: 10). Normal liver function and no stricture of the bile duct were detected with ultrasonography.Primary closure of choledochotomy and subsequent transcystic drainage is a simple and less invasive procedure than T-tube placement.

Laparoscopic common bile duct exploration (LCBDE) has been recently introduced for management of CBD stone in patients with previous biliary surgery history. The aim of this study was to evaluate the safety and effectiveness of primary closure in patients with previous biliary surgery history compared to T-tube drainage. Eighty patients with previous biliary surgery history including laparoscopic cholecystectomy, open cholecystectomy, or open common bile duct exploration were enrolled in the retrospective study. The patients were divided into 2 groups according to the methods of choledochotomy closure. Group A: patients with primary closure after LCBDE (n = 51); group B: patients with T-tube drainage after LCBDE (n = 29). Group A exhibited a shorter postoperative hospital stay and lower hospitalization expenses compared to group B. There was no significant difference in conversion rate to open surgery, operating time, intraoperative blood loss, bile leakage rate, overall complication rate, and stone recurrence rate between the 2 groups. Biliary stricture was not observed in the 2 groups during the follow-up period. Primary closure following LCBDE is safe and effective for the management of CBD stones in patients with previous biliary surgery history.

Background: A recent meta-analysis showed that the primary closure (PC) of the biliary duct in the absence of T-tube (TT) drainage is a safe alternative for cholelithiasis after laparoscopic biliar...

Objective Primary closure of the common bile duct (CBD) after laparoscopic CBD exploration (LCBDE) is a technical challenge. The present study was performed to evaluate the safety and effectiveness of this surgical method. Methods This retrospective study of surgical efficacy and safety involved 79 patients who underwent primary CBD closure with a knotless unidirectional barbed suture or traditional T-tube drainage after LCBDE for CBD stones. Results The average suturing time, operation time, and postoperative hospital stay were significantly shorter in the primary closure group than T-tube group. There were no significant differences in the mean diameter of the CBD, number of stones, or incidence of postoperative complications between the two groups. No patients developed recurrence of CBD stones during the median follow-up of 21.5 months. Conclusions After LCBDE and intraoperative choledochoscopy, primary closure with knotless unidirectional barbed sutures is a safe and effective therapeutic option for patients with cholelithiasis and concurrent CBD stones. This is especially true when the CBD is dilated more than 8 mm.

Summary Background Spontaneous perforation of the extrahepatic bile duct is very rare. We report a patient with a spontaneous perforation of the left hepatic bile duct who was diagnosed preoperatively. Case Report A 65-year-old woman was admitted to our hospital complaining of a right upper quadrant pain lasting for two days. She was diagnosed as having a perforated bile duct and peritonitis and underwent a laparotomy. After a cholecystectomy, T-tube drainage of the left hepatic duct was performed. The postoperative course was uneventful. The T tube was removed 25 days after the surgery. Conclusions A more noninvasive procedure, such as endoscopic treatment, should play a central role in the management of extra bile duct perforation. For this case, however, we chose to perform a laparotomy based on the patient’s general condition and the presence of peritonitis. T tube decompression is effective and a safe and reliable method. The goal of treatment is to stop the bile leakage, resolve the choledocholithiasis and cholangitis, and reconstruct the bile duct.

Complications related to the T tube drainage of the common bile duct are not uncommon. Some, like dislocations of the T tube out of the common bile duct, could be very serious, particularly if developed during the first few days after surgery, when the abdominal drain in the subhepatic space had been already removed. Then, an emergency reoperation might be necessary. The slip of the T tube upwards or downwards inside the common bile duct is not so rare. Fortunately, it is less dangerous and can usually be resolved without reoperation. It takes place several days after surgery, followed by the right subcostal pain, occasionally with temperature, rise of the bilirubin and with decrease or complete cessation of the bile drainage through the T tube. The diagnosis can be made only on the basis of T tube cholangiography. The re-establishment of the proper T tube position must be done under X-ray visualization. Seven cases of the T tube slip within the common bile duct, its clinical presentation, diagnosis and method of repositioning were presented. Possible mechanism of complication was described. As far as we know, the complications have not been described by other authors.

Controversy surrounds the indications for and effectiveness of the abdominal drain. There are a variety of factors which mitigate against formulating rigid guidelines for the indications of drains, but surgeons should understand the benefits and applications of drainage and the tissue responses to the constituent materials. Drains are not a substitute for meticulous surgical technique.

BACKGROUND/AIM Although common bile duct stones are generally treated endoscopically, surgery is required if endoscopic removal is impossible. The aim of this study was to compare the surgical options in such patients. MATERIALS AND METHODS A total of 282 patients with common bile duct stones underwent open choledochotomy; primary closure was applied in 48 (17.0%), primary closure with T-tube drainage in 81 (28.7%), and choledochoduodenostomy in 153 (54.3%) patients. RESULTS Postoperative complications were seen in 8 (16.7%) patients in the primary closure, 33 (40.7%) patients in the primary closure with T-drainage, and 37 (24.2%) patients in the choledochoduodenostomy group. No significant differences were observed among the groups (P > 0.05). The mean postoperative hospital stays in the primary closure, primary closure with T-tube drainage, and choledochoduodenostomy groups were 5.5, 13.5, and 8.9 days, respectively. The mean postoperative hospitalization was significantly shorter in the primary closure group than in the other groups (P < 0.05). CONCLUSION Primary closure is a safe and feasible method in selected patients.

External drainage of the common bile duct by placement of a T-tube is a common practice after choledochotomy. This practice may result in the specific complication of bile peritonitis due to leakage after removal of the T-tube. This complication has multiple causes: some are patient-related (corticotherapy, chemotherapy, ascites), and others are due to technical factors (inappropriate suturing of the drain to the ductal wall, minimal inflammatory reaction related to some drain materials). The clinical presentation is quite variable depending on the amount and rapidity of intra-peritoneal spread of of bile leakage. Abdominal ultrasound (US), with US-guided needle aspiration and occasionally Technetium(99) scintigraphy are useful for diagnosis. Traditional therapy consists of surgical intervention including peritoneal lavage and re-intubation of the choledochal fistulous tract to allow for a further period of external drainage. When leakage is walled off and well-tolerated, a more nuanced and less invasive conservative therapy may combine percutaneous drainage with endoscopic placement of a trans-ampullary biliary drainage.

Background Traditionally, the common bile duct (CBD) is closed with T-tube drainage after choledochotomy and removal of CBD stones. However, the insertion of a T-tube is not without complication and the patients have to carry it for several weeks before removal. In the laparoscopic era, surgery is performed with minimally invasive techniques in order to reduce the trauma, hasten recovery, and reduce the hospital stay of patients. T-tube insertion seems to negate these benefits. This randomized study was designed to compare the two methods applied after LCBDE and to determine whether primary closure can be as safe as closure with T-tube drainage. Methods From May 2000 to January 2008, 93 consecutive patients with common bile duct stones (CBDS) and gallbladder in situ were enrolled in this randomized study to undergo laparoscopic cholecystectomy with laparoscopic common bile duct exploration (LCBDE). Intraoperative findings, postoperative complications, postoperative stay, and hospital expenses were recorded and analyzed. Results There was no mortality in both groups. A T-tube was inserted in 46 patients and the CBD was closed primarily in 47. There were no differences in the demographic characteristics or clinical presentations between the two groups. Compared with the T-tube group, the operative time and postoperative stay were significantly shorter, the hospital expenses were significantly lower, and the incidences of overall postoperative complications and biliary complications were statistically and insignificantly lower in the primary closure group. Conclusion LCBDE with primary closure without external drainage after laparoscopic choledochotomy is feasible and as safe as T-tube insertion.

INTRODUCTION The aim of this study was the assessment of patient outcome, peri-operative complications, length of stay and duration of operation after laparoscopic primary closure of the common bile duct (CBD) compared with choledochotomy with T-tube drainage and trans-cystic exploration. PATIENTS AND METHODS Analysis of prospectively collected data on 71 explorations of the common bile duct between July 2001 and March 2006. RESULTS A total of 71 patients had exploration of the CBD. Within this group, 12 were referred after failed endoscopic retrograde cholangiopancreatography (ERCP). The methods of exploration included trans-cystic (9 cases), choledochotomy with Ttube (12), and choledochotomy with primary closure (50). CBD stones were found in 66 patients. In the remaining cases, we found a stricture in 1, debris in 2, and dilatation of the CBD without a stone in 2. There were 5 conversions to open technique and 3 patients required postoperative ERCP (1 with permanent stenting). Peri-operative complications included T-tube (3), primary closure group (9), and trans-cystic (0). There was no statistical significant difference (Chi-square test, P = 0.296) between the groups. There was a trend towards a shorter length of stay in the primary closure group as compared with the trans-cystic and T-tube groups of 4.16, 4.44, and 6.33 days, respectively. However, it did not reach statistical significance (one-way analysis of variance with Boneferroni correction, mean difference between groups 1.89, 0.28, 2,17, statistical significance at P < 0.05). The shortest operating time was in the primary closure group (95.92 min) which was statistically significant (P < 0.001). We did not use a biliary drain in the last 48 patients. CONCLUSIONS Primary laparoscopic closure of the CBD is safe and results in a reduction in operating time. Choledochoscopy ensures clearance of the CBD and eliminates the need for T-tube.

Background: Intrabiliary rupture is one of the most serious complications of liver hydatid cysts (LHC). The kind of surgery for these patients is still controversial. T-tube drainage and choledochoduodenostomy (CD) are used by most of the surgeons. But there is no comparative study in the literature. Methods: Eighty patients with symptomatic intrabiliary rupture were treated between 1980 and 1995. All patients had jaundice. In addition to treatment of the cyst cavity, T-tube drainage of the common bile duct (CBD) was performed in 53 patients, 25 patients underwent a CD for biliary drainage and two patients were treated by a T-tube placed in the CBD without treating the cyst. The T-tube drainage and CD groups were compared in regard to morbidity, mortality, duration of the operation, rate of relaparatomy and duration of postoperative hospital stay. Results: The morbidity rate was 40% (10/25) after CD and 18.1% (10/55) after T-tube drainage. Relaparatomy was necessary in 8% (2/25) and 1.8% (1/55) of patients treated with CD and T-tube drainage, respectively. T-tube drainage was performed much more rapidly than CD (p < 0.05). The length of hospital stay for both groups was the same. One patient who was treated with CD died postoperatively. Conclusion: Our results suggest that T-tube drainage is superior to CD for intrabiliary rupture of LHC in most cases.

Spontaneous perforation of the bile duct is a rare but well documented condition of infants. Six infants are described, five presenting within 2 months of birth without apparent antecedent factors and one associated with an ‘acquired’ type I biliary atresia at 8 months. All infants underwent definitive surgery, which included decompression of the biliary tree with cholecystenterostomy or T tube drainage. There was no morbidity or mortality associated with such surgical intervention.

Since 1976, the authors have used T-tube drainage for the treatment of diaphragmatic type, high jejunal atresia. Twelve cases were operated on. All cases survived the operation. On the fourteenth to thirtieth postoperative day, T-tubes were removed when the dilated proximal intestine returned to normal size.

Insertion of semirigid penile prosthesis is a surgical option to correct male erectile dysfunction. Postoperative infection of penile prosthesis necessitates removal and drainage of corporeal chambers. We describe a technique to drain infected corporeal cavities with T-tubes.

Laparoscopic cholecystectomy (LC) has rapidly become the procedure of choice for the management of patients with gall-bladder stones. This contrasts with patients who have common bile duct and intrahepatic duct stones who still usually need an open operation. On the basis of experience of a number of LC by one surgeon and animal experiments, we have completed laparoscopic exploration of both intra- and extrahepatic ducts and T-tube drainage of 57 patients with intra- and extrahepatic bile duct calculi over 13 months during 1992-1993 with satisfactory results. The average operating time was 150 min, with a range of 100 to 220 min. Most patients were mobile and on oral fluids within 24 h postoperative. Average hospital stay was 4 days. Retained stones were found via T-tube cholangiography in four patients (7%) and for each patient these were removed by fibre-optic choledochoscope 2 weeks postoperatively. Laparoscopic exploration of intra- and extrahepatic bile ducts is achievable by experienced surgeons and may be particularly helpful for patients who are not a good operative risk.

T-tube drainage of the common bile duct (CBD) following duct exploration has become standard surgical practice. This randomized prospective study has compared primary closure versus T-tube drainage of the CBD following exploration for calculous disease. Thirty-seven patients underwent primary closure and 26 underwent closure over T-tube. Both groups were comparable in terms of age, indications for surgery, associated illnesses, pre-operative bilirubin, amylase and white cell count. Forty-three per cent of operations were performed by a consultant in the primary closure group and 65% in the T-tube group. There was no significant difference in the duration of operation, incidence of wound infection, surgical or other complications following operation between the two groups. However, the postoperative stay was significantly prolonged in the T-tube group, to a median of 11 days, compared to 8 days in the primary closure group (P= 0.0001). This prolongation in stay was unrelated to whether admission was as an emergency or elective. T-tube drainage of the bile continued for a median of 7 days postoperative, whereas the bile drained via a wound drain in only 13 (35%) of the primary closure group, for a median of 5 days in these 13 patients. Long-term follow up was achieved in 48 patients, by a questionnaire sent at a median of 2.8 years following operation. Abdominal pains following recovery from the operation were experienced by 18% of the primary closure group and 20% of the T-tube group. No patient developed jaundice or pancreatitis, nor needed further biliary surgery following operation. Primary closure of the CBD following exploration for calculous disease significantly reduces hospital stay, and is as safe as closure with T-tube, in both the short and long-term.

Duodenal injuries may be caused by blunt or penetrating trauma. There is a high mortality rate with this type of injury, particularly when associated with pancreatic trauma. The surgical management of such injuries is difficult and a technique is described which may reduce postoperative morbidity, as illustrated by the two cases described.

Objective: To evaluate the safety and feasibility of laparoscopic choledocholithotomy via choledochotomy for the treatment of choledocholithiasis. Design: A prospective series of 1332 consecutive patients who underwent laparoscopic cholecystectomies, with a mean follow-up of 21.2 months. Setting: University-affiliated referral center. Patients: Forty-three patients (3%) with documented common bile duct stones from January 1991 to February 1995. Interventions: Laparoscopic choledocholithotomy with choledochotomy and T tube drainage were performed in 40 patients. Postoperative endoscopic sphincterotomy after laparoscopic cholecystectomy was performed in three patients. Main Outcome Measures: Documented removal of common bile duct stones and procedure-related complications. Results: Laparoscopic choledocholithotomy via choledochotomy was successful in 35 (88%) of 40 patients in whom this procedure was attempted. The mean (±SD) operation time was 191.3±75.4 minutes, and the mean (±SD) length of postoperative stay was 10.4±2.7 days. Seven complications (18%) were recorded, including three major complications (8%) and two retained stones (5%). Conclusions: Laparoscopic choledocholithotomy via choledochotomy can be performed safely, without increasing the morbidity rate as compared with that of open choledocholithotomy. Thus, some of the advantages of minimally invasive surgery are preserved. (Arch Surg. 1996;131:407-411)

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 purpose of this study was to determine the source of organisms responsible for biliary infection associated with T-tube placement. Two groups of patients who had had T-tubes placed following common bile duct exploration were studied. In one group of 34 patients, bacterial cultures were taken daily from the drainage bag and the lumen of the T-tube. In the second group of patients, paired daily bacterial cultures were taken from the T-tube lumen and the skin tract surrounding the T-tube. Results of the first group showed the drainage bag to be the initial site of infection in seven cases, with “descending” infection from the patient's skin occurring in 27 cases, 14 in whom the organism was initially present in the bile while in the other 13 the organism appeared later. In the second group, of 32 isolates only five were found extraluminally before they appeared within the lumen, these five being allStaphylococcus epidermidis.Thus the majority of bile infections occurring after T-tube placement were found to originate from the patient's own biliary tree or skin.

• Cholecystostomy was performed on 22 patients with acute cholecystitis after partial (13) or complete (9) removal of gallbladder stones. One patient had complementary common-duct drainage. Early mortality occurred in two patients. Three patients with associated cholangitis but intraoperative reflux of cystic-duct bile were all treated by cholecystostomy alone and survived. For the poor-risk patient with cholecystitis, cholecystostomy is effective. When there is associated cholangitis and documented cystic-duct patency, cholecystostomy is also sufficient. When accompanying cholangitis is associated with cystic-duct occlusion, choledochotomy and T tube drainage should be added. ( Arch Surg 114:515-518, 1979)

The biliary excretion of tetroxoprim (TXP) was studied in 10 patients with T-tube drainage. A mean biliary peak of 32.56 +/- 7.69 micrograms/ml was observed 2-3 h after a single oral dose of 200 mg. The biliary elimination rate constant (kb) of TXP was found to be 0;056 (h-1), indicating a longer elimination from the bile than from the central blood compartment. Taking into account the TXP serum levels, following the same oral dose as reported in the literature, concentration factors of 6-8 can be calculated in the bile.

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