Sir
Interesting though the paper on T tube modification by Crnojevic et al. (Br J Surg 1989; 76: 342-3) is, it is not clear from the results why the authors feel that smaller T tubes are preferable. The data clearly show that the force necessary to remove a sculpted T tube is equally low for all tube sizes between 12 and 18 French, the implication of this being that the risk of bile peritonitis is similarly low. One of the functions of the T tube is to allow access to the bile ducts for the non-operative management of retained stones. Percutaneous T tube track removal of stones' is simple, successful and safe but requires a T tube track of 14 French or larger. The alternatives of endoscopic removal' or surgery are more risky. As Crnojevic et al. indicate, the risk of bile peritonitis following T tube extraction is less than 1 per cent, but the risk ofretained stones, even in the most experienced hands, is about 5 per cent3. Is it sensible on the basis of in vitro evidence to suggest that we should deprive ourselves of an effective method of treating a relatively common complication of bile duct surgery in order to avoid a rare complication? A compromise is necessary. Surely surgeons should use a 14 French sculpted T tube brought out subcostally in the right flank. This avoids the risks which may be associated with excessive force for the removal of the tube but allows T tube track extraction of retained stones.