Title: Residual Choledocholithiasis after Choledocholithotomy T-tube Drainage: What is the
best intervention Strategy?
Version: 3 Date: 23 Aug 2022
Reviewer's report:
First of all, I would like to comment about the systematic use of  T-tube. According to the series
published concerning of closure methods following common bile duct exploration, the results
do not justify the routine placement of T-tube (1, 2, 3, 4) . As the authors of this article mark,
T-tube closing  produces digestive, gastrointestinal, nutritional dysfunction and discomfort in
patients, in addition to the risk of biliary peritonitis after withdrawal, without offering advantage
versus primary closure or stent insertion. We strongly recommend reconsidering this point.
Materials and methods
There are some facts that would be interesting to know.
How many patients underwent choledochectomy T-tube drainage in the study period?
What is the rate of residual choledocholithiasis in your study?
Which are the clinical and analytical criteria that motivated the study of a possible residual
choledocholithiasis?
Discussion
The authors claim that “ERCP has become a preferred treatment for choledocholithiasis”.
However, according to reference  used by them (5), “Many studies and meta-analyses have been
conducted by various authors regarding the comparison between one-session and two-session
treatments for patients with concomitant gallbladder and CBD stones. The findings have shown
equivalent success rates, postoperative morbidity, stone clearance, mortality, conversion to other
procedures, total operation time, and failure rate, but one-session treatment is characterized by
a shorter hospital stay and more cost benefits”.
1. Estellés Vidagany N, Domingo Del Pozo C, Peris Tomás N, Díez Ares JÁ, Vázquez
Tarragón A, Blanes Masson F. Eleven years of primary closure of common bile duct after
choledochotomy for choledocholithiasis. Surg Endosc. 2016 May;30(5):1975-82. doi: 10.1007/
s00464-015-4424-2. Epub 2015 Jul 23. PMID: 26201414.
2. Hua J, Meng H, Yao L, Gong J, Xu B, Yang T, Sun W, Wang Y, Mao Y, Zhang T,
Zhou B, Song Z. Five hundred consecutive laparoscopic common bile duct explorations: 5-
year experience at a single institution. Surg Endosc. 2017 Sep;31(9):3581-3589. doi: 10.1007/
s00464-016-5388-6. Epub 2016 Dec 30. PMID: 28039642.
3. Parra-Membrives P, Martínez-Baena D, Lorente-Herce J, Jiménez-Riera G. Comparative
Study of Three Bile Duct Closure Methods Following Laparoscopic Common Bile
Duct Exploration for Choledocholithiasis. J Laparoendosc Adv Surg Tech A. 2018
Feb;28(2):145-151. doi: 10.1089/lap.2017.0433. Epub 2017 Oct 4. PMID: 28976804.
4. Xiao LK, Xiang JF, Wu K, Fu X, Zheng MY, Song XX, Xie W. The reasonable drainage
option after laparoscopic common bile duct exploration for the treatment of choledocholithiasis.
Clin Res Hepatol Gastroenterol. 2018 Dec;42(6):564-569. doi: 10.1016/j.clinre.2018.07.005.
Epub 2018 Aug 23. PMID: 30145281.
5. Cianci P, Restini E. Management of cholelithiasis with choledocholithiasis: Endoscopic and
surgical approaches. World J Gastroenterol 2021; 27(28): 4536-4554 [PMID: 34366622 DOI:
10.3748/wjg.v27.i28.4536]
Title: Residual Choledocholithiasis after Choledocholithotomy T-tube Drainage: What is the
best intervention Strategy?
Version: 3 Date: 23 Aug 2022
Reviewer's report:
First of all, I would like to comment about the systematic use of  T-tube. According to the series
published concerning of closure methods following common bile duct exploration, the results
do not justify the routine placement of T-tube (1, 2, 3, 4) . As the authors of this article mark,
T-tube closing  produces digestive, gastrointestinal, nutritional dysfunction and discomfort in
patients, in addition to the risk of biliary peritonitis after withdrawal, without offering advantage
versus primary closure or stent insertion. We strongly recommend reconsidering this point.
Materials and methods
There are some facts that would be interesting to know.
How many patients underwent choledochectomy T-tube drainage in the study period?
What is the rate of residual choledocholithiasis in your study?
Which are the clinical and analytical criteria that motivated the study of a possible residual
choledocholithiasis?
Discussion
The authors claim that “ERCP has become a preferred treatment for choledocholithiasis”.
However, according to reference  used by them (5), “Many studies and meta-analyses have been
conducted by various authors regarding the comparison between one-session and two-session
treatments for patients with concomitant gallbladder and CBD stones. The findings have shown
equivalent success rates, postoperative morbidity, stone clearance, mortality, conversion to other
procedures, total operation time, and failure rate, but one-session treatment is characterized by
a shorter hospital stay and more cost benefits”.
1. Estellés Vidagany N, Domingo Del Pozo C, Peris Tomás N, Díez Ares JÁ, Vázquez
Tarragón A, Blanes Masson F. Eleven years of primary closure of common bile duct after
choledochotomy for choledocholithiasis. Surg Endosc. 2016 May;30(5):1975-82. doi: 10.1007/
s00464-015-4424-2. Epub 2015 Jul 23. PMID: 26201414.
2. Hua J, Meng H, Yao L, Gong J, Xu B, Yang T, Sun W, Wang Y, Mao Y, Zhang T,
Zhou B, Song Z. Five hundred consecutive laparoscopic common bile duct explorations: 5-
year experience at a single institution. Surg Endosc. 2017 Sep;31(9):3581-3589. doi: 10.1007/
s00464-016-5388-6. Epub 2016 Dec 30. PMID: 28039642.
3. Parra-Membrives P, Martínez-Baena D, Lorente-Herce J, Jiménez-Riera G. Comparative
Study of Three Bile Duct Closure Methods Following Laparoscopic Common Bile
Duct Exploration for Choledocholithiasis. J Laparoendosc Adv Surg Tech A. 2018
Feb;28(2):145-151. doi: 10.1089/lap.2017.0433. Epub 2017 Oct 4. PMID: 28976804.
4. Xiao LK, Xiang JF, Wu K, Fu X, Zheng MY, Song XX, Xie W. The reasonable drainage
option after laparoscopic common bile duct exploration for the treatment of choledocholithiasis.
Clin Res Hepatol Gastroenterol. 2018 Dec;42(6):564-569. doi: 10.1016/j.clinre.2018.07.005.
Epub 2018 Aug 23. PMID: 30145281.
5. Cianci P, Restini E. Management of cholelithiasis with choledocholithiasis: Endoscopic and
surgical approaches. World J Gastroenterol 2021; 27(28): 4536-4554 [PMID: 34366622 DOI:
10.3748/wjg.v27.i28.4536]
Please review this paper.
user
Title: Residual Choledocholithiasis after Choledocholithotomy T-tube Drainage: What is the
best intervention Strategy?
Version: 3 Date: 23 Aug 2022
Reviewer's report:
First of all, I would like to comment about the systematic use of  T-tube. According to the series
published concerning of closure methods following common bile duct exploration, the results
do not justify the routine placement of T-tube (1, 2, 3, 4) . As the authors of this article mark,
T-tube closing  produces digestive, gastrointestinal, nutritional dysfunction and discomfort in
patients, in addition to the risk of biliary peritonitis after withdrawal, without offering advantage
versus primary closure or stent insertion. We strongly recommend reconsidering this point.
Materials and methods
There are some facts that would be interesting to know.
How many patients underwent choledochectomy T-tube drainage in the study period?
What is the rate of residual choledocholithiasis in your study?
Which are the clinical and analytical criteria that motivated the study of a possible residual
choledocholithiasis?
Discussion
The authors claim that “ERCP has become a preferred treatment for choledocholithiasis”.
However, according to reference  used by them (5), “Many studies and meta-analyses have been
conducted by various authors regarding the comparison between one-session and two-session
treatments for patients with concomitant gallbladder and CBD stones. The findings have shown
equivalent success rates, postoperative morbidity, stone clearance, mortality, conversion to other
procedures, total operation time, and failure rate, but one-session treatment is characterized by
a shorter hospital stay and more cost benefits”.
1. Estellés Vidagany N, Domingo Del Pozo C, Peris Tomás N, Díez Ares JÁ, Vázquez
Tarragón A, Blanes Masson F. Eleven years of primary closure of common bile duct after
choledochotomy for choledocholithiasis. Surg Endosc. 2016 May;30(5):1975-82. doi: 10.1007/
s00464-015-4424-2. Epub 2015 Jul 23. PMID: 26201414.
2. Hua J, Meng H, Yao L, Gong J, Xu B, Yang T, Sun W, Wang Y, Mao Y, Zhang T,
Zhou B, Song Z. Five hundred consecutive laparoscopic common bile duct explorations: 5-
year experience at a single institution. Surg Endosc. 2017 Sep;31(9):3581-3589. doi: 10.1007/
s00464-016-5388-6. Epub 2016 Dec 30. PMID: 28039642.
3. Parra-Membrives P, Martínez-Baena D, Lorente-Herce J, Jiménez-Riera G. Comparative
Study of Three Bile Duct Closure Methods Following Laparoscopic Common Bile
Duct Exploration for Choledocholithiasis. J Laparoendosc Adv Surg Tech A. 2018
Feb;28(2):145-151. doi: 10.1089/lap.2017.0433. Epub 2017 Oct 4. PMID: 28976804.
4. Xiao LK, Xiang JF, Wu K, Fu X, Zheng MY, Song XX, Xie W. The reasonable drainage
option after laparoscopic common bile duct exploration for the treatment of choledocholithiasis.
Clin Res Hepatol Gastroenterol. 2018 Dec;42(6):564-569. doi: 10.1016/j.clinre.2018.07.005.
Epub 2018 Aug 23. PMID: 30145281.
5. Cianci P, Restini E. Management of cholelithiasis with choledocholithiasis: Endoscopic and
surgical approaches. World J Gastroenterol 2021; 27(28): 4536-4554 [PMID: 34366622 DOI:
10.3748/wjg.v27.i28.4536]
assistant