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.

The experience of collecting 120 transhepatic portograms, performed in patients with different degrees of portal hypertension, affords the opportunity for discussing the anatomical and hemodynamic features of portosystemic communications. Multiple pathways of decompression were found. The coronary-gastroesophageal collateral formed pathways in 108 cases, other major collaterals in 41, and minor collaterals in 2. This multiplicity of communications suggests that no one vessel is indispensable as a collateral pathway.

The problem of recurrent strictures following repair for bile duct injuries or in patients with sclerosing cholangitis is well recognized. For the most part, the recurrent problems have required repeated operations. The possibility of controlling the recurrent strictures by dilatation has been postulated, but repeated dilatations obviously require simple access to the entire biliary tree. We have found that stomatization of the afferent limb of a choledochojejunostomy or hepaticojejunostomy provides ready access to the biliary tree through which strictures can be readily traversed and dilated. Our early results with this procedure suggest that long-term patency can be expected following dilatation of these strictures.

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