Clinical Application Value of Modified Laparoscopic Radical Resection for Congenital Choledochal Cyst

Clinical Application Value of Modified Laparoscopic Radical Resection for Congenital Choledochal Cyst | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical Application Value of Modified Laparoscopic Radical Resection for Congenital Choledochal Cyst Jie Zhang, Xiaofeng Lv, Weiwei Jiang, Weibing Tang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8542701/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective : To evaluate the clinical efficacy of the modified laparoscopic radical resection of congenital choledochal cysts. Methods : A retrospective analysis was conducted on 33 pediatric patients with congenital choledochal cysts treated at our institution from September 2018 to December 2024. The control group (n=18) underwent traditional laparoscopic surgery (September 2018–December 2021), while the modified group (n=15) received the modified technique (January 2022–December 2024). Baseline characteristics (gender, age, weight, preoperative laboratory tests) and perioperative outcomes (intraoperative blood loss, postoperative drainage volume, tube indwelling time, time to initiate feeding, hospital stay, costs, and complications) were compared between the two groups. Results : No significant differences were observed in baseline characteristics (age, gender, weight) or preoperative laboratory parameters (white blood cell count, hemoglobin, prealbumin, retinol-binding protein, liver enzymes, conjugated bilirubin, etc.) between the two groups (P > 0.05). There was no statistically significant difference in postoperative complications (fever, vomiting, abdominal distension, anastomotic leakage, anastomotic stenosis, bleeding, intra-abdominal infection, cholangitis, pancreatic fistula, and wound infection) between the two groups (P > 0.05).The modified group showed significantly reduced postoperative drainage volume, shorter abdominal drainage/gastric tube indwelling time, earlier feeding initiation, shorter hospital stays, and lower costs (P <0.05). Conclusion : Modified laparoscopic radical resection for congenital choledochal cysts reduces postoperative exudate, accelerates recovery, lowers hospitalization costs, demonstrating clinical safety and efficacy. Congenita choledochal cyst modified laparoscopic radical resection drainage tube Complications Figures Figure 1 Introduction Congenital choledochal cyst (CCC), or congenital biliary dilatation, refers to a congenital bile duct malformation characterized by localized dilation[ 1 ]. Its incidence varies geographically: 1:100,000–1:150,000 in Western populations but rises to 1:1,000 in East Asia, with a female predominance [ 2 ]. Clinical presentation typically includes abdominal pain, palpable mass, and jaundice,making CCC the most common congenital biliary anomaly[ 3 ]. While its etiologyremains incompletely understood, an abnormal pancreaticobiliary junction (common channel > 4–5 mm in children) is a widely implicated factor [ 2 , 4 ]. The treatment of congenital choledochal cyst mainly relies on surgery, and there are various surgical methods. In the early stage, open surgery was performed, including choledochal cystostomy (external drainage), cyst-intestine anastomosis (internal drainage), and cyst resection with biliary reconstruction. After years of development and demonstration, complete resection of the extrahepatic dilated common bile duct and Roux-en-Y anastomosis between the common hepatic duct and the jejunum is recognized as the preferred surgical method [ 5 ]. The advantages of this method are that it removes the dilated and diseased biliary tract, changes the biliary outflow pathway, avoids the reflux of pancreatic juice, and can effectively reduce the incidence of cholangiocarcinoma [ 5 , 6 ].Laparoscopic techniques, first described by Frello et al. in 1995 [ 7 ], have since demonstrated superiority over open surgery in operative time and perioperative outcomes, establishing laparoscopy as the preferred approach [ 8 ]. Since 2018, our center has adopted laparoscopic CCC resection with enhanced recovery after surgery (ERAS) protocols. However, we observed significant bile leakage during CCC resection, accompanied by increased postoperative inflammatory exudate and sustained medium-volume abdominal drainage. These factors, along with delayed gastrointestinal recovery, resulted in prolonged postoperative hospitalization compared to established benchmarks in contemporary literature [ 9 ]. To address these issues, Professor Tang Weibing’s team modified the surgical technique. The refined technique yielded multiple clinical benefits: a marked reduction in postoperative abdominal exudate, earlier removal of abdominal drainage and gastric tubes, accelerated resumption of oral intake, and shorter postoperative hospitalization, all while maintaining comparable complication rates to conventional methods. These improvements translated into significant cost savings without compromising surgical safety. Patients and Methods Patients This retrospective comparative study analyzed 33 consecutive pediatric patients who underwent laparoscopic choledochal cyst excision by Professor Tang's surgical team between September 2018 and December 2024, meeting the following inclusion criteria: (1) confirmed diagnosis requiring surgical intervention, (2) successful completion of the planned laparoscopic procedure without conversion, and (3) availability of complete perioperative data. Patients with major congenital comorbidities (n = 1) or requiring conversion to open surgery (n = 4) were excluded from the analysis. The cohort was divided into two groups based on surgical technique and treatment period. Fifteen patients (female:male = 9:6) underwent modified laparoscopic resection between January 2022 and December 2024, while eighteen patients (female:male = 16:2) received conventional laparoscopic surgery between September 2018 and December 2021. This study was approved by the Institutional Ethics Committee of Children’s Hospital of Nanjing Medical University (Approval number:202512052-1) . Observation Indicators The study observed the intraoperative blood loss volume of the two groups, postoperative indicators (including the average daily volume of abdominal drainage fluid in the first 3 days after surgery, the indwelling time of the abdominal drainage tube after surgery, the indwelling time of the gastric tube after surgery, the time to first water intake after surgery, the time to first milk feeding after surgery, the white blood cell count on the first day after surgery, C-reactive protein level, the time to first defecation after surgery, the average postoperative hospital stay, and hospitalization expenses), and postoperative complications (fever, vomiting, abdominal distension, anastomotic leakage, anastomotic stenosis, bleeding, abdominal infection, cholangitis, pancreatic leakage, incision infection, etc.).Surgical procedures and ERAS perioperative management Surgical procedures Modified Laparoscopic Surgical Method The modified group underwent the modified laparoscopic surgical method.The modified laparoscopic procedure was performed through a standardized four-port approach (5-mm umbilical, two 5-mm right-sided, and 3-mmor 5-mmleft upper quadrant ports). Initial steps focused on biliary tree evaluation, beginning with gallbladder fundus exteriorization and cannulation. A drainage tube was inserted for contrast cholangiography, complete bile aspiration, and controlled saline distension of the cyst (Fig. 1 A). The tube was then secured within the gallbladder and both were carefully repositioned into the abdominal cavity (Fig. 1 B).The gallbladder and choledochal cyst were separated.The jejunal bile branch was constructed in vitro through the umbilicus.Theindwelling drainage tube provided critical anatomical guidance, enabling precise identification of the cystic duct and common hepatic duct openings (Fig. 1 C),followed by gallbladder removal,choledochal cyst resection,,and completion of hepatodochal jejunoanastomosis under laparoscopy. Traditional Laparoscopic Surgical Method The traditional laparoscopic four-port surgical plan involves laparoscopic cholangiography, separation and resection of the choledochal cyst and gallbladder, external construction of the jejunobile branch through the navel, and completion of Roux-en-Y hepatodochal jejunoanastomosis under laparoscopy[10、11]. ERAS Perioperative Management Both groups underwent ERAS perioperative management. The specific measures were as follows: (1) Conduct a nutritional assessment before surgery. For those at high risk of malnutrition, provide nutritional support treatment for 7 to 10 days; (2) Prohibit milk intake 6 hours before surgery, breast milk intake 4 hours before surgery, and allow the patient to drink 10 ml/kg of 10% glucose solution 2 hours before surgery; (3) Do not perform clean retrograde enema on the morning of surgery, but simply use glycerin suppositories for defecation once; (4) Administer prophylactic antibiotics 0.5 to 1 hour before surgery; (5) Place a gastrointestinal decompression tube after anesthesia; (6) Use a warming blanket, an infusion warmer, and control of operating room temperature to maintain patient warmth throughout surgery, while monitoring body temperature; (7) Adopt multimodal analgesia methods such as postoperative oral paracetamol, sucking on a pacifier dipped in 5% sucrose solution, and music therapy; (8) Encourage parents to hold the child for activities on the second day after surgery; (9) Implement early postoperative feeding. Statistical Methods All data analysis was completed based on the R version 4.2.2 (2022-10-31) software. All statistical tests adopted two-sided tests, and P < 0.05 was considered to indicate a statistically significant difference. Measurement data that follow a normal distribution are expressed as mean ± standard deviation (Mean ± SD), and the independent samples t-test is used for comparison between groups. Measurement data that do not follow a normal distribution are expressed as median and interquartile range [M (Q1, Q3)], and the Mann Whitney U test is used for comparison between groups. Enumeration data are expressed as the number of cases and constituent ratio [n (%)]. For comparison between groups of unordered categorical data, the Pearson χ2 test or Fisher’s exact probability method is used, and for comparison between groups of ordered categorical data, the Mann Whitney U test is used. At the same time, the standardized mean difference (SMD) is used to compare the differences between groups. Generally, SMD < 0.10 indicates that the data balance between groups is acceptable, SMD between 0.10 and 0.34 indicates that there is a small difference in the data between groups, SMD between 0.35 and 0.64 indicates that there is a moderate difference in the data between groups, SMD between 0.65 and 1.19 indicates that there is a large difference in the data between groups, and SMD ≥ 1.20 indicates that the difference in the data between groups is extremely large [ 12 ]. Results Comparative analysis revealed comparable baseline characteristics between groups: median weight (5.000 [Q1-Q3: 4.450–5.400] vs 5.150 [3.850–6.900] kg; Z=-0.072, p = 0.942), median age (48.000 [36.000-82.500] vs 65.000 [37.750–173.000] days; Z=-0.651, p = 0.515), and hematological parameters including median WBC count (9.370 [7.485–11.800] vs 10.190 [7.525–13.505] ×10⁹/L; W = 112.000, p = 0.421) and mean hemoglobin levels (111.200 ± 15.077 vs 120.444 ± 21.208 g/L; t=-1.415, p = 0.167). Standardized mean differences ranged from 0.221 to 0.702 across all parameters, confirming baseline comparability (all p > 0.05) (Tables 1 and 2 ). Table 1 Comparison of general data between the improved group and the control group Group Total( n = 33) Sex, n (%) Weight(Kg), M (Q 1 , Q 3 ) Age(day), M (Q 1 , Q 3 ) WBC(*10^9/L), M (Q 1 , Q 3 ) HB(g/L), Mean ± SD femal male Modified group 15 9 (60.000) 6 (40.000) 5.000 (4.450, 5.400) 48.000 (36.000, 82.500) 9.370 (7.485, 11.800) 111.200 ± 15.077 Control group 18 16 (88.889) 2 (11.111) 5.150 (3.850, 6.900) 65.000 (37.750, 173.000) 10.190 (7.525, 13.505) 120.444 ± 21.208 Statistics - 2 Z =-0.072 3 Z =-0.651 3 W = 112.000 3 t =-1.415 1 P 0.101 0.942 0.515 0.421 0.167 SMD 0.702 0.221 0.382 0.366 0.518 Notes: 1. fisher exact probability method; 2. Mann Whitney U test for continuity correction; 3. Independent sample t test for variance correction. Table 2 Comparison of general data between the improved group and the control group Group Total(n = 33) Prealbumin(g/L), M (Q1, Q3) Retinol conjugated protein(mg/L), M (Q1, Q3) ALT(U/L), M (Q1, Q3) GGT(umol/L), M (Q1, Q3) DBIL(umol/L), M (Q1, Q3) Modified group 15 0.120 (0.105, 0.145) 20.440 (18.675, 26.840) 24.000 (16.000, 31.500) 109.000 (51.500, 305.500) 6.600 (3.895, 14.270) Control group 18 0.120 (0.100, 0.147) 20.060 (14.350, 22.480) 34.000 (18.250, 60.500) 305.000 (29.500, 566.500) 13.710 (5.037, 34.097) statistics -- Z = 0.073 W = 164.000 Z =-1.266 W = 125.000 W = 100.000 P 0.942 0.307 0.206 0.735 0.215 SMD 0.343 0.268 0.368 0.113 0.642 Notes: Independent sample t test for variance correction. The modified group exhibited significantly better outcomes than the control group across multiple postoperative parameters, with statistically significant reductions (P < 0.05)in theaverage daily abdominal drainage volume during the first three postoperative days,abdominal drainage tube indwelling duration,gastric tube retention period,time to initial oralwaterintake,interval to first milk feeding, mean postoperative hospitalization duration, and total hospitalization expenses.However, no statistically significant differences were observed between the groups regarding intraoperative blood loss volume, first postoperative day white blood cell count, C-reactive protein levels, or time to first defecation, as detailed in Tables 3 and 4 . Table 3 Comparison of intraoperative bleeding and postoperative indexes between the two groups group Total ( n = 33) Intraoperative blood loss(ml), M (Q 1 , Q 3 ) Average intraperitoneal drainage in the first 3 days after surgery(ml), M (Q 1 , Q 3 ) Postoperative abdominal drainage catheter indwelling time(h), Mean ± SD Postoperative gastric tube retention time(h), M (Q 1 , Q 3 ) Time to initial oralwaterintake(h), M (Q 1 , Q 3 ) Time to first milk feeding after surgery(h), M (Q 1 , Q 3 ) Modified group 15 10.000 (10.000, 20.000) 20.670 (12.865, 26.330) 104.667 ± 22.598 24.000 (17.500, 42.500) 42.000 (40.500, 44.000) 65.000 (50.000, 66.500) Control group 18 20.000 (12.750, 23.750) 34.000 (26.350, 58.248) 134.167 ± 20.971 48.500 (28.750, 66.000) 66.000 (42.500, 87.750) 88.000 (67.000, 112.500) statistics - Z= -1.404 2 Z=-3.001 2 t =-3.885 3 Z =-2.371 2 Z =-2.502 3 Z =-2.591 1 P - 0.160 0.003 0.001 0.018 0.012 0.002 SMD - 0.503 1.302 1.397 0.871 1.066 1.087 Notes: 1. Mann Whitney U test for continuity correction; 2. Independent sample t test for variance correction; 3. Independent sample t test. Table 4 Comparison of intraoperative bleeding and postoperative indexes between the two groups. group Total( n = 33) White blood cell count on the first day after surgery (*10^12/L), Mean ± SD CRP on the first day after surgery(mg/L), M (Q 1 , Q 3 ) Time to first postoperative defecation(h), M (Q 1 , Q 3 ) Postoperative hospital stay(d), M (Q1, Q3) Hospitalization expenses(CNY), Mean ± SD Modified group 15 10.857 ± 1.906 13.330 (3.500, 17.220) 37.000 (18.500, 42.500) 8.000 (7.000, 8.000) 34909.035 ± 3580.155 Control group 18 10.783 ± 3.288 5.000 (5.000, 8.000) 42.500 (36.250, 52.000) 11.000 (10.000, 12.000) 40875.154 ± 6596.433 statistics - t = 0.077 1 Z = 0.829 2 Z=-1.598 2 Z=-3.786 2 t =-3.298 3 P - 0.939 0.407 0.110 < 0.001 0.003 SMD - 0.028 0.605 0.660 1.343 1.158 Notes: 1. fisher exact probability method; 2. Independent sample t test for variance correction; 3. Independent sample t test. Postoperative complications in the modified group included 6 cases of fever, 4 cases of vomiting, 2 cases of abdominal distension, and 1 case of anastomotic stenosis, while the control group had 5 cases of fever, 2 cases of vomiting, 1 case of abdominal distension, and no cases of anastomotic stenosis, with no statistically significant difference observed between the two groups (P > 0.05) as shown in Tables 5 and 6 . Notably, neither group experienced any instances of postoperative bleeding, anastomotic leakage, intra-abdominal infection, cholangitis, pancreatic fistula, or surgical site infection following the procedures, as detailed in Tables 5 and 6 . Table 5 Comparison of postoperative complications between the two groups of children group Total( n = 33) Number of complications, n (%) Absent Present Modified group 15 8 (53.333) 7 (46.667) Control group 18 11 (61.111) 7 (38.889) statistics - - P - 0.733 SMD - 0.158 Notes: fisher exact probability method. Table 6 Comparison of postoperative complications between the two groups of childrengroup Fever, n (%) Vomit, n (%) Abdominal distension, n (%) Anastomotic stenosis, n (%) Absent Present Absent Present Absent Present Absent Present Modified group 9 (60.000) 6 (40.000) 11 (73.333) 4 (26.667) 13 (86.667) 2 (13.333) 14 (93.333) 1 (6.667) Control group 13(72.222) 5 (27.778) 16 (88.889) 2 (11.111) 17 (94.444) 1 (5.556) 18 (100.000) 0 (0.000) statistics - - - - P 0.488 0.375 0.579 0.455 SMD 0.260 0.405 0.268 0.378 Notes: Mann Whitney U test for continuity correction Discussion The surgical management of congenital choledochal cysts has evolved considerably with the refinement of minimally invasive techniques. Currently, laparoscopic complete cyst excision with Roux-en-Y hepaticojejunostomy has become the gold standard treatment, supported by substantial clinical evidence demonstrating its safety and efficacy [ 13 , 14 ]. This approach has been progressively adopted in numerous medical institutions across China [ 15 ], reflecting the growing expertise in advanced laparoscopic hepatobiliary surgery. Since September 2018, our department has systematically performed this procedure while implementing comprehensive enhanced recovery after surgery (ERAS) protocols. Compared to traditional open surgery, our experience confirms significant reductions in both postoperative hospitalization duration and overall treatment costs, while maintaining comparable surgical outcomes. Despite these advantages,we have found that if too much bile leaks into the abdominal cavity after the resection of the choledochal cyst during the operation, it will lead to an increase in the inflammatory exudation in the abdominal cavity during and after the operation. The amount of exudate drained from the abdominal cavity drainage tube after the operation is relatively large, and the recovery of intestinal function is slow, which in turn leads to a still relatively long hospital stay. Therefore, since January 2022, the diagnosis and treatment team led by Professor Tang Weibing of the Department of Neonatal Surgery in our hospital has made some improvements to the traditional laparoscopic choledochal cyst resection and hepaticojejunostomy in Roux-en-Y pattern:(1)Insert a drainage tube through the fundus of the gallbladder outside the body, inject contrast medium for cholangiography, aspirate the bileafter placing the drainage tube into CCC, and inject an appropriate amount of normal saline to refill the cyst. An appropriate amount of normal saline is injected to refill the choledochal cystso that the common bile duct cyst maintains proper tension for separation. (2) After the gallbladder and the choledochal cyst are separated, the jejunal biliary limb is made first. After it is completed,the gallbladder and the choledochal cyst are resected under laparoscopy. Then, hepaticojejunostomy is performed. Before closing the abdomen, the resected gallbladder, choledochal cyst and the drainage tube are removed from the abdominal cavity. These modifications have ensured that almost no bile leaks into the abdominal cavity when separating and resecting the choledochal cyst and the gallbladder, avoiding the induction of bile peritonitis and reducing the impact of bile on the recovery of the intestinal function of children after the operation. Injecting an appropriate amount of normal saline can maintain a certain tension of the choledochal cyst, facilitating the separation of the cyst. Through these modifications, the average daily volume of abdominal cavity drainage fluid in the first 3 days after the operation, the indwelling time of the abdominal cavity drainage tube after the operation, the indwelling time of the gastric tube after the operation, the time of the first water intake after the operation, and the time of the first milk feeding after the operation of children have been significantly shortened, and the recovery has been accelerated. As a result, the average postoperative hospital stay and hospitalization expenses have significantly decreased. These modifications have been rarely reported at home and abroad and are somewhat innovative. The laparoscopic radical choledochal cyst technique is becoming increasingly mature, but there are still certain complications.Hepatic duct injury represents a significant technical challenge in radical resection of choledochal cysts[ 16 ]. In the past, we found that the opening of the cystic duct and the opening of the common hepatic duct in children are close to each other, and the orifice of common hepatic duct is difficult to identify. In addition, the common hepatic duct is dilated in some cases, and sometimes it is impossible to distinguish the junction between the common hepatic duct and the common bile duct during the operation. When resecting the gallbladder and the choledochal cyst, it is easy to accidentally injure the opening of the common hepatic duct.To address thischallenge, following intraoperative cholangiography, we maintain part of the drainage tube in the gallbladder and the choledochal cyst, and put the drainage tube together with the gallbladder back into the abdominal cavity. The gallbladder and the choledochal cyst are dissected with the tube in place.Our technique involves initially incising the anterior cyst wall, which permits precise identification of the cystic duct and common hepatic duct orifices under direct catheter guidance, thereby facilitating safe resection while protecting the common hepatic duct. This technical adaptation represents a novel approach that, to our knowledge, has not been previously documented in the medical literature. Complications after radical resection of choledochal cysts also include damage to tissues around the biliary tract (including blood vessels, duodenum and pancreatic duct injuries), bleeding, bile leakage, postoperative biliary obstruction, cholelithiasis formation, cholangitis, pancreatic calculus formation, pancreatitis, torsion and obstruction of the Roux jejunal biliary limb, and carcinogenesis due to incomplete resection [ 17 , 18 ]. There were no cases of bleeding, anastomotic leakage, abdominal cavity infection, cholangitis, pancreatic leakage, incision infection, etc. in both groups after the operation.There was no statistically significant difference between the two groups,indicating that the modified laparoscopic radical resection of choledochal cysts did not increase short-term and long-term postoperative complications after 6 months to 5 years follow-up. The present study has several limitations that warrant consideration. First, its retrospective design inherently limits the strength of conclusions compared to prospective randomized trials. Second, the relatively small cohort size (33 patients) and unequal group distribution (15 vs 18 patients) may affect statistical power for detecting subtle differences in complication rates. Third, the single-center nature of the study may limit generalizability to institutions with different surgical protocols or patient populations. Finally, our mean follow-up duration of 17 months, while adequate for assessing immediate postoperative outcomes, may be insufficient to evaluate long-term complications such as anastomotic strictures or biliary malignancies. In conclusion, our experience demonstrates that the modified laparoscopic technique for choledochal cyst excision is both safe and effective, offering several practical advantages over conventional approaches. The technical refinements we describe - particularly the complete bile aspiration with saline replacement and guided dissection using the indwelling catheter - represent reproducible innovations that address specific challenges in laparoscopic biliary surgery. While further multicenter studies with larger patient cohorts and longer follow-up are needed to validate these findings, our results suggest that these modifications can be safely incorporated into standard practice to optimize outcomes for pediatric patients with congenital choledochal cysts. Declarations Funding: This study was funded by Medical Research Project of Jiangsu Provincial Health Commission - Guiding Project (Z2021028). Data availability The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests: The authors declare no competing interests. References Schober, P., Mascha, E. J., & Vetter, T. R. (2021). Statistics From A (Agreement) to Z (z Score): A Guide to Interpreting Common Measures of Association, Agreement, Diagnostic Accuracy, Effect Size, Heterogeneity, and Reliability in Medical Research. Anesthesia and analgesia , 133 (6), 1633–1641.https://doi.org/10.1213/ANE.0000000000005773. Cazares, J., Koga, H., & Yamataka, A. (2023). Choledochal cyst. Pediatric surgery international, 39(1), 209.https://doi.org/10.1007/s00383-023-05483-1. 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Laparoscopic management of choledochal cysts in children: complications and their prevention [in Chinese]. Journal of Clinical Pediatric Surgery, 2023, 22(1): 7-11. DOI: 10.3760/cma.j.cn101785-202205002-002.. Zhang, B., Wu, D., Fang, Y., Bai, J., Huang, W., Liu, M., Chen, J., & Li, L. (2019). Early complications after laparoscopic resection of choledochal cyst. Pediatric surgery international , 35 (8), 845–852. https://doi.org/10.1007/s00383-019-04489-y. Anxiao, M., Yifeng, S., Mei, D., Qi, L., Xu, L., & Long, L. (2025). Reoperation related to Roux-en-Y jejunal limb after hepaticojejunostomy of choledochal cyst. Pediatric surgery international , 41 (1), 167. https://doi.org/10.1007/s00383-025-06056-0 Additional Declarations No competing interests reported. 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University","correspondingAuthor":false,"prefix":"","firstName":"Xiaofeng","middleName":"","lastName":"Lv","suffix":""},{"id":577509462,"identity":"c52bc53a-41c7-4fa6-b688-0acccf9841b8","order_by":2,"name":"Weiwei Jiang","email":"","orcid":"","institution":"Children’s Hospital of Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Weiwei","middleName":"","lastName":"Jiang","suffix":""},{"id":577509463,"identity":"ee57bddd-dd37-43bc-b870-9f5c0f5b7248","order_by":3,"name":"Weibing Tang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAtUlEQVRIiWNgGAWjYFACHiCuYGCGs4nQAFJ2hmQtjG1INhIE9hK5Bz8XzrvDrjsjgfHB2zYGeXOCtkjkJUvP3PaM2exGArPh3DYGw50NhLRI55gx8247DNLCJs3bxpBgcIAoLXPAWth/k6ClAWILM3Fa7r9LluY5BtRy5mGz5JxzEoYbCGlh7zl78DNPzeFks+PJBz+8KbORJ2gLDCQDY6cBSEsQqR4I7IhXOgpGwSgYBSMOAABlkDj7e/Zg4QAAAABJRU5ErkJggg==","orcid":"","institution":"Children’s Hospital of Nanjing Medical University","correspondingAuthor":true,"prefix":"","firstName":"Weibing","middleName":"","lastName":"Tang","suffix":""}],"badges":[],"createdAt":"2026-01-07 14:38:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8542701/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8542701/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":100866184,"identity":"1e982b7c-a545-493a-a8d0-3e183abba773","added_by":"auto","created_at":"2026-01-22 08:32:13","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":989724,"visible":true,"origin":"","legend":"","description":"","filename":"manuscriptforCholedochocystPSI.docx","url":"https://assets-eu.researchsquare.com/files/rs-8542701/v1/8f5d3054e7a21f3a9882f731.docx"},{"id":100866183,"identity":"6949faa0-7ad7-421e-b87d-f124385fbb8f","added_by":"auto","created_at":"2026-01-22 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08:32:14","extension":"xml","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":85583,"visible":true,"origin":"","legend":"","description":"","filename":"3e645958c3754b9891c95524a1a76f891structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8542701/v1/56e4dad762c9cbdd4e8a5237.xml"},{"id":100866186,"identity":"39bf359e-7a71-44bb-828d-384aef299784","added_by":"auto","created_at":"2026-01-22 08:32:13","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":94462,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8542701/v1/d9c3b7748b36e3738c55b105.html"},{"id":100866203,"identity":"121246b3-c0b9-4688-aa9e-45f2292aa1bd","added_by":"auto","created_at":"2026-01-22 08:32:14","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":831383,"visible":true,"origin":"","legend":"\u003cp\u003eInsertion of the drainage tube into the gallbladder and choledochal cyst.\u003c/p\u003e\n\u003cp\u003eA: Insert a drainage tube through the fundus of the gallbladder outside the body, inject contrast medium for cholangiography, aspirate bile, and inject an appropriate amount of normal saline to refill the cyst.\u003cbr\u003e\nB: Place the drainage tube together with the gallbladder back into the abdominal cavity，and separate the gallbladder and the choledochal cyst.\u003cbr\u003e\nC: Locate the openings of the cystic duct and common hepatic duct under the guidance of the drainage tube.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8542701/v1/2ca80289447d66da5adce723.png"},{"id":101890413,"identity":"347d722b-3ec4-4806-8535-a6b901a48dcc","added_by":"auto","created_at":"2026-02-04 16:11:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2220536,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8542701/v1/e82fe66c-d3fa-4767-826f-0473b1ffc0da.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical Application Value of Modified Laparoscopic Radical Resection for Congenital Choledochal Cyst","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCongenital choledochal cyst (CCC), or congenital biliary dilatation, refers to a congenital bile duct malformation characterized by localized dilation[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Its incidence varies geographically: 1:100,000\u0026ndash;1:150,000 in Western populations but rises to 1:1,000 in East Asia, with a female predominance [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Clinical presentation typically includes abdominal pain, palpable mass, and jaundice,making CCC the most common congenital biliary anomaly[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. While its etiologyremains incompletely understood, an abnormal pancreaticobiliary junction (common channel\u0026thinsp;\u0026gt;\u0026thinsp;4\u0026ndash;5 mm in children) is a widely implicated factor [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe treatment of congenital choledochal cyst mainly relies on surgery, and there are various surgical methods. In the early stage, open surgery was performed, including choledochal cystostomy (external drainage), cyst-intestine anastomosis (internal drainage), and cyst resection with biliary reconstruction. After years of development and demonstration, complete resection of the extrahepatic dilated common bile duct and Roux-en-Y anastomosis between the common hepatic duct and the jejunum is recognized as the preferred surgical method [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The advantages of this method are that it removes the dilated and diseased biliary tract, changes the biliary outflow pathway, avoids the reflux of pancreatic juice, and can effectively reduce the incidence of cholangiocarcinoma [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].Laparoscopic techniques, first described by Frello et al. in 1995 [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e], have since demonstrated superiority over open surgery in operative time and perioperative outcomes, establishing laparoscopy as the preferred approach [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSince 2018, our center has adopted laparoscopic CCC resection with enhanced recovery after surgery (ERAS) protocols. However, we observed significant bile leakage during CCC resection, accompanied by increased postoperative inflammatory exudate and sustained medium-volume abdominal drainage. These factors, along with delayed gastrointestinal recovery, resulted in prolonged postoperative hospitalization compared to established benchmarks in contemporary literature [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo address these issues, Professor Tang Weibing\u0026rsquo;s team modified the surgical technique. The refined technique yielded multiple clinical benefits: a marked reduction in postoperative abdominal exudate, earlier removal of abdominal drainage and gastric tubes, accelerated resumption of oral intake, and shorter postoperative hospitalization, all while maintaining comparable complication rates to conventional methods. These improvements translated into significant cost savings without compromising surgical safety.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003ePatients\u003c/h2\u003e\n \u003cp\u003eThis retrospective comparative study analyzed 33 consecutive pediatric patients who underwent laparoscopic choledochal cyst excision by Professor Tang\u0026apos;s surgical team between September 2018 and December 2024, meeting the following inclusion criteria: (1) confirmed diagnosis requiring surgical intervention, (2) successful completion of the planned laparoscopic procedure without conversion, and (3) availability of complete perioperative data. Patients with major congenital comorbidities (n\u0026thinsp;=\u0026thinsp;1) or requiring conversion to open surgery (n\u0026thinsp;=\u0026thinsp;4) were excluded from the analysis.\u003c/p\u003e\n \u003cp\u003eThe cohort was divided into two groups based on surgical technique and treatment period. Fifteen patients (female:male\u0026thinsp;=\u0026thinsp;9:6) underwent modified laparoscopic resection between January 2022 and December 2024, while eighteen patients (female:male\u0026thinsp;=\u0026thinsp;16:2) received conventional laparoscopic surgery between September 2018 and December 2021.\u003c/p\u003e\n \u003cp\u003eThis study was approved by the Institutional Ethics Committee of Children\u0026rsquo;s Hospital of Nanjing Medical University (Approval number:202512052-1) .\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eObservation Indicators\u003c/h3\u003e\n\u003cp\u003eThe study observed the intraoperative blood loss volume of the two groups, postoperative indicators (including the average daily volume of abdominal drainage fluid in the first 3 days after surgery, the indwelling time of the abdominal drainage tube after surgery, the indwelling time of the gastric tube after surgery, the time to first water intake after surgery, the time to first milk feeding after surgery, the white blood cell count on the first day after surgery, C-reactive protein level, the time to first defecation after surgery, the average postoperative hospital stay, and hospitalization expenses), and postoperative complications (fever, vomiting, abdominal distension, anastomotic leakage, anastomotic stenosis, bleeding, abdominal infection, cholangitis, pancreatic leakage, incision infection, etc.).Surgical procedures and ERAS perioperative management\u003c/p\u003e\n\u003ch3\u003eSurgical procedures\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003eModified Laparoscopic Surgical Method\u003c/h2\u003e\n \u003cp\u003eThe modified group underwent the modified laparoscopic surgical method.The modified laparoscopic procedure was performed through a standardized four-port approach (5-mm umbilical, two 5-mm right-sided, and 3-mmor 5-mmleft upper quadrant ports). Initial steps focused on biliary tree evaluation, beginning with gallbladder fundus exteriorization and cannulation. A drainage tube was inserted for contrast cholangiography, complete bile aspiration, and controlled saline distension of the cyst (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eA). The tube was then secured within the gallbladder and both were carefully repositioned into the abdominal cavity (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eB).The gallbladder and choledochal cyst were separated.The jejunal bile branch was constructed in vitro through the umbilicus.Theindwelling drainage tube provided critical anatomical guidance, enabling precise identification of the cystic duct and common hepatic duct openings (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003eC),followed by gallbladder removal,choledochal cyst resection,,and completion of hepatodochal jejunoanastomosis under laparoscopy.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eTraditional Laparoscopic Surgical Method\u003c/h3\u003e\n\u003cp\u003eThe traditional laparoscopic four-port surgical plan involves laparoscopic cholangiography, separation and resection of the choledochal cyst and gallbladder, external construction of the jejunobile branch through the navel, and completion of Roux-en-Y hepatodochal jejunoanastomosis under laparoscopy[10、11].\u003c/p\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\n \u003ch2\u003eERAS Perioperative Management\u003c/h2\u003e\n \u003cp\u003eBoth groups underwent ERAS perioperative management. The specific measures were as follows: (1) Conduct a nutritional assessment before surgery. For those at high risk of malnutrition, provide nutritional support treatment for 7 to 10 days; (2) Prohibit milk intake 6 hours before surgery, breast milk intake 4 hours before surgery, and allow the patient to drink 10 ml/kg of 10% glucose solution 2 hours before surgery; (3) Do not perform clean retrograde enema on the morning of surgery, but simply use glycerin suppositories for defecation once; (4) Administer prophylactic antibiotics 0.5 to 1 hour before surgery; (5) Place a gastrointestinal decompression tube after anesthesia; (6) Use a warming blanket, an infusion warmer, and control of operating room temperature to maintain patient warmth throughout surgery, while monitoring body temperature; (7) Adopt multimodal analgesia methods such as postoperative oral paracetamol, sucking on a pacifier dipped in 5% sucrose solution, and music therapy; (8) Encourage parents to hold the child for activities on the second day after surgery; (9) Implement early postoperative feeding.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eStatistical Methods\u003c/h3\u003e\n\u003cp\u003eAll data analysis was completed based on the R version 4.2.2 (2022-10-31) software. All statistical tests adopted two-sided tests, and P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to indicate a statistically significant difference. Measurement data that follow a normal distribution are expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD), and the independent samples t-test is used for comparison between groups. Measurement data that do not follow a normal distribution are expressed as median and interquartile range [M (Q1, Q3)], and the Mann Whitney U test is used for comparison between groups. Enumeration data are expressed as the number of cases and constituent ratio [n (%)]. For comparison between groups of unordered categorical data, the Pearson \u0026chi;2 test or Fisher\u0026rsquo;s exact probability method is used, and for comparison between groups of ordered categorical data, the Mann Whitney U test is used. At the same time, the standardized mean difference (SMD) is used to compare the differences between groups. Generally, SMD\u0026thinsp;\u0026lt;\u0026thinsp;0.10 indicates that the data balance between groups is acceptable, SMD between 0.10 and 0.34 indicates that there is a small difference in the data between groups, SMD between 0.35 and 0.64 indicates that there is a moderate difference in the data between groups, SMD between 0.65 and 1.19 indicates that there is a large difference in the data between groups, and SMD\u0026thinsp;\u0026ge;\u0026thinsp;1.20 indicates that the difference in the data between groups is extremely large [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eComparative analysis revealed comparable baseline characteristics between groups: median weight (5.000 [Q1-Q3: 4.450\u0026ndash;5.400] vs 5.150 [3.850\u0026ndash;6.900] kg; Z=-0.072, p\u0026thinsp;=\u0026thinsp;0.942), median age (48.000 [36.000-82.500] vs 65.000 [37.750\u0026ndash;173.000] days; Z=-0.651, p\u0026thinsp;=\u0026thinsp;0.515), and hematological parameters including median WBC count (9.370 [7.485\u0026ndash;11.800] vs 10.190 [7.525\u0026ndash;13.505] \u0026times;10⁹/L; W\u0026thinsp;=\u0026thinsp;112.000, p\u0026thinsp;=\u0026thinsp;0.421) and mean hemoglobin levels (111.200\u0026thinsp;\u0026plusmn;\u0026thinsp;15.077 vs 120.444\u0026thinsp;\u0026plusmn;\u0026thinsp;21.208 g/L; t=-1.415, p\u0026thinsp;=\u0026thinsp;0.167). Standardized mean differences ranged from 0.221 to 0.702 across all parameters, confirming baseline comparability (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of general data between the improved group and the control group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eSex, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWeight(Kg), M (Q\u003csub\u003e1\u003c/sub\u003e, Q\u003csub\u003e3\u003c/sub\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAge(day), M (Q\u003csub\u003e1\u003c/sub\u003e, Q\u003csub\u003e3\u003c/sub\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eWBC(*10^9/L), M (Q\u003csub\u003e1\u003c/sub\u003e, Q\u003csub\u003e3\u003c/sub\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHB(g/L), Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003efemal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003emale\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModified group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (60.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (40.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.000 (4.450, 5.400)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e48.000 (36.000, 82.500)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e9.370 (7.485, 11.800)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e111.200\u0026thinsp;\u0026plusmn;\u0026thinsp;15.077\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (88.889)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 (11.111)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.150 (3.850, 6.900)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e65.000 (37.750, 173.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e10.190 (7.525, 13.505)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e120.444\u0026thinsp;\u0026plusmn;\u0026thinsp;21.208\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStatistics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e-\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e=-0.072\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e=-0.651\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eW\u0026thinsp;=\u0026thinsp;112.000\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e=-1.415\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0.101\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.942\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.515\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.421\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.167\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSMD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0.702\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.221\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.382\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.366\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.518\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eNotes: 1. fisher exact probability method; 2. Mann Whitney U test for continuity correction; 3. Independent sample t test for variance correction.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of general data between the improved group and the control group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal(n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrealbumin(g/L), M (Q1, Q3)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRetinol conjugated protein(mg/L), M (Q1, Q3)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eALT(U/L), M (Q1, Q3)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eGGT(umol/L), M (Q1, Q3)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eDBIL(umol/L), M (Q1, Q3)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModified group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.120 (0.105, 0.145)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.440 (18.675, 26.840)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.000 (16.000, 31.500)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e109.000 (51.500, 305.500)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6.600 (3.895, 14.270)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.120 (0.100, 0.147)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.060 (14.350, 22.480)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e34.000 (18.250, 60.500)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e305.000 (29.500, 566.500)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e13.710 (5.037, 34.097)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003estatistics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e--\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.073\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eW\u0026thinsp;=\u0026thinsp;164.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e=-1.266\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eW\u0026thinsp;=\u0026thinsp;125.000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eW\u0026thinsp;=\u0026thinsp;100.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.942\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.307\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.206\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.735\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.215\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSMD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.343\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.368\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.642\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNotes: Independent sample t test for variance correction.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe modified group exhibited significantly better outcomes than the control group across multiple postoperative parameters, with statistically significant reductions (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05)in theaverage daily abdominal drainage volume during the first three postoperative days,abdominal drainage tube indwelling duration,gastric tube retention period,time to initial oralwaterintake,interval to first milk feeding, mean postoperative hospitalization duration, and total hospitalization expenses.However, no statistically significant differences were observed between the groups regarding intraoperative blood loss volume, first postoperative day white blood cell count, C-reactive protein levels, or time to first defecation, as detailed in Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of intraoperative bleeding and postoperative indexes between the two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003egroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIntraoperative blood loss(ml), M (Q\u003csub\u003e1\u003c/sub\u003e, Q\u003csub\u003e3\u003c/sub\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAverage intraperitoneal drainage in the first 3 days after surgery(ml), M (Q\u003csub\u003e1\u003c/sub\u003e, Q\u003csub\u003e3\u003c/sub\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePostoperative abdominal drainage catheter indwelling time(h), Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePostoperative gastric tube retention time(h), M (Q\u003csub\u003e1\u003c/sub\u003e, Q\u003csub\u003e3\u003c/sub\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTime to initial oralwaterintake(h), M (Q\u003csub\u003e1\u003c/sub\u003e, Q\u003csub\u003e3\u003c/sub\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eTime to first milk feeding after surgery(h), M (Q\u003csub\u003e1\u003c/sub\u003e, Q\u003csub\u003e3\u003c/sub\u003e)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModified group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.000 (10.000, 20.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.670 (12.865, 26.330)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e104.667\u0026thinsp;\u0026plusmn;\u0026thinsp;22.598\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e24.000 (17.500, 42.500)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e42.000 (40.500, 44.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e65.000 (50.000, 66.500)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20.000 (12.750, 23.750)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e34.000 (26.350, 58.248)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e134.167\u0026thinsp;\u0026plusmn;\u0026thinsp;20.971\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e48.500 (28.750, 66.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e66.000 (42.500, 87.750)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e88.000 (67.000, 112.500)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003estatistics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eZ=\u003c/em\u003e-1.404\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eZ=-3.001\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e=-3.885\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e=-2.371\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e=-2.502\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eZ\u003c/em\u003e=-2.591\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSMD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.503\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.302\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.397\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.871\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.066\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.087\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"8\"\u003eNotes: 1. Mann Whitney U test for continuity correction; 2. Independent sample t test for variance correction; 3. Independent sample t test.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of intraoperative bleeding and postoperative indexes between the two groups.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003egroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWhite blood cell count on the first day after surgery\u003c/p\u003e \u003cp\u003e(*10^12/L), Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCRP on the first day after surgery(mg/L), M (Q\u003csub\u003e1\u003c/sub\u003e, Q\u003csub\u003e3\u003c/sub\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eTime to first postoperative defecation(h), M (Q\u003csub\u003e1\u003c/sub\u003e, Q\u003csub\u003e3\u003c/sub\u003e)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePostoperative hospital stay(d), M (Q1, Q3)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eHospitalization expenses(CNY), Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModified group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.857\u0026thinsp;\u0026plusmn;\u0026thinsp;1.906\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13.330 (3.500, 17.220)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e37.000 (18.500, 42.500)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8.000 (7.000, 8.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e34909.035\u0026thinsp;\u0026plusmn;\u0026thinsp;3580.155\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.783\u0026thinsp;\u0026plusmn;\u0026thinsp;3.288\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.000 (5.000, 8.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42.500 (36.250, 52.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e11.000 (10.000, 12.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e40875.154\u0026thinsp;\u0026plusmn;\u0026thinsp;6596.433\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003estatistics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003et\u0026thinsp;=\u0026thinsp;0.077\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eZ\u0026thinsp;=\u0026thinsp;0.829\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eZ=-1.598\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eZ=-3.786\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e=-3.298\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.939\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.407\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSMD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.028\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.605\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.660\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.343\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1.158\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNotes: 1. fisher exact probability method; 2. Independent sample t test for variance correction; 3. Independent sample t test.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePostoperative complications in the modified group included 6 cases of fever, 4 cases of vomiting, 2 cases of abdominal distension, and 1 case of anastomotic stenosis, while the control group had 5 cases of fever, 2 cases of vomiting, 1 case of abdominal distension, and no cases of anastomotic stenosis, with no statistically significant difference observed between the two groups (P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) as shown in Tables\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e and \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e. Notably, neither group experienced any instances of postoperative bleeding, anastomotic leakage, intra-abdominal infection, cholangitis, pancreatic fistula, or surgical site infection following the procedures, as detailed in Tables\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e and \u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of postoperative complications between the two groups of children\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003egroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTotal(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eNumber of complications, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModified group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (53.333)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (46.667)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (61.111)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7 (38.889)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003estatistics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0.733\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSMD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e0.158\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNotes: fisher exact probability method.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of postoperative complications between the two groups of childrengroup\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eFever, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eVomit, \u003cem\u003en\u003c/em\u003e (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eAbdominal distension, n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eAnastomotic stenosis, n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eAbsent\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePresent\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eModified group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9 (60.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (40.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11 (73.333)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4 (26.667)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e13 (86.667)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 (13.333)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e14 (93.333)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1 (6.667)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13(72.222)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (27.778)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16 (88.889)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2 (11.111)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e17 (94.444)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1 (5.556)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e18 (100.000)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e0 (0.000)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003estatistics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e0.488\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.375\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.579\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.455\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSMD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e0.260\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e0.405\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e0.268\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e0.378\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eNotes: Mann Whitney U test for continuity correction\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe surgical management of congenital choledochal cysts has evolved considerably with the refinement of minimally invasive techniques. Currently, laparoscopic complete cyst excision with Roux-en-Y hepaticojejunostomy has become the gold standard treatment, supported by substantial clinical evidence demonstrating its safety and efficacy [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. This approach has been progressively adopted in numerous medical institutions across China [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], reflecting the growing expertise in advanced laparoscopic hepatobiliary surgery. Since September 2018, our department has systematically performed this procedure while implementing comprehensive enhanced recovery after surgery (ERAS) protocols. Compared to traditional open surgery, our experience confirms significant reductions in both postoperative hospitalization duration and overall treatment costs, while maintaining comparable surgical outcomes.\u003c/p\u003e \u003cp\u003eDespite these advantages,we have found that if too much bile leaks into the abdominal cavity after the resection of the choledochal cyst during the operation, it will lead to an increase in the inflammatory exudation in the abdominal cavity during and after the operation. The amount of exudate drained from the abdominal cavity drainage tube after the operation is relatively large, and the recovery of intestinal function is slow, which in turn leads to a still relatively long hospital stay. Therefore, since January 2022, the diagnosis and treatment team led by Professor Tang Weibing of the Department of Neonatal Surgery in our hospital has made some improvements to the traditional laparoscopic choledochal cyst resection and hepaticojejunostomy in Roux-en-Y pattern:(1)Insert a drainage tube through the fundus of the gallbladder outside the body, inject contrast medium for cholangiography, aspirate the bileafter placing the drainage tube into CCC, and inject an appropriate amount of normal saline to refill the cyst. An appropriate amount of normal saline is injected to refill the choledochal cystso that the common bile duct cyst maintains proper tension for separation. (2) After the gallbladder and the choledochal cyst are separated, the jejunal biliary limb is made first. After it is completed,the gallbladder and the choledochal cyst are resected under laparoscopy. Then, hepaticojejunostomy is performed. Before closing the abdomen, the resected gallbladder, choledochal cyst and the drainage tube are removed from the abdominal cavity. These modifications have ensured that almost no bile leaks into the abdominal cavity when separating and resecting the choledochal cyst and the gallbladder, avoiding the induction of bile peritonitis and reducing the impact of bile on the recovery of the intestinal function of children after the operation. Injecting an appropriate amount of normal saline can maintain a certain tension of the choledochal cyst, facilitating the separation of the cyst. Through these modifications, the average daily volume of abdominal cavity drainage fluid in the first 3 days after the operation, the indwelling time of the abdominal cavity drainage tube after the operation, the indwelling time of the gastric tube after the operation, the time of the first water intake after the operation, and the time of the first milk feeding after the operation of children have been significantly shortened, and the recovery has been accelerated. As a result, the average postoperative hospital stay and hospitalization expenses have significantly decreased. These modifications have been rarely reported at home and abroad and are somewhat innovative.\u003c/p\u003e \u003cp\u003eThe laparoscopic radical choledochal cyst technique is becoming increasingly mature, but there are still certain complications.Hepatic duct injury represents a significant technical challenge in radical resection of choledochal cysts[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In the past, we found that the opening of the cystic duct and the opening of the common hepatic duct in children are close to each other, and the orifice of common hepatic duct is difficult to identify. In addition, the common hepatic duct is dilated in some cases, and sometimes it is impossible to distinguish the junction between the common hepatic duct and the common bile duct during the operation. When resecting the gallbladder and the choledochal cyst, it is easy to accidentally injure the opening of the common hepatic duct.To address thischallenge, following intraoperative cholangiography, we maintain part of the drainage tube in the gallbladder and the choledochal cyst, and put the drainage tube together with the gallbladder back into the abdominal cavity. The gallbladder and the choledochal cyst are dissected with the tube in place.Our technique involves initially incising the anterior cyst wall, which permits precise identification of the cystic duct and common hepatic duct orifices under direct catheter guidance, thereby facilitating safe resection while protecting the common hepatic duct. This technical adaptation represents a novel approach that, to our knowledge, has not been previously documented in the medical literature.\u003c/p\u003e \u003cp\u003eComplications after radical resection of choledochal cysts also include damage to tissues around the biliary tract (including blood vessels, duodenum and pancreatic duct injuries), bleeding, bile leakage, postoperative biliary obstruction, cholelithiasis formation, cholangitis, pancreatic calculus formation, pancreatitis, torsion and obstruction of the Roux jejunal biliary limb, and carcinogenesis due to incomplete resection [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. There were no cases of bleeding, anastomotic leakage, abdominal cavity infection, cholangitis, pancreatic leakage, incision infection, etc. in both groups after the operation.There was no statistically significant difference between the two groups,indicating that the modified laparoscopic radical resection of choledochal cysts did not increase short-term and long-term postoperative complications after 6 months to 5 years follow-up.\u003c/p\u003e \u003cp\u003eThe present study has several limitations that warrant consideration. First, its retrospective design inherently limits the strength of conclusions compared to prospective randomized trials. Second, the relatively small cohort size (33 patients) and unequal group distribution (15 vs 18 patients) may affect statistical power for detecting subtle differences in complication rates. Third, the single-center nature of the study may limit generalizability to institutions with different surgical protocols or patient populations. Finally, our mean follow-up duration of 17 months, while adequate for assessing immediate postoperative outcomes, may be insufficient to evaluate long-term complications such as anastomotic strictures or biliary malignancies.\u003c/p\u003e \u003cp\u003eIn conclusion, our experience demonstrates that the modified laparoscopic technique for choledochal cyst excision is both safe and effective, offering several practical advantages over conventional approaches. The technical refinements we describe - particularly the complete bile aspiration with saline replacement and guided dissection using the indwelling catheter - represent reproducible innovations that address specific challenges in laparoscopic biliary surgery. While further multicenter studies with larger patient cohorts and longer follow-up are needed to validate these findings, our results suggest that these modifications can be safely incorporated into standard practice to optimize outcomes for pediatric patients with congenital choledochal cysts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis study was funded by Medical Research Project of Jiangsu Provincial Health Commission - Guiding Project (Z2021028).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eSchober, P., Mascha, E. J., \u0026amp; Vetter, T. R. (2021). Statistics From A (Agreement) to Z (z Score): A Guide to Interpreting Common Measures of Association, Agreement, Diagnostic Accuracy, Effect Size, Heterogeneity, and Reliability in Medical Research.\u003cem\u003eAnesthesia and analgesia\u003c/em\u003e,\u003cem\u003e133\u003c/em\u003e(6), 1633\u0026ndash;1641.https://doi.org/10.1213/ANE.0000000000005773.\u003c/li\u003e\n \u003cli\u003eCazares, J., Koga, H., \u0026amp; Yamataka, A. (2023). Choledochal cyst. Pediatric surgery international, 39(1), 209.https://doi.org/10.1007/s00383-023-05483-1.\u003c/li\u003e\n \u003cli\u003eProfessional Committee of Pediatric Robotic Surgery, Medical Robotic Surgery Doctor Branch of Chinese Medical Doctor Association \u0026amp; Professional Committee of Maternal and Child Minimally Invasive Surgery, China Maternal and Child Health Association. Chinese expert consensus on robot-assisted choledochal cyst excision in children (2022) [J]. Chinese Journal of Robotic Surgery, 2023, 4(4): 376-388.\u003cu\u003ehttps://doi.org/10.12180/j.issn.2096-7721.2023.04.010\u003c/u\u003e\u003c/li\u003e\n \u003cli\u003eMisra, S. P., \u0026amp; Dwivedi, M. (1990). Pancreaticobiliary ductal union.\u003cem\u003eGut\u003c/em\u003e,\u003cem\u003e31\u003c/em\u003e(10), 1144\u0026ndash;1149.https://doi.org/10.1136/gut.31.10.1144.\u003c/li\u003e\n \u003cli\u003eFunabiki, T., Matsubara, T., Miyakawa, S., \u0026amp; Ishihara, S. (2009). Pancreaticobiliary maljunction and carcinogenesis to biliary and pancreatic malignancy. \u003cem\u003eLangenbeck\u0026apos;s archives of surgery\u003c/em\u003e, \u003cem\u003e394\u003c/em\u003e(1), 159\u0026ndash;169. https://doi.org/10.1007/s00423-008-0336-0.\u003c/li\u003e\n \u003cli\u003eUecker, M., Lehmann, U., Braubach, P., Schukfeh, N., Madadi-Sanjani, O., Ure, B. M., Petersen, C., \u0026amp; Kuebler, J. F. (2021). Choledochal Cysts Resected during Childhood Show No Mutations of KRAS and BRAF as Early Markers of Malignancy in Cholangiocytes. \u003cem\u003eEuropean journal of pediatric surgery : official journal of Austrian Association of Pediatric Surgery ... [et al] = Zeitschrift fur Kinderchirurgie\u003c/em\u003e, \u003cem\u003e31\u003c/em\u003e(1), 20\u0026ndash;24. https://doi.org/10.1055/s-0040-1715610.\u003c/li\u003e\n \u003cli\u003eFarello GA, Cerofolini A, Rebonato M, et al. Congenital choledochal cyst: video-guided laparoscopic treatment [J]. Surg Laparosc Endosc, 1995, 5(5): 354-358. DOI: 10.1007/BF00189002.\u003c/li\u003e\n \u003cli\u003eOnishi, S., Murakami, M., Ishimaru, T., Miyano, G., Scholz, S., Perger, L., Yamada, K., Pandya, S., \u0026amp; Ieiri, S. (2024). Current Practice of Laparoscopic Surgery for Choledochal Cyst in Children -A Survey on Opinion and Experience Among IPEG Members. \u003cem\u003eJournal of pediatric surgery\u003c/em\u003e, \u003cem\u003e59\u003c/em\u003e(12), 161683. https://doi.org/10.1016/j.jpedsurg.2024.08.023.\u003c/li\u003e\n \u003cli\u003eDiao, M., Li, L., \u0026amp; Cheng, W. (2018). Single-incision laparoscopic hepaticojejunostomy for children with perforated choledochal cysts. \u003cem\u003eSurgical endoscopy\u003c/em\u003e, \u003cem\u003e32\u003c/em\u003e(7), 3402\u0026ndash;3409. https://doi.org/10.1007/s00464-018-6047-x.\u003c/li\u003e\n \u003cli\u003eLi, L., Liu, S. L., Hou, W. Y., Cui, L., Liu, X. L., Jun, Z., Liu-Ming, H., Gang, L., \u0026amp; Kamal, N. A. (2008). Laparoscopic correction of biliary duct stenosis in choledochal cyst. Journal of pediatric surgery, 43(4), 644\u0026ndash;646.https://doi.org/10.1016/j.jpedsurg.2007.10.064.\u003c/li\u003e\n \u003cli\u003eLin, Y., Xu, X., Chen, S., Zhang, L., Wang, J., Qiu, X., \u0026amp; Li, L. (2024). Construction of nomogram based on clinical factors for the risk prediction of postoperative complications in children with choledochal cysts.\u003cem\u003eFrontiers in pediatrics\u003c/em\u003e,\u003cem\u003e12\u003c/em\u003e, 1372514.https://doi.org/10.3389/fped.2024.1372514.\u003c/li\u003e\n \u003cli\u003eSchober, P., Mascha, E. J., \u0026amp; Vetter, T. R. (2021). Statistics From A (Agreement) to Z (z Score): A Guide to Interpreting Common Measures of Association, Agreement, Diagnostic Accuracy, Effect Size, Heterogeneity, and Reliability in Medical Research. Anesthesia and analgesia, 133(6), 1633\u0026ndash;1641.https://doi.org/10.1213/ANE.0000000000005773.\u003c/li\u003e\n \u003cli\u003eSubspecialty Group of Neonatal Surgery, Branch of Pediatric Surgery, Chinese Medical Association; Subspecialty Group of Pediatric Biliary Surgery, Branch of Pediatric Surgery, Chinese Medical Association. Guidelines for diagnosing and treating pediatric pancreaticobiliary maljunction [J]. J Clin Hepatol, 2019, 35(12): 2712－2715. (in Chinese).\u003c/li\u003e\n \u003cli\u003eSun, R., Zhao, N., Zhao, K., Su, Z., Zhang, Y., Diao, M., \u0026amp; Li, L. (2020). Comparison of efficacy and safety of laparoscopic excision and open operation in children with choledochal cysts: A systematic review and update meta-analysis. \u003cem\u003ePloS one\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(9), e0239857. https://doi.org/10.1371/journal.pone.0239857.\u003c/li\u003e\n \u003cli\u003eLi AW. Management and surgical techniques for hepatic duct stricture or distal common bile duct protein plug during laparoscopic excision of choledochal cysts [in Chinese]. Journal of Clinical Pediatric Surgery, 2019, 18(07): 545-547.\u003c/li\u003e\n \u003cli\u003eDiao M, Li L. Laparoscopic management of choledochal cysts in children: complications and their prevention [in Chinese]. Journal of Clinical Pediatric Surgery, 2023, 22(1): 7-11. DOI: 10.3760/cma.j.cn101785-202205002-002..\u003c/li\u003e\n \u003cli\u003eZhang, B., Wu, D., Fang, Y., Bai, J., Huang, W., Liu, M., Chen, J., \u0026amp; Li, L. (2019). Early complications after laparoscopic resection of choledochal cyst. \u003cem\u003ePediatric surgery international\u003c/em\u003e, \u003cem\u003e35\u003c/em\u003e(8), 845\u0026ndash;852. https://doi.org/10.1007/s00383-019-04489-y.\u003c/li\u003e\n \u003cli\u003eAnxiao, M., Yifeng, S., Mei, D., Qi, L., Xu, L., \u0026amp; Long, L. (2025). Reoperation related to Roux-en-Y jejunal limb after hepaticojejunostomy of choledochal cyst. \u003cem\u003ePediatric surgery international\u003c/em\u003e, \u003cem\u003e41\u003c/em\u003e(1), 167. https://doi.org/10.1007/s00383-025-06056-0\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Congenita choledochal cyst, modified laparoscopic radical resection, drainage tube, Complications","lastPublishedDoi":"10.21203/rs.3.rs-8542701/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8542701/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e: To evaluate the clinical efficacy of the modified laparoscopic radical resection of congenital choledochal cysts.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A retrospective analysis was conducted on 33 pediatric patients with congenital choledochal cysts treated at our institution from September 2018 to December 2024. The control group (n=18) underwent traditional laparoscopic surgery (September 2018–December 2021), while the modified group (n=15) received the modified technique (January 2022–December 2024). Baseline characteristics (gender, age, weight, preoperative laboratory tests) and perioperative outcomes (intraoperative blood loss, postoperative drainage volume, tube indwelling time, time to initiate feeding, hospital stay, costs, and complications) were compared between the two groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: No significant differences were observed in baseline characteristics (age, gender, weight) or preoperative laboratory parameters (white blood cell count, hemoglobin, prealbumin, retinol-binding protein, liver enzymes, conjugated bilirubin, etc.) between the two groups (P \u0026gt; 0.05). There was no statistically significant difference in postoperative complications (fever, vomiting, abdominal distension, anastomotic leakage, anastomotic stenosis, bleeding, intra-abdominal infection, cholangitis, pancreatic fistula, and wound infection) between the two groups (P \u0026gt; 0.05).The modified group showed significantly reduced postoperative drainage volume, shorter abdominal drainage/gastric tube indwelling time, earlier feeding initiation, shorter hospital stays, and lower costs (P \u0026lt;0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Modified laparoscopic radical resection for congenital choledochal cysts reduces postoperative exudate, accelerates recovery, lowers hospitalization costs, demonstrating clinical safety and efficacy.\u003c/p\u003e","manuscriptTitle":"Clinical Application Value of Modified Laparoscopic Radical Resection for Congenital Choledochal Cyst","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-22 08:32:06","doi":"10.21203/rs.3.rs-8542701/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f03a06c4-51cb-45a3-839f-8d643a6d3205","owner":[],"postedDate":"January 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-04T16:09:55+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-22 08:32:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8542701","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8542701","identity":"rs-8542701","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}