Total versus conventional laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy in children with choledochal cysts: a case-control study

Total versus conventional laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy in children with choledochal cysts: a case-control study | 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 Total versus conventional laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy in children with choledochal cysts: a case-control study FEI LIU, Xiaogang Xu, Menglong Lan, Boyuan Tao, Le Li, Qiang Wu, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-35680/v4 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 17 Oct, 2020 Read the published version in BMC Surgery → Version 4 posted 2 You are reading this latest preprint version Show more versions Abstract Background : To compare the efficacy of total and conventional laparoscopic hepaticojejunostomy (TLH and CLH) in children with choledochal cysts (CDCs). Methods: Data from patients undergoing TLH and CLH between August 2017 and December 2018 were retrospectively analyzed. Intraoperative blood loss, time for jejunum-cojejunum anastomosis, time to oral intake, postoperative hospital stay, hospitalization expenses, and postoperative complications were compared. Results: All 55 patients (TLH=30, CLH=25) were successfully treated without conversion to open surgery. In the TLH and CLH groups, the time to oral intake was 3.57±0.19 d and 4.56±0.27 d, respectively ( t =3.07, P <0.01), the postoperative hospital stay was 5.50±0.28 d and 7.00±0.74 d ( t =2.03, P <0.05), and the hospitalization expenses were CNY 40085±2447 and CNY 26084±2776 ( t =3.79, P <0.001). There were no significant differences in intraoperative blood loss (9.57±3.28 ml vs 8.2±1.13 ml, t =0.37, P = 0.72) or time for jejunum-cojejunum anastomosis (80.5±2.46 min vs 75.00±2.04 min, t =1.68, P =0.10). The median follow-up periods of the TLH and CLH groups were 17 and 16 months, respectively. Overall complication rates were comparable between the two groups (10% vs 8%, c ² =0.07, P =0.79). Conclusions: TLH in children with CDCs has the advantages of rapid gastrointestinal functional recovery and a short hospitalization. However, hospitalization is relatively expensive. General Surgery Pediatrics Total laparoscopic Choledochal cyst Children Congenital Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 1. Background Choledochal cysts (CDCs) are a rare congenital biliary malformation. The incidence of CDCs in Western countries ranges from 1/50,000 to 1/200,000, while that in Japan is approximately 1/13,000, with a male-to-female ratio of 1:4 [1-3]. Total cyst excision with Roux-en-Y hepaticoenterostomy has become the standard procedure [4]. In 1995, Farello et al. [5] reported for the first time the laparoscopic-assisted treatment of CDCs. Currently, the laparoscopic treatment of CDCs has been widely accepted by surgeons and children due to its advantages of a small incision, less trauma, less pain and a quick recovery [6,7]. The gradual improvement of laparoscopic instruments and surgical techniques has made it possible to treat CDCs in children by total laparoscopy. However, considering the limited space of the abdominal cavity, the difficulty of the operation and the high cost of hospitalization, it has not been widely performed [8]. From August 2017 to December 2018, we compared the efficacy of total laparoscopic hepaticojejunostomy (TLH) and conventional laparoscopic hepaticojejunostomy (CLH) in children with CDCs. 2. Methods We retrospectively analyzed the data of 30 children who underwent TLH and 25 children who underwent CLH from August 2017 to December 2018. All patients were evaluated by ultrasonography, computed tomography (CT), or magnetic resonance cholangiopancreatography (MRCP) before the operation. Considering the limited abdominal cavity space of a child, we set the inclusion criteria for the TLH group as children >1 year old with CDCs. The exclusion criteria were as follows: (a) children <1 year old, (b) children with a history of upper abdominal surgery, (c) children who experienced uncontrolled acute cholangitis, (d) children who suffered from cardiovascular or other diseases that contraindicate total laparoscopic surgery, or (e) children whose parents did not accept total laparoscopic surgery. Patients with no following preconditions were included in the CLH group: (a) upper abdominal surgery history, (b) uncontrolled acute cholangitis, (c) cardiovascular or other diseases that contraindicate laparoscopic surgery, and (d) parents who did not accept laparoscopic surgery. Ethical approval from the Institutional Review Board of Guangzhou Women and Children’s Medical Center and written parental consent were obtained. The research was conducted in compliance with the World Medical Association Declaration of Helsinki. 2.1 Operative Techniques 2.1.1 Total laparoscopic CDC excision and Roux-en-Y hepaticojejunostomy The ligament of Treitz was identified under laparoscopy, and the proximal jejunum 20 cm distal to the ligament was cut off using an Endo-GIA Tri-Staple instrument (COVIDIEN, USA) through the fourth port after extending the incision to 1.5-2.0 cm (Fig. 4). The jejunal mesentery was fully released (Fig. 5). To minimize the redundant Roux loop, an individualized jejunal Roux loop length was tailored by the distance between the umbilicus and the hepatic hilum [9]. The Roux loop was passed up to the hilum retrocolically. A side-hole jejunotomy was created on the antimesenteric border 1 cm from the end of the jejunal limb to match the diameter of the hepatic duct. End-to-side hepaticojejunal anastomosis was accomplished laparoscopically with continuous 5-0 or 6-0 PDS sutures (Fig. 6, Fig. 7). Then, the Endo-GIA Tri-Staple instrument was used to complete the jejunal side-to-side anastomosis (Fig. 8). The residual stoma was closed using continuous 5-0 PDS sutures, and the seromuscular layer was reinforced using intermittent 5-0 PDS sutures (Fig. 9). 2.1.2 Conventional laparoscopic CDC excision and Roux-en-Y hepaticojejunostomy The trocar locations, cyst excision and Roux-en-Y hepaticojejunostomy were all consistent with those in the TLH group; the main difference was that the end-to-side jejunum-jejunum anastomosis was performed by extracorporeal manual sewing. The specific procedures were as follows: Firstly, identify the ligament of Treitz under laparoscopy. Secondly, capture the proximal jejunum 20 cm distal to the ligament with a bowel clamp, exteriorize it through the umbilical trocar site after extending the incision to 1.5 or 2.0 cm. Finally, carry out the Roux-en-Y end-to-side jejunojejunostomy with 2-layer interrupted sutures manually outside the abdomen and the closed jejunum limb was then lifted through an incision in the right side of the mesocolon to accomplish the end-to-side hepaticojejunal anastomosis. Postoperatively, the patients were allowed to start oral intake when they met the following standards: (1) no abdominal distension;(2) light gastric juice color with a volume<20 ml/d; and (3) patients had passage of flatus and recovery of bowel sounds. When the patients were afebrile and had no need for intravenous fluids, their wound was healing well, and their blood test results were normal, they were discharged. 2.2 Follow up Postoperative follow-ups were conducted to all patients 1, 3, 6 and 12 months since surgery completion and every 6 months thereafter. Each visit was constituted of physical examination, abdominal ultrasonography, and laboratory tests. Postoperative complications, for instance pancreatitis, anastomotic stenosis, intrahepatic stone formation and pancreatic calculi formation, were clinically evaluated matching with appropriate investigations. 2.3 Statistical analysis Data were analyzed with the SPSS 21.0 package. c² tests were performed to compare the distribution of sex, CDC type and postoperative complications between the TLH and CLH groups. Student’s t- tests were applied to compare the age, CDC length, CDC diameter, time to oral intake, postoperative hospital stay, hospitalization expenses, intraoperative blood loss and time for jejunum-cojejunum anastomosis. A level of P <0.05 was considered statistically significant. 3. Results In our study, 55 patients (TLH=30, CLH=25) with a diagnosis of CDCs underwent cyst resection and end-to-side hepaticojejunostomy. There were no significant differences in the demographic variables or pathological manifestations of the cysts between the two groups (Table 1). The postoperative hospital stay and time to oral intake in the TLH group were significantly shorter than those in the CLH group (5.50±0.28 d vs 7.00±0.74, P <0.05; 3.57±0.19 vs 4.56±0.27, P <0.01). It is worth noting that the hospitalization cost in the TLH group was significantly higher than that in the CLH group (CNY 40085±2447 vs CNY 26084±2776, P <0.001). There were no significant differences in the intraoperative blood loss volume, time for jejunum-cojejunum anastomosis or complications between the two groups (Table 2). The median follow-up periods of the TLH and CLH groups were 17 (11–27 months) and 16 (11–27 months) months, respectively. All patients, except for those mentioned below, were free of abdominal pain, fever and jaundice. Group TLH had 3 postoperative complications. One patient experienced obstruction and necrosis 1 week after discharge (2 weeks after the operation) because the distal biliary jejunum herniated from the transverse mesocolic hiatus into the colon and compressed the proximal biliary jejunum , and choledochojejunostomy was performed again. One patient presented adhesive intestinal obstruction 1 month after discharge (1 month after surgery), which improved after conservative treatment. One patient underwent choledochojejunostomy again 1 month after discharge (1 month after surgery) because of severe adhesion in the abdominal cavity due to suppurative appendicitis and obstruction necrosis caused by cord compression of the proximal biliary jejunum. Group CLH had 2 postoperative complications. One patient presented with an intestinal obstruction 1 week after the operation, and no relief was achieved after conservative treatment. This obstruction was found to be caused by umbilical incision and intestinal tube adhesion via a reoperation. One patient presented with fever, abdominal bloating, and increased leucocytes and amylase at 1 week after the operation, and ultrasonic examination indicated peritoneal effusion, which was not improved after conservative treatment. A pancreatic fistula was confirmed by surgery. 4. Discussion CDCs are a rare disorder of bile duct dilation that was first described by Vater and Ezler in 1723 [10]. Although cysts are benign lesions, they are closely related to many serious complications, such as malignant bile duct tumors, cholangitis, pancreatitis and intrahepatic bile duct stones [2,11]. Therefore, surgery should be performed as soon as possible after the diagnosis is clear [12,13]. Compared with traditional open surgery, laparoscopic CDC surgery has the following advantages [14,15]: ① Laparoscopy can magnify the tissue 4–8 times, allowing precise separation of the cyst from the surrounding tissues, such as the hepatic artery, portal vein, pancreas and capillary network around the cyst, and thus avoiding side effects. ② Laparoscopy can penetrate into the hepatic hilum for a more accurate operation; meanwhile, bile duct abnormalities, such as labyrinthine bile duct and hepatic stenosis, can be visually detected. ③ Laparoscopic surgery causes less intestinal disturbance and allows faster postoperative intestinal peristalsis recovery. ④ The incision is small and aesthetic, and the pain is mild. The incidence of wound infection and incisional hernia is reduced after this operation. Total laparoscopic surgery, in addition to the above advantages, has an additional advantage in that the umbilical incision is smaller and more aesthetic, which is more satisfactory according to the needs of the children and their families. In the CLH group, the bowel was pulled out through an umbilical incision to complete the jejunal end-to-side anastomosis. Intestinal traction and exposure increase the risk of intestinal injury and adhesions in theory. We successfully performed total laparoscopic CDC excision and Roux-en-Y hepaticojejunostomy in 30 children. Compared with those in the CLH group, the postoperative fasting time and hospitalization duration were significantly shorter in the TLH group. These findings show that the total laparoscopic approach disturbs the bowel less and allows faster recovery of gastrointestinal function. However, it is worth noting that the hospitalization cost in the TLH group was significantly higher than that in the CLH group, which may be due to the high cost of laparoscopic instruments. With the continuous development of surgical instruments, we believe that in the near future, the cost of laparoscopic instruments will gradually decrease. The main difference between TLH and CLH is jejunum-to-jejunum anastomosis. We need to pay attention to the following points: ① When the jejunum is cut using an endoscopic stapler, the intestinal tube should be fully flattened to avoid overlap, which could result in insufficient cutting and an intestinal fistula. ② A side-hole jejunotomy was created on the antimesenteric border just 0.5 cm from the end of the proximal jejunum, to minimize the occurrence of a "blind pouch". ③ When using an endoscopic cutter stapler for jejunal side-to-side anastomosis, the puncture hole in the intestinal wall does not need to be large. Its size should be suitable for placement at the end of the stapler to minimize the residual stoma and reduce the operative duration. Additionally, side-to-side anastomosis of the jejunum should be arranged in parallel with the mesentery to ensure full contact with the stapler. In the early stages of implementing total laparoscopic surgery, there was one case in which a child underwent jejunal side-to-side anastomosis with an uneven arrangement, resulting in excessive residual anastomosis, increased suture difficulties and a prolonged operation. In this study, the time for jejunal side-to-side anastomosis in the TLH group was longer than the time for jejunal end-to-side anastomosis in the CLH group, but there was no significant difference. We consider that this finding may be related to the learning curve for mastering total laparoscopic surgery. Postoperative complications of laparoscopic CDC excision include pancreatitis [16], pancreatic fistula [17], cholangitis [1], biliary fistula and intestinal obstruction [18]. In this study, one child in the TLH group required reoperation because the distal biliary jejunum herniated from the transverse mesocolic hiatus and compressed the proximal biliary loops, resulting in obstruction and necrosis. The transverse mesocolon and gastrocolonic ligament are often thicker in older children with CDCs complicated with repeated infection; thus, we suggest that after establishing a retrocolonic tunnel to cross the transverse mesocolon, the gastrocolonic ligament should be fully separated at the same time so that the intestinal tube can pass smoothly. Subsequently, the hepatic limb jejunal and transverse mesocolon should be sutured intermittently with 3 to 4 needles to avoid obstruction caused by intestinal hernia. In the CLH group, one child developed a postoperative pancreatic fistula and needed reoperation to retain the abdominal drainage tube. We considered the pancreatic fistula to have been caused by too deep of an operating position when the distal end of the cyst was separated, resulting in damage to the pancreatic duct. Li et al. [19] believed that in children with cystic dilatation, not ligating the distal stump is a feasible approach and may minimize pancreatic duct injury. The limitations of this study are that the number of cases is small and that the follow-up period is short. The long-term effect in the two groups needs further study. 5. Conclusions In summary, total laparoscopic CDC resection and Roux-en-Y hepaticojejunostomy are safe and feasible. Although the TLH operation was difficult because of the limited abdominal cavity capacity of children, resulting in a narrow operation space within delicate tissue, recovery was faster and the hospitalization duration was shorter in the TLH group than in the CLH group. Based on our experience with radical laparoscopic CDC excision and intestinal anastomosis with a stapler, tacit cooperation and precise operations can ensure the safety and efficacy of the operation. In addition, the hospitalization cost in the TLH group was relatively high, so surgical plans should be optimized for patients considering their family's economic situation. Abbreviations TLH: total laparoscopic hepaticojejunostomy; CLH: conventional laparoscopic hepaticojejunostomy; CDC: choledochal cyst; CT: computed tomography; MRCP: magnetic resonance cholangiopancreatography Declarations Ethics approval and consent to participate Ethical approval from the Institutional Review Board of Guangzhou Women and Children’s Medical Center and written parental consent were obtained. The research was conducted in compliance with the World Medical Association Declaration of Helsinki. Consent for publication Not Applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study was supported by the fund from Guangzhou Women and Children's Medical Center (No.IP-2018-008). It had no involvement in study design, collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the article for publication. Authors ’ contributions All authors have read and approved the final manuscript. Study concept and design: FL, JXZ; Acquisition of data: XGX, BYT; Analysis and interpretation of data: MLL; Drafting of the manuscript: FL; Critical revision of the manuscript for important intellectual content: LL, QW, CWC, JXZ; Study supervision: JXZ. Acknowledgements Not applicable. References 1 Atkinson HDE, Fischer CP, De Jong CHC, Madhavan KK, Parks RW, Garden OJ. Choledochal cysts in adults and their complications. HPB(Oxford). 2003;5:105-110. 2 Soares KC, Arnaoutakis DJ, Kamel I, Rastegar N, Anders R, Maithel S, et al. Choledochal cysts: presentation, clinical differentiation, and management. J Am Coll Surg. 2014;219:1167-1180. 3 Silva-Baez H, Coello-Ramírez P, Ixtabalán-Escalante EM, Sotelo-Anaya E, Gallo-Morales M, Cordero-Estrada E, et al. Treatment of choledochal cyst in a pediatric population. A single institution experience of 15-years.Case series. Ann Med Surg. 2016;5:81-85. 4 Qiao G, Li L, Li S, Tang S, Wang B, Xi H, et al. Laparoscopic cyst excision and Roux-Y hepaticojejunostomy for children with choledochal cysts in China: a multicenter study. Surg Endosc. 2015; 29:140-144. 5 Farello GA, Cerofolini A, Rebonato M, Bergamaschi G, Ferrari C, Chiappetta A. Congenital choledochal cyst: video-guided laparoscopic treatment. Surg Laparosc Endosc. 1995;5:354-358. 6 Liu Y, Diao M, Li L. Using laparoscopic double hemicircumferential running single-layer suture in hepaticojejunostomy for choledochal cysts in children. J Pediatr Surg. 2018;53:199-202. 7 Sica M, Molinaro F, Angotti R, Bindi E, Brandigi E, Messina M. Choledochal cysy: Early experience by laparoscopic approach. J Ped Surg Case Reports. 2016;11:4-6. 8 Ahn SM, Jun JY, Lee WJ, Oh JT, Han SJ, Choi SH, et al. Laparoscopic total intracorporeal correction of choledochal cyst in pediatric population. J Laparoendosc Adv Surg Tech. 2009;19:683-686. 9 Diao M, Li L, Zhang JZ, Cheng W. A shorter loop in Roux-Y hepatojejunostomy reconstruction for choledochal cysts is equally effective: preliminary results of a prospective randomized study. J Pediatr Surg. 2010;45:845-847. 10 Vater A, Ezler C, Vater CA. Dissertatio de Scirrhis viserum occasione sections viri tymponite defunte. Wittenburgae Pamphlets. 1723; 4:22. 11 Hamidi S, Livingston MH, Alnaqi A, Yousef Y, Walton M. Management of a massive choledochal cyst in a 12 year-old girl: Which imaging modalities should be performed preoperatively?. J Ped Surg Case Reports. 2016;10:42-46. 12 Diao M, Li L, Li Q, Ye M, Cheng W. Challenges and strategies for single-incision laparoscopic Roux-en-Y hepaticojejunostomy in managing giant choledochal cysts. Int J Surg. 2014;12:412-417. 13 Ryu HS, Lee JY, Kim DY, Kim SC, Namgoong JM. Minimally-invasive neonatal surgery: laparoscopic excision of choledochal cysts in neonates. Ann Surg Treat Res. 2019;97:21-26. 14 Choi SB, Choi SY. Current status and future perspective of laparoscopic surgery in hepatobiliary disease. Kaohsiung J Med Sci. 2016;32:281-291. 15 Mohammed Ilyas MI, Tieman J, Alkhoury F. Laparoscopic single stage procedure for perforated choledochal cyst. J Ped Surg Case Reports. 2015;3:436-439. 16 Fujishiro J, Masumoto K, Urita Y, Shinkai T, Gotoh C. Pancreatic complications in pediatric choledochal cysts. J Pediatr Surg. 2013;48:1897-1902. 17 Ohba G, Yamamoto H, Nakayama M, Honda S, Taketomi A. Single-stage operation for perforated choledochal cyst. J Pediatr Surg. 2018;53:653-655. 18 Diao M, Li L, Cheng W. Timing of surgery for prenatally diagnosed asymptomatic choledochal cysts: a prospective randomized study. J Pediatr Surg. 2012;47:506-512. 19 Diao M, Li L, Cheng W. Is it necessary to ligate distal common bile duct stumps after excising choledochal cysts? Pediatr Surg Int. 2011;27:829-832. Tables Table 1. Demographics of the TLH group vs the CLH group. TLH group (n=30) CLH group (n=25) P Sex (Male/Female) 8/22 6/19 0.82 a Age (y) 4.31±0.46 (1.3 y-12 y) 3.62±0.50 (30 d-10 y) 0.30 b CDC Todani classification (I/IV) 16/14 19/6 0.08 a CDC length (mm) 46.47±4.35 45.56±3.59 0.88 b CDC diameter (mm) 28.67±4.12 26.16±2.67 0.63 b Values are mean ±standard deviation. a c ² test b Student t test Table 2 . P erioperative characteristics of the TLH group vs the CLH group. TLH group (n=30) CLH group (n=25) P Time to oral intake (days) 3.57±0.19 4.56±0.27 <0.01 b Postoperative hospital stay (days) 5.50±0.28 7.00±0.74 <0.05 b Hospitalization expenses (CNY) 40085±2447 26084±2776 <0.001 b Intraoperative blood loss (ml) 9.57±3.28 8.20±1.13 0.72 b Time for jejunum-co-jejunum anastomosis (min) 80.50±2.46 75.00±2.04 0.10 b Postoperative complications (%) 3/30 2/25 0.79 a Values are mean ±standard deviation. a c ² test b Student t test Supplementary Files FigureS1.tif FigureS2.tif Cite Share Download PDF Status: Published Journal Publication published 17 Oct, 2020 Read the published version in BMC Surgery → Version 4 posted Submission checks completed at journal 09 Oct, 2020 Editorial decision: Accept 09 Oct, 2020 You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-35680","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research article","associatedPublications":[],"authors":[{"id":3293317,"identity":"3795d31a-7cb7-4558-a529-c5cceda3fea8","order_by":0,"name":"FEI LIU","email":"","orcid":"https://orcid.org/0000-0001-7632-3066","institution":"Guangzhou Women and Children's Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"FEI","middleName":"","lastName":"LIU","suffix":""},{"id":3293318,"identity":"b71ef5b7-8848-4175-8f84-6ee1afb10ede","order_by":1,"name":"Xiaogang Xu","email":"","orcid":"","institution":"Guangzhou Women and Children's Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Xiaogang","middleName":"","lastName":"Xu","suffix":""},{"id":3293319,"identity":"cff1a81e-2f42-49a7-8183-f9672d9269af","order_by":2,"name":"Menglong Lan","email":"","orcid":"","institution":"Guangzhou Women and Children's Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Menglong","middleName":"","lastName":"Lan","suffix":""},{"id":3293320,"identity":"becd7e78-4078-49cb-8eb6-43335b681634","order_by":3,"name":"Boyuan Tao","email":"","orcid":"","institution":"Guangzhou Women and Children's Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Boyuan","middleName":"","lastName":"Tao","suffix":""},{"id":3293321,"identity":"140a427b-7cef-4b7c-b01d-3166c4f048bf","order_by":4,"name":"Le Li","email":"","orcid":"","institution":"Guangzhou Women and Children's Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Le","middleName":"","lastName":"Li","suffix":""},{"id":3293322,"identity":"6bb6372c-580c-4d5a-ab79-770b6f23095c","order_by":5,"name":"Qiang Wu","email":"","orcid":"","institution":"Guangzhou Women and Children's Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Qiang","middleName":"","lastName":"Wu","suffix":""},{"id":3293323,"identity":"1f5e7bc1-130c-41a6-9063-af40f51a863a","order_by":6,"name":"Chengwei Chai","email":"","orcid":"","institution":"Guangzhou Women and Children's Medical Center","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Chengwei","middleName":"","lastName":"Chai","suffix":""},{"id":3293324,"identity":"0ed20805-98fc-4fb3-a09b-9ae1235032ca","order_by":7,"name":"Jixiao Zeng","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0klEQVRIiWNgGAWjYLACCQMGHgYG5gMHPvwgTQtb4sGZPaTZxWN8mIONCHXy7b2HX1gUHJbhb+/5cBhomTy/2AH8Whh7zqVZSBik8UicObvhcIEFg+HM2Qn4tTBL5JgZSBjY8DDcyN1weAYPQ4LBbQJa2OTfgLRI8MjfyHlwmIeNCC08EjzGD0C2GNzIYSBOiwRPjhkDyC+GZ44ZAANZgrBf5NvPGH+W+HPYXu548+MPH37YyPNLE9AC8o60BJKtBJWDAPPHD0SpGwWjYBSMghELALMHP3ERwjZaAAAAAElFTkSuQmCC","orcid":"","institution":"Guangzhou Women and Children's Medical Center","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Jixiao","middleName":"","lastName":"Zeng","suffix":""}],"badges":[],"createdAt":"2020-06-14 23:00:50","currentVersionCode":4,"declarations":"","doi":"10.21203/rs.3.rs-35680/v4","doiUrl":"https://doi.org/10.21203/rs.3.rs-35680/v4","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12893-020-00906-5","type":"published","date":"2020-10-17T12:00:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":3041570,"identity":"f595d60b-dd06-4909-aa97-2a0262912a0c","added_by":"auto","created_at":"2020-10-17 22:47:59","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":443816,"visible":true,"origin":"","legend":"Separation of anterior wall of choledochal cyst","description":"","filename":"FigA.png","url":"https://assets-eu.researchsquare.com/files/rs-35680/v4/d3bf0d189317d41423fdf981.png"},{"id":3041572,"identity":"dd25a1f7-c1fb-4a71-90ec-92b47a453b1a","added_by":"auto","created_at":"2020-10-17 22:47:59","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":425643,"visible":true,"origin":"","legend":"Ligating and excising distal end of common bile duct ","description":"","filename":"FigB.png","url":"https://assets-eu.researchsquare.com/files/rs-35680/v4/87d278e93977d0ad1c8a83f9.png"},{"id":3041573,"identity":"c9dff4c9-fd45-4446-820d-0320b58f1c20","added_by":"auto","created_at":"2020-10-17 22:47:59","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":448691,"visible":true,"origin":"","legend":" Separation of posterior wall of choledochal cyst ","description":"","filename":"FigC.png","url":"https://assets-eu.researchsquare.com/files/rs-35680/v4/dd10619ff054feeead96fb9d.png"},{"id":3041574,"identity":"ebb8fc3f-3203-40b4-a0ae-d1f10ef2946b","added_by":"auto","created_at":"2020-10-17 22:47:59","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":419611,"visible":true,"origin":"","legend":"Excising proximal jejunum with Endo-GIA Tri-staple ","description":"","filename":"FigD.png","url":"https://assets-eu.researchsquare.com/files/rs-35680/v4/4e7849afebf77655c6b9b955.png"},{"id":3041575,"identity":"ba9f0be4-3c10-47cd-81ee-f7ae19601ef0","added_by":"auto","created_at":"2020-10-17 22:47:59","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":430420,"visible":true,"origin":"","legend":"Fully releasing jejunal mesentery","description":"","filename":"FigE.png","url":"https://assets-eu.researchsquare.com/files/rs-35680/v4/c18beb86d1576b12c02388b7.png"},{"id":3041576,"identity":"2ec7ca08-6ee4-42c8-bfba-6dcad7a975ed","added_by":"auto","created_at":"2020-10-17 22:47:59","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":468521,"visible":true,"origin":"","legend":"Posterior wall anastomosis during hepaticojejunostomy ","description":"","filename":"FigF.png","url":"https://assets-eu.researchsquare.com/files/rs-35680/v4/8f803ad3f81331b8f2dfc5c4.png"},{"id":3041577,"identity":"2eb21d28-6d66-4f4b-b79b-2cb4705cb785","added_by":"auto","created_at":"2020-10-17 22:48:00","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":481664,"visible":true,"origin":"","legend":"Anterior wall anastomosis during hepaticojejunostomy","description":"","filename":"FigG.png","url":"https://assets-eu.researchsquare.com/files/rs-35680/v4/ab92fc271f8f26c50f2e5664.png"},{"id":3041578,"identity":"de26f8e7-c653-4bc8-8f03-80a3dd3d89dd","added_by":"auto","created_at":"2020-10-17 22:48:00","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":393471,"visible":true,"origin":"","legend":"Jejunal side-to-side anastomosis with Endo-GIA Tri-staple ","description":"","filename":"FigH.png","url":"https://assets-eu.researchsquare.com/files/rs-35680/v4/b7492faa5d1410174bf52d8e.png"},{"id":3041579,"identity":"5f369c81-c3ff-4c76-becc-89e1e25c0b69","added_by":"auto","created_at":"2020-10-17 22:48:00","extension":"png","order_by":9,"title":"Figure 9","display":"","copyAsset":false,"role":"figure","size":452164,"visible":true,"origin":"","legend":"Suturing residual anastomosis","description":"","filename":"FigI.png","url":"https://assets-eu.researchsquare.com/files/rs-35680/v4/196e554016d78cc153dea0f8.png"},{"id":13604321,"identity":"f921e7cb-a473-41c2-aa07-f36d7e1c07e1","added_by":"auto","created_at":"2021-09-17 05:59:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":7487240,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-35680/v4/481fbc3d-33e4-4124-8cc1-1d9f88f23a3a.pdf"},{"id":3041569,"identity":"f41c0b6b-784a-4b5c-b1ec-d9274714a223","added_by":"auto","created_at":"2020-10-17 22:47:59","extension":"tif","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":1122110,"visible":true,"origin":"","legend":"","description":"","filename":"FigureS1.tif","url":"https://assets-eu.researchsquare.com/files/rs-35680/v4/04ac39458eab99f9321710f1.tif"},{"id":3041571,"identity":"16c8668b-6fa0-4d19-93c2-0c056fb0d5ed","added_by":"auto","created_at":"2020-10-17 22:47:59","extension":"tif","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":526862,"visible":true,"origin":"","legend":"","description":"","filename":"FigureS2.tif","url":"https://assets-eu.researchsquare.com/files/rs-35680/v4/022ebbcfb73f74cfdfdd11c7.tif"}],"financialInterests":"","formattedTitle":"Total versus conventional laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy in children with choledochal cysts: a case-control study","fulltext":[{"header":"1. Background","content":"\u003cp\u003eCholedochal cysts (CDCs) are a rare congenital biliary malformation. The incidence of CDCs in Western countries ranges from 1/50,000 to 1/200,000, while that in Japan is approximately 1/13,000, with a male-to-female ratio of 1:4 [1-3]. Total cyst excision with Roux-en-Y hepaticoenterostomy has become the standard procedure [4]. In 1995, Farello et al. [5] reported for the first time the laparoscopic-assisted treatment of CDCs. Currently, the laparoscopic treatment of CDCs has been widely accepted by surgeons and children due to its advantages of a small incision, less trauma, less pain and a quick recovery [6,7]. The gradual improvement of laparoscopic instruments and surgical techniques has made it possible to treat CDCs in children by total laparoscopy. However, considering the limited space of the abdominal cavity, the difficulty of the operation and the high cost of hospitalization, it has not been widely performed [8]. From August 2017 to December 2018, we compared the efficacy of total laparoscopic hepaticojejunostomy (TLH) and conventional laparoscopic hepaticojejunostomy (CLH) in children with CDCs.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003eWe retrospectively analyzed the data of 30 children who underwent TLH and 25 children who underwent CLH from August 2017 to December 2018. All patients were evaluated by ultrasonography, computed tomography (CT), or magnetic resonance cholangiopancreatography (MRCP) before the operation. Considering the limited abdominal cavity space of a child, we set the inclusion criteria for the TLH group as children \u0026gt;1 year old with CDCs. The exclusion criteria were as follows: (a) children \u0026lt;1 year old, (b) children with a history of upper abdominal surgery, (c) children who experienced uncontrolled acute cholangitis, (d) children who suffered from cardiovascular or other diseases that contraindicate total laparoscopic surgery, or (e) children whose parents did not accept total laparoscopic surgery.\u003c/p\u003e\n\u003cp\u003ePatients with no following preconditions were included in the CLH group: (a) upper abdominal surgery history, (b) uncontrolled acute cholangitis, (c) cardiovascular or other diseases that contraindicate laparoscopic surgery, and (d) parents who did not accept laparoscopic surgery. Ethical approval from the Institutional Review Board of Guangzhou Women and Children\u0026rsquo;s Medical Center and written parental consent were obtained. The research was conducted in compliance with the World Medical Association Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.1 Operative Techniques\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e2.1.1 Total laparoscopic CDC excision and Roux-en-Y hepaticojejunostomy\u003c/p\u003e\n\u003cp\u003eThe ligament of Treitz was identified under laparoscopy, and the proximal jejunum 20 cm distal to the ligament was cut off using an Endo-GIA Tri-Staple instrument (COVIDIEN, USA) through the fourth port after extending the incision to 1.5-2.0 cm (Fig. 4). The jejunal mesentery was fully released (Fig. 5). To minimize the redundant Roux loop, an individualized jejunal Roux loop length was tailored by the distance between the umbilicus and the hepatic hilum [9]. The Roux loop was passed up to the hilum retrocolically. A side-hole jejunotomy was created on the antimesenteric border 1 cm from the end of the jejunal limb to match the diameter of the hepatic duct. End-to-side hepaticojejunal anastomosis was accomplished laparoscopically with continuous 5-0 or 6-0 PDS sutures (Fig. 6, Fig. 7). Then, the Endo-GIA Tri-Staple instrument was used to complete the jejunal side-to-side anastomosis (Fig. 8). The residual stoma was closed using continuous 5-0 PDS sutures, and the seromuscular layer was reinforced using intermittent 5-0 PDS sutures (Fig. 9).\u003c/p\u003e\n\u003cp\u003e2.1.2 Conventional laparoscopic CDC excision and Roux-en-Y hepaticojejunostomy\u003c/p\u003e\n\u003cp\u003eThe trocar locations, cyst excision and Roux-en-Y hepaticojejunostomy were all consistent with those in the TLH group; the main difference was that the end-to-side jejunum-jejunum anastomosis was performed by extracorporeal manual sewing. The specific procedures were as follows: Firstly, identify the ligament of Treitz under laparoscopy. Secondly, capture the proximal jejunum 20 cm distal to the ligament with a bowel clamp, exteriorize it through the umbilical trocar site after extending the incision to 1.5 or 2.0 cm. Finally, carry out the Roux-en-Y end-to-side jejunojejunostomy with 2-layer interrupted sutures manually outside the abdomen and the closed jejunum limb was then lifted through an incision in the right side of the mesocolon to accomplish the end-to-side hepaticojejunal anastomosis.\u003c/p\u003e\n\u003cp\u003ePostoperatively, the patients were allowed to start oral intake when they met the following standards: (1) no abdominal distension;(2) light gastric juice color with a volume\u0026lt;20 ml/d; and (3) patients had passage of flatus and recovery of bowel sounds. When the patients were afebrile and had no need for intravenous fluids, their wound was healing well, and their blood test results were normal, they were discharged.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.2 Follow up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePostoperative follow-ups were conducted to all patients 1, 3, 6 and 12 months since surgery completion and every 6 months thereafter. Each visit was constituted of physical examination, abdominal ultrasonography, and laboratory tests. Postoperative complications, for instance pancreatitis, anastomotic stenosis, intrahepatic stone formation and pancreatic calculi formation, were clinically evaluated matching with appropriate investigations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2.3 Statistical analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were analyzed with the SPSS 21.0 package. c\u0026sup2; tests were performed to compare the distribution of sex, CDC type and postoperative complications between the TLH and CLH groups. Student\u0026rsquo;s \u003cem\u003et-\u003c/em\u003etests were applied to compare the age, CDC length, CDC diameter, time to oral intake, postoperative hospital stay, hospitalization expenses, intraoperative blood loss and time for jejunum-cojejunum anastomosis. A level of \u003cem\u003eP\u003c/em\u003e\u0026lt;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eIn our study, 55 patients (TLH=30, CLH=25) with a diagnosis of CDCs underwent cyst resection and end-to-side hepaticojejunostomy. There were no significant differences in the demographic variables or pathological manifestations of the cysts between the two groups (Table 1).\u003c/p\u003e\n\n\u003cp\u003eThe postoperative hospital stay and time to oral intake in the TLH group were significantly shorter than those in the CLH group (5.50±0.28 d vs 7.00±0.74, \u003cem\u003eP\u003c/em\u003e\u0026amp;lt;0.05; 3.57±0.19 vs 4.56±0.27, \u003cem\u003eP\u003c/em\u003e\u0026amp;lt;0.01). It is worth noting that the hospitalization cost in the TLH group was significantly higher than that in the CLH group (CNY 40085±2447 vs CNY 26084±2776,\u003cem\u003e P\u003c/em\u003e\u0026amp;lt;0.001). There were no significant differences in the intraoperative blood loss volume, time for jejunum-cojejunum anastomosis or complications between the two groups (Table 2).\u003c/p\u003e\n\n\u003cp\u003eThe median follow-up periods of the TLH and CLH groups were 17 (11–27 months) and 16 (11–27 months) months, respectively. All patients, except for those mentioned below, were free of abdominal pain, fever and jaundice. Group TLH had 3 postoperative complications. One patient experienced obstruction and necrosis 1 week after discharge (2 weeks after the operation) because \u003ca name=\"_Hlk50207780\"\u003ethe distal biliary jejunum herniated from the transverse mesocolic hiatus into the colon and compressed the proximal biliary jejunum\u003c/a\u003e, and choledochojejunostomy was performed again. One patient presented adhesive intestinal obstruction 1 month after discharge (1 month after surgery), which improved after conservative treatment. One patient underwent choledochojejunostomy again 1 month after discharge (1 month after surgery) because of severe adhesion in the abdominal cavity due to suppurative appendicitis and obstruction necrosis caused by cord compression of the proximal biliary jejunum.\u003c/p\u003e\n\n\u003cp\u003eGroup CLH had 2 postoperative complications. One patient presented with an intestinal obstruction 1 week after the operation, and no relief was achieved after conservative treatment. This obstruction was found to be caused by umbilical incision and intestinal tube adhesion via a reoperation. One patient presented with fever, abdominal bloating, and increased leucocytes and amylase at 1 week after the operation, and ultrasonic examination indicated peritoneal effusion, which was not improved after conservative treatment. A pancreatic fistula was confirmed by surgery. \u003c/p\u003e\n\n "},{"header":"4. Discussion","content":"\u003cp\u003eCDCs are a rare disorder of bile duct dilation that was first described by Vater and Ezler in 1723 [10]. Although cysts are benign lesions, they are closely related to many serious complications, such as malignant bile duct tumors, cholangitis, pancreatitis and intrahepatic bile duct stones [2,11]. Therefore, surgery should be performed as soon as possible after the diagnosis is clear [12,13]. Compared with traditional open surgery, laparoscopic CDC surgery has the following advantages [14,15]: ① Laparoscopy can magnify the tissue 4\u0026ndash;8 times, allowing precise separation of the cyst from the surrounding tissues, such as the hepatic artery, portal vein, pancreas and capillary network around the cyst, and thus avoiding side effects. ② Laparoscopy can penetrate into the hepatic hilum for a more accurate operation; meanwhile, bile duct abnormalities, such as labyrinthine bile duct and hepatic stenosis, can be visually detected. ③ Laparoscopic surgery causes less intestinal disturbance and allows faster postoperative intestinal peristalsis recovery. ④ The incision is small and aesthetic, and the pain is mild. The incidence of wound infection and incisional hernia is reduced after this operation. Total laparoscopic surgery, in addition to the above advantages, has an additional advantage in that the umbilical incision is smaller and more aesthetic, which is more satisfactory according to the needs of the children and their families.\u003c/p\u003e\n\u003cp\u003eIn the CLH group, the bowel was pulled out through an umbilical incision to complete the jejunal end-to-side anastomosis. Intestinal traction and exposure increase the risk of intestinal injury and adhesions in theory. We successfully performed total laparoscopic CDC excision and Roux-en-Y hepaticojejunostomy in 30 children. Compared with those in the CLH group, the postoperative fasting time and hospitalization duration were significantly shorter in the TLH group. These findings show that the total laparoscopic approach disturbs the bowel less and allows faster recovery of gastrointestinal function. However, it is worth noting that the hospitalization cost in the TLH group was significantly higher than that in the CLH group, which may be due to the high cost of laparoscopic instruments. With the continuous development of surgical instruments, we believe that in the near future, the cost of laparoscopic instruments will gradually decrease.\u003c/p\u003e\n\u003cp\u003eThe main difference between TLH and CLH is jejunum-to-jejunum anastomosis. We need to pay attention to the following points: ① When the jejunum is cut using an endoscopic stapler, the intestinal tube should be fully flattened to avoid overlap, which could result in insufficient cutting and an intestinal fistula. ② A side-hole jejunotomy was created on the antimesenteric border just 0.5 cm from the end of the proximal jejunum, to minimize the occurrence of a \"blind pouch\". ③ When using an endoscopic cutter stapler for jejunal side-to-side anastomosis, the puncture hole in the intestinal wall does not need to be large. Its size should be suitable for placement at the end of the stapler to minimize the residual stoma and reduce the operative duration. Additionally, side-to-side anastomosis of the jejunum should be arranged in parallel with the mesentery to ensure full contact with the stapler. In the early stages of implementing total laparoscopic surgery, there was one case in which a child underwent jejunal side-to-side anastomosis with an uneven arrangement, resulting in excessive residual anastomosis, increased suture difficulties and a prolonged operation. In this study, the time for jejunal side-to-side anastomosis in the TLH group was longer than the time for jejunal end-to-side anastomosis in the CLH group, but there was no significant difference. We consider that this finding may be related to the learning curve for mastering total laparoscopic surgery.\u003c/p\u003e\n\u003cp\u003ePostoperative complications of laparoscopic CDC excision include pancreatitis [16], pancreatic fistula [17], cholangitis [1], biliary fistula and intestinal obstruction [18]. In this study, one child in the TLH group required reoperation because the distal biliary jejunum herniated from the transverse mesocolic hiatus and compressed the proximal biliary loops, resulting in obstruction and necrosis. The transverse mesocolon and gastrocolonic ligament are often thicker in older children with CDCs complicated with repeated infection; thus, we suggest that after establishing a retrocolonic tunnel to cross the transverse mesocolon, the gastrocolonic ligament should be fully separated at the same time so that the intestinal tube can pass smoothly. Subsequently, the hepatic limb jejunal and transverse mesocolon should be sutured intermittently with 3 to 4 needles to avoid obstruction caused by intestinal hernia. In the CLH group, one child developed a postoperative pancreatic fistula and needed reoperation to retain the abdominal drainage tube. We considered the pancreatic fistula to have been caused by too deep of an operating position when the distal end of the cyst was separated, resulting in damage to the pancreatic duct. Li et al. [19] believed that in children with cystic dilatation, not ligating the distal stump is a feasible approach and may minimize pancreatic duct injury.\u003c/p\u003e\n\u003cp\u003eThe limitations of this study are that the number of cases is small and that the follow-up period is short. The long-term effect in the two groups needs further study.\u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eIn summary, total laparoscopic CDC resection and Roux-en-Y hepaticojejunostomy are safe and feasible. Although the TLH operation was difficult because of the limited abdominal cavity capacity of children, resulting in a narrow operation space within delicate tissue, recovery was faster and the hospitalization duration was shorter in the TLH group than in the CLH group. Based on our experience with radical laparoscopic CDC excision and intestinal anastomosis with a stapler, tacit cooperation and precise operations can ensure the safety and efficacy of the operation. In addition, the hospitalization cost in the TLH group was relatively high, so surgical plans should be optimized for patients considering their family's economic situation.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTLH: total laparoscopic hepaticojejunostomy;\u003c/p\u003e\n\u003cp\u003eCLH: conventional laparoscopic hepaticojejunostomy;\u003c/p\u003e\n\u003cp\u003eCDC: choledochal cyst;\u003c/p\u003e\n\u003cp\u003eCT: computed tomography;\u003c/p\u003e\n\u003cp\u003eMRCP: magnetic resonance cholangiopancreatography\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval from the Institutional Review Board of Guangzhou Women and Children\u0026rsquo;s Medical Center and written parental consent were obtained. The research was conducted in compliance with the World Medical Association Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the fund from Guangzhou Women and Children's Medical Center (No.IP-2018-008). It had no involvement in study design, collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the article for publication.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u003c/strong\u003e\u003cstrong\u003e\u0026rsquo; \u003c/strong\u003e\u003cstrong\u003econtributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors have read and approved the final manuscript. Study concept and design: FL, JXZ; Acquisition of data: XGX, BYT; Analysis and interpretation of data: MLL; Drafting of the manuscript: FL; Critical revision of the manuscript for important intellectual content: LL, QW, CWC, JXZ; Study supervision: JXZ.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003cp\u003e1 Atkinson HDE, Fischer CP, De Jong CHC, Madhavan KK, Parks RW, Garden OJ. Choledochal cysts in adults and their complications. HPB(Oxford). 2003;5:105-110.\u003c/p\u003e\n\u003cp\u003e2 Soares KC, Arnaoutakis DJ, Kamel I, Rastegar N, Anders R, Maithel S, et al. Choledochal cysts: presentation, clinical differentiation, and management. J Am Coll Surg. 2014;219:1167-1180.\u003c/p\u003e\n\u003cp\u003e3 Silva-Baez H, Coello-Ram\u0026iacute;rez P, Ixtabal\u0026aacute;n-Escalante EM, Sotelo-Anaya E, Gallo-Morales M, Cordero-Estrada E, et al. Treatment of choledochal cyst in a pediatric population. A single institution experience of 15-years.Case series. Ann Med Surg. 2016;5:81-85.\u003c/p\u003e\n\u003cp\u003e4 Qiao G, Li L, Li S, Tang S, Wang B, Xi H, et al. Laparoscopic cyst excision and Roux-Y hepaticojejunostomy for children with choledochal cysts in China: a multicenter study. Surg Endosc. 2015; 29:140-144.\u003c/p\u003e\n\u003cp\u003e5 Farello GA, Cerofolini A, Rebonato M, Bergamaschi G, Ferrari C, Chiappetta A. Congenital choledochal cyst: video-guided laparoscopic treatment. Surg Laparosc Endosc. 1995;5:354-358.\u003c/p\u003e\n\u003cp\u003e6 Liu Y, Diao M, Li L. Using laparoscopic double hemicircumferential running single-layer suture in hepaticojejunostomy for choledochal cysts in children. J Pediatr Surg. 2018;53:199-202.\u003c/p\u003e\n\u003cp\u003e7 Sica M, Molinaro F, Angotti R, Bindi E, Brandigi E, Messina M. Choledochal cysy: Early experience by laparoscopic approach. J Ped Surg Case Reports. 2016;11:4-6.\u003c/p\u003e\n\u003cp\u003e8 Ahn SM, Jun JY, Lee WJ, Oh JT, Han SJ, Choi SH, et al. Laparoscopic total intracorporeal correction of choledochal cyst in pediatric population. J Laparoendosc Adv Surg Tech. 2009;19:683-686.\u003c/p\u003e\n\u003cp\u003e9 Diao M, Li L, Zhang JZ, Cheng W. A shorter loop in Roux-Y hepatojejunostomy reconstruction for choledochal cysts is equally effective: preliminary results of a prospective randomized study. J Pediatr Surg. 2010;45:845-847.\u003c/p\u003e\n\u003cp\u003e10 Vater A, Ezler C, Vater CA. Dissertatio de Scirrhis viserum occasione sections viri tymponite defunte. Wittenburgae Pamphlets. 1723; 4:22.\u003c/p\u003e\n\u003cp\u003e11 Hamidi S, Livingston MH, Alnaqi A, Yousef Y, Walton M. Management of a massive choledochal cyst in a 12 year-old girl: Which imaging modalities should be performed preoperatively?. J Ped Surg Case Reports. 2016;10:42-46.\u003c/p\u003e\n\u003cp\u003e12 Diao M, Li L, Li Q, Ye M, Cheng W. Challenges and strategies for single-incision laparoscopic Roux-en-Y hepaticojejunostomy in managing giant choledochal cysts. Int J Surg. 2014;12:412-417.\u003c/p\u003e\n\u003cp\u003e13 Ryu HS, Lee JY, Kim DY, Kim SC, Namgoong JM. Minimally-invasive neonatal surgery: laparoscopic excision of choledochal cysts in neonates. Ann Surg Treat Res. 2019;97:21-26.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e14 Choi SB, Choi SY. Current status and future perspective of laparoscopic surgery in hepatobiliary disease. Kaohsiung J Med Sci. 2016;32:281-291.\u003c/p\u003e\n\u003cp\u003e15 Mohammed Ilyas MI, Tieman J, Alkhoury F. Laparoscopic single stage procedure for perforated choledochal cyst. J Ped Surg Case Reports. 2015;3:436-439.\u003c/p\u003e\n\u003cp\u003e16 Fujishiro J, Masumoto K, Urita Y, Shinkai T, Gotoh C. Pancreatic complications in pediatric choledochal cysts. J Pediatr Surg. 2013;48:1897-1902.\u003c/p\u003e\n\u003cp\u003e17 Ohba G, Yamamoto H, Nakayama M, Honda S, Taketomi A. Single-stage operation for perforated choledochal cyst. J Pediatr Surg. 2018;53:653-655.\u003c/p\u003e\n\u003cp\u003e18 Diao M, Li L, Cheng W. Timing of surgery for prenatally diagnosed asymptomatic choledochal cysts: a prospective randomized study. J Pediatr Surg. 2012;47:506-512.\u003c/p\u003e\n\u003cp\u003e19 Diao M, Li L, Cheng W. Is it necessary to ligate distal common bile duct stumps after excising choledochal cysts? Pediatr Surg Int. 2011;27:829-832.\u003c/p\u003e"},{"header":"Tables","content":"\u003cp style=\"line-height: 150%;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 14.0pt; line-height: 150%;\"\u003eTable 1. \u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size: 14.0pt; line-height: 150%;\"\u003eDemographics of the TLH group vs the CLH group.\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"border-collapse: collapse; border: none;\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 369.9pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt;\" colspan=\"5\" width=\"493\"\u003e\n\u003cp style=\"text-align: center; text-indent: 102.0pt;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003eTLH group (n=30)\u0026nbsp;\u0026nbsp; CLH group (n=25)\u0026nbsp;\u0026nbsp; \u003cem\u003eP\u003c/em\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 108.8pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"145\"\u003e\n\u003cp\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003eSex (Male/Female)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 106.35pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" colspan=\"2\" width=\"142\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003e\u0026nbsp;\u0026nbsp; 8/22\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 106.3pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"142\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003e6/19\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 48.45pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"65\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003e0.82\u003csup\u003ea\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 130.1pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" colspan=\"2\" width=\"173\"\u003e\n\u003cp\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003eAge (y)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 85.05pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"113\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003e4.31\u0026plusmn;0.46 \u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003e(1.3 y-12 y)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 106.3pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"142\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003e3.62\u0026plusmn;0.50\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003e\u0026nbsp;(30 d-10 y)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 48.45pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"65\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003e0.30\u003csup\u003eb\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 130.1pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" colspan=\"2\" width=\"173\"\u003e\n\u003cp\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003eCDC Todani classification (I/IV)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 85.05pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"113\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003e16/14\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 106.3pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"142\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003e19/6\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 48.45pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"65\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003e0.08\u003csup\u003ea\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 130.1pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" colspan=\"2\" width=\"173\"\u003e\n\u003cp\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003eCDC length (mm)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 85.05pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"113\"\u003e\n\u003cp style=\"text-align: center; text-indent: 12.0pt;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003e46.47\u0026plusmn;4.35\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 106.3pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"142\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003e45.56\u0026plusmn;3.59\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 48.45pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"65\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003e0.88\u003csup\u003eb\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 130.1pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt;\" colspan=\"2\" width=\"173\"\u003e\n\u003cp\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003eCDC diameter (mm)\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 85.05pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt;\" width=\"113\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003e\u0026nbsp; 28.67\u0026plusmn;4.12\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 106.3pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt;\" width=\"142\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003e26.16\u0026plusmn;2.67\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 48.45pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt;\" width=\"65\"\u003e\n\u003cp style=\"text-align: center;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003e0.63\u003csup\u003eb\u003c/sup\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"border: none;\" width=\"145\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"border: none;\" width=\"28\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"border: none;\" width=\"113\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"border: none;\" width=\"142\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"border: none;\" width=\"65\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cspan style=\"font-size: 12pt; line-height: 107%; font-family: 'Times New Roman', serif;\"\u003eValues are mean\u003c/span\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003e\u0026plusmn;standard deviation. \u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003ea\u003c/span\u003e\u003c/sup\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: Symbol;\"\u003ec\u003c/span\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: SimSun;\"\u003e\u0026sup2; \u003c/span\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003etest\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003eb\u003c/span\u003e\u003c/sup\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003eStudent \u003cem\u003et\u003c/em\u003e test\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp style=\"line-height: 150%;\"\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 14.0pt; line-height: 150%;\"\u003eTable \u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 14.0pt; line-height: 150%;\"\u003e2\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan style=\"font-size: 14.0pt; line-height: 150%;\"\u003e. \u003c/span\u003e\u003c/strong\u003e\u003cspan style=\"font-size: 14.0pt; line-height: 150%;\"\u003eP\u003c/span\u003e\u003cspan style=\"font-size: 14.0pt; line-height: 150%;\"\u003eerioperative characteristics of the TLH group vs the CLH group.\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"border-collapse: collapse; border: none;\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 369.9pt; border-top: solid windowtext 1.0pt; border-left: none; border-bottom: solid windowtext 1.0pt; border-right: none; padding: 0in 5.4pt 0in 5.4pt;\" colspan=\"4\" width=\"493\"\u003e\n\u003cp style=\"text-align: center; text-indent: 102.0pt;\"\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003eTLH group (n=30)\u0026nbsp;\u0026nbsp; CLH group (n=25)\u0026nbsp;\u0026nbsp; \u003cem\u003eP\u003c/em\u003e\u003c/span\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 108.8pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"145\"\u003e\n\u003cp style=\"line-height: 150%;\"\u003eTime to oral intake (days)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 106.35pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"142\"\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e3.57\u0026plusmn;0.19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 106.3pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"142\"\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e4.56\u0026plusmn;0.27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 48.45pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"65\"\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e\u0026lt;0.01\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 108.8pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"145\"\u003e\n\u003cp style=\"line-height: 150%;\"\u003ePostoperative hospital stay (days)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 106.35pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"142\"\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e5.50\u0026plusmn;0.28\u003c/p\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 106.3pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"142\"\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e7.00\u0026plusmn;0.74\u003c/p\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 48.45pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"65\"\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e\u0026lt;0.05\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 108.8pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"145\"\u003e\n\u003cp style=\"line-height: 150%;\"\u003eHospitalization expenses (CNY)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 106.35pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"142\"\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e40085\u0026plusmn;2447\u003c/p\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 106.3pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"142\"\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e26084\u0026plusmn;2776\u003c/p\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 48.45pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"65\"\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e\u0026lt;0.001\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 108.8pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"145\"\u003e\n\u003cp style=\"line-height: 150%;\"\u003eIntraoperative blood loss (ml)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 106.35pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"142\"\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e9.57\u0026plusmn;3.28\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 106.3pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"142\"\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e8.20\u0026plusmn;1.13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 48.45pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"65\"\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e0.72\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 108.8pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"145\"\u003e\n\u003cp style=\"line-height: 150%;\"\u003eTime for jejunum-co-jejunum anastomosis (min)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 106.35pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"142\"\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e80.50\u0026plusmn;2.46\u003c/p\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 106.3pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"142\"\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e75.00\u0026plusmn;2.04\u003c/p\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 48.45pt; border: none; padding: 0in 5.4pt 0in 5.4pt;\" width=\"65\"\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e0.10\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 108.8pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt;\" width=\"145\"\u003e\n\u003cp style=\"line-height: 150%;\"\u003ePostoperative complications (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 106.35pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt;\" width=\"142\"\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e3/30\u003c/p\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 106.3pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt;\" width=\"142\"\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e2/25\u003c/p\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 48.45pt; border: none; border-bottom: solid windowtext 1.0pt; padding: 0in 5.4pt 0in 5.4pt;\" width=\"65\"\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e0.79\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n\u003cp style=\"text-align: center; line-height: 150%;\"\u003e\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cspan style=\"font-size: 12pt; line-height: 107%; font-family: 'Times New Roman', serif;\"\u003eValues are mean\u003c/span\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003e\u0026plusmn;standard deviation. \u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003ea\u003c/span\u003e\u003c/sup\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: Symbol;\"\u003ec\u003c/span\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: SimSun;\"\u003e\u0026sup2; \u003c/span\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003etest\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003eb\u003c/span\u003e\u003c/sup\u003e\u003cspan style=\"font-size: 12.0pt; line-height: 107%; font-family: 'Times New Roman',serif;\"\u003eStudent \u003cem\u003et\u003c/em\u003e test\u003c/span\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Total laparoscopic, Choledochal cyst, Children, Congenital","lastPublishedDoi":"10.21203/rs.3.rs-35680/v4","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-35680/v4","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground :\u0026nbsp;To compare the efficacy of total and conventional laparoscopic\u0026nbsp;hepaticojejunostomy (TLH and CLH) in\u0026nbsp;children with choledochal cysts (CDCs). \u003c/p\u003e\u003cp\u003eMethods:\u0026nbsp;Data from patients undergoing TLH and CLH between August 2017 and December 2018\u0026nbsp;were retrospectively analyzed. Intraoperative blood loss, time for jejunum-cojejunum anastomosis, time to oral intake,\u0026nbsp;postoperative hospital\u0026nbsp;stay, hospitalization expenses, and\u0026nbsp;postoperative complications were compared. \u003c/p\u003e\u003cp\u003eResults:\u0026nbsp;\u0026nbsp;All 55 patients (TLH=30, CLH=25)\u0026nbsp;were successfully treated without conversion to open surgery. In the TLH and CLH groups, the time to oral intake\u0026nbsp;was 3.57±0.19\u0026nbsp;d and\u0026nbsp;4.56±0.27\u0026nbsp;d,\u0026nbsp;respectively ( t =3.07,\u0026nbsp;P \u0026lt;0.01),\u0026nbsp;the postoperative hospital\u0026nbsp;stay\u0026nbsp;was 5.50±0.28\u0026nbsp;d and 7.00±0.74\u0026nbsp;d ( t =2.03, P \u0026lt;0.05), and\u0026nbsp;the hospitalization expenses were CNY 40085±2447\u0026nbsp;and CNY 26084±2776\u0026nbsp;( t =3.79, P \u0026lt;0.001). There were no significant differences in intraoperative blood loss\u0026nbsp;(9.57±3.28\u0026nbsp;ml vs 8.2±1.13 ml, t =0.37, P = 0.72) or\u0026nbsp;time for jejunum-cojejunum anastomosis\u0026nbsp;(80.5±2.46 min vs 75.00±2.04 min, t =1.68, P =0.10). The median follow-up periods of the\u0026nbsp;TLH and CLH groups\u0026nbsp;were 17 and 16 months,\u0026nbsp;respectively. Overall complication\u0026nbsp;rates were comparable\u0026nbsp;between the two groups (10% vs 8%,\u0026nbsp;c ² =0.07,\u0026nbsp;P =0.79). \u003c/p\u003e\u003cp\u003eConclusions: TLH in\u0026nbsp;children\u0026nbsp;with CDCs has the advantages of rapid gastrointestinal functional recovery and a short hospitalization.\u0026nbsp;However, hospitalization is relatively expensive.\u003c/p\u003e","manuscriptTitle":"Total versus conventional laparoscopic cyst excision and Roux-en-Y hepaticojejunostomy in children with choledochal cysts: a case-control study","msid":"","msnumber":"","nonDraftVersions":[{"code":4,"date":"2020-10-17 22:47:57","doi":"10.21203/rs.3.rs-35680/v4","editorialEvents":[{"type":"communityComments","content":0},{"type":"checksComplete","content":"","date":"2020-10-09T12:00:00+00:00","index":"","fulltext":""},{"type":"decision","content":"Accept","date":"2020-10-09T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":3,"date":"2020-10-14 20:43:17","doi":"10.21203/rs.3.rs-35680/v3","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Minor revision","date":"2020-10-05T12:00:00+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2020-10-01T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-09-30T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-09-30T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":2,"date":"2020-09-13 20:43:17","doi":"10.21203/rs.3.rs-35680/v2","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2020-09-25T12:00:00+00:00","index":2,"fulltext":"Recommendation: Accept after minor essential revisions\nForm responses:\n---\n\nComments to Author:\n---\nPlease include all comments for the authors in this box rather than uploading your report as an attachment. Please only upload as attachments annotated versions of manuscripts, graphs, supporting materials or other aspects of your report which cannot be included in a text format.\nPlease overwrite this text when adding your comments to the authors.\n\nThe authors addressed the issues I raised in the previous review.\nHowever, the text would still benefit from careful English editing.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **No**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"decision","content":"Minor revision","date":"2020-09-25T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-09-14T12:00:00+00:00","index":1,"fulltext":"Recommendation: Accept without revision\nForm responses:\n---\n\nComments to Author:\n---\nThe authors have adequately addressed all comments/queries.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Declaration of competing interests: **No conflicts of interest or disclosures to report**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n* Is the study design appropriate to answer the research question (including the use of appropriate controls), and are the conclusions supported by the evidence presented?: **Yes**\n* Are the methods sufficiently described to allow the study to be repeated?: **Yes**\n* Is the use of statistics and treatment of uncertainties appropriate?: **Yes**\n* Is the presentation of the work clear?: **Yes**\n* Are the images in this manuscript (including electrophoretic gels and blots) free from apparent manipulation?: **Yes**\n"},{"type":"reviewersInvited","content":"","date":"2020-09-13T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-09-13T12:00:00+00:00","index":1,"fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-09-13T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-09-09T12:00:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2020-09-08T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-09-08T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2020-06-25 14:45:59","doi":"10.21203/rs.3.rs-35680/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2020-08-13T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-07-17T12:00:00+00:00","index":3,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2020-07-14T12:00:00+00:00","index":2,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nPlease include all comments for the authors in this box rather than uploading your report as an attachment. Please only upload as attachments annotated versions of manuscripts, graphs, supporting materials or other aspects of your report which cannot be included in a text format.\nPlease overwrite this text when adding your comments to the authors.\n\n\nThank you for the opportunity to review this interesting manuscript. The authors compared two laparoscopic methods for choledochal cyst excision in children, total laparoscopic hepatic-J Roux-en-Y reconstruction versus conventional reconstruction in which the intestines were brought out through the umbilicus in an mini open fashion. They showed that the total laparoscopic group had decreased time to oral feed and hospital stay but had significantly increased hospital cost, hypothesized by the author to be due to laparoscopic equipment costs.\n\nThe paper was easily understood, and makes logical arguments. I have the following questions/concerns:\n\n1. How do you decide which operative technique to apply to each individual patients? Is it because of Time, surgeon preference, or some other indication in which total or conventional laparoscopic technique was used?\n\n2. On page 9 line 173, please explicitly compare the hospital stay and time to oral intake between the two groups, like you have done on line 176 in regards to hospital cost.\n\n3. I am concerned that the TLH group had 2 significant postoperative technical complications. This was not addressed adequately in the discussion. What is the timing of these complications. By the paper, I assumed they were discovered late, and the initial hospital stay and time to oral feed were not affected, but they represented with delayed findings of technical complication that required reoperations. These are serious Clavien class 4 complications that needed to be accounted for. And I would think is more important to address than 1.5 days shorter hospital stay, and 1 day quicker oral intake. Furthermore, the report of TLH complications in the discussion section is inconsistent with that presented in the results. In the discussion page 13-14 line 266-285. It was stated that \"one\" child required reoperation for biliary jejunum complication. While in page 9 line 186, the results stated that \"two\" patients required reoperation for reconstruction. Also, \"one\" child in TLH was stated to have postoperative pancreatic fistula (page 14, line 279), but the authors failed to mention this complication in results about TLH patients in the results section. I would this to be clarified.\n\n4. There is no need to present postoperative laboratory findings in Table 2. (page 10, line 190-192).\n\n5. Table 1 can be split into two tables. One with demographics, second with perioperative outcomes.\n\n6. Discussion. Page 11, line 213. I don't understand what authors mean by \"no interference with intestinal tract. Further, please provide citation for these statements. or is this authors' hypothesis that needs data to be backed up?\n\n7. Discussion. Page 13, line 254-265. No need for discussion of portal dissection in this paper as the difference in techniques does not affect this portion of the operation.\n\nI look forward to the authors clarifications on the postoperative complications in these patients.* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **No**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n"},{"type":"editorInvitedReview","content":"","date":"2020-07-13T12:00:00+00:00","index":1,"fulltext":"Recommendation: Major revisions required\nForm responses:\n---\n\nComments to Author:\n---\nFei Liu and colleagues expound on their experience with laparoscopic excision of CDCs using two similar techniques with a difference largely in the manner of creation of the J-J anastomosis. The results of their paper are not surprising however I would like to congratulate the authors or adeptly addressing the subject matter and for a well written manuscript. A few comments/queries are as follows:\n\nIntroduction\ni) Paragraph 1, line 7 of introduction: I would replace endoscopic with laparoscopic. I imagine that is what the authors are alluding to.\n\nMethods\ni) Did the authors employ an exclusion criteria? If yes, what were the reasons for excluding a record?\nii) Was the choice of operation (TLH or CLH) based on personal surgeon preference? Given the results of this study, have the authors now transitioned to employing TLH as the sole technique when operating on these children.\niii) I appreciate the inclusion of the description of both operative techniques in the methods section.\n\n\nResults\ni) What is driving the increased cost associated with TLH? One would imagine that a shorter time to feeds and a shorter hospital stay would lead to a decrease in cost. Are the authors able to provide a breakdown of the cost of care and which aspect of care delivery is leading to this increase in cost?\n\nDiscussion\ni) The authors postulate that the increased cost of TLH is driven from the use of laparoscopic instruments. From the description of operative technique it would seem, that besides the use of extra-corporeal JJ anastomosis in CLH, the laparoscopic instruments and tray used would be the same for CLH and TLH. Are the OR and instrument costs the true drivers of this increased cost or is this speculation by the authors? Are the authors able to verify this and provide a breakdown of cost of care?\nii) Well written. Minor grammatical errors that would benefit from input by careful proofreading.\niii) Finally, have the results of this study changed the authors' practice patterns? Have they adopted TLH as the operative technique of choice at their institution. \n* Publons Reviewer Recognition. Springer Nature can send verification of this review directly to Publons (a subsidiary of Clarivate Analytics). If you would like to take advantage of this service, please click on the “Yes” option below. Your name, email address, title of the reviewed manuscript, name of the journal, and date of your review submission (the “Review Data”) will then be transmitted to Publons upon publication of the manuscript. If you have already registered at Publons, they will notify you of the receipt of this review and update your profile as per your settings and their policy. If you are not registered with Publons, you will receive an email from them asking you to register in order for them to be able to recognize your review on your new profile page. Publons may use the Review Data to generate derivative metadata for the benefit of Publons and you as a reviewer, carefully considering the sensitivity of such information. For example, Publons may verify your record as a reviewer by updating your profile published on its webservice if you have registered for such service or help editors to identify candidate reviewers. Please find the details of processing in Publons’ privacy policy https://publons.com/about/terms: **Yes**\n* Are the methods appropriate and well described?: **Yes**\n* Does the work include the necessary controls?: **Yes**\n* Are the conclusions drawn adequately supported by the data shown?: **Yes**\n* Are you able to assess any statistics in the manuscript or would you recommend an additional statistical review?: **I am able to assess the statistics**\n* Quality of written English: **Acceptable**\n* Declaration of competing interests: **I declare that I have no competing interests**\n* Reviewer Publication Consent. I agree for my report to be made available under an Open Access Creative Commons CC-BY License (http://creativecommons.org/licenses/by/4.0) if this manuscript is accepted for publication. Any comments that I do not wish to be included in the published report have been included as confidential comments to the editor, which will not be published.: **I agree to the terms of the CC-BY 4.0 license; please do not publish my name with my report. (default)**\n"},{"type":"reviewerAgreed","content":"","date":"2020-06-23T12:00:00+00:00","index":2,"fulltext":""},{"type":"editorAssigned","content":"","date":"2020-06-20T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2020-06-20T12:00:00+00:00","index":"","fulltext":""},{"type":"reviewerAgreed","content":"","date":"2020-06-20T12:00:00+00:00","index":1,"fulltext":""},{"type":"checksComplete","content":"","date":"2020-06-19T12:00:00+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2020-06-19T12:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"","date":"2020-06-10T12:00:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0373d4b8-ae76-4a75-afab-2cf6063bc42e","owner":[],"postedDate":"October 17th, 2020","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":739026,"name":"General Surgery"},{"id":739027,"name":"Pediatrics"}],"tags":[],"updatedAt":"2020-10-18T15:02:45+00:00","versionOfRecord":{"articleIdentity":"rs-35680","link":"https://doi.org/10.1186/s12893-020-00906-5","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2020-10-17 12:00:00","publishedOnDateReadable":"October 17th, 2020"},"versionCreatedAt":"2020-10-17 22:47:57","video":"","vorDoi":"10.1186/s12893-020-00906-5","vorDoiUrl":"https://doi.org/10.1186/s12893-020-00906-5","workflowStages":[]},"version":"v4","identity":"rs-35680","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-35680","identity":"rs-35680","version":["v4"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}