Reoperation related to Roux-en-Y jejunal limb after hepaticojejunostomy of Choledochal Cyst

Reoperation related to Roux-en-Y jejunal limb after hepaticojejunostomy of Choledochal Cyst | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Reoperation related to Roux-en-Y jejunal limb after hepaticojejunostomy of Choledochal Cyst Anxiao Ming, Yifeng Shao, Mei Diao, Qi Li, Xu Li, Long Li This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6236745/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Jun, 2025 Read the published version in Pediatric Surgery International → Version 1 posted 9 You are reading this latest preprint version Abstract Objective: To summarize the case data of reoperations related to the Roux-en-Y jejunal limb following hepaticojejunostomy for choledochal cysts at our center, aiming to provide insights into the prevention of adverse events. Method : A retrospective analysis was conducted on 5 cases from April 2019 to October 2024 at our center, in which reoperations were required due to errors or necrosis in the Roux-en-Y jejunal limb following hepaticojejunostomy for choledochal cysts. Among the patients, 4 were female, and 1 was male. Three cases presented with recurrent cholangitis and intestinal dilatation, while 2 cases involved Roux-en-Y jejunal limb necrosis and bile leakage. All patients underwent laparotomy for exploration. Surgical outcomes, operation times, and treatment approaches were summarized, and the duration of hospitalization and postoperative outcomes were also analyzed. Result : In 3 cases with recurrent cholangitis, intraoperative exploration revealed a misconnection in the Roux-en-Y anastomosis, leading to the formation of a jejunal limb from the elevated proximal intestine. Corrective Roux-en-Y hepaticojejunostomy was then performed. Symptoms such as cholangitis and intestinal dilation were completely alleviated postoperatively. In 2 cases with bile leakage, necrotic jejunal limbs were resected, followed by corrective Roux-en-Y hepaticojejunostomy. After reoperation, the bile leakage was resolved, and infection indicators returned to normal. The average postoperative hospital stay was 10.5 ± 5.5 days (range: 5–21 days), with a median follow-up of 12 months (range: 2–53 months). Follow-up results indicated that the patients were in good general condition, with no abnormalities in liver function or infection indicators detected during follow-up. Conclusion: Reoperations due to technical errors or necrosis in Roux-en-Y jejunal limbs are uncommon, but they can be severe and life-threatening. Early diagnosis and timely surgical intervention can effectively relieve symptoms and reduce patient suffering. Preventive measures should be prioritized since adherence to standard procedures can help prevent these complications. Choledochal Cyst Roux-en-Y jejunal limb Erroneous or necrosis Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Roux-en-Y hepaticojejunostomy during definitive surgery for choledochal cysts is performed to reconstruct the extrahepatic biliary tract and facilitate bile drainage. The procedure begins with the identification of Treitz's ligament, followed by transecting the jejunum 5 to 15 cm from its origin. The distal jejunal segment is then elevated 15 to 40 cm to create the Roux-en-Y jejunal limb, which is subsequently anastomosed to the hepatic duct. A side-to-end anastomosis is performed between the distal jejunal loop and the proximal jejunum[1]. Currently, the primary surgical approaches include open and laparoscopic surgery, both of which are relatively complex and associated with significant postoperative complications. Common complications include leakage or stricture of the hepaticojejunal anastomosis, intraoperative and postoperative hemorrhage, pancreatic leakage, and pancreatitis[2]. Reports on reoperations due to Roux-en-Y jejunal limb complications remain rare. Since 2019, our center has managed five pediatric cases requiring reoperation for complications related to the Roux-en-Y jejunal limb following choledochal cyst surgery. These cases involved intricate diagnostic evaluations and therapeutic interventions. To derive meaningful insights and summarize our experiences, we analyzed these cases' clinical characteristics and treatment outcomes. Methods A retrospective analysis was performed on cases treated at our center from April 2019 to October 2024 involving reoperations for complications in the Roux-en-Y jejunal limb following choledochal cyst surgery. The diagnosis of hepaticojejunostomy complications involving the Roux-en-Y jejunal limb was confirmed in all cases based on intraoperative findings. For patients who underwent resection of necrotic intestinal segments, the diagnosis was further confirmed by pathological examination. The study was approved by the Institutional Review Board of the Capital Institute of Pediatrics. Given its retrospective nature, the requirement for informed consent was waived. The data collected during the patients' clinical visits included demographic information, previous symptoms, signs, laboratory test results, previous surgical procedures, and postoperative complications. Symptoms, signs, intraoperative findings, surgical procedures, duration of hospital stay, and follow-up period were also recorded during this visit. Patient data were examined and presented by descriptive statistics. Results Between April 1, 2019, and October 1, 2024, five patients were admitted to our center for reoperation due to complications of the jejunal limb following hepaticojejunostomy, including 4 females and 1 male. One patient was initially admitted for a choledochal cyst and underwent laparoscopic conversion to laparotomy for radical choledochal cystectomy. Four patients had previously undergone suboptimal Roux-en-Y hepaticojejunostomy at other hospitals and were referred to our center with recurrent biliary cholangitis and jejunal limb perforation, where further surgical treatment was performed. Demographic information, previous medical consultations, and outcomes of prior surgeries were compiled for all patients (Table 1). Three patients (cases 1, 2, and 3) were treated for recurrent postoperative cholangitis, which presented with recurrent postoperative fever, elevated infection markers, and liver function abnormalities (Table 2). Despite anti-infective treatment, cholangitis recurred shortly after the discontinuation of antibiotics. The duration of symptoms in the three patients ranged from 3 months to 5 years, during which the children received repeated anti-infective therapy, severely affecting their daily lives. CT imaging revealed dilated intrahepatic bile ducts with pneumobilia and stones (Figures 1, 2, and 4). Case 4 is a 7-year-old female who underwent laparoscopic choledochal cyst excision five years ago. Two months ago, she was admitted for emergency laparotomy due to strangulated intestinal obstruction and septic shock. Intraoperatively, a mesenteric hernia involving the Roux-en-Y jejunal limb was identified, leading to compromised blood flow to the jejunal bile limb due to mesenteric compression. However, resection of the bile limb was not performed at that time. On the third postoperative day, yellow bile-like drainage fluid was observed from the abdominal drain, with an output of approximately 200 mL per day. Case 5 is a female patient who was diagnosed with a choledochal cyst seven months ago and initially underwent biliary external drainage. One month ago, she underwent a laparotomy for choledochal cyst excision. On the fourth postoperative day, she developed abdominal pain and fever. A reoperation revealed a bile leakage at the hepatojejunal anastomosis and perforation of the jejunal bile limb. During the surgery, external drainage was performed, but resection of the necrotic intestinal segment was not done. Postoperatively, the patient developed an abdominal wound infection, bile leakage, intra-abdominal infection, and septic shock. Reoperative exploration revealed that in the first three patients with recurrent cholangitis, the surgeon had mistakenly elevated the proximal intestine to form the limb of hepaticojejunostomy during their previous surgery, and the intestine had been dissected at incorrect locations—50 cm and 100 cm from Treitz's ligament, and 20 cm from the ileum, respectively (Figure 3). During reoperation, the dilated jejunal bile duct was resected, and a correct Roux-en-Y jejunal end-to-end anastomosis, along with a hepaticojejunal anastomosis, was performed. Two patients who developed shock following radical choledochal cyst surgery were found to have necrosis of the Roux-en-Y jejunal limb during the procedure. In case 4, bile leakage caused by mesenteric internal herniation and necrosis of the jejunal limb of hepaticojejunostomy were identified during reoperation. In case 5, reoperation revealed small intestine end-to-side anastomotic leakage, hepaticojejunal anastomotic leakage, and multiple perforations of the jejunal limb of hepaticojejunostomy. In both cases, the original jejunal limb of hepaticojejunostomy measured approximately 50 cm in length. During reoperation, the necrotic portion of the jejunum was resected, and a new jejunal limb of hepaticojejunostomy, about 25 cm in length, was re-established. All five patients recovered well after surgery, with an average postoperative hospital stay of 10.5 days (range: 5–21 days). All children experienced complete resolution of abdominal pain, fever, and shock-related symptoms, with normal laboratory test results at discharge. The postoperative follow-up period ranged from 1 to 53 months, with a median of 12 months. The children recovered well, with no abnormalities observed in liver function or laboratory results. The patients' age at the time of this visit, preoperative laboratory tests, CT findings, and intraoperative findings are summarized in Table 2. Table 1: General Condition of Children at the Time of Radical Surgery and Main Postoperative Symptoms: No. Gender Age at Radical Surgery History of Radical Surgery Postoperative Symptoms Type Age at Diagnosis Cyst Diameter （cm） Surgical Approach Clinical Manifestations Time of symptom onset after surgery Duration of symptoms 1 Female 10 days Type I a Prenatal 5.3 Open Surgery b Fever, abdominal distension, elevated transaminases 17 days 5 years 2 Female 7 months Type I Prenatal 4.9 Laparoscopic Surgery 3 days 7 months 3 Male 5 years 10 months Type IV 5 years 8 months 1.2 Conversion from Laparoscopic to Open Surgery 2 days 3 months 4 Female 2 years 8 months Type I 2 years 7 months 4.3 Laparoscopic Surgery Bile leakage, intra-abdominal infection 5 years 2 months 5 Female 4 years 2 months Type IV 2 years 7 months 10.2 Open Surgery 4 days 1 month a, Associated with malrotation of the intestine; b, Simultaneously underwent corrective surgery for intestinal malrotation. Table 2: Condition of Children and Surgical Findings at the Time of Reoperation: No. Age Imaging findings Laboratory tests Intraoperative findings WBC (*109 /L) CRP (mg/L) ALT (U/L) AST (U/L) GGT (U/L) Observations The length of the Roux-en-Y jejunal limb（cm） Position of the ileo-ileal anastomosis 1 5 years and 4 months Intrahepatic bile duct dilation with pneumobilia, and dilated bowel at the hepatic hilum 15.84↑ 80.2↑ 6.2 11.7 21.8 elevated the proximal intestine to form the limb of hepaticojejunostomy，dilatation of the Roux-en-Y jejunal limb with accumulation of intestinal contents 30 50 cm from the beginning of the jejunum 2 1 year and 2 months 16.8↑ 74↑ 59.3 72.8 397 30 25 cm from the ileocecum 3 6 years and 1 month 12.2↑ 11.8↑ 7.8 8.1 54 30 100 cm from the beginning of the jejunum 4 7 years and 10 months irregular low-density shadow in the right upper abdomen 4.8 32↑ 17.6 27.6 49 Necrosis of the distal Roux-en-Y jejunal limb with bile-enteric anastomosis leakage 50 50 cm from the beginning of the jejunum 5 4 years and 3 months 10.8↑ 31↑ 25.7 43.4 112.7 Multiple necrotic perforations of the Roux-en-Y jejunal limb with bile-enteric and enteric-enteric anastomotic leakage 50 50 cm from the beginning of the jejunum WBC, White Blood Cell Count; CRP, C-Reactive Protein; ALT, Alanine Aminotransferase; AST, Aspartate Aminotransferase; GGT, Gamma-Glutamyl Transferase ↑ indicators elevated Discussion The key to performing a jejunal Roux-en-Y anastomosis lies in accurately identifying the starting point of the jejunum. After transecting the jejunum, the distal segment is elevated to form the Roux-en-Y jejunal limb. Elevating the proximal segment instead of the distal one as the Roux-en-Y jejunal limb may lead to retrograde peristalsis in the jejunal limb. This can cause intrahepatic stasis of intestinal contents, impaired bile drainage, recurrent cholangitis, intrahepatic bile duct dilation, pneumobilia, and the accumulation of bile sludge or food debris in the hepatic hilum and intrahepatic bile ducts. Clinically, the affected child may present with recurrent fever, poor appetite, and other symptoms that significantly compromise their health and growth. In this report, the first three cases of postoperative recurrent cholangitis were attributed to the inadvertent elevation of the proximal intestinal segment, which incorrectly formed the Roux-en-Y jejunal limb. However, the site of intestinal transection varied among the patients: in two cases, it occurred 50 cm and 100 cm from the jejunal origin, while in the third case, it was 20 cm from the cecum. The clinical presentations were similar across all patients: 1) High fever, elevated infection markers, and other signs of cholangitis developed shortly after surgery. 2) Initial fasting and anti-infective treatment provided temporary relief, but symptoms recurred rapidly once medication was discontinued. Imaging studies consistently revealed: 1) Intrahepatic bile duct dilation accompanied by pneumobilia. 2) Cholesterol-like stones and food residue accumulation in the hepatic hilum and intrahepatic bile ducts. 3) Dilation of the jejunal bile limb at the hepatic hilum or extensive intestinal loop dilation within the abdominal cavity. These imaging patterns are relatively rare following choledochal cyst surgery. When such findings arise, the possibility of misdirection of the Roux-en-Y jejunal limb should be carefully considered. Although the clinical symptoms were evident, many doctors lacked sufficient experience with this postoperative complication, leading to delays in diagnosis and treatment. In all three cases, the issue was only identified during intraoperative exploration, as a definitive diagnosis had not been established preoperatively. The treatment process was complex and caused significant distress to the patients. The intervals between corrective surgery and the initial procedure were 5 years, 14 months, and 3 months, respectively. However, after proper reconstruction of the Roux-en-Y jejunal anastomosis, symptoms rapidly resolved. To prevent these complications, strict adherence to standardized surgical procedures is essential, particularly in accurately identifying the jejunal starting point. Whether performing open or laparoscopic surgery, confirming the location of Treitz's ligament is crucial. Before transecting the jejunum, both the direction and length of the proximal intestinal segment must be carefully verified. In special cases, such as those involving intestinal malrotation, a Ladd procedure should be performed first. The jejunal origin should then be determined based on the duodenal configuration. In open surgery, performing the jejunal Roux-en-Y anastomosis under direct visualization significantly reduces the risk of errors. In laparoscopic procedures, most surgeons prefer to first identify the jejunal origin, then exteriorize the jejunum through the umbilicus to complete the Roux-en-Y anastomosis. During this process, it is crucial to mark and differentiate the proximal and distal ends of the jejunum to ensure proper orientation[ 3 ]. Regardless of whether the procedure is performed via open or laparoscopic surgery, it is essential to re-evaluate the jejunal origin and configuration after completing the anastomosis. Only after confirming its accuracy should the hepaticojejunostomy be performed. Based on our experience, most cases of perforated choledochal cysts do not lead to severe intestinal adhesions, allowing definitive surgery to be performed typically within 1 to 2 weeks after external cyst drainage. In the third case of this report, the patient underwent surgery at our hospital. During the initial exploration procedure, extensive upper abdominal adhesions were observed, significantly complicating exposure of the common bile duct. The adhesions were widespread, with areas of saponification necrosis caused by pancreatic fluid erosion. This was likely due to pancreatic fluid refluxing into the common bile duct through the pancreaticobiliary junction and subsequently leaking into the abdominal cavity through the perforation. Definitive surgery was performed nine days after drainage. However, due to the short drainage period, intra-abdominal adhesions had not sufficiently resolved. Attempts to separate these adhesions during surgery were unsuccessful, leading to postoperative complications. Therefore, when severe intra-abdominal adhesions are encountered during exploration, initial external drainage via the gallbladder or common bile duct should be considered. In cases where protein plugs obstruct the common channel, endoscopic retrograde cholangiopancreatography (ERCP) can be used to clear the obstruction, ensuring smooth bile and pancreatic fluid drainage. Treatment should then continue for at least three months to allow the adhesions to subside before performing definitive surgery. This approach helps prevent complications arising from the inability to effectively separate bowel adhesions. In this study, two patients developed necrosis of the Roux-en-Y jejunal limb, leading to bile leakage. In the first case, internal herniation through a mesenteric defect resulted in distal jejunal segment necrosis and subsequent bile leakage following Roux-en-Y hepaticojejunostomy. In the second case, improper handling of the mesentery of the Roux-en-Y limb caused ischemia and necrosis, leading to bile leakage at both the biliary-enteric and enteric-enteric anastomoses. During re-exploration, the necrotic segment was not excised, and the bowel was not properly anastomosed, contributing to further complications. Internal herniation through a mesenteric rent after choledochal cyst is rare but highly risky. Delayed surgery can result in life-threatening intestinal necrosis[ 4 , 5 ]. Postoperative mesenteric defects can be classified into two types:1.Mesenteric defect between the proximal jejunal mesentery and the Roux-en-Y jejunal limb: This defect occurs at the junction where the bile limb diverges from the starting portion of the jejunum, creating a defect between the proximal jejunal mesentery and the mesentery of the bile limb; 2.Mesenteric Defect between the Roux-en-Y Jejunal Limb and the transverse colon mesentery: This defect occurs when the Roux-en-Y jejunal limb passes through the mesentery of the transverse colon. If the opening in the transverse colon mesentery is excessively widened during the formation of the retrocolic tunnel, it can create a large mesenteric defect. Such defects may allow small bowel loops to herniate above the transverse colon, leading to a mesenteric hernia[ 6 ]. Proper surgical handling is crucial, including the precise closure of mesenteric defects and minimizing the size of openings in the transverse colon mesentery. These measures are essential to reduce the risk of mesenteric hernias and their associated complications[ 7 ]. The incidence of cholangitis following surgery for choledochal cysts is relatively low, primarily due to anastomotic stenosis and poor bile drainage resulting from the dilation of the intrahepatic bile ducts. Research indicates that postoperative cholangitis is not caused by the reflux of intestinal contents[ 8 ]. As a result, an increasing number of medical centers are adopting the use of a short Roux-en-Y jejunal limb during surgery for choledochal cysts in children[ 9 , 10 ]. Utilizing a short Roux-en-Y jejunal limb can also help reduce the risk of intestinal torsion associated with excessive intestinal length. A shorter Roux-en-Y jejunal limb reduces the risk of intestinal volvulus and minimizes extensive mesenteric dissection and vessel ligation. This creates a smaller mesenteric defect, making closure easier and lowering the risk of herniation. In the last two cases, the Roux-en-Y limb was initially 50 cm long. Excessive limb length complicates mesenteric handling and may compromise blood supply to the intestinal segment. In practice, our center utilizes a personalized short Roux-en-Y jejunal limb. After performing the intestinal anastomosis extracorporeally, we carefully close the mesenteric defect between the proximal jejunal loop and the Roux-en-Y jejunal limb. Additionally, we recommend that the anastomosis site not be positioned too far from the jejunal origin. At our center, a limb length of 5–10 cm is used. A longer proximal jejunal segment may complicate the identification of the correct intestinal orientation or result in a larger mesenteric defect, which is more challenging to close completely. Reoperations due to errors or necrosis in Roux-en-Y jejunal limbs are rare but can be severe and life-threatening. Early diagnosis and prompt surgical intervention can quickly alleviate symptoms and significantly reduce patient suffering. Preventive measures should be prioritized, as adhering to standard procedures can help avoid these complications. Declarations Author Contribution AM and YS: Data acquisition; AM: Drafting of manuscript; YS: Analysis and data interpretation,visualization; QL and XL:writing – review & editing; MD and LL: Critical revision of manuscript.All authors reviewed the manuscript.AM and YS contributed equally to this work and should be considered co-first authors.MD and LL contributed equally to this work and should be considered co-corresponding authors. Data Availability The data generated and/or analyzed in this study are not open to the public to safeguard individual privacy but are available from the corresponding author on reasonable request. Fund program: Research Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment, Chinese Academy of Medical Sciences（2021RU015） References Cazares, J., H. Koga and A. Yamataka, Choledochal cyst. Pediatr Surg Int, 2023. 39(1): p. 209. Zheng, J., et al., Short-Term Complications After Laparoscopic Choledochal Cyst Radical Surgery: Prevention and Treatment. Front Surg, 2020. 7: p. 583210. Diao, M., L. Li and W. Cheng, Role of laparoscopy in treatment of choledochal cysts in children. Pediatr Surg Int, 2013. 29(4): p. 317-26. Bedda, S., et al., [Internal herniation through a mesenteric defect after Roux-en-Y anastomosis]. Ann Chir, 2006. 131(1): p. 45-7. Kawakami, M., et al., Obstructive jaundice due to internal herniation: a case report and review of the literature. Hepatogastroenterology, 2002. 49(46): p. 1030-2. Xu, Z. and W. Guo, [Clinical research progress of mesenteric internal hernia after Roux-en-Y reconstruction]. Zhonghua Wei Chang Wai Ke Za Zhi, 2017. 20(3): p. 352-356. Vuagniaux, A., et al., Meticulous Closure of Mesenteric Defects Effectively Reduces the Incidence of Internal Hernia After Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg, 2024. 34(8): p. 2806-2813. Felder, S.I., et al., Hepaticojejunostomy using short-limb Roux-en-Y reconstruction. JAMA Surg, 2013. 148(3): p. 253-7; discussion 257-8. Yamataka, A., et al., Recommendations for preventing complications related to Roux-en-Y hepatico-jejunostomy performed during excision of choledochal cyst in children. J Pediatr Surg, 2003. 38(12): p. 1830-2. Diao, M., et al., 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(4): p. 845-7. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 12 Jun, 2025 Read the published version in Pediatric Surgery International → Version 1 posted Editorial decision: Revision requested 11 May, 2025 Reviews received at journal 20 Apr, 2025 Reviews received at journal 10 Apr, 2025 Reviewers agreed at journal 08 Apr, 2025 Reviewers agreed at journal 01 Apr, 2025 Reviewers invited by journal 29 Mar, 2025 Editor assigned by journal 18 Mar, 2025 Submission checks completed at journal 17 Mar, 2025 First submitted to journal 16 Mar, 2025 You are reading this latest preprint version 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. 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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-6236745","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":441150730,"identity":"327eb44b-ac0f-4388-ba29-f7b48937f3ff","order_by":0,"name":"Anxiao Ming","email":"","orcid":"","institution":"Capital Institute of Pediatrics, Chinese Academy of Medical Sciences （2021RU015）","correspondingAuthor":false,"prefix":"","firstName":"Anxiao","middleName":"","lastName":"Ming","suffix":""},{"id":441150731,"identity":"e8bfd01a-046c-4ed0-8513-593dbb4d8a33","order_by":1,"name":"Yifeng Shao","email":"","orcid":"","institution":"Capital 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09:08:18","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":64799,"visible":true,"origin":"","legend":"\u003cp\u003eCase 2, CT showed dilatation of intrahepatic bile ducts with pneumobilia (A) and dilated bowel in the right upper abdomen (B).\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6236745/v1/044c30ad50a73ddf559e9c3a.jpeg"},{"id":81017122,"identity":"c016ae59-710e-4f77-876f-031e7cd3671c","added_by":"auto","created_at":"2025-04-21 09:08:19","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":81708,"visible":true,"origin":"","legend":"\u003cp\u003eCase 3, CT shows dilatation of intrahepatic bile ducts with pneumobilia (A) and dilated bowel in the right upper abdomen (B).\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6236745/v1/d60683a013b09a404d8f799f.jpeg"},{"id":81017109,"identity":"a026e26e-2454-4357-9fc5-f1f2f846269e","added_by":"auto","created_at":"2025-04-21 09:08:18","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":251510,"visible":true,"origin":"","legend":"\u003cp\u003eCase 2,the ileum was severed 25 cm from the ileocecum, and the proximal intestine was lifted 30 cm to form the jejunal limb of hepaticojejunostomy. The jejunal limb of hepaticojejunostomy (1) and ileocecum (2) are shown.\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-6236745/v1/0ec53851975ceb1ce7a4b694.png"},{"id":84726835,"identity":"069cd56e-252e-40a8-a23b-50d3f271e3fc","added_by":"auto","created_at":"2025-06-16 16:08:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":929533,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6236745/v1/fdc8a4bf-1d74-49cb-8843-e6780a1cd0fc.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Reoperation related to Roux-en-Y jejunal limb after hepaticojejunostomy of Choledochal Cyst","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRoux-en-Y hepaticojejunostomy during definitive surgery for choledochal cysts is performed to reconstruct the extrahepatic biliary tract and facilitate bile drainage. The procedure begins with the identification of Treitz\u0026apos;s ligament, followed by transecting the jejunum 5 to 15 cm from its origin. The distal jejunal segment is then elevated 15 to 40 cm to create the Roux-en-Y jejunal limb, which is subsequently anastomosed to the hepatic duct. A side-to-end anastomosis is performed between the distal jejunal loop and the proximal jejunum[1].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCurrently, the primary surgical approaches include open and laparoscopic surgery, both of which are relatively complex and associated with significant postoperative complications. Common complications include leakage or stricture of the hepaticojejunal anastomosis, intraoperative and postoperative hemorrhage, pancreatic leakage, and pancreatitis[2]. Reports on reoperations due to Roux-en-Y jejunal limb complications remain rare. Since 2019, our center has managed five pediatric cases requiring reoperation for complications related to the Roux-en-Y jejunal limb following choledochal cyst surgery. These cases involved intricate diagnostic evaluations and therapeutic interventions. To derive meaningful insights and summarize our experiences, we analyzed these cases\u0026apos; clinical characteristics and treatment outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eA retrospective analysis was performed on cases treated at our center from April 2019 to October 2024 involving reoperations for complications in the Roux-en-Y jejunal limb following choledochal cyst surgery.\u003c/p\u003e\n\u003cp\u003eThe diagnosis of hepaticojejunostomy complications involving the Roux-en-Y jejunal limb was confirmed in all cases based on intraoperative findings. For patients who underwent resection of necrotic intestinal segments, the diagnosis was further confirmed by pathological examination.\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Institutional Review Board of the Capital Institute of Pediatrics. Given its retrospective nature, the requirement for informed consent was waived. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe data collected during the patients\u0026apos; clinical visits included demographic information, previous symptoms, signs, laboratory test results, previous surgical procedures, and postoperative complications. Symptoms, signs, intraoperative findings, surgical procedures, duration of hospital stay, and follow-up period were also recorded during this visit.\u003c/p\u003e\n\u003cp\u003ePatient data were examined and presented by descriptive statistics.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eBetween April 1, 2019, and October 1, 2024, five patients were admitted to our center for reoperation due to complications of the jejunal limb following hepaticojejunostomy, including 4 females and 1 male. One patient was initially admitted for a choledochal cyst and underwent laparoscopic conversion to laparotomy for radical choledochal cystectomy. Four patients had previously undergone suboptimal Roux-en-Y hepaticojejunostomy at other hospitals and were referred to our center with recurrent biliary cholangitis and jejunal limb perforation, where further surgical treatment was performed.\u003c/p\u003e\n\u003cp\u003eDemographic information, previous medical consultations, and outcomes of prior surgeries were compiled for all patients (Table 1).\u003c/p\u003e\n\u003cp\u003eThree patients (cases 1, 2, and 3) were treated for recurrent postoperative cholangitis, which presented with recurrent postoperative fever, elevated infection markers, and liver function abnormalities (Table 2). Despite anti-infective treatment, cholangitis recurred shortly after the discontinuation of antibiotics. The duration of symptoms in the three patients ranged from 3 months to 5 years, during which the children received repeated anti-infective therapy, severely affecting their daily lives. CT imaging revealed dilated intrahepatic bile ducts with pneumobilia and stones (Figures 1, 2, and 4).\u003c/p\u003e\n\u003cp\u003eCase 4 is a 7-year-old female who underwent laparoscopic choledochal cyst excision five years ago. Two months ago, she was admitted for emergency laparotomy due to strangulated intestinal obstruction and septic shock. Intraoperatively, a mesenteric hernia involving the Roux-en-Y jejunal limb was identified, leading to compromised blood flow to the jejunal bile limb due to mesenteric compression. However, resection of the bile limb was not performed at that time. On the third postoperative day, yellow bile-like drainage fluid was observed from the abdominal drain, with an output of approximately 200 mL per day.\u003c/p\u003e\n\u003cp\u003eCase 5 is a female patient who was diagnosed with a choledochal cyst seven months ago and initially underwent biliary external drainage. One month ago, she underwent a laparotomy for choledochal cyst excision. On the fourth postoperative day, she developed abdominal pain and fever. A reoperation revealed a bile leakage at the hepatojejunal anastomosis and perforation of the jejunal bile limb. During the surgery, external drainage was performed, but resection of the necrotic intestinal segment was not done. Postoperatively, the patient developed an abdominal wound infection, bile leakage, intra-abdominal infection, and septic shock.\u003c/p\u003e\n\u003cp\u003eReoperative exploration revealed that in the first three patients with recurrent cholangitis, the surgeon had mistakenly elevated the proximal intestine to form the limb of hepaticojejunostomy during their previous surgery, and the intestine had been dissected at incorrect locations\u0026mdash;50 cm and 100 cm from Treitz\u0026apos;s ligament, and 20 cm from the ileum, respectively (Figure 3). During reoperation, the dilated jejunal bile duct was resected, and a correct Roux-en-Y jejunal end-to-end anastomosis, along with a hepaticojejunal anastomosis, was performed.\u003c/p\u003e\n\u003cp\u003eTwo patients who developed shock following radical choledochal cyst surgery were found to have necrosis of the Roux-en-Y jejunal limb during the procedure.\u003c/p\u003e\n\u003cp\u003eIn case 4, bile leakage caused by mesenteric internal herniation and necrosis of the jejunal limb of hepaticojejunostomy were identified during reoperation. In case 5, reoperation revealed small intestine end-to-side anastomotic leakage, hepaticojejunal anastomotic leakage, and multiple perforations of the jejunal limb of hepaticojejunostomy. In both cases, the original jejunal limb of hepaticojejunostomy measured approximately 50 cm in length. During reoperation, the necrotic portion of the jejunum was resected, and a new jejunal limb of hepaticojejunostomy, about 25 cm in length, was re-established.\u003c/p\u003e\n\u003cp\u003eAll five patients recovered well after surgery, with an average postoperative hospital stay of 10.5 days (range: 5\u0026ndash;21 days). All children experienced complete resolution of abdominal pain, fever, and shock-related symptoms, with normal laboratory test results at discharge.\u003c/p\u003e\n\u003cp\u003eThe postoperative follow-up period ranged from 1 to 53 months, with a median of 12 months. The children recovered well, with no abnormalities observed in liver function or laboratory results.\u003c/p\u003e\n\u003cp\u003eThe patients\u0026apos; age at the time of this visit, preoperative laboratory tests, CT findings, and intraoperative findings are summarized in Table 2.\u003c/p\u003e\n\u003cp\u003eTable 1: General Condition of Children at the Time of Radical Surgery and Main Postoperative Symptoms:\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"652\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eAge at Radical Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"4\"\u003e\n \u003cp\u003eHistory of Radical Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003ePostoperative Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 34px;\"\u003e\n \u003cp\u003eType\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 59px;\"\u003e\n \u003cp\u003eAge at Diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 54px;\"\u003e\n \u003cp\u003eCyst Diameter （cm）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 74px;\"\u003e\n \u003cp\u003eSurgical Approach\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 84px;\"\u003e\n \u003cp\u003eClinical Manifestations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 137px;\"\u003e\n \u003cp\u003eTime of symptom onset after surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003eDuration of symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eType I\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePrenatal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eOpen Surgery\u003csup\u003e\u0026nbsp;b\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003eFever, abdominal distension, elevated transaminases\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eType I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePrenatal\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLaparoscopic Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e7 months\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 years 10 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eType IV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 years 8 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eConversion from Laparoscopic to Open Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 years 8 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eType I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 years 7 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLaparoscopic Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eBile leakage, intra-abdominal infection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e2 months\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 years 2 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eType IV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2 years 7 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e10.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eOpen Surgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1 month\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003ea, Associated with malrotation of the intestine; b, Simultaneously underwent corrective surgery for intestinal malrotation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTable 2: Condition of Children and Surgical Findings at the Time of Reoperation:\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"918\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" style=\"width: 46px;\"\u003e\n \u003cp\u003eNo.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 69px;\"\u003e\n \u003cp\u003eAge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 116px;\"\u003e\n \u003cp\u003eImaging findings\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"5\" style=\"width: 315px;\"\u003e\n \u003cp\u003eLaboratory tests\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 372px;\"\u003e\n \u003cp\u003eIntraoperative findings\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003eWBC\u003c/p\u003e\n \u003cp\u003e(*109 /L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003eCRP\u003c/p\u003e\n \u003cp\u003e(mg/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003eALT\u003c/p\u003e\n \u003cp\u003e(U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003eAST\u003c/p\u003e\n \u003cp\u003e(U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003eGGT\u003c/p\u003e\n \u003cp\u003e(U/L)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 186px;\"\u003e\n \u003cp\u003eObservations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 77px;\"\u003e\n \u003cp\u003eThe length of the Roux-en-Y jejunal limb（cm）\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003ePosition of the ileo-ileal anastomosis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e5 years and 4 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 116px;\"\u003e\n \u003cp\u003eIntrahepatic bile duct dilation with pneumobilia, and dilated bowel at the hepatic hilum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e15.84\u0026uarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e80.2\u0026uarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e6.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e11.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e21.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 186px;\"\u003e\n \u003cp\u003eelevated the proximal intestine to form the limb of hepaticojejunostomy，dilatation of the Roux-en-Y jejunal limb with accumulation of intestinal contents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e50 cm from the beginning of the jejunum\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e1 year and 2 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e16.8\u0026uarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e74\u0026uarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e59.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e72.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e397\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e25 cm from the ileocecum\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e6 years and 1 month\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e12.2\u0026uarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e11.8\u0026uarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e7.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e8.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e100 cm from the beginning of the jejunum\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e7 years and 10 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" style=\"width: 116px;\"\u003e\n \u003cp\u003eirregular low-density shadow in the right upper abdomen\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e4.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e32\u0026uarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e17.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e27.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 186px;\"\u003e\n \u003cp\u003eNecrosis of the distal Roux-en-Y jejunal limb with bile-enteric anastomosis leakage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e50 cm from the beginning of the jejunum\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e4 years and 3 months\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e10.8\u0026uarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 69px;\"\u003e\n \u003cp\u003e31\u0026uarr;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e25.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 61px;\"\u003e\n \u003cp\u003e43.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e112.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 186px;\"\u003e\n \u003cp\u003eMultiple necrotic perforations of the Roux-en-Y jejunal limb with bile-enteric and enteric-enteric anastomotic leakage\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 77px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 108px;\"\u003e\n \u003cp\u003e50 cm from the beginning of the jejunum\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eWBC, White Blood Cell Count; CRP, C-Reactive Protein; ALT, Alanine Aminotransferase; AST, Aspartate Aminotransferase; GGT, Gamma-Glutamyl Transferase\u003c/p\u003e\n\u003cp\u003e\u0026uarr; indicators elevated\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe key to performing a jejunal Roux-en-Y anastomosis lies in accurately identifying the starting point of the jejunum. After transecting the jejunum, the distal segment is elevated to form the Roux-en-Y jejunal limb. Elevating the proximal segment instead of the distal one as the Roux-en-Y jejunal limb may lead to retrograde peristalsis in the jejunal limb. This can cause intrahepatic stasis of intestinal contents, impaired bile drainage, recurrent cholangitis, intrahepatic bile duct dilation, pneumobilia, and the accumulation of bile sludge or food debris in the hepatic hilum and intrahepatic bile ducts. Clinically, the affected child may present with recurrent fever, poor appetite, and other symptoms that significantly compromise their health and growth.\u003c/p\u003e \u003cp\u003eIn this report, the first three cases of postoperative recurrent cholangitis were attributed to the inadvertent elevation of the proximal intestinal segment, which incorrectly formed the Roux-en-Y jejunal limb. However, the site of intestinal transection varied among the patients: in two cases, it occurred 50 cm and 100 cm from the jejunal origin, while in the third case, it was 20 cm from the cecum.\u003c/p\u003e \u003cp\u003eThe clinical presentations were similar across all patients: 1) High fever, elevated infection markers, and other signs of cholangitis developed shortly after surgery. 2) Initial fasting and anti-infective treatment provided temporary relief, but symptoms recurred rapidly once medication was discontinued.\u003c/p\u003e \u003cp\u003eImaging studies consistently revealed: 1) Intrahepatic bile duct dilation accompanied by pneumobilia. 2) Cholesterol-like stones and food residue accumulation in the hepatic hilum and intrahepatic bile ducts. 3) Dilation of the jejunal bile limb at the hepatic hilum or extensive intestinal loop dilation within the abdominal cavity. These imaging patterns are relatively rare following choledochal cyst surgery. When such findings arise, the possibility of misdirection of the Roux-en-Y jejunal limb should be carefully considered.\u003c/p\u003e \u003cp\u003eAlthough the clinical symptoms were evident, many doctors lacked sufficient experience with this postoperative complication, leading to delays in diagnosis and treatment. In all three cases, the issue was only identified during intraoperative exploration, as a definitive diagnosis had not been established preoperatively. The treatment process was complex and caused significant distress to the patients. The intervals between corrective surgery and the initial procedure were 5 years, 14 months, and 3 months, respectively. However, after proper reconstruction of the Roux-en-Y jejunal anastomosis, symptoms rapidly resolved.\u003c/p\u003e \u003cp\u003eTo prevent these complications, strict adherence to standardized surgical procedures is essential, particularly in accurately identifying the jejunal starting point. Whether performing open or laparoscopic surgery, confirming the location of Treitz's ligament is crucial. Before transecting the jejunum, both the direction and length of the proximal intestinal segment must be carefully verified. In special cases, such as those involving intestinal malrotation, a Ladd procedure should be performed first. The jejunal origin should then be determined based on the duodenal configuration.\u003c/p\u003e \u003cp\u003eIn open surgery, performing the jejunal Roux-en-Y anastomosis under direct visualization significantly reduces the risk of errors. In laparoscopic procedures, most surgeons prefer to first identify the jejunal origin, then exteriorize the jejunum through the umbilicus to complete the Roux-en-Y anastomosis. During this process, it is crucial to mark and differentiate the proximal and distal ends of the jejunum to ensure proper orientation[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegardless of whether the procedure is performed via open or laparoscopic surgery, it is essential to re-evaluate the jejunal origin and configuration after completing the anastomosis. Only after confirming its accuracy should the hepaticojejunostomy be performed.\u003c/p\u003e \u003cp\u003eBased on our experience, most cases of perforated choledochal cysts do not lead to severe intestinal adhesions, allowing definitive surgery to be performed typically within 1 to 2 weeks after external cyst drainage. In the third case of this report, the patient underwent surgery at our hospital. During the initial exploration procedure, extensive upper abdominal adhesions were observed, significantly complicating exposure of the common bile duct. The adhesions were widespread, with areas of saponification necrosis caused by pancreatic fluid erosion. This was likely due to pancreatic fluid refluxing into the common bile duct through the pancreaticobiliary junction and subsequently leaking into the abdominal cavity through the perforation.\u003c/p\u003e \u003cp\u003eDefinitive surgery was performed nine days after drainage. However, due to the short drainage period, intra-abdominal adhesions had not sufficiently resolved. Attempts to separate these adhesions during surgery were unsuccessful, leading to postoperative complications. Therefore, when severe intra-abdominal adhesions are encountered during exploration, initial external drainage via the gallbladder or common bile duct should be considered. In cases where protein plugs obstruct the common channel, endoscopic retrograde cholangiopancreatography (ERCP) can be used to clear the obstruction, ensuring smooth bile and pancreatic fluid drainage. Treatment should then continue for at least three months to allow the adhesions to subside before performing definitive surgery. This approach helps prevent complications arising from the inability to effectively separate bowel adhesions.\u003c/p\u003e \u003cp\u003eIn this study, two patients developed necrosis of the Roux-en-Y jejunal limb, leading to bile leakage. In the first case, internal herniation through a mesenteric defect resulted in distal jejunal segment necrosis and subsequent bile leakage following Roux-en-Y hepaticojejunostomy. In the second case, improper handling of the mesentery of the Roux-en-Y limb caused ischemia and necrosis, leading to bile leakage at both the biliary-enteric and enteric-enteric anastomoses. During re-exploration, the necrotic segment was not excised, and the bowel was not properly anastomosed, contributing to further complications.\u003c/p\u003e \u003cp\u003eInternal herniation through a mesenteric rent after choledochal cyst is rare but highly risky. Delayed surgery can result in life-threatening intestinal necrosis[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Postoperative mesenteric defects can be classified into two types:1.Mesenteric defect between the proximal jejunal mesentery and the Roux-en-Y jejunal limb: This defect occurs at the junction where the bile limb diverges from the starting portion of the jejunum, creating a defect between the proximal jejunal mesentery and the mesentery of the bile limb; 2.Mesenteric Defect between the Roux-en-Y Jejunal Limb and the transverse colon mesentery: This defect occurs when the Roux-en-Y jejunal limb passes through the mesentery of the transverse colon. If the opening in the transverse colon mesentery is excessively widened during the formation of the retrocolic tunnel, it can create a large mesenteric defect. Such defects may allow small bowel loops to herniate above the transverse colon, leading to a mesenteric hernia[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eProper surgical handling is crucial, including the precise closure of mesenteric defects and minimizing the size of openings in the transverse colon mesentery. These measures are essential to reduce the risk of mesenteric hernias and their associated complications[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe incidence of cholangitis following surgery for choledochal cysts is relatively low, primarily due to anastomotic stenosis and poor bile drainage resulting from the dilation of the intrahepatic bile ducts. Research indicates that postoperative cholangitis is not caused by the reflux of intestinal contents[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. As a result, an increasing number of medical centers are adopting the use of a short Roux-en-Y jejunal limb during surgery for choledochal cysts in children[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Utilizing a short Roux-en-Y jejunal limb can also help reduce the risk of intestinal torsion associated with excessive intestinal length.\u003c/p\u003e \u003cp\u003eA shorter Roux-en-Y jejunal limb reduces the risk of intestinal volvulus and minimizes extensive mesenteric dissection and vessel ligation. This creates a smaller mesenteric defect, making closure easier and lowering the risk of herniation. In the last two cases, the Roux-en-Y limb was initially 50 cm long. Excessive limb length complicates mesenteric handling and may compromise blood supply to the intestinal segment.\u003c/p\u003e \u003cp\u003eIn practice, our center utilizes a personalized short Roux-en-Y jejunal limb. After performing the intestinal anastomosis extracorporeally, we carefully close the mesenteric defect between the proximal jejunal loop and the Roux-en-Y jejunal limb. Additionally, we recommend that the anastomosis site not be positioned too far from the jejunal origin. At our center, a limb length of 5\u0026ndash;10 cm is used. A longer proximal jejunal segment may complicate the identification of the correct intestinal orientation or result in a larger mesenteric defect, which is more challenging to close completely.\u003c/p\u003e \u003cp\u003eReoperations due to errors or necrosis in Roux-en-Y jejunal limbs are rare but can be severe and life-threatening. Early diagnosis and prompt surgical intervention can quickly alleviate symptoms and significantly reduce patient suffering. Preventive measures should be prioritized, as adhering to standard procedures can help avoid these complications.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAM and YS: Data acquisition; AM: Drafting of manuscript; YS: Analysis and data interpretation,visualization; QL and XL:writing \u0026ndash; review \u0026amp; editing; MD and LL: Critical revision of manuscript.All authors reviewed the manuscript.AM and YS contributed equally to this work and should be considered co-first authors.MD and LL contributed equally to this work and should be considered co-corresponding authors.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data generated and/or analyzed in this study are not open to the public to safeguard individual privacy but are available from the corresponding author on reasonable request.\u003c/p\u003e\u003ch2\u003eFund program:\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eResearch Unit of Minimally Invasive Pediatric Surgery on Diagnosis and Treatment, Chinese Academy of Medical Sciences（2021RU015）\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCazares, J., H. Koga and A. Yamataka, Choledochal cyst. Pediatr Surg Int, 2023. 39(1): p. 209.\u003c/li\u003e\n\u003cli\u003eZheng, J., et al., Short-Term Complications After Laparoscopic Choledochal Cyst Radical Surgery: Prevention and Treatment. Front Surg, 2020. 7: p. 583210.\u003c/li\u003e\n\u003cli\u003eDiao, M., L. Li and W. Cheng, Role of laparoscopy in treatment of choledochal cysts in children. Pediatr Surg Int, 2013. 29(4): p. 317-26.\u003c/li\u003e\n\u003cli\u003eBedda, S., et al., [Internal herniation through a mesenteric defect after Roux-en-Y anastomosis]. Ann Chir, 2006. 131(1): p. 45-7.\u003c/li\u003e\n\u003cli\u003eKawakami, M., et al., Obstructive jaundice due to internal herniation: a case report and review of the literature. Hepatogastroenterology, 2002. 49(46): p. 1030-2.\u003c/li\u003e\n\u003cli\u003eXu, Z. and W. Guo, [Clinical research progress of mesenteric internal hernia after Roux-en-Y reconstruction]. Zhonghua Wei Chang Wai Ke Za Zhi, 2017. 20(3): p. 352-356.\u003c/li\u003e\n\u003cli\u003eVuagniaux, A., et al., Meticulous Closure of Mesenteric Defects Effectively Reduces the Incidence of Internal Hernia After Laparoscopic Roux-en-Y Gastric Bypass. Obes Surg, 2024. 34(8): p. 2806-2813.\u003c/li\u003e\n\u003cli\u003eFelder, S.I., et al., Hepaticojejunostomy using short-limb Roux-en-Y reconstruction. JAMA Surg, 2013. 148(3): p. 253-7; discussion 257-8.\u003c/li\u003e\n\u003cli\u003eYamataka, A., et al., Recommendations for preventing complications related to Roux-en-Y hepatico-jejunostomy performed during excision of choledochal cyst in children. J Pediatr Surg, 2003. 38(12): p. 1830-2.\u003c/li\u003e\n\u003cli\u003eDiao, M., et al., 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(4): p. 845-7.\u003c/li\u003e\n\u003c/ol\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":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Choledochal Cyst, Roux-en-Y jejunal limb, Erroneous or necrosis","lastPublishedDoi":"10.21203/rs.3.rs-6236745/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6236745/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eTo summarize the case data of reoperations related to the Roux-en-Y jejunal limb following hepaticojejunostomy for choledochal cysts at our center, aiming to provide insights into the prevention of adverse events.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e: A retrospective analysis was conducted on 5 cases from April 2019 to October 2024 at our center, in which reoperations were required due to errors or necrosis in the Roux-en-Y jejunal limb following hepaticojejunostomy for choledochal cysts. Among the patients, 4 were female, and 1 was male. Three cases presented with recurrent cholangitis and intestinal dilatation, while 2 cases involved Roux-en-Y jejunal limb necrosis and bile leakage. All patients underwent laparotomy for exploration. Surgical outcomes, operation times, and treatment approaches were summarized, and the duration of hospitalization and postoperative outcomes were also analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResult\u003c/strong\u003e: In 3 cases with recurrent cholangitis, intraoperative exploration revealed a misconnection in the Roux-en-Y anastomosis, leading to the formation of a jejunal limb from the elevated proximal intestine. Corrective Roux-en-Y hepaticojejunostomy was then performed. Symptoms such as cholangitis and intestinal dilation were completely alleviated postoperatively. In 2 cases with bile leakage, necrotic jejunal limbs were resected, followed by corrective Roux-en-Y hepaticojejunostomy. After reoperation, the bile leakage was resolved, and infection indicators returned to normal. The average postoperative hospital stay was 10.5 ± 5.5 days (range: 5–21 days), with a median follow-up of 12 months (range: 2–53 months). Follow-up results indicated that the patients were in good general condition, with no abnormalities in liver function or infection indicators detected during follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u0026nbsp;\u003c/strong\u003eReoperations due to technical errors or necrosis in Roux-en-Y jejunal limbs are uncommon, but they can be severe and life-threatening. Early diagnosis and timely surgical intervention can effectively relieve symptoms and reduce patient suffering. Preventive measures should be prioritized since adherence to standard procedures can help prevent these complications.\u003c/p\u003e","manuscriptTitle":"Reoperation related to Roux-en-Y jejunal limb after hepaticojejunostomy of Choledochal Cyst","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-21 09:08:08","doi":"10.21203/rs.3.rs-6236745/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-12T01:19:45+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-20T17:19:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-10T11:49:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"86449304226246518533979144552402575667","date":"2025-04-08T18:00:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"159957862627406086730953895236156956119","date":"2025-04-01T09:27:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-29T23:05:10+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-18T06:26:08+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-17T14:16:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"Pediatric Surgery International","date":"2025-03-16T09:11:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"pediatric-surgery-international","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pesi","sideBox":"Learn more about [Pediatric Surgery International](http://link.springer.com/journal/383)","snPcode":"383","submissionUrl":"https://submission.nature.com/new-submission/383/3","title":"Pediatric Surgery International","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"40ae52c0-d7db-43a8-b64e-cc24c684615b","owner":[],"postedDate":"April 21st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-06-16T16:06:20+00:00","versionOfRecord":{"articleIdentity":"rs-6236745","link":"https://doi.org/10.1007/s00383-025-06056-0","journal":{"identity":"pediatric-surgery-international","isVorOnly":false,"title":"Pediatric Surgery International"},"publishedOn":"2025-06-12 15:57:39","publishedOnDateReadable":"June 12th, 2025"},"versionCreatedAt":"2025-04-21 09:08:08","video":"","vorDoi":"10.1007/s00383-025-06056-0","vorDoiUrl":"https://doi.org/10.1007/s00383-025-06056-0","workflowStages":[]},"version":"v1","identity":"rs-6236745","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6236745","identity":"rs-6236745","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}