Corneal pseudoectasia: a case series.

OBJECTIVE: To raise awareness of conditions that can tomographically mimic corneal ectasia and describe the actions required to avoid misdiagnosis. METHODS: We report a retrospective case series of seven patients presenting at two tertiary care centers in Israel with a presumed diagnosis of keratoconus or post-refractive ectasia. Upon further examination, the ectasia diagnosis was reconsidered and eventually ruled out. RESULTS: Included were ten eyes of seven patients. Cases included bilateral diffuse Salzmann's nodular degeneration, ophthalmoplegia with strabismus which precluded proper fixation during the acquisition of tomography images, two cases of incorrect Pentacam parameter settings, a patient with a history of hyperopic laser-assisted in situ keratomileusis (LASIK) treatment in one eye and myopic LASIK in the fellow eye, a case of old post-photorefractive keratectomy (PRK) stromal haze, and a patient with posterior polymorphous corneal dystrophy. CONCLUSIONS: Tomography patterns mimicking corneal ectasia can appear in patients without ectatic pathology. The comprehensive ophthalmologist should be aware of such cases as they may substantially alter the treatment course and prognosis of these patients.

Tomographic Predictors of Ectasia Development After Keratorefractive Surgery.

PURPOSE: The aim of this study was to identify the risk factors for postkeratorefractive surgery ectasia in unsuspicious tomographies and to report a new index coined diameter of peak locations (DPLs). METHODS: All patients who underwent keratorefractive surgery between 2011 and 2018 at Care-Vision Laser Centers, Israel, and later developed ectasia were included. For each ectasia case, 3 matched controls were selected. Demographic and preoperative, intraoperative, and postoperative data were collected. Multivariate analysis was performed to evaluate the interdependence of the variables. RESULTS: The retrospective study included 19 ectasia and 58 control eyes. There were no significant differences between the groups in ablation depth ( P = 0.73), preoperative spherical equivalent ( P = 0.12), percent tissue altered ( P = 0.71), residual stromal bed ( P = 0.73), and Ectasia Risk Score System ( P = 0.60). The anterior and the posterior symmetry index were significantly higher ( P < 0.001), and DPL was significantly tighter in the ectasia group ( P = 0.01). Binary multiple logistic regression found the symmetry index of the posterior cornea and DPL to be better predictors than age, percent tissue altered, Ectasia Risk Score System, residual stromal bed, and ablation depth. CONCLUSIONS: A higher posterior symmetry index and a tighter DPL are predictors of ectasia in patients with otherwise normal tomographies. A tight DPL implies a weak area in the cornea, which is thin and slightly bulging, increasing the risk of this area becoming ectatic.

The Initial Experience of Laparoscopic Management for Type VI Choledochal Cyst in Children.

Purposes: Dilatation of cystic duct is very rare and had been classified as Todani type VI choledochal cyst. Choledochal cyst combined with dilatation of cystic duct is difficult to diagnose preoperatively. The purpose of this study is to report the rare variants and discuss the significance and laparoscopic management strategy in children. Methods: The subjects for this study were 10 consecutive patients with type VI choledochal cyst who had laparoscopic procedures at our institute between January 2009 and January 2023. Laparoscopic cholecystectomy, excision of the dilated cystic duct, and choledochal cyst were carried out, and the continuity of the biliary duct was re-established through a Roux-en-Y hepaticojejunostomy. Results: Cystic duct combined with the common bile duct dilatation was revealed in all the patients intraoperatively. Laparoscopic procedures were completed with no conversions. The postoperative recovery was uneventful. The mean follow-up duration was 27 ± 12.7 months (range 5-36 months) with no postoperative complications encountered. Conclusions: The rare entity of type VI choledochal cyst should be recognized as a distinct type of choledochal cyst and need to be given enough attention clinically. The laparoscopic procedure is a feasible option for experienced surgeons.

Surgical Strategies for Neonates with Prenatally Diagnosed Congenital Biliary Dilatation.

BACKGROUND: This study aimed to develop a postnatal treatment strategy for infants with prenatally diagnosed congenital biliary dilatation. METHODS: We performed a retrospective study of patients with prenatal diagnosed congenital biliary dilatation (CBD), aged <1 year who underwent surgery at our hospital between 2013 and 2023. We classified the patients into two groups, the "early group," consisting of patients who could not wait for growth, and required early surgery, and the "scheduled group," consisting of patients who were asymptomatic and could undergo scheduled surgery, and compared them. The parameters for early surgical prediction were AST, ALT, TB, DB, and CRP levels at birth, 1 week, 2 weeks, 1 month, 2 months, and 3 months after birth, and immediately before surgery, as well as the cyst diameter, presence of intrahepatic bile duct dilation, and presence of debris in the common bile duct. RESULTS: During the study period, 15 patients were diagnosed prenatally. The cyst diameter was significantly larger at all points in the early group. Patients with a cyst diameter of >30 mm at birth, intrahepatic bile duct dilatation at birth, and postnatal enlargement of the common bile duct to >30 mm are more likely to develop symptoms early. Blood biochemistry tests showed no significant differences between the two groups. CONCLUSIONS: Patients with a cyst diameter >30 mm in the early postnatal period require careful postnatal management and parents should be counseled regarding the high likelihood of their child needing surgery within the first 3 months of life. LEVEL OF EVIDENCE: Level IV.

Truncal valve repair in an adolescent with severe annular dilatation.

Approximately 20% of patients with truncus arteriosus might need a truncal valve procedure within 20 years after anatomical repair due to regurgitation. These patients commonly develop valve regurgitation due to root dilatation with a sufficient amount of good quality valvular tissue. Thus, the reduction of the truncal annulus is the single most important factor to achieve durable repair, especially in patients in whom the Ross procedure is not an option.

Corneal Allogenic Intrastromal Ring Segments (CAIRS) for Corneal Ectasia: A Comprehensive Segmental Tomography Evaluation.

PURPOSE: To evaluate the visual, refractive, and tomographic results of patients with corneal ectasia treated with corneal allogenic intrastromal ring segments (CAIRS) insertion without concomitant corneal cross-linking. METHODS: Fifty-two eyes from 39 patients with stable corneal ectasia and unsatisfactory visual acuity with contact lenses were included. All patients underwent CAIRS insertion with no concomitant corneal procedure at the American University of Beirut Medical Center between September 2019 and July 2022. Visual, refractive, topographic, aberrometric, epithelial, stromal, and segment thickness data were measured relative to baseline at 1 week, 1 month, and at least 3 months postoperatively. Evaluations included slit-lamp examination, manifest refraction, uncorrected (UDVA) and corrected (CDVA) distance visual acuity, and tomography using anterior segment optical coherence tomography. RESULTS: Mean follow-up time was 6.9 ± 5.2 months. UDVA and CDVA improved from 0.97 ± 0.47 and 0.56 ± 0.19 preoperatively to 0.52 ± 0.21 (P < .001) and 0.23 ± 0.19 (P < .001) 3 months postoperatively. Manifest refraction spherical equivalent and cylinder improved from -6.71 ± 6.51 and -4.02 ± 2.24 diopters (D) preoperatively to -3.78 ± 4.07 D (P < .001) and -2.35 ± 1.98 D (P < .001) 3 months postoperatively, respectively. Maximum anterior keratometry and vertical coma decreased from 58.09 ± 7.92 D and 1.56 ± 1.09 µm to 52.48 ± 6.69 D (P < .001) and 0.43 ± 0.77 µm, respectively (P < .001). Corneal epithelium thickened proximal to the allogenic segment by 7.25 µm (P < .001), whereas stromal elevation at the cone decreased from 38.61 ± 18.5 to 23.82 ± 13.4 µm, respectively (P < .001). No major complications were observed and only 1 eye lost one line of CDVA. CONCLUSIONS: Treatment of corneal ectasia with CAIRS improved visual, refractive, topographic, and tomographic parameters. Epithelial thickening central to CAIRS, along with anterior stromal flattening is postulated to contribute to tomographic flattening and regularization. [J Refract Surg. 2023;39(11):767-776.].

Corneal ectasia following photorefractive keratectomy: a confocal microscopic case report and literature review.

The occurrence of corneal ectasia after photorefractive keratectomy is a rare but serious complication of refractive surgery. Possible risk factors are not well assessed, but a probable reason is the failure to detect keratoconus preoperatively. In this report, we describe a case of corneal ectasia after photorefractive keratectomy in a patient who presented a suspicious tomography pattern preoperatively but had no degenerative alterations associated with pathologic keratoconus, as revealed by in vivo corneal confocal microscopy. We also review eligible case reports of post-photorefractive keratectomy ectasia to find similar characteristics.

High Astigmatism Secondary to Peripheral Ectasia Recurrence in Postpenetrating Keratoplasty Eyes Managed With Miniscleral Contact Lenses.

OBJECTIVES: After penetrating keratoplasty (PK) for keratoconus, vision can be impaired by high-degree astigmatism, particularly in those patients with recurrent peripheral ectasia. Scleral contact lenses (CLs) have long been used in the management of keratoconus both in treatment-naive corneas and those postcorneal transplants. We report the use of miniscleral CLs and their related visual and clinical outcomes in a series of patients with post-PK peripheral rim ectasia. METHODS: In this retrospective case series, 5 patients (7 eyes) presented because of reduced visual acuity with their spectacles/CLs and/or reduced comfort with their existing rigid gas-permeable lenses. All patients in this series underwent PK more than two decades ago for keratoconus (mean 28.7 years±7.2). All patients demonstrated characteristic thinning at the graft-host junction, with anterior chamber deepening. Central corneas had remained clear in all patients inferring high visual potential. Contact lenses used were No 7 Comfort 15 miniscleral and the Onefit MED scleral with 14.5 mm and 15.6 mm diameters, respectively. RESULTS: All eyes achieved a best-corrected visual acuity of 6/9 or greater. One case had difficulty with insertion and removal and has since discontinued wearing lens at this time. All others are successfully wearing the lenses regularly. CONCLUSION: Despite advances in CL design, surgical management is still required in some patients. Miniscleral CLs are effective in the refractive management of peripheral ectasia in keratoconic post-PK eyes and should be considered in such eyes before proceeding with repeat surgical intervention.

[Corneal ectasia following small-incision lenticule extraction: a case report].

A 22-year-old male presented with complaints of blurred vision in his right eye over the past 2 years following small incision lenticule extraction (SMILE) surgery conducted 4 years ago. Following a thorough ocular examination and evaluation, he was diagnosed with corneal ectasia in the right eye after the SMILE procedure. Subsequently, the patient underwent corneal cross-linking (CXL) treatment in the right eye to prevent the progression of the condition. After 3 months of treatment, the corneal ectasia remained stable. This article outlines the process of diagnosis and treatment, reviews the corneal conditions prior to the SMILE surgery, and analyzes the possible reasons behind the occurrence of postoperative corneal ectasia.

Crosslinking for post-laser-assisted in situ keratomileusis corneal ectasia: Transepithelial flap-on 30 minute and flap-lift 4 minute protocol.

Purpose: To evaluate the outcomes of transepithelial corneal collagen crosslinking (CXL) for management of corneal ectasia after laser-assisted in situ keratomileusis (LASIK). Methods: CXL was performed on 18 eyes of 16 patients either with LASIK flap lift (n = 9; 365 nm, 30 mW/cm2, 4 minutes, pulse) or with transepithelial flap-on (n = 9 eyes; 365 nm, 3 mW/cm2, 30 minutes) technique. Postoperative change in maximum keratometry (Kmax), anterior elevation, posterior elevation, spherical equivalent (SE), logMAR uncorrected distance visual acuity (UDVA), aberrations, and central corneal thickness (CCT) were evaluated at 12 months postoperatively. Results: A total of 18 eyes of 16 patients (11 males, 5 females) were included. Overall, Kmax flattened more after flap-on CXL (P = 0.014) compared to flap-lift CXL. The endothelial cell density and posterior elevation were stable throughout the follow-up period. Index of vertical asymmetry (IVA), keratoconus index (KI), and central keratoconus index (CKI) decreased after flap-on CXL at 12 months, postoperatively (P < 0.05), whereas there were no statistically significant changes in these parameters after flap-off CXL group. The spherical aberrations and total root mean square decreased after flap-lift CXL at 12 months, postoperatively (P < 0.05). Conclusion: In our study, transepithelial collagen crosslinking was successfully used to halt disease progression in post-LASIK keratectasia. We recommend flap-on surgical technique for these cases.

Impact of topographic localization of corneal ectasia on the outcomes of deep anterior lamellar keratoplasty employing large (9 mm) versus conventional diameter (8 mm) grafts.

OBJECTIVES: Visual and topographic outcomes of large (9.0 mm) versus conventional (8.0 mm) deep anterior lamellar keratoplasty (DALK) for the treatment of keratoconus (KC) were compared in relation to the different localization of the corneal ectasia (within or beyond the central 8.0 mm). METHODS: This is a retrospective, comparative case series. Preoperatively, the topographic extension of the conus was calculated by measuring the distance from the geometric center of the cornea and the outermost point of the corneal ectasia (ectasia <8.0 mm, group A; ectasia ≥8.0 mm, group B). DALK was performed using both small grafts (8.0 mm, group 1) and large grafts (9.0 mm, group 2). Best-corrected visual acuity and topographic astigmatism were evaluated preoperatively (T0) and postoperatively after complete suture removal (1 year, T1). RESULTS: Data from 224 eyes of 196 patients (mean age 37.6 ± 15.1 years) were evaluated. Topographic astigmatism improved from T0 to T1 (4.94 ± 2.92 diopters (D) [95% CI, 4.56-5.33] vs 4.19 ± 2.45 D [95% CI, 3.87-4.51], p = 0.001). There was no significant difference in postoperative topographic cylinder between group 1 and group 2 when considering eyes with corneal ectasia <8.0 mm (group 1 A, 4.15 ± 2.19 D [95% CI, 3.64-4.66] vs group 2 A, 3.65 ± 2.13 D [95% CI, 2.92-4.38], p = 0.14); conversely, the difference was significant considering eyes with corneal ectasia ≥8.0 mm (group 1B, 4.74 ± 2.90 D [95% CI, 4.09-5.38] vs group 2B, 3.68 ± 1.94 D [95% CI, 3.10-4.26], p = 0.02). CONCLUSIONS: Large 9.0-mm DALK provided better anatomical outcomes compared to conventional 8.0-mm DALK, particularly in eyes with corneal ectasia extending beyond the central 8.0 mm.

Transoral Outlet Reduction to Tackle Weight Regain After Roux-en-Y Gastric Bypass: a Single Center Initial Experience.

BACKGROUND: Long-term failure after Roux-en-Y gastric bypass (RYGB) is well known and occurs in 10-15% of patients according to the literature. Causes are multifactorial and dilatation of the gastro-jejunal anastomosis (GJA) is only one of these. A transoral outlet reduction (TORe) with endoscopic sutures to reinstall more restriction could be a valid and safe alternative to reduce regained weight after failed gastric bypass surgery. The objective of this article is to describe our single-center experience and discuss the adverse events of the technique. OBJECTIVES: To describe our single-center case series and adverse events after TORe for weight regain after RYGB. METHODS: We report a case series of 20 patients referred due to weight regain after RYGB with a dilated GJA. TORe was performed using an endoscopic full-thickness suture device (Apollo OverStitch®) to reduce the diameter of the GJA and the volume of the gastric reservoir. Prospectively collected data on technical feasibility, safety and efficacy are described with a median follow-up of 22 (6-38) months. RESULTS: Mean BMI was 44.5 kg/m2 at the time of RYGB. Postoperative nadir BMI was 27,7 kg/m2. The average time to TORe was 12.1 years after initial RYGB. Patients regained a mean 45.9% of excess body weight loss (EWL) before TORe and had a mean preprocedural BMI of 35.3 kg/m2. The aim was to reduce the aperture of the GJA to 5 mm which was done with a mean of 1.7 sutures and 3.5 stitches. The mean absolute weight loss was 13 kg and BMI reduction was 3.9 kg/m2 after 6 months. After a median follow-up of 22 months, a BMI of 31.4 kg/m2 was observed. Dumping symptoms resolved in four of our patients 6 weeks after TORe. Procedural adverse events were nausea and vomiting, sore throat, mild transient abdominal pain, diarrhea and constipation. All of them were treated conservatively. Due to a lack of weight loss, a suture failure was assumed in two of our patients. We describe one case of postprocedural mediastinitis, presumably due to a distal esophageal perforation, treated with a laparoscopic drainage without clinical evidence for perforation. CONCLUSIONS: Endoscopic TORe by narrowing the dilated GJA appears to be an efficient and safe minimal invasive option to tackle weight regain after RYGB and should be more used in clinical practice.

Corneal tissue addition keratoplasty: new intrastromal inlay procedure for keratoconus using femtosecond laser-shaped preserved corneal tissue.

PURPOSE: To report results of Corneal Tissue Addition Keratoplasty (CTAK) for keratoconus (KC) and ectasia after laser in situ keratomileusis. SETTING: Cornea and refractive surgery practice. DESIGN: Single center, prospective, open label clinical trial. METHODS: 21 eyes of 18 patients underwent CTAK. A tissue inlay of preserved corneal tissue was cut to customized specifications with a femtosecond laser and placed in a laser-created channel in the host cornea. Postoperative uncorrected and corrected distance visual acuity (UDVA, CDVA), manifest refraction spherical equivalent (MRSE), topographic mean keratometry (Kmean), maximum keratometry (Kmax), and the point of maximum flattening (Kmaxflat) were measured. RESULTS: Average UDVA improved from 1.21 ± 0.35 logMAR lines (LL) (20/327) to 0.61 ± 0.25 LL (20/82) ( P < .001). Average CDVA improved from 0.62 ± 0.33 LL (20/82) to 0.34 ± 0.21 LL (20/43) ( P = .002), and average MRSE improved from -6.25 ± 5.45 diopters (D) to -1.61 ± 3.33 D ( P = .002). Individually, 20 eyes (95.2%) gained more than 2 lines of UDVA, with 10 eyes (47.6%) gaining more than 6 lines, and no eyes worsening. 12 eyes (57.1%) gained at least 2 lines of CDVA, with 1 eye worsening by more than 2 lines. At 6 months, average Kmean flattened by -8.44 D ( P = .002), Kmax flattened by -6.91 D ( P = .096), and mean Kmaxflat was -16.03 D. CONCLUSIONS: CTAK is a promising procedure to improve visual acuity and topography in patients with KC and ectasia.

Congenital segmental dilatation of the colon in a newborn: a radiologic perspective of an unusual entity.

A newborn with congenital segmental dilatation of the intestine affecting the colon is presented. This rare condition, unrelated to Hirschsprung's disease, may affect any portion of the bowel and is characterized by focal dilatation of a segment of bowel flanked by normal proximal and distal bowel. While reported in the surgical literature, congenital segmental dilatation of the intestine has not been reported in the pediatric radiology literature even though pediatric radiologists may be the first to encounter imaging suggesting the diagnosis. We therefore present the characteristic imaging findings, including abdominal radiographs and images from a contrast enema, and discuss the clinical presentation, pathology findings, associations, treatment, and prognosis of congenital segmental dilatation of the intestine to increase awareness of this unusual diagnosis.

Autograft reoperations after the Ross procedure.

OBJECTIVES: After a Ross procedure, autograft failure can occur. At reoperation, repair of the autograft preserves the advantages of the Ross procedure. The aim of this retrospective study was to assess mid-term results after reoperation of a failed autograft. METHODS: Between 1997 and 2022, 30 consecutive patients (83% male; age 41 ± 11 years) underwent autograft reintervention between 60 days and 24 years (median 10 years) after a Ross procedure. The initial technique varied, full-root replacement (n = 25) being the most frequent. The indication for reoperation was isolated autograft regurgitation (n = 7), root dilatation (>43 mm) with (n = 17) or without (n = 2) autograft regurgitation, mixed dysfunction (n = 2) and endocarditis (n = 2). In 4 instances, the valve was replaced by valve (n = 1) or combined valve and root replacement (n = 3). Valve-sparing procedures consisted of isolated valve repair (n = 7) or root replacement (n = 19), and tubular aortic replacement. Cusp repair was performed in all but 2. Mean follow-up was 5.4 ± 6 years (35 days to 24 years). RESULTS: Mean cross-clamp and perfusion times were 74 ± 26 and 132 ± 64 min. There were 2 perioperative deaths (7%; both valve replacement) and 2 patients died late (32 days to 1.2 years postoperatively). Freedom from cardiac death at 10 years was 96% after valve repair and 50% after replacement. Two patients required reoperation (1.68 and 16 years) following repair. One underwent valve replacement for cusp perforation, the other, root remodelling for dilatation. Freedom from autograft reintervention at 15 years was 95%. CONCLUSIONS: Autograft reoperations after the Ross procedure can be performed as valve-sparing operations in the majority of cases. With valve-sparing, long-term survival and freedom from reoperation are excellent.

Recurrent Keratoconus: Corneal Transplants for Keratoconus Develop Tomographic Ectatic Changes.

PURPOSE: The purpose of this study was to evaluate postoperative Scheimpflug imaging changes during the first 5 years after penetrating keratoplasty (PK) in patients with keratoconus (KC). METHODS: This retrospective, interventional case series includes 31 eyes of 31 patients who underwent their first PK with a history of KC. Postoperative Scheimpflug imaging was performed 3 months after the removal of the last suture (baseline) and then repeated 3 and 5 years after the PK. Demographic data, donor and host trephination diameter, and Scheimpflug imaging (Pentacam HR, Oculus, Germany) parameters indicative of ectasia were analyzed to evaluate postoperative graft changes that occur after PK. RESULTS: The maximal keratometry (Kmax) progressed significantly between baseline (53.5 ± 6.1 D) and postoperative year 3 and year 5 [56.5 ± 6.1 diopter (D) and 58.8 ± 7.9 D, P < 0.001]. Significant changes were also observed for the anterior best fit sphere and posterior best fit sphere ( P < 0.001 for 3 and 5 years compared with baseline). Kmax increased by at least 2 Ds for 74.2% of patients and up to 7 Ds or more for 25.8% of the patients. A significant inverse correlation was observed for host trephine size and progression of Kmax (r = -0.52, P = 0.01), which indicated that larger host trephination size was associated with a smaller increase in postoperative Kmax. CONCLUSIONS: Tomographic graft changes indicative of ectasia were observed within 3 to 5 years after PK in patients with KC. These changes were observed more frequently and sooner after corneal transplants than previously reported.

Introducing a Revised Tissue Saving Protocol for Combined Topography-Guided Photorefractive Keratectomy and Cross-Linking in Keratoconic Corneas.

PURPOSE: The aim of this study was to introduce a revised tissue-saving technique for combined topography-guided photorefractive keratectomy (PRK) and cross-linking for keratoconus (KC) treatment and to evaluate its efficacy, safety, and stability. METHODS: This retrospective, noncontrolled study was performed at Maadi Eye Subspecialty Center and Eye Care Center, Cairo, Egypt. The technique was performed on virgin keratoconic corneas with 3 different morphological patterns of ectasia. It involves performing topography-guided PRK before epithelial removal, followed by customized phototherapeutic keratectomy (PTK) that is tailored to each cornea after studying the treatment profile on the laser treatment screen. The electronic medical records were explored for preoperative and postoperative data, including subjective refraction and topographic data (using Sirius topographer). RESULTS: The study was conducted on 123 eyes of 93 patients with a mean age of 27.98 years ±6.06. The follow-up ranged from 6 to 36 months (mean ± SD of 16.2 months ±10.4). The results showed statistically nonsignificant differences among the 3 ectasia subgroups in treatment spherical equivalent, treatment maximum depth, thickness of removed epithelium, and thinnest residual stromal bed. There were statistically significant differences in almost all values between the preoperative and postoperative data, with significant postoperative patients' improvement ( P value <0.001). The subgroups' results were almost the same as the whole cohort's results. The safety and efficacy indices of the performed procedure showed remarkably high values (1.48 ± 0.21 and 0.87 ± 0.40, respectively). CONCLUSIONS: This revised protocol for KC management maximally preserves stromal tissue with proven efficacy, safety, and stability.

Factors predicting surgical difficulties in congenital biliary dilatation in pediatric patients.

BACKGROUND: The effects of disease classification and the patient's preoperative condition on the difficulty of performing a laparotomy for pediatric congenital biliary dilatation (CBD) have not been fully elucidated. METHODS: The present study retrospectively analyzed 46 pediatric CBD laparotomies performed at the study center between March 2010 and December 2021 and predictors of operative time. The patients were separated into a short operative time group (SOT) (≤ 360 min, n = 27) and a long operative time group (LOT) (> 360 min, n = 19). RESULTS: The preoperative AST and ALT values were higher, and the bile duct anastomosis diameter was larger, in the LOT. Correlation analysis demonstrated that the maximum cyst diameter, preoperative neutrophil-to-lymphocyte ratio, AST, ALT, AMY, and bile duct anastomosis diameter correlated positively with operative time. Multivariate analysis identified the maximal cyst diameter, preoperative AST, and bile duct anastomosis diameter as significant factors affecting surgical time. Postoperatively, intrapancreatic stones and paralytic ileus were observed in one patient each in the SOT, and mild bile leakage was observed in one patient in the LOT. CONCLUSIONS: The maximum cyst diameter, preoperative AST, and bile duct anastomosis diameter have the potential to predict the difficulty of performing a pediatric CBD laparotomy.