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Posterior sagittal anorectoplasty: Results in the management of 332 cases of anorectal malformations
1080
try. The study showed a reduction in nerve fibers storing vasoactive intestinal peptide (VIP), substance P (SP), and a total depletion of nerves storing enkephalin and gastrin-releasing peptide in aganglionic intestine. Nerve fibers storing peptide histidine isoleueine (PHI) or neurokinin A (NKA) were also examined. It was shown that VIP coexisted with PHI and SP with NKA, and that the number of nerve fibers containing these substances was markedly reduced in the smooth muscle layers in aganglionic bowel. On the other hand, in the mucosa the innervation was virtually unchanged. Thus, it appears that the mucosal secretory and sensory innervation is not reduced, and that the defects in peptidergic innvervation in Hirschpsrung's disease mainly involve motor neurons.--Prem Puri Neuronal Intestinal Dysplasia. Modern Diagnosis and Therapy-Report of 23 Patients. G. Pistor, S. Hofmann-von Kap-herr, R.
Grussner, et al. Pediatr Surg Internat 2:352-358, (November), 1987. Findings in 23 children with neuronal intestinal dysplasia (NID) are presented. Twelve children had Hirschprung's disease that masked the existence of proximal NID. In all cases the diagnosis was established by histological-histochemical examination. Amelioration of symptoms by conservative treatment alone was achieved in four children; in 13 cases, colostomy was necessary. In six patients, colon resection was performed; two suffered from both colitis and obstruction and the other four were treated for obstruction, multiple perforations, persistent adynamia of the left colon, and fistulation. In nine patients, the colostomy was closed. Four of six children who did not have sonographic confirmation of motility had complications due to colon dysmotility after closure of their normally functioning colostomy. Therapeutic measures are based exclusively on clinical and functional parameters. The clinical picture dictates the emergency measures (colostomy, colon resection, and eolectomy). Normal colostomy function is not a sufficient criterion of normal colon motility. Functional sonography of the colon is included in the planning of further therapy. Indications, timing, and extent of colon resection can be reliably determined using the sonographic method.--Prem Puri Surgical Management of Anorectal Malformations: A Unified Concept. A. Pena. Pediatr Surg Internat 3:82-93, (March), 1988.
Posterior sagittal anorectoplasty (PSARP) is a new approach for the treatment of anorectal malformations. It has allowed direct
exposure of the anatomy of these defects, enabling the author to describe the spectrum of this malformation. It also permits patients to be grouped on the basis of their potential for continence and the correlation of operative findings with clinical results. Traditional anatomic concepts have proven to be very inaccurate. The new approach allows separation of the rectum from the genitourinary tract without damaging important structures. The rectum is located within the limits of the striated muscle structures in a precise manner. This approach has important implications for therapy, evaluation of results, classification, and terminology. All defects can be treated with PSARP. The size of the incision will vary according to the complexity of the malformation, from minimal PSARP in low malformations to full PSARP in higher defects. In addition, approximately 10% of all cases will require a laparotomy. Colostomy is recommended in most patients except for those with low malformations. A new classification is proposed based on practical therapeutic purposes. Patients are also grouped according to their common potential for continence, which is important for the evaluation and comparison of results. The decision to create a protective colostomy is based on clinical facts in 80% to 90% of cases, and on invertograms and other diagnostic tests in the remaining 10% to 20%.~Prem Puri
INTERNATIONAL ABSTRACTS The Role of Colostomy in the Management of Anoreetal Malformations. S. Wilkins and A. Pena. Pediatr Surg Internat 3:105-109,
(March), t988. The role of the colostomy in the definitive correction of anorectal malformations is controversial not only with regard to indications for its use but also to locations and type. The authors reviewed the records of 272 patients with 307 colostomies and analyzed the frequency of complications related to these controversial points. There were 250 completely divided and 57 loop colostomies constructed in either the sigmoid or transverse colon. Twenty-five colostomies were associated with complications that included retraction, stenosis, dehiscence, prolapse, infection, bowel obstruction, sepsis, and death. Twelve additional colostomies were placed in positions that impeded the definitive correction of the malformation: nine sigmoidostomies were too distal and three were located in the right upper abdominal quadrant and did not permit pull-through without tension. Colostomy prolapse and pull-through infection were statistically less likely with a completely diverting colostomy. Thirtyfive patients with rectovestibular malformations were encountered in this series. Ten were referred from other institutions after attempted repair without a eolostomy, and all ten had complications of infection, dehiscence, retraction, and reopening of the fistula. In contrast, there were no complications in the remaining 25 in whom the repair was preceded by a colostomy, nor after re-repair of the other ten. These findings support the need for a colostomy prior to the repair of this malformation. The authors recommend a carefully constructed, high, completely diverting sigmoid colostomy prior to the initial definitive repair of anorectal malformations. A right transverse colostomy is preferable preceding reoperations.--Prem Puri Posterior Sagittal Anorectoplasty: Results in the Management of 332 Cases of Anorectal Malformations. A, Penn, Ped~atr Surg
Internat 3:94-104, (March), 1988. This is a retrospective evaluation of the functional results obtained in 332 patients who underwent posterior sagittal anorectoplasty (PSARP) for the treatment of an anorectal malformation. All patients were operated on by the author between 1980 and 1987. One hundred sixty-one patients were excluded: younger than 3 years of age, mentally retarded, colostomy still open, deaths, lost to follow-up, and having complex malformations. Patients were grouped according to their potential for continence. Voluntary bowel movements were considered one of the best indicators of fecal continence and were found among patients with a normal sacrum in 77% of those with rectourethral fistula and 30% of those with a vesical fistula. Except for one case, all patients with a normal sacrum and low malformation, vestibular fistula, anorectal agenesis without fistula, persistent cloaca, and atresia or stenosis had voluntary bowel movements. Soiling was present in patients with a normal sacrum including 20% with vestibular fistula, 30% with no fistula, 25% with atresia or stenosis, 6.1% with rectourethral fistula, 75% with cloacas, 50% with vesical fistulae, and 0% low malformations. Constipation was found in patients with a normal sacrum including 50% with low malformations, 70% with vestibular fistulae, 55% with no fistula, 25% with atresia or stenosis, 30% with urethral fistulae, 75% with cloacas, and 50% with vesical fistulae. In contrast, only 20% of patients with more than three sacral vertebrae missing achieved voluntary bowel movements; 60% suffered constant soiling, 20% had constipation, and 60% had urinary incontinence. All evaluations were performed without medical management. The average age of patients with voluntary bowel movements was 4.5 years; for patients without voluntary bowel movements it was 4 years. Patients with a normal sacrum and fecal incontinence operated on elsewhere underwent secondary PSARP, achieving "marked improvement" in 45% of cases, "some improvement" in 37%, and "no improvement" in
INTERNATIONAL ABSTRACTS
18%. In contrast, those with an abnormal sacrum achieved 20%, 30%, and 50%, respectively, in each of the abovementioned categories.--Prem Purl Spectrum of Genitourinary Malformations in Patients With Imperforate Anus. M..4. Rich, W.A. Brock, and A. Pena. Pediatr Surg
Internat 3:110-113, (March), 1988. A retrospective review of 244 cases of imperforate anus demonstrated a 48% incidence of associated genitourinary (GU) anomalies. The incidence and severity of associated GU anomalies was directly related to the level of the fistula between the blind-ending rectum and the GU tract. High-level fistulae to the bladder neck in males and the cloaca in females demonstrated a 90% incidence of associated genitourinary anomalies. In contrast, lower-level fistulae to the perineum showed only a 14% incidence of associated GU anomalies. Classification of anorectal anomalies by fistula level provides an accurate means of predicting the likelihood of an associated GU malformation.--Prem Purl Localization of the Blind Rectal Pouch in Imperforate Anus With t h e CT S c a n n e r . H. Krasna, J.L. Nosher, J. .4morosa, et al. Pediatr
Surg lnternat 3:114-I 19, (March), 1988. Localization of the site of atresia in imperforate anus has classically been carried out by the "upside down" radiograph identifying the blind rectal end, pubic bone, and coccyx on lateral x-rays. This method is often inaccurate because of difficulty in identifying the bony structures and absence of air in the blind rectum. The authors studied six neonates with computed tomography (CT) scans of the pelvis: two males with a "high" imperforate anus, one male with a "low" imperforate anus, a female with a cloacal anomaly, a normal stillborn, and a baby with myelomeningocele with a normal anorecturn. The CT scan clearly and accurately identifies all bony structures and pelvic muscles and determines if bowel is present below the pubococcygeal line, or if it ends above it. In addition, the CT software can generate sagittal and coronal (frontal) reconstructed views from the axial sections to identify the blind rectal end and anus, and to measure the distance between them. Bowel contents (air and meconium) are distinct in radiographic density from muscle and other pelvic structures, and CT can identify these. Identification of the blind pouch by CT is not meant to replace the conventional radiographic evaluations but may be useful in difficult cases. CT has the potential to identify the level of the blind pouch immediately after birth without waiting for air to reach the blind rectal end.-Prem Purl Recurrent Fistula: Post-Surgical Treatment of Anorectal Malformations. P. Debeugny. Chir Pediatr 28:158-163, (April), 1987.
This is a multicentric study of 19 recurrent urethrorectal fistulas and 23 cases of vaginorectal fistulas. There were 15 patients with high anomalies, 12 with intermediate form, and 15 with low malformations. Frequency was below 5% in this study. Possible factors in determinating recurrence of the fistulas were analyzed. Neither associated malformations, choice of surgical approach, nor time of primary repair were of significant value. Perirectal pouch dissection (v submucosal dissection), secondary stenosis, and coloanal suture with tension seemed to be important factors resulting in recurrent fistulas. However, statistical analysis was not provided. Surgical treatment of these fistulas were either by an abdominoperineal approach or a perineal one only. In these last cases, 25% presented a third fistula and all have been reoperated on. Long-term results are reported to be good in 40 patients. One required a permanent colostomy.--J.M. Guys
1081 Morphological Investigations in Piglets With Anal Atresia. W.
Lambrecht and t4I. Lierse. Z Kinderchir 42:350-351, (December), 1987. Thirty-three newborn piglets (24 males, 9 females) with anorectal atresia were investigated histologically. Eighteen piglets had high deformities with rectourethral and rectovaginal fistulas. Fifteen animals had low deformities. The authors were able to demonstrate internal as well as external sphincter muscles in all animals. The internal sphincter muscles were positioned around the fistulas. The fistulas also exhibited other characteristics of a normal anal opening. The authors conclude that operative results could be improved by developing a surgical techique that uses the internal sphincter in anorectal atresia.-- Thomas .4. Angerpointner
ABDOMEN Congenital Cystic Dilatation of the Common Bile Duct. O. Cusse-
not, J. Valayer, and F. Gauthier. Chir Podiatr 28:8-19, (January), 1987. Over an 18-year period, 41 pediatric cases &congenital dilatation of the common bile duct (CDBD) are reported. Females predominated 5:1. All (but one) were operated on and 27% before 1 year of age. Postoperative complications were reported in 30% of the cases: hepatojejunal stenosis following partial kystectomy (2), cholangitis (6), and external biliary fistula (3). Operative procedures included partial or complete excision of the cyst with a Roux-en-Y anastomosis in 88% of the patients. Average follow-up was 7 years. Good results were reported in 83% of the cases. There were three deaths in children <1 year of age with severe cirrhosis at the time of diagnosis. The authors emphasize the following points. (1) Abdominal echotomography and transparietal cholangiogram are the most useful preoperative investigations. (2) A close etiopathogenic relation exists between the CDBD and a common hepaticopancreatic duct (>40% in this series). (3) Early surgical treatment must be undertaken. Total cyst excision with a Roux-en-Y hepaticojejunostomy should give the best long-term results with minimal exposure to secondary malignancies of the biliary tract.--J.M. Guys Reoperation for Congenital Choledochal Cyst. T. Todani, Y. Wata-
nabe, A. Toki, et al. Ann Surg 207:142-147, (February), 1988. Between 1960 and 1986, 92 patients with choledoebal cyst underwent surgical intervention (primary excision of the cyst 60, secondary excision 13). Seventy-three patients underwent excisional procedures with biliary reconstruction: hepaticoduodenostomy (51), hepaticojejunostomy (Roux-en-Y) (20), pancreatoduodenectomy (1), and excision of the cholcdochocele (1). Twenty-three patients underwent reoperation for choledochal cyst and are analyzed. Eight initially underwent external drainage, eight internal drainage, and seven underwent excision. Reoperation rate in the total population was 14.3%. The eight patients with external drainage underwent secondary excision with favorable results. Five patients with internal drainage underwent secondary excision of the cyst because of recurrent cholangitis and abdominal pain; three were for carcinoma. The seven patients undergoing excisional procedures required reoperation for anastomic leak (4) and bleeding (3). Eleven patients were lost to follow-up. Excisional procedures with biliary reconstruction is the treatment of choice in preventing malignant complications of choledochal cyst. The authors present a lengthy discussion of the complications associated with choledochal cyst, surgical interventions, and the alternatives for pre, peri, and postoperative management of those complications.--Edward G. Ford
try. The study showed a reduction in nerve fibers storing vasoactive intestinal peptide (VIP), substance P (SP), and a total depletion of nerves storing enkephalin and gastrin-releasing peptide in aganglionic intestine. Nerve fibers storing peptide histidine isoleueine (PHI) or neurokinin A (NKA) were also examined. It was shown that VIP coexisted with PHI and SP with NKA, and that the number of nerve fibers containing these substances was markedly reduced in the smooth muscle layers in aganglionic bowel. On the other hand, in the mucosa the innervation was virtually unchanged. Thus, it appears that the mucosal secretory and sensory innervation is not reduced, and that the defects in peptidergic innvervation in Hirschpsrung's disease mainly involve motor neurons.--Prem Puri Neuronal Intestinal Dysplasia. Modern Diagnosis and Therapy-Report of 23 Patients. G. Pistor, S. Hofmann-von Kap-herr, R.
Grussner, et al. Pediatr Surg Internat 2:352-358, (November), 1987. Findings in 23 children with neuronal intestinal dysplasia (NID) are presented. Twelve children had Hirschprung's disease that masked the existence of proximal NID. In all cases the diagnosis was established by histological-histochemical examination. Amelioration of symptoms by conservative treatment alone was achieved in four children; in 13 cases, colostomy was necessary. In six patients, colon resection was performed; two suffered from both colitis and obstruction and the other four were treated for obstruction, multiple perforations, persistent adynamia of the left colon, and fistulation. In nine patients, the colostomy was closed. Four of six children who did not have sonographic confirmation of motility had complications due to colon dysmotility after closure of their normally functioning colostomy. Therapeutic measures are based exclusively on clinical and functional parameters. The clinical picture dictates the emergency measures (colostomy, colon resection, and eolectomy). Normal colostomy function is not a sufficient criterion of normal colon motility. Functional sonography of the colon is included in the planning of further therapy. Indications, timing, and extent of colon resection can be reliably determined using the sonographic method.--Prem Puri Surgical Management of Anorectal Malformations: A Unified Concept. A. Pena. Pediatr Surg Internat 3:82-93, (March), 1988.
Posterior sagittal anorectoplasty (PSARP) is a new approach for the treatment of anorectal malformations. It has allowed direct
exposure of the anatomy of these defects, enabling the author to describe the spectrum of this malformation. It also permits patients to be grouped on the basis of their potential for continence and the correlation of operative findings with clinical results. Traditional anatomic concepts have proven to be very inaccurate. The new approach allows separation of the rectum from the genitourinary tract without damaging important structures. The rectum is located within the limits of the striated muscle structures in a precise manner. This approach has important implications for therapy, evaluation of results, classification, and terminology. All defects can be treated with PSARP. The size of the incision will vary according to the complexity of the malformation, from minimal PSARP in low malformations to full PSARP in higher defects. In addition, approximately 10% of all cases will require a laparotomy. Colostomy is recommended in most patients except for those with low malformations. A new classification is proposed based on practical therapeutic purposes. Patients are also grouped according to their common potential for continence, which is important for the evaluation and comparison of results. The decision to create a protective colostomy is based on clinical facts in 80% to 90% of cases, and on invertograms and other diagnostic tests in the remaining 10% to 20%.~Prem Puri
INTERNATIONAL ABSTRACTS The Role of Colostomy in the Management of Anoreetal Malformations. S. Wilkins and A. Pena. Pediatr Surg Internat 3:105-109,
(March), t988. The role of the colostomy in the definitive correction of anorectal malformations is controversial not only with regard to indications for its use but also to locations and type. The authors reviewed the records of 272 patients with 307 colostomies and analyzed the frequency of complications related to these controversial points. There were 250 completely divided and 57 loop colostomies constructed in either the sigmoid or transverse colon. Twenty-five colostomies were associated with complications that included retraction, stenosis, dehiscence, prolapse, infection, bowel obstruction, sepsis, and death. Twelve additional colostomies were placed in positions that impeded the definitive correction of the malformation: nine sigmoidostomies were too distal and three were located in the right upper abdominal quadrant and did not permit pull-through without tension. Colostomy prolapse and pull-through infection were statistically less likely with a completely diverting colostomy. Thirtyfive patients with rectovestibular malformations were encountered in this series. Ten were referred from other institutions after attempted repair without a eolostomy, and all ten had complications of infection, dehiscence, retraction, and reopening of the fistula. In contrast, there were no complications in the remaining 25 in whom the repair was preceded by a colostomy, nor after re-repair of the other ten. These findings support the need for a colostomy prior to the repair of this malformation. The authors recommend a carefully constructed, high, completely diverting sigmoid colostomy prior to the initial definitive repair of anorectal malformations. A right transverse colostomy is preferable preceding reoperations.--Prem Puri Posterior Sagittal Anorectoplasty: Results in the Management of 332 Cases of Anorectal Malformations. A, Penn, Ped~atr Surg
Internat 3:94-104, (March), 1988. This is a retrospective evaluation of the functional results obtained in 332 patients who underwent posterior sagittal anorectoplasty (PSARP) for the treatment of an anorectal malformation. All patients were operated on by the author between 1980 and 1987. One hundred sixty-one patients were excluded: younger than 3 years of age, mentally retarded, colostomy still open, deaths, lost to follow-up, and having complex malformations. Patients were grouped according to their potential for continence. Voluntary bowel movements were considered one of the best indicators of fecal continence and were found among patients with a normal sacrum in 77% of those with rectourethral fistula and 30% of those with a vesical fistula. Except for one case, all patients with a normal sacrum and low malformation, vestibular fistula, anorectal agenesis without fistula, persistent cloaca, and atresia or stenosis had voluntary bowel movements. Soiling was present in patients with a normal sacrum including 20% with vestibular fistula, 30% with no fistula, 25% with atresia or stenosis, 6.1% with rectourethral fistula, 75% with cloacas, 50% with vesical fistulae, and 0% low malformations. Constipation was found in patients with a normal sacrum including 50% with low malformations, 70% with vestibular fistulae, 55% with no fistula, 25% with atresia or stenosis, 30% with urethral fistulae, 75% with cloacas, and 50% with vesical fistulae. In contrast, only 20% of patients with more than three sacral vertebrae missing achieved voluntary bowel movements; 60% suffered constant soiling, 20% had constipation, and 60% had urinary incontinence. All evaluations were performed without medical management. The average age of patients with voluntary bowel movements was 4.5 years; for patients without voluntary bowel movements it was 4 years. Patients with a normal sacrum and fecal incontinence operated on elsewhere underwent secondary PSARP, achieving "marked improvement" in 45% of cases, "some improvement" in 37%, and "no improvement" in
INTERNATIONAL ABSTRACTS
18%. In contrast, those with an abnormal sacrum achieved 20%, 30%, and 50%, respectively, in each of the abovementioned categories.--Prem Purl Spectrum of Genitourinary Malformations in Patients With Imperforate Anus. M..4. Rich, W.A. Brock, and A. Pena. Pediatr Surg
Internat 3:110-113, (March), 1988. A retrospective review of 244 cases of imperforate anus demonstrated a 48% incidence of associated genitourinary (GU) anomalies. The incidence and severity of associated GU anomalies was directly related to the level of the fistula between the blind-ending rectum and the GU tract. High-level fistulae to the bladder neck in males and the cloaca in females demonstrated a 90% incidence of associated genitourinary anomalies. In contrast, lower-level fistulae to the perineum showed only a 14% incidence of associated GU anomalies. Classification of anorectal anomalies by fistula level provides an accurate means of predicting the likelihood of an associated GU malformation.--Prem Purl Localization of the Blind Rectal Pouch in Imperforate Anus With t h e CT S c a n n e r . H. Krasna, J.L. Nosher, J. .4morosa, et al. Pediatr
Surg lnternat 3:114-I 19, (March), 1988. Localization of the site of atresia in imperforate anus has classically been carried out by the "upside down" radiograph identifying the blind rectal end, pubic bone, and coccyx on lateral x-rays. This method is often inaccurate because of difficulty in identifying the bony structures and absence of air in the blind rectum. The authors studied six neonates with computed tomography (CT) scans of the pelvis: two males with a "high" imperforate anus, one male with a "low" imperforate anus, a female with a cloacal anomaly, a normal stillborn, and a baby with myelomeningocele with a normal anorecturn. The CT scan clearly and accurately identifies all bony structures and pelvic muscles and determines if bowel is present below the pubococcygeal line, or if it ends above it. In addition, the CT software can generate sagittal and coronal (frontal) reconstructed views from the axial sections to identify the blind rectal end and anus, and to measure the distance between them. Bowel contents (air and meconium) are distinct in radiographic density from muscle and other pelvic structures, and CT can identify these. Identification of the blind pouch by CT is not meant to replace the conventional radiographic evaluations but may be useful in difficult cases. CT has the potential to identify the level of the blind pouch immediately after birth without waiting for air to reach the blind rectal end.-Prem Purl Recurrent Fistula: Post-Surgical Treatment of Anorectal Malformations. P. Debeugny. Chir Pediatr 28:158-163, (April), 1987.
This is a multicentric study of 19 recurrent urethrorectal fistulas and 23 cases of vaginorectal fistulas. There were 15 patients with high anomalies, 12 with intermediate form, and 15 with low malformations. Frequency was below 5% in this study. Possible factors in determinating recurrence of the fistulas were analyzed. Neither associated malformations, choice of surgical approach, nor time of primary repair were of significant value. Perirectal pouch dissection (v submucosal dissection), secondary stenosis, and coloanal suture with tension seemed to be important factors resulting in recurrent fistulas. However, statistical analysis was not provided. Surgical treatment of these fistulas were either by an abdominoperineal approach or a perineal one only. In these last cases, 25% presented a third fistula and all have been reoperated on. Long-term results are reported to be good in 40 patients. One required a permanent colostomy.--J.M. Guys
1081 Morphological Investigations in Piglets With Anal Atresia. W.
Lambrecht and t4I. Lierse. Z Kinderchir 42:350-351, (December), 1987. Thirty-three newborn piglets (24 males, 9 females) with anorectal atresia were investigated histologically. Eighteen piglets had high deformities with rectourethral and rectovaginal fistulas. Fifteen animals had low deformities. The authors were able to demonstrate internal as well as external sphincter muscles in all animals. The internal sphincter muscles were positioned around the fistulas. The fistulas also exhibited other characteristics of a normal anal opening. The authors conclude that operative results could be improved by developing a surgical techique that uses the internal sphincter in anorectal atresia.-- Thomas .4. Angerpointner
ABDOMEN Congenital Cystic Dilatation of the Common Bile Duct. O. Cusse-
not, J. Valayer, and F. Gauthier. Chir Podiatr 28:8-19, (January), 1987. Over an 18-year period, 41 pediatric cases &congenital dilatation of the common bile duct (CDBD) are reported. Females predominated 5:1. All (but one) were operated on and 27% before 1 year of age. Postoperative complications were reported in 30% of the cases: hepatojejunal stenosis following partial kystectomy (2), cholangitis (6), and external biliary fistula (3). Operative procedures included partial or complete excision of the cyst with a Roux-en-Y anastomosis in 88% of the patients. Average follow-up was 7 years. Good results were reported in 83% of the cases. There were three deaths in children <1 year of age with severe cirrhosis at the time of diagnosis. The authors emphasize the following points. (1) Abdominal echotomography and transparietal cholangiogram are the most useful preoperative investigations. (2) A close etiopathogenic relation exists between the CDBD and a common hepaticopancreatic duct (>40% in this series). (3) Early surgical treatment must be undertaken. Total cyst excision with a Roux-en-Y hepaticojejunostomy should give the best long-term results with minimal exposure to secondary malignancies of the biliary tract.--J.M. Guys Reoperation for Congenital Choledochal Cyst. T. Todani, Y. Wata-
nabe, A. Toki, et al. Ann Surg 207:142-147, (February), 1988. Between 1960 and 1986, 92 patients with choledoebal cyst underwent surgical intervention (primary excision of the cyst 60, secondary excision 13). Seventy-three patients underwent excisional procedures with biliary reconstruction: hepaticoduodenostomy (51), hepaticojejunostomy (Roux-en-Y) (20), pancreatoduodenectomy (1), and excision of the cholcdochocele (1). Twenty-three patients underwent reoperation for choledochal cyst and are analyzed. Eight initially underwent external drainage, eight internal drainage, and seven underwent excision. Reoperation rate in the total population was 14.3%. The eight patients with external drainage underwent secondary excision with favorable results. Five patients with internal drainage underwent secondary excision of the cyst because of recurrent cholangitis and abdominal pain; three were for carcinoma. The seven patients undergoing excisional procedures required reoperation for anastomic leak (4) and bleeding (3). Eleven patients were lost to follow-up. Excisional procedures with biliary reconstruction is the treatment of choice in preventing malignant complications of choledochal cyst. The authors present a lengthy discussion of the complications associated with choledochal cyst, surgical interventions, and the alternatives for pre, peri, and postoperative management of those complications.--Edward G. Ford