Reply to Comments on “Bile Exposure and Postoperative Cholangitis After Laparoscopic Resection of Choledochal Cysts: Clarifying Exposure, Controlling Confounding”

We sincerely appreciate Shaikh and colleagues for their meaningful and constructive comment on the letter regarding our multicenter retrospective study on intraoperative bile exposure (BE) and postoperative cholangitis after laparoscopic excision of choledochal cysts [1]. We appreciate their careful methodological appraisal and welcome the opportunity to clarify several points.

Regarding the definition of BE, we agree that a strict distinction between intraoperative bile contamination and postoperative bile leakage is methodologically important. In our study, however, BE was intentionally defined in a pragmatic manner to reflect clinically relevant surgical scenarios encountered during laparoscopic choledochal cyst excision. Our primary objective was not to establish a mechanistic model, but rather to explore whether clinically apparent bile exposure during the operative procedure was associated with postoperative outcomes. While we acknowledge that inclusion of immediate postoperative leakage may complicate interpretation, we believe the definition used reflects real‐world surgical practice and provides clinically meaningful insight. Nonetheless, we agree that sensitivity analyses using narrower definitions would be valuable in future investigations.

We also acknowledge the potential influence of surgical procedure and improving operative techniques. Although all procedures were supervised by a single experienced surgeon and performed within a consistent institutional framework, refinements in operative sequencing were introduced over time with the aim of reducing bile exposure. These changes were an integral part of quality improvement in surgical practice rather than an independent exposure of interest. We agree that learning‐curve or era effects cannot be entirely excluded, and future studies with a large number of cohorts would benefit from analytical approaches that more explicitly account for temporal trends.

With respect to statistical methodology, we recognize that multivariable or propensity‐based analyses may better address confounding. In our study, given the limited sample size and sparse outcome events, we elected to use simpler analytical approaches to avoid model instability and overfitting. Our findings should therefore be interpreted as exploratory and hypothesis‐generating rather than definitive evidence of causality.

We concur that separating different mechanisms contributing to bile exposure—such as prolonged exposure due to operative sequencing versus bile duct injury—may further refine understanding of postoperative cholangitis. Similarly, standardized definitions and adjudication of postoperative cholangitis would strengthen future multicenter studies.

Regarding follow‐up duration, we agree that longer‐term surveillance is essential for the assessment of late biliary complications. The present analysis focused primarily on early and intermediate postoperative outcomes, and extended follow‐up of this cohort is ongoing.

Finally, we thank the authors for drawing attention to discrepancies in the reporting of drain removal timing and p values. We acknowledge these inconsistencies and appreciate the opportunity to address them to improve clarity.

In conclusion, we are grateful to Shaikh et al. for their insightful commentary, which highlights important methodological considerations and underscores the need for larger, methodologically robust studies. We believe that our findings, interpreted within their acknowledged limitations, contribute to the ongoing discussion regarding surgical strategies aimed at minimizing postoperative cholangitis after pediatric choledochal cyst surgery.

Conflicts of Interest

The authors declare no conflicts of interest.