Choledochal cysts (CCs) are congenital disorders presenting as abnormal cystic dilatation of the intrahepatic and/or extrahepatic bile ducts (1), and can develop at all ages; however, approximately 80% of CCs are diagnosed before the age of 10 years (1, 2). CCs are thought to be more common in Asia than in Europe and the Americas, with incidence rates ranging from 1:1,000 live births in Japan to 1:13,500 live births in the United States (3), and approximately four times the incidence of CCs in females than in males in Western countries (4). CCs can lead to several serious complications such as recurrent cholangitis, acute pancreatitis, secondary biliary cirrhosis, and severe malignancies (5). Surgery is considered the cornerstone of the treatment of CCs (6), and surgical resection of the lesion and reconstruction of the bile ducts are effective in reducing the long-term risk of cancer, pancreatitis, and cholangitis (7).

In the early days, CCs were treated with open surgery using Roux-en-Y hepaticojejunostomy (8). However, since the 21st century, minimally invasive surgery using laparoscopy has been increasingly used for CCs (9), and robot-assisted surgery has become a trend in pediatric surgery (10), both of which have demonstrated better intraoperative and postoperative outcomes than open surgery, and the development of surgical modalities has been effective in decreasing mortality rates in children with CCs (11, 12). Despite the fact that surgical treatment is effective in treating CCs, perioperative complications as well as complications due to poor postoperative management remain a major threat to the health of patients (13, 14). Postoperative follow-up and long-term monitoring have become necessary programs for patients with CCs after surgery (15).

Bibliometrics uses mathematical and statistical methods to quantitatively analyze information from the literature. This approach permits the examination of quantitative and distributional patterns in the literature, which helps to explore the patterns and characteristics of scientific activity in depth (16). By examining publication data (e.g., number of articles, citations, and collaborative networks), bibliometrics provides a clear view of the research landscape (17). This provides an alternative perspective to traditional analytical approaches to facilitate evidence-based decision-making in academia (18). Using this approach, we can shed light on research patterns, evolutionary trajectories, emerging hotspots, research frontiers, and future trends in specific scientific fields (19, 20).

Therefore, this study presents the first bibliometric analysis of the surgical treatment of CCs, aiming to quantitatively map the global research landscape from 2001 to 2024, to identify seminal publications and evolving research priorities, and to predict translational pathways to optimize clinical practice, which in turn will identify future international research trends in the surgical treatment of CCs.

Since the beginning of the 21st century, the interest of researchers in the surgical treatment of CCs has continued to increase. In particular, since the beginning of 2019, there has been a significant increase in research results in this field, which may be attributed to the rise in interest in cholestatic diseases in children, of which CCs are an important component (21). Consequently, research organizations have increased their support for research on CCs, and research funding has been increasing, contributing to the rapid development of this field.

The prevalence of CCs in Asia is among the highest in the world, and China and Japan represent this (22–24). This explains why China and Japan have participated in the largest number of studies related to the surgical treatment of CCs, and four of the top five countries in terms of the number of participating studies are located in Asia. The most involved author was LI L (Long Li) from the Capital Institute of Pediatrics, China, whose research focused mainly on laparoscopic and robotic surgery for CCs and its complications (11, 25, 26), exploring the advantages of laparoscopic and robotic use for CCs surgery, especially in total cyst excision of choledochal cysts and Roux-en-Y hepatoenterostomy (27, 28). These studies provide strong evidence and support for the use of laparoscopic and robotic surgery for CCs. Also the country with the highest number of MCPs. However, we should also note that the top five countries have low MCP rates and that inter-author collaborations are basically within the country, which illustrates the limited international collaborations in CCs and the potential to improve research competitiveness through cross-national collaborations, highlighting the need for broader international inter-institutional collaborations. The increased risk of cholangiocarcinoma after Roux-en-Y anastomosis requires multinational cohorts to establish evidence-based surveillance programs (29). Differences in robotic surgery adoption rates between high-and low-income regions call for increased international collaboration in sharing technical training frameworks for global public health building. Regional genetic differences in the pathogenesis of CCs call for studies in diverse populations to develop precision prevention strategies.

Highly cited publications provide valuable insights into influential research. The most cited article published in ANNALS OF SURGERY “Late development of bile duct cancer in patients who had biliary-enteric drainage for benign disease: a follow-up study of more than 1,000 patients” demonstrated a link between biliary-enteric anastomosis and the development of biliary malignancies and revealed that the Roux-en-Y technique is expected to produce a lower incidence of cholangitis (29). These studies emphasize the need for proper surgical selection for the management of postoperative complications. The second most cited article titled Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct compared endoscopic sphincterotomy and laparoscopic exploration of the common bile duct (29).

and laparoscopic exploration for bile duct stone removal, demonstrating the advantages of laparoscopic surgery in terms of reducing complications and providing support for the early use of laparoscopy in biliary surgery (30). The use of novel surgical approaches is necessary in the surgical treatment of CCs, while surgeons should not ignore the presence of complications when dealing with patients with CCs and should individualize the diagnosis and treatment for the conditions present in different patients in order to reduce postoperative recurrence and complications.

The keyword analysis highlights the main research trends in the surgical management of CCs. The most frequent word “management” proves that CCs surgical research in the 21st century has focused on preoperative and postoperative course management. The most frequent words “resection,” “excision” and “surgery” illustrate that the surgical resection protocol for CCs represented by the Roux-en-Y hepaticojejunostomy for cyst removal is the most popular one in the 21st century. Roux-en-Y hepaticojejunostomy for cysts is the primary surgical resection option for CCs. Therefore, the management of complications after resection of CCs is an important area of research, and the development of biliary tract cancer after resection of CCs is mainly observed in patients with type I and type IV cysts (31). Although the surgical removal of CCs reduces the risk of developing biliary tract cancer (32), the risk of malignancy does not return to baseline population levels (33). Secondary postoperative cholangitis and bacterial infection are risk factors for poor prognosis and even cancer development (34). Therefore, the prevention of infection and intraoperative attention to pancreaticobiliary injuries are important aspects of management (35). The high frequency of the word “children” indicates that although CCs are diagnosed in all age groups, surgery in childhood is still predominantly performed (36). The term “diagnosis” illustrates the great significance of preoperative diagnosis, and early differentiation of CCs from other biliary disorders such as biliary atresia by prenatal ultrasound and MMP7 monitoring is the focus of clinical research (21). “Dilatation,” on the other hand, is indicative of the attention paid to the morphological aspects of pathological changes in CCs, and the different pathologic and structural alterations caused by the numerous subtypes of CCs pose a challenge for definitive diagnosis and surgical procedures to be performed (37, 38). The evolution of keywords over time also shows that the research on CCs in the 21st century has developed a “structure-surgery-management” model. The focus of researchers is no longer limited to the disease and the procedure itself but is more focused on the long-term prognosis of the patient, reducing the cost of patient care and readmission rates (39).

The most common surgical approaches for CCs are cystectomy and Roux-en-Y hepaticojejunostomy, particularly for type I CCs. The traditional approach is open surgery, which is associated with complications such as high trauma, intraoperative bleeding, and pancreaticobiliary injury (40, 41). Farello et al. were the first to describe cystectomy and Roux-en-Y hepaticojejunostomy using laparoscopy in a 6-year-old child with type I choledochal cyst in 1995 (42). This has marked the official use of laparoscopy for CCs. Compared with conventional open surgery, laparoscopic resection is associated with less surgical blood loss, shorter recovery time for bowel function, shorter time to tolerate diet, shorter hospitalization, and shorter time to require parenteral nutrition (43). Crucially, laparoscopy significantly reduces short-term postoperative complications of CCs and long-term complications, including strictures, cholangitis, cirrhosis, and malignancy, most notably type III CCs (11, 44). However, previous analyses have shown that laparoscopic resection is more technically demanding and surgeon experience is critical for good outcomes in pediatric laparoscopic biliary surgery (45, 46). Meanwhile, studies on long-term complications after laparoscopic surgery still remain single-center studies (47), so the management of long-term complications and comparative studies of long-term complications between novel surgical approaches and open surgery, especially large multicenter studies, remain the focus of future surgical research in CCs.

With the development of minimally invasive technologies, robot-assisted surgery, represented by the da Vinci robotic surgical system, has enabled surgeons to perform a wide range of procedures (48). The first case of robotic surgery in a child was reported in 2001 (49). After the first da Vinci robotic surgical system-assisted excision of CCs was performed in the United States by Woo et al. in 2006, robot-assisted excision of CCs has been reported worldwide (50, 51). The population undergoing surgery has also gradually expanded from older children and adolescents to neonates (10). Current studies have demonstrated that robotic-assisted CCs surgery significantly shortens the duration of the procedure, and at the same time, due to visibility and simplification in terms of maneuvering, it will be easier for the surgeon to complete the operation and improve the surgical conversion rate (12, 45). Previous studies have shown that robotic Roux-en-Y gastric bypass surgery has a significantly lower incidence of anastomotic stricture than laparoscopic surgery (52), and is also superior to laparoscopic surgery in terms of early complications and short-term outcomes of choledochal cyst resection and hepaticojejunal anastomosis in children (53). However, robotic-assisted surgery also faces the problems of higher surgical costs, high maintenance costs, and unfamiliarity of beginners with the strength of the robotic arm system, which may lead to poor outcomes, such as implant breakage (45). Strong clinical training and education in robot-assisted surgery, as well as reducing the cost of robot-assisted surgery through upgrading, is the future of pediatric surgery (10). Meanwhile, similar to laparoscopic surgery, there are still insufficient studies on the long-term postoperative outcomes of robot-assisted CCs surgery, which will be the direction of robot-assisted CCs surgery research in the future.

Preoperative diagnosis is a key aspect of CC surgery. Owing to the non-specificity of the clinical manifestations of CCs, imaging tools have been used as the main methods to diagnose CCs (54). Early endoscopic retrograde cholangiopancreatography (ERCP) is considered the most accurate diagnostic tool to characterize the different types of choledochal cysts and to detect associated ductal anomalies (55). In 2005, Do Hyun Park et al. proposed that magnetic resonance cholangiopancreatography (MRCP), instead of ERCP, would become the gold standard for the diagnosis of CCs, which can describe the anatomical structure of cysts in detail with–90-100% sensitivity and 90% specificity (56). It can characterize the anatomical structure of cysts in detail with 90–100% sensitivity and 90% specificity, thus determining the staging of CCs to specify the type of operation (56). With the rapid development of AI technology, AI-enabled quantitative MRCP (MRCP+) has emerged as a new diagnostic tool for biliary diseases (57). MRCP+ can process 3D MRCP acquisitions with AI-driven pathfinding algorithms and renal tubule enhancement to derive quantitative parametric models of the biliary tree and pancreatic ducts (58), which provides quantitative surgical indications for biliary diseases. The application of MRCP+ to the preoperative diagnosis of CCs will change the subjective nature of the current surgical indications for CCs. The combination of multi-omics analysis techniques with artificial intelligence technology will help in the development and refinement of surgical plans (59). Prenatal diagnosis is also an important part of preoperative management of CCs. Diao et al. reported in their randomized controlled trial that patients with prenatal diagnosis and early surgical resection of the cysts had a lower risk of liver fibrosis over time (60). Aggressive prenatal diagnosis for early detection of the disease would positively impact the preoperative management of CCs, as well as surgical outcomes.

In terms of long-term prognosis after surgery, annual repeat ultrasound and Ca19.9 are recommended for lifelong follow-up because of the risk of anastomotic stenosis, cholangitis, intrahepatic stone formation, and a higher risk of malignant cancers after resection of CCs than in the normal population (54). The classification of CCs into different subtypes, whether open or laparoscopic, should be enhanced, and the Todani classification is essential to guide treatment (61). Implementing precise and individualized prognostic protocols for different individual patients with different intraoperative conditions is a trend in prognostic management (2).

This analysis provides actionable insights for optimizing the treatment of choledochal cysts. Given the advantages of laparoscopic total cystectomy in reducing perioperative morbidity and long-term complications, surgeons should consider it as the treatment of choice for type I/IV cysts, especially in the pediatric population (11, 43, 44). Robotic-assisted techniques should be considered for complex reconstructions or neonatal cases when institutional resources allow, and cost constraints should be addressed through structured training programs while recognizing their technical advantages (10, 12, 45, 53). Preoperative evaluation must include MRCP as a diagnostic cornerstone for anatomical characterization and Todani classification (56), and prenatal diagnosis requires early postnatal intervention to reduce the risk of liver fibrosis (21, 25, 60). Postoperative protocols require lifelong surveillance through annual ultrasound and CA19-9 monitoring to reduce the likelihood of malignancy (33, 54), as well as meticulous intraoperative techniques to prevent pancreaticobiliary duct injury and infection (34, 35). Finally, the establishment of multinational registries to track longitudinal outcomes of minimally invasive approaches would close current evidence gaps and standardize management paradigms (47).

This study is the first to use bibliometric methods to investigate the development and prospects of surgery for CCs. However, this study had some methodological limitations. First, reliance on the Web of Science Core Collection as the sole source of data may create a systematic bias in mapping the research landscape, as it excludes publications from emerging journals and regional databases. Second, assessment frameworks centered on citation frequency and publication volume may not adequately reflect scholarly innovation because of journal prestige and disciplinary publishing preferences. In addition, inherent limitations of the bibliometric approach remain, including the inability to contextualize citation motivations, the reduced visibility of non-English literature, and unaddressed self-citation bias. Finally, while the analysis uses the most recent available data, the rapid development of driving technologies in the AI era requires continuous data update mechanisms and the integration of technology foresight methods to address time constraints and capture dynamically evolving research frontiers and application scenarios.

The bibliometric analysis suggests that surgical research on CCs is accelerating due to increasing clinical interest in long-term outcomes and new technologies (laparoscopic/robotic). Immediate priorities include improving preoperative diagnosis and postoperative complication management. These evolving trends provide strategic direction for researchers and clinicians to optimize prognostic pathways.