Safety and feasibility of duct-to-duct biliary anastomosis in pediatric liver transplantation: A single-center retrospective study

The objective of this study was to assess the safety and feasibility of duct-to-duct anastomosis (DDA) in pediatric liver transplantation with left-sided grafts. The Roux-en-Y hepaticojejunostomy (HJ) represents the gold standard for biliary reconstruction in pediatric liver transplantation. Nevertheless, the feasibility of DDA in pediatric liver transplantation remains a topic of contention and is a relatively limited technique. A total of 3307 pediatric recipients who underwent LT at Renji Hospital between October 2006 and October 2023 were enrolled in the study. Of these, 218 underwent DDA with high hilar dissection and patch anastomosis, in accordance with a prospective protocol. A comprehensive analysis was conducted to determine the risk factors for exclusion from DDA and the outcomes of recipients of DDA. The mean operative time was significantly shorter in the DDA group (DDA vs. HJ=6.5 h vs. 7.0 h, p <0.001). A minimum of 1 year of follow-up revealed that biliary complications occurred in 8 cases of recipients of DDA (3.7%) and 1 case of a recipient of HJ (1.6%), with no statistically significant difference ( p =0.69). No significant difference was observed in mortality between the DDA and HJ groups (DDA vs. HJ=1.8% vs. 1.6%, p >0.99). The graft survival rates at 1 and 3 years after DDA were 98.2% and 96.8%, respectively. However, patients with Langerhans cell histiocytosis may be unsuitable candidates for DDA due to their elevated rates of DDA exclusion and biliary complications. Appropriate learning and decision-making processes ensure the safety and feasibility of DDA, with excellent perioperative and long-term outcomes. It is therefore recommended that DDA should be considered the first choice for biliary reconstruction in eligible pediatric patients of transplant.