Background: Roux-en-Y hepaticojejunostomy(HJ) is the standard-of-care for biliary reconstruction in pediatric liver transplantation(LT), especially in left sided grafts. This study aimed to investigate the learning curve and the risk of biliary complication of duct-to-duct biliary anastomosis(DDA) in pediatric LT using left sided grafts.

Method: This was a retrospective study from a surgical unit of a university-affiliated center. From 2017-2020, DDA was performed in pediatric LT with a high hilar dissection and patch anastomosis technique under a prospective protocol.(Figure 1) The exclusion criteria were: 1) disease mandated HJ, 2) widely separated graft bile ducts that ductoplasty was infeasible, 3) native biliary anatomical factors that rendered a patch infeasible. Size discrepancy was not a contraindication. The primary endpoint was the risk of biliary complication at 1-year after LT.

Results: During study period, 137 pediatric recipients fulfilled inclusion and were considered eligible for DDA, 110 (80.3%) patients had DDA. The pre-transplant characteristics were listed in table 1. The first 40 patients belonged to learning curve period and after that, more patients were eligible for DDA (7.2% vs. 15.1%, P<0.001). The overall risk of biliary complication at 1-year was 2.9% (4/137) and it was higher in the learning phase (9.1% vs 1.3%, P=0.045). Of the 4 biliary complications: 1 had bile leakage and stricture and required endoscopic stenting; 3 had biliary stricture with 2 required conversion to HJ and 1 had endoscopic stenting. All 4 patients have normal graft function at time of analysis. There was only one hospital mortality (1/137, 0.7%) and was due to post-operative bleeding and was unrelated to biliary complication. Graft survival rates at 1-and 3-year after DDA were 98.2% and 96.8% respectively.

Conclusion: DDA was safe and feasible with excellent perioperative and long-term outcomes and should be considered the primary choice for biliary reconstruction in eligible pediatric transplant patients.