Outcomes of choledochoduodenostomy in pediatric liver transplantation.

Background: The most common types of biliary reconstruction in pediatric liver transplantation are end-to-end choledochocholedocostomy (CC) and choledochojejunostomy (CJ). Choledochoduodenostomy (CD) is seldom used, and consequently, there are very few reports in the literature about the outcomes of CD reconstruction in pediatric liver transplant. We hypothesized that CD is a safe alternative for pediatric liver transplantation.

Methods: Between 1/2017-2/2024, 186 consecutive primary liver transplants in children (<21 y) were performed at Stanford Medicine Children's Health. Seventy-three patients underwent CC, 55 underwent CJ, and 41 underwent CD.

Results: The type of bile duct reconstruction did not influence the 5-year patient and graft survival rates (p=0.14). Intraductal stents were used in 6%, 100%, and 95% of the CC, CJ, and CD groups, respectively. Biliary strictures were observed more frequently in the CC than in the CJ and CD groups (21% vs. 5% vs. 2%, respectively; p<0.001). Four percent (P=0.06) in the CC group experienced bile leaks, and no bile leaks were observed among patients with CJ or CD reconstructions. The incidence of cholangitis in the CC, CJ, and CD groups was 1%, 10%, and 5%, respectively (p=0.10). Overall, patients with CD had the fewest biliary complications (p=0.01). In the CC group, 2 (2.4%) patients required conversion to CD and 6 (7.3%) required conversion to CJ for bile duct obstruction (9.7%). One patient (2%) in the CD cohort and no patients in the CC cohort required stent removal post-transplantation.

Conclusions: Choledochoduodenostomy is considered a safe alternative. Biliary complications were not associated with graft loss or mortality. Post-operative biliary complications are infrequent, suggesting that CD is a suitable and possibly superior type of biliary reconstruction compared to conventional CC or CJ anastomosis.