Kaihang Wang, Omid Madadi-Sanjani, Yuan Liu, Dimitri A Raptis, Vasanthakumar Gunasekaran, Ashwin Rammohan, Seisuke Sakamoto, Hajime Uchida, Piotr Kaliciński, Nicolas Goldaracena, Cornelius J van Beekum, Felix J Krendl, Itsuko Chih-Yi Chen, Bryanna N Domenick, Alfred Kow, Yuji Soejima, Katryn N Furuya, George V Mazariegos, Vidyadhar Padmakar Mali, Stephen Dunn, Kim Olthoff, Samir Abu-Gazala, Elizabeth B Rand, Ian Leipnitz, Chao-Long Chen, Deniz Balci, Elvan Onur Kirimker, Silvio Nadalin, Stefan Schneeberger, Debra L Sudan, Moritz Schmelzle, Uta Herden, Lutz Fischer, Blayne A Sayed, Vicky L Ng, Grzegorz Kowalewski, Mureo Kasahara, Mohamed Rela, Dieter C Broering, Qiang Xia, Pierre-Alain Clavien, Zhihao Li
Biliary reconstruction is often considered the Achilles' heel of liver transplantation, yet risk factors and outcomes remain poorly defined, particularly in pediatric living donor liver transplantation (LDLT). This international multicenter study aims to identify predictors of biliary complications and evaluate their impact on long-term outcomes. 2,665 pediatric patients who underwent LDLT between January 2019 and December 2023 across 19 centers were included. Multivariable logistic regression was performed to identify risk factors, while time-dependent Cox models were used to assess impact on survival. The median recipient age was 11 months (IQR: 6.3-34.6) and biliary atresia was the most common diagnosis (59.7%). Bile leak and anastomotic stricture occurred in 3.6% (n=97) and 1.9% (n=51) of patients, respectively. For bile leak, higher donor BMI was an independent predictor (OR 1.09 per kg/m², 95% CI: 1.02-1.17). For anastomotic strictures, longer cold ischemia time was a significant predictor (OR 1.36 per hour, 95% CI: 1.03-1.79). Bile leak (aHR 4.39, 95% CI: 1.04-18.60) and biliary stricture (aHR 6.26, 95% CI: 1.58-24.80) were associated with worse graft survival. Patient survival was not significantly impacted by bile leak and stricture. Early complications more often required surgery, but survival and failure-to-rescue rates were similar regardless of treatment approach. Ultimately, bile leak and anastomotic stricture remain significant threats to graft survival. The identified risk factors offer insights for risk stratification and prevention strategies aimed at improving outcomes in children undergoing LDLT.