Outcomes of Biliary Complications in Pediatric Liver Transplantation: Is There a Role of Anastomosis Type and Epstein–Barr Virus Viremia?

Background: Biliary complications remain a common adverse event after pediatric liver transplantation, with distinct etiologies and management approaches based on timing. This study aimed to evaluate the incidence, risk factors, and outcomes of early and late biliary complications in a high-volume living donor pediatric liver transplant center. Methods: We retrospectively analyzed 98 pediatric liver transplantations performed between January 2018 and February 2024. Biliary complications were categorized as early (≤90 days) or late (>90 days) post-transplant. Risk factors were assessed using univariate and multivariable logistic regression models. The impact of biliary complications on overall survival was also evaluated. Results: Biliary complications occurred in 34.6% (n = 34) of cases. Early complications (19.4%, n = 19) were predominantly bile leaks, with duct-to-duct anastomosis identified as an independent risk factor (OR: 5.179, 95% CI: 1.511-17.756). Late complications (15.3%, n = 15) were primarily biliary strictures. Older recipient age and EBV viremia emerged as significant independent risk factors for late biliary complications (OR: 1.140 and OR: 60.793, respectively). No significant difference in overall survival was observed between patients with and without biliary complications (P = .158). Conclusion: Duct-to-duct anastomosis remains a safe and reliable option in anatomically suitable pediatric cases when performed by experienced teams, despite a higher risk of early complications. EBV viremia and increased recipient age are significant predictors of late biliary strictures. These findings emphasize the need for vigilant surveillance, individualized transplant timing, and standardized EBV management strategies to reduce long-term biliary morbidity.