Risk factors for biliary complications after pediatric liver transplantation: a retrospective study and twenty years of experience from a single center in China

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However, postoperative biliary complications (BCs) are still a challenge and threaten patients' quality of life and survival. To conduct valuable management and therapy strategies, this study retrospectively analyzed the clinical characteristics of pediatric LT patients and investigated the risk factors for BC in a single transplant center in China. Methods: Data from 174 pediatric patients (BC and non-BC) treated at the Liver Transplant Center of West China Hospital between 2001 and 2023 were collected. The authors retrospectively reviewed medical records, including patient characteristics, surgical procedures, and prognoses, and searched for risk factors of BC with univariate and multivariable analyses. Results: BCs occurred in 30 of the 174 pediatric recipients (17.2%). The main types were bile leak, biliary stricture, and cholangitis. Among them, 10 bile leaks, constituting 26.3% of all BCs, 22 biliary strictures, representing 57.9%, and 6 cases of cholangitis. Children with bile leaks or cholangitis were usually cured after conservative treatment, while children with biliary strictures needed surgical intervention or endoscopic therapies. The multivariable analyses revealed that preoperative hypoalbuminemia in recipients (OR = 22.337, 95% CI 8.054–64.969, P = 0.001), postoperative hepatic artery complications (OR = 12.308, 95% Cl 2.665–56.838, P = 0.001), and prolonged intensive care unit (ICU) stay (OR = 1.002, 95% Cl 1.000 to 1.003, P = 0.012) were independent risk factors for BC after pediatric liver transplantation. Conclusions: Preoperative hypoalbuminemia in recipients, postoperative hepatic artery complications, and prolonged ICU stay are positively associated with BC in pediatric patients after LT. Biliary complications Children Hypoalbuminemia Liver transplantation Risk factors Figures Figure 1 Figure 2 Figure 3 1. Introduction For children with end-stage liver disease and certain metabolic disorders, liver transplantation (LT) serves as the only potentially effective curative treatment, offering opportunities to prolong survival and improve quality of life. However, biliary complications (BCs) remain a challenge and pose a significant threat to patient outcomes. The incidence of BC ranges from 10–20% in adult living donor liver transplantation (LDLT) [1] , whereas in pediatric LDLT, it ranges from 5–35% [2] . Some studies have revealed that BC can result in graft failure, necessitating retransplantation in 6–13% of patients, leading to poor long-term prognosis [3] . BCs are classified into biliary strictures (BSs), which can be anastomotic or intrahepatic, bile leaks (BLs), bilomas, excluded ducts, stones, and cast formations, among others [4] . The occurrence and development of BC are closely related to every aspect of the perioperative procedure. The therapeutic strategy for BC is multidisciplinary, based on the type and severity of the complication and the biliary reconstruction technique applied, including nonoperative and invasive treatment. The effective identification of risk factors for BC, along with early diagnosis and timely intervention, could lead to better outcomes. In this study, we retrospectively investigated potential risk factors and concluded therapy strategies for biliary complications in pediatric patients who underwent LT at a single transplant center, with the overarching aim of preventing postoperative BC. 2. Methods 2.1 Patient selection This study was conducted at West China Hospital, Sichuan University, China. We retrieved data from a retrospective research database containing detailed clinical, demographic, therapeutic, pathological, and follow-up information for all patients who underwent LT at our institution. Patients younger than 14 who received liver transplants were enrolled between October 2001 and February 2023. All patients followed a standardized regimen for immunosuppression, antibiotic therapy, and prophylaxis. Patients with incomplete clinical information and those who were lost to follow-up were excluded from the study. This study report was prepared following the guidelines outlined in the Strengthening the Reporting of Cohort cross-sectional and case‒control studies in surgery (STROCSS) statement. 2.2 Postoperative management of LT recipients Postoperative children were routinely transferred to the intensive care unit (ICU) for continued medical management. Regular monitoring included liver and renal function tests, routine blood examinations, and blood coagulation function examinations. The volume and color of the abdominal drainage fluid were carefully observed, and biliary stent drainage fluid was periodically collected for culture. Liver and abdominal ultrasonography were performed regularly to assess the diameters, blood flow velocities, and resistance indices of the portal vein, hepatic veins, and hepatic artery. To evaluate the intrahepatic and extrahepatic biliary systems, if necessary, CT and/or MRI could be performed. 2.3 Data collection The liver transplantation donor and recipient parameters were collected. In accordance with the LT procedure, the following variables were analyzed via univariate and multivariate analyses. Preoperative data included the donor's and recipient’s demographic and clinical data, such as sex, age, blood type, weight, height, and baseline liver and renal function parameters. Surgical data included the type and volume of grafts, GRWR, hepatic artery reconstruction techniques, biliary stent insertion, biliary reconstruction techniques, warm and cold ischemia time, length of the anhepatic phase, amount of intraoperative intravenous input and blood loss, RBC transfusions, and operation time. Postoperative data included cases of hepatic artery complications, the length of ICU stay, and the duration of hospitalization. 2.4 Definitions Biliary stricture was defined as a narrowing of more than 50% of the biliary lumen or a dilatation of the biliary tree of more than 2 mm [5] . Biliary anastomotic stricture was defined as a focal narrowing occurring within 5 mm of the surgical anastomosis [6] . Non-anastomotic biliary stricture was characterized by an irregular narrowing located more than 5 mm from the anastomosis [7] . Biliary cast information referred to a series of pathological manifestations resulting from the accumulation of necrotic and sloughed biliary epithelial cell debris within the bile duct lumen. Bile leak was defined as a drain bilirubin concentration > 3-fold serum concentration on POD 3 or later [8] . Cholangitis was defined as a bile infection manifesting clinically with a combination of symptoms (fever, jaundice) and with biochemical alterations (predominantly in alanine aminotransferase, gamma-glutamyltransferase and/or direct bilirubin) but not necessarily positive radiological findings [5] . The ALBI score was calculated according to the following equation [ALBI score=-0.085 (albumin g/L) + 0.66 log10 (Tbil µmol/L)]. ALBI grades were inductively defined as follows: grade 1 -2.60 to ≤-1.39 and grade 3 >-1.39 [9] . Hypoalbuminemia was considered when the serum albumin level was < 35 g/L [10] . Postoperative mortality was defined as death within 90 days after liver transplantation. 2.5 Statistical analysis All the statistical analyses were performed via SPSS Windows version 27.0 (SPSS Inc., Chicago, IL). Continuous variables were reported as the mean ± SD or as the median (range) for continuous variables with a non-normal distribution. Intergroup comparisons were analyzed via Student’s t test or the Mann‒Whitney U test, as appropriate. Categorical variables were reported as counts (percentages) and compared via the chi-square test or Fisher’s exact test. Multivariate analysis was performed by the binary logistic regression model. To include as many variables as possible in the multivariable analysis, variables with a P value < 0.1 in the univariate analysis were incorporated into the regression model to evaluate independent risk factors for biliary complications. The risk predictions were reported as P values, odds ratios (ORs), and 95% confidence intervals (CIs). Overall survival curves were generated via the Kaplan–Meier method. The calculated P values were 2-sided, and a P value < 0.05 was considered statistically significant. 3. Results 3.1 Demographic and preoperative clinical characteristics of LT recipients and donors Between November 2001 and February 2023, a total of 188 children who underwent LT were screened for eligibility. After 14 cases involving liver autotransplantation, significant data deficiencies, and loss to follow-up were excluded, 174 patients were ultimately enrolled in the study (Fig. 1, flowchart of included patients), including 30 children who experienced BC. The overall BC rate in the cohort was 17.2% (30/174). The mean post-transplantation follow-up period was 83 months (range, 0–271 months). The demographic and baseline preoperative clinical characteristics of the recipients are summarized in Table 1 (Table 1 , Baseline demographic and preoperative clinical characteristics of the LT recipients). The male-to-female ratio was 1.02:1, with a median age at surgery of 10 months (range, 3–178 months) and a mean age of 41 ± 5 months. The median weight was 8.6 kg (range, 6.15–17.00 kg). Within our cohort, 30 patients (17.3%) were classified as ALBI grade 1, 89 patients (51.1%) were classified as grade 2, and 55 patients (31.6%) were classified as grade 3. The primary diagnoses included 144 cases of severe liver cirrhosis (134/174), predominantly biliary atresia (121/174), which accounted for 69.5% of all recipients in this cohort, 19 metabolic liver disorders (10.8%), 7 liver tumors (4.1%), 6 retransplantations (3.5%), and 8 others (4.6%) (details in Table 1 ). Table 1 Baseline demographic and preoperative clinical characteristics of LT recipients Characteristic BC Group(n = 30) NBC Group(n = 144) P Sex, n (%) 0.740 male 16(53.3) 72(50.0) female 14(46.7) 72(50.0) Age, month, median(range) 8.00(6.00, 60.25) 10.00(6.25, 67.00) 0.439 Weight, Kg, median (range) 8.50(6.15, 15.63) 8.65(7.00, 17.00) 0.601 Height, cm, median (range) 70.00(61.75, 106.50) 68.00(62.00, 103.63) 0.936 Blood type, n (%) 0.782 A 11(36.7) 42(29.2) B 7(23.3) 32(22.2) AB 3(10.0) 14(9.7) O 9(30.0) 56(38.9) ABO-incompatible LT, n (%) 0(0) 4(2.8) 0.604 TBIL, µmol, median (range) 246.20(239.44 ± 154.90) 182.30(27.85, 317.65) 0.156 ALB, g/L, median (range) 33.40(31.65, 39.85) 37.90(33.13, 41.88) 0.044 SCr, µmol, median (range) 18.00(14.00, 26.75) 21.00(15.23, 34.08) 0.101 BUN, mmol/L, median(range) 4.08(3.20, 5.53) 4.25(3.35, 5.68) 0.102 INR, median (range) 1.40(1.14, 1.67) 1.26(1.09, 1.53) 0.191 PELD score, median (range) 16.00(16.73 ± 8.73) 13.00(5.00, 20.75) 0.052 Causes for LT, n (%) 0.759 liver cirrhosis 26(86.7) 108(75.0) metabolic liver disorders 3(10.0) 16(11.1) liver tumors 0(0) 7(4.9) retransplantation 0(0) 6(4.2) other 1(3.3) 7(4.9) History of abdominal surgery, n (%) 16(53.3) 72(50.0) 0.740 Child-Pugh classification, n (%) 0.287 A 1(3.3) 20(13.9) B 15(50.0) 69(47.9) C 14(46.7) 55(38.2) ALBI grade, n (%) 0.036 I 2(6.7) 28(19.4) II 13(43.3) 76(52.8) III 15(50.0) 40(27.8) Hypoalbuminemia, n (%) 21(70.0) 50(34.7) <0.001 TBIL = total bilirubin, ALB = albumin, SCr = serum creatinine, BUN = blood urea nitrogen, INR = international normalized ratio. Meanwhile, the baseline clinical characteristics and liver function parameters of LT donors in both groups are summarized in Table 2 (Table 2 , Baseline demographic and preoperative clinical characteristics of LT donors), and there were no significant differences in those characteristics. Table 2 Baseline demographic and preoperative clinical characteristics of LT donors Characteristic BC Group(n = 30) NBC Group(n = 144) P Sex, n (%) 0.230 male 15(50.0) 60(41.7) female 15(50.0) 84(58.3) Age, month, median(range) 384.50(313.75, 447.00) 370.00(301.50, 444.75) 0.790 Weight, Kg, median (range) 60.00(49.75, 65.25) 55.00(49.25, 65.00) 0.555 Height, cm, median (range) 161.50(156.75, 170.00) 160.00(155.00, 167.00) 0.502 Blood type, n (%) 0.883 A 11(36.7) 43(29.9) B 7(23.3) 33(22.9) AB 3(10.0) 15(10.4) O 9(30.0) 53(36.8) Hb, g/L, median (range) 130.00(116.00, 140.00) 123.00(115.00, 135.00) 0.147 WBC, 10 9 /L, median (range) 6.14(4.82, 7.31) 6.39(5.08, 7.92) 0.363 PLT, 10 9 /dL, mean (SD) 176.00(73.93) 177.50(74.12) 0.897 TBIL, µmol, median (range) 11.15(8.05, 20.38) 13.10(8.83, 19.78) 0.792 ALB, g/L, mean (SD) 43.88 (4.90) 42.91 (5.29) 0.357 ALP, U/L, median (range) 76.50(57.00, 88.75) 80.00(61.00, 98.15) 0.320 γGT, U/L, median (range) 17.00(10.75, 39.25) 19.55(12.00, 37.50) 0.932 AST, U/L, median (range) 20.00(16.00, 29.00) 24.50(18.00, 39.75) 0.556 ALT, U/L, median (range) 22.00(13.00, 39.75) 27.00(15.00, 42.75) 0.220 Glu, mmol/L, median(range) 4.96(4.64, 5.56) 5.00(4.60, 5.85) 0.702 SCr, µmol, median (range) 66.85(49.00, 76.50) 62.10(53.00, 79.83) 0.577 BUN, mmol/L, median(range) 4.08(3.20, 5.53) 4.25(3.35, 5.68) 0.102 WBC = white blood cell, PLT = platelet count, ALP = alkaline phosphatase, γ-GT = glutamyl transpeptidase, ALT = alanine aminotransferase, AST = aspartate aminotransferase. 3.2 Intraoperative characteristics Among the 30 BC children, 25 underwent LDLT (including 8 liver left lobes and 17 left lateral segments), 3 underwent split liver transplantation (all were liver left lateral segments), and 2 underwent whole-liver transplantation. The NBC group consisted of 108 LDLTs (including 55 liver left lobes, 7 right lobes, and 46 left lateral segments), 32 split liver transplantations (14 left lobes, 2 right lobes, and 16 left lateral segments), and 4 whole-liver transplantations (Table 3 , Intraoperative characteristics of the recipients). In terms of the incidence of BC, there were no significant differences in the types of grafts, which was different from the findings of the study by Diamond et al [11] . With respect to biliary reconstruction techniques, children in the BC group had a greater incidence of biliary stent insertion (43.3% vs. 25.0%, P = 0.042), whereas in the BC group, 5 underwent duct-to-duct anastomosis, and 25 underwent hepaticojejunostomy. They also had more RBC transfusions (300.00 ml vs. 262.50 ml, P = 0.904), although the median estimated blood loss was 300 ml in both the BC group (range, 200–525 ml) and the NBC group (range, 200–500 ml) (P = 0.841). There were significant differences in hepatic artery reconstruction techniques and biliary stent insertion (13 (43.4%) vs 36 (25.0%), P = 0.042) between the BC group and the NBC group (Table 3 , P < 0.05 for all). Table 3 Intraoperative characteristics of recipients Characteristic BC Group(n = 30) NBC Group(n = 144) P Type of graft, n (%) 0.164 Live-donor graft 25(83.3) 108(75.0) Split liver 3(10.0) 32(22.2) Whole liver 2(6.7) 4(2.8) Type of graft, n (%) 0.373 LDLT Left lobe 8(26.6) 55(48.2) Right lobe 0(0) 7(4.9) Left lateral segment 17(56.7) 46(31.9) Deceased donors Left lobe 0(0) 14(9.8) Right lobe 0(0) 2(1.3) Left lateral segment 3(10.0) 16(11.1) Whole liver 2(6.7) 4(2.8) Hepatic artery reconstruction techniques, n (%) 0.047 Interrupted only 20(66.7) 119(82.6) Continuous posterior and interrupted anterior 10(33.3) 25(17.4) Biliary reconstruction techniques, n (%) 0.451 Duct-to-duct anastomosis 5(16.7) 33(22.9) Hepaticojejunostomy 25(83.3) 111(77.1) Biliary stent insertion, n (%) 13(43.3) 36(25.0) 0.042 Graft volume, g, median (range) 266.50(231.15, 300.00) 269.50(226.75, 330.00) 0.390 GRWR, (%) 2.95(1.59, 3.90) 2.87(1.54, 3.89) 0.973 Warm ischemia time, min, median (range) 2.00(1.00, 5.00) 2.00(1.00, 3.00) 0.696 Intraoperative intravenous input, ml, median (range) 1060.00(819.75, 1562.50) 1160.00(680.00, 2106.25) 0.768 Blood loss, ml, median (range) 300.00(200.00, 525.00) 300.00(200.00, 500.00) 0.841 Cold ischemia time, mean (SD) 227.93(117.84) 262.07(118.16) 0.073 Length of anhepatic phase, min, median (range) 73.50(62.10, 93.64) 75.00(63.00, 95.00) 0.866 RBC transfusions, ml, median (range) 300.00(195.00, 495.00) 262.50(150.00, 450.00) 0.904 Operation time, min, mean (SD) 525.70 (94.10) 525.00(95.00) 0.823 GRWR = graft-to-recipient body weight ratio, RBC = red blood cell. 3.3 Postoperative characteristics of the patients Children in the BC group had a greater incidence of hepatic artery complications (20.0% vs. 5.6%, P = 0.018), and they also had a longer duration of ICU stay (hour, median 378.50, range 208.25–809.25 vs. median 250.00, range 160.75–477.75, P = 0.027) and hospital stay (day, median 47.00, range 33.00–58.25 vs. median 38.00, range 32.00–52.75, P = 0.107) (Table 4 , Postoperative characteristics of LT recipients). Table 4 Postoperative characteristics of LT recipients Characteristic BC Group(n = 30) NBC Group(n = 144) P ICU stay, hour, median (range) 378.50(208.25, 809.25) 250.00(160.75, 477.75) 0.027 Hospital stay, day, median (range) 47.00(33.00, 58.25) 38.00(32.00, 52.75) 0.107 Hepatic artery complications, n, (%) 6(20.0) 8(5.6) 0.018 3.4 Incidence, Therapy Strategy, and Outcomes of Biliary Complications Among the 174 recipients, 30 (17.2%) had BCs. BCs occurred within a median post-transplantation period of 5.5 months (range, 0–24 months). The types, clinical management, and outcomes of the BCs are presented in Table 5 (Table 5 , Biliary complications, correlative treatment and outcomes). Of the 10 pediatric patients who presented with BL, 2 additionally developed anastomotic bile duct stricture (AS), and 1 presented with biliary stones simultaneously or sequentially. Biliary structure occurred in 22 recipients, and cholangitis occurred in 6 recipients. Twenty-nine of the 30 patients were treated with corresponding treatment, 20 of the 23 patients were taken invasive percutaneous treatments and/or endoscopic approaches without surgical intervention, and the success rate was 95.0% (19/20) in those patients. Six recipients died during the follow-up periods. The postoperative mortality rate was 10.0% (3/30). The causes of mortality were related to BC in three patients, and the other three patients experienced rejection or liver tumor recurrence. The overall 1-, 5-, and 10-year patient survival rates for the 174 pediatric LT recipients were 97.0%, 90.5%, and 82.0%, respectively. The overall 1-, 5-, and 10-year patient survival rates for the 30 pediatric LT recipients with BCs were 94.2%, 85.5%, and 71.3%, respectively, for the 144 recipients with NBCs, the rates were 97.1%, 90.1%, and 81.5%, showing no statistically significant difference, although there was a trend (P = 0.721) (Fig. 2, patient survival rates of the two groups). Table 5 Biliary complications, correlative treatment and outcomes Characteristic Incidence, n Treatment Prognosis Singular BC BL 6 Conservative approach 4 Recovered, 2 died for MODS BL 1 Surgical intervention Recovered AS 2 PTCD Recovered AS 1 Reject any therapy Died AS 1 ERCP + ENBD + ERBD Recovered AS 1 ERCP + ERBD + ENBD Chronic rejection, ultimately dead AS 1 ERCP + ERBD Died for upper gastrointestinal bleeding AS 1 PTCD + ERBD Recovered NAS 1 PTCD + ERBD Recovered Cholangitis 5 Antibiotic therapy 4 Recovered,1 retransplantation for rejection BCF 1 ERCP + ERBD Died for MODS BCF 1 PTCD + ERBD Recovered Biliary stone 1 PTCD Recovered Mixed BC BL + AS 1 Surgical intervention Recovered BL + AS 1 ERCP + ENBD + PTCD + Biliary reconstruction Recovered BL + Biliary stone 1 PTCD Recovered AS + Cholangitis 1 PTCD + Balloon dilatation Recovered AS + Biliary stone 3 PTCD + Balloon dilatation Recovered AS = anastomotic bile duct stricture, NAS = non-anastomotic bile duct stricture, BCF = biliary cast formation, PTCD = percutaneous transhepatic cholangial drainage, PTCS = percutaneous transhepatic choledochoscopy, ERBD = endoscopic retrograde biliary drainage, ENBD = endoscopic nasobiliary drainage, ERCP = endoscopic retrograde cholangiopancreatography, MODS = multiple dysfunction syndrome. In our experience, patients with bile leakage or cholangitis typically achieve resolution after conservative treatment, with only a few conditions requiring surgical or endoscopic interventions due to concurrent acute conditions or biliary stricture. In contrast, patients with AS or ischemic-type biliary lesions (ITBLs) appeared to necessitate interventional and endoscopic treatment, and a second surgical biliary reconstruction was needed in some pediatric patients (Table 5 ). 3.5 Risk factors for BC: Univariate and multivariable analyses According to the pediatric LT procedure, the following variables were included in the univariate analysis, and the possible risk factors for BC are shown in Tables 1 , 3 , and 4 . In the univariate analysis, the concentration of preoperative recipient’s ALB (P = 0.044), ALBI grade (P = 0.036), hypoalbuminemia (P < 0.001), hepatic artery reconstruction technique (P = 0.047), postoperative hepatic artery complications (P = 0.018), biliary stent insertion (P = 0.042), and ICU stay time (P = 0.027) were revealed as significant risk factors for BC. However, the type of graft (P = 0.373), biliary reconstruction technique (P = 0.451), preoperative Tbil (P = 0.156), and GRWR (P = 0.973) were not significant risk factors for BC. Indicators from the univariate analysis with P values < 0.1 were included in the multivariable analyses by the binary logistic regression model, and the results revealed that hypoalbuminemia (OR = 22.337, 95% Cl 8.054–64.969, P = 0.001), postoperative hepatic artery complications (OR = 12.308, 95% Cl 2.665–56.838, P = 0.001), and prolonged ICU stay time (OR = 1.002, 95% Cl 1.000-1.003, P = 0.012) were independent risk factors for biliary complications after pediatric liver transplantation (Table 6, Risk factors for BC in pediatric LT in the univariate and multivariable analyses) (Fig. 3, Forest plot of the independent risk factors for BC). 4. Discussion In the present study, we report the risk factors, outcomes, and therapeutic strategies for BC in pediatric patients who underwent LT. In addition to the various risk factors previously described, this research identified several specific risk factors, such as preoperative hypoalbuminemia in the recipients, which, to our knowledge, is the first formal presentation of this point. 4.1 ALBI score and classification Currently, the assessment of liver function in patients with hepatocellular carcinoma (HCC) is primarily based on the Child‒Pugh score. This system has been widely utilized in clinical practice since its inception, however, it has notable limitations due to the subjective nature of certain parameters and the inevitable information loss during score calculation [12, 13] . The Albumin-Bilirubin score system was first proposed by Johnson et al [9] in 2014, which was calculated based solely on the levels of serum ALB and total bilirubin, and has been validated through multicenter studies with large sample sizes, demonstrating its efficacy in assessing liver function in HCC patients. Multiple studies have confirmed its reliability as a predictor of survival, tumor recurrence, and the risk of hepatic failure following liver resection in candidates for potential treatment modalities (such as hepatic resection and ablation) [14, 15] . In recent years, researchers have also applied this tool to assess the efficacy of liver transplantation in adult patients, indicating that ALBI grade 3 was associated with lower post-transplant survival, suggesting its potential as a tool for risk stratification in liver transplantation [16–18] . Within our cohort, 15 of the 30 patients (50.0%) in the BC group were classified as ALBI grade 3, and 40 of the 144 patients (27.8%) in the NBC group, respectively, which was significantly different according to the univariate analysis. Compared with ALBI grade 1 patients, the risk of BC was greater in pediatric patients with ALBI grade 3 patients. Similar conclusions have been presented in other liver transplantation centers [17, 19] . We believe that the ALBI score system, as a novel tool due to its objectivity and accessibility of data, may serve as an instrument for assessing hepatic functional reserve in pediatric patients on the waiting list. We propose that the preoperative ALBI grade could be a simple, noninvasive predictor of biliary complications and outcomes in pediatric recipients. 4.2 Stent or not Whether a biliary stent should be inserted during biliary reconstruction remains controversial. The effects of stent insertion on the occurrence and progression of various biliary complications are inconsistent. On the one hand, for very small accessory ducts or high-risk marginal grafts, biliary stenting could provide effective support for biliary anastomosis, minimize intraductal pressure, and prevent bile leak and biliary stricture [20, 21] . Furthermore, postoperative surveillance can be effectively implemented to assess liver function by evaluating the characteristics and volume of bile drainage immediately or performing cholangiography. On the other hand, stent insertion may result in complications associated with the stent itself, such as bile leak caused by accidental stent removal [22] , as well as cholangitis resulting from retrograde flow through the external biliary stent [23] . Current meta-analyses have reported inconsistent results regarding the influence of stents on BCs. Sun et al. [24] reported that there were no significant differences in bile leak, anastomotic stricture, or mortality associated with BC between the stent group and the non-stent group. In contrast, other research highlighted that the overall incidence of BC, bile leak, and cholangitis was greater in the stent group, although the biliary stricture rate was significantly lower [25, 26] . Unfortunately, several analyses focusing specifically on BC following pediatric LT have not addressed the impact of stent insertion on the incidence of BC or prognosis [27–29] . On the basis of the developmental history and experience of our center, we have gradually reduced the use of stents since 2022. However, in pediatric patients with unhealthy imprecise biliary anastomoses or unequal tension on either side of the anastomosis, stent support is cautiously evaluated for insertion, provided that the distance from the anastomosis is greater than 1 cm and the diameter of the stent is less than that of the bile lumen. This approach has yielded positive short-term clinical outcomes, and we plan to evaluate long-term outcomes in this population in the foreseeable future. 4.3 Hepatic arterial reconstruction strategy and hepatic arterial complications Arterial suture techniques are categorized into interruption only and interrupted anterior plus continuous posterior sutures. Generally, interrupted suturing has the advantages of ease in adjusting suture spacing and minimal impact on vessel diameter, however, it may prolong the duration of the anastomosis. Continuous anastomosis, on the other hand, reduces the procedure time and provides better hemostatic outcomes compared to interrupted anastomosis. Nevertheless, it is associated with a greater risk of tearing injuries to the vessel wall and subsequent stenosis. In this study, 20 of the 30 patients (66.7%) in the BC group utilized interrupted sutures only, whereas 10 of the 30 patients in the BC group (33.3%) used interrupted anterior and continuous posterior sutures. In the NBC group, 119 patients underwent interrupted anastomosis, accounting for 82.6% of the group, with interrupted anterior and continuous posterior anastomosis comprising 25 (17.4%). Statistical analysis revealed that applying the interrupted suture technique only may effectively reduce the incidence of BC in pediatric patients. Studies have revealed that the blood supply to the biliary system following LT is derived primarily from the hepatic artery [30, 31] . Owing to the complexity of hepatic artery reconstruction, any factors influencing it, including the selection of anastomotic branches, the duration of anastomosis, the number of anastomoses, and the suturing technique, could impact the hepatic arterial system and blood flow to the bile ducts [32–34] . Hepatic complications, including hepatic artery thrombosis (HAT) and hepatic artery stenosis (HAS), have been identified as significant risk factors for BC following LT in recent studies [35–37] . HATs can lead to interruption of the blood supply to the graft, resulting in ischemic injury to the biliary system, which induces various BCs, for the biliary tree is notably dependent on blood flow provided by the hepatic artery. Furthermore, HAS can also restrict blood flow to the liver, similarly leading to biliary dysfunction and potential complications. In cases of left liver grafts and left lateral segment grafts of living donors, ischemia of the arterial supply to the left hepatic duct may result in biliary anastomotic stricture [30] , and similarly, regarding whole and reduced liver grafts, ischemia of the common bile duct or hepatic duct is a principal risk factor contributing to biliary stricture [38] . Hepatic artery reconstruction techniques and HAC significantly influence the incidence of BC in pediatric recipients, necessitating that surgeons at transplant centers carefully assess the condition of the arteries and continually optimize arterial reconstruction techniques to improve patient outcomes. 4.4 ICU stay time For patients undergoing non-transplant surgeries, existing studies have demonstrated a correlation between prolonged ICU stay and increased mortality rates [39–41] . Similar findings have been reported in organ transplant recipients. A study investigating the relationship between the length of ICU stay and postoperative adverse outcomes in patients undergoing cardiac transplantation surgeries indicated that patients with prolonged ICU stays (> 3 days) had significantly higher mortality rates [42] . In this study, the average length of ICU stay for the BC group was 378.50 hours (range 208.25-809.25), whereas that for the NBC group was 250.00 hours (range 160.75-477.75). Our study revealed a positive association between the duration of ICU stay and BC incidence, and the multivariable analysis indicated that prolonged ICU stay was a significant risk factor for BC. Furthermore, according to the adverse outcomes reported in numerous studies regarding the relationship between organ donors and the length of ICU stay of recipients [43–45] , the authors believe that prolonged ICU duration reflects the severity of the postoperative course, including infections, graft dysfunction, or hemodynamic instability, which not only prolongs the ICU stay but also indirectly affects the biliary system of grafts, impacting the prognosis of pediatric recipients. However, the authors admitted that this finding may reflect reverse causality, that patients who developed early complications or had more severe illness were more likely to have prolonged ICU stays. The relationship between the length of ICU stay and the BCs is not merely straightforwardly causal, rather, it involves mutual influence and reflection. Therefore, the deeper and more complex interactions within this relationship warrant further investigation. 4.5 Hypoalbuminemia Albumin is a water-soluble protein synthesized by the liver, comprising a significant portion of the total serum protein [10] . It plays a critical role in maintaining colloidal osmotic pressure and the binding of various endogenous and exogenous compounds, thereby serving essential functions in transport, antioxidant activity, and the maintenance of electrolyte balance [46–49] . The concentration of serum ALB is influenced by several factors, including its synthesis rate, metabolic degradation, distribution within the body, and loss [50, 51] . Hypoalbuminemia, which is typically affected by nutritional intake and inflammatory responses, is commonly observed in states of malnutrition, hepatic dysfunction or failure, and conditions of high metabolic demand. The current prevailing view reveals that serum ALB levels serve as a reliable prognostic indicator across various clinical conditions. For patients with hypoalbuminemia-associated disorders, those with low albumin levels often present more severe clinical presentations, higher morbidity and mortality rates, and worse overall prognoses than patients with normal serum albumin levels do [52, 53] . Furthermore, when specific disease conditions are considered, serum ALB levels are significantly negatively correlated with adverse outcomes [54, 55] . In our center, among the pediatric patients who underwent LT, those with preoperative hypoalbuminemia were at greater risk of developing BCs. Preoperative hypoalbuminemia was an independent risk factor for BC (OR = 22.337, 95% CI 8.054–64.969, P = 0.001). On the one hand, serum ALB plays a crucial role in human physiology, and its deficiency can be detrimental. On the other hand, preoperative hypoalbuminemia reflects the severity of the patient's liver functional reverses. Although there is no other evidence in the literature to suggest a direct link between hypoalbuminemia and BCs, interestingly, the cohort at our center demonstrated that of the 46 individuals who had hypoalbuminemia corrected preoperatively (46/174), only 5 developed postoperative biliary complications (5/46, 10.9%), whereas a total of 30 out of the 71 who did not have hypoalbuminemia corrected (30/71, 42.3%), which confirms the plausibility of this finding. Therefore, we believe that it is essential to focus on and optimize the nutritional status of pediatric patients prior to transplantation, which may directly reduce the risk of BC and improve patient outcomes. We recommend that the hypoalbuminemia of all LT recipients should be corrected preoperatively, e.g., via direct intravenous infusion of human ALB. Additionally, further research is needed to explore in greater depth the impact of preoperative hypoalbuminemia on the development of postoperative BC and to establish evidence-based guidelines for the management of hypoalbuminemia in pediatric LT recipients. 4.6 Limitations The current study has several limitations. The inclusion of a small number of cases in this study thus limits the broad applicability of the findings. In addition, this study is a single-center retrospective study, therefore, its findings may lack generalizability and do not encompass several significant findings from other studies. Furthermore, while the authors performed multivariable analysis, potential confounders such as immunosuppression regimens, infection rates, and surgical expertise are not thoroughly discussed or adjusted for. Consequently, there is a need for large-sample, multi-center prospective research to further explore the risk factors associated with biliary complications following pediatric liver transplantation, as well as experiences in diagnosis and management. We have already designed a randomized trial of nutritional interventions focused on the concentration of serum ALB, and a prospective registry for biliary complications is ongoing. 5. Conclusions Hypoalbuminemia, postoperative hepatic artery complications, and prolonged ICU stay time were independent risk factors for biliary complications. Correcting hypoalbuminemia preoperatively, minimizing the occurrence of hepatic artery complications, and reducing unnecessary postoperative ICU stay duration are essential and may contribute to beneficial outcomes. Abbreviations ALB albumin AS anastomotic bile duct stricture BC biliary complication BL bile leak BS biliary stricture CI confidence interval GRWR graft-to-recipient body weight ratio HAC hepatic artery complications HAS hepatic artery stenosis HAT hepatic artery thrombosis HCC hepatocellular carcinoma ITBL ischemic-type biliary lesion LDLT living donor liver transplantation LT liver transplantation NAS non-anastomotic bile duct stricture OR odds ratio PTCD percutaneous transhepatic cholangial drainage Declarations Ethics approval and consent to participate: This study was approved by the Ethics Committee of West China Hospital, Sichuan University (approval no. 20230357). Informed consent was waived due to the retrospective nature of the study and the use of anonymized clinical data. The waiver aligns with China’s Regulations on the Management of Human Genetic Resources and the West China Hospital’s IRB policies for minimal-risk retrospective studies. The study adhered to the 1964 Declaration of Helsinki and its later amendments. Data availability statement : The datasets used or analyzed during the study are available from the Corresponding Author on reasonable request. Competing Interests: On behalf of all authors, the corresponding author states that there are no conflicts of interest. Funding: Not applicable. Consent for publication: Not Applicable. Clinical trial number: Not applicable. Author contributions: Yun Peng: Writing – review & editing, Writing – original draft, Visualization, Methodology, Data curation, Conceptualization. Meng Zhang: Writing – original draft, Validation, Supervision, Data curation. Liangcai He: Conceptualization, Validation, Supervision, Data curation. Zhenyu Xie: Writing – review & editing, Validation. Bo Xiang: Writing – review & editing, Validation. Formal analysis Jiayin Yang: Writing – review & editing, Validation. Shuguang Jin: Writing – review & editing, Validation. Writing – original draft, Validation, Supervision, Conceptualization. Acknowledgements: Not applicable. References YOSHIZUMI T, HARADA N, MORI M. Biliary Stricture: The Achilles Heel of Pediatric Living Donor Liver Transplantation [J]. Transplantation, 2019, 103(9): 1758-9. JOHNSON L B, AL-KAWAS F H. The bile duct--the Achilles' heel of living donor liver transplantation [J]. The American journal of gastroenterology, 2004, 99(7): 1296-7. SHAMSAEEFAR A, NIKEGHBALIAN S, KAZEMI K, et al. Thirteen-Year Evaluation of the Management of Biliary Tract Complication After Deceased Donor Liver Transplantation [J]. Progress in transplantation (Aliso Viejo, Calif), 2017, 27(2): 192-5. FEIER F H, DA FONSECA E A, SEDA-NETO J, et al. Biliary complications after pediatric liver transplantation: Risk factors, diagnosis and management [J]. World journal of hepatology, 2015, 7(18): 2162-70. DARIUS T, RIVERA J, FUSARO F, et al. 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Prognostic utility of albumin-bilirubin grade in Japanese patients with primary biliary cholangitis [J]. JHEP reports : innovation in hepatology, 2023, 5(4): 100662. MARTININO A, PEREIRA J P S, SPOLETINI G, et al. The use of the T-tube in biliary tract reconstruction during orthotopic liver transplantation: An umbrella review [J]. Transplantation reviews (Orlando, Fla), 2022, 36(4): 100711. LóPEZ-ANDúJAR R, ORóN E M, CARREGNATO A F, et al. T-tube or no T-tube in cadaveric orthotopic liver transplantation: the eternal dilemma: results of a prospective and randomized clinical trial [J]. Annals of surgery, 2013, 258(1): 21-9. TEPETES K, KARAVIAS D, FELEKOURAS E, et al. Bile leakage following T-tube removal in orthotopic liver transplantation [J]. Hepato-gastroenterology, 1999, 46(25): 425-7. SCATTON O, MEUNIER B, CHERQUI D, et al. Randomized trial of choledochocholedochostomy with or without a T tube in orthotopic liver transplantation [J]. Annals of surgery, 2001, 233(3): 432-7. SUN N, ZHANG J, LI X, et al. Biliary tract reconstruction with or without T-tube in orthotopic liver transplantation: a systematic review and meta-analysis [J]. Expert review of gastroenterology & hepatology, 2015, 9(4): 529-38. SONG S, LU T, YANG W, et al. T-tube or no T-tube for biliary tract reconstruction in orthotopic liver transplantation: an updated systematic review and meta-analysis [J]. Expert review of gastroenterology & hepatology, 2021, 15(10): 1201-13. SOTIROPOULOS G C, SGOURAKIS G, RADTKE A, et al. Orthotopic liver transplantation: T-tube or not T-tube? Systematic review and meta-analysis of results [J]. Transplantation, 2009, 87(11): 1672-80. HSIAO C Y, HO C M, WU Y M, et al. Biliary Complication in Pediatric Liver Transplantation: a Single-Center 15-Year Experience [J]. J Gastrointest Surg, 2019, 23(4): 751-9. LAURENCE J M, SAPISOCHIN G, DEANGELIS M, et al. Biliary complications in pediatric liver transplantation: Incidence and management over a decade [J]. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 2015, 21(8): 1082-90. KARAKAYALı F, KıRNAP M, AKDUR A, et al. Biliary complications after pediatric liver transplantation [J]. Transplantation proceedings, 2013, 45(10): 3524-7. NORTHOVER J M, TERBLANCHE J. A new look at the arterial supply of the bile duct in man and its surgical implications [J]. The British journal of surgery, 1979, 66(6): 379-84. YAMAGUCHI N, MATSUYAMA R, KIKUCHI Y, et al. Role of the Intramural Vascular Network of the Extrahepatic Bile Duct for the Blood Circulation in the Recipient Extrahepatic Bile Duct Used for Duct-to-Duct-Biliary-Anastomosis in Living Donor Liver Transplantation [J]. Transpl Int, 2022, 35(10276. SOLIMAN T, BODINGBAUER M, LANGER F, et al. The role of complex hepatic artery reconstruction in orthotopic liver transplantation [J]. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 2003, 9(9): 970-5. TAN B K, FONG H C, TAN E K, et al. Strategies for a successful hepatic artery anastomosis in liver transplantation: A review of 51 cases [J]. Annals of the Academy of Medicine, Singapore, 2021, 50(9): 679-85. HERRERO A, SOUCHE R, JOLY E, et al. Early Hepatic Artery Thrombosis After Liver Transplantation: What is the Impact of the Arterial Reconstruction Type? [J]. World journal of surgery, 2017, 41(8): 2101-10. SEDA-NETO J, ANTUNES DA FONSECA E, PUGLIESE R, et al. Twenty Years of Experience in Pediatric Living Donor Liver Transplantation: Focus on Hepatic Artery Reconstruction, Complications, and Outcomes [J]. Transplantation, 2016, 100(5): 1066-72. STANGE B J, GLANEMANN M, NUESSLER N C, et al. Hepatic artery thrombosis after adult liver transplantation [J]. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 2003, 9(6): 612-20. JAIN A, REYES J, KASHYAP R, et al. Long-term survival after liver transplantation in 4,000 consecutive patients at a single center [J]. Annals of surgery, 2000, 232(4): 490-500. GUNJI H, CHO A, TOHMA T, et al. The blood supply of the hilar bile duct and its relationship to the communicating arcade located between the right and left hepatic arteries [J]. American journal of surgery, 2006, 192(3): 276-80. MARTINI V, LEDERER A K, LAESSLE C, et al. Clinical Characteristics and Outcomes of Surgical Patients with Intensive Care Unit Lengths of Stay of 90 Days and Greater [J]. Crit Care Res Pract, 2017, 2017(9852017. MARTIN C M, HILL A D, BURNS K, et al. Characteristics and outcomes for critically ill patients with prolonged intensive care unit stays [J]. Crit Care Med, 2005, 33(9): 1922-7; quiz 36. LIPSETT P A, SWOBODA S M, DICKERSON J, et al. Survival and functional outcome after prolonged intensive care unit stay [J]. Annals of surgery, 2000, 231(2): 262-8. MAHESH B, CHOONG C K, GOLDSMITH K, et al. Prolonged stay in intensive care unit is a powerful predictor of adverse outcomes after cardiac operations [J]. Ann Thorac Surg, 2012, 94(1): 109-16. MISAR A, MCLIN V A, CALINESCU A M, et al. Impact of length of donor ICU stay on outcome of patients after pediatric liver transplantation with whole and ex situ split liver grafts [J]. Pediatric transplantation, 2022, 26(2): e14186. CERUTTI E, STRATTA C, ROMAGNOLI R, et al. Bacterial- and fungal-positive cultures in organ donors: clinical impact in liver transplantation [J]. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 2006, 12(8): 1253-9. CORMAN DINCER P, TORE ALTUN G, BIRTAN D, et al. Incidence and Risk Factors for Systemic Infection in Deceased Donors [J]. Transplantation proceedings, 2019, 51(7): 2195-7. GROOTENDORST A F, VAN WILGENBURG M G, DE LAAT P H, et al. Albumin abuse in intensive care medicine [J]. Intensive care medicine, 1988, 14(5): 554-7. KOCH-WESER J, SELLERS E M. Binding of drugs to serum albumin (first of two parts) [J]. The New England journal of medicine, 1976, 294(6): 311-6. TULLIS J L. Albumin. 1. Background and use [J]. Jama, 1977, 237(4): 355-60 contd. NICHOLSON J P, WOLMARANS M R, PARK G R. The role of albumin in critical illness [J]. British journal of anaesthesia, 2000, 85(4): 599-610. FLECK A, RAINES G, HAWKER F, et al. Increased vascular permeability: a major cause of hypoalbuminaemia in disease and injury [J]. Lancet (London, England), 1985, 1(8432): 781-4. ROTHSCHILD M A, ORATZ M, SCHREIBER S S. Albumin synthesis. 1 [J]. The New England journal of medicine, 1972, 286(14): 748-57. OSTER H S, DOLEV Y, KEHAT O, et al. Serum Hypoalbuminemia Is a Long-Term Prognostic Marker in Medical Hospitalized Patients, Irrespective of the Underlying Disease [J]. Journal of clinical medicine, 2022, 11(5): KNAUS W A, WAGNER D P, DRAPER E A, et al. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults [J]. Chest, 1991, 100(6): 1619-36. APELGREN K N, ROMBEAU J L, TWOMEY P L, et al. Comparison of nutritional indices and outcome in critically ill patients [J]. Crit Care Med, 1982, 10(5): 305-7. GOLUB R, SORRENTO J J, JR., CANTU R, JR., et al. Efficacy of albumin supplementation in the surgical intensive care unit: a prospective, randomized study [J]. Crit Care Med, 1994, 22(4): 613-9. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7246266","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":504245280,"identity":"a1e0a199-20b5-4c92-9bb8-ec09f1140248","order_by":0,"name":"Yun Peng","email":"","orcid":"","institution":"West China Hospital of Sichuan University","correspondingAuthor":false,"prefix":"","firstName":"Yun","middleName":"","lastName":"Peng","suffix":""},{"id":504245281,"identity":"b1e3da66-7ee1-45c1-b9d2-86348a81f186","order_by":1,"name":"Meng Zhang","email":"","orcid":"","institution":"West China Tianfu 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06:44:15","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1463013,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7246266/v1/e65834e1-50a0-4213-aafc-86e288171773.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Risk factors for biliary complications after pediatric liver transplantation: a retrospective study and twenty years of experience from a single center in China","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eFor children with end-stage liver disease and certain metabolic disorders, liver transplantation (LT) serves as the only potentially effective curative treatment, offering opportunities to prolong survival and improve quality of life. However, biliary complications (BCs) remain a challenge and pose a significant threat to patient outcomes. The incidence of BC ranges from 10\u0026ndash;20% in adult living donor liver transplantation (LDLT)\u003csup\u003e[1]\u003c/sup\u003e, whereas in pediatric LDLT, it ranges from 5\u0026ndash;35%\u003csup\u003e[2]\u003c/sup\u003e. Some studies have revealed that BC can result in graft failure, necessitating retransplantation in 6\u0026ndash;13% of patients, leading to poor long-term prognosis\u003csup\u003e[3]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eBCs are classified into biliary strictures (BSs), which can be anastomotic or intrahepatic, bile leaks (BLs), bilomas, excluded ducts, stones, and cast formations, among others\u003csup\u003e[4]\u003c/sup\u003e. The occurrence and development of BC are closely related to every aspect of the perioperative procedure. The therapeutic strategy for BC is multidisciplinary, based on the type and severity of the complication and the biliary reconstruction technique applied, including nonoperative and invasive treatment. The effective identification of risk factors for BC, along with early diagnosis and timely intervention, could lead to better outcomes.\u003c/p\u003e\u003cp\u003eIn this study, we retrospectively investigated potential risk factors and concluded therapy strategies for biliary complications in pediatric patients who underwent LT at a single transplant center, with the overarching aim of preventing postoperative BC.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Patient selection\u003c/h2\u003e\u003cp\u003eThis study was conducted at West China Hospital, Sichuan University, China. We retrieved data from a retrospective research database containing detailed clinical, demographic, therapeutic, pathological, and follow-up information for all patients who underwent LT at our institution. Patients younger than 14 who received liver transplants were enrolled between October 2001 and February 2023. All patients followed a standardized regimen for immunosuppression, antibiotic therapy, and prophylaxis. Patients with incomplete clinical information and those who were lost to follow-up were excluded from the study. This study report was prepared following the guidelines outlined in the Strengthening the Reporting of Cohort cross-sectional and case‒control studies in surgery (STROCSS) statement.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Postoperative management of LT recipients\u003c/h2\u003e\u003cp\u003ePostoperative children were routinely transferred to the intensive care unit (ICU) for continued medical management. Regular monitoring included liver and renal function tests, routine blood examinations, and blood coagulation function examinations. The volume and color of the abdominal drainage fluid were carefully observed, and biliary stent drainage fluid was periodically collected for culture. Liver and abdominal ultrasonography were performed regularly to assess the diameters, blood flow velocities, and resistance indices of the portal vein, hepatic veins, and hepatic artery. To evaluate the intrahepatic and extrahepatic biliary systems, if necessary, CT and/or MRI could be performed.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Data collection\u003c/h2\u003e\u003cp\u003eThe liver transplantation donor and recipient parameters were collected. In accordance with the LT procedure, the following variables were analyzed via univariate and multivariate analyses. Preoperative data included the donor's and recipient\u0026rsquo;s demographic and clinical data, such as sex, age, blood type, weight, height, and baseline liver and renal function parameters. Surgical data included the type and volume of grafts, GRWR, hepatic artery reconstruction techniques, biliary stent insertion, biliary reconstruction techniques, warm and cold ischemia time, length of the anhepatic phase, amount of intraoperative intravenous input and blood loss, RBC transfusions, and operation time. Postoperative data included cases of hepatic artery complications, the length of ICU stay, and the duration of hospitalization.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Definitions\u003c/h2\u003e\u003cp\u003eBiliary stricture was defined as a narrowing of more than 50% of the biliary lumen or a dilatation of the biliary tree of more than 2 mm\u003csup\u003e[5]\u003c/sup\u003e. Biliary anastomotic stricture was defined as a focal narrowing occurring within 5 mm of the surgical anastomosis\u003csup\u003e[6]\u003c/sup\u003e. Non-anastomotic biliary stricture was characterized by an irregular narrowing located more than 5 mm from the anastomosis\u003csup\u003e[7]\u003c/sup\u003e. Biliary cast information referred to a series of pathological manifestations resulting from the accumulation of necrotic and sloughed biliary epithelial cell debris within the bile duct lumen. Bile leak was defined as a drain bilirubin concentration\u0026thinsp;\u0026gt;\u0026thinsp;3-fold serum concentration on POD 3 or later\u003csup\u003e[8]\u003c/sup\u003e. Cholangitis was defined as a bile infection manifesting clinically with a combination of symptoms (fever, jaundice) and with biochemical alterations (predominantly in alanine aminotransferase, gamma-glutamyltransferase and/or direct bilirubin) but not necessarily positive radiological findings\u003csup\u003e[5]\u003c/sup\u003e. The ALBI score was calculated according to the following equation [ALBI score=-0.085 (albumin g/L)\u0026thinsp;+\u0026thinsp;0.66 log10 (Tbil \u0026micro;mol/L)]. ALBI grades were inductively defined as follows: grade 1 \u0026lt;-2.60, grade 2 \u0026gt;-2.60 to \u0026le;-1.39 and grade 3 \u0026gt;-1.39\u003csup\u003e[9]\u003c/sup\u003e. Hypoalbuminemia was considered when the serum albumin level was \u0026lt;\u0026thinsp;35 g/L\u003csup\u003e[10]\u003c/sup\u003e. Postoperative mortality was defined as death within 90 days after liver transplantation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.5 Statistical analysis\u003c/h2\u003e\u003cp\u003eAll the statistical analyses were performed via SPSS Windows version 27.0 (SPSS Inc., Chicago, IL). Continuous variables were reported as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or as the median (range) for continuous variables with a non-normal distribution. Intergroup comparisons were analyzed via Student\u0026rsquo;s t test or the Mann‒Whitney U test, as appropriate. Categorical variables were reported as counts (percentages) and compared via the chi-square test or Fisher\u0026rsquo;s exact test. Multivariate analysis was performed by the binary logistic regression model. To include as many variables as possible in the multivariable analysis, variables with a P value\u0026thinsp;\u0026lt;\u0026thinsp;0.1 in the univariate analysis were incorporated into the regression model to evaluate independent risk factors for biliary complications. The risk predictions were reported as P values, odds ratios (ORs), and 95% confidence intervals (CIs). Overall survival curves were generated via the Kaplan\u0026ndash;Meier method. The calculated P values were 2-sided, and a P value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Demographic and preoperative clinical characteristics of LT recipients and donors\u003c/h2\u003e\u003cp\u003eBetween November 2001 and February 2023, a total of 188 children who underwent LT were screened for eligibility. After 14 cases involving liver autotransplantation, significant data deficiencies, and loss to follow-up were excluded, 174 patients were ultimately enrolled in the study (Fig.\u0026nbsp;1, flowchart of included patients), including 30 children who experienced BC. The overall BC rate in the cohort was 17.2% (30/174). The mean post-transplantation follow-up period was 83 months (range, 0\u0026ndash;271 months). The demographic and baseline preoperative clinical characteristics of the recipients are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, Baseline demographic and preoperative clinical characteristics of the LT recipients). The male-to-female ratio was 1.02:1, with a median age at surgery of 10 months (range, 3\u0026ndash;178 months) and a mean age of 41\u0026thinsp;\u0026plusmn;\u0026thinsp;5 months. The median weight was 8.6 kg (range, 6.15\u0026ndash;17.00 kg). Within our cohort, 30 patients (17.3%) were classified as ALBI grade 1, 89 patients (51.1%) were classified as grade 2, and 55 patients (31.6%) were classified as grade 3. The primary diagnoses included 144 cases of severe liver cirrhosis (134/174), predominantly biliary atresia (121/174), which accounted for 69.5% of all recipients in this cohort, 19 metabolic liver disorders (10.8%), 7 liver tumors (4.1%), 6 retransplantations (3.5%), and 8 others (4.6%) (details in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline demographic and preoperative clinical characteristics of LT recipients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBC Group(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNBC Group(n\u0026thinsp;=\u0026thinsp;144)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.740\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16(53.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e72(50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003efemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14(46.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e72(50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, month, median(range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.00(6.00, 60.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10.00(6.25, 67.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.439\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight, Kg, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8.50(6.15, 15.63)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8.65(7.00, 17.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.601\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight, cm, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70.00(61.75, 106.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e68.00(62.00, 103.63)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.936\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood type, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.782\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11(36.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e42(29.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7(23.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32(22.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3(10.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14(9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eO\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9(30.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e56(38.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eABO-incompatible LT, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4(2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.604\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTBIL, \u0026micro;mol, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e246.20(239.44\u0026thinsp;\u0026plusmn;\u0026thinsp;154.90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e182.30(27.85, 317.65)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.156\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eALB, g/L, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e33.40(31.65, 39.85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e37.90(33.13, 41.88)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.044\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSCr, \u0026micro;mol, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18.00(14.00, 26.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21.00(15.23, 34.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.101\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBUN, mmol/L, median(range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.08(3.20, 5.53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.25(3.35, 5.68)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.102\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eINR, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.40(1.14, 1.67)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1.26(1.09, 1.53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.191\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePELD score, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16.00(16.73\u0026thinsp;\u0026plusmn;\u0026thinsp;8.73)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13.00(5.00, 20.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.052\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCauses for LT, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.759\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eliver cirrhosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26(86.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e108(75.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emetabolic liver disorders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3(10.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16(11.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eliver tumors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eretransplantation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6(4.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eother\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1(3.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistory of abdominal surgery, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16(53.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e72(50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.740\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChild-Pugh classification,\u003c/p\u003e\u003cp\u003en (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.287\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1(3.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20(13.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15(50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e69(47.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14(46.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e55(38.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eALBI grade, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.036\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(6.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e28(19.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13(43.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e76(52.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIII\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15(50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e40(27.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypoalbuminemia, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21(70.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e50(34.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eTBIL\u0026thinsp;=\u0026thinsp;total bilirubin, ALB\u0026thinsp;=\u0026thinsp;albumin, SCr\u0026thinsp;=\u0026thinsp;serum creatinine, BUN\u0026thinsp;=\u0026thinsp;blood urea nitrogen, INR\u0026thinsp;=\u0026thinsp;international normalized ratio.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMeanwhile, the baseline clinical characteristics and liver function parameters of LT donors in both groups are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Baseline demographic and preoperative clinical characteristics of LT donors), and there were no significant differences in those characteristics.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBaseline demographic and preoperative clinical characteristics of LT donors\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBC Group(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNBC Group(n\u0026thinsp;=\u0026thinsp;144)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.230\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003emale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15(50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e60(41.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003efemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e15(50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e84(58.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, month, median(range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e384.50(313.75, 447.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e370.00(301.50, 444.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.790\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight, Kg, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e60.00(49.75, 65.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e55.00(49.25, 65.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.555\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight, cm, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e161.50(156.75, 170.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e160.00(155.00, 167.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.502\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood type, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.883\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11(36.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e43(29.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7(23.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e33(22.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3(10.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15(10.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eO\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9(30.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e53(36.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHb, g/L, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e130.00(116.00, 140.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e123.00(115.00, 135.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.147\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWBC,\u0026nbsp;10\u003csup\u003e9\u003c/sup\u003e/L, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6.14(4.82, 7.31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6.39(5.08, 7.92)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.363\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePLT, 10\u003csup\u003e9\u003c/sup\u003e/dL, mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e176.00(73.93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e177.50(74.12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.897\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTBIL, \u0026micro;mol, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11.15(8.05, 20.38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e13.10(8.83, 19.78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.792\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eALB, g/L, mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43.88 (4.90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e42.91 (5.29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.357\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eALP, U/L, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e76.50(57.00, 88.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e80.00(61.00, 98.15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.320\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eγGT, U/L, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17.00(10.75, 39.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19.55(12.00, 37.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.932\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAST, U/L, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e20.00(16.00, 29.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e24.50(18.00, 39.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.556\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eALT, U/L, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22.00(13.00, 39.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e27.00(15.00, 42.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.220\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGlu, mmol/L, median(range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4.96(4.64, 5.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5.00(4.60, 5.85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.702\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSCr, \u0026micro;mol, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e66.85(49.00, 76.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e62.10(53.00, 79.83)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.577\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBUN, mmol/L, median(range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4.08(3.20, 5.53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4.25(3.35, 5.68)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.102\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eWBC\u0026thinsp;=\u0026thinsp;white blood cell, PLT\u0026thinsp;=\u0026thinsp;platelet count, ALP\u0026thinsp;=\u0026thinsp;alkaline phosphatase, γ-GT\u0026thinsp;=\u0026thinsp;glutamyl transpeptidase, ALT\u0026thinsp;=\u0026thinsp;alanine aminotransferase, AST\u0026thinsp;=\u0026thinsp;aspartate aminotransferase.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Intraoperative characteristics\u003c/h2\u003e\u003cp\u003eAmong the 30 BC children, 25 underwent LDLT (including 8 liver left lobes and 17 left lateral segments), 3 underwent split liver transplantation (all were liver left lateral segments), and 2 underwent whole-liver transplantation. The NBC group consisted of 108 LDLTs (including 55 liver left lobes, 7 right lobes, and 46 left lateral segments), 32 split liver transplantations (14 left lobes, 2 right lobes, and 16 left lateral segments), and 4 whole-liver transplantations (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, Intraoperative characteristics of the recipients). In terms of the incidence of BC, there were no significant differences in the types of grafts, which was different from the findings of the study by Diamond et al\u003csup\u003e[11]\u003c/sup\u003e. With respect to biliary reconstruction techniques, children in the BC group had a greater incidence of biliary stent insertion (43.3% vs. 25.0%, P\u0026thinsp;=\u0026thinsp;0.042), whereas in the BC group, 5 underwent duct-to-duct anastomosis, and 25 underwent hepaticojejunostomy. They also had more RBC transfusions (300.00 ml vs. 262.50 ml, P\u0026thinsp;=\u0026thinsp;0.904), although the median estimated blood loss was 300 ml in both the BC group (range, 200\u0026ndash;525 ml) and the NBC group (range, 200\u0026ndash;500 ml) (P\u0026thinsp;=\u0026thinsp;0.841). There were significant differences in hepatic artery reconstruction techniques and biliary stent insertion (13 (43.4%) vs 36 (25.0%), P\u0026thinsp;=\u0026thinsp;0.042) between the BC group and the NBC group (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for all).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eIntraoperative characteristics of recipients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBC Group(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNBC Group(n\u0026thinsp;=\u0026thinsp;144)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType of graft, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.164\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLive-donor graft\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25(83.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e108(75.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSplit liver\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3(10.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e32(22.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhole liver\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(6.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4(2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eType of graft, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.373\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLDLT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft lobe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8(26.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e55(48.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight lobe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7(4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft lateral segment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17(56.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e46(31.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDeceased donors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft lobe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e14(9.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRight lobe\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0(0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2(1.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLeft lateral segment\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3(10.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16(11.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhole liver\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(6.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4(2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHepatic artery reconstruction techniques, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.047\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eInterrupted only\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20(66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e119(82.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eContinuous posterior and interrupted anterior\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10(33.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e25(17.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBiliary reconstruction techniques, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.451\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDuct-to-duct anastomosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5(16.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e33(22.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHepaticojejunostomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25(83.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e111(77.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBiliary stent insertion, n (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13(43.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e36(25.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.042\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGraft volume, g, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e266.50(231.15, 300.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e269.50(226.75, 330.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.390\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGRWR, (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.95(1.59, 3.90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.87(1.54, 3.89)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.973\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWarm ischemia time, min, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.00(1.00, 5.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.00(1.00, 3.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.696\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntraoperative intravenous input, ml, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1060.00(819.75, 1562.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1160.00(680.00, 2106.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.768\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood loss, ml, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e300.00(200.00, 525.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e300.00(200.00, 500.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.841\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCold ischemia time, mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e227.93(117.84)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e262.07(118.16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.073\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLength of anhepatic phase, min, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e73.50(62.10, 93.64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e75.00(63.00, 95.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.866\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRBC transfusions, ml, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e300.00(195.00, 495.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e262.50(150.00, 450.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.904\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperation time, min, mean (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e525.70 (94.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e525.00(95.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.823\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eGRWR\u0026thinsp;=\u0026thinsp;graft-to-recipient body weight ratio, RBC\u0026thinsp;=\u0026thinsp;red blood cell.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Postoperative characteristics of the patients\u003c/h2\u003e\u003cp\u003eChildren in the BC group had a greater incidence of hepatic artery complications (20.0% vs. 5.6%, P\u0026thinsp;=\u0026thinsp;0.018), and they also had a longer duration of ICU stay (hour, median 378.50, range 208.25\u0026ndash;809.25 vs. median 250.00, range 160.75\u0026ndash;477.75, P\u0026thinsp;=\u0026thinsp;0.027) and hospital stay (day, median 47.00, range 33.00\u0026ndash;58.25 vs. median 38.00, range 32.00\u0026ndash;52.75, P\u0026thinsp;=\u0026thinsp;0.107) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, Postoperative characteristics of LT recipients).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePostoperative characteristics of LT recipients\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBC Group(n\u0026thinsp;=\u0026thinsp;30)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNBC Group(n\u0026thinsp;=\u0026thinsp;144)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eP\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eICU stay, hour, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e378.50(208.25, 809.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e250.00(160.75, 477.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.027\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital stay, day, median (range)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e47.00(33.00, 58.25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38.00(32.00, 52.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.107\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHepatic artery complications, n, (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6(20.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8(5.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.018\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.4 Incidence, Therapy Strategy, and Outcomes of Biliary Complications\u003c/h2\u003e\u003cp\u003eAmong the 174 recipients, 30 (17.2%) had BCs. BCs occurred within a median post-transplantation period of 5.5 months (range, 0\u0026ndash;24 months). The types, clinical management, and outcomes of the BCs are presented in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, Biliary complications, correlative treatment and outcomes). Of the 10 pediatric patients who presented with BL, 2 additionally developed anastomotic bile duct stricture (AS), and 1 presented with biliary stones simultaneously or sequentially. Biliary structure occurred in 22 recipients, and cholangitis occurred in 6 recipients. Twenty-nine of the 30 patients were treated with corresponding treatment, 20 of the 23 patients were taken invasive percutaneous treatments and/or endoscopic approaches without surgical intervention, and the success rate was 95.0% (19/20) in those patients. Six recipients died during the follow-up periods. The postoperative mortality rate was 10.0% (3/30). The causes of mortality were related to BC in three patients, and the other three patients experienced rejection or liver tumor recurrence. The overall 1-, 5-, and 10-year patient survival rates for the 174 pediatric LT recipients were 97.0%, 90.5%, and 82.0%, respectively. The overall 1-, 5-, and 10-year patient survival rates for the 30 pediatric LT recipients with BCs were 94.2%, 85.5%, and 71.3%, respectively, for the 144 recipients with NBCs, the rates were 97.1%, 90.1%, and 81.5%, showing no statistically significant difference, although there was a trend (P\u0026thinsp;=\u0026thinsp;0.721) (Fig.\u0026nbsp;2, patient survival rates of the two groups).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eBiliary complications, correlative treatment and outcomes\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristic\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIncidence, n\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTreatment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePrognosis\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSingular BC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eConservative approach\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 Recovered, 2 died for MODS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBL\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSurgical intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRecovered\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePTCD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRecovered\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eReject any therapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDied\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eERCP\u0026thinsp;+\u0026thinsp;ENBD\u0026thinsp;+\u0026thinsp;ERBD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRecovered\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eERCP\u0026thinsp;+\u0026thinsp;ERBD\u0026thinsp;+\u0026thinsp;ENBD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eChronic rejection, ultimately dead\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eERCP\u0026thinsp;+\u0026thinsp;ERBD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDied for upper gastrointestinal bleeding\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePTCD\u0026thinsp;+\u0026thinsp;ERBD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRecovered\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNAS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePTCD\u0026thinsp;+\u0026thinsp;ERBD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRecovered\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCholangitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAntibiotic therapy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 Recovered,1 retransplantation for rejection\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBCF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eERCP\u0026thinsp;+\u0026thinsp;ERBD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDied for MODS\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBCF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePTCD\u0026thinsp;+\u0026thinsp;ERBD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRecovered\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBiliary stone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePTCD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRecovered\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMixed BC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBL\u0026thinsp;+\u0026thinsp;AS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSurgical intervention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRecovered\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBL\u0026thinsp;+\u0026thinsp;AS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eERCP\u0026thinsp;+\u0026thinsp;ENBD\u0026thinsp;+\u0026thinsp;PTCD\u0026thinsp;+\u0026thinsp;Biliary reconstruction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRecovered\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBL\u0026thinsp;+\u0026thinsp;Biliary stone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePTCD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRecovered\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAS\u0026thinsp;+\u0026thinsp;Cholangitis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePTCD\u0026thinsp;+\u0026thinsp;Balloon dilatation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRecovered\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAS\u0026thinsp;+\u0026thinsp;Biliary stone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePTCD\u0026thinsp;+\u0026thinsp;Balloon dilatation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRecovered\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eAS\u0026thinsp;=\u0026thinsp;anastomotic bile duct stricture, NAS\u0026thinsp;=\u0026thinsp;non-anastomotic bile duct stricture, BCF\u0026thinsp;=\u0026thinsp;biliary cast formation, PTCD\u0026thinsp;=\u0026thinsp;percutaneous transhepatic cholangial drainage, PTCS\u0026thinsp;=\u0026thinsp;percutaneous transhepatic choledochoscopy, ERBD\u0026thinsp;=\u0026thinsp;endoscopic retrograde biliary drainage, ENBD\u0026thinsp;=\u0026thinsp;endoscopic nasobiliary drainage, ERCP\u0026thinsp;=\u0026thinsp;endoscopic retrograde cholangiopancreatography, MODS\u0026thinsp;=\u0026thinsp;multiple dysfunction syndrome.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIn our experience, patients with bile leakage or cholangitis typically achieve resolution after conservative treatment, with only a few conditions requiring surgical or endoscopic interventions due to concurrent acute conditions or biliary stricture. In contrast, patients with AS or ischemic-type biliary lesions (ITBLs) appeared to necessitate interventional and endoscopic treatment, and a second surgical biliary reconstruction was needed in some pediatric patients (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.5 Risk factors for BC: Univariate and multivariable analyses\u003c/h2\u003e\u003cp\u003eAccording to the pediatric LT procedure, the following variables were included in the univariate analysis, and the possible risk factors for BC are shown in Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. In the univariate analysis, the concentration of preoperative recipient\u0026rsquo;s ALB (P\u0026thinsp;=\u0026thinsp;0.044), ALBI grade (P\u0026thinsp;=\u0026thinsp;0.036), hypoalbuminemia (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), hepatic artery reconstruction technique (P\u0026thinsp;=\u0026thinsp;0.047), postoperative hepatic artery complications (P\u0026thinsp;=\u0026thinsp;0.018), biliary stent insertion (P\u0026thinsp;=\u0026thinsp;0.042), and ICU stay time (P\u0026thinsp;=\u0026thinsp;0.027) were revealed as significant risk factors for BC. However, the type of graft (P\u0026thinsp;=\u0026thinsp;0.373), biliary reconstruction technique (P\u0026thinsp;=\u0026thinsp;0.451), preoperative Tbil (P\u0026thinsp;=\u0026thinsp;0.156), and GRWR (P\u0026thinsp;=\u0026thinsp;0.973) were not significant risk factors for BC.\u003c/p\u003e\u003cp\u003eIndicators from the univariate analysis with P values\u0026thinsp;\u0026lt;\u0026thinsp;0.1 were included in the multivariable analyses by the binary logistic regression model, and the results revealed that hypoalbuminemia (OR\u0026thinsp;=\u0026thinsp;22.337, 95% Cl 8.054\u0026ndash;64.969, P\u0026thinsp;=\u0026thinsp;0.001), postoperative hepatic artery complications (OR\u0026thinsp;=\u0026thinsp;12.308, 95% Cl 2.665\u0026ndash;56.838, P\u0026thinsp;=\u0026thinsp;0.001), and prolonged ICU stay time (OR\u0026thinsp;=\u0026thinsp;1.002, 95% Cl 1.000-1.003, P\u0026thinsp;=\u0026thinsp;0.012) were independent risk factors for biliary complications after pediatric liver transplantation (Table\u0026nbsp;6, Risk factors for BC in pediatric LT in the univariate and multivariable analyses) (Fig.\u0026nbsp;3, Forest plot of the independent risk factors for BC).\u003c/p\u003e\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eIn the present study, we report the risk factors, outcomes, and therapeutic strategies for BC in pediatric patients who underwent LT. In addition to the various risk factors previously described, this research identified several specific risk factors, such as preoperative hypoalbuminemia in the recipients, which, to our knowledge, is the first formal presentation of this point.\u003c/p\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003e4.1 ALBI score and classification\u003c/h2\u003e\u003cp\u003eCurrently, the assessment of liver function in patients with hepatocellular carcinoma (HCC) is primarily based on the Child‒Pugh score. This system has been widely utilized in clinical practice since its inception, however, it has notable limitations due to the subjective nature of certain parameters and the inevitable information loss during score calculation\u003csup\u003e[12, 13]\u003c/sup\u003e. The Albumin-Bilirubin score system was first proposed by Johnson et al\u003csup\u003e[9]\u003c/sup\u003e in 2014, which was calculated based solely on the levels of serum ALB and total bilirubin, and has been validated through multicenter studies with large sample sizes, demonstrating its efficacy in assessing liver function in HCC patients. Multiple studies have confirmed its reliability as a predictor of survival, tumor recurrence, and the risk of hepatic failure following liver resection in candidates for potential treatment modalities (such as hepatic resection and ablation)\u003csup\u003e[14, 15]\u003c/sup\u003e. In recent years, researchers have also applied this tool to assess the efficacy of liver transplantation in adult patients, indicating that ALBI grade 3 was associated with lower post-transplant survival, suggesting its potential as a tool for risk stratification in liver transplantation\u003csup\u003e[16\u0026ndash;18]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eWithin our cohort, 15 of the 30 patients (50.0%) in the BC group were classified as ALBI grade 3, and 40 of the 144 patients (27.8%) in the NBC group, respectively, which was significantly different according to the univariate analysis. Compared with ALBI grade 1 patients, the risk of BC was greater in pediatric patients with ALBI grade 3 patients. Similar conclusions have been presented in other liver transplantation centers\u003csup\u003e[17, 19]\u003c/sup\u003e. We believe that the ALBI score system, as a novel tool due to its objectivity and accessibility of data, may serve as an instrument for assessing hepatic functional reserve in pediatric patients on the waiting list. We propose that the preoperative ALBI grade could be a simple, noninvasive predictor of biliary complications and outcomes in pediatric recipients.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003e4.2 Stent or not\u003c/h2\u003e\u003cp\u003eWhether a biliary stent should be inserted during biliary reconstruction remains controversial. The effects of stent insertion on the occurrence and progression of various biliary complications are inconsistent. On the one hand, for very small accessory ducts or high-risk marginal grafts, biliary stenting could provide effective support for biliary anastomosis, minimize intraductal pressure, and prevent bile leak and biliary stricture\u003csup\u003e[20, 21]\u003c/sup\u003e. Furthermore, postoperative surveillance can be effectively implemented to assess liver function by evaluating the characteristics and volume of bile drainage immediately or performing cholangiography. On the other hand, stent insertion may result in complications associated with the stent itself, such as bile leak caused by accidental stent removal\u003csup\u003e[22]\u003c/sup\u003e, as well as cholangitis resulting from retrograde flow through the external biliary stent\u003csup\u003e[23]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eCurrent meta-analyses have reported inconsistent results regarding the influence of stents on BCs. Sun et al.\u003csup\u003e[24]\u003c/sup\u003e reported that there were no significant differences in bile leak, anastomotic stricture, or mortality associated with BC between the stent group and the non-stent group. In contrast, other research highlighted that the overall incidence of BC, bile leak, and cholangitis was greater in the stent group, although the biliary stricture rate was significantly lower\u003csup\u003e[25, 26]\u003c/sup\u003e. Unfortunately, several analyses focusing specifically on BC following pediatric LT have not addressed the impact of stent insertion on the incidence of BC or prognosis\u003csup\u003e[27\u0026ndash;29]\u003c/sup\u003e. On the basis of the developmental history and experience of our center, we have gradually reduced the use of stents since 2022. However, in pediatric patients with unhealthy imprecise biliary anastomoses or unequal tension on either side of the anastomosis, stent support is cautiously evaluated for insertion, provided that the distance from the anastomosis is greater than 1 cm and the diameter of the stent is less than that of the bile lumen. This approach has yielded positive short-term clinical outcomes, and we plan to evaluate long-term outcomes in this population in the foreseeable future.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003e4.3 Hepatic arterial reconstruction strategy and hepatic arterial complications\u003c/h2\u003e\u003cp\u003eArterial suture techniques are categorized into interruption only and interrupted anterior plus continuous posterior sutures. Generally, interrupted suturing has the advantages of ease in adjusting suture spacing and minimal impact on vessel diameter, however, it may prolong the duration of the anastomosis. Continuous anastomosis, on the other hand, reduces the procedure time and provides better hemostatic outcomes compared to interrupted anastomosis. Nevertheless, it is associated with a greater risk of tearing injuries to the vessel wall and subsequent stenosis. In this study, 20 of the 30 patients (66.7%) in the BC group utilized interrupted sutures only, whereas 10 of the 30 patients in the BC group (33.3%) used interrupted anterior and continuous posterior sutures. In the NBC group, 119 patients underwent interrupted anastomosis, accounting for 82.6% of the group, with interrupted anterior and continuous posterior anastomosis comprising 25 (17.4%). Statistical analysis revealed that applying the interrupted suture technique only may effectively reduce the incidence of BC in pediatric patients. Studies have revealed that the blood supply to the biliary system following LT is derived primarily from the hepatic artery\u003csup\u003e[30, 31]\u003c/sup\u003e. Owing to the complexity of hepatic artery reconstruction, any factors influencing it, including the selection of anastomotic branches, the duration of anastomosis, the number of anastomoses, and the suturing technique, could impact the hepatic arterial system and blood flow to the bile ducts\u003csup\u003e[32\u0026ndash;34]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eHepatic complications, including hepatic artery thrombosis (HAT) and hepatic artery stenosis (HAS), have been identified as significant risk factors for BC following LT in recent studies\u003csup\u003e[35\u0026ndash;37]\u003c/sup\u003e. HATs can lead to interruption of the blood supply to the graft, resulting in ischemic injury to the biliary system, which induces various BCs, for the biliary tree is notably dependent on blood flow provided by the hepatic artery. Furthermore, HAS can also restrict blood flow to the liver, similarly leading to biliary dysfunction and potential complications. In cases of left liver grafts and left lateral segment grafts of living donors, ischemia of the arterial supply to the left hepatic duct may result in biliary anastomotic stricture\u003csup\u003e[30]\u003c/sup\u003e, and similarly, regarding whole and reduced liver grafts, ischemia of the common bile duct or hepatic duct is a principal risk factor contributing to biliary stricture\u003csup\u003e[38]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eHepatic artery reconstruction techniques and HAC significantly influence the incidence of BC in pediatric recipients, necessitating that surgeons at transplant centers carefully assess the condition of the arteries and continually optimize arterial reconstruction techniques to improve patient outcomes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003e4.4 ICU stay time\u003c/h2\u003e\u003cp\u003eFor patients undergoing non-transplant surgeries, existing studies have demonstrated a correlation between prolonged ICU stay and increased mortality rates\u003csup\u003e[39\u0026ndash;41]\u003c/sup\u003e. Similar findings have been reported in organ transplant recipients. A study investigating the relationship between the length of ICU stay and postoperative adverse outcomes in patients undergoing cardiac transplantation surgeries indicated that patients with prolonged ICU stays (\u0026gt;\u0026thinsp;3 days) had significantly higher mortality rates\u003csup\u003e[42]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn this study, the average length of ICU stay for the BC group was 378.50 hours (range 208.25-809.25), whereas that for the NBC group was 250.00 hours (range 160.75-477.75). Our study revealed a positive association between the duration of ICU stay and BC incidence, and the multivariable analysis indicated that prolonged ICU stay was a significant risk factor for BC. Furthermore, according to the adverse outcomes reported in numerous studies regarding the relationship between organ donors and the length of ICU stay of recipients\u003csup\u003e[43\u0026ndash;45]\u003c/sup\u003e, the authors believe that prolonged ICU duration reflects the severity of the postoperative course, including infections, graft dysfunction, or hemodynamic instability, which not only prolongs the ICU stay but also indirectly affects the biliary system of grafts, impacting the prognosis of pediatric recipients. However, the authors admitted that this finding may reflect reverse causality, that patients who developed early complications or had more severe illness were more likely to have prolonged ICU stays. The relationship between the length of ICU stay and the BCs is not merely straightforwardly causal, rather, it involves mutual influence and reflection. Therefore, the deeper and more complex interactions within this relationship warrant further investigation.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003e4.5 Hypoalbuminemia\u003c/h2\u003e\u003cp\u003eAlbumin is a water-soluble protein synthesized by the liver, comprising a significant portion of the total serum protein\u003csup\u003e[10]\u003c/sup\u003e. It plays a critical role in maintaining colloidal osmotic pressure and the binding of various endogenous and exogenous compounds, thereby serving essential functions in transport, antioxidant activity, and the maintenance of electrolyte balance\u003csup\u003e[46\u0026ndash;49]\u003c/sup\u003e. The concentration of serum ALB is influenced by several factors, including its synthesis rate, metabolic degradation, distribution within the body, and loss\u003csup\u003e[50, 51]\u003c/sup\u003e. Hypoalbuminemia, which is typically affected by nutritional intake and inflammatory responses, is commonly observed in states of malnutrition, hepatic dysfunction or failure, and conditions of high metabolic demand. The current prevailing view reveals that serum ALB levels serve as a reliable prognostic indicator across various clinical conditions. For patients with hypoalbuminemia-associated disorders, those with low albumin levels often present more severe clinical presentations, higher morbidity and mortality rates, and worse overall prognoses than patients with normal serum albumin levels do\u003csup\u003e[52, 53]\u003c/sup\u003e. Furthermore, when specific disease conditions are considered, serum ALB levels are significantly negatively correlated with adverse outcomes\u003csup\u003e[54, 55]\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn our center, among the pediatric patients who underwent LT, those with preoperative hypoalbuminemia were at greater risk of developing BCs. Preoperative hypoalbuminemia was an independent risk factor for BC (OR\u0026thinsp;=\u0026thinsp;22.337, 95% CI 8.054\u0026ndash;64.969, P\u0026thinsp;=\u0026thinsp;0.001). On the one hand, serum ALB plays a crucial role in human physiology, and its deficiency can be detrimental. On the other hand, preoperative hypoalbuminemia reflects the severity of the patient's liver functional reverses. Although there is no other evidence in the literature to suggest a direct link between hypoalbuminemia and BCs, interestingly, the cohort at our center demonstrated that of the 46 individuals who had hypoalbuminemia corrected preoperatively (46/174), only 5 developed postoperative biliary complications (5/46, 10.9%), whereas a total of 30 out of the 71 who did not have hypoalbuminemia corrected (30/71, 42.3%), which confirms the plausibility of this finding. Therefore, we believe that it is essential to focus on and optimize the nutritional status of pediatric patients prior to transplantation, which may directly reduce the risk of BC and improve patient outcomes. We recommend that the hypoalbuminemia of all LT recipients should be corrected preoperatively, e.g., via direct intravenous infusion of human ALB. Additionally, further research is needed to explore in greater depth the impact of preoperative hypoalbuminemia on the development of postoperative BC and to establish evidence-based guidelines for the management of hypoalbuminemia in pediatric LT recipients.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003e4.6 Limitations\u003c/h2\u003e\u003cp\u003eThe current study has several limitations. The inclusion of a small number of cases in this study thus limits the broad applicability of the findings. In addition, this study is a single-center retrospective study, therefore, its findings may lack generalizability and do not encompass several significant findings from other studies. Furthermore, while the authors performed multivariable analysis, potential confounders such as immunosuppression regimens, infection rates, and surgical expertise are not thoroughly discussed or adjusted for. Consequently, there is a need for large-sample, multi-center prospective research to further explore the risk factors associated with biliary complications following pediatric liver transplantation, as well as experiences in diagnosis and management. We have already designed a randomized trial of nutritional interventions focused on the concentration of serum ALB, and a prospective registry for biliary complications is ongoing.\u003c/p\u003e\u003c/div\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003eHypoalbuminemia, postoperative hepatic artery complications, and prolonged ICU stay time were independent risk factors for biliary complications. Correcting hypoalbuminemia preoperatively, minimizing the occurrence of hepatic artery complications, and reducing unnecessary postoperative ICU stay duration are essential and may contribute to beneficial outcomes.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eALB\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ealbumin\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eanastomotic bile duct stricture\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ebiliary complication\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ebile leak\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eBS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ebiliary stricture\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCI\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003econfidence interval\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGRWR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003egraft-to-recipient body weight ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHAC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ehepatic artery complications\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHAS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ehepatic artery stenosis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHAT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ehepatic artery thrombosis\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHCC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ehepatocellular carcinoma\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eITBL\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eischemic-type biliary lesion\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLDLT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eliving donor liver transplantation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eliver transplantation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eNAS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003enon-anastomotic bile duct stricture\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eOR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eodds ratio\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003ePTCD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003epercutaneous transhepatic cholangial drainage\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e This study was approved by the Ethics Committee of West China Hospital, Sichuan University (approval no. 20230357). Informed consent was waived due to the retrospective nature of the study and the use of anonymized clinical data. The waiver aligns with China\u0026rsquo;s Regulations on the Management of Human Genetic Resources and the West China Hospital\u0026rsquo;s IRB policies for minimal-risk retrospective studies. The study adhered to the 1964 Declaration of Helsinki and its later amendments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability statement\u003c/strong\u003e: The datasets used or analyzed during the study are available from the Corresponding Author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests:\u003c/strong\u003e On behalf of all authors, the corresponding author states that there are no conflicts of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not Applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYun Peng: Writing\u0026nbsp;\u0026ndash;\u0026nbsp;review \u0026amp; editing, Writing\u0026nbsp;\u0026ndash;\u0026nbsp;original draft, Visualization, Methodology, Data curation, Conceptualization.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMeng Zhang: Writing\u0026nbsp;\u0026ndash;\u0026nbsp;original draft, Validation, Supervision, Data curation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLiangcai He: Conceptualization, Validation, Supervision, Data curation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eZhenyu Xie: Writing\u0026nbsp;\u0026ndash;\u0026nbsp;review \u0026amp; editing, Validation.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBo Xiang: Writing\u0026nbsp;\u0026ndash;\u0026nbsp;review \u0026amp; editing, Validation. Formal analysis\u003c/p\u003e\n\u003cp\u003eJiayin Yang: Writing\u0026nbsp;\u0026ndash;\u0026nbsp;review \u0026amp; editing, Validation.\u003c/p\u003e\n\u003cp\u003eShuguang Jin: Writing\u0026nbsp;\u0026ndash;\u0026nbsp;review \u0026amp; editing, Validation. Writing\u0026nbsp;\u0026ndash;\u0026nbsp;original draft, Validation, Supervision, Conceptualization.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eYOSHIZUMI T, HARADA N, MORI M. Biliary Stricture: The Achilles Heel of Pediatric Living Donor Liver Transplantation [J]. Transplantation, 2019, 103(9): 1758-9.\u003c/li\u003e\n\u003cli\u003eJOHNSON L B, AL-KAWAS F H. The bile duct--the Achilles\u0026apos; heel of living donor liver transplantation [J]. The American journal of gastroenterology, 2004, 99(7): 1296-7.\u003c/li\u003e\n\u003cli\u003eSHAMSAEEFAR A, NIKEGHBALIAN S, KAZEMI K, et al. 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Long-term survival after liver transplantation in 4,000 consecutive patients at a single center [J]. Annals of surgery, 2000, 232(4): 490-500.\u003c/li\u003e\n\u003cli\u003eGUNJI H, CHO A, TOHMA T, et al. The blood supply of the hilar bile duct and its relationship to the communicating arcade located between the right and left hepatic arteries [J]. American journal of surgery, 2006, 192(3): 276-80.\u003c/li\u003e\n\u003cli\u003eMARTINI V, LEDERER A K, LAESSLE C, et al. Clinical Characteristics and Outcomes of Surgical Patients with Intensive Care Unit Lengths of Stay of 90 Days and Greater [J]. Crit Care Res Pract, 2017, 2017(9852017.\u003c/li\u003e\n\u003cli\u003eMARTIN C M, HILL A D, BURNS K, et al. Characteristics and outcomes for critically ill patients with prolonged intensive care unit stays [J]. Crit Care Med, 2005, 33(9): 1922-7; quiz 36.\u003c/li\u003e\n\u003cli\u003eLIPSETT P A, SWOBODA S M, DICKERSON J, et al. Survival and functional outcome after prolonged intensive care unit stay [J]. Annals of surgery, 2000, 231(2): 262-8.\u003c/li\u003e\n\u003cli\u003eMAHESH B, CHOONG C K, GOLDSMITH K, et al. Prolonged stay in intensive care unit is a powerful predictor of adverse outcomes after cardiac operations [J]. Ann Thorac Surg, 2012, 94(1): 109-16.\u003c/li\u003e\n\u003cli\u003eMISAR A, MCLIN V A, CALINESCU A M, et al. Impact of length of donor ICU stay on outcome of patients after pediatric liver transplantation with whole and ex situ split liver grafts [J]. Pediatric transplantation, 2022, 26(2): e14186.\u003c/li\u003e\n\u003cli\u003eCERUTTI E, STRATTA C, ROMAGNOLI R, et al. Bacterial- and fungal-positive cultures in organ donors: clinical impact in liver transplantation [J]. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 2006, 12(8): 1253-9.\u003c/li\u003e\n\u003cli\u003eCORMAN DINCER P, TORE ALTUN G, BIRTAN D, et al. Incidence and Risk Factors for Systemic Infection in Deceased Donors [J]. Transplantation proceedings, 2019, 51(7): 2195-7.\u003c/li\u003e\n\u003cli\u003eGROOTENDORST A F, VAN WILGENBURG M G, DE LAAT P H, et al. Albumin abuse in intensive care medicine [J]. Intensive care medicine, 1988, 14(5): 554-7.\u003c/li\u003e\n\u003cli\u003eKOCH-WESER J, SELLERS E M. Binding of drugs to serum albumin (first of two parts) [J]. The New England journal of medicine, 1976, 294(6): 311-6.\u003c/li\u003e\n\u003cli\u003eTULLIS J L. Albumin. 1. Background and use [J]. Jama, 1977, 237(4): 355-60 contd.\u003c/li\u003e\n\u003cli\u003eNICHOLSON J P, WOLMARANS M R, PARK G R. The role of albumin in critical illness [J]. British journal of anaesthesia, 2000, 85(4): 599-610.\u003c/li\u003e\n\u003cli\u003eFLECK A, RAINES G, HAWKER F, et al. Increased vascular permeability: a major cause of hypoalbuminaemia in disease and injury [J]. Lancet (London, England), 1985, 1(8432): 781-4.\u003c/li\u003e\n\u003cli\u003eROTHSCHILD M A, ORATZ M, SCHREIBER S S. Albumin synthesis. 1 [J]. The New England journal of medicine, 1972, 286(14): 748-57.\u003c/li\u003e\n\u003cli\u003eOSTER H S, DOLEV Y, KEHAT O, et al. Serum Hypoalbuminemia Is a Long-Term Prognostic Marker in Medical Hospitalized Patients, Irrespective of the Underlying Disease [J]. Journal of clinical medicine, 2022, 11(5):\u003c/li\u003e\n\u003cli\u003eKNAUS W A, WAGNER D P, DRAPER E A, et al. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults [J]. Chest, 1991, 100(6): 1619-36.\u003c/li\u003e\n\u003cli\u003eAPELGREN K N, ROMBEAU J L, TWOMEY P L, et al. Comparison of nutritional indices and outcome in critically ill patients [J]. Crit Care Med, 1982, 10(5): 305-7.\u003c/li\u003e\n\u003cli\u003eGOLUB R, SORRENTO J J, JR., CANTU R, JR., et al. Efficacy of albumin supplementation in the surgical intensive care unit: a prospective, randomized study [J]. Crit Care Med, 1994, 22(4): 613-9.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Biliary complications, Children, Hypoalbuminemia, Liver transplantation, Risk factors","lastPublishedDoi":"10.21203/rs.3.rs-7246266/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7246266/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eLiver transplantation (LT) has become the only possible effective treatment for children with end-stage liver diseases and some metabolic disorders. However, postoperative biliary complications (BCs) are still a challenge and threaten patients' quality of life and survival. To conduct valuable management and therapy strategies, this study retrospectively analyzed the clinical characteristics of pediatric LT patients and investigated the risk factors for BC in a single transplant center in China.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eData from 174 pediatric patients (BC and non-BC) treated at the Liver Transplant Center of West China Hospital between 2001 and 2023 were collected. The authors retrospectively reviewed medical records, including patient characteristics, surgical procedures, and prognoses, and searched for risk factors of BC with univariate and multivariable analyses.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eBCs occurred in 30 of the 174 pediatric recipients (17.2%). The main types were bile leak, biliary stricture, and cholangitis. Among them, 10 bile leaks, constituting 26.3% of all BCs, 22 biliary strictures, representing 57.9%, and 6 cases of cholangitis. Children with bile leaks or cholangitis were usually cured after conservative treatment, while children with biliary strictures needed surgical intervention or endoscopic therapies. The multivariable analyses revealed that preoperative hypoalbuminemia in recipients (OR\u0026thinsp;=\u0026thinsp;22.337, 95% CI 8.054\u0026ndash;64.969, P\u0026thinsp;=\u0026thinsp;0.001), postoperative hepatic artery complications (OR\u0026thinsp;=\u0026thinsp;12.308, 95% Cl 2.665\u0026ndash;56.838, P\u0026thinsp;=\u0026thinsp;0.001), and prolonged intensive care unit (ICU) stay (OR\u0026thinsp;=\u0026thinsp;1.002, 95% Cl 1.000 to 1.003, P\u0026thinsp;=\u0026thinsp;0.012) were independent risk factors for BC after pediatric liver transplantation.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003ePreoperative hypoalbuminemia in recipients, postoperative hepatic artery complications, and prolonged ICU stay are positively associated with BC in pediatric patients after LT.\u003c/p\u003e","manuscriptTitle":"Risk factors for biliary complications after pediatric liver transplantation: a retrospective study and twenty years of experience from a single center in China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-27 06:20:09","doi":"10.21203/rs.3.rs-7246266/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-29T08:35:33+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-19T11:42:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-18T15:03:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79675532889807730439352271819441625597","date":"2025-09-09T17:11:11+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"263283401732976219615045871898387559886","date":"2025-09-08T01:56:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-19T11:40:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"296304796867442445964014729736492896319","date":"2025-08-19T11:13:06+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-17T07:41:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-12T07:26:41+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-12T03:26:58+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-08-12T03:23:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"1f77f85b-8279-4f91-a288-587c086e8e9a","owner":[],"postedDate":"August 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-04-29T08:41:14+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-27 06:20:09","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7246266","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7246266","identity":"rs-7246266","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}