In pediatric liver transplantation, both for cadaveric and living-related patients, the Roux-en-Y hepaticojejunostomy is often preferable to biliary reconstruction. Duct-to-duct biliary reconstruction in pediatric patients has been utilized only in a limited numbers of studies. Here, we retrospectively review our experience with duct-to-duct biliary reconstruction in pediatric liver transplantation patients. Since September 2001, 46 liver transplantations have been performed in 44 patients (29 boys and 15 girls of mean age, 8.4 +/- 5.5 years). For the anastomoses, a corner-saving suture technique was used with 6-0 or 7-0 polypropylene monofilament nonabsorbable suture. A T tube was used in three patients, and in 11 patients, a straight feeding tube was inserted from the recipient common bile duct to the anastomotic site. A transhepatic biliary catheter insertion technique was used in 28 patients for external bile drainage; the remaining four patients had no tubes or stents. Four patients developed bile leakage in the early postoperative period. Three of these patients were treated with percutaneous drainage with excellent outcomes; the remaining patient required reoperation with a Roux-en-Y hepaticojejunostomy for bile leakage. Four biliary stenoses occurred in the late postoperative period. All biliary stenoses were successfully treated with balloon dilatation. There was no mortality or graft loss due to biliary complications. Of the 44 original patients, 36 (82%) are well at this time, with optimal liver function during follow-up (2-34 months). The remaining eight (18%) died during the study from acute respiratory distress syndrome (n = 2), sepsis with multiorgan failure (n = 5), and intracranial bleeding (n = 1). Our results showed that duct-to-duct biliary reconstruction is a safe and easy technique for pediatric patients.