Technical feasibility should not outweigh long-term outcomes in biliary reconstruction for children.

The choice of biliary reconstruction after excision of choledochal malformations in children should prioritize long-term physiological outcomes over operative convenience. In response to the article by Kanojia et al. on the management of aberrant bile ducts at the porta hepatis during minimally invasive surgery, we wish to highlight that while hepaticoduodenostomy is technically attractive (particularly with laparoscopic and robotic platforms) evidence suggests it is associated with increased biliary reflux and reflux-related morbidity, especially in cases with complex hilar anatomy requiring multiple ductal anastomoses. In pediatric patients with a long life expectancy, these risks may have significant long-term consequences. We therefore emphasize that Roux-en-Y hepaticojejunostomy should remain the preferred reconstructive option in most children undergoing excision of choledochal malformations.