Transanal Hemorrhoidal Dearterialization With Mucopexy Versus Ferguson Hemorrhoidectomy for Prolapsed Internal Hemorrhoids: A Multicenter Prospective Study.

OBJECTIVE: To compare transanal hemorrhoidal dearterialization (THD) with mucopexy to Ferguson hemorrhoidectomy in terms of recurrence rates and quality of life. BACKGROUND: There is uncertainty regarding the durability of the therapeutic effect of THD with mucopexy compared with Ferguson hemorrhoidectomy in terms of recurrence rates. METHODS: This was a multicenter prospective study. Participating surgeons performed the operation they knew best enrolling 10 patients each. Surgeons' unedited videos were reviewed by an independent expert. Patients with prolapsed internal hemorrhoids in at least 3 columns were eligible. The primary endpoint was recurrence rates defined as prolapsing internal hemorrhoids. Patient-reported outcomes and satisfaction were evaluated with Pain Scale and Brief Pain Inventory, Fecal Incontinence Quality Of Life (FIQOL), Cleveland Clinic Incontinence, Constipation, Short-Form 12 scores, and Patient satisfaction (4-point Likert) scale. RESULTS: Twenty surgeons enrolled 197 patients. THD patients had lower Visual pain scores at postoperative day (POD) 1 (6.2 vs 8.3, P =0.047), POD7 (4.5 vs 7.7, P =0.021), POD14 (2.8 vs 5.3, P <0.001), and medication use at POD14 (23% vs 58%, P <0.001). Median follow-up was 3.1 (1.0-5.5) years. Recurrence rates did not differ between the study arms (5.9% vs 2.4%, P =0.253). Patient satisfaction rate was higher after THD at POD14 (76.4% vs 52.5%, P =0.031) and 3 months (95.1% vs 63.3%, P =0.029), but did not differ at 6 months (91.7% vs 88%, P =0.228) and 1 year (94.2% vs 88%, P =0.836). CONCLUSION: THD with mucopexy was associated with improved patient-reported outcomes and quality of life as compared with Ferguson hemorrhoidectomy with nonsignificantly different recurrence rates.

Pathogenesis and persistence of cryptoglandular anal fistula: a systematic review.

Anal fistulas continue to be a problem for patients and surgeons alike despite scientific advances. While patient and anatomical characteristics are important to surgeons who are evaluating patients with anal fistulas, their development and persistence likely involves a multifaceted interaction of histological, microbiological, and molecular factors. Histological studies have shown that anal fistulas are variably epithelialized and are surrounded by dense collagen tissue with pockets of inflammatory cells. Yet, it remains unknown if or how histological differences impact fistula healing. The presence of a perianal abscess that contains gut flora commonly leads to the development of anal fistula. This implies a microbiological component, but bacteria are infrequently found in chronic fistulas. Recent work has shown an increased expression of proinflammatory cytokines and epithelial to mesenchymal cell transition in both cryptoglandular and Crohn's perianal fistulas. This suggests that molecular mechanisms may also play a role in both fistula development and persistence. The aim of this study was to examine the histological, microbiological, molecular, and host factors that contribute to the development and persistence of anal fistulas.

Prospective multicenter study of a synthetic bioabsorbable anal fistula plug to treat cryptoglandular transsphincteric anal fistulas.

BACKGROUND: Although interest in sphincter-sparing treatments for anal fistulas is increasing, few large prospective studies of these approaches have been conducted. OBJECTIVE: The study assessed outcomes after implantation of a synthetic bioabsorbable anal fistula plug. DESIGN: A prospective, multicenter investigation was performed. SETTING: The study was conducted at 11 colon and rectal centers. PATIENTS: Ninety-three patients (71 men; mean age, 47 years) with complex cryptoglandular transsphincteric anal fistulas were enrolled. Exclusion criteria included Crohn's disease, an active infection, a multitract fistula, and an immunocompromised status. INTERVENTION: Draining setons were used at the surgeon's discretion. Patients had follow-up evaluations at 1, 3, 6, and 12 months postoperatively. MAIN OUTCOME MEASURES: The primary end point was healing of the fistula, defined as drainage cessation plus closure of the external opening, at 6 and 12 months. Secondary end points were fecal continence, duration of drainage from the fistula, pain, and adverse events during follow-up. RESULTS: Thirteen patients were lost to follow-up and 21 were withdrawn, primarily to undergo an alternative treatment. The fistula healing rates at 6 and 12 months were 41% (95% CI, 30%-52%; total n = 74) and 49% (95% CI, 38%-61%; total n = 73). Half the patients in whom a previous treatment failed had healing. By 6 months, the mean Wexner score had improved significantly (p = 0.0003). By 12 months, 93% of patients had no or minimal pain. Adverse events included 11 infections/abscesses, 2 new fistulas, and 8 total and 5 partial plug extrusions. The fistula healed in 3 patients with a partial extrusion. LIMITATIONS: The study was nonrandomized and had relatively high rates of loss to follow-up. CONCLUSION: Implantation of a synthetic bioabsorbable fistula plug is a reasonably efficacious treatment for complex transsphincteric anal fistulas, especially given the simplicity and low morbidity of the procedure.

Obesity increases the risk of postoperative peripheral neuropathy after minimally invasive colon and rectal surgery.

BACKGROUND: Abdominal surgery in the obese can be a major challenge in the perioperative period. Peripheral neuropathy is an uncommon but well-described complication after abdominal surgery. OBJECTIVE: Our aim was to evaluate the incidence of postoperative peripheral neuropathy after colorectal surgery and to identify its risk factors. DESIGN: A retrospective review of a prospectively maintained database of consecutive patients undergoing colorectal operations was performed. The incidence of postoperative nerve injury was compared between minimally invasive and open surgeries. BMI and other potential risk factors for developing peripheral neuropathy were evaluated. SETTINGS: This investigation was conducted at a single institution. PATIENTS: Over a 7-year period, 1514 colorectal operations were performed. 945(62.4%) of these operations were performed either laparoscopically or via hand-assisted laparoscopy, 166 (11.0%) were robotic assisted, and 403 (26.6%) were open procedures. Twenty-three patients (1.5%) developed peripheral neuropathy in the postoperative period. MAIN OUTCOME MEASURES: Forward stepwise logistic regression was used for multivariate analysis. RESULTS: All 23 of the patients with peripheral neuropathy had sensory deficits, and 1 patient had both sensory and motor deficits. All of the symptoms resolved without any residual neurologic deficits within 1 year. Twenty-two of the 23 patients with peripheral neuropathy were in the minimally invasive surgery group (incidence, 2%). One patient from the open group had peripheral neuropathy. By logistic regression analysis, only BMI was an independent predictor for peripheral neuropathy (p = 0.016) in minimally invasive surgery. LIMITATIONS: A limitation of our study is that postoperative neuropathy identification depended on reporting of symptoms, and there was no objective method of assessment. In addition, because of the relatively small number of patients with postoperative neuropathy, the study may be underpowered to detect significant differences in potential risk factors for developing neuropathy. CONCLUSIONS: The incidence of postoperative peripheral neuropathy was 2.0% in minimally invasive surgery and 0.2% in open surgery. Minimally invasive surgery, age, lithotomy positioning, operative time, and Pfannenstiel incision all significantly increased the risk of peripheral neuropathy. However, only obesity was an independent risk factor for peripheral neuropathy in patients undergoing minimally invasive colorectal surgery. Preventive measures should be instituted and documented in obese patients undergoing minimally invasive colorectal procedures.

Management of anastomotic leak: lessons learned from a large colon and rectal surgery training program.

BACKGROUND: Anastomotic leak is a dreaded surgical complication that can lead to significant morbidity and mortality. Despite its prevalence, there is no consensus on the management of anastomotic leak. This study aimed to review the management of anastomotic leak in the Division of Colon and Rectal Surgery at two institutions. METHODS: This is a retrospective review of all anastomotic leaks occurring after surgery in the Division of Colon and Rectal Surgery at two teaching institutions during 1997-2008. RESULTS: Altogether, 103 leaks occurred in 1,707 anastomoses (6 %), with a median time to diagnosis of 20 days (2-1,400 days). The 90-day mortality rate was 3 %. The majority of cases were managed nonoperatively (73 %), and the majority of leaks were from an extraperitoneal anastomosis (67 %). Success (i.e., radiographic demonstration of a healed leak, restored gastrointestinal continuity) occurred in 54 % of operatively managed leaks and 57 % of nonoperatively managed leaks (56 % overall). Operative management differed by leak location. In 91 % of patients with intraperitoneal leaks, the anastomosis was resected. In 76 % of patients with extraperitoneal leaks, diversion and drainage alone was performed without manipulating the anastomosis. Nonoperative management was successful for 57 % of extraperitoneal leaks and 58 % of intraperitoneal leaks. There was no significant difference in the success rates based on type of management (operative/nonoperative) for either extraperitoneal or intraperitoneal leaks. CONCLUSIONS: Anastomotic leak continues to result in patient morbidity and mortality. Its diverse presentation requires tailoring management to the patient. Nonoperative and operative treatments are viable options for intraperitoneal and extraperitoneal leaks based on patient presentation.

Cost-effectiveness of laparoscopic vs open resection for colon and rectal cancer.

BACKGROUND: Whether laparoscopic surgery for colon and rectal cancer is cost-effective in comparison with open surgery remains unclear, because laparoscopic surgery results in shorter hospital stays but is associated with increased equipment costs. OBJECTIVE: This study aimed to investigate the cost-effectiveness of laparoscopic versus open surgery for colon and rectal cancer, incorporating factors not included in previous cost-effectiveness studies. DESIGN: A decision analysis model was constructed, and extensive sensitivity analyses were performed to test the assumptions of the model. SETTING: Data were taken from previously published studies; data from large randomized trials were used whenever possible as inputs into the model. PATIENTS: Patients enrolled in the trials from which data were gathered for the model. INTERVENTIONS: There were no interventions. MAIN OUTCOME MEASURES: The primary outcome measured was the cost-effectiveness of laparoscopic versus open surgery for colon and rectal cancer, expressed as cost per quality-adjusted life-year. RESULTS: Laparoscopic resection results in savings of $4283 and essentially no difference in quality-adjusted life-years (0.001 more quality-adjusted life-years than open resection). Sensitivity analyses indicate that laparoscopic surgery is cost-effective at <$50,000 per quality-adjusted life-year under almost all conditions. The only circumstance that affects the cost-effectiveness of laparoscopic surgery is postoperative hernia rates. Because of the additional time off work for hernia repair, laparoscopic resection is cost-effective only if it results in a hernia rate less than or equal to open surgery. For all other variables, the laparoscopic approach remains less costly than the open approach with no difference in quality of life. LIMITATIONS: The model relies on data from other studies, rather than being an independent trial designed to specifically collect these data. CONCLUSIONS: Laparoscopic resection for colon and rectal cancer results in decreased costs and equivalent quality of life, making it the preferred approach in suitable patients.

Ligation of intersphincteric fistula tract: early results of a pilot study.

BACKGROUND: Transsphincteric fistulotomy is associated with a variable degree of fecal incontinence that is directly related to the thickness of the sphincter mechanism overlying the fistula. Staged fistulotomy with seton or the use of cutting seton designed to reduce the proportionate incontinence rates have failed to do so. This has resulted in attempts to find novel sphincter-sparing techniques in the past 2 decades including draining seton, fibrin sealant, anal fistula plug, dermal advancement, and endorectal advancement flaps. These operations have a variable success rates of 30% to 80% reported in the literature. OBJECTIVE: In 2007, Rojanasakul from Thailand demonstrated a novel technique, ligation of intersphincteric fistula tract, and reported a 94% success rate in a small series. Since then, a few other small cohorts of patients have been reported in the literature with success rates varying from 57% to 82%. An institutional review board-approved study was proposed to measure our results and compare them with the published data. DESIGN: This study was undertaken to evaluate the success of ligation of intersphincteric fistula tract procedures in a group of unselected transsphincteric fistulas deemed unsuitable for lay-open fistulotomy. SETTING: The procedure was performed in 3 different settings: a public institution, a major university hospital, and a large private hospital. PATIENTS: A total of 40 patients underwent 41 ligation of intersphincteric fistula tract procedures performed by 6 Board-certified colon and rectal surgeons. RESULTS: In a mean follow-up of 18 weeks, 74% of the patients achieved healing. In patients who underwent ligation of intersphincteric fistula tract as their primary procedure, the healing rate was 90%. The limitation of this study is its "case series" nature and the short mean follow-up period of 18 weeks. CONCLUSION: Ligation of intersphincteric fistula tract has had excellent success in transsphincteric fistulas in multiple small series. A larger number of patients and longer follow-up period are needed to validate the early favorable results.

A comparison of open and robotic total mesorectal excision for rectal adenocarcinoma.

PURPOSE: This retrospective study was designed to compare open with robot-assisted total mesorectal excision for rectal adenocarcinoma. METHODS: With use of predefined exclusion criteria, all consecutive laparoscopic-assisted (51 patients) and robot-assisted (36 patients) rectal resections for adenocarcinoma from August 2005 to November 2009 at a single institution were considered. Hand-assisted laparoscopy was used for splenic flexure mobilization in all cases. Patients were assigned into robotic and open groups on the basis of the technique used for total mesorectal excision. All 36 robot-assisted resections had the total mesorectal excision performed with robotic assistance and were included in the robotic group. Forty-six of the 51 patients who received a laparoscopic-assisted procedure had the total mesorectal excision performed through the hand port using open surgical technique and were included in the open group. Both groups were compared with respect to patient demographics, perioperative outcomes, and pathology. RESULTS: The robotic and open groups were comparable in age, sex, body mass index, history of prior abdominal surgery, ASA class, number of patients receiving neoadjuvant chemoradiation, and tumor stage. There were more abdominoperineal resections (P = .019) and more low and mid rectal tumors (P = .007) in the robotic group. Total procedure time was longer in the robotic group (P = .003), but blood loss was less (P = .036). Lymph node yield, intraoperative and postoperative complications, and length of stay were all comparable. There were 3 positive circumferential margins in the open group vs none in the robotic group, but this did not reach statistical significance. CONCLUSIONS: Robotic total mesorectal excision is feasible and safe, and is comparable to open total mesorectal excision in terms of perioperative and pathological outcomes. The longer operative time associated with robotic total mesorectal excision could decrease as experience with this relatively new technique increases. Large randomized trials are necessary to validate the potential benefits of less blood loss and lower margin positivity rates observed in this study.

Robotic cylindrical abdominoperineal resection with transabdominal levator transection.

PURPOSE: The extralevator approach to abdominoperineal resection is an emerging surgical option for patients with low rectal cancer. This technique involves a wide excision of the levator muscles that could reduce the high incidence of circumferential margin positivity associated with conventional abdominoperineal resections. We present our technique of robotic cylindrical abdominoperineal resection where the daVinci robot is used to perform a controlled transection of the levator muscles transabdominally under direct visualization. METHODS: Five patients with rectal adenocarcinoma within 5 cm of the anal verge underwent robot-assisted cylindrical abdominoperineal resection. Safety, feasibility, immediate postoperative outcomes, and pathological adequacy of the specimen were assessed. RESULTS: The procedure was successfully completed in all 5 patients without any intraoperative complications, robot-associated morbidity, or conversion to the open approach. The mean operative time and length of hospital stay were 343 minutes and 5.8 days. An intact mesorectal envelope and negative circumferential margin was achieved in all cases. All specimens had a cylindrical shape. CONCLUSIONS: Robotic assistance enables the transabdominal transection of the levator muscles in cylindrical abdominoperineal resection, with acceptable perioperative and pathological outcomes. Further studies are essential to objectively define the safety, efficacy, and long-term results of this new technique.

Incisional hernia, midline versus low transverse incision: what is the ideal incision for specimen extraction and hand-assisted laparoscopy?

BACKGROUND: Minimally invasive surgery is associated with smaller surgical incisions than those of traditional midline laparotomy. However, most colorectal resections and all hand-assisted procedures require an incision either for specimen retrieval or insertion of the hand-assist device. The ideal site of this incision has not been evaluated with respect to the incidence of incisional hernia. This study compares the rates of incisional hernia associated with a standard midline laparotomy, a midline incision of reduced length, and a Pfannenstiel incision. METHODS: From March 2004 to July 2007, 512 consecutive patients were identified from a prospectively maintained database according to predefined inclusion and exclusion criteria. Patients were divided into three groups depending on the type of incision (open, midline, and Pfannenstiel). Demographic variables, rate of incisional hernia, and risk factors for hernia were compared among the groups. RESULTS: There were 142, 231, and 139 patients in the open, midline, and Pfannenstiel groups, respectively. All three groups were comparable with respect to age, gender, steroid use, diabetes, number of patients with malignancy, and duration of follow-up. The Pfannenstiel group had a higher mean BMI (p = 0.015) and the open group had a higher rate of wound infection (28.2%) compared to the other groups. Incidence of incisional hernia was similar for the open and midline groups (19.7 and 16%, p = 0.36). At a mean follow-up of 17.5 months, not a single patient with a Pfannenstiel incision developed an incisional hernia (p < 0.001). BMI (p = 0.019), follow-up (p < 0.001), and Pfannenstiel incision (p < 0.001) were found to be predictors (protectors) of incisional hernia on multivariate analysis. CONCLUSION: A Pfannenstiel incision is associated with the lowest rate of incisional hernia and should be the incision of choice for hand assistance and specimen extraction in minimally invasive colorectal resections wherever applicable.

Robotic pursestring technique in low anterior resection.

PURPOSE: Rectal division and anastomosis are difficult steps in a laparoscopic low anterior resection. This difficulty is due to the limitations of laparoscopic instrumentation within the anatomical confines of the pelvis. Robotic technology overcomes most of these limitations to simplify the procedure. We describe our technique of controlled rectal transection and robotic purse-string placement by use of the da Vinci Robotic system. METHODS: Three patients with rectal cancer who were scheduled to undergo a robot-assisted low anterior resection were selected to undergo this procedure. Safety, feasibility, and immediate postoperative outcomes were assessed. RESULTS: The procedure was successfully completed in all 3 patients with no intraoperative complications. One patient had a postoperative bilateral femoral neuropathy that resolved spontaneously. The mean operating time was 339.6 minutes, and all 3 patients were sent home by the fifth postoperative day. CONCLUSIONS: The advanced surgical dexterity of the da Vinci Robot enables a controlled rectal transection and purse-string suture placement on the rectal stump. This achieves a right-angled rectal division and a secure, single-stapled anastomosis in a low anterior resection. The feasibility of this technique has been demonstrated in 3 patients, in whom this technique has been safely performed with acceptable results. A larger series of patients and a long-term follow-up is required to demonstrate an objective benefit.

Total mesorectal excision for rectal cancer: the potential advantage of robotic assistance.

PURPOSE: The purpose of this study was to analyze the safety, feasibility, and efficacy of the da Vinci S HD robotic system in mesorectal excision for rectal adenocarcinoma, with the aim to identify areas of potential advantage for the robot in this procedure. METHODS: This study was conducted as a retrospective review of a prospectively maintained database of 44 consecutive cases of robot-assisted mesorectal excision for rectal adenocarcinoma performed between August 2005 and February 2010. Patient demographics, perioperative outcomes, and complications were evaluated and compared with similar published reports and relevant literature. RESULTS: There were 28 (63.6%) men and 16 (36.4%) women, with a mean age of 63 years. The majority of patients were either overweight or obese and 88.7% of lesions were in the mid or low rectum. We performed 36 low anterior resections (6 intersphincteric) and 8 abdominoperineal resections with a median blood loss of 150 mL (range, 50-1000), a median operative time of 347 minutes (range, 155-510), and a median length of stay of 5 days (range, 3-36). The median lymph node yield was 14 (range, 5-45) and the circumferential resection margin was negative in all patients. We had 1 distal margin positivity (2.7%), 2 anastomotic leaks (5.6%), 1 death (2.7%), and 2 conversions (4.5%) to the open approach. No robot-associated morbidity occurred in this series. CONCLUSIONS: This series compares favorably with similar published reports with regard to the safety and feasibility of robotic assistance in total mesorectal excision for rectal cancer. The lower conversion rates reported for robotic rectal resection compared with laparoscopy require validation in large randomized trials.

Robotic assistance in right hemicolectomy: is there a role?

PURPOSE: The purpose of this study was to evaluate the results, postoperative outcomes, and cost of robotic assistance in right hemicolectomy and determine its safety, feasibility, and efficacy as compared with the conventional laparoscopic approach. METHODS: From August 2005 to February 2009, 40 robot-assisted right hemicolectomies were performed by the authors at a single institution. These were compared with 135 laparoscopic right hemicolectomies performed by the authors, at the same hospital and during the same time period. Cost data from July 2006 until the end of the study period were compared between the 2 groups. RESULTS: Both groups were comparable with respect to age, sex, body mass index, American Society of Anesthesiologists' class, history of prior abdominal surgery, and diagnosis. There was no significant difference in the lymph node harvest, estimated blood loss, conversion rate, length of stay, or incidence of complications and wound infection between the 2 groups. A robotic procedure was associated with a longer operative time (P < .001) and a higher cost (P = .003). CONCLUSION: Robotic assistance in right hemicolectomy is safe and feasible but is associated with a longer operative time and, at present, with a higher cost compared with laparoscopy. However, right hemicolectomy serves as an ideal procedure to begin the learning curve in robotic colorectal surgery, which can subsequently progress to robotic rectal resections where the robot has the greatest potential for benefit.

Robotic colon and rectal surgery: a series of 131 cases.

BACKGROUND: Laparoscopic colorectal surgery has become a mainstay in the treatment of benign and malignant colorectal diseases. There are inherent limitations to conventional laparoscopy which can be overcome by the robot. Here we present our experience with 131 cases of robotic and robot-assisted colon and rectal resections. METHODS: This is a retrospective review of a prospectively maintained database. From August 2005 through June 2009, we performed a total of 131 totally robotic and robot-assisted colorectal resections. These included 42 right colectomies (RC), 16 anterior resections (AR) for benign disease, 8 AR with rectopexy for prolapse, 7 total proctocolectomies (TPC), 47 low and ultralow anterior resections (LAR) for rectal cancer, and 11 abdominal perineal resections (APR). All LARs were done as a hybrid procedure (laparoscopic splenic flexure mobilization followed by robotic rectal dissection), and all APR specimens were extracted through the perineal incision. All coloanal anastomoses were diverted with a loop ileostomy. RESULTS: There were no intraoperative complications in this series. Postoperative complications included 10 patients with ileus or small bowel obstruction (SBO), 2 patients with anastomotic leaks, 1 patient with an abscess, and 3 patients with temporary peripheral neuropathy that resolved spontaneously. Five patients required reoperation and there were a total of 4 conversions (3.7%) across all case types. CONCLUSIONS: Robotic colon and rectal resections are safe and feasible options for the treatment of both benign and malignant disease processes. Further studies comparing oncologic and perioperative outcomes of robotic, laparoscopic, and open techniques are needed to determine the utility and efficacy of this technology in the field of colorectal surgery.

Staged approach for abdominal wound closure following combined liver and intestinal transplantation from living donors in pediatric patients.

Primary closure of the abdominal wall after combined liver and intestine transplantation from a living donor into a pediatric patient is usually not possible, because of the size of the donor organ, graft edema, and preexisting scars or stomas of the abdominal wall. Closure under tension may lead to abdominal compartment syndrome with vascular compromise and necrosis of the transplanted organ. We describe our experience of abdominal wound closure after liver and intestinal transplant in the pediatric patient using a staged approach. From February 2003 to June 2006, we managed five pediatric liver and intestinal living donor transplant recipients. Because of the large post-transplantation abdominal wall defect, a staged technique of abdominal wound closure was utilized. Initially, an absorbable Polygalactin mesh was sutured around the layer of the defect. As soon as adequate granulation tissue was formed over the mesh a STSG was applied. From the wound stand point all five patients were managed successfully with staged wound closure after transplantation. Granulation tissue filled and covered the mesh within 7.6 wk. A STSG was then used to cover the defect. All infants recovered well and none had a significant wound complication in the immediate post-operative period following STSG. At a mean follow-up of 24 months only one patient developed an entero-cutaneous fistula five months post-transplant. Staged abdominal wall coverage with the use of Polygalactin mesh followed by STSG is a simple and effective technique. A closed wound is achieved in a timely fashion with protection of the viscera. Residual ventral hernia will need to be managed in the future with one of several reconstructive techniques.

Simultaneous or sequential combined living donor-intestine transplantation in children.

BACKGROUND: Since the report of the first successful living donor combined liver-intestine transplant in pediatric patients, three other cases have been performed. In this article, we describe surgical technique, outcome, and propose a broader application of this procedure using deceased donors. PATIENTS: Four children of mean age 15.5 months (11-24 months) and weight 9.5 kg (8-10.9 kg) affected by end-stage liver and intestinal failure underwent living donor combined liver-intestine transplant with a left lateral liver and a distal segment of jejunum. In one case, the organs were transplanted simultaneously and in three in staged procedures. In all cases the liver transplant was performed first. The intestine was always transplanted with systemic venous drainage. The biliary anastomosis was a duct-to-duct, a biliodigestive, or a combined one according to the biliary anatomy of the liver graft. The abdomen was routinely closed with a Vicryl mesh followed by a skin graft. A loop graft ileostomy was fashioned for protocol biopsies and taken down within 3 months. RESULTS: One intestine was lost to generalized ischemia. The child was promptly retransplanted with another living donor graft. All children are alive and well at an average follow-up of 30 months (18-54 months). CONCLUSIONS: Living donor combined liver-intestine transplant can be performed successfully with excellent early outcome. The in situ splitting technique here described can be applied to obtain grafts for small children from appropriate adult deceased donors.