The entire length of the small bowel from the ligament of Treitz to the ileocecal valve is measured. Subsequently, the cecum and the terminal ileum are identified and marked approximately 30 cm proximal from the ileocecal junction. The donor operation consists of harvesting 200 cm of distal ileum (160 cm for pediatric recipients), preserving at least 20–30 cm of terminal ileum and ileocecal valve to avoid macrocytic anemia and shortened transit time. The vascular pedicle of the graft is formed by the distal branches of the SMA and SMV or, alternately, by the ileocolic artery and vein, and they are anastomosed to the infrarenal aorta and cava of the recipient, respectively.

If the procedure involved a combined intestinal and liver transplant, the donor operation becomes more complex. Combined living donor intestinal and liver transplants have only been done for pediatric patients. If the recipient remains stable after the liver is implanted, the intestinal procurement (and consequently the transplant) can be performed; otherwise, the incision is closed and the intestinal transplant is rescheduled, preferably within the two first weeks after the liver transplant.

It is very important that the donors have adequate follow-up care. After discharge, they need to be evaluated on a monthly basis and then annually to review their eating and defecation patterns as well as any complications. The donor should also undergo vitamin B12 assays at 1, 6, and 12 months postdonation to ensure adequate vitamin B12 absorption.

Benedetti et al. report a case of chronic diarrhea among the donors, but it was resolved with medical therapy consisting of Imodium and cholestyramine [11]. For 11 donors, out of their total cohort of LD intestinal transplants at the University of Illinois Hospital, the authors also reported a 36.4 % reduction in LDL and a 22.3 % decrease in total cholesterol levels when compared with their respective predonation lipid profiles, and they noted the difference was statistically significant [12]. However, a further follow-up in a greater cohort should be completed to conclude this finding.

Although the number of LD intestinal transplants is relatively small, there have been no reports of donor mortality or life-threatening complications [13]. Nevertheless, a more extensive follow-up is necessary to determine the presence of postsurgical complications, such as intestinal adhesions.

Registry data suggest that the patient and graft survival rates are similar for both LD and DD intestinal transplants. Nevertheless, using a living donor can reduce the mortality rate for those on the waiting list, which is especially high for candidates for combined liver/bowel transplant less than 5 years of age (www.​unos.​org, SRTR & OPTN Annual Data Report, 2012).

About 15 % of patients receiving TPN for more than 1 year develop end-stage liver disease. In children, the incidence of liver disease is higher, especially in patients with less than 30–40 cm of remnant bowel [14]. Liver disease remains the leading indication for performing intestinal transplantation in children, followed by loss of central venous access to provide parenteral nutrition.

The indications for intestinal transplantation in pediatric patients were updated in 2010 by Avitzur and Grant [15] (Table 28.2).

A multidisciplinary evaluation of the patient with intestinal failure is essential to assess adequate candidacy for transplantation and to ensure best outcomes. The evaluation process must elucidate the following: (1) the failure to wean of TPN after application of other surgical strategies for intestinal rehabilitation, besides transplantation; (2) the need of intestine or combined liver/intestine transplantation; (3) the state of the remnant intestine and the patency of the great vessels; (4) and the absence of absolute contraindications or associated disease that can put the patient at risk during the procedure or postoperative period. All the aspects of the recipient evaluation are summarized in Table 28.3.