There is some evidence that portal venous drainage may offer immunologic and metabolic advantages in small bowel transplantation. Isolated small bowel transplantation was performed in 14 adult patients. In all cases, the donor pancreas was transplanted into another patient. During the donor procedure, the superior mesenteric artery and vein were separated below the division of the inferior pancreaticoduodenal artery and below the veins of the pancreatic head. An arterial interposition graft was used in all cases. One donor mesenteric artery was reconstructed in 6 patients; two arteries in 5 patients; and three arteries in 3 patients. Proximal arteries of the graft were ligated and the upper part of the jejunum resected. In 10 patients, a direct anastomosis was performed in an end-to side fashion between donor superior mesenteric vein (SMV) and recipient inferior mesenteric vein (IMV). In 2 patients, a branch of the superior mesenteric vein was used and 2 patients required a venous interposition graft to confluence using the donor iliac vein. Patency of the venous anastomosis was documented by magnetic resonance imaging (MRI) angiography after 6 months. No vascular complications have been observed to date. Portal venous drainage is technically feasible in most cases. An anastomosis to the recipient IMV offers the advantage of being direct despite the short donor vein segment. Furthermore, donor and recipient vessels are well matched for size. Using microsurgical techniques, vascular complications may be avoided.