The migrated liver transplantation candidate: waitlist time affects mortality.

prolong biologic treatment in pediatric patients, we cannot make a generalized statement recommending early surgical treatment for these patients. An individualized decision made by the pediatric gastroenterologist, surgeon, patient, and parents of the patient is critical. At the same time, their study can be used as a reference to bring up an intellectual discussion for parents to understand the potential risks of failed medical therapy in pediatric patients. As for stopping the biologics within 12 weeks before surgery, this is something with which we agree. We are very liberal about staging the ileal pouch procedure with an initial subtotal colectomy and an end ileostomy rather than creating an ileal pouch under suboptimal conditions. With this approach, we decreased our perioperative anastomotic complications. We recommend being liberal with a low threshold for an initial colectomy in the era of the biologics and staging the ileal pouch anal anastomosis procedure. We are concerned about Drs Pellino and Selvaggi’s opinion of using routine mucosectomy and hand-sewn anastomosis. We do believe a stapled anastomosis provides better functional outcomes, quality of life, and fewer septic complications compared with hand-sewn anastomosis. We have also shown that a mucosectomy is not assurance for proof of safety preventing neoplastic activity. Our experience showed that patients undergoing a mucosectomy and hand-sewn anastomosis are also prone to develop cancer. Doing a hand-sewn anastomosis can actually preclude us from a proper surveillance by bringing the pouch through the anal canal and covering the mucosectomized anal transitional zone, which can harbor leftover columnar epithelium that has a potential for neoplastic progression. However, we recommend a mucosectomy and hand-sewn anastomosis in patients with dysplasia, early-stage cancer of the lower rectum, or in familial adenomatous polyposis patients whose anal transitional zones are carpeted with polyps. In conclusion, we thank our colleagues for their interest in our article, and stapled ileal pouch-anal anastomosis is our preferred technique when it is technically feasible. Stapled anastomosis provides better function, fewer complications, and potentially more reliable surveying of the ileal pouch and the anal canal.