To assess the long-term outcome after combined liver-intestinal and multivisceral transplantation and the impact of the contained liver on rejection and survival. Between May 1990 and July 2005 a total of 353 transplants were given to 325 consecutive patients; 54% adults and 46% children. The liver was part of 189 visceral grafts (Group I); 124 liver-intestine and 85 multivisceral. The remaining 144 allografts were intestine-only (Group II). The most common indication for hepatic replacement was TPN associated liver failure in the combined liver-intestinal recipients and visceral vascular thrombosis in the multivisceral patients With 15 years of experience, the actuarial patient survival was 82% (1-year), 58% (5-years), 34% (10-years) and 31% (15-years) with 75%, 48%, 32% and 26% functioning graft survival, respectively. The composite grafts that contained liver has best long-term survival with significantly (p=0.001) higher 15-year conditional survival (50%) compared to intestinealone. The survival difference was due to cumulative graft loss due to early acute refractory and late chronic rejection. Immune-modulation did not improve survival but reduced risk of rejection particularly among Group II. With recipient pretreatment, the one year (92%) and four year (77%) survival has significantly (p=0.0001) improved in both groups with reduction in hospital stay (median-27 days), spaced doses of tacrolimus (62%) and improved quality of life. These survival rates were favorably comparable with the national one-year liver allograft survival and historic four-year TPN-dependent patient survival. The liver contained intestinal allograft has best long-term survival with reduced risk of rejection.