Improved body mass index after mesenterico-portal bypass

Optimal Treatment for Patients With Cavernous Transformation of the Portal Vein

Cavernous transformation of the portal vein (CTPV) is a sequela of extrahepatic and/or intrahepatic portal vein obstruction caused by a combination of local and risk factors. It was ever taken as a relatively rare disease due to its scant literature, which was mainly based on clinical series and case reports. CTPV often manifests as gastroesophageal variceal bleeding, splenomegaly, and portal biliopathy after the long-term insidious presentation. It is unable for CTPV to be recanalized with anticoagulation because it is a complete obstruction of the mesentericoportal axis. Endoscopic therapy is mainly used for temporary hemostasis in acute variceal bleeding. Meso-Rex shunting characterized by portal-flow-preserving shunts has been widely performed in children with CTPV. The multitude of complications associated with CTPV in adults can be effectively addressed by various interventional vascular therapies. With the ubiquity of radiological examinations, optimal treatment for patients with CTPV becomes important. Multivisceral transplantation, such as liver-small intestinal transplantation, may be lifesaving and should be considered for patients with diffuse mesenteric venous thrombosis.

Surgical shunts for extrahepatic portal vein obstruction in pediatric patients: a systematic review

BACKGROUND

Extrahepatic portal vein obstruction (EHPVO) causes portal hypertension in noncirrhotic children. Among surgical treatments, it is unclear whether the meso-Rex shunt (MRS) or portosystemic shunt (PSS) offers lower post-operative morbidity and superior patency over time. Our objective was to evaluate long-term outcomes comparing MRS and PSS for pediatric patients with EHPVO.

METHODS

A systematic review was conducted of articles reporting children undergoing surgical shunts for EHPVO from 1/2000-2/2020. Of 87 articles screened, 22 were eligible for inclusion. The primary outcome was shunt thrombosis and secondary outcomes included non-operative complications, stenosis, and re-operation.

RESULTS

Eighteen of 22 studies were of good quality and four had fair quality. Of 461 patients included, 340 underwent MRS and 121 underwent PSS. MRS were associated with a higher rate of post-operative thrombosis when compared to PSS (14.1% vs 5.8%, p = 0.021). There were 40/340 MRS patients (11.8%) that required at least one re-operation for either shunt thrombosis or stenosis, versus 5/121 PSS patients (4.1%), p = 0.019.

CONCLUSION

Both MRS and PSS result in acceptable long-term patency rates, but the more technically demanding MRS is associated with higher post-shunt thrombosis, often requiring further operative intervention. This study suggests that PSS may offer advantages for pediatric patients with EHPVO.

Standard or Variant Meso-Rex Shunts for Children with Variceal Bleeding due to Extrahepatic Portal Vein Obstruction: A Report of Two Cases

Extrahepatic portal vein obstruction (EHPVO) is the most common cause of pediatric portal hypertension and can cause life-threatening variceal bleeding. Meso-Rex shunt (MRS) is a surgical procedure that restores physiological portal venous blood flow to the liver by using a graft to connect the superior mesenteric vein and the left portal vein within the Rex recess, and can relieve variceal bleeding and other complications associated with EHPVO. Although the MRS is regarded as an optimal and potentially curative treatment with good long-term patency, graft thrombosis or failure due to unknown causes is not rare, prompting the need for further research on the risk factors of graft failure or poor patency. Herein, we report two cases of EHPVO in patients with recurrent or uncontrolled variceal bleeding, one treated with the classic Rex shunt and the other with the modified Rex shunt, which resulted in a failure and success, respectively.

Liver atrophy and regeneration in noncirrhotic portal vein thrombosis: Effect of surgical shunts

The goal of the study is to characterize the relationship between portal vein thrombosis (PVT) and hepatic atrophy in patients without cirrhosis and the effect of various types of surgical shunts on liver regeneration and splenomegaly. Patients without cirrhosis with PVT suffer from presinusoidal portal hypertension, and often hepatic atrophy is a topic that has received little attention. We hypothesized that patients with PVT have decreased liver volumes, and shunts that preserve intrahepatic portal flow enhance liver regeneration. Sixty-four adult and pediatric patients with PVT who underwent surgical shunt placement between 1998 and 2011 were included in a retrospective study. Baseline liver volumes from adult patients were compared with standard liver volume (SLV) as well as a group of healthy controls undergoing evaluation for liver donation. Clinical assessment, liver function tests, and liver and spleen volumes from cross-sectional imaging were compared before and after surgery. A total of 40 patients received portal flow-preserving shunts (32 mesoportal and 8 selective splenorenal), whereas 24 received portal flow-diverting shunts (16 nonselective splenorenal and 8 mesocaval). Baseline adult liver volumes were 26% smaller than SLV (1248 versus 1624 cm³ ; P = 0.02) and 20% smaller than the control volumes (1248 versus 1552 cm³ ; P = 0.02). Baseline adult spleen volumes were larger compared with controls (1258 versus 229 cm³ ; P < 0.001). Preserving shunts were associated with significant increase in liver volumes (886 versus 1131 cm³ ; P = 0.01), whereas diverting shunts were not. Diverting shunts significantly improved splenomegaly. In conclusion, we have demonstrated that patients without cirrhosis with PVT have significant liver atrophy and splenomegaly. Significant liver regeneration was achieved after portal flow-preserving shunts. Liver Transplantation 24 881-887 2018 AASLD.

Metabolic profile of children with extrahepatic portal vein obstruction undergoing meso-Rex bypass

BACKGROUND

Extrahepatic portal vein obstruction (EHPVO) in children is often associated with growth restriction, which improves after the restoration of portal venous flow with a meso-Rex bypass, but the physiologic mechanism is unknown. The purpose of this study was to investigate the mechanism of growth delay in children with EHPVO by detailing the metabolic and nutritional profile before and after meso-Rex bypass.

METHODS

Twenty consecutive children with EHPVO were prospectively studied before and 1 year after meso-Rex bypass. Caloric balance was determined by investigating caloric intake via a calorie count, total energy expenditure via a doubly labeled water isotope assay and stool caloric loss by bomb calorimetry. Laboratory markers of nutrition and growth hormone resistance were tested.

RESULTS

Fifteen of the 20 children underwent successful meso-Rex bypass at a median age of 4.3 years. Prealbumin level was abnormally low (14.6 ± 3.0 mg/dL) at surgery but improved (17.0 ± 4.3 mg/dL) 1 year later (P = 0.026). Mean insulin-like growth factor 1 (IGF-1) level at baseline was 1.57 standard deviations below normal. IGF-1 levels increased from 88.3 ± 38.9 to 117.3 ± 54.5 ng/mL in the year after surgery (P = 0.047). Caloric intake divided by basal metabolic rate (1.90 ± 0.61), total energy expenditure (97.2 ± 15.0% of expected), and stool caloric losses (3.7 ± 1.8% of caloric intake) were all normal at baseline.

CONCLUSIONS

Children with EHPVO suffer from malnutrition and growth hormone resistance, which may explain their well-established finding of growth restriction. Prealbumin and IGF-1 levels improve after a successful meso-Rex bypass.

Revisiting extra hepatic portal vein obstruction in children from the north Indian gangetic plain

OBJECTIVES

To study the demographic features, etiology, clinical, radiology and laboratory findings in children with Extra hepatic portal vein obstruction (EHPVO) from the North Indian Gangetic Plain.

METHODS

A prospective analysis of 53 patients of EHPVO (<14 y of age) was done. Data for clinical presentation, laboratory workup, endoscopic procedures, growth and development, management and outcome were analyzed.

RESULTS

A total of 53 patients (32 male, 21 female) with mean age of 8.66 ± 3.32 y at presentation were included. Growth retardation was present in 30 (56.60 %) patients at time of diagnosis. The most common presenting symptoms were upper gastrointestinal bleeding (86.80 %) and an incidental finding of splenomegaly (13.2 %). Hematological parameters of hypersplenism were present in 9 (17 %) patients. Protein C (PC), Protein S (PS), antithrombin III (AT) deficiency were found in 8 (20 %), 4 (10 %) and 6 (15 %) of the patients respectively in 40 patients tested. On first endoscopy, esophageal varices were present in all patients. Endoscopic sclerotherapy (EST)/band ligation (EBL) was performed in 46 bleeder patients and success rate was 83.3 % for sclerotherapy and 90 % for band ligation.

CONCLUSIONS

The etiology of EHPVO in the majority of patients remains elusive. It results in impaired somatic growth. Sclerotherapy and endoscopic banding are effective means for treatment for bleeding varices. It is still not clear whether deficiency of anticoagulant proteins is a primary event or secondary to disease process.

Non-cirrhotic portal hypertension - diagnosis and management

NCPH is a heterogeneous group of liver disorders of vascular origin, leading to PHT with near normal HVPG. NCPF/IPH is a disorder of young adults or middle aged women, whereas EHPVO is a disorder of childhood. Early age acute or recurrent infections in an individual with thrombotic predisposition constitute the likely pathogenesis. Both disorders present with clinically significant PHT with preserved liver functions. Diagnosis is easy and can often be made clinically with support from imaging modalities. Management centers on control and prophylaxis of variceal bleeding. In EHPVO, there are additional concerns of growth faltering, portal biliopathy, MHE and parenchymal dysfunction. Surgical shunts are indicated in patients with failure of endotherapy, bleeding from sites not amenable to endotherapy, symptomatic hypersplenism or symptomatic biliopathy. Persistent growth failure, symptomatic and recurrent hepatic encephalopathy, impaired quality of life or massive splenomegaly that interferes with daily activities are other surgical indications. Rex-shunt or MLPVB is the recommended shunt for EHPVO, but needs proper pre-operative radiological assessment and surgical expertise. Both disorders have otherwise a fairly good prognosis, but need regular and careful surveillance. Hepatic schistosomiasis, CHF and NRH have similar presentation and comparable prognosis.

Portal cavernoma cholangiopathy: consensus statement of a working party of the Indian national association for study of the liver

Portal cavernoma cholangiopathy (PCC) is defined as abnormalities in the extrahepatic biliary system including the cystic duct and gallbladder with or without abnormalities in the 1st and 2nd generation biliary ducts in a patient with portal cavernoma. Presence of a portal cavernoma, typical cholangiographic changes on endoscopic or magnetic resonance cholangiography and the absence of other causes of these biliary changes like bile duct injury, primary sclerosing cholangitis, cholangiocarcinoma etc are mandatory to arrive a diagnosis. Compression by porto-portal collateral veins involving the paracholedochal and epicholedochal venous plexuses and cholecystic veins and ischemic insult due to deficient portal blood supply or prolonged compression by collaterals bring about biliary changes. While the former are reversible after porto-systemic shunt surgery, the latter are not. Majority of the patients with PCC are asymptomatic and approximately 21% are symptomatic. Symptoms in PCC could be in the form of long standing jaundice due to chronic cholestasis, or biliary pain with or without cholangitis due to biliary stones. Endoscopic retrograde cholangiography has no diagnostic role because it is invasive and is associated with risk of complications, hence it is reserved for therapeutic procedures. Magnetic resonance cholangiography and portovenography is a noninvasive and comprehensive imaging technique, and is the modality of choice for mapping of the biliary and vascular abnormalities in these patients. PCC is a progressive condition and symptoms develop late in the course of portal hypertension only in patients with severe or advanced changes of cholangiopathy. Asymptomatic patients with PCC do not require any treatment. Treatment of symptomatic PCC can be approached in a phased manner, coping first with biliary clearance by nasobiliary or biliary stent placement for acute cholangitis and endoscopic biliary sphincterotomy for biliary stone removal; second, with portal decompression by creating portosystemic shunt; and third, with persistent biliary obstruction by performing second-stage biliary drainage surgery such as hepaticojejunostomy or choledochoduodenostomy. Patients with symptomatic PCC have good prognosis after successful endoscopic biliary drainage and after successful shunt surgery.

Results of a stepwise approach to extrahepatic portal vein obstruction in children

BACKGROUND

The management of extrahepatic portal vein obstruction (EHPVO) in children is controversial. We report our experience with a prospective evaluation of a stepwise protocol based on severity of portal hypertension and feasibility of mesoportal bypass (MPB).

METHODS

After diagnosis, children with EHPVO underwent surveillance endoscopies and received nonselective β-blockers (NSBBs) or endoscopic variceal obliteration (EVO) when large varices were detected. In patients who failed NSBBs and EVO, we considered MPB as first-line and shunts or transjugular intrahepatic portosystemic shunt (TIPS) as second-line options.

RESULTS

Sixty-five children, median age 12.5 (range 1.6-25.8), whose age at diagnosis was 3.5 (0.2-17.5) years, were referred to our unit. Forty-three (66%) had a neonatal illness, 36 (55%) an umbilical vein catheterisation. Thirty-two (49%) presented with bleeding at a median age of 3.8 years (0.5-15.5); during an 8.4-year follow-up period (1-16), 43 (66%) had a bleeding episode, 52 (80%) were started on NSBBs, 55 (85%) required EVO, and 33 (51%) required surgery or TIPS. The Rex recessus was patent in 24 of 54 (44%), negatively affected by a history of umbilical catheterisation (P = 0.01). Thirty-four (53%) patients underwent a major procedure: MPB (13), proximal splenorenal (13), distal splenorenal (2), mesocaval shunt (3), TIPS (2), and OLT (1). At the last follow-up, 2 patients died, 53 of 57 (93%) are alive with bleeding control, 27 of 33 (82%) have a patent conduit.

CONCLUSIONS

Children with EHPVO have a high rate of bleeding episodes early in life. A stepwise approach comprising of medical, endoscopic, and surgical options provided excellent survival and bleeding control in this population.

Advantages of the meso-Rex bypass compared with portosystemic shunts in the management of extrahepatic portal vein obstruction in children

BACKGROUND

Consequences of extrahepatic portal vein obstruction (EHPVO) include variceal bleeding and hypersplenism due to portal hypertension, as well as metabolic abnormalities secondary to impaired portal venous circulation. The purpose of this study was to compare the effectiveness of meso-Rex bypass and portosystemic shunt (PSS) for reversing these symptoms in children with EHPVO.

STUDY DESIGN

All children with idiopathic EHPVO evaluated for potential meso-Rex bypass at a single institution between 1997 and 2010 were reviewed. Portosystemic shunt was performed in patients with refractory portal hypertension when meso-Rex bypass was not technically feasible. Outcomes of meso-Rex bypass and PSS were compared, including resolution of portal hypertensive bleeding and hypersplenism, as well as changes in liver synthetic function, ammonia levels, and somatic growth.

RESULTS

Sixty-five children with EHPVO underwent successful meso-Rex bypass, while 16 required PSS. Nearly all patients experienced complete relief of variceal bleeding after meso-Rex (96%) bypass and PSS (100%). The improvements in platelet count (+82.1 ± 60.0 vs +32.4 ± 56.3 thousand/μL; p=0.004), internal normalized ratio (-0.22 ± 0.27 vs 0.01 ± 0.14; p=0.022), and serum ammonia level (-26.8 ± 36.8 vs +19.4 ± 33.1 μM/L; p=0.002) were greater after meso-Rex bypass than PSS. Among patients with below average (standard deviation z-score<0) preoperative weight for age, the improvement in weight-for-age z-score was greater after meso-Rex bypass (+0.84 ± 0.98) than PSS (+0.17 ± 0.79, p=0.044). Median duration of follow-up was 4.45 years after meso-Rex bypass and 1.8 years after PSS.

CONCLUSIONS

Both meso-Rex bypass and PSS effectively relieve symptoms of portal hypertensive bleeding in children with EHPVO, although the meso-Rex better relieves hypersplenism. By restoring normal portal venous circulation, the meso-Rex bypass has additional metabolic benefits.

A prospective study comparing histology and enteric enzyme function of patients with extrahepatic portal vein obstruction before and after shunt surgery

BACKGROUND

This was a prospective observational study carried out to objectively assess the effect of shunt surgery on intestinal morphology and function in patients with extrahepatic portal vein obstruction (EHPVO) and correlate it with growth improvement.

PATIENTS AND METHODS

Twenty patients who were operated upon for EHPVO were divided into two groups for the purpose of analysis depending on the outcome of surgery: group A--patients who underwent successful shunt surgery (n=14) and group B--patients who underwent splenectomy with devascularization (n=1) and those with thrombosed shunts (n=5). The patient groups were created on the basis of the type and outcome of the surgery and not prospective stratification. Growth parameters, endoscopy findings, duodenal histology, brush border enzyme activity, urinary D-xylose levels, fecal steatocrit, fecal α-1 antitrypsin, serum growth hormone and insulin-like growth factor-1 levels, and quality-of-life scores were assessed before surgery and at a mean of 24.9 weeks after surgery.

RESULTS

There was no significant difference between the preoperative and postoperative duodenal histology. Preoperative brush border lactase activity was significantly lower than normal and did not change significantly after surgery. EHPVO did not affect intestinal absorption or permeability. Shunt surgery resulted in significantly improved z scores for height after surgery as well as quality of life. There was no significant growth hormone resistance.

CONCLUSION

Our patients did not have any significant malabsorption or abnormality in small intestinal structure and function when compared with established normal levels. There was no significant change in the above parameters after shunt surgery, although an improvement in growth was observed. Thus, factors other than enteropathy or other lesser known enteral factors seem to be responsible for the growth retardation observed in EHPVO and its subsequent improvement after shunt surgery.

Surgical management of portal hypertension in children

The management of children with portal hypertension has dramatically changed during the past decade, with an improvement in outcome. This has been achieved by improved efficiency of endoscopic variceal control and the success of liver transplantation. Emergency surgical shunt procedures are rarely required, with acute bleeding episodes generally controlled endoscopically or, occasionally in adults, by interventional radiological procedures. Portosystemic shunts may be considered as a bridge to transplant in adults but are rarely used in this context in children. Nontransplant surgery or radiological interventions may still be indicated for noncirrhotic portal hypertension when the primary cause can be cured and to allow normalization of portal pressure before liver parenchyma is damaged by chronic secondary changes in some specific diseases. The meso-Rex bypass shunt is used widely but is limited to those with a favorable anatomy and can even be performed preemptively. Elective portosystemic shunt surgery is reserved for failure to respond to conservative management in the absence of alternative therapies.

A single-institution review of portosystemic shunts in children: an ongoing discussion

Purpose. Review the safety and long-term success with portosystemic shunts in children at a single institution. Methods. An IRB-approved, retrospective chart review of all children ages 19 and undergoing surgical portosystemic shunt from January 1990–September 2008. Results. Ten patients were identified, 8 females and 2 males, with a mean age of 15 years (range 5–19 years). Primary diagnoses were congenital hepatic fibrosis (5), hepatic vein thrombosis (2), portal vein thrombosis (2), and cystic fibrosis (1). Primary indications were repeated variceal bleeding (6), symptomatic hypersplenism (2), and significant liver dysfunction (2). Procedures performed were distal splenorenal bypass (4), side-to-side portocaval shunt (3), proximal splenorenal shunt (2), and an interposition H-graft portocaval shunt (1). There was no perioperative mortality and only minor morbidity. Seventy percent of patients had improvement of their symptoms. Eighty percent of shunts remained patent. Two were occluded at a median follow-up of 50 months (range 0.5–13.16 years). Two patients underwent subsequent liver transplantation. Two patients died at 0.5 and 12.8 years postoperatively, one from multisystem failure with cystic fibrosis and one from post-operative transplant complications. Conclusions. The need for portosystemic shunts in children is rare. However, in the era of liver transplantation, portosystemic shunts in selected patients with well-preserved liver function remains important. We conclude that portosystemic shunts are safe and efficacious in the control of variceal hemorrhage and symptoms related to hypersplenism.

Mesoportal bypass for extrahepatic portal vein obstruction in children: close to a cure for most!

AIM

Extrahepatic portal vein obstruction (EPVO) is a common cause of portal hypertension in children and can lead to life-threatening bleeding, thrombocytopenia, and coagulation disorders. Mesoportal bypass (MPB) restores normal physiologic portal flow to the liver and corrects portal hypertension. There is, however, little long-term outcome data after MPB. The aim of our study was to analyze the long-term outcome after MPB in children.

METHODS

Retrospective single-center review of all MPB with more than 5-year follow-up was performed in children between 1998 and 2003.

RESULTS

Thirty children underwent MPB, which was successful in 29. Long-term follow-up is available for 24. Median age at the time of bypass was 8.5 years (range, 0.4-14.2 years). Material used for bypass was as follows: left internal jugular vein (n = 20), recanalized umbilical vein (n = 2), gastric vein, and a large colic vein (n = 2). Median time since MPB is 8 years (range, 5.3-8.8 years). One MPB using recanalized umbilical vein thrombosed at 4 months but was successfully refashioned using Gortex. One MPB with left internal jugular vein was thrombosed at 1 year after cardiac surgery. Overall, 23 of 24 children have a patent bypass and resolution of portal hypertension. All showed an decrease in spleen size. Recurrent blood flow in the cavernoma with secondary increase in spleen size occurred in 5 children (median time, 3.4 years after MPB). Further evaluation of these 5 revealed no recurrence of portal hypertension.

CONCLUSION

The MPB provides long-term correction of portal hypertension owing to EPVO. Where technically feasible, MPB is the preferred surgical procedure for treatment of EPVO.

Growth impairment in children with extrahepatic portal vein obstruction is improved by mesenterico-left portal vein bypass

BACKGROUND

Extrahepatic portal vein obstruction (EHPVO) has been associated with growth impairment in children. We hypothesized that growth parameters improve after reversal of portal hypertension and restoration of mesenteric venous blood flow to the liver by the mesenterico-left portal vein bypass (MLPVB).

METHODS

A retrospective review of 45 children with idiopathic EHPVO who underwent MLPVB between 1997 and 2007 and had follow-up data for analysis was carried out. Growth was assessed using SD scores (z scores) for height, weight, and body mass index (BMI) at the time of operation and at early (5-12 months) and late (13-24 months) follow-up.

RESULTS

The mean height and weight of children with EHPVO was significantly lower than the general population before surgery. Mean BMI was also lower, although statistically insignificant. All parameters increased significantly after MLPVB as follows: height from -0.42 before surgery to -0.12 (P = .027) at 5 to 12 months and -0.14 (P = .026) at 13 to 24 months; weight from -0.49 before surgery to 0.03 (P < .001) at 5 to 12 months and 0.35 (P < .001) at 13 to 24 months; and BMI from -0.22 before surgery to 0.17 (P = .001) at 5 to 12 months and 0.48 (P < .001) at 13 to 24 months.

CONCLUSION

Restoration of portal blood flow to the liver by MLPVB improves growth in children with EHPVO.

Preoperative imaging of left portal vein at the Rex recess for Rex shunt formation using wedged hepatic vein carbon dioxide portography

BACKGROUND

In children with extrahepatic portal vein obstruction (EHPVO), formation of a mesentericoportal bypass (Rex shunt) restores hepatopetal flow, relieves portal hypertension, and reduces variceal bleeding and hypersplenism. The Rex shunt is created by inserting a vein graft between the superior mesenteric vein and the umbilical segment (Rex) of the left portal vein within the Rex recess of the liver. The preoperative evaluation of a patient with EHPVO includes an accurate assessment of the venous inflow and outflow. The inflow portal vein is readily assessed by ultrasound and magnetic resonance imaging. The outflow intrahepatic portal vein is harder to assess. We report our experience of patients evaluated with wedged hepatic vein carbon dioxide portography (WHVCP).

METHOD

All children referred for venography from October 2001 to October 2007 were prospectively identified, and clinical and radiologic data were reviewed retrospectively. The imaging findings were correlated to findings at surgery.

RESULTS

Eleven children (range, 3-14 years, median, 6 years) were referred for preoperative wedged hepatic venography. The left portal vein at the Rex recess was clearly identified in 9 patients (82%). In the other 2 patients (18%), the Rex segment was not identified despite opacification of left and right intrahepatic portal veins; this was taken to indicate an occluded segment. Wedged venography was performed with carbon dioxide in 10 patients (91%). Carbon dioxide was contraindicated in the final patient because of the presence of a ventricular septal defect.

CONCLUSION

Our series demonstrates the use of WHVCP as a diagnostic tool in preoperative assessment of the Rex segment of left portal vein in children with extrahepatic portal vein obstruction.

Effectiveness of Rex shunt in children with portal hypertension following liver transplantation or with primary portal hypertension

Portal vein thrombosis can occur as a result of primary anomalies, after liver transplantation, and for other reasons. It may result in severe complications secondary to portal hypertension, such as bleeding from esophageal or gastric varices, hypersplenism, or impaired somatic growth. In this retrospective study, we analyzed the outcome of 25 children who underwent a Rex shunt procedure. The following venous grafts were used as the shunt: the autologous internal or external jugular vein (n = 17) or a cryopreserved graft (n = 5); in three patients the umbilical vein was recanalized. The median follow up time was 109 months (range 18 days-146 months). The best results were achieved in patients in whom an autologous jugular vein segment was used as a vascular graft for the Rex shunt (shunt patency of 88%). In patients with a functioning shunt no further lower or upper gastrointestinal bleeding occurred. And in the entire study population hypersplenism syndrome improved after surgery. In our large cohort of pediatric patients, the Rex shunt has shown to be an effective method to eliminate portal hypertension and to revascularize the liver and thereby prevents the possible consequences of long-term portosystemic shunting.