title: Advantages of the meso-Rex bypass compared with portosystemic shunts in the management of extrahepatic portal vein obstruction in children.
abstract: 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.
  
  
  METHODS
  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.
authors.affiliation: Department of Surgery, Ann & Robert H Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL, USA.
authors.forename: Timothy B
authors.initials: TB
authors.lastname: Lautz
authors.forename: Lisa A
authors.initials: LA
authors.lastname: Keys
authors.forename: Joseph C
authors.initials: JC
authors.lastname: Melvin
authors.forename: Joy
authors.initials: J
authors.lastname: Ito
authors.forename: Riccardo A
authors.initials: RA
authors.lastname: Superina
mesh_terms: D002648:Child; D002675:Child, Preschool; D004932:Esophageal and Gastric Varices / Q000209:etiology / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006471:Gastrointestinal Hemorrhage / Q000209:etiology / Q000601:surgery; D006801:Humans; D006971:Hypersplenism / Q000209:etiology / Q000601:surgery; D006975:Hypertension, Portal / Q000209:etiology / Q000601:surgery*; D007223:Infant; D007601:Jugular Veins / Q000637:transplantation*; D008297:Male; D008642:Mesenteric Veins / Q000601:surgery*; D011169:Portal Vein / Q000473:pathology / Q000601:surgery*; D011170:Portasystemic Shunt, Surgical; D012189:Retrospective Studies; D016896:Treatment Outcome; D058017:Vascular Grafting / Q000379:methods*; D020246:Venous Thrombosis / Q000150:complications / Q000601:surgery*