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Esophageal varices are dilated distal submucosal esophageal veins that connect the portal and systemic circulations. They are formed due to portal hypertension, which commonly resulted from cirrhosis. We presented an 8-year-old girl with esophageal varices without signs of cirrhosis. This case report aims to describe non-cirrhotic portal hypertension causing esophageal varices in a school-age girl. An 8-year-old girl presented with one month of progressive hematemesis. The patient had been diagnosed with esophageal varices since she was 6 years old. Liver function test was within normal limits, complete blood count revealed bicytopenia. Due to well-preserved liver function, the patient underwent distal splenorenal shunt (DSRS). After the surgical procedure, the patient's clinical condition generally improved. NCPH (non-cirrhotic portal hypertension) is treated similarly with cirrhotic portal hypertension. DSRS could be the treatment of choice for refractory esophageal varices. • Esophageal varices occasionally caused by Non-Cirrhotic Portal Hypertension (NCPH). • Early treatment prevents variceal rupture, the most fatal complication. • The patient was diagnosed with esophageal varices since she was 6 years old. • Distal splenorenal shunt from the splenic vein to the left renal vein branch was successful. [ABSTRACT FROM AUTHOR]

Dr Dean Warren was born in 1924 and died prematurely from cancer in 1989. He was a man of uncommon intelligence, wit, collegiality, integrity, honesty, and a true leader in American surgery. In 1966, he and his colleagues (Drs Zeppa and Fomon) presented a new concept for surgical shunts to control variceal hemorrhage while maintaining portal perfusion or hepatopetal blood flow. He termed this new shunt the distal splenorenal shunt (DSRS), which was the first selective shunt invented. The DSRS selective shunt was a brilliant improvement over the total shunt concept proposed by Nicolai Eck and was practiced worldwide during the 1980s. In a space of 2 decades, Dr Warren's pioneering work would show that the selective DSRS was superior to total shunts for treatment of portal hypertension, but that endoscopic sclerotherapy was a better first-line treatment for variceal hemorrhage than his own creation. His absolute adherence to the principles he espoused in his presidential address to the Society for Surgery of the Alimentary Tract in 1973 were employed in his research and treatment of patients. This paper details Dr Warren's extraordinary research accomplishments and sets a lesson for us that well-designed clinical trials including randomization are essential in the advancement of the care of surgical patients. [ABSTRACT FROM AUTHOR]

The management of portal hypertension (PHT) in children with well compensated cirrhosis and cystic fibrosis (CF) is controversial. We present our experience with distal splenorenal shunting (DSRS) for the treatment of PHT as an alternative to liver transplantation (LT). Between 2008 and 2017, 5 CF children underwent a DSRS at a pediatric hepatobiliary and transplantation referral center. LT (n = 9) was reserved for patients with decompensated cirrhosis. Statistical analysis was done using the paired t-test (p < 0.05 considered significant). Mean PELD/MELD score was significantly lower for DSRS patients than LT (3 ± 6 vs 28 ± 4, p < 0.001). All 5 DSRS patients had grade III–IV varices. One bled prior to surgery. After DSRS, spleen size decreased significantly from 8.4 ± 1.5 cm to 4.4 ± 1.8 cm (p = 0.019). Mean platelet count remained stable (87.8 ± 48 to 91.8 ± 35, p = 0.9). There were no postoperative complications. No DSRS patient experienced variceal bleeding following shunt creation. Liver function tests remained stable in the DSRS group, and no patient required a liver transplant (median follow up 4.65 years, range 1.24–7.79). Patients with cystic fibrosis who have well-compensated cirrhosis and symptomatic portal hypertension can be palliated with distal splenorenal shunting and do not need liver transplants. These patients can undergo shunting with minimal morbidity. Case series with no comparison group. IV. [ABSTRACT FROM AUTHOR]

Background: In cases of portal hypertension with splenic infarcts, splenectomy with proximal splenorenal shunt has been recommended. We are sharing our experience with distal splenorenal shunt in these cases contrary to the popular belief. Materials and Methods: Splenic infarcts were graded as mild, moderate and severe according to the pre-operative CT portogram. Mild, moderate and severe infarcts were defined as an infarct involving < 25%, 25-50% and > 50% area of the spleen, respectively. Mild and moderate infarcts were managed by spleen-preserving distal splenorenal shunt while those with extensive infarcts were subjected to splenectomy and proximal splenorenal shunt. Those with spleen-preserving shunts were closely followed in the post-operative period according to a uniform protocol. Clinical examination was regularly done to assess the size of the spleen and note the presence of pain, tenderness in the left intercostal space. An ultrasound Doppler was done after 7 days to assess shunt patency while CT portogram was repeated at 6 monthly intervals. Results: Fourteen cases with splenic infarcts formed the study group. Eight cases had mild infarcts, 3 had moderate infarcts and 3 had severe infarcts. Four underwent proximal splenorenal shunt, and 10 underwent warren′s shunt (8 with mild and 2 with moderate infarcts). In 9/10 (90%), spleen could eventually be retained. Spleen completely regressed in them and so did the infarct. Conclusions:Spleen-preserving distal splenorenal shunt can be considered as a viable option in the management of cases with mild and carefully selected moderate splenic infarcts.

Hepatic encephalopathy (HE) is a common long term complication of porto-systemic shunt. We report herein the case of a 59-year-old man with Child-Pugh A cirrhosis treated successfully 9 years earlier with distal splenorenal shunt for uncontrolled variceal bleeding. In the last year, he developed a severe and persistent hepatic encephalopathy secondary to the shunt, which was resistant to medical therapy. As liver transplantation was not available and obliteration of the shunt was hazardous, we performed subtotal colectomy in order to reduce ammonia production. This therapeutic option proved successful, as the grade of encephalopathy decreased and the patient improved. Our experience indicates that colonic exclusion should be considered as an option in the management of HE refractory to medical treatment in highly selected patients when liver transplantation is not available or even as a bridge given the long waiting time on lists.

Background: In cases of portal hypertension with splenic infarcts, splenectomy with proximal splenorenal shunt has been recommended. We are sharing our experience with distal splenorenal shunt in these cases contrary to the popular belief. Materials and Methods: Splenic infarcts were graded as mild, moderate and severe according to the pre-operative CT portogram. Mild, moderate and severe infarcts were defined as an infarct involving < 25%, 25-50% and > 50% area of the spleen, respectively. Mild and moderate infarcts were managed by spleen-preserving distal splenorenal shunt while those with extensive infarcts were subjected to splenectomy and proximal splenorenal shunt. Those with spleen-preserving shunts were closely followed in the post-operative period according to a uniform protocol. Clinical examination was regularly done to assess the size of the spleen and note the presence of pain, tenderness in the left intercostal space. An ultrasound Doppler was done after 7 days to assess shunt patency while CT portogram was repeated at 6 monthly intervals. Results: Fourteen cases with splenic infarcts formed the study group. Eight cases had mild infarcts, 3 had moderate infarcts and 3 had severe infarcts. Four underwent proximal splenorenal shunt, and 10 underwent warren's shunt (8 with mild and 2 with moderate infarcts). In 9/10 (90%), spleen could eventually be retained. Spleen completely regressed in them and so did the infarct. Conclusions: Spleen-preserving distal splenorenal shunt can be considered as a viable option in the management of cases with mild and carefully selected moderate splenic infarcts. [ABSTRACT FROM AUTHOR]

A number of surgical procedures have been developed to manage esophageal varices. Broadly, these can be classified as shunting and non-shunting procedures. While total shunt effectively reduces the incidence of variceal bleeding, it is associated with a high risk of hepatic encephalopathy. The distal splenorenal shunt (DSRS), a selective shunt, was developed by Warren in 1967 to preserve portal blood flow through the liver while lowering variceal pressure. The hope was that both bleeding and hyperammonemia would be prevented. The DSRS effectively prevents rebleeding, but still carries a risk of hyperammonemia. We improved the DSRS procedure by additionally performing splenopancreatic disconnection (SPD, i.e. skeletonization of the splenic vein from the pancreas to its bifurcation at the splenic hilum) and gastric transection (GT, i.e. transection and anastomosis of the upper stomach with an autosuture instrument). An alternative to shunting was developed by Sugiura and Futagawa in 1973. Esophageal transection (ET) divides and reanastomoses the distal esophagus and devascularizes the distal esophagus and proximal stomach; splenectomy, selective vagotomy, and pyloroplasty are performed concomitantly. DSRS was more effective than ET in preventing recurrence of esophageal varices, but was associated with a higher incidence of hyperammonemia. The incidence of hyperammonemia in patients who underwent DSRS with SPD plus GT was significantly lower than that in patients who underwent DSRS alone or those who underwent DSRS with SPD. In conclusion, there are various surgical treatments for esophagogastric varices. Distal splenorenal shunt with SPD plus GT is considered an adequate treatment for patients with esophagogastric varices. [ABSTRACT FROM AUTHOR]

Introduction: The distal splenorenal shunt (DERD), selective portosystemic shunt has the advantage slow the progression of hepatic encephalopathy, events of upper gastrointestinal bleeding. We aim to establish that the DERD can be performed in pediatric patients having the same benefits as adults. Material and methods: retrospective, observational, transversal, in patients with portal hypertension and hypersplenism, any genre, two or more episodes of gastrointestinal bleeding, aged between 12 and 203 months, operated as a portosystemic shunt. Records were reviewed in September 2004 to September 2006. Results: We evaluated 11 patients with pulmonary hypertension secondary to portal cavernomatosa degeneration (PCD) (63.6%), cryptogenic cirrhosis (27.3%), choledochal cyst (9%), 6 men and 5 women, median age 72 (19-146) months and weight 20.5 (13.3-44) kg, followed for 7-19 months. We DERD 7, 2 and 2 leads mesocaval Sugiura procedures. No thrombosis or complications. After the shunt was no increase in platelet count (p 0.04), hospital stay was less than 10 days, two patients had a weight below 15 kilograms. Discussion: In our study the most common cause of HP is the DCP. Although there are no reports in children weighing 20 kg for the high risk of stenosis or thrombosis, our patients recovered well during the 19 months follow up. [ABSTRACT FROM AUTHOR]

Background: A prospective study was carried out to evaluate the results of distal splenorenal shunt (DSRS) with or without splenic artery ligation (SAL) in patients with schistosomal portal hypertension.Materials and methods: Thirty patients were divided into two groups: 15 were submitted to DSRS (Group I) and the other 15 were submitted to DSRS + SAL (Group II). They were observed for 24 months. Clinical and laboratory features were analyzed.Results: There was neither mortality nor clinical manifestation of portosystemic encephalopathy in both groups. Recurrent hemorrhage and thrombosis incidence had no statistical difference. Although patients in Group II presented higher levels of postoperative pain and fever, spleen size reduction was higher than in Group I. White blood cells and platelets were increased in patients who underwent DSRS + SAL, even though there was no statistically significant difference between the groups. An increase in bilirubin was observed on the first postoperative day. Arterial blood ammonia and liver function were similar in both groups. Endoscopic control showed reduction in size of varices or their disappearance in 80 and 93% of patients from Groups I and II, respectively.Conclusions: Although SAL associated with DSRS was responsible for increasing postoperative morbidity, it did not increase the incidence of shunt thrombosis and improved white blood cells and platelets count as well as reduced the spleen size. Therefore, the authors believe that SAL associated with DSRS is an effective treatment for schistosomal portal hypertension. Besides, it should be performed when a large spleen and hypersplenism are present. [Copyright &y& Elsevier]

Profound thrombocytopenia resulting from portal hypertension may exacerbate gastrointestinal bleeding, precipitate spontaneous bleeding, preclude surgical intervention for associated disorders, and severely limit life-style because of the danger of splenic injury. Although splenectomy can reverse the thrombocytopenia, the procedure should be avoided in children. We reviewed our experience with distal splenorenal shunting (DSRS) in children, particularly when performed for the sole purpose of reversing severe thrombocytopenia resulting from portal hypertension. DSRS was performed in 11 children between the ages of 7 and 15 years: five for severe thrombocytopenia (group 1), four for advanced hypersplenism and congenital hepatic fibrosis prior to renal transplantation (group 2), and two for esophageal bleeding (group 3). One child in group 1 with severe heart disease and Child’s class C cirrhosis due to hepatitis C died of progressive cardiac failure and was excluded from further analysis. Of the eight remaining patients in groups 1 and 2, four children had congenital hepatic fibrosis, two had portal vein thrombosis, one had hepatitis B, and one had Wilson’s disease. After DSRS, the mean platelet count increased from 37,000 ±18,000 to 137,600 ±81,000 (P = 0.01). The platelet count improved significantly in all seven children with presinusoidal portal hypertension or stable cirrhosis but did not increase in the child with hepatitis Band Child’s class B cirrhosis. The white blood cell count increased from an average of 3.3 ±1.1 to 5.4 ± 2.6 (P= 0.02). There were no postoperative complications in this group. The improved platelet count allowed the four children with congenital hepatic fibrosis and renal failure to undergo renal transplantation with full posttransplant immunosuppression including azathioprine. Postoperative Doppler ultrasound examination demonstrated shunt patency at 6 months in all cases. Spleen size decreased appreciably in all children in groups 1 and 2. All children were able to resume full activity including contact sports. In summary, DSRS effectively controls profound thrombocytopenia resulting from presinusoidal portal hypertension or stable cirrhosis without sacrificing the spleen and should be the treatment of choice for this condition. [ABSTRACT FROM AUTHOR]

In 50 consecutive patients portal blood flow was determined using computed liver perfusion scintigraphy preoperatively and at 6, 12, 24, 36, 48, 60, 72, and 84 months postoperatively between 1 January 1983 and 1 January 1990. All 25 subjects had undergone placement of a distal splenorenal shunt (DSRS) and 25, insertion of low-diameter PTFE mesocaval interposition shunt (LDMIS) between 15 January 1983 and 1 January 1988. Indications for shunt operation included recurrent variceal hemorrhage in spite of long-term endoscopic sclerotherapy, a Child-Pugh classification of A or B, a sonographically determined liver volume of between 1000 and 2500 ml, exclusion of the activity and progression of liver disease by biopsy and stenosis of the hepatic artery or coeliac trunk. DSRS was performed when the portal perfusion index (PPI) was greater than 30% (normal values 56 +/- 5%) and LDMIS was carried out when the PPI was 10% to 30%. In all cases the underlying disease was liver cirrhosis of alcoholic (n = 34, 68%) or hepatic (n = 12, 24%) etiology. Five patients who underwent LDMIS had originally scheduled for DSRS at a PPI of greater than 30%; because the DSRS would have been technically difficult due to severe chronic pancreatitis, a LDMIS was performed. One in-hospital death due to liver failure had occurred in each group by 1 January 1990. One patient in the DSRS group and two in the LDMIS group died later, and in each group one patient was lost to follow-up.(ABSTRACT TRUNCATED AT 250 WORDS) [ABSTRACT FROM AUTHOR]

A case of myocardial infarction following a distal splenorenal shunt, a selective portal-systemic shunt, in a cirrhotic patient is reported. The post-operative cardiac morbidity was probably related to the hyperdynamic cardiovascular state associated with liver cirrhosis and the increase in intramyocardial tension upon formation of the distal splenorenal shunt. [ABSTRACT FROM PUBLISHER]

We previously reported severe hemolysis in one patient immediately after distal splenorenal shunt (DSRS). The purpose of the present study was to evaluate changes in red cell survival after DSRS. In ten patients with nonalcoholic cirrhosis in whom DSRS was performed for esophageal varices, red cell survival and splenic quantitative hemodynamic studies were performed before and after DSRS. The splenic venous blood flow per unit volume (flow/volume ratio) was calculated. The red cell survival was significantly ( P<0.05) shortened after DSRS; the apparent half-life survival time (T1/2) before and after DSRS was 24.6±5.9 (mean±SD) and 16.3±8.5 days, respectively. After DSRS, the spleen volume was significantly ( P<0.05) decreased, whereas the splenic venous blood flow was slightly increased. The spleen flow/volume ratio was significantly ( P<0.05) increased after DSRS. There was a significant and negative correlation ( r=−0.684, P<0.05) between the postoperative percentage change in T1/2 and the spleen flow/volume ratio. These findings suggest that the red cell survival period is significantly decreased after DSRS in patients with nonalcoholic cirrhosis, and that the increased splenic blood flow per unit spleen volume after DSRS may play an important role in the hemolytic reaction in the spleen after this procedure. [ABSTRACT FROM AUTHOR]

The effect of the mesocaval interposition shunt ( n=12) and the distal splenorenal shunt ( n=9) on the wedged hepatic venous pressure, the estimated hepatic blood flow, quantitative hepatic function, and the rate of portal systemic encephalopathy was evaluated in 21 patients who had bled from esophageal varices. After mesocaval shunt the wedged hepatic venous pressure was significantly reduced by 42% (from 26±3 mm Hg to 15±5 mm Hg, P<0.001) compared to 16% only (from 25±3 mm Hg to 21±2 mm Hg, P<0.005) after distal splenorenal shunt. The estimated hepatic blood flow also decreased significantly after mesocaval shunt by 61% (from 1.45±0.46 l/min to 0.56±0.25 l/min, P<0.001) compared to 29% (from 1.29±0.32 l/min to 0.91±0.39 l/min, P<0.05) after distal splenorenal shunt. Despite significantly different influences of both types of shunt operations on wedged hepatic venous pressure and estimated hepatic blood flow ( P<0.001), postoperative changes of hepatic function were comparable in both groups of patients. The galactose elimination capacity, the initial plasma disappearance rate of Bromsulphalein, and the plasma ratio of valine, leucine, and isoleucine to phenylalanine and tyrosine were reduced by 13%, 26%, and 29%, respectively, after mesocaval shunt, compared to 12%, 25%, and 17% after distal splenorenal shunt. Only two patients of the mesocaval shunt group with the largest decrease in estimated hepatic blood flow developed portal systemic encephalopathy postoperatively, and the distal splenorenal shunt patients with their minor hemodynamic sequelae remained free of portal systemic encephalopathy. [ABSTRACT FROM AUTHOR]

This paper reports the clinical results of a retrospective study comparing endoscopic injection sclerotherapy (EIS) and back-up surgical treatment after EIS in the management of acute variceal bleeding. The 74 patients included in the study were divided into 2 groups. Group I consisted of 41 patients who received EIS over a mean period of 2.2 sessions and Group II consisted of 33 patients who underwent EIS and subsequent surgical intervention, in the form of 19 distal splenorenal shunts and 14 nonshunting procedures. The overall percentage of patients in whom initial control of variceal bleeding was achieved was 91.8 per cent. Four of the Group II patients were saved by emergency nonshunting operations. Rebleeding was experienced by 4 (28.6 per cent) of the 14 patients who underwent nonshunting surgery but by only 1 (5.3 per cent) of the 19 patients who underwent selective shunt surgery. The cumulative survival in Group II was significantly superior to that in Group I with 2 year survival being achieved in 66.7 per cent of the Group II patients but in only 23 per cent of Group I patients. Thus, the combination of initial EIS and back-up surgical intervention may be more benefical than sclerotherapy alone for patients with acute variceal bleeding, while, the distal splenorenal shunt may be a more suitable surgical technique for patients having previously EIS. [ABSTRACT FROM AUTHOR]

A prospective randomized trial of selective distal splenorenal shunt (DSRS) versus H-graft interposition total shunt at Emory Hospital in 1971 showed DSRS to be superior to a total shunt in shunt patency, prevention of variceal bleeding, preserving hepatic cell function, preserving the quality of life and patient survival. These results were particularly evident in the non-alcoholic patients. In the alcoholic patients, there was a greater loss of hepatic portal perfusion. In a later phase of the study, it was found that pancreatic veins formed a pathway of collaterals to the shunt, that is a socalled pancreatic siphon. In order to prevent loss of portal and pancreatic flow through the siphon, a total spleno-pancreatic disconnection was developed, whereby the hormone diversion is expected to be diminished. [ABSTRACT FROM AUTHOR]

A 27 year old cirrhotic male underwent stenosis of the distal splenorenal shunt to treat bleeding of esophageal varices. Percutaneous transluminal angioplasty was performed first by catheterization of the right femoral vein, but without success. Therefore, a direct puncture of the splenic vein through the spleen was made, under sonographic guidance, followed by balloon dilatation of the stenotic anastomosis. The pressure of the splenic vein before and after PTA was 35 and 29 cm HO, respectively. Both the follow-up barium esophagogram and esophagoscopy showed marked regression of the esophageal varices. [ABSTRACT FROM AUTHOR]

In attempts to produce esophageal varices in dogs, we designed a procedure based on the concept of hyperdynamic flow. The first stage operation involved the achievement of an arteriovenous shunt between the left renal artery and the proximal splenic vein, in concert with the distal splenic venous-left renal venous shunt. About one month after the initial operation, sixteen of the twenty-eight dogs had tolerated the manipulations. Both shunts proved to be functioning well in six of sixteen survivors, in which an ameroid constrictor was placed around the splenic vein just proximal to the confluence of the left gastric vein. Again one month later, in five of these six, esophageal varices were evidenced, both endoscopically and histologically. Arterialization of left gastric vein concomitant with the distal splenorenal shunt, gave rise to a hyperdynamic state in the upper stomach and resulting in reproducible esophageal varices. [ABSTRACT FROM AUTHOR]

Sixty patients who underwent distal splenorenal shunt were followed up from one to ten years, with an average of 5.6 years. Postoperative portography through the superior mesenteric artery was carried out in 58 of these patients and the remaining two were studied at autopsy. The diameter of the portal vein was unchanged in 65 per cent of the patients within 30 postoperative days, but it decreased remarkably in size one year after the surgery in one third of the patients, and it was observed in about half of the patients at 5 years after the surgery. Numerous collaterals had developed around the pancreas and stomach in the majority of cases presenting narrowing of the portal vein. Enormously dilated pancreatic veins directed to non-isolated distal splenic vein were identified in the autopsied cases. These findings strongly suggest that pancreatic veins connecting to the distal vein may play a leading role in production of malcirculation of the portal system after distal splenorenal shunt. [ABSTRACT FROM AUTHOR]

A patient with splenic artery aneurysm which developed after creation of selective distal spleno-renal shunt for hepatic cirrhosis and portal hypertension was presented. Three months after operation, an aneurysm of the splenic artery with a diameter of about 20 mm was detected. This aneurysm reached 4 cm three months later, and a resection was carried out. An arterial continuity was established by means of end-to-end anastomosis of the sectioned arterial ends. Because the flow through the splenic artery was about 60% of the total flow of the selective distal spleno-renal shunt, it is important to maintain continuity in order to avoid thrombosis of the shunt. [ABSTRACT FROM AUTHOR]

To evaluate the validity and complications of modifying the distal splenorenal shunt (DSRS) by performing splenopancreatic disconnection (SPD), hemodynamic changes in the portal system were assessed by visceral angiography in 93 patients with nonalcoholic portal hypertension during early postoperative follow-up after DSRS. There were 40 patients who underwent DSRS alone and 53 who underwent DSRS plus SPD. Early follow-up angiography showed that portal vein perfusion was well maintained, and that the diameter of the portal vein had decreased significantly by the same degree in both groups. Hepatofugal collaterals for the shunt had developed to a greater extent in the DSRS group, while they were almost completely absent in the DSRS with SPD group. Nevertheless, partial portal vein thrombosis was not detected in the DSRS group, although it was seen in seven (13.2%) of the patients who underwent DSRS plus SPD, in whom the left proximal splenic vein was not visible. The proximal splenic vein was seen in significantly less of the DSRS with SPD patients (47.2%) than the DSRS group patients (85%). In conclusion, SPD more effectively prevented the early postoperative development of collateral pathways for the shunt compared with standard DSRS; however, the possible stagnation of blood flow in the left proximal splenic vein may predispose to a risk of partial portal vein thrombosis developing during the early postoperative period after DSRS with SPD. [ABSTRACT FROM AUTHOR]

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Pancreaticoduodenectomy with vascular resection/reconstruction can be safely completed following 6 standard steps plus basic principles of vascular surgery. Particular attention is paid to the location of the tumor relative to the 2 first-order vein branches, portal vein -splenic vein -superior mesenteric vein confluence, inferior mesenteric vein, and the presence of arterial perineural invasion. Successful resection following neoadjuvant therapy can result in median survival 3 times that of historical controls., Competing Interests: Disclosure None., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Extrahepatic portal vein thrombosis (PVT) is the most common cause of portal hypertension (PH), particularly in children. PH-related manifestations include refractory variceal bleeding, splenomegaly and ascites. Albeit more rarely performed, the distal splenorenal shunt (Warren's shunt) has proven to be effective in selectively decompressing the collateral circulation. The aim of our study was to describe our experience with the distal splenorenal shunt and to determine the long-term effect on PH-related side-effects., Methods: Distal splenorenal shunt operations performed at our institution between 2000 and 2014 were reviewed for: age, male/female ratio, children/adults ratio, body mass index, indications, grade of PVT (Yerdel classification), maximal shunt-flow velocity, shunt patency and thrombosis, re-intervention for variceal bleeding and survival. Complications of PH (esophageal variceal bleeding and ascites) were compared pre- versus post-operatively (last follow-up). Paired student t -test and fisher's exact were applied for pre- versus post-operative comparison. Results are reported as median [range]., Results: Fourteen patients with PVT and refractory complications of PH underwent distal splenorenal shunt surgery. Age was 15 years [4.5-66]. Male/female ratio was 7/7. PVT -grade was 2 [1-4]. Follow-up was 3 [0.5-14]. All shunts were patent (100%) with no shunt thrombosis (0%) at last follow-up. There was no re-intervention for variceal bleeding (0%) and survival at last follow-up was 100%. Occurrence of esophageal variceal bleeding was higher pre-operatively (57%) than postoperatively (0%) ( p  = .0032) and also the incidence of ascites was higher pre-operatively (79%) than postoperatively (0%) ( p  < .0001)., Conclusions: Based on our experience, the distal splenorenal shunt can be considered a valuable surgical technique for PVT-induced PH, with excellent post-operative prevention of complications of PH.

The authors report two patients with extrahepatic portal hypertension and repeated massive␣bleeding from esophageal varices who underwent urgent distal splenorenal shunting (DSRS) after having proved refractory to medical treatment, endoscopic sclerotherapy, and ligation of esophageal varices. Their ages and weights were 18 months/10 kg, and 11 months/6.4 kg, respectively. The splenic veins were 6 and 4 mm in diameter. During follow-up of 4 and 3 years, respectively, the shunts have remained patent in both patients as demonstrated by Doppler Ultrasound. Gastrointestinal hemorrhage has not recurred, splenomegaly regressed, and platelet and white blood cell counts increased gradually. Nither patient developed a significant encephalopathy, and liver function tests showed no significant changes throughout the observed period. The authors considered the shunting feasible despite the relatively narrow splenic veins. In both patients the anatomic position of the splenic vein – more caudal to the posterior wall of the pancreas – facilitated its isolation. In the smaller infant, the inferior mesenteric vein was sutured to gain a satisfactory segment of splenic vein. The successful use of a DSRS to control actively bleeding varices in a child weighing 6.4 kg has not been previously reported. [ABSTRACT FROM AUTHOR]