Three Decades of Rex Shunt for Pediatric Extrahepatic Portal Vein Obstruction: A Narrative Review of Advances from Surgical Evolution to Holistic Management.

BACKGROUND: Since its introduction in 1992, the Rex shunt (also called Meso-Rex bypass, MRB) has substantially advanced the management of pediatric extrahepatic portal vein obstruction (EHPVO) by restoring physiological hepatopetal portal flow. However, a comprehensive synthesis of the accumulating evidence and evolving practices is notably lacking, especially given that the latest Baveno VI consensus was published nine years ago in 2016. OBJECTIVE: This review aims to synthesize three decades of advances in Rex shunt evolution, from a novel technique to a widely adopted first-line surgical option. METHODS: We conducted a narrative review, synthesizing evidence from key studies, large case series, and expert consensus statements. RESULTS: Key topics addressed include the comparison between Rex shunt and portosystemic shunts, evolving surgical indications, technical evolution of the procedure, critical aspects of perioperative management, identification of prognostic factors, and management of vascular complications. The review highlights the superior potential of the Rex shunt in resolving the sequelae of EHPVO and outlines the importance of a holistic management approach. CONCLUSION: The Rex shunt represents a major advance in the management of pediatric EHPVO. Optimal outcomes depend on careful patient selection, meticulous surgical technique, and comprehensive perioperative care, supported by an experienced multidisciplinary team.