Development and validation of a prediction model for esophageal varices by changes in spleen size after Rex surgery

Development and validation of a prediction model for esophageal varices by changes in spleen size after Rex surgery | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development and validation of a prediction model for esophageal varices by changes in spleen size after Rex surgery Yunpei Chen, Zhiqiang Chen, Liu Chen, Jiancai Chen, Linyi Zeng, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4576774/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose To develop a noninvasive prediction model for esophageal varices (EVs) based on changes in spleen size after Rex surgery. Method The clinical data of children with cavernous transformation of the portal vein who underwent Rex surgery at the Department of Hepatobiliary Surgery of our hospital from 2014-09 to 2021-12 were collected, and the children were divided into a no-to-mild group and a moderate-to-severe group according to the EV status on postoperative gastroscopy. Variables related to changes in spleen size were included in logistic regression models. Construction and internal validation of a postoperative moderate-to-severe EV risk prediction model. Results A total of 78 children were included, 55 in the no-mild group and 23 in the moderate-severe group. The splenic thickness difference (STD), splenic long diameter difference (SDD), and splenic volume difference (SVD) were included in the multifactorial logistic regression analysis, and the regression equation obtained was modeled as logit(P)= -STDx0.18-SVDx0.011+0.502. The STD and SVD are independent risk factors for moderate-to-severe EV after surgery. The area under the ROC curve was 89.73%, the optimal threshold point was -0.952, and its specificity and sensitivity were 82.6% and 83.3%, respectively.The model was internally validated, and the C-index was 0.897, indicating good discrimination and calibration. Conclusion The model constructed by multifactorial logistic regression is valuable and effective for the noninvasive detection of postoperative EVs, and deserves further research. Rex surgery portal vein cavernous changes esophageal varices noninvasive detection Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Rex surgery was first used in 1992 by de Ville de Goyet [1] for the treatment of portal vein thrombosis after liver transplantation and has since evolved to become the ideal procedure for the treatment of cavernous transformation of the portal vein (CTPV) in children, with a success rate ranging from 60% to 96% [2-5]. Factors such as thrombosis, anastomotic stenosis, and a small diameter of bypass vessels are the main reasons for unsatisfactory surgical results; some children still have esophageal varices (EVs) after surgery, and approximately 4%-20% [5-8] are at risk of rupture and bleeding from EVs. Postoperative EV is mainly clarified by gastroscopy via invasive tests. There is no predictive model for children after Rex surgery. Although many noninvasive predictive models have been proposed for EVs in adults with cirrhosis, they are not suitable for application in children because most cirrhosis in adults is associated with liver function impairment. The aim of this study was to establish a Rex postoperative moderate-severe EV risk prediction model in combination with the clinical experience of our hospital and to verify the validity of the model, identify high-risk groups in the early postoperative period, and reduce the probability of postoperative gastrointestinal bleeding in children. Materials and methods 1.1 Clinical data The clinical data of children with CTPV who visited our hepatobiliary surgery department for Rex surgery from 09/2014 to 12/2021 were collected. The inclusion criteria were as follows: (1) a clear diagnosis of CTPV in combination with preoperative abdominal enhanced CT/MRI and three-dimensional reconstruction of the portal venous system and vascular ultrasound of the child; (2) age < 18 years; (3) clear indications for surgery, e.g., gastrointestinal bleeding, severe hypersplenism, severe varicose veins, etc., and successful Rex surgery performed in our hospital; and (4) complete case data and regular follow-up for more than 1 year. The exclusion criteria were as follows: (1) had a history of liver disease such as cirrhosis; (2) were lost to follow-up or unable to provide complete preoperative, postoperative, or follow-up data; and (3) had undergone previous splenectomy. Based on postoperative gastroscopy, the children were categorized into a no-mild EV group and a moderate-severe EV group. According to the Consensus on Prevention and Treatment of Esophagogastric Variceal Bleeding in Cirrhotic Portal Vein Hypertension (Hangzhou, China 2008) [ 9 ], the severity of EV was classified as mild, moderate, or severe: Mild (G1): EVs are linear or slightly tortuous with no red sign and a vein diameter < 5 mm; Moderate (G2): EVs are linear or slightly tortuous with a red sign, or EVs are serpentine with tortuous bulges but no red sign; vein diameter ≥ 5 mm. Severe (G3): EVs that are serpentine and raised with a red sign or EVs that are beaded, nodular, or tuberculate (with or without a red sign) with a vein diameter ≥ 5 mm. The splenic thickness (ST) and splenic long diameter (SD) from the preoperative and postoperative ultrasound of the children were collected, CT reconstruction was performed with software to calculate the splenic volume (SV), and the preoperative and postoperative differences were calculated to obtain the STD, SDD, and SVD, respectively. The differences in the above data were analyzed, and a prediction model was established and validated. This study was approved by the hospital Ethics Committee (No.090A01). All patients signed informed consent forms. 1.2 Preoperative Preparation In addition to routine preoperative examination, color ultrasound, CTA/MRA, etc., are required for children to understand the condition of the liver and spleen and the vascular condition of the portal vein system, to clarify the condition of the graft vessels, to exclude variations, and to assess the inferior vena cava and both renal veins. In some children with poor visualization of the portal vein system, digital subtraction angiography (DSA) can be used to visualize the portal vein system retrogradely through the hepatic vein to clarify the sagittal portion of the left branch of the portal vein. For children with unstable conditions such as active gastrointestinal bleeding, fasting, intravenous nutrition, hemostatic drugs, proton pump inhibitors, growth inhibitors, and other symptomatic conservative treatments are given, and blood transfusion therapy is given to maintain hemoglobin at 70–80 g/L if necessary. 1.3 Follow-up visit All children were followed up for more than 1 year via telephone follow-up, outpatient information, or readmission treatment records, and the review included laboratory tests, ultrasound, CT/MR, and gastroscopy. 所有资料采集患儿术后10–14个月, As of January 2023, there were no lost cases or deaths. 1.4 Statistical analysis SPSS 25.0 and R 4.2.2 software were used for statistical data processing, and the results were directly evaluated by computer statistics. P < 0.05 was considered to indicate statistical significance. Count data are expressed as the mean ± standard deviation (`X ± S), and the differences between groups were first tested for normality and chi-square tests; t tests were used for normally distributed data and chi-square tests were used, and rank-sum tests were used for nonnormally distributed data. Differences between groups of categorical measures were analyzed with the c2 test. After adjusting for confounding factors, the risk factors related to postoperative moderate to severe EV were screened by multivariate binary logistic regression analysis. The Hosmer–Lemeshow test was used to test the goodness of fit of the model. The results of the model were presented by using a column graph, the optimized model was internally verified by resampling (bootstrapping = 1000), and the model differentiation and calibration were evaluated by receiver operating characteristic (ROC) curve and calibration curve analyses. Results A total of 78 children were included, 55 in the no-mild group and 23 in the moderate-severe group. The differences between the two groups were not statistically significant for age, sex, preoperative EV degree, preoperative and postoperative PVP, postoperative SD, postoperative ST, or postoperative SV; the differences were statistically significant for PVP difference, STD, SDD, and SVD (P < 0.05); and the differences in PVP, STD, SDD, and SVD in the moderate-severe EV group were significantly lower than those in the no-mild EV group (P < 0.05) (Table 1 ). Table 1 Comparison of relevant information between the two groups Factors 1 = no-mild EV group 2 = moderate-severe EV group χ 2 /t value P value Age 5.82 ± 2.82 5.29 ± 3.63 0.697 0.488 Sex 0.081 0.776 1 = male 33 13 2 = female 22 10 preoperative EV degree 0.209 1 = no-mild 12 2 2 = moderate-severe 39 19 preoperative PVP 25.09 ± 4.49 23.26 ± 3.67 1.726 0.088 postoperative PVP 18.17 ± 3.79 19.57 ± 4.63 1.385 0.170 PVP difference 6.92 ± 3.28 3.70 ± 3.36 3.929 < 0.001 postoperative ST 33.96 ± 7.97 38.00 ± 6.26 1.949 0.055 postoperative SD 111.60 ± 24.41 119.78 ± 23.36 1.238 0.220 postoperative SV 251.27 ± 161.23 309.64 ± 163.41 1.418 0.161 STD 8.89 ± 8.49 -0.06 ± 7.12 4.004 < 0.001 SDD 22.46 ± 20.72 0.33 ± 18.81 3.993 < 0.001 SVD 187.57 ± 165.84 9.08 ± 151.55 4.303 < 0.001 Development and validation of a predictive model of splenic size change and postoperative moderate-to-severe EV. Development and validation of a predictive model of splenic size change and postoperative moderate-to-severe EV. Considering the possible collinearity of SDD, STD, and SVD, the variance inflation factor (VIF) was used for detection, with STD VIF = 1.361, SDD VIF = 1.462, and SVD VIF = 1.212, and there was no collinearity. SDD, STD, and SVD were included in the multivariate binary logistic regression analysis, and the stepwise regression method was adopted to screen variables. The results showed that STD (OR = 0.889, 95% CI 0.811–0.975, P < 0.05) and SVD (OR = 0.989, 95% CI 0.982–0.996, P < 0.05) were independent risk factors for postoperative moderate to severe EV (Table 2 ), and STD, SVD were protective factors. According to the results of the logistic regression analysis, the final regression equation model is as follows: logit(P)= -STD×0.118-SVD×0.011 + 0.502. The omnibus test was used, and the likelihood ratio (χ 2 = 29.649, P = 0.000) showed that the model was statistically significant. The Hosmer–Lemeshow goodness of fit test was used to determine the goodness of fit of the regression equation (P = 0.674), and the goodness of fit was high (Fig. 1 ). The area under the ROC curve was 89.73%, 95% CI 81.07%-98.39% (Fig. 2 ), the optimal threshold point was − 0.952, and its specificity was 82.6%. The sensitivity was 83.3%. A nomogram of the postoperative moderate-severe EV prediction model was constructed (Fig. 3 ) and internally validated, with a C-index of 0.897 indicating good discrimination; the calibration curve showed satisfactory calibration (Fig. 4 ). Table 2 Multifactorial logistic regression analysis variant B-value SE-value Wald-value P value OR-value (95% CI) STD -0.118 0.047 6.296 0.012 0.889(0.811–0.975) SVD -0.011 0.004 10.331 0.001 0.989(0.982–0.996) Constant 0.502 0.477 1.109 0.292 1.652 Discussion Cavernous transformation of the portal vein (CTPV) has many treatment options, mainly surgical treatment; traditional surgical methods include shunt surgery, severance surgery, shunt severance combined surgery, etc[ 10 ]. The Rex shunt, as the only curative procedure for this disease[ 11 ], was first used in 1992 by de Ville de Goyet [ 1 ] for the treatment of children with portal vein thrombosis after liver transplantation, with good results, and has since become the ideal procedure for the treatment of EHPVO in children. Primary prevention of gastrointestinal bleeding due to portal hypertension in adults is relatively well established [ 12 ], but in children, the concept of primary prevention of bleeding in children with portal hypertension has not been recognized overall [ 13 ]. Duche [ 13 ] et al. analyzed 1300 adults aged more than 25 years with portal hypertension (PH) and identified severe EV and moderate EV with red signs as high-risk EV for bleeding, and 96% of 246 children with spontaneous bleeding were at high risk for bleeding. Therefore, the identification of moderate-to-severe EVs is highly important for preventing postoperative gastrointestinal bleeding in children. Gastroscopy is still the "gold standard" for EV diagnosis, but it is invasive, complicated, expensive, and requires anesthesia, which is not conducive to patient review. A multicenter prospective study by Cardey[ 14 ] et al. compared esophageal capsule endoscopy with gastroscopy, and the overall accuracy rate reached 97% while reducing the pain of children. However, the popularity of capsule endoscopy is low, and the age limitations of children are not favorable for follow-up, so a noninvasive test is urgently needed as an alternative. In the field of CTPV in children, no predictive model for postoperative EV has been reported in the literature. There are physiological differences between children and adults, and the pathological processes of portal hypertension caused by extrahepatic portal vein obstruction and cirrhosis are also different. Most cirrhosis in adults is combined with liver function injury, which can cause abnormal biochemical and coagulation indices such as AST, ALT, and INR; therefore, the LOK, King, and TIB-4 scores are well predictive of the EV status of adults with cirrhosis. Correlation. However, children with CTPV have prehepatic portal hypertension and no liver function impairment, biochemical indices should not be used in children, and the application of the above scores in the field of children is greatly restricted. For the selection of variables, due to the small sample size of the positive group, the inclusion of more variables easily led to overfitting. Therefore, only 3 variables related to spleen size were included. Although there were differences in PVP between the two groups, the PVP was not suitable for inclusion in the model because the preoperative and postoperative PVP were measured during the operation, the hemodynamics were not stabilized after the completion of the vascular bypass, and the PVP in the immediate postoperative period did not reflect the mid- or long-term outcomes. Therefore, it is hoped that imaging may be used to construct a prediction model for EV after Rex surgery. The size of the spleen is directly related to portal venous pressure,研究表明, 术后脾脏大小直接缩小, 脾脏大小缓解不明显, 有可能与手术效果不良相关 and the indirect evaluation of EVs by spleen size-related indices is a very clinically meaningful study. In this study, we used color ultrasound and CT, which are more easily accessible, as the breakthrough points of the study and applied relevant factors, such as spleen length, thickness, and volume, to predict postoperative EV remission through changes in the spleen. Considering that the volume of the spleen varies at different ages in children, we used the difference between the preoperative and postoperative periods as the predictive index, and we tried to eliminate the differences in growth and development to guide the clinical practice. SDD, STD, and SVD associated with spleen size changes were included in the multifactorial logistic regression, and considering the possible covariance of SDD, STD, and SVD, the variance inflation factor (VIF), which was not present in STD VIF = 1.361, SDD VIF = 1.462, and SVD VIF = 1.212, was used to detect covariance. The stepwise regression method was used to screen the variables, and the results showed that STD (OR = 0.889, 95% CI 0.811–0.975, P < 0.05) and SVD (OR = 0.989, 95% CI 0.982–0.996, P < 0.05) were the independent risk factors for moderate-to-severe postoperative EV, and STD and SVD were protective factors; i.e., the more the spleen was reduced from the preoperative level, the lower the probability of the presence of moderate-severe EV after surgery. According to the results of the logistic regression analysis, the final regression equation model was obtained as logit(P)= -STD×0.118- SVD×0.011 + 0.502, and using the omnibus test of the model coefficients, the likelihood ratio was χ2 = 29.649, P = 0.000, and the model was statistically significant in general. The Hosmer–Lemeshow goodness-of-fit test was used to determine the goodness-of-fit of the regression equation (P = 0.674), the goodness-of-fit was high, and the validation accuracy of the logistic regression risk prediction model was 85.9%, the area under the ROC curve was 89.73%, the 95% CI was 81.07%-98.39%, the optimal threshold point was − 0.952, and its specificity and sensitivity were 82.6% and 83.3%, respectively. The column line graph of the postoperative moderate-severe EV prediction model was plotted and internally validated, and the C-index was 0.897, indicating good discrimination; the calibration curve showed satisfactory calibration. This model can well predict the risk of postoperative moderate-severe EV in children and is an effective prediction method. The main shortcoming of this study is the small sample size. CTPV is a rare disease in pediatric surgery, and the incidence rate is low. This study included 78 children and 23 patients in the postoperative moderate-severe EV group. Although there was no uniform standard for the sample content of logistic regression analysis, the sample size was small, and the maximum likelihood estimation of the logistic regression may still have a certain degree of error. Second, for the validation of the model effect, due to the insufficient sample size, it is impossible to establish a validation group, and differentiation and calibration may have a small bias. Finally, there is no effective noninvasive test for the assessment of EV in children. This study provides a new method for the assessment of EV after Rex, but the method is only suitable for the assessment of EV after Rex and whether it is suitable for the assessment of EV after Warren surgery in children. However, further studies are needed. Conclusion The postoperative STD, SVD, and the degree of postoperative EV are well correlated, and the multifactorial prediction model has good specificity and sensitivity and has a certain value in predicting children's postoperative EV. Declarations Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Conflicts of interest None. Authors’ contributions Yunpei Chen drafted the manuscript. Yunpei Chen and Zhiqiang Chen participated in the design of the study, data collection and performed the statistical analysis. These authors have contributed equally to this work. Jiancai Chen and Linyi Zeng conceived of the study, participated in its design and helped to draft the manuscript. Zhe Wen and Liu Chen are the director of the project and provides guidance. All authors read and approved the final manuscript. References de Ville de Goyet, P Clapuyt, Otte JB. Extrahilar mesenterico-left portal shunt to relieve extrahepatic portal hypertension after partial liver transplant. Transplantation 1992;53:231-232. Lautz TB, Keys LA, Melvin JC, et al. Advantages of the meso-Rex bypass compared with portosystemic shunts in the management of extrahepatic portal vein obstruction in children. J Am Coll Surg 2013;216:83-89. Guerin F, Bidault V, Gonzales E, et al. Meso-Rex bypass for extrahepatic portal vein obstruction in children. Br J Surg 2013;100:1606-1613. Krebs-Schmitt D, Briem-Richter A, Grabhorn E, et al. Effectiveness of Rex shunt in children with portal hypertension following liver transplantation or with primary portal hypertension. Pediatr Transplant 2009;13:540-544. Zhang YQ, Wang Q, Wu M, et al. Optimal Rex shunt procedures as a treatment for pediatric extrahepatic portal hypertension. Pediatr Surg Int 2021; 37:597-606. Fuchs J, Warmann S, Kardorff R, et al. Mesenterico-left portal vein bypass in children with congenital extrahepatic portal vein thrombosis: a unique curative approach. J Pediatr Gastroenterol Nutr 2003;36:213-216. Bhat R, Lautz TB, Superina RA, et al. Perioperative strategies and thrombophilia in children with extrahepatic portal vein obstruction undergoing the meso-Rex bypass. J Gastrointest Surg 2013;17:949-955. Zhang JS, Li L, Cheng W. The optimal procedure of modified Rex shunt for the treatment of extrahepatic portal hypertension in children. J Vasc Surg Venous Lymphat Disord 2017;5:805-809. Chinese Society of Digestive Endoscopy. Prevention and treatment of esophageal and gastric varices bleeding with portal hypertension in liver cirrhosis[in chinese]. Chinese Journal of Digestion. 2008; 28:551-558. Wei B, Huang Z, Tang C. Optimal Treatment for Patients With Cavernous Transformation of the Portal Vein. Front Med (Lausanne) 2022; 9:8531-38. de Franchis R, VIF B. Expanding consensus in portal hypertension: report of the baveno VI consensus workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol 2015;63:743-752. Vashishtha C, Sarin SK. Primary prophylaxis of gastric variceal bleeding: the choices need to be tested!! Hepatology international 2021;15:863-867. Duche M, Ducot B, Ackermann O, et al. Portal hypertension in children: High-risk varices, primary prophylaxis and consequences of bleeding. J Hepatol 2017;66:320-327. Cardey J, Le Gall C, Michaud L, et al. Screening of esophageal varices in children using esophageal capsule endoscopy: a multicenter prospective study. Endoscopy 2019;51:10-17. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4576774","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":317955419,"identity":"3b30b6d6-a462-4d31-b17b-27fade5bb53b","order_by":0,"name":"Yunpei Chen","email":"","orcid":"","institution":"Fujian Children's Hospital","correspondingAuthor":false,"prefix":"","firstName":"Yunpei","middleName":"","lastName":"Chen","suffix":""},{"id":317955420,"identity":"2b07f3a0-d984-4c2e-87a4-3ff8062cf7f3","order_by":1,"name":"Zhiqiang Chen","email":"","orcid":"","institution":"Fujian Children's 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the predictive model\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-4576774/v1/8af29061c613cc821f6f342b.png"},{"id":60197813,"identity":"a7364e6b-7e5c-417b-963d-70bde7aa3b15","added_by":"auto","created_at":"2024-07-13 01:59:50","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":130488,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative moderate–severe EV prediction model nomogram\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-4576774/v1/0182ec15fca85b9f5d7be430.png"},{"id":60197815,"identity":"9ac00e05-1eea-4491-8c54-78172543412b","added_by":"auto","created_at":"2024-07-13 01:59:50","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":21307,"visible":true,"origin":"","legend":"\u003cp\u003ePredictive model calibration curve\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-4576774/v1/3bf9e7298d86dc810c74898b.png"},{"id":60198905,"identity":"4d538cfb-81a8-4881-9a08-a177f1594db1","added_by":"auto","created_at":"2024-07-13 02:15:52","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":721226,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4576774/v1/2521fbd0-43be-45ff-aa50-c56fb8c206d1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development and validation of a prediction model for esophageal varices by changes in spleen size after Rex surgery","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRex surgery was first used in 1992 by de Ville de Goyet [1] for the treatment of portal vein thrombosis after liver transplantation and has since evolved to become the ideal procedure for the treatment of cavernous transformation of the portal vein (CTPV) in children, with a success rate ranging from 60% to 96% [2-5]. Factors such as thrombosis, anastomotic stenosis, and a small diameter of bypass vessels are the main reasons for unsatisfactory surgical results; some children still have esophageal varices (EVs) after surgery, and approximately 4%-20% [5-8] are at risk of rupture and bleeding from EVs. Postoperative EV is mainly clarified by gastroscopy via invasive tests. There is no predictive model for children after Rex surgery. Although many noninvasive predictive models have been proposed for EVs in adults with cirrhosis, they are not suitable for application in children because most cirrhosis in adults is associated with liver function impairment. The aim of this study was to establish a Rex postoperative moderate-severe EV risk prediction model in combination with the clinical experience of our hospital and to verify the validity of the model, identify high-risk groups in the early postoperative period, and reduce the probability of postoperative gastrointestinal bleeding in children.\u003c/p\u003e\n"},{"header":"Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Clinical data\u003c/h2\u003e \u003cp\u003eThe clinical data of children with CTPV who visited our hepatobiliary surgery department for Rex surgery from 09/2014 to 12/2021 were collected. The inclusion criteria were as follows: (1) a clear diagnosis of CTPV in combination with preoperative abdominal enhanced CT/MRI and three-dimensional reconstruction of the portal venous system and vascular ultrasound of the child; (2) age\u0026thinsp;\u0026lt;\u0026thinsp;18 years; (3) clear indications for surgery, e.g., gastrointestinal bleeding, severe hypersplenism, severe varicose veins, etc., and successful Rex surgery performed in our hospital; and (4) complete case data and regular follow-up for more than 1 year. The exclusion criteria were as follows: (1) had a history of liver disease such as cirrhosis; (2) were lost to follow-up or unable to provide complete preoperative, postoperative, or follow-up data; and (3) had undergone previous splenectomy. Based on postoperative gastroscopy, the children were categorized into a no-mild EV group and a moderate-severe EV group.\u003c/p\u003e \u003cp\u003eAccording to the Consensus on Prevention and Treatment of Esophagogastric Variceal Bleeding in Cirrhotic Portal Vein Hypertension (Hangzhou, China 2008) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], the severity of EV was classified as mild, moderate, or severe:\u003c/p\u003e \u003cp\u003eMild (G1): EVs are linear or slightly tortuous with no red sign and a vein diameter\u0026thinsp;\u0026lt;\u0026thinsp;5 mm;\u003c/p\u003e \u003cp\u003eModerate (G2): EVs are linear or slightly tortuous with a red sign, or EVs are serpentine with tortuous bulges but no red sign; vein diameter\u0026thinsp;\u0026ge;\u0026thinsp;5 mm.\u003c/p\u003e \u003cp\u003eSevere (G3): EVs that are serpentine and raised with a red sign or EVs that are beaded, nodular, or tuberculate (with or without a red sign) with a vein diameter\u0026thinsp;\u0026ge;\u0026thinsp;5 mm.\u003c/p\u003e \u003cp\u003eThe splenic thickness (ST) and splenic long diameter (SD) from the preoperative and postoperative ultrasound of the children were collected, CT reconstruction was performed with software to calculate the splenic volume (SV), and the preoperative and postoperative differences were calculated to obtain the STD, SDD, and SVD, respectively. The differences in the above data were analyzed, and a prediction model was established and validated.\u003c/p\u003e \u003cp\u003eThis study was approved by the hospital Ethics Committee (No.090A01). All patients signed informed consent forms.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Preoperative Preparation\u003c/h2\u003e \u003cp\u003eIn addition to routine preoperative examination, color ultrasound, CTA/MRA, etc., are required for children to understand the condition of the liver and spleen and the vascular condition of the portal vein system, to clarify the condition of the graft vessels, to exclude variations, and to assess the inferior vena cava and both renal veins. In some children with poor visualization of the portal vein system, digital subtraction angiography (DSA) can be used to visualize the portal vein system retrogradely through the hepatic vein to clarify the sagittal portion of the left branch of the portal vein. For children with unstable conditions such as active gastrointestinal bleeding, fasting, intravenous nutrition, hemostatic drugs, proton pump inhibitors, growth inhibitors, and other symptomatic conservative treatments are given, and blood transfusion therapy is given to maintain hemoglobin at 70\u0026ndash;80 g/L if necessary.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e1.3 Follow-up visit\u003c/h2\u003e \u003cp\u003eAll children were followed up for more than 1 year via telephone follow-up, outpatient information, or readmission treatment records, and the review included laboratory tests, ultrasound, CT/MR, and gastroscopy. 所有资料采集患儿术后10\u0026ndash;14个月, As of January 2023, there were no lost cases or deaths.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e1.4 Statistical analysis\u003c/h2\u003e \u003cp\u003eSPSS 25.0 and R 4.2.2 software were used for statistical data processing, and the results were directly evaluated by computer statistics. P\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to indicate statistical significance. Count data are expressed as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (`X\u0026thinsp;\u0026plusmn;\u0026thinsp;S), and the differences between groups were first tested for normality and chi-square tests; t tests were used for normally distributed data and chi-square tests were used, and rank-sum tests were used for nonnormally distributed data. Differences between groups of categorical measures were analyzed with the c2 test. After adjusting for confounding factors, the risk factors related to postoperative moderate to severe EV were screened by multivariate binary logistic regression analysis. The Hosmer\u0026ndash;Lemeshow test was used to test the goodness of fit of the model. The results of the model were presented by using a column graph, the optimized model was internally verified by resampling (bootstrapping\u0026thinsp;=\u0026thinsp;1000), and the model differentiation and calibration were evaluated by receiver operating characteristic (ROC) curve and calibration curve analyses.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 78 children were included, 55 in the no-mild group and 23 in the moderate-severe group. The differences between the two groups were not statistically significant for age, sex, preoperative EV degree, preoperative and postoperative PVP, postoperative SD, postoperative ST, or postoperative SV; the differences were statistically significant for PVP difference, STD, SDD, and SVD (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05); and the differences in PVP, STD, SDD, and SVD in the moderate-severe EV group were significantly lower than those in the no-mild EV group (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of relevant information between the two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactors\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u0026thinsp;=\u0026thinsp;no-mild EV group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u0026thinsp;=\u0026thinsp;moderate-severe EV group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e/t value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.82\u0026thinsp;\u0026plusmn;\u0026thinsp;2.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.29\u0026thinsp;\u0026plusmn;\u0026thinsp;3.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.697\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.488\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.081\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.776\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026thinsp;=\u0026thinsp;male\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026thinsp;=\u0026thinsp;female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epreoperative EV degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.209\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026thinsp;=\u0026thinsp;no-mild\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u0026thinsp;=\u0026thinsp;moderate-severe\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epreoperative PVP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.09\u0026thinsp;\u0026plusmn;\u0026thinsp;4.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.26\u0026thinsp;\u0026plusmn;\u0026thinsp;3.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.726\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.088\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epostoperative PVP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18.17\u0026thinsp;\u0026plusmn;\u0026thinsp;3.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19.57\u0026thinsp;\u0026plusmn;\u0026thinsp;4.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.385\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.170\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePVP difference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6.92\u0026thinsp;\u0026plusmn;\u0026thinsp;3.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.70\u0026thinsp;\u0026plusmn;\u0026thinsp;3.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.929\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epostoperative ST\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.96\u0026thinsp;\u0026plusmn;\u0026thinsp;7.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38.00\u0026thinsp;\u0026plusmn;\u0026thinsp;6.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.949\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.055\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epostoperative SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111.60\u0026thinsp;\u0026plusmn;\u0026thinsp;24.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e119.78\u0026thinsp;\u0026plusmn;\u0026thinsp;23.36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.238\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.220\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003epostoperative SV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e251.27\u0026thinsp;\u0026plusmn;\u0026thinsp;161.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e309.64\u0026thinsp;\u0026plusmn;\u0026thinsp;163.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.418\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.161\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSTD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.89\u0026thinsp;\u0026plusmn;\u0026thinsp;8.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-0.06\u0026thinsp;\u0026plusmn;\u0026thinsp;7.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSDD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.46\u0026thinsp;\u0026plusmn;\u0026thinsp;20.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.33\u0026thinsp;\u0026plusmn;\u0026thinsp;18.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e3.993\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSVD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e187.57\u0026thinsp;\u0026plusmn;\u0026thinsp;165.84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.08\u0026thinsp;\u0026plusmn;\u0026thinsp;151.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.303\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eDevelopment and validation of a predictive model of splenic size change and postoperative moderate-to-severe EV.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eDevelopment and validation of a predictive model of splenic size change and postoperative moderate-to-severe EV.\u003c/p\u003e \u003cp\u003eConsidering the possible collinearity of SDD, STD, and SVD, the variance inflation factor (VIF) was used for detection, with STD VIF\u0026thinsp;=\u0026thinsp;1.361, SDD VIF\u0026thinsp;=\u0026thinsp;1.462, and SVD VIF\u0026thinsp;=\u0026thinsp;1.212, and there was no collinearity. SDD, STD, and SVD were included in the multivariate binary logistic regression analysis, and the stepwise regression method was adopted to screen variables. The results showed that STD (OR\u0026thinsp;=\u0026thinsp;0.889, 95% CI 0.811\u0026ndash;0.975, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and SVD (OR\u0026thinsp;=\u0026thinsp;0.989, 95% CI 0.982\u0026ndash;0.996, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) were independent risk factors for postoperative moderate to severe EV (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), and STD, SVD were protective factors. According to the results of the logistic regression analysis, the final regression equation model is as follows: logit(P)= -STD\u0026times;0.118-SVD\u0026times;0.011\u0026thinsp;+\u0026thinsp;0.502. The omnibus test was used, and the likelihood ratio (χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;29.649, P\u0026thinsp;=\u0026thinsp;0.000) showed that the model was statistically significant. The Hosmer\u0026ndash;Lemeshow goodness of fit test was used to determine the goodness of fit of the regression equation (P\u0026thinsp;=\u0026thinsp;0.674), and the goodness of fit was high (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The area under the ROC curve was 89.73%, 95% CI 81.07%-98.39% (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e2\u003c/span\u003e), the optimal threshold point was \u0026minus;\u0026thinsp;0.952, and its specificity was 82.6%. The sensitivity was 83.3%. A nomogram of the postoperative moderate-severe EV prediction model was constructed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e) and internally validated, with a C-index of 0.897 indicating good discrimination; the calibration curve showed satisfactory calibration (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMultifactorial logistic regression analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003evariant\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWald-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eOR-value (95% CI)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSTD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.296\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.012\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.889(0.811\u0026ndash;0.975)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSVD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.011\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e10.331\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.989(0.982\u0026ndash;0.996)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.502\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.477\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.292\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e1.652\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eCavernous transformation of the portal vein (CTPV) has many treatment options, mainly surgical treatment; traditional surgical methods include shunt surgery, severance surgery, shunt severance combined surgery, etc[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The Rex shunt, as the only curative procedure for this disease[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], was first used in 1992 by de Ville de Goyet [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e] for the treatment of children with portal vein thrombosis after liver transplantation, with good results, and has since become the ideal procedure for the treatment of EHPVO in children.\u003c/p\u003e \u003cp\u003ePrimary prevention of gastrointestinal bleeding due to portal hypertension in adults is relatively well established [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], but in children, the concept of primary prevention of bleeding in children with portal hypertension has not been recognized overall [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Duche [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] et al. analyzed 1300 adults aged more than 25 years with portal hypertension (PH) and identified severe EV and moderate EV with red signs as high-risk EV for bleeding, and 96% of 246 children with spontaneous bleeding were at high risk for bleeding. Therefore, the identification of moderate-to-severe EVs is highly important for preventing postoperative gastrointestinal bleeding in children.\u003c/p\u003e \u003cp\u003eGastroscopy is still the \"gold standard\" for EV diagnosis, but it is invasive, complicated, expensive, and requires anesthesia, which is not conducive to patient review. A multicenter prospective study by Cardey[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] et al. compared esophageal capsule endoscopy with gastroscopy, and the overall accuracy rate reached 97% while reducing the pain of children. However, the popularity of capsule endoscopy is low, and the age limitations of children are not favorable for follow-up, so a noninvasive test is urgently needed as an alternative.\u003c/p\u003e \u003cp\u003eIn the field of CTPV in children, no predictive model for postoperative EV has been reported in the literature. There are physiological differences between children and adults, and the pathological processes of portal hypertension caused by extrahepatic portal vein obstruction and cirrhosis are also different. Most cirrhosis in adults is combined with liver function injury, which can cause abnormal biochemical and coagulation indices such as AST, ALT, and INR; therefore, the LOK, King, and TIB-4 scores are well predictive of the EV status of adults with cirrhosis. Correlation. However, children with CTPV have prehepatic portal hypertension and no liver function impairment, biochemical indices should not be used in children, and the application of the above scores in the field of children is greatly restricted.\u003c/p\u003e \u003cp\u003eFor the selection of variables, due to the small sample size of the positive group, the inclusion of more variables easily led to overfitting. Therefore, only 3 variables related to spleen size were included. Although there were differences in PVP between the two groups, the PVP was not suitable for inclusion in the model because the preoperative and postoperative PVP were measured during the operation, the hemodynamics were not stabilized after the completion of the vascular bypass, and the PVP in the immediate postoperative period did not reflect the mid- or long-term outcomes. Therefore, it is hoped that imaging may be used to construct a prediction model for EV after Rex surgery. The size of the spleen is directly related to portal venous pressure,研究表明, 术后脾脏大小直接缩小, 脾脏大小缓解不明显, 有可能与手术效果不良相关 and the indirect evaluation of EVs by spleen size-related indices is a very clinically meaningful study. In this study, we used color ultrasound and CT, which are more easily accessible, as the breakthrough points of the study and applied relevant factors, such as spleen length, thickness, and volume, to predict postoperative EV remission through changes in the spleen. Considering that the volume of the spleen varies at different ages in children, we used the difference between the preoperative and postoperative periods as the predictive index, and we tried to eliminate the differences in growth and development to guide the clinical practice. SDD, STD, and SVD associated with spleen size changes were included in the multifactorial logistic regression, and considering the possible covariance of SDD, STD, and SVD, the variance inflation factor (VIF), which was not present in STD VIF\u0026thinsp;=\u0026thinsp;1.361, SDD VIF\u0026thinsp;=\u0026thinsp;1.462, and SVD VIF\u0026thinsp;=\u0026thinsp;1.212, was used to detect covariance. The stepwise regression method was used to screen the variables, and the results showed that STD (OR\u0026thinsp;=\u0026thinsp;0.889, 95% CI 0.811\u0026ndash;0.975, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and SVD (OR\u0026thinsp;=\u0026thinsp;0.989, 95% CI 0.982\u0026ndash;0.996, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05) were the independent risk factors for moderate-to-severe postoperative EV, and STD and SVD were protective factors; i.e., the more the spleen was reduced from the preoperative level, the lower the probability of the presence of moderate-severe EV after surgery. According to the results of the logistic regression analysis, the final regression equation model was obtained as logit(P)= -STD\u0026times;0.118- SVD\u0026times;0.011\u0026thinsp;+\u0026thinsp;0.502, and using the omnibus test of the model coefficients, the likelihood ratio was χ2\u0026thinsp;=\u0026thinsp;29.649, P\u0026thinsp;=\u0026thinsp;0.000, and the model was statistically significant in general. The Hosmer\u0026ndash;Lemeshow goodness-of-fit test was used to determine the goodness-of-fit of the regression equation (P\u0026thinsp;=\u0026thinsp;0.674), the goodness-of-fit was high, and the validation accuracy of the logistic regression risk prediction model was 85.9%, the area under the ROC curve was 89.73%, the 95% CI was 81.07%-98.39%, the optimal threshold point was \u0026minus;\u0026thinsp;0.952, and its specificity and sensitivity were 82.6% and 83.3%, respectively. The column line graph of the postoperative moderate-severe EV prediction model was plotted and internally validated, and the C-index was 0.897, indicating good discrimination; the calibration curve showed satisfactory calibration. This model can well predict the risk of postoperative moderate-severe EV in children and is an effective prediction method.\u003c/p\u003e \u003cp\u003eThe main shortcoming of this study is the small sample size. CTPV is a rare disease in pediatric surgery, and the incidence rate is low. This study included 78 children and 23 patients in the postoperative moderate-severe EV group. Although there was no uniform standard for the sample content of logistic regression analysis, the sample size was small, and the maximum likelihood estimation of the logistic regression may still have a certain degree of error. Second, for the validation of the model effect, due to the insufficient sample size, it is impossible to establish a validation group, and differentiation and calibration may have a small bias. Finally, there is no effective noninvasive test for the assessment of EV in children. This study provides a new method for the assessment of EV after Rex, but the method is only suitable for the assessment of EV after Rex and whether it is suitable for the assessment of EV after Warren surgery in children. However, further studies are needed.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe postoperative STD, SVD, and the degree of postoperative EV are well correlated, and the multifactorial prediction model has good specificity and sensitivity and has a certain value in predicting children's postoperative EV.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYunpei Chen drafted the manuscript. Yunpei Chen and Zhiqiang Chen participated in the design of the study, data collection and performed the statistical analysis. These authors have contributed equally to this work. Jiancai Chen and Linyi Zeng conceived of the study, participated in its design and helped to draft the manuscript. Zhe Wen and Liu Chen are the director of the project and provides guidance. All authors read and approved the final manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003ede Ville de Goyet, P Clapuyt, Otte JB. Extrahilar mesenterico-left portal shunt to relieve extrahepatic portal hypertension after partial liver transplant. Transplantation 1992;53:231-232.\u003c/li\u003e\n\u003cli\u003eLautz TB, Keys LA, Melvin JC, et al. Advantages of the meso-Rex bypass compared with portosystemic shunts in the management of extrahepatic portal vein obstruction in children. J Am Coll Surg 2013;216:83-89.\u003c/li\u003e\n\u003cli\u003eGuerin F, Bidault V, Gonzales E, et al. Meso-Rex bypass for extrahepatic portal vein obstruction in children. Br J Surg 2013;100:1606-1613.\u003c/li\u003e\n\u003cli\u003eKrebs-Schmitt D, Briem-Richter A, Grabhorn E, et al. Effectiveness of Rex shunt in children with portal hypertension following liver transplantation or with primary portal hypertension. Pediatr Transplant 2009;13:540-544.\u003c/li\u003e\n\u003cli\u003eZhang YQ, Wang Q, Wu M, et al. Optimal Rex shunt procedures as a treatment for pediatric extrahepatic portal hypertension. Pediatr Surg Int 2021; 37:597-606.\u003c/li\u003e\n\u003cli\u003eFuchs J, Warmann S, Kardorff R, et al. Mesenterico-left portal vein bypass in children with congenital extrahepatic portal vein thrombosis: a unique curative approach. J Pediatr Gastroenterol Nutr 2003;36:213-216.\u003c/li\u003e\n\u003cli\u003eBhat R, Lautz TB, Superina RA, et al. Perioperative strategies and thrombophilia in children with extrahepatic portal vein obstruction undergoing the meso-Rex bypass. J Gastrointest Surg 2013;17:949-955.\u003c/li\u003e\n\u003cli\u003eZhang JS, Li L, Cheng W. The optimal procedure of modified Rex shunt for the treatment of extrahepatic portal hypertension in children. J Vasc Surg Venous Lymphat Disord 2017;5:805-809.\u003c/li\u003e\n\u003cli\u003eChinese Society of Digestive Endoscopy. Prevention and treatment of esophageal and gastric varices bleeding with portal hypertension in liver cirrhosis[in chinese]. Chinese Journal of Digestion. 2008; 28:551-558.\u003c/li\u003e\n\u003cli\u003eWei B, Huang Z, Tang C. Optimal Treatment for Patients With Cavernous Transformation of the Portal Vein. Front Med (Lausanne) 2022; 9:8531-38.\u003c/li\u003e\n\u003cli\u003ede Franchis R, VIF B. Expanding consensus in portal hypertension: report of the baveno VI consensus workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol 2015;63:743-752.\u003c/li\u003e\n\u003cli\u003eVashishtha C, Sarin SK. Primary prophylaxis of gastric variceal bleeding: the choices need to be tested!! Hepatology international 2021;15:863-867.\u003c/li\u003e\n\u003cli\u003eDuche M, Ducot B, Ackermann O, et al. Portal hypertension in children: High-risk varices, primary prophylaxis and consequences of bleeding. J Hepatol 2017;66:320-327.\u003c/li\u003e\n\u003cli\u003eCardey J, Le Gall C, Michaud L, et al. Screening of esophageal varices in children using esophageal capsule endoscopy: a multicenter prospective study. Endoscopy 2019;51:10-17.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Rex surgery, portal vein cavernous changes, esophageal varices, noninvasive detection","lastPublishedDoi":"10.21203/rs.3.rs-4576774/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4576774/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose\u003c/strong\u003e To develop a noninvasive prediction model for esophageal varices (EVs) based on changes in spleen size after Rex surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod \u003c/strong\u003eThe clinical data of children with cavernous transformation of the portal vein who underwent Rex surgery at the Department of Hepatobiliary Surgery of our hospital from 2014-09 to 2021-12 were collected, and the children were divided into a no-to-mild group and a moderate-to-severe group according to the EV status on postoperative gastroscopy. Variables related to changes in spleen size were included in logistic regression models. Construction and internal validation of a postoperative moderate-to-severe EV risk prediction model.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e A total of 78 children were included, 55 in the no-mild group and 23 in the moderate-severe group. The splenic thickness difference (STD), splenic long diameter difference (SDD), and splenic volume difference (SVD) were included in the multifactorial logistic regression analysis, and the regression equation obtained was modeled as logit(P)= -STDx0.18-SVDx0.011+0.502. The STD and SVD are independent risk factors for moderate-to-severe EV after surgery. The area under the ROC curve was 89.73%, the optimal threshold point was -0.952, and its specificity and sensitivity were 82.6% and 83.3%, respectively.The model was internally validated, and the C-index was 0.897, indicating good discrimination and calibration.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e The model constructed by multifactorial logistic regression is valuable and effective for the noninvasive detection of postoperative EVs, and deserves further research.\u003c/p\u003e","manuscriptTitle":"Development and validation of a prediction model for esophageal varices by changes in spleen size after Rex surgery","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-13 01:59:45","doi":"10.21203/rs.3.rs-4576774/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"132bbd19-e1c4-42ca-94af-dd17b6c0aa56","owner":[],"postedDate":"July 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-07-13T01:59:48+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-13 01:59:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4576774","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4576774","identity":"rs-4576774","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}