Suggestive for splenoazygos shunt. Possible entry into the vena cava cranially is technically possible, yet not evident. I am more concerned for splenoazygos shunt. Regardless, the ameroid constrictor placement would be similar in both cases at the level of the extrahepatic shunt derivation from the splenic vein as it enters into the portal vein. The width of the shunt is approximately 0.5 cm. However, significant microhepatica is present as well as hepatic remodeling. Therefore, it is debatable whether this patient can handle new volume without forming portal hypertension at surgery. The surgeon should be prepared for portal hypertension occurrence post surgery. Therefore, a recheck sonogram is recommended post surgery as well as 48-72 hours post surgery to assess portal vein velocities and the potential for portal hypertension. Concurrent liver biopsy is recommended to rule out portal vein hypoplasia would also be warranted at that time as well as cystotomy for stone removal and analysis (likely ammonium biurate). Screening for Addison’s disease is also warranted given the small adrenal glands. Baseline cortisol or full ACTH stimulation is recommended as well as a full bile acid profile of pre and post hepatic bile acids.