case_images: PMC11408172_01
case_images: Gastroduodenoscopy and computed tomography scan of the upper abdomen in a 47-year-old female patient who had been vomiting blood repeatedly for 6 years before admission. (A,B) Gastroduodenoscopy suggests severe varices of the esophageal and fundal veins (yellow arrows); (C,D) CT scan of the upper abdomen suggests cirrhosis, splenomegaly, and portal hypertension (widening of the main portal vein and varicose splenic veins) (blue arrows).
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case_images: fig1
case_images: Upon admission, she underwent relevant examinations, and a gastrointestinal endoscopy revealed severe esophagogastric varices and portal hypertension gastropathy (Figures 1A,B). Plain and contrast-enhanced scans of the upper abdominal vein, hepatic artery, and inferior vena cava revealed the presence of liver cirrhosis (maximum oblique diameter of the right lobe, 10.25 cm; thickness and length of the left lobe, 4.24 cm and 6.12 cm, respectively; thickness of the right lobe, 9.13 cm), splenomegaly (longitudinal diameter and thickness of the spleen, 14.22 cm and 7.98 cm, respectively), portal hypertension (main trunk of the portal vein, 1.58 cm), and splenic varices (Figures 1C,D).
case_images: A 47-year-old female patient underwent obot-assisted laparoscopic splenectomy combined with pericardial devascularization (LSPD). (A) Chest CT 4 days after LSPD showed bilateral pleural effusions and most of the lower lobes of both lungs were atelectatic (white arrows); (B) percutaneous percutaneous drainage of the right pleural effusion was performed, and a follow-up CT 8 days after the operation showed a decrease in the bilateral pleural effusions (red arrows); (C) Chest CT 47 days after the operation showed a small amount of effusion in the right pleural cavity (yellow arrow); (D) The mediastinal window of the chest CT on day 116 postoperatively showed a large right pleural effusion, complete atelectasis of the right lung, and left shift of the trachea, heart, and mediastinum (red arrow); (E) the patient underwent percutaneous right pleural effusion puncture and drainage, and chest CT on day 129 postoperatively still showed a large right pleural effusion (yellow arrow); (F) chest CT on day 137 postoperatively showed a large right pleural effusion but less than before (blue arrow).
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case_images: fig2
case_images: On the fourth postoperative day, the patient suddenly felt chest tightness and underwent a chest CT, which showed bilateral pleural effusions, atelectasis in most of the lower lobes of both lungs, and a small amount of pericardial effusion (Figure 2A). CT reexamination images showed that the bilateral pleural effusions had decreased (Figure 2B). Continued symptomatic supportive treatment resulted in a stable condition and improved mental state on the 11th post-operative day. Later, 47 days after the LSPD, chest CT images showed only a small amount of right-sided pleural effusion (Figure 2C). Chest CT reexamination showed a large amount of right-sided pleural effusion, complete atelectasis of the right lung, and left displacement of the trachea, heart, and mediastinum (Figure 2D). However, 129 days after the LSPD, the chest CT images still showed a large right-sided pleural effusion (Figure 2E). CT showed a large pleural effusion on the right side that was smaller than the previous one (Figure 2F). Conservative treatment was continued with fasting, nutritional support, continuous chest drainage, and intrathoracic injection of pingyangmycin (16 mg of pingyangmycin +10 mg of dexamethasone, chest injection, 5-7 days/time, continuous treatment for 3 times) taking into consideration the massive chylothorax of the patient.
case_images: A 47-year-old female patient underwent robot-assisted LSPD. (A) 165 days after LSPD, ultrasound-guided lymphangiography through the inguinal region showed no abnormalities in the shape of the pelvic and lumbar lymphatic vessels, and no visualization of the thoracic lymphatic vessels (red arrows); (B) Compared with the pre-LSPD, the portal vein width before TIPS increased from 1.58 cm to 1.7 cm (yellow arrow); (C) During TIPS treatment, thrombosis in the portal vein was found. The patient underwent TIPS treatment under general anesthesia 169 days after LSPD (blue arrow).
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case_images: fig3
case_images: The imaging results showed normal morphology and lymphatic vessels course in the pelvic and lumbar segments, and we found no significant fistulas in the thoracic segment (Figure 3A). Compared with the preoperative LSPD, the portal vein width had increased from 1.58 cm to 1.7 cm (Figure 3B). We communicated with the patient's family and obtained a signed surgical consent form, the patient underwent TIPS under general anesthesia on day 169 after the initial LSPD (Figure 3C). In addition, we found irregular filling defects in the main portal vein and left and right branches of the portal vein that appeared to be thrombosis lesions (Figure 3C).
case_images: A 47-year-old female patient underwent robotic assisted LSPD, TIPS treatment was performed 169 days after LSPD surgery. (A) On the 4th day after TIPS surgery, a chest CT scan (chest window) showed a small amount of pleural effusion on the right side, which was significantly improved compared to before (red arrow); (B) 14 days after TIPS surgery, chest CT showed no obvious effusion in the right chest cavity and good lung expansion (yellow arrow); (C,D) The patient's serum alanine aminotransferase (ALT) level and chest drainage fluid decreased significantly after TIPS.
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case_images: fig4
case_images: After therapy for liver protection, electrolyte imbalance correction, anti-infection, and other symptomatic treatments, the chest CT images showed improvement in the right-sided pleural effusion compared with the pre-operative findings (Figure 4A). TIPS, chest CT images showed a small pleural effusion on the right side and local thickening and adhesion of the bilateral pleuras (Figure 4B).