Refractory massive chylothorax following robot-assisted laparoscopic splenectomy with pericardial devascularization treated with trans-jugular intrahepatic portosystemic shunt: a case report

Abstract

The development of a chylothorax after robot-assisted laparoscopic splenectomy combined with pericardial devascularization (LSPD) is rare. The robot-assisted procedure is similar to the standard LSPD, but surgeons must remain vigilant about potential chylothorax caused by recurrence of portal hypertension in patients with cirrhosis, an event that leads to variceal bleeding in the gastric fundus or a massive chylothorax caused by a thoracic duct fistula. We report a rare case of massive chylothorax after robot-assisted LSPD and review the literature to help elucidate the mechanisms of portal hypertension after LSPD, reduce surgical complications, and improve long-term patient outcomes. After LSPD, portal pressure monitoring, coagulation function testing, and portal vein CT imaging help in excluding portal vein thromboses and ensuring appropriate anticoagulation to reduce the development of thoracic duct fistulas. If portal hypertension recurs after surgery and a high-output chylothorax develops, conservative treatment becomes ineffective. Treatment with an active trans-jugular intrahepatic portosystemic shunt (TIPS) is recommended to lower the portal pressure.

Keywords: LSPD; gastric fundus varices; massive chylothorax; portal hypertension; tips.

Figure 1

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).

Figure 2

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).

Figure 3

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).

Figure 4

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.