Massive chylous ascites in nine-year-old with malrotation - a case report

Abstract

Malrotation leading to massive chylous ascites is rare. A nine-year-old girl was investigated for slowly increasing abdominal distension under a year. She had no vomiting, weight loss or pain, but was bothered in social situations. Medical investigations, including ultrasound and CT scans, revealed massive ascites. Laparocentesis yielded milk colored fluid, confirmed as lymph through laboratory analysis. A complete blood count, liver function and hematologic parameters, chyle cytology, bacterial cultures and PCR for tuberculosis were all within normal limits. She was referred to a tertiary center for vascular anomalies. A dynamic contrast enhanced MR lymphangiography showed normal lymphatic anatomy without leakage or flow obstruction. A whole-body MRI revealed a central mesenteric rotation. She was referred to a tertiary center for pediatric surgery, where a laparoscopic Ladd’s procedure was performed using a new 5 mm pediatric sealing device, along with an appendectomy using a 5 mm stapler. To derotate the bowel, fenestrations were created in compartments containing a substantial amount of chyle and ascites, resulting in the drainage of 2.4 liters of fluid. She was discharged the day after surgery and has been in good health for one year. We present a video illustrating the Ladd’s procedure steps in this patient.