Background: This case describes a rare clinical situation of chylous ascites due to lymphatic obstruction in the setting of small bowel volvulus. A 32-year-old man presented with acute onset abdominal pain in the preceding 3 hours, associated with nausea and vomiting. He underwent a computed tomography (CT) scan which was concerning for an internal hernia involving the small bowel. On subsequent laparoscopy, milky fluid suggestive of chyle was found within the pelvis, along with a torted segment of the small bowel. The bowel was gently reduced with ease using atraumatic laparoscopic graspers. On closer examination, the mesenteric border of the torted small bowel had a white edge suggestive of lymphatic build-up. This case report highlights the pertinent clinical features associated with this clinical scenario, important for the laparoscopic gastrointestinal surgeon.

IntroductionDespite advances in achieving low mortality rates with pancreaticoduodenectomy (PD), morbidity remains high. A key contributor to this morbidity is delayed gastric emptying (DGE) occurring with an incidence of up to 30%. The utility of a Braun enteroenterostomy (BE) appears promising to reducing the incidence of DGE, but current research is not definitive.Methods and analysisThis project will be designed as a prospective multicentre randomised controlled blinded study to assess how BE effects the rate of DGE after PD in the setting of malignancy, within Australia—with blinding of patients, outcome assessors and data analysts. Patients will be randomly assigned to PD with Billroth II reconstruction with BE versus PD with Billroth II reconstruction without BE. The primary outcome is the incidence of DGE as defined by the International Study Group of Pancreatic Surgery. Secondary outcomes will include length of hospital stay, postoperative pancreatic fistula incidence, development of major complications (Clavien-Dindo≥3 a), quality of life and 90-day mortality.The study will be powered at 80% to detect a reduction in DGE rate from 30% to 15%, requiring a total of 264 study participants. An interim analysis will be performed once a total of 104 study participants have been recruited at which point the study will be able to detect reduction in DGE from 30% to 10% with 80% power. Statistical analysis will be done with intention-to-treat principles. The proportion of patients suffering DGE will be compared between treatment arms using a χ2test, with p values used to represent statistical significance.Ethics and disseminationThe study has been ethically approved by the Hunter New England Human Research Ethics Committee (2021/ETH11939), with results disseminated through presentation and publication.Trial registration numberCTRN12622000048785.