# Please Help!!! Torsed Stomach



## Williealawishes (Oct 5, 2010)

Hello.  i am really confused on this case.  I am unable to find a stomach code for this case.  I was planning on using the dx 537.89 as well but can't seem to match anything up....any suggestions would be wonderful.  Thanks in advance...  Tracy




PREOPERATIVE DIAGNOSES
1. Suspected gastric torsion.
2. History of previous laparoscopic cholecystectomy laparoscopic Nissen
fundoplication June 2000.

POSTOPERATIVE DIAGNOSES
1. Gastric torsion with the greater curvature curled up anterior and
medial.
2. History of previous laparoscopic cholecystectomy laparoscopic Nissen
fundoplication June 2000.

PROCEDURE
1. Reduction of gastric torsion with gastropexy.
2. Placement of gastrostomy tube.

The patient tolerated the procedure well.

ESTIMATED BLOOD LOSS: Less than 100 mL

INDICATIONS FOR PROCEDURE: This patient is a pleasant, 54-year-old, white
female who presented with a call to the office this date complaining of
upper abdominal and lower chest discomfort after trying to eat some pieces
of peach and grapes. She had recurrent vomiting, tried to keep liquids
down, but could not keep them down. Because of this, as an outpatient she
was sent for CBC, comprehensive metabolic profile, along with a
Gastrografin swallow to be followed by barium if the wrap was okay. The
patient had a history of previous Nissen fundoplication laparoscopically 3
to 4 months ago.

The patient was seen in the office prior to admission after the outpatient
procedure because after the surgery that I was then received call I
reviewed the Gastrografin swallow with Dr. Patramanis from radiology and
this showed a blockage of the mid stomach. No dye went through and the
patient did have a mild emesis after drinking the Gastrografin.

The patient reports that periodically since her Nissen fundoplication. She
seems to have had intermittent upper abdominal pain after eating. She
cannot correlate this with any specific types of food that she eats, it
tends to occur especially after a slightly bigger meals. She has had
occasional vomiting and she has been able to vomit.

Because of her findings it was felt that she should be admitted, I
explained that she may need surgery and the first treatment of choice would
be to do upper gastrointestinal endoscopy to review the internal findings
and possibly see if endoscopy can be used to de-torse the stomach and then
maybe keep it de-torsed by placing a PEG tube. We will consult GI on call
for her husband's gastroenterology group, Gastroenterology Consultants
Incorporated. After thorough evaluation with endoscopy the distal stomach
could be reached however, it appeared on endoscopy when I was present with
Dr. G, that stomach re-twisted. Because of this, the risks
including bleeding, infection, possible ischemia to the stomach, possible
need for gastrostomy tube and possible need to take down the Nissen
fundoplication have been described to the patient and her husband. I
explained that initially we will try to de-torse the stomach and then
tacked it into a position where it will not re-torse. I explained the
thoughts from the radiologist and Dr. G and the patient and husband
agree and we will plan to proceed with surgery

DESCRIPTION OF PROCEDURE: The patient was placed in the supine position on
the operating room table and SCD hose were applied and an NG tube had
already been replaced in ICU prior to coming to surgery. The patient has
been n.p.o. except for the Gastrografin swallow since about 6 hours to 7
hours prior. Therefore, Dr. K used precautions for aspiration, but
had no trouble intubating the patient. The patient received a gram of Ancef
preop and received 1 g when she arrived in the ICU around noon today.

Following this, the entire abdomen was prepped and draped in the usual
sterile fashion and a midline incision was made from the xiphoid to just a
little bit above the umbilicus. The patient had a long midriff so we did
not have to go around the umbilicus. I did discuss possible laparoscopy,
but dismissed this in view of the difficulty of placing a percutaneous PEG
tube laparoscopically without T-connectors and other devices. It was felt
that the patient would be best served with an open technique to carefully
detect the source and cause of her torsion.

Following this, the abdomen was entered under standard fashion through a
midline incision, excising the linea alba and tenting up the peritoneum. We
then carefully performed upper abdominal exploration. The gallbladder was
absent. There were some adhesions of the omentum to the liver and we did
not take these down. The liver had normal palpation. I did not run the
entire small bowel but the small bowel in the upper abdomen was carefully
inspected and was unremarkable. Transverse colon coming across the upper
abdomen was unremarkable. I then carefully retracted the left upper
quadrant and we carefully palpated the stomach. Nissen fundoplication
seemed to be intact and this was at the gastroesophageal junction or the
crura as shown by the upper GI study. It appeared that the floppy greater
curvature of the stomach had rotated anteriorly and then migrated
superiorly with the posterior and inferior portion of the stomach actually
apparently herniated up between the floppy wrap and the left side of the
fundoplication. The stomach was grasped serially with Babcocks and
carefully retracted down.  I carefully palpated superior to the wrap and
could feel the NG tube in the intra-abdominal esophagus and the upper part
of the stomach. With the rotation of the stomach bringing the former
anterior surface inferiorly and laterally the stomach de-torsed and I was
able to pull approximately 8 cm of this floppy part of the stomach out of
the wrap after lysing several adhesions of what appeared to be gastrocolic
omentum that had become adhesed under the left lobe of the liver and along
the suture line for the crura. This was probably what was preventing it
from being de-torsed with scope.

Once this was accomplished we carefully maneuvered the NG tube and Dr.
Khalgatgi advanced it. I was able to advance it into the body of the
stomach and then bring the tip down close to the pylorus. By this, I knew
that I had completely de-torsed the stomach and then we carefully decided
on a site underneath the left anterior abdominal wall for pexy of the
stomach. Because of the apparent mild ischemia to the stomach wall. I
decided not to try to suture the stomach at the level of the Nissen
fundoplication to the lateral part of the wrap, but rather simply do a
fairly wide pexy of the anterior surface of the lateral body of the stomach
to the anterior abdominal wall, which started at the site where we chose to
bring the G-tube through and extended about 3 cm cephalad. Three to 4
sutures of 2-0 silk were placed in the stomach and then through the
anterior abdominal wall peritoneum. At a site just inferior to this the
stomach was prepared for a Stamm gastrostomy.

Stamm gastrostomy was then performed in a standard fashion with two
pursestring sutures making an incision between these and bring the MIC
gastrostomy tube through a stab wound in the left upper quadrant
approximately 4 cm off the midline and well below the costal margin. A
G-tube was brought through the anterior abdominal wall after penetrating
with tonsil.  We checked the balloon once it came through and pulled the
G-tube on through the anterior abdominal wall, pulling the Silastic ring up
to portion of the Y portion of the G-tube. G-tube was inserted to the
opening between the pursestring the pursestring was tied without
difficulty. They were left long and lateral one was sewn to the anterior
abdominal wall on the lateral side of the G-tube exit site and the medial
one on the opposite side. We then placed 2 more pexing 2-0 silk sutures to
close off the space between the G-tube the previously placed sutures, and
this 
gave wide pexy of the anterior lateral wall of the stomach to the
anterior abdominal wall. We then again checked the NG tube, which seemed to
nicely lie nicely in a curved fashion within the body of the stomach with
the tips extending toward the pylorus. The balloon of the G-tube had been
blown up with 10 mL and pulled out such that Silastic ring was situated at
the 5-1/2 marked on G-tube. This kept the stomach wall up against the
anterior abdominal wall nicely. Following this, we carefully irrigated the
abdomen. There were no signs of perforation or other problems. Stomach wall
appeared viable.

Following this, closure was completed with 4 interrupted #1 Vicryl spaced
evenly along the length of the incision as internal stay sutures. These
were left long and hemostatic. Following this, an 0 loop Biosyn was started
from each end and run toward the middle and tied. The internal retention
sutures were then tied over the wound irrigated and staples were used to
close the incision. Telfa 4 x 4s, Microfoam tape were placed, and Telfa was
placed underneath the Silastic ring G-tube site. The patient tolerated the
procedure well. Estimated blood loss again was less than 100 mL.


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## preserene (Oct 6, 2010)

Yes  , you are right in the sense that 537.89  though in the Index given under gastric, it does not describe the real scenerio. 
so we would go for the real situation what occurred there. the torsion or rotation of the stomach/ bowel happens as a consequence of *Mesentric Rotation- [rotation on its mesentric axis into an abnormal position. 
/B] basically(its embryonal anatomical evolution).
Mesentric Rotaion or torsion is the basic pathology occuring in torsion gastric/ bowel/ intestines etc. this is otherwise called VOLVULUS (of the site it occurs). Generally and most commonly volvulus occurs in intestines but stomach is not excempted.

So you look for VOLVULUS or MESENTRIC ROTATION- You arrive at 560.2

Hope it solves your search*


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