# Side-to-Side Gastrojejunostomy/Roux-en-Y cholecystojenjunostomy



## hpierce (Feb 17, 2012)

We are having a debate in our office regarding how to code this procedure. One group says 47741 and 47100, the other group says 43820, 47740, and 47100. Can anyone help clear this up??? Heather 

PREOPERATIVE DIAGNOSIS: Pancreatic mass.
POSTOPERATIVE DIAGNOSIS: Metastatic pancreatic adenocarcinoma.
PROCEDURES:
     1.  Exploratory laparotomy.
     2.  Lysis of adhesions.
     3.  Side-to-side gastrojejunostomy.
     4.  Roux-en-Y cholecystojejunostomy.
     5.  Wedge liver biopsy.
ANESTHESIA: General endotracheal by Dr. X
ESTIMATED BLOOD LOSS: 100 cc.
COMPLICATIONS: None.
SPECIMEN:
     1.  Liver biopsy.
     2.  Cholelithiasis.
CONDITION: Stable.
INDICATIONS FOR PROCEDURE:
The patient is a 73-year-old female, who came to the hospital with jaundice, abdominal pain, and nausea.  She was found to have a very large mass in the pancreatic head, which appeared to be a resectable due to multiple lymph nodes in the retroperitoneum and also possible liver metastatic disease.  The patient had a bilirubin of 17 and was having some symptoms compatible with gastric outlet obstruction.  She was consented for a GI tract bypass and also a biliary tree bypass.  The consent was for gastrojejunostomy and cholecystojejunostomy/choledochojejunostomy.
DESCRIPTION OF PROCEDURE:
The patient received intravenous antibiotics and SCDs were placed on both lower extremities.  She had undergone an epidural catheter insertion prior to the transfer to the operating room. After she was placed supine on the operative table and was under general anesthesia, Foley catheter was inserted and the abdominal wall was prepped and draped in the usual surgical fashion.  The appropriate time-out was performed. The patient had a previous midline scar from a right hemicolectomy.  This was slightly above the umbilicus and then way down to the suprapubic area.  We started our surgery with a midline incision from the xiphoid process to the level of the umbilicus and slightly lower.  In this area, the scar was followed.  This was carried down through subcutaneous tissue with the Bovie cautery as well as the fascia and then the peritoneum was incised sharply and the abdominal cavity entered. The surgery started with an exploration and the patient had this large, probably 8 cm in diameter mass in the pancreatic head, which was very hard and actually palpable prior to the incision. The patient had a very distended gallbladder as well.  The NG tube was checked and it was in the gastric lumen.  Upon examination of the liver, the patient had at least three or four areas of obvious metastatic disease.  An area on the left lobe, which was very close to the edge, was biopsied with the Bovie cautery taking a wedge of the liver to incorporate this mass, which was probably 1.5 cm in diameter.  This was sent for pathologic examination and came back metastatic adenocarcinoma, very likely of pancreatic in origin.  At this point, we decided not to biopsy the pancreatic head since we had the obvious diagnosis. The bypass for the GI tract was done in a side-to-side gastrojejunostomy.  The ligament of Treitz was followed and then the appropriate loop was taken to the anterior wall of the stomach and this was antecolic side-to-side gastrojejunostomy, which was done in a hand-sewn fashion.  To do the anastomosis, two layers were done with silk in interrupted fashion for the back wall and then Vicryl suture in a running fashion for the mucosa and then reinforced again in the front with silk sutures in an interrupted fashion.  This created a wide anastomosis, which appeared to be very patent and no mucosa was seen and exposed.  Following this, we transected the jejunum distally, approximately at 15-20 cm from the gastrojejunostomy to create the Roux-en-Y.  The distal blind loop was brought up to create the cholecystojejunostomy. We opened the gallbladder at the fundus since the patient had multiple palpable stones.  Actually, the patient had one of the stones of the size of a golf ball.  She also had multiple stones, which were removed from the gallbladder carefully to make sure no stones were left behind.  After this was done, the gallbladder was flushed and all the bile was suctioned.  To make sure this was a patent cystic duct, a clamp was used and felt in the common bile duct.  This was going very easily since the cystic duct appeared to be fairly dilated.  Some bile was seen coming from the biliary tree at some point into the gallbladder. I believe the obstruction was fairly distal to the junction of the cystic duct with the common hepatic duct and this should create an appropriate bypass.  The cholecystojejunostomy was then performed with a 25 circular stapler.  To do that, we created an opening in the inferior wall of the gallbladder and the anvil of the stapler was introduced into the lumen of the gallbladder and then brought out through that opening in the bottom.  The distal blind loop of the jejunum was then transected at the staple line and this created access to the lumen.  The 25-French stapler was introduced through the lumen and the spike brought out at the antimesenteric border.  This was hooked to the anvil and closed with two nice round complete doughnuts found at the end of the anastomosis.  To close the fundus of the gallbladder, a 60-mm linear stapler was used. Then, the end of the jejunum was closed with another row of the TLC 75 stapler. Done with the gastrojejunostomy and the cholecystojejunostomy, we directed our attention to the Roux-en-Y anastomosis.  This was done with a single load of the 75 GIA, creating two openings in a side-to-side anastomosis.  The opening was then closed with a TA 60 again.  This created a wide patent anastomosis.  Some of the anastomosis was reinforced with Vicryl sutures in interrupted fashion. The abdominal cavity was then copiously irrigated with saline and most of the fluid suctioned.  The patient's area was inspected one more time including the liver, which had no  bleeding.  The bleeding from the liver was controlled at the beginning of the surgery with the Bovie cautery alone, but this had to be up to 80 and sprayed.  However, this created a very nice hemostasis of the liver.    A 19-French Blake drain was left in the abdominal cavity, very close to both anastomosis.  At the beginning of the case, we also had to do lysis of adhesions, particularly from the omentum in the lower abdomen to get the transverse colon out of the field and to completely extend the incision.  The patient had these omental adhesions in the lower portion from the previous colectomy.  However, no significant adhesions were found in the  jejunum at the area of the multiple anastomosis. The fascia was closed with 0 Prolene sutures in an interrupted figure-of-eight fashion and the skin was closed with staples.The drain was secured with a 3-0 nylon. The appropriate dressing was applied.  The patient was then successfully extubated and transferred to the recovery room in stable condition.


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## mjewett (Feb 20, 2012)

my vote is:  47741 and 47100 .   Code 43820 is correct that it is a gastrojejunostomy, but code 47741 includes gastrojejunostomy (CPT description states gastroenterostomy.... entero meaning small bowel, jejunum is small bowel.)  

Hope this helps.


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## hpierce (Feb 20, 2012)

Thanks for your thoughts. I was thinking the same thing.


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