# Pyloroplasty with oversew...



## Jarts

I am unsure how to code this surgery beyond 43800 dx: 532.00. Any help would be appreciated.
Thanks,
Julie

POST OPERATIVE DIAGNOSIS: Duodenal bleed secondary to an ulcer.

PROCEDURE PERFORMED:
1. Exploratory laparotomy.
2. Pyloroplasty with oversew of gastroduodenal vessel and oversew of anterior duodenal bulb ulcer.
3. Duodenal kocherization.
4. Appendectomy.

INDICATIONS FOR SURGERY: The patient is a 70-year-old female admitted for respiratory difficulty, ultimately developed an aggressive upper GI bleed consisting of a 7-unit bleed and upper GI endoscopy revealed a bleeding vessel and a large duodenal ulcer that was difficult to control endoscopically. Thus, it was recommended she proceed to surgery for definitive surgical treatment.

PROCEDURE IN DETAIL: The patient was brought to the operating room after proper identification, confirmation, and PARQ. Patient was placed in supine position. After adequate general anesthesia, a generous midline incision was made and carried down to the abdominal cavity. Upon entry into the abdominal cavity, the colon was completely distended with air and blood and made it very difficult to completely mobilize the duodenum and stomach. The NG tube had previously been placed to decompress the stomach. Thus, given the amount of air from her upper endoscopy and amount of blood in her colon, I felt it would be beneficial to proceed with her surgery by decompressing the colon. Thus she had a very small mobile appendix. A pursestring was then placed around the appendix and appendiceal mesoappendix was divided between Pean clamps and tied, and then the appendix was amputated, and then the suction was inserted in appendiceal stump, and decompressed the colon with good success. The pursestring was then brought down around the appendectomy site. The appendectomy site was then closed again with a 30-mm stapler. The abdominal wall was then retracted using Bookwalter retractor. Small bowel and contents were packed into the lower abdomen. The duodenal sweep was then mobilized in the standard Kocher technique down to the midportion of the third portion of the duedenum and up to the the level of the pylorus. The pancreas was identified. There did not appear to be any other pathology in the region. A pyloroplasty was then performed across the pylorus placing 2 full thickness stay sutures. We then explored the duodenum with the finding of a 1-cm anterior wall ulcer with erosion all the way through to just the serosa and a classic kissing ulcer from the huge posterior ulcer approximately 6 cm in length x 3 cm in width. There was not any active bleeding in the ulcer bed. Th standard sutures were placed to control the gastroduodenal vessel. At both the superior and inferior component bed of the ulcer, there was significant electrocautery artifact. This area was oversewn in a triangular fashion at both the superior and inferior aspect as well as the medial aspect. We were able to identify the suspect vessel, which was also controlled with a figure-of-eight 3-0 Vicryl as well. The ulcer bed was then irrigated with copious amounts of normal saline and inspetected for any signs of ongoing bleeding. None was identified. The anterior ulcer was then addressed. We discussed possibly excising the ulcer and oversewing as part of the pylorplasty closure, but I felt it would leave too big of a defect. Thus, the ulcer was closed in 2 layers with interrupted 3-0 Victryl on the internal aspect of the duodenum and then interrupted 3-0 silk on the serosal side. This resulted in good closer of the ulcer bed. Then, once being satisfied with the repair of the ulcer and th bleeding vessels, decision was made to close the pyloroplasty. This was done with standard fashion taking the longitudinal opening and creating a transverse opening. An inner layer of 3-0 Vicryl was done in a running fashion and standard canal fashion from each end of the incision into the middle and then tied. Then, a second layer of interrupted subserosal full-thickness sutures were placed on the serosal surface. The NG tube had previously been placed across the closure site. This was pulled back into the stomach. A tongue of omentum was then brought up from the gastrocolic region and pexied over the anterior ulcer repair site as well as the pyloroplasty site. The abdomen was then irrigated with copious amounts of normal saline and inspected for any other abnormalities. The appendiceal stump was inspected for any concerns. There were no concerns and decision was made to close.


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## Jarts

I am thinking of using 48300-22 for the pyloroplasty with control of duodenal ulcer bleed and 44955 for the appy. Do you think the mod 22 is appropriate for the oversew of the bleed or is there a specific code I should use?

Any help appreciated,
Julie


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## aguelfi

Look at 43840 and don't forget 49905 for the omental flap and 44955.


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## Jarts

Thanks SO much for your input!
whoops. My typo. I meant 43800, not 48300. So since 43800 is bundled with 43840, is your advice to just use:

43840
49905
44955-51
dx: 532.00

Julie


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## aguelfi

that's what i was leaning toward.


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