# Peritonitis from leak following gastrectomy



## laura_clffrd@yahoo.com (Dec 12, 2011)

Procedure: Exploratory laparotomy extensive wash out of the abdomen, drainage of the perforated sleeve proximally, jejunal feeding tube placement, and incision and drainage right abdominal wound. 

42 year old pt who is 5 days status post sleeve gastrectomy which was performed laparoscopically.  A midline incision was made and the abdomen was safely entered.  There was a copious amount of greenish cloudy foul smelling fluid.  some was sent for culture and the remainder was aspirated out.  The distal stomach was identified and the omental sutures to this were being taken down and identified when we suddenly encountered some brisk arterial bleeding controlled with finger pressure.  We extended the incision somewhat caudad to get better exposure and we were able to put a very long allis over the bleeding vessel and figure of eight silk stitch took care of this.  The area was then irrigated profusely.  We did not see the actual perforation but the site was belied to be the most proximal aspect of the sleeve.  The abdomen was copiously irrigated with the several liters of sterile saline.  after this was done, and the abdomen was completely irrigated and rinsed a spot on the proximal jejunum was selected for the jejunal feeding tube, an 18 french t tube was then trimmed and fashioned and placed through the abdominal wall and then placed into the jejunum after suture was performed w/silk.   A JP DRAIN WAS PLACED THROUGH THE RIGHT ABDOMEN. Incision was closed. The site of the prior drain in the right abdomen appeared to be infected and therefore this was incised and the purulent fluid then was drained. I  then irrigated this out well w/normal saline and backed w/idoform gauze as well.  

CPT suggestions and modifier can this be billed as a complication to the sleeve global days?


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## Lujanwj (Dec 14, 2011)

I can understand your confusion.   It looks like DR did a control of bleeding (35840), shows that it was active but wasn't clear if it was caused by the approach or if it was pre-exsisting.  If bleeding happened as part of the approach, Dr did an explore 49000.  JP drains are always included in the more extensive procedure.  

Possible coding scenario:
35840-78
20005-78
44015-78
    OR
49000-78
20005-78

Good Luck!


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## laura_clffrd@yahoo.com (Dec 30, 2011)

Thanks! Any thoughts on changing the 20005 to 10180? I don't see where he entered any more then subcutaneous tissue..... I think I am liking the 49000 10180....


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