# Partial Gastrectomy on patient w/bypass



## jdibble (Jun 7, 2012)

Hi everyone,

My surgeon performed what he called a partial gastrectomy for an ulcer and perforation on a patient with gastric bypass. He states he removed the body of the stomach but since the patient had bypass already it does not appear that he needed to do any anastomosis.  He picked code 43610 - excision local, ulcer or benign tumor of stomach.  I think that this was more involved than this, but not sure if 43631 is appropriate.  Or would an unlisted code be a better choice? Can someone please review the note and tell me what they believe the correct code(s) would be?  Sorry - it is a long one! 

OPERATIVE FINDINGS:  This patient status post gastrointestinal bypass surgery
with Roux-en-Y gastrojejunostomy.
Upon entering the abdomen, she was noted to have diffuse inflammation and
diffuse brownish turbid fluid throughout the abdomen including up over the
liver.  With inspection of the abdomen, the lower abdomen did not appear to be 
the source of the problem.  The gallbladder and the duodenum appeared normal.
However, in progressing to the left upper quadrant, the patient was noted to
have a frankly bilious collection in the area of the left hiatus.  There was
eventually discovered to be a 1.5 cm sharply demarcated perforated ulcer in
the body of the stomach distal to the staple across the functional part of the
stomach and with a through-and-through perforation with bile leakage.  There
was no active bleeding.  There were several silk sutures noted to be within
the area of this ulceration.  The functional anastomosis of the jejunum to the
proximal gastric remnant was not involved.  No other significant abnormalities
were noted.

DESCRIPTION OF PROCEDURE:  The patient was taken to the Main Operating Room,
given general anesthesia and prepped and draped in a sterile fashion.
Initially, a 1 cm incision was made at the umbilicus and a Veress needle was
inserted.  The abdomen was insufflated with CO2.  A blunt 10 port was then
placed through the infraumbilical incision.  The laparoscope was placed down
through this port.  Another 5 port was placed left lateral and a grasping
instrument was introduced.  Upon entering the abdominal cavity, the patient
was noted to have a diffuse inflammatory process with a widely spread brownish
turbid fluid.  Utilizing the grasping instrument and the suction irrigator,
all the fluid was suctioned and some was sent for culture.  The abdominal
cavity was copiously irrigated.  The filmy adhesions were taken down.  There
was no evidence of obstruction.  No evidence of specific bowel distension or
thickening.  The appendix was noted to be grossly normal.  The small bowel and
colon were noted to be generally grossly normal.  While there was some fluid
in the pelvis that was consistent with the other diffuse fluid, however, upon
laparoscopic examination of the left upper quadrant, the patient was noted to
have a much thicker bilious collection there.

Utilizing laparoscopic instrumentation, that area was cleared up and better
visualized.  There was noted to be a distinct hole in what was decided to be
the anterior surface of the stomach.  It was partially covered over with
omentum but not completely effectively.  When the omentum was peeled away and
with further examination, the patient was noted to have an antecolic  Roux-en-
Y gastric bypass in the form of a gastrojejunostomy.  The gastric remnant
proximally which was the functional portion of the stomach was small and up
under liver at the hiatus.  It was anastomosed to a Roux-Y limb of jejunum
which was in the shape of a J.  That anastomosis was entirely intact, not
disrupted, not involved, and there were no ulcerations there or in the
duodenal area.  There was however noted to be a very punctate 1.5 cm
ulceration that was defined as being in the body of the stomach on the mid
anterior wall approximately 4-6 cm distal to the stapled across edge of the
now nonfunctional portion of the stomach.  It was concluded that since there
was bile coming from this ulcer that it must be part of the distal
nonfunctional portion of the stomach versus the actual functional gastric
pouch.  Oddly, there were noted to be 2-3 large silk sutures in the mucosal
aspect of this ulceration.  There was no obvious mass effect but that cannot
be clearly delineated.  All the omental attachments were taken down for better
identification and visualization.  All of the upper abdomen was copiously
irrigated.
 
With having defined the problem as being the above, it was elected to perform
an exploratory laparotomy with a partial gastrectomy.  This was chosen
primarily because it was realized that this area of the stomach could not be
approached endoscopically per orum.  Thus, there would be no ability to follow
this ulcer and there would be no ability to biopsy it to see if it was a
malignant etiology.  Also, this felt to be the nonfunctional portion of the
stomach and so a resection should have minimal consequences to the patient's
future well-being.  It was felt this would provide the most definitive cure
for an oddly located ulcer and the most definitive diagnosis.  For that
reason, the laparoscopic instruments were removed as were the ports.  A
modified Kocher incision was made in the patient's left upper quadrant.  It
was taken from just right of the midline out lateral to the lateral edge of
the rectus muscle and taken down through the skin and subcutaneous tissue, the
anterior rectus fascia and the rectus muscle and the posterior rectus fascia
entering the abdominal cavity.  The previously noted findings were confirmed.
The left upper quadrant of the abdomen was irrigated.  The ulceration was
noted to be a free perforation and was indeed on the anterior wall of the
stomach within the nonfunctional portion of the stomach.  It was elected to
widely resect this.

The area of the greater curve on the distal body of the stomach across to the
lesser curve was circumferentially cleared of surrounding tissue.  The TA-90
stapling device was obtained, placed across the stomach at this level and
fired sealing off the distal aspect of the stomach and effectively reducing
the volume of that distal portion of stomach in half.  The short gastric
vessels was then transected along the greater curvature of the stomach up to
and around the fundus utilizing the Harmonic wave for hemostasis.  This
included taking down the gastrosplenic vessel and that was accomplished
without injury to the spleen or bleeding.  Next along the lesser curvature of
the stomach, the in-feeding vessels were clamped and bisected with the
Harmonic wave.  In this fashion, the proximal aspect of the defunctionalized
stomach was completely freed of surrounding vascular supply and connective
tissue.  The cut across edge of that portion of the stomach was opened and
that opening was utilized to confirm that in fact the proximal edge of that
portion of the stomach had been previously stapled across and there was no
opening.  That portion of stomach was then removed and sent to Pathology as a
specimen.  It was actually opened on the operating table to visualize the
mucosa and there was not noted to be any mass effect or mucosal lesions but
there were 3-4 large silk sutures presumably previously placed that may have
been the etiology of ulceration.  Anyway, that portion of the stomach which
was resected was sent to the pathologist for review.

The abdominal cavity was then irrigated.  All the irrigant was suctioned until
clear.  Hemostasis was noted.  The previous gastrojejunostomy was left intact
as an antecolic Roux-en-Y connection.  The patient's lower abdomen was
palpated and there was no other abnormalities or fluid collections.  The
appendix was palpated and appeared grossly normal.  The posterior rectus
sheath was then closed with a running #1 PDS suture.  The anterior rectus
sheath was closed with a running #1 PDS suture.  The skin incisions were then
all closed with staples.  Sterile dressings were applied.  The patient
tolerated the procedure well.  No operative complication.  Blood loss was
minimal.

SPECIMENS:
1.     Peritoneal fluid for cultures.
2.     Body of the stomach.

The patient was taken to the Post Anesthesia Care Unit in good condition.

Thanks for all the help you can give!


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## jdibble (Jun 8, 2012)

Anyone have an idea on this?


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## jdibble (Jul 2, 2012)

Still hoping someone has an idea on this!!


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