# Laps gastrectomy/esophagectomy



## ksrkelly7 (Feb 5, 2015)

Here is my dilemma....It is my understanding that the CPT 43644 should only be used for bariatric surgery.  I'm thinking both of these procedures are unlisted 43659 and 43289, but I'm hoping I'm wrong.  Could you please take a look at this OP report and help me out with the CPT codes?  Thanks for any input.....

Indication for Surgery 
 gastric cancer
Preoperative Diagnosis 
gastric cancer 
Postoperative Diagnosis 
gastric and esophageal cancer 

Operation 
laparoscopic extended total gastrectomy
laparoscopic distal esophagectomy
jejunostomy feeding tube
creation of roux Y limb 

Findings 
the proximal esophageal margin initially positive but the distal stomach largely infiltrated with tumor on gross specimen eval requiring total gastrectomy.  A roux Y limb was constructed to reconnect esophagus.  Thoracotomy done to further dissect esophagus but the new proximal margin also focally positive but the maximum length of Roux Y limb reached so no further esophagus could be taken.  No obvious metastatic disease but multiple grossly involved nodes.   
Specimen(s) 
 stomach
additional distal esophagus

Technique 
After informed consent patient brought to OR and given preoperative antibiotics and general anesthesia.  The abdomen was prepped with chloraprep and allowed to dry for 3 minutes before draping in sterile fashion.  I placed a 12 optiview trocar in midline, another two 12 trocars in either upper quadrant, and a 5 trocar in lateral abdomen.  Inspection of abdomen shows no metastatic disease.  I retracted left lobe of liver via the right port.  The stomach was removed from large hiatal hernia and the hernia sac dissected free.  The greater curve of stomach freed up taking all perigastric lymph nodes.  The nodal tissue around the right gastroepiploic was kept on the specimen.  Once the distal esophagus was freed up there appeared to be adequate length to allow a proximal margin above the GEJ of at least 2 cm.  No tumor was seen above the GEJ on multiple endoscopy.  So we decided to proceed with transection of the esophagus with GIA stapler about 2 cm above the GEJ.  Once this was done, it was noted that multiple involved nodes were seen around the GEJ.  It was best to perform a total gastrectomy to remove the nodal tissue along lesser curve.  So the gastroepiploic vessels were divided and the duodenum transected with stapler just beyond pylorus.  The specimen swept up off the pancreas and hepatic artery using ligasure.  The origin of the left gastric artery was taken with ligasure and clips.  The specimen was then completely free.  A small laparotomy incision was made in the left subcostal area and a wound protector placed.  The stomach was removed and frozen section showed positive esophageal margin and evidence of almost 10 cm of tumor penetration into the stomach also.  Since the stomach was completely removed, we opted to use a jejunal Roux Y limb to reconnect intestinal continuity with the esophagus.
I pulled up jejunum and 30 cm distal to LOT we transected the jejunum with endo stapler and I made a 50 cm roux Y limb.  The jejunojejunostomy was formed with stapled side to side and I closed enterotomy with 3-0 PDS and 3-0 vicryl.  The abdomen was reinsufflated and the Roux Y limb brought under the transverse mesocolon.  The Roux limb was sutured to the distal esophagus with 2-0 vicryl laparoscopically.  I then removed the ports.  I closed the 12 sites with 0 vicryl.  I then placed 16 red robinson catheter near the mini laparotomy site and placed into jejunum distal to roux Y using Witzell tunnel and tacking to the peritoneum.  I then closed the mini lap incision with 0 vicryl.  Skin closed with staples and dressings applied.  We then turned patient lateral and did a thoracotomy to reanastomosis the roux Y to the distal esophagus.  


Kelly C CPC-A


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## ksrkelly7 (Feb 6, 2015)

still needing help......any takers on this one?


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## cynthiabrown (Feb 6, 2015)

look at 43633  use unlisted lap for stomach   43659 equivalent to 43633   feeding tube bundled


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## ksrkelly7 (Feb 6, 2015)

Thanks.  I was looking at that but hoping to not use the unlisted procedure.  Any thoughts on the laps esophagectomy?  unlisted 43289?  Appreciate the help.


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## cynthiabrown (Feb 6, 2015)

on second thought look at this  43621   and really no code for the little bit of esophagus,,,,he physician removes the stomach and approximates a limb of small bowel to the esophagus by performing an esophagoenterostomy in 43620 or a Roux-en-Y esophagojejunostomy in 43621. The physician makes a midline abdominal incision. The stomach is dissected free of surrounding structures and its blood supply is divided. The stomach is divided at the gastroesophageal junction and at the gastroduodenal junction and removed. In 43620, the remaining duodenal end of the intestine is simply mobilized to the end of the esophagus and connected. In 43621, a measured limb of Roux, or limb of small intestine, is created by dividing the upper jejunum. The distal part of the now divided upper jejunum, the limb in continuity with the ileum, is brought up and anastomosed to the esophagus. The proximal end of the divided jejunum, the segment containing the duodenum, must be connected back into the limb of small bowel farther down from the esophageal anastomosis. This maintains continuity for the duodenal section, which was sealed upon removal of the stomach, but which is also receiving bile from the liver and gallbladder as well as pancreatic juice.


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## ksrkelly7 (Feb 9, 2015)

Ok, but then would we be doing laps converted to open?


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