# Completely stumped on perforated gastric lesion



## trinalankford (Nov 9, 2011)

I have been sitting on this op note for a while now, and I just cannot figure it out. 

PROCEDURES:
1. Exploratory laparotomy with wedge resection of gastric perforation.
2. En bloc resection of mesenteric mass including the transverse colon mesentery and portion of the transverse colon.

PREOPERATIVE DIAGNOSIS: Perforated gastric lesion.

POSTOPERATIVE DIAGNOSES:
1. Perforated gastric lesion.
2. Mesenteric abscess versus neoplastic lesion.

FINDINGS: The stomach is pliable and soft, not distended. She has an NG tube in place. There is a large mass involving the inferior greater curvature aspect and posterior aspect of the stomach at mid stomach. The mass is about 10 cm in diameter, hard, fibrotic, and consistent with either chronic process or neoplastic process. It essentially obliterated the lesser sac in this area and involved the transverse mesocolon mesentery. This appears after exam and resection to have been a *gastric perforation posteriorly into the mesentery*, etiology undetermined, with subsequent perforation of the abscess cavity free into the abdominal space. There was very little free fluid in the belly, no more than 15 mL. There was fibrinopurulent exuate ovr the anterior surface of the stomach. There were no adhesions. There was no bleeding or stool. No evidence of metastastic implants.

DESCRIPTION: The patient was identified...The abdomen was prepped..and entered through an incision in the upper abdomen and carried down through all layers. There was no evidence of adhesions. The abdomen was explored with the above-noted findings.

I elected to do an *en bloc resection involving the involved portion of the stomach and mesentery of the transverse colon* and then include that portion of the colon involved with the process. the colon was mobilized proximal and distally to the segment to be resected and then divided with the GIA on a suture staple device. The mesentery of the transverse colon was wedged out using the Surgilase.

The *stomach was then partially resected* using 2 suture lines of GIA Auto Suture. The gastric suture line was oversewn. The bowel was transected using GIA suture. The specimen was passed off the table.

*The colon was reanastomosed* using side-to-side Auto Suture with a posterior row in the seromuscular layer. The GIA suture device was placed, the anastomosis was created, and then the small defect in the two loops of bowel closed with running chromic on the mucosa. 

The mesenteric defect was closed with a running lock suture of Vicryl. The fascia was closed with a single layer of PDS. Subcutaneous fat was closed with Vicryl.

PATHOLOGY REPORT:
1. Perforated gastric ulcer.
2. Mesenteric abscess, mesenteric perforation.
3. Gastrocolonic adhesions.

PROCEDURES GIVEN ON DISCHARGE SUMMARY:
1. Exploratory laparotomy.
2. Wedge resection of gastric perforation.
3. En bloc resection of mesenteric mass including transverse colon mesentery and portion of transverse colon.

I am just frazzled with this one and not sure how to proceed from here. Confused by which one includes which one and which one can't be reported by itself, etc.

43840 - Gastrorrhaphy?
43631-43632 - Partial gastrectomy with gastrojejunostomy (wouldn't it be gastrogastrostomy?)
44820 - Excision of lesion of mesentery

If you're still with me, thank you. It is greatly appreciated.


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## nrichard (Nov 9, 2011)

*I can only offer hope w/ the first one.*

43610 in my coding software led me to a coding path that stated wedge resection, so you might want to check this one out. 
The second set of codes I agree but I'm not sure which one.
The third I agree w/ you.
Sorry I'm not much help w/ this, but hopefully someone else knows the answer to this one, I'm anxious to see it.


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