# Small bowel resection with anastomosis and enteroenterostomy



## maine4me (Mar 3, 2017)

I need help coding this procedure.  As you can see in the attached operative report the provider resected the bowel on side of the mass and created an anastomosis, then another portion of the bowel was resected and the enteroenterostomy was created.  I am having difficulty with all code combinations hitting CCI edits, with the exception of 44120 and 44121.  I do not think this combination is appropriate in this case.  I hope someone will share their expertise.


PREOPERATIVE DIAGNOSIS: Progressive mesenteric lymphoma with high-grade small bowel obstruction.

POSTOPERATIVE DIAGNOSIS: Same with mesenteric mass involving root of mesentery unable to safely resect status post prior small bowel bypass with distal obstruction approximately 12 to 18 inches distally.

OPERATION:
1. Exploratory laparotomy with lysis of adhesions.
2. Small bowel resection with side-to side, functional end-to-end stapled anastomosis.
3. Small bowel bypass with side-to side stapled enteroenterostomy - total functional bowel lost is less than 2 fee from preexisting state.

FINDINGS:  The patient had an intense sclerotic mass extending up to the root of the mesentery and involving all branches save for the most proximal first jejunal branch of the mesenteric vasculature.  This resulted in small bowel being plastered to all sides of this mass and the prior small bowel bypass performed in May of 2016 being entrapped approximately 12 to 18 inches distally against the mass at two separate sites.  In order to accommodate this, a small bowel resection, resecting less than 4 inches of small bowel with a side-to side, functional end-to end enteroenterostomy was performed .  This allowed an additional one foot of small bowel preservation and then an easy side-to side enteroenterostomy bypass proximal to the prior bypass and the mass.  Decisions to preform this were made after extensive mobilization, division of the overlying omentum and full dissection at the root of the mesentery, identifying that safe preservation of mesenteric vasculature was not likely for full resection.  No peritoneal findings suspicious for metastatic disease were identified.  A drain was left in place due to the necessity of fulgurating the 4 inch segment of small bowel with was resected because of its adherence to the mass and the small amount of devascularized omentum left on top of the mass.

INDICATIONS:  The patient presented with a high-grade small bowel obstruction from progressive B-cell mesenteric lymphoma.  The patient had received intermittent transfusions over the last three weeks and had progressive obstructive symptoms that resulted in him being completely obstipated.  He was admitted.  We were consulted after CT scan showed high-grade proximal small bowel obstruction emanating from the known mesenteric involved lymphoma.  Preoperatively, the risks and benefits of the procedure that included resection versus bypass were discussed with the patient who agreed to proceed as follows.  He also had an NG tube placed for 24 hours prior to operation in an attempt to maximally decompress his stomach.

PROCEDURE IN DETAIL:  Following general endotracheal anesthesia, patient had an indwelling Foley catheter placed and his NG tube was manipulated and ultimately confirmed to be in proper position by palpation of the stomach.  His abdomen was prepped and draped in the usual sterile fashion.  A midline ciliotomy was performed with mobilization of adhesions underlying his left paramedian incision.  The omentum was divided leaving a small amount on the mass unable to be removed without significant small bowel injury that, again was essentially adherent to all sides of the mass.  The amount of devascularized omentum present was small-volume.  The findings are noted as above.  A resection of portion of the bowel approximately 12 to 18 inches downstream of the prior bypass was addressed as noted above.  A stapled side-to-side, functional end-to end anastomosis was performed using two fires of a GIA-70 with no mesenteric defect to close.  The small bowel that was left on the mass was ultimately removed and small amount of remaining mucosa was fulgurated with electrocautery.  A side-to-side enteroenterostomy was preformed with a single fire of a GIA-75 after lining up the antimesenteric surfaces of the small bowel and then closing the enterotomies with a single fire of a TA-60 stapler.  This was proximal to the prior bypass and ultimately resulted an exclusion of no more than 18 to 24 inches of small bowel from what preexisted with the prior bypass.  All four quadrants of the abdomen were explored with the findings noted above prior to placing a 19-French fluted round drain into the area where the fulgurated mucosa was performed as well as the small amount of devascularized omentum, which had been divided with the large LigaSure electrocautery device.  The midline fascia was closed with running #1PDS knotted at either end and in the midline.  Subcutaneous tissues were irrigated.  Skin staples were applied.  Drain was secured into place in the right lower quadrant.  The patient tolerated the procedure well, was extubated in the Operating Room.


Thank you in advance for your help.


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