# Roux-en-y gastric bypass for GERD



## ch81059 (Jun 14, 2013)

Hi,

My physician performed a Roux-en-y gastric bypass for a patient with GERD.  The pouch was made significantly larger than for a weight loss patient and is documented in the op note.  Would I use the lap gatric bypass roux-en-y code (43644) since the description indicates a pouch of less than 150 cm?  Or would I use the unlisted code of 43659 since it's not indicated for anything other than weight loss?  I have attached the operative report.  Thanks!

PREOPERATIVE DIAGNOSES
1. Recalcitrant gastroesophageal reflux disease.
2. A peristaltic esophagus with patulous gastroesophageal junction at
lower esophageal sphincter.
3. A 3 cm hiatal hernia.

POSTOPERATIVE DIAGNOSES
1. Recalcitrant gastroesophageal reflux disease.
2. A peristaltic esophagus with patulous gastroesophageal junction at
lower esophageal sphincter.
3. A 3 cm hiatal hernia.

OPERATIVE PROCEDURE
Robotic Roux-en-Y gastric bypass.

INDICATION FOR SURGERY
This is a 36-year-old male with severe GERD but esophageal dysmotility.
We have discussed the various options and he elected to proceed with a
surgical intervention in the form of a Roux-en-Y gastric bypass.

OPERATIVE FINDINGS
Liver, bowel, peritoneal surfaces appeared normal. We made the gastric
pouch larger than we would for gastric bypass, a 40 cm biliopancreatic
limb, and only 50 cm Roux limb.

PROCEDURE IN DETAIL
With the patient in the supine position, general anesthetic was
administered. The abdomen was prepped with ChloraPrep and sterilely
draped. After infiltration of local anesthetic, a Veress needle inserted
into the peritoneal cavity and pneumoperitoneum was established with
carbon dioxide. A 12 mm trocar was inserted in this incision just above
the umbilicus and laparoscopic exploration of the abdomen revealed the
above-noted findings; 5 mm robotic trocars were placed in the left
anterior axillary line and in the left midclavicular line, and again in
the right subcostal region. A 10 mm assistant port was placed in right
midclavicular line. The Nathanson retractor was inserted in the
subxiphoid region to retract the left lobe of the liver anteriorly. We
began by dividing the peritoneal reflection at the angle of His. Then
beginning a little more than 6 cm distal to the GE junction on the
lesser curvature of stomach, began the dissection of the stomach and
created a window posterior to the stomach. The gastric pouch was then
created with an additional firing of the powered echelon flex 60 with a
blue cartridge, transversely. Then with a 40-French bougie through the
stent in the GE junction and along the lesser curvature the pouch
creation was completed with sequential firings of the Echelon Flex 60
with the green cartridge with SeamGuard. I did not snug up against the
bougie like we do at a gastric bypass for weight loss, but instead gave
him a little more patulous pouch. The gastric pouch was completed and
then divided the omentum beginning at the mid transverse colon. The
splits on either side allow the Ethicon orientation of the Roux limb.
Then identified the ligament of Treitz and cut it at about 40 cm
distally. The small bowel was then divided 40 cm distal to the ligament
of Treitz using Echelon Flex 60 with a white cartridge. Created, then
measured a 50 cm Roux limb. I created enterotomies in both sides of the
jejunum and the jejunojejunostomy was created using intraluminal firing
of the Echelon Flex 60 with a white cartridge. The enterotomy was then
closed with a running 2-0 Vicryl, which I did in 2 layers. I closed the
jejunojejunostomy mesenteric defect with running 2-0 silk. Next the Roux
limb was brought up to the gastric pouch. I then created a 2 layer
anastomosis with a running 2-0 Vicryl as an outer layer. I then created
an enterotomy with the Harmonic Scalpel, in both the stomach and the
jejunum. The inner layer was created with a running 2-0 Vicryl,
posteriorly first and then running. I then stented the anastomosis with
a 40-French bougie. I then completed the anterior aspect of the
anastomosis with the inner layer first, followed by an outer layer.
After this was completed, we clamped the jejunum just distal to the
gastrojejunostomy and performed a saline submersion test and there was
no bubbling, thus suggesting integrity anastomosis. It was hemostatic
intraluminally. I was actually able to intubate the jejunum all the way
down to the jejunojejunostomy and it appeared intact as well. At this
point the endoscope was removed. The abdomen was irrigated and
hemostasis confirmed. The Nathanson retractor was removed. The
pneumoperitoneum deflated and trocars were removed. The 12 mm fascial
site was closed with 0 Vicryl suture and each of the skin incisions
closed with 4-0 Monocryl subcuticular sutures and Mastisol and Steri-
Strips. Patient tolerated the procedure well.


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