amanda19791
Networker
Could anyone give some advice on what code to use for the conversion of gf-tube to g-tube button? Also, the enterectomy resection? See Op note below.
Findings:
Roux-en-Y jejunostomy performed 20 cm beyond the ligament of Treitz with a 14 French MIC tube in the jejunostomy stoma. The gastrostomy was replaced with a 14 French, 1.0 cm MIC-KEY gastrostomy button.
Procedure:
Indications: This is a 19-month-old child with hypoxic ischemic encephalopathy secondary to nuchal cord at birth. I have known her since that time and at 1 month of age performed a Nissen fundoplication and placed a gastrostomy tube. The patient has never tolerate secretions and several months later the patient was noted to have poor gastric emptying and despite the Nissen had persistent reflux. A gastrojejunostomy tube feeding tube was placed which seemed to ameliorate the symptoms and she started to gain weight with jejunal feeds and decompression of the stomach through the gastrostomy aspect of the tube. Over the last few months she has developed bile reflux gastritis and studies suggest that the gastrojejunostomy tube is occluding the pylorus and the duodenum downstream request was made for separate jejunostomy feeding tube. I reviewed her chart and discussed this at length with Dr. Michael fields, pediatric pulmonology, who felt that this procedure would be beneficial and if we could decrease the amount of reflux, even though she does not tolerate secretions, her pulmonary status might improve. The patient has a scheduled for jejunostomy feeding tube. The patient is taken to the operating room on an elective basis for the above procedure following a discussion with the family of the intended procedure and its attendant risks which include but are not limited to infection, bleeding, injury to normal structures, need for additional operation.
Details of procedure: The patient was identified and placed in the supine position on the operating table. Adequate anesthesia was induced. Timeout was performed and all present were in agreement. Antibiotics were administered. A midline incision was made through the umbilicus about 2 cm above the umbilicus and 1 cm below the dissection was carried down to the skin and soft tissues in the midline with electrocautery. Abdominal cavity was entered bluntly and the incision extended and the fascia for better exposure. The small bowel was eviscerated and the ligament of Treitz was identified. Approximately 20 cm beyond the ligament of Treitz a marking silk suture was placed and then another silk suture placed about 4 cm distal to this. The bowel at the proximal circumflex was divided between bowel clamps and then the Roux-en-Y jejunostomy was performed. This was done by bringing the open end of the proximal jejunum to the antimesenteric side of the jejunum at the second silk marking suture. Stay sutures were placed between the mesenteric and the antimesenteric ligaments of the proximal jejunum to corresponding positions on the antimesenteric side of the distal jejunum. An enterotomy was made in the antimesenteric aspect and then using interrupted 4-0 Vicryl suture a single layer handsewn anastomosis was performed to create the Roux limb. Integrity of the anastomosis was confirmed by milking enteric contents across and there was no evidence of any leak and the defect was widely patent. The bowel was returned to the abdominal cavity and baby Kocher clamps were placed on the right side of the abdominal wall fascia. Suitable site for the jejunostomy was identified, skin incision was made at this point and after bluntly dissecting a defect in the peritoneum, the MIC gastrostomy tube was placed into the abdominal cavity through this incision. A 2 row pursestring was placed on the distal jejunum through which the MIC gastrostomy tube was placed and inflated with 3 mL of water. The pursestring sutures were tied and then the jejunum was tacked to the abdominal wall in Stamm fashion with interrupted 4-0 Vicryl suture. Minimal spillage was encountered. Satisfied we had a good Roux limb, well away from the midline incision that was widely patent and there was no evidence of anastomotic leak the fascia was closed with running 4-0 Vicryl suture. The dermis was approximated with running 4-0 Vicryl suture and the skin was approximated with running 5-0 Monocryl suture. The wound was infiltrated with Marcaine as an umbilical block. The jejunostomy feeding tube was secured by bringing the bolster down to the skin. I then removed the packing from the gastrostomy and inserted a new 14 French, 1.0 cm MIC-KEY button and gastric contents were aspirated to confirm placement. The balloon was filled with 5 mL of water. Discussed with the anesthesiologist determined that the child will remain intubated and be taken directly to the PICU for further management. The procedure was well tolerated, and there were no complications.
Findings:
Roux-en-Y jejunostomy performed 20 cm beyond the ligament of Treitz with a 14 French MIC tube in the jejunostomy stoma. The gastrostomy was replaced with a 14 French, 1.0 cm MIC-KEY gastrostomy button.
Procedure:
Indications: This is a 19-month-old child with hypoxic ischemic encephalopathy secondary to nuchal cord at birth. I have known her since that time and at 1 month of age performed a Nissen fundoplication and placed a gastrostomy tube. The patient has never tolerate secretions and several months later the patient was noted to have poor gastric emptying and despite the Nissen had persistent reflux. A gastrojejunostomy tube feeding tube was placed which seemed to ameliorate the symptoms and she started to gain weight with jejunal feeds and decompression of the stomach through the gastrostomy aspect of the tube. Over the last few months she has developed bile reflux gastritis and studies suggest that the gastrojejunostomy tube is occluding the pylorus and the duodenum downstream request was made for separate jejunostomy feeding tube. I reviewed her chart and discussed this at length with Dr. Michael fields, pediatric pulmonology, who felt that this procedure would be beneficial and if we could decrease the amount of reflux, even though she does not tolerate secretions, her pulmonary status might improve. The patient has a scheduled for jejunostomy feeding tube. The patient is taken to the operating room on an elective basis for the above procedure following a discussion with the family of the intended procedure and its attendant risks which include but are not limited to infection, bleeding, injury to normal structures, need for additional operation.
Details of procedure: The patient was identified and placed in the supine position on the operating table. Adequate anesthesia was induced. Timeout was performed and all present were in agreement. Antibiotics were administered. A midline incision was made through the umbilicus about 2 cm above the umbilicus and 1 cm below the dissection was carried down to the skin and soft tissues in the midline with electrocautery. Abdominal cavity was entered bluntly and the incision extended and the fascia for better exposure. The small bowel was eviscerated and the ligament of Treitz was identified. Approximately 20 cm beyond the ligament of Treitz a marking silk suture was placed and then another silk suture placed about 4 cm distal to this. The bowel at the proximal circumflex was divided between bowel clamps and then the Roux-en-Y jejunostomy was performed. This was done by bringing the open end of the proximal jejunum to the antimesenteric side of the jejunum at the second silk marking suture. Stay sutures were placed between the mesenteric and the antimesenteric ligaments of the proximal jejunum to corresponding positions on the antimesenteric side of the distal jejunum. An enterotomy was made in the antimesenteric aspect and then using interrupted 4-0 Vicryl suture a single layer handsewn anastomosis was performed to create the Roux limb. Integrity of the anastomosis was confirmed by milking enteric contents across and there was no evidence of any leak and the defect was widely patent. The bowel was returned to the abdominal cavity and baby Kocher clamps were placed on the right side of the abdominal wall fascia. Suitable site for the jejunostomy was identified, skin incision was made at this point and after bluntly dissecting a defect in the peritoneum, the MIC gastrostomy tube was placed into the abdominal cavity through this incision. A 2 row pursestring was placed on the distal jejunum through which the MIC gastrostomy tube was placed and inflated with 3 mL of water. The pursestring sutures were tied and then the jejunum was tacked to the abdominal wall in Stamm fashion with interrupted 4-0 Vicryl suture. Minimal spillage was encountered. Satisfied we had a good Roux limb, well away from the midline incision that was widely patent and there was no evidence of anastomotic leak the fascia was closed with running 4-0 Vicryl suture. The dermis was approximated with running 4-0 Vicryl suture and the skin was approximated with running 5-0 Monocryl suture. The wound was infiltrated with Marcaine as an umbilical block. The jejunostomy feeding tube was secured by bringing the bolster down to the skin. I then removed the packing from the gastrostomy and inserted a new 14 French, 1.0 cm MIC-KEY button and gastric contents were aspirated to confirm placement. The balloon was filled with 5 mL of water. Discussed with the anesthesiologist determined that the child will remain intubated and be taken directly to the PICU for further management. The procedure was well tolerated, and there were no complications.