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  #1  
Old 02-05-2010, 11:29 AM
LLovett LLovett is offline
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Question Help! Ivor Lewis, Collis, or neither....

This procedure has been coded by 3 of us. Its a bit long and time consuming but I would greatly appreciate any help.

1st set,2nd set,3rd set
43112 43113 43117
43520 43326 43247
43247 43520 31622
31622 31622 44015
44015 43247
XXXXX 44015

PROCEDURE:
1. Bronchoscopy.
2. Esophagogastroduodenoscopy with retrieval of retained
material.
3. Esophagectomy via laparotomy and right thoracotomy.
4. J-tube placement.
5. Pyloromyotomy.
PROCEDURE: The patient was brought to the operating room and placed in supine position on the operating room table. After
adequate anesthesia was obtained, a bronchoscopy was performed in
order to assure no tracheal involvement from the mid esophageal
mass. The bronchoscopy appeared essentially normal with no
evidence of mucosal defects or invasions to suggest involvement.
An upper endoscopy was then performed and the scope was passed
and the esophagus. At the mid level of the esophagus there
appeared to be extra mucosal compression consistent with extra
mucosal mass and an associated diverticulum. Beyond this at the
distal esophagus there was mucosal change with erosion consistent
with adenocarcinoma that was known. As the scope was passed into
the stomach, the stomach appeared normal. The scope was
retroflexed and GE junction appeared normal in the gastric view.
At the distal antrum of the stomach, there was a white appearing
no foreign body, which raised concerns of possible tooth, given
the patient's poor dentition. As the scope was passed closer to
inspect this and passed through the pylorus into the duodenum.
The pylorus was cannulated and the duodenum inspected. The
foreign body was identified and using a snare the foreign body
was captured and removed and found to be merely retained fairly
solid mucoid material and not a tooth. The pylorus and duodenum
otherwise appeared normal.

Next, the patient was prepped and draped in the standard sterile
surgical fashion and the presurgical safety check was completed
satisfactorily. The abdomen was then entered through an upper
midline laparotomy. The abdomen was explored. There were no
palpable masses within the liver, peritoneal studding or
otherwise abnormal identified masses to suggest any distant
disease. A Bookwalter retractor was placed to expose the upper
abdomen and the triangular ligament was taken down and the liver
retracted. There was fairly extensive adhesions from a prior
inflammatory process within the upper abdomen and these adhesions
were taken down, freeing the greater curvature in the colon and
the omentum. At this point, the omentum was mobilized from the
colon and the lesser sac entered and the greater curvature was
then fully mobilized and using a Harmonic scalpel, dissected free
of the omentum, leaving a small rim including the gastroepiploic
artery. This was maintained through its entire course. During
the course of mobilization a small splenic capsular tear was
created with some bleeding. Topical thrombin and Gelfoam was
placed to obtain adequate hemostasis. The greater curvature was
then further mobilized, taking down the short gastrics again with
the Harmonic scalpel up to the level of the GE junction. Next,
all adhesions and connective tissue along the lesser sac was then
lysed, the lesser curvature was then mobilized along the lesser
omentum up to the GE junction and the phrenoesophageal ligament
was taken down using a right angle dissection, electrocautery and
Harmonic scalpel.

Now with the stomach fully mobilized the left gastric artery was
isolated circumferentially controlled and suture ligated with 0
silk ties and placing proximal Hemoclips the left gastric vein
was ligated also with 0 silk ties and Hemoclips. Next, the crura
were mobilized from the esophagus and the esophagus
circumferentially controlled and a Penrose drain placed around
the esophagus. Dissection was then extended through the hiatus.
The hiatus was enlarged anteriorly with a 2 centimeter incision
in the diaphragm and placing 2-0 silk ties around the crossing
phrenic vein. The transhiatal dissection was continued,
circumferentially mobilizing the esophagus to the level of mid
esophagus where the mass was palpated. The mass was palpated and
found to be quite large and not readily mobilized. At this
point, it was decided that blunt and blind dissection of this
mass may pose a risk of injury to surrounding structures and the
transhiatal approach was then decided to be inappropriate. It
was determined that right thoracotomy to safely mobilize the mid
esophagus including the mass would be required.

Prior to exiting the abdomen, a full Kocher maneuver was
performed to further mobilize the duodenum and provide an access
link to the stomach. Now with the abdominal portion of
dissection completed, the skin was closed with staples and a
Tegaderm applied. The patient was then repositioned in the
lateral decubitus position, right side up, left side down and
reprepped and draped in the standard sterile surgical fashion.
The right chest was then entered with a posterolateral
thoracotomy, transecting the latissimus and sparing the serratus.
The fifth interspace was utilized, taking a 1 centimeter segment
posteriorly of the fifth rib to provide greater access. Now with
adequate exposure to the chest, the lung was mobilized anteriorly
and the esophageal bed inspected. There was a visible mass from
the mid trachea extending down to the carina. The esophagus and
mass were all mobilized using a right angle dissection all and
electrocautery. The esophagus was controlled with both proximal
and distal mass with a Penrose drain and the esophagus elevated
including the mass. There is a small diverticulum associated
with the esophagus at this level and the mass was fully contained
within the muscular layer. The muscular layer was split
longitudinally, separating longitudinal muscular fibers and
transecting the circular muscular fibers to expose the mass. The
mass was easily separated from the muscular layer and dissected
out fully circumferentially and found to be completely separated
from the mucosal layer consistent with allow myoma. An 0 silk
stitch was placed within the mass to elevate it and it was fully
mobilized and excised and sent to pathology for frozen section
analysis, which was confirmed to demonstrate cellular findings
consistent with leiomyoma. The muscular layer was reapproximated
using running 2-0 Vicryl stitch and then the intrathoracic
portion of the esophagus was fully mobilized.

Next, the stomach was retrieved through the hiatus and pulled up
into the chest and the esophagus then transected just distal to
the resection site of the leiomyoma and the stomach elevated for
distal resection line. The lesser curvature was suctioned free
of the vascular bundle, which was then ligated with an 0 silk
stitch proximally and distally and transected with Harmonic
scalpel. A GIA stapler was used to perform the distal resection
with 100-mm GIA stapler and the specimen was then removed and
sent to pathology. Next, the staple line was oversewn using a
running 3-0 Prolene stitch and now with the gastric tube created
as the neoesophagus, it was then positioned adjacent to the
esophagus for distal anastomosis. It reached comfortably to the
upper aspect of the thorax and the mid esophagus, including the
resection site of the leiomyoma was then excised and sent to
pathology. The proximal esophagus and stomach were placed
adjacent to each other and using six 2-0 Vicryl stitches, they
were secured in a side-to-side fashion. A gastrotomy was
created, the NG tube was pulled back and using an Endo-GIA
stapler, a side-to-side stapled anastomosis was created between
the proximal esophagus and the gastric tube neoesophagus.

Next, the remaining gastrotomy and transected esophagus were
closed using eight 3-0 Vicryl pop off stitches. The anastomosis
was then reinforced with small portion of the remaining gastric
omentum. Now with esophagogastric anastomosis completed, two
Blake drains were placed on either side of the anastomosis. An
ON-Q subpleural pain pump was placed with one catheter extending
superiorly, one catheter extending inferiorly in the subpleural
plane and brought out through separate incisions. The ribs were
then reapproximated using three figure-of-eight #2 Vicryl
stitches and the lungs reinflated. The latissimus was closed
with running 0 Vicryl, the subcutaneous layer closed with running
2-0 Vicryl and the skin closed with skin staples. Next, a
sterile dressing was applied and the patient was placed back in
supine position and reprepped and draped. The laparotomy
incision was reopened and a Bookwalter retractor placed. The
abdomen was reinspected for hemostasis which was adequate. The
stomach was again exposed and the pylorus was identified and a
pyloromyotomy created and this was then reinforced with a small
piece of adjacent omentum.

Next, the ligament of Treitz was identified and the jejunum was
traced back approximately 30 centimeters to create a J-tube. A
3-0 Vicryl pursestring was placed on the antimesenteric side and
a 16-French T-tube was then inserted. This was brought out
through a separate stab incision on the left mid abdominal wall
and the jejunum secured in place with a 3-0 Prolene pursestring.
Next, the abdomen was closed with running #1 looped PDS and the
skin closed with skin staples.

At the conclusion of the case, all counts were reported correct.
The patient tolerated the procedure well and was awakened from
anesthesia, extubated and transported to recovery room in good
condition.


Thanks

Laura, CPC, CPMA, CEMC
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  #2  
Old 02-08-2010, 09:18 AM
lisigirl lisigirl is offline
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I would say this is an Ivor Lewis esophagectomy. I would bill the following:

43117
43247
44015

I do not think 43112 or 43113 are appropriate because the surgeon did not cut into the neck nor reconstruct the colon. I'm not sure I would bill for the bronchoscopy either. If the surgeon performed the bronchoscopy to get a "lay of the land" before proceeding with excision, I would say don't bill for it. The Society of Thoracic Surgeons has repeatedly said you should not bill for a bronchoscopy done with more extensive procedures unless it is clear that no bronchoscopies were done prior.

Lisi, CPC
eharkler@nmh.org
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  #3  
Old 02-08-2010, 10:30 AM
LLovett LLovett is offline
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Thanks Lisi, I greatly appreciate it!

Laura, CPC, CPMA, CEMC
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