Cats3
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I am newer to coding Gastro and I am stuck on this! Can anyone help me? Point me in the right direction? Something? Thank you!!
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Indications: History of Roux-en-Y gastric bypass with choledocholithiasis and afferent limb syndrome
Sedation/Medications: General anesthesia, 500 mg of IV Levaquin, 1 g of glucagon
Procedure Details
Informed consent was obtained for the procedure, including conscious sedation. Risks of pancreatitis, infection, perforation, hemorrhage, adverse drug reaction and aspiration were discussed. The patient was placed in the left lateral decubitus position. She was monitored continuously with ECG tracing, pulse oximetry, blood pressure monitoring, and direct observation.
The gastroscope was inserted into the mouth and advanced under direct vision to the second portion of the duodenum. A careful inspection was made as the gastroscope was withdrawn, including a retroflexed view of the proximal stomach and Incisora; findings are described below. Appropriate photodocumentation was obtained.
Findings:
Normal-appearing esophagus with GE junction at 38 cm from the incisors. Large gastric pouch with some retained food. No evidence of gastric fistula. Healthy appearing gastrojejunal anastomosis at 42 cm from the incisors approximately 12 mm in diameter. No marginal ulceration.
The pediatric colonoscope was advanced deeply to the E ferret limb. Multiple areas of acute angulation were identified however no definitive stricture was seen. The jejunojejunal anastomosis was not clearly identified the furthest extent reached with the pediatric colonoscope with us tattooed with 3 cc of Spot ink.
GATE
The decision was made to create a gastro-gastrostomy using the AXIOS stent system.
The gastric remnant was identified when viewing from the gastric pouch. Endosonographic images of the excluded stomach were unremarkable. Once an appropriate position was identified, the wall between the gastric pouch and the excluded stomach was interrogated utilizing color Doppler imaging to identify interposed vessels. The gastric wall and the excluded stomach wall were punctured under endosonographic guidance with the 19 gauge needle. Dilute contrast with sterile water was introduced into the excluded stomach (around 500 mL). This was confirmed on fluoroscopy with the excluded stomach and duodenum filling with contrast solution. The needle was withdrawn and the echoendoscope withdrawn to find a therapeutic window into the excluded stomach.
The AXIOS stent and electrocautery device were introduced through the working channel and advanced freehand. Current was applied to the cautery tip and the AXIOS device was advanced into the insufflated stomach. A 20 mm x 10 mm AXIOS stent was placed with the flanges in close approximation to the walls of the excluded stomach and the gastric pouch through the gastro-gastrostomy. A long jagwire was advanced into the excluded stomach and coiled several times. The stent was placed successfully. A TTS dilator was passed through the scope. Dilation of the fistula was performed using a 8-9-10 mm balloon dilator to a maximum of 10 mm was performed under fluoroscopic gudiance.
Given orientation of the duodenoscope through the remnant, the decision was made not to proceed with ERCP and to delay this to a later date to allow the stent to mature. The echoendoscope was exchanged for a regular gastroscope to traverse the stent and examine the ampulla. A 10 Fr x 3 cm plastic double pigtail stent was advanced through the AXIOS to anchor it and was in good position.
Estimated Blood Loss: minimal
Complications: none
Disposition: Home
Condition: Stable
Impression:
- Roux-en-Y gastric bypass anatomy. Deep enteroscopy performed without finding stricture however multiple areas of acute angulation are seen. Unable to reach jejunal jejunal anastomosis. Furthest extent reached tattooed.
- Successful creation of GATE using 20 mm x 10 mm AXIOS stent. Coaxial 10 fr x 3 cm plastic pigtail stent placed.
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Indications: History of Roux-en-Y gastric bypass with choledocholithiasis and afferent limb syndrome
Sedation/Medications: General anesthesia, 500 mg of IV Levaquin, 1 g of glucagon
Procedure Details
Informed consent was obtained for the procedure, including conscious sedation. Risks of pancreatitis, infection, perforation, hemorrhage, adverse drug reaction and aspiration were discussed. The patient was placed in the left lateral decubitus position. She was monitored continuously with ECG tracing, pulse oximetry, blood pressure monitoring, and direct observation.
The gastroscope was inserted into the mouth and advanced under direct vision to the second portion of the duodenum. A careful inspection was made as the gastroscope was withdrawn, including a retroflexed view of the proximal stomach and Incisora; findings are described below. Appropriate photodocumentation was obtained.
Findings:
Normal-appearing esophagus with GE junction at 38 cm from the incisors. Large gastric pouch with some retained food. No evidence of gastric fistula. Healthy appearing gastrojejunal anastomosis at 42 cm from the incisors approximately 12 mm in diameter. No marginal ulceration.
The pediatric colonoscope was advanced deeply to the E ferret limb. Multiple areas of acute angulation were identified however no definitive stricture was seen. The jejunojejunal anastomosis was not clearly identified the furthest extent reached with the pediatric colonoscope with us tattooed with 3 cc of Spot ink.
GATE
The decision was made to create a gastro-gastrostomy using the AXIOS stent system.
The gastric remnant was identified when viewing from the gastric pouch. Endosonographic images of the excluded stomach were unremarkable. Once an appropriate position was identified, the wall between the gastric pouch and the excluded stomach was interrogated utilizing color Doppler imaging to identify interposed vessels. The gastric wall and the excluded stomach wall were punctured under endosonographic guidance with the 19 gauge needle. Dilute contrast with sterile water was introduced into the excluded stomach (around 500 mL). This was confirmed on fluoroscopy with the excluded stomach and duodenum filling with contrast solution. The needle was withdrawn and the echoendoscope withdrawn to find a therapeutic window into the excluded stomach.
The AXIOS stent and electrocautery device were introduced through the working channel and advanced freehand. Current was applied to the cautery tip and the AXIOS device was advanced into the insufflated stomach. A 20 mm x 10 mm AXIOS stent was placed with the flanges in close approximation to the walls of the excluded stomach and the gastric pouch through the gastro-gastrostomy. A long jagwire was advanced into the excluded stomach and coiled several times. The stent was placed successfully. A TTS dilator was passed through the scope. Dilation of the fistula was performed using a 8-9-10 mm balloon dilator to a maximum of 10 mm was performed under fluoroscopic gudiance.
Given orientation of the duodenoscope through the remnant, the decision was made not to proceed with ERCP and to delay this to a later date to allow the stent to mature. The echoendoscope was exchanged for a regular gastroscope to traverse the stent and examine the ampulla. A 10 Fr x 3 cm plastic double pigtail stent was advanced through the AXIOS to anchor it and was in good position.
Estimated Blood Loss: minimal
Complications: none
Disposition: Home
Condition: Stable
Impression:
- Roux-en-Y gastric bypass anatomy. Deep enteroscopy performed without finding stricture however multiple areas of acute angulation are seen. Unable to reach jejunal jejunal anastomosis. Furthest extent reached tattooed.
- Successful creation of GATE using 20 mm x 10 mm AXIOS stent. Coaxial 10 fr x 3 cm plastic pigtail stent placed.