EGD with TORE procedure

allowry5

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Looking for opinions on the following op report. Would I use 43659?



Procedure performed:
  1. EGD with TORe

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Anesthesiologist: Dr. Wright/Darian Allen, AAS


Surgeon: Dr. Chetan Mittal


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Preoperative diagnosis:​


    • Morbid Obesity

    • Hx of Roux-en-y




Postoperative diagnosis:


S/p Trans-oral outlet reduction





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Impression:
Roux-en-Y anatomy with a dilated gastro-jejunal anastomosis (> 25 mm) and a 5 cm gastric pouch.​
s/p Trans-oral outlet reduction to 8 mm using circumferential APC (60 W) and circumferential endoscopic suturing.



Description of procedure:




Patient was brought to endoscopy operating room and met by staff and physicians.  After procedure was confirmed and appropriate procedure was identified preparations were made for sedation.  A time out was taken to identify the patients name, procedure site/type, and ID badge.  The patient was then sedated, and an oral bite block was placed between the incisors.  When the patient was appropriately sedated the GIF Olympus forward-viewing upper endoscope was used to perform the procedure.





The endoscope was passed under direct visualization to the level of the 2nd portion of the duodenum.





Hypopharynx:  Limited views of the hypopharynx, vocal cords and piriform sinuses revealed no abnormalities. These views were limited and were not comprehensive as a flexible endoscopy was used.





Esophagus:  The lining of the upper esophagus was normal in appearance.


There was no difficulty passing the endoscope.


The squamo-columnar junction was measured at 35 cm.
The gastric folds were measured at 35 cm.
The diaphragmatic hiatus was measured at 35 cm.
There is no evidence of Barrett's, esophagitis or hiatal hernia.





There is evidence of prior gastric surgery with a small (~ 5 cm) gastric pouch and a healthy appearing gastro-jejunal anastomosis, consistent with Roux-en Y gastrojejunal anatomy.
The GE junction is located at 35 cm and GJ anastomosis is located at 40 cm.
The diameter of the anastomosis measures > 25 mm.
There were 2 metal clips seen at the GJ anastomosis (6 o clock) without any ulcerations or other mucosal abnormalities.





The blind limb measured about 10 cm in length.
The efferent limb was located to the visual right.




We then applied APC (1 Lt per minute, 60 Watts) circumferentially around the gastro-jejunal anastomosis extending 1 cm on the gastric and jejunal side.





==============Suturing==================





In order to ensure adequate reduction in the size of GJ anastomosis, the Apollo Overstitch endoscopic suturing device was used to place 1 set of running sutures on the gastric side of the anastomosis. An esophageal overtube was placed to assist with suturing.


The 2T therapeutic upper endoscope was used for suturing.
2.0 Polypropylene non-absorbable suture was used.
APC was used to mark the five o'clock position on the gastric side for orientation during suture placement.
The sutures were applied in a single running fashion to approximate the GJ anastomosis. Eight bites were taken in a running fashion starting at 11 o clock and moving counter clockwise.
An 8-10 mm CRE balloon was used to size the anastomosis. The balloon was advanced into the efferent jejunum. The balloon was inflated to 8 mm. The suture was then tightened over the inflated balloon and cinched in place.
Additional suturing of the gastric pouch was not felt to be necessary given the small size of the pouch.

The anastomosis was re-examined. There was no evidence of active bleeding or perforation. The GJ anastomosis appeared appropriately narrowed.





The endoscope  Was moved back to the stomach.  The insufflated air was removed.​


The endoscope was slowly withdrawn with additional careful examination of the esophagus.
 
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