Help with CPT coding of Exploration of fistulas and dilatation of stoma.


Lima, Ohio
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I did try and do a search for this procedure, but no luck.

PREOPERATIVE DIAGNOSIS: Stomal stenosis. Colocutaneous fistula.

POSTOPERATIVE DIAGNOSIS: Stomal stenosis. Colocutaneous fistula.

OPERATION PERFORMED: Exploration of fistulas and dilatation of stoma.

SUMMARY OF PROCEDURE: On 01-06-11, the patient was in a supine position and administered intravenous sedation, subsequently prepped with Betadine solution and draped in the usual fashion. Anesthetized around the stoma with 1% Xylocaine. Utilizing a curved hemostat, I was actually able to open up her stoma, which had become fairly stenotic. I could then insert at least the tip of my finger down 1.5cm. She had two sinus tracts, more toward the midline, both draining frank stool. I suctioned this free and actually explored this area with suction apparatus. It basically is a subcutaneous cavity almost 5cm in diameter. Utilizing irrigation, I could not irrigate into this fistulous tract. It actually goes right though the stoma, obviously attesting to the communication. Utilizing my index finger, I was able to dilate the stoma. I went down through the skin and through the fascia and into the bowel itself. It was fairly tight and fairly fibrotic, but I was able to dilate it. Basically reapplied the appliance.

The patient was taken back to her room in satisfactory condition.

GROSS PATHOLOGY: This is an 82-year-old female who has a recurrent colorectal carcinoma with a rectovaginal fistula. She had undergone a previous diverting colostomy several months ago. She basically had issues with the stoma. She developed retraction of the stoma itself. She developed some inflammatory changes around the base of the stoma and has developed a fistula toward the midline. She has had now, over the past month, episodes of stomal stenosis requiring finger dilatation on two separate occasions. This is done in the office. There was a fair amount of discomfort. The plan was to bring her in today, explore the stoma with possible revision. My concern is the thick, fibrotic tissue. There appears to be some migration of the skin down in the stoma track. This was fairly fibrotic, fairly large fistula and subcutaneous cavity is identified. If this helps the problem, great, and at least controls the drainage. Otherwise, feel the patient is going to be an eventual candidate for a diverting ileostomy and go from there.

Any help would be appreciated. Thank you.