Cats3
Networker
Is this going to be an unlisted GI code? Thank you in advance?
The Linear echoendoscope was inserted into the mouth and advanced under direct vision to the jejunal limb. Therapeutic endoscope was advanced to the mouth to the mid jejunum. The XP neonatal endoscope was advanced from the mouth to the mid jejunum.
Findings:
Esophagus normal, no esophageal varices.
Z-line at 38 cm from the incisors. Normal
Evidence of prior gastric bypass was identified. The gastric pouch was 5 cm in length extending from 38 cm from the incisors to 43 cm. This was characterized by healthy-appearing mucosa. The gastrojejunal anastomosis was approximately 12 mm in diameter and healthy appearing without evidence of marginal ulceration. The blind and efferent limbs were normal in appearance.
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. The excluded stomach was found to be severely dilated and filled with thick fluid. 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. 5 cc of murky brown fluid was aspirated. 20 cc of contrast was injected into the gastric remnant confirming location on fluoroscopy. The needle was withdrawn and the echoendoscope withdrawn to find a therapeutic window into the excluded stomach.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 with a 10-11-12 mm balloon dilator to a maximum of 12 mm was performed under fluoroscopic gudiance.
Given orientation of the duodenoscope through the remnant, the decision was made not to proceed with full evaluation of the duodenal obstruction and to delay this to a later date to allow the stent to mature. A 10 Fr x 3 cm plastic double pigtail stent was advanced through the AXIOS to anchor it and was in good position. The echoendoscope was exchanged for an XP neonatal gastroscope to traverse the stent and examine the excluded stomach. The gastric remnant mucosa was normal in appearance. Biopsies were obtained with cold forceps for histology to rule out H Pylori.
Impression:
- Successful placement of EUS guided lams from gastric pouch to obstructed gastric remnant with decompression of the stomach using 20 mm x 10 mm LAMS AXIOS.
- Otherwise normal-appearing Roux-en-Y gastric bypass anatomy.
The Linear echoendoscope was inserted into the mouth and advanced under direct vision to the jejunal limb. Therapeutic endoscope was advanced to the mouth to the mid jejunum. The XP neonatal endoscope was advanced from the mouth to the mid jejunum.
Findings:
Esophagus normal, no esophageal varices.
Z-line at 38 cm from the incisors. Normal
Evidence of prior gastric bypass was identified. The gastric pouch was 5 cm in length extending from 38 cm from the incisors to 43 cm. This was characterized by healthy-appearing mucosa. The gastrojejunal anastomosis was approximately 12 mm in diameter and healthy appearing without evidence of marginal ulceration. The blind and efferent limbs were normal in appearance.
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. The excluded stomach was found to be severely dilated and filled with thick fluid. 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. 5 cc of murky brown fluid was aspirated. 20 cc of contrast was injected into the gastric remnant confirming location on fluoroscopy. 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 with a 10-11-12 mm balloon dilator to a maximum of 12 mm was performed under fluoroscopic gudiance.
Given orientation of the duodenoscope through the remnant, the decision was made not to proceed with full evaluation of the duodenal obstruction and to delay this to a later date to allow the stent to mature. A 10 Fr x 3 cm plastic double pigtail stent was advanced through the AXIOS to anchor it and was in good position. The echoendoscope was exchanged for an XP neonatal gastroscope to traverse the stent and examine the excluded stomach. The gastric remnant mucosa was normal in appearance. Biopsies were obtained with cold forceps for histology to rule out H Pylori.
Impression:
- Successful placement of EUS guided lams from gastric pouch to obstructed gastric remnant with decompression of the stomach using 20 mm x 10 mm LAMS AXIOS.
- Otherwise normal-appearing Roux-en-Y gastric bypass anatomy.