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Thread: Help! Ivor Lewis, Collis, or neither....

  1. #1
    Join Date
    Apr 2007
    Posts
    1,716

    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

  2. #2

    Default

    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

  3. #3
    Join Date
    Apr 2007
    Posts
    1,716

    Default

    Thanks Lisi, I greatly appreciate it!

    Laura, CPC, CPMA, CEMC

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