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Thread: Revision of pyloroplasty

  1. #1
    Join Date
    Apr 2007

    Question Revision of pyloroplasty

    AAPC: Back to School
    I am beyond confused on this op note-any help is appreciate!

    NARRATIVE: This is an unfortunate 43-year-old male who last year had a Heller myotomy with pyloroplasty done laparoscopically by Dr. Pyloroplasty was performed because of gastroparesis. Postoperatively during this hospitalization he did fine but he went home and had quite a bit of lobster and a large amount of food because he could eat finally. He came back to the hospital very sick-appearing. He was explored and found to have blown out his pyloroplasty. He had extensive surgery including a T-tube placement through the pyloroplasty. He eventually got better. Since then he has been in and out of the hospital intermittently for abscesses and abdominal pain. Interestingly, each time he gets an obscure form of Candida in his culture for unknown reason. Recent CT scan shows no problems in the right upper quadrant. There is no active inflammation in the area of the T-tube but there appears to be two lumens within the duodenum. He is agreeable for exploration and revision of the T-tube site.
    On the day of surgery he was brought into the operating room and placed in the supine position on the operating table. General endotracheal anesthesia was administered. The abdomen was prepped and draped in the usual sterile fashion. The previous incision was used. The scar was excised. The abdomen was entered under direct vision. The fascia was divided. There were some omental adhesions to the anterior abdominal wall and this was taken down with the LigaSure device. The stomach was identified. It was freed off of the transverse colon so that the stomach was mobile. It was densely adherent to the left lobe of the liver. The falciform ligament was taken down and the previous T-tube site was explored and it was followed down into a wad of inflammatory tissue surrounded with omentum which was carefully taken down and the body Foley catheter the stomach was followed down to the antrum and the pylorus. There was dense inflammation in the area but eventually this anterior surface was cleared off with some assistance by getting in the retrogastric space but taking the greater omentum off of the stomach. Eventually with sharp and blunt dissection the pylorus and antrum and proximal duodenum were removed from the left lobe of the liver and this resulted in entry into the duodenum likely at the site of the T-tube exit site. This opening was extended in a transverse plane so that the area could be well visualized. Proximally the pylorus was widely patent. The NG tube was advanced into this region. Distally the duodenum was widely patent but interestingly the lumen of the duodenum contained a second lumen likely from the T-tube. It was felt that perhaps some food gets lodged in this second channel and causes persistent opening within the previous T-tube site. This area was cleared out. The bridge between the lumens within the duodenum was divided with electrocautery. The pylorus was closed in two layers. Corner stitches of 3-0 silk were placed and a running full thickness 3-0 PDS stitch was used to close the pylorus. There was good thick tissue used to close the duodenum and then seromuscular stitches of 3-0 silk were used to close the second layer. The NG tube was advanced in and out of the pyloroplasty without difficulty. The area was explored. There was no significant bleeding. The area was generously irrigated and suctioned free. No other bleeding was noted. After generous irrigation the area was suctioned free. A 10 mm Jackson-Pratt drain was placed in the right mid abdomen and it laid across the area of the pyloroplasty. The abdomen was then closed with a running looped 0 PDS stitch, two in number. In the mid portion of the incision where he had had a fungal abscess this area was debrided and it was closed within the incision. The skin was closed with staples. The patient tolerated the procedure well and was extubated and brought to the Recovery Room in satisfactory condition.

    I dont even know where to begin....

  2. #2
    Join Date
    Apr 2007


    Im confused, wouldnt that be a G-Tube then. The purpose of this procedure is to revise that. See 43830 or 43831

    -I like lobster as well.

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