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Thread: Roux-en-y gastric bypass for GERD

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    Question Roux-en-y gastric bypass for GERD

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    Hi,

    My physician performed a Roux-en-y gastric bypass for a patient with GERD. The pouch was made significantly larger than for a weight loss patient and is documented in the op note. Would I use the lap gatric bypass roux-en-y code (43644) since the description indicates a pouch of less than 150 cm? Or would I use the unlisted code of 43659 since it's not indicated for anything other than weight loss? I have attached the operative report. Thanks!

    PREOPERATIVE DIAGNOSES
    1. Recalcitrant gastroesophageal reflux disease.
    2. A peristaltic esophagus with patulous gastroesophageal junction at
    lower esophageal sphincter.
    3. A 3 cm hiatal hernia.

    POSTOPERATIVE DIAGNOSES
    1. Recalcitrant gastroesophageal reflux disease.
    2. A peristaltic esophagus with patulous gastroesophageal junction at
    lower esophageal sphincter.
    3. A 3 cm hiatal hernia.

    OPERATIVE PROCEDURE
    Robotic Roux-en-Y gastric bypass.

    INDICATION FOR SURGERY
    This is a 36-year-old male with severe GERD but esophageal dysmotility.
    We have discussed the various options and he elected to proceed with a
    surgical intervention in the form of a Roux-en-Y gastric bypass.

    OPERATIVE FINDINGS
    Liver, bowel, peritoneal surfaces appeared normal. We made the gastric
    pouch larger than we would for gastric bypass, a 40 cm biliopancreatic
    limb, and only 50 cm Roux limb.

    PROCEDURE IN DETAIL
    With the patient in the supine position, general anesthetic was
    administered. The abdomen was prepped with ChloraPrep and sterilely
    draped. After infiltration of local anesthetic, a Veress needle inserted
    into the peritoneal cavity and pneumoperitoneum was established with
    carbon dioxide. A 12 mm trocar was inserted in this incision just above
    the umbilicus and laparoscopic exploration of the abdomen revealed the
    above-noted findings; 5 mm robotic trocars were placed in the left
    anterior axillary line and in the left midclavicular line, and again in
    the right subcostal region. A 10 mm assistant port was placed in right
    midclavicular line. The Nathanson retractor was inserted in the
    subxiphoid region to retract the left lobe of the liver anteriorly. We
    began by dividing the peritoneal reflection at the angle of His. Then
    beginning a little more than 6 cm distal to the GE junction on the
    lesser curvature of stomach, began the dissection of the stomach and
    created a window posterior to the stomach. The gastric pouch was then
    created with an additional firing of the powered echelon flex 60 with a
    blue cartridge, transversely. Then with a 40-French bougie through the
    stent in the GE junction and along the lesser curvature the pouch
    creation was completed with sequential firings of the Echelon Flex 60
    with the green cartridge with SeamGuard. I did not snug up against the
    bougie like we do at a gastric bypass for weight loss, but instead gave
    him a little more patulous pouch. The gastric pouch was completed and
    then divided the omentum beginning at the mid transverse colon. The
    splits on either side allow the Ethicon orientation of the Roux limb.
    Then identified the ligament of Treitz and cut it at about 40 cm
    distally. The small bowel was then divided 40 cm distal to the ligament
    of Treitz using Echelon Flex 60 with a white cartridge. Created, then
    measured a 50 cm Roux limb. I created enterotomies in both sides of the
    jejunum and the jejunojejunostomy was created using intraluminal firing
    of the Echelon Flex 60 with a white cartridge. The enterotomy was then
    closed with a running 2-0 Vicryl, which I did in 2 layers. I closed the
    jejunojejunostomy mesenteric defect with running 2-0 silk. Next the Roux
    limb was brought up to the gastric pouch. I then created a 2 layer
    anastomosis with a running 2-0 Vicryl as an outer layer. I then created
    an enterotomy with the Harmonic Scalpel, in both the stomach and the
    jejunum. The inner layer was created with a running 2-0 Vicryl,
    posteriorly first and then running. I then stented the anastomosis with
    a 40-French bougie. I then completed the anterior aspect of the
    anastomosis with the inner layer first, followed by an outer layer.
    After this was completed, we clamped the jejunum just distal to the
    gastrojejunostomy and performed a saline submersion test and there was
    no bubbling, thus suggesting integrity anastomosis. It was hemostatic
    intraluminally. I was actually able to intubate the jejunum all the way
    down to the jejunojejunostomy and it appeared intact as well. At this
    point the endoscope was removed. The abdomen was irrigated and
    hemostasis confirmed. The Nathanson retractor was removed. The
    pneumoperitoneum deflated and trocars were removed. The 12 mm fascial
    site was closed with 0 Vicryl suture and each of the skin incisions
    closed with 4-0 Monocryl subcuticular sutures and Mastisol and Steri-
    Strips. Patient tolerated the procedure well.
    Last edited by ch81059; 06-14-2013 at 08:58 AM. Reason: incorrect information

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