Bronchoscopy & Tube Replacement

PATIENT NAME: KO, KANGWEI
DATE OF OPERATION: 11/06/2014
MEDICAL RECORD #: 40498087
ENCOUNTER #: 500007724577
SURGEON: LAWRENCE GLASSMAN 057166

OPERATIVE REPORT

DOB: 10/24/1976

FIRST ASSISTANT: ALAN ROY HARTMAN, MD (088237)

PREOPERATIVE DIAGNOSES: Tracheal stenosis.
POSTOPERATIVE DIAGNOSIS: Tracheal stenosis.

NATURE OF OPERATION: Flexible bronchoscopy.

CLINICAL SUMMARY AND OPERATIVE FINDINGS: This is a 38-year-old gentleman in the operating room immediately after aortic valve replacement. He had a know tracheal stenosis and bronchoscopy, was requested to evaluate this area.

PROCEDURE: The patient was under general endotracheal anesthesia with a 7.0 endotracheal tube, which had passed with a slight difficulty across the area of stenosis. A flexible bronchoscope was introduced through the airway and the endotracheal tube was gradually withdrawn. The carina and distal airways were normal. The distal trachea was normal. The proximal subglottic trachea had a short segment tracheal stenosis, which was circumferential, slightly oval in appearance and mildly to moderately narrowed about 7 mm in diameter. The decision was then made to maintain the airway with a slightly larger tube. A tube exchanger was inserted and a 7.5 endotracheal tube was able to be passed across the area of stenosis and this was then secured in standard fashion. The patient tolerated the procedure well.

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DICT:      LAWRENCE GLASSMAN, MD (057166) 11/06/2014 04:19 PM
TRANS:   PJAMT3/V_JDSEN_P 11/06/2014 04:26 PM
JOB:       2081046

Electronically Signed by: LAWRENCE RICHAR GLASSMAN 11/16/2014 08:13:20 AM

Aortic Valve Replacement & Ablation

PATIENT NAME: KO, KANGWEI
DATE OF OPERATION: 11/06/2014
MEDICAL RECORD #: 40498087
ENCOUNTER #: 500007724577
SURGEON: ALAN HARTMAN

OPERATIVE REPORT

DOB: 10/24/1976

CO-SURGEON: LAWRENCE GLASSMAN, MD (057166)
FIRST ASSISTANT: Sanya PA
REFERRING PHYSICIANS: DR. SHUE AND DR. WARSCHAUER
CARDIAC ANESTHESIOLOGIST: IRENE STADNYK, MD (101758)

PREOPERATIVE DIAGNOSES:
1.   Severe aortic insufficiency.
2.   Obesity, status post morbid obesity surgery with complications including

      ventral hernia and wound infection and ultimately a tracheal stenosis, which

      was identified preoperatively.
3.   Atrial fibrillation.

POSTOPERATIVE DIAGNOSIS: Atrial fibrillation

NATURE OF OPERATION: Procedure done today was an aortic valve replacement utilizing 25 bovine pericardial valve, Edwards Lifesciences, serial number 4093078. Bicuspid aortic valve was removed. Also, additional procedure was a bronchoscopy, examination of tracheal stenosis, and tube exchange. The surgeon was Dr. Hartman on the valve and Dr. Glassman on the bronchoscopy. Partial radiofrequency maze procedure.

SPECIMEN: Bicuspid aortic valve.

OPERATIVE INDICATIONS: The patient is a 38-year-old gentleman who has been in heart failure, severe aortic insufficiency, wide-open aortic insufficiency, and evidence of bicuspid aortic valve, who has had a difficult recovery from morbid obesity surgery. At the time that we examined him preoperatively, he clearly has evidence of tracheal stenosis for which this was worked up and found not to be stenotic significantly, but enough so that we felt that it needed to be examined through bronchoscopy during this procedure.

OPERATIVE PROCEDURE: He was placed on the OR table in supine fashion. After placement of arterial monitoring line, he was induced under general anesthesia. Swan-Ganz catheter placed. He was prepped and draped in usual sterile fashion. Midline sternotomy incision was made. Sternum divided with reciprocating saw. The pericardium was opened, tacked to soft tissue. Mediastinal pleura was opened into the right pleural space and a 32 channel drain was left in the right pleural space. Cannulation sutures placed in ascending aorta as well as right atrium. Heparin 30,000 units had been administered to achieve an activated clotting time of over 5000 seconds. The cannulation achieved. Cardiopulmonary bypass commenced, cooling to 28 degrees. Retrograde cardioplegia line was placed only; no antegrade because of the severe aortic insufficiency; vent line through the right superior pulmonary vein. Aorta was cross-clamped. Retrograde was given. The topical ice was used to augment myocardial cooling, kept below 10 degrees centigrade. A transverse aortotomy incision was made. Actually, it should also be noted that preoperatively, the patient had atrial fibrillation and the patient also had a partial radiogrequency maze procedure. An intraoperative partial maze procedure done with radiofrequency energy source. After cardiopulmonary bypass had been commenced and the patient was cooled down to 28 degrees and good cooling of the heart was achieved, the pulmonary veins on the right side were encircled and the cardioablation was done of the pulmonary veins on the right side. Once that was done, the ablation was done on the left pulmonary veins and this was done as well as bipolar coagulator. With that completed, attention was then placed toward the aortotomy. The aortic valve was excised. Annulus was debrided. A total of 19 sutures were placed circumferentially around the aortic annulus and through a 25 bovine pericardial valve. The valve was seated. Sutured were tied. Cardioplegia re-administered every 10 to 15 minutes. With good seating of the aortic valve, aortotomy was closed with two layers of 4-0 Prolene suture in running mattress fashion. Deairing maneuvers done. Once that was completed, rewarming commenced. The ablation was then done of the right atrium. Three lesion sets were placed in the right atrium including the atrial appendage, superior vena cava and inferior vena cava bipolar lesion sets. With that completed, deairing maneuvers were done further as AV sequential pacing ensured and drains were left, two mediastinal drains and also Blake drain. At 37 degrees, with good AV sequential pacing, the patient was weaned from cardiopulmonary bypass with excellent hemodynamics. The echocardiogram looked good. The protamine was administered. Two mediastinal chest tubes were left as mentioned. The sternum was closed with Robicsek technique, leaving wire on the right hemisternum and then double monofilament wire from both sternal halves.

. The bone was then irrigated with polymyxin. Soft tissue brought together with 0 Vicryl suture followed by 2-0 Vicryl suture. Skin closed with Biosyn. Actually, it should be noted that bacitracin was not used in the antibiotic solution, only polymyxin, because of his allergy. The soft tissue brought together with 0 Vicryl suture followed by 2-0 Vicryl suture. The skin was closed with Biosyn. Once that was completed, Dr. Lawrence Glassman arrived in the room and did a fiberoptic bronchoscopy. The trachea was examined. The circumferential narrowing was noted of the trachea and this area was examined, but not felt to be overly stenotic. The tube was changed from 7 to 7.5 and then the patient returned to the cardiothoracic intensive care unit in stable condition.

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DICT:      ALAN R HARTMAN, MD (088237) 11/06/2014 04:17 PM
TRANS:   V_JDVIJ_I/ 11/06/2014 19:45
JOB:       2081045

Electronically Signed by: ALAN R. HARTMAN 11/07/2014 04:12:16 PM

Cardiac MRI - August 1, 2014

Birthday Celebration

Surgical VAC Change

Operative Note Summary

Patient:  Kang Wei Ko
MRN:  2492702
Encounter Date:  Oct 19, 2012

Operative Note:
PT NAME:  KANG WEI KO
MRN:  100554653

SURGEON MD#:
SURGEON NAME:  Alfons Pomp, MD [PO089]

PROCEDURE DATE:  10/19/2012

ADMIT DATE: 9/21/2012
PREOPERATIVE DIAGNOSIS: Open, infected wound with (likely) enterocutaneous fistula
POSTOPERATIVE DIAGNOSIS: Same
OPERATION: Dressing change
ATTENDING SURGEON: Alfons Pomp, MD [PO089]
ASSISTANT SURGEON: Jennifer Murphy MD, Mike Chervonski MD

The patient is a 35 yo male with history of morbid obesity and laparoscopic Roux-en-Y Gastric Bypass in March 2012. He required emergency laparotomy and revision of gastrojejunostomy at an outside hospital in May 2012 where he underwent laparotomy with resection of gastro-jejunostomy and partial resection of gastric remnant. Gastrointestinal anatomy was left in discontinuity  After an prolonged period of recovery and significant weight loss on 9/21/2012 he underwent esophagogastric-jejunal anastomosis and reconstruction of Roux-en-Y gastric bypass and advancement flaps to close the abdomen: the wound was left open. The patient has a wound "VAC" in place and we obtained consent to change the VAC device and debride his wound while under anesthesia.

PROCEDURE: The patient was in his monitored bed on 8 North (the operating room was not available)  Following appropriate identification, anesthesia
surveillance was "induced" (without orotracheal intubation).  No antibiotics
were considered necessary.

The "VAC" dressing was removed and  the operative site was examined and
hemostasis was verified. The wound appeared clean without purulence and with good granulation tissue. The "VAC" dressing was re-applied (white and black foam). Anesthesia was well tolerated. Estimated blood loss was < 25cc. Sponge, needle and instrument counts were not judged necessary.

I was present during the entire procedure.

Alfons Pomp, MD, FACS

_____________________________________________
Note electronically signed by  Alfons Pomp on Mon Oct 22, 2012  8:28 AM

Placement of Stent Within a Stent

NY Presbyterian Hospital - Cornell
Operative Report

Name: KO, KANG WEI
MRN: 02492702
ATT:
DICT: Brendon Stiles, M.D.
Admit Date:09/21/2012
Discharge Date:
Procedure Date:10/14/2012
SURGEON: Brendon Stiles, M.D.

CONSULTANT:
ASSISTANT:
PREOPERATIVE DIAGNOSIS: Anastomotic leak status post gastrojejunostomy.
POSTOPERATIVE DIAGNOSIS: Anastomotic leak status post gastrojejunostomy.
OPERATION: Esophageal stent placement under fluoroscopic guidance.
ANESTHESIA:
ANESTHESIOLOGIST:

BRIEF HISTORY:
Mr. Ko is a patient well known to my service. He had a complicated bariatric surgery with postoperative complications requiring leaving him with discontinuity. He had recently been explored and continuity reestablished with a gastrojejunostomy. Postoperatively, he developed a small leak from this. I previously stented it placing a stent across the gastrojejunal anastomosis and well into the jejunum at the request of the primary surgeons, Dr. Pomp and Dr. Rubino. He has continued to have some output however from a wound VAC and JP drain. A swallow study suggests a very small leak proximally. I was therefore asked to take him back to the operating room to place another more proximal stent. Risks and benefits of the procedure were explained in detail to the patient. Written consent was obtained.

DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room and general endotracheal anesthesia was induced. The primary team was also going to perform a wound debridement in the same setting.

I then performed an endoscopy. GIF endoscope was advanced through the patient's esophagus across the GE junction and into the gastric remnant and inserted into the gastric pouch. The stent was visualized below the GE junction. I could pass through it and into the jejunum. I then pulled back slightly more proximally and placed a wire through the current indwelling stent. It was done under live fluoroscopic guidance. The scope was then brought back and pulled out. I then advanced a stent down over the wire across the GE junction and carefully pushing it into the existing stent under direct vision with fluoroscopy. This was a 23 mm diameter x 12.5 cm long stent. I then deployed it under direct fluoroscopic guidance with the distal end in the previous stent and the proximal end in the lower esophagus. It deployed well. Endoscopy was performed afterwards to confirm position. It looked good. The bowel was ex-sufflated and the scope was removed. I was present for and performed the entire procedure.

DD:10/14/2012
DT:10/14/2012
Job:869666
Message Control: 869666

BRENDON STILES
ELECTRONICALLY SIGNED 10/26/2012 13:27

Wound Debridement

Operative Note Summary

Patient:  Kang Wei Ko
MRN:  2492702
Encounter Date:  Oct 12, 2012

Operative Note:
PT NAME:  KANG WEI KO
MRN:  100554653

SURGEON MD#:
SURGEON NAME:  Alfons Pomp, MD [PO089]

PROCEDURE DATE: 10/12/2012
ADMIT DATE: 9/21/2012
PREOPERATIVE DIAGNOSIS: Open, infected wound with (likely) enterocutaneous fistula
POSTOPERATIVE DIAGNOSIS: Same
OPERATION: Wound debridement
ATTENDING SURGEON: Alfons Pomp, MD [PO089]
ASSISTANT SURGEON: Jennifer Murphy MD, Mike Chervonski MD

The patient is a 35 yo male with history of morbid obesity and laparoscopic Roux en Y Gastric Bypass in March 2012. Postoperatively he had recurrent episodes of marginal ulcers with gastrointestinal bleeding. He required emergency laparotomy and revision of gastrojejunostomy at an outside hospital in May 2012 where he underwent laparotomy with resection of gastro-jejunostomy and partial resection of gastric remnant. Gastrointestinal anatomy was left in discontinuity and the abdomen was left open due to edematous bowel. He was then transferred to WCMC where he underwent abdominal exploration and washout with placement of feeding jejunostomy and cervical esophagostomy. After an prolonged period of recovery and significant weight loss on 9/21/2012 he underwent esophagogastric-jejunal anastomosis and reconstruction of Roux-en-Y gastric bypass and advancement flaps to close the abdomen: the wound was left open. The post-operative course has been notable for a low volume enterocutaneous fistula likely from an anastomotic leak; imaging was preformed yesterday (CT scan) and today (upper GI series) Initially Dr Stiles performed upper endoscopy with insertion of a covered stent (proximal and through the previously placed stent of October 5th). The patient has a wound "VAC" in place and we obtained consent to change the VAC device and debride his wound while under anesthesia.

PROCEDURE: The patient entered the operating room. Following appropriate identification, he was placed in supine position on the operating table. Venodyne boots were applied. Full general anesthesia was induced with orotracheal intubation. Dr. Stiles completed his procedure (separate operative report).

The VAC was removed. There was a significant amount of devitalized tissue in the wound which was sharply debrided. (total surface debrided 40 square cm). Tthere was also some purulent fluid expressed by applying pressure under the left costal margin, a sample was sent for culture. It was decided to connect the LUQ site of the previous jejunostomy and the medican incision and this was done with electrocautery.

The operative site was examined and hemostasis was verified. The wound was irrigated copiously with saline. With this being satisfactory, The VAC was applied, white foam/black foam and then the clear plastic dressing.

Anesthesia was well tolerated. The patient was extubated on the table and accompanied by the surgical team to the recovery room. Estimated blood loss was approximately 100cc. Sponge, needle and instrument counts were reported correct to the surgeon.

I was present during the entire procedure.

Alfons Pomp, MD, FACS
_____________________________________________
Note electronically signed by  Alfons Pomp on Sat Oct 13, 2012  4:01 PM