Esophagoscopy & Esophagostomy

NY Presbyterian Hospital - Cornell
Operative Report

Name: KO, KANG WEI
MRN: 02492702
ATT:
DICT: Brendon Stiles, M.D.
Admit Date:04/23/2012
Discharge Date:
Procedure Date:05/02/2012
SURGEON: Brendon Stiles, M.D.

CONSULTANT:
ASSISTANT: DR. MICHAEL NAZERIAN
PREOPERATIVE DIAGNOSIS: Bariatric surgery with postoperative bleeding requiring partial gastrectomy and esophagus left in discontinuity.
POSTOPERATIVE DIAGNOSIS:
OPERATION: 1. Esophagoscopy. 2. Esophagostomy tube via cervical incision.
ANESTHESIA: General endotracheal anesthesia.
ANESTHESIOLOGIST:

BRIEF HISTORY:
Mr. Ko is a young male who underwent gastric bypass surgery. Postoperative course was complicated by bleeding and exploration at an outside hospital at which time a partial gastrectomy was performed. The patient was left in discontinuity. I had previously performed an endoscopy to ensure that he had a well-healing upper stomach. At that time we noted an approximately 2-3 cm proximal gastric pouch that looked fine. We elected to wait for more definitive procedures at that instance. He was brought back to the operating room today hopefully for abdominal closure by Dr. Rubino's team. I was also asked to re-evaluate him to place a more definitive esophageal drain. We had discussed the option of diverting him, but I did not want to leave a long segment of stomach and the upper gastric pouch in discontinuity for fear that we would have no where to drain and that it would rupture. Although I had described to the family that even with tube drainage there was some risk of rupture, I deemed this to be a safer operation than leaving the entire tracking complete discontinuity without drainage. I therefore recommended a cervical esophagostomy tube. The risks and benefits of this were described and written consent was obtained.

DESCRIPTION OF PROCEDURE:
The patient was brought to the operating room, placed supine upon the operating room table. I performed an esophagoscopy first. The esophagus looked good and healthy. The GE junction was approximately 40 cm. Distal to that there was approximately 2-3 cm of gastric remnant. This appeared to be well healed without evidence of leak. The entire thing was well drained with the existing NG tube. The scope was then pulled back and removed. At this point Dr. Rubino's was in the operating room too. We prepped the whole field as one going from the chin down to the pelvis. He began work on the abdomen, which will be dictated separately. I had extended the neck and made a left transverse cervical incision. Underlying platysma and subcutaneous tissue was cauterized. Sternocleidomastoid was identified and retracted laterally. Carotid sheath and its contents were mobilized laterally as well. The thyroid vein was divided, exposed the tracheoesophageal junction. I dissected bluntly behind the esophagus freeing it up from its posterior attachments to vertebral bodies. I then bluntly and circumferentially dissected it taking care to stay close to the wall of the esophagus rather than the trachea. A Penrose drain was placed around it and the esophagus was mobilized both proximally and distally. It was then pulled up into view. The NG tube was removed. I placed a pursestring suture around the left lateral wall of the esophagus. A small esophagostomy was made and enlarged slightly. An 18-French NG tube was passed through a small counter incision in the skin and then through the esophagostomy and down into the distal esophagus. It was fixed in place with the pursestring suture. A repeat esophagostomy was performed. Demonstrated no evidence of stricturing of the esophagus with the pursestring and it showed that the NG tube was in good position. The scope was then pulled back. Incision was closed with layers of absorbable suture disclosing the platysma and the skin. Drain was fixed in place with a simple drain stitch. I was present and performed this entire part of the operation. The rest will be dictated separately by Dr. Rubino.

DD:05/02/2012
DT:05/02/2012
Job:395270
Message Control: 395270

BRENDON STILES
ELECTRONICALLY SIGNED 5/9/2012 8:19