Sunday, October 21, 2012
Friday, October 19, 2012
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
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
Note electronically signed by Alfons Pomp on Mon Oct 22, 2012 8:28 AM
Sunday, October 14, 2012
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
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
Friday, October 12, 2012
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
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
Friday, October 5, 2012
Wound Debridement
Operative Note Summary
Patient: Kang Wei Ko
MRN: 2492702
Encounter Date: Oct 05, 2012
Operative Note:
PT NAME: KANG WEI KO
MRN: 100554653
SURGEON MD#:
SURGEON NAME: Alfons Pomp, MD [PO089]
PROCEDURE DATE: 10/5/2012
ADMIT DATE: 9/21/2012
PREOPERATIVE DIAGNOSIS: Open, infected wound with enterocutaneous fistula
POSTOPERATIVE DIAGNOSIS: Same
OPERATION: Wound debridement
ATTENDING SURGEON: Alfons Pomp, MD [PO089]
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 an enterocutaneous fistula likely from an anastomotic leak and Dr Stiles performed upper endoscopy today with insertion of a covered stent. He has a wound "VAC" in place and we obtained consent to change the VAC device 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)
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 25cc. Sponge, needle and instrument counts were reported correct to the surgeon.
I was present during the entire procedure.
Alfons Pomp, MD, FACS
Patient: Kang Wei Ko
MRN: 2492702
Encounter Date: Oct 05, 2012
Operative Note:
PT NAME: KANG WEI KO
MRN: 100554653
SURGEON MD#:
SURGEON NAME: Alfons Pomp, MD [PO089]
PROCEDURE DATE: 10/5/2012
ADMIT DATE: 9/21/2012
PREOPERATIVE DIAGNOSIS: Open, infected wound with enterocutaneous fistula
POSTOPERATIVE DIAGNOSIS: Same
OPERATION: Wound debridement
ATTENDING SURGEON: Alfons Pomp, MD [PO089]
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 an enterocutaneous fistula likely from an anastomotic leak and Dr Stiles performed upper endoscopy today with insertion of a covered stent. He has a wound "VAC" in place and we obtained consent to change the VAC device 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)
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 25cc. 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 6, 2012 1:34 PM
Note electronically signed by Alfons Pomp on Sat Oct 6, 2012 1:34 PM
Endoscopy & Placement of 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:10/05/2012
SURGEON: Brendon Stiles, M.D.
CONSULTANT:
ASSISTANT: ALFONS POMP, M.D.
PREOPERATIVE DIAGNOSIS: Anastomotic leak status post revision for bariatric surgery.
POSTOPERATIVE DIAGNOSIS: Anastomotic leak status post revision for bariatric surgery.
OPERATION: 1. Upper endoscopy down to jejunum with covered stent placement. 2. Debridement which was done exclusively by Dr. Pomp.
ANESTHESIA:
ANESTHESIOLOGIST:
BRIEF HISTORY:
Mr. Ko is a 35-year-old male who is status post bariatric surgery. His postoperative course was complicated by bleeding which had required taking down of his gastrojejunostomy. He had recently presented to Dr. Rubino and to Dr. Pomp for revision. This had been a technically challenging operation, but the patient had initially done quite well afterwards. He subsequently developed what appeared to be an enterocutaneous fistula. Studies indicated that there might be a leak coming from the gastric pouch or the anastomosis. I was asked to see him and perform an endoscopy with potential stenting if that was found. The risks and benefits of the procedure were explained in detail to the patient. In particular, I described to him the chances for stent migration and the possible need for revisions. Written consent was obtained.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room where general endotracheal anesthesia was induced. A GIF endoscope was advanced through his oropharynx, down his esophagus, and across the GE junction. He had a small gastric pouch remnant. This appeared to be healthy with no obvious large defects. I was able to easily pass through the anastomosis to the jejunum. There was some granulation tissue along the staple line, but I did not see any evidence of large leaks or defects. However, with aggressive insufflation there was some leaking bubbles from the enterocutaneous fistula, suggesting that this was likely the site of the leak. I passed the scope into the blind end of the jejunum. I did not see any defects there or in the more distal jejunal channel. The scope was then pulled back.
I elected to place a stent under fluoroscopic guidance. I initially placed a 23 mm x 12.5 cm long stent just crossing the GE junction and into that jejunal limb. I then asked Dr. Pomp to come in and evaluate it. We discussed this extensively and eventually decided that he may be better served by placing the stent farther down the jejunum as I was unable to get a perfect seal with it in this position. Dr. Pomp felt that it would be fine to cover the blind jejunal end. I therefore elected to remove this stent. Dr. Pomp and I then looked at the area again. I then was able to pass the scope into the jejunal limb a little bit farther. I placed a wire through here, and then under fluoroscopic guidance I deployed a 23 mm diameter x 15 cm long stent, this time completely crossing the gastrojejunal anastomosis as well as the GE junction. It extended down into the jejunum 5 or 6 cm. I was able to advance the scope through it into the jejunal channel. Abdomen was exsufflated and the scope was then pulled back.
Dr. Pomp and his team performed an extensive wound debridement which he will dictate separately. I was present for and performed the entire endoscopy and stenting.
DD:10/05/2012
DT:10/05/2012
Job:845048
Message Control: 845048
BRENDON STILES
ELECTRONICALLY SIGNED 10/11/2012 9:02
Operative Report
Name: KO, KANG WEI
MRN: 02492702
ATT:
DICT: Brendon Stiles, M.D.
Admit Date:09/21/2012
Discharge Date:
Procedure Date:10/05/2012
SURGEON: Brendon Stiles, M.D.
CONSULTANT:
ASSISTANT: ALFONS POMP, M.D.
PREOPERATIVE DIAGNOSIS: Anastomotic leak status post revision for bariatric surgery.
POSTOPERATIVE DIAGNOSIS: Anastomotic leak status post revision for bariatric surgery.
OPERATION: 1. Upper endoscopy down to jejunum with covered stent placement. 2. Debridement which was done exclusively by Dr. Pomp.
ANESTHESIA:
ANESTHESIOLOGIST:
BRIEF HISTORY:
Mr. Ko is a 35-year-old male who is status post bariatric surgery. His postoperative course was complicated by bleeding which had required taking down of his gastrojejunostomy. He had recently presented to Dr. Rubino and to Dr. Pomp for revision. This had been a technically challenging operation, but the patient had initially done quite well afterwards. He subsequently developed what appeared to be an enterocutaneous fistula. Studies indicated that there might be a leak coming from the gastric pouch or the anastomosis. I was asked to see him and perform an endoscopy with potential stenting if that was found. The risks and benefits of the procedure were explained in detail to the patient. In particular, I described to him the chances for stent migration and the possible need for revisions. Written consent was obtained.
DESCRIPTION OF PROCEDURE:
The patient was taken to the operating room where general endotracheal anesthesia was induced. A GIF endoscope was advanced through his oropharynx, down his esophagus, and across the GE junction. He had a small gastric pouch remnant. This appeared to be healthy with no obvious large defects. I was able to easily pass through the anastomosis to the jejunum. There was some granulation tissue along the staple line, but I did not see any evidence of large leaks or defects. However, with aggressive insufflation there was some leaking bubbles from the enterocutaneous fistula, suggesting that this was likely the site of the leak. I passed the scope into the blind end of the jejunum. I did not see any defects there or in the more distal jejunal channel. The scope was then pulled back.
I elected to place a stent under fluoroscopic guidance. I initially placed a 23 mm x 12.5 cm long stent just crossing the GE junction and into that jejunal limb. I then asked Dr. Pomp to come in and evaluate it. We discussed this extensively and eventually decided that he may be better served by placing the stent farther down the jejunum as I was unable to get a perfect seal with it in this position. Dr. Pomp felt that it would be fine to cover the blind jejunal end. I therefore elected to remove this stent. Dr. Pomp and I then looked at the area again. I then was able to pass the scope into the jejunal limb a little bit farther. I placed a wire through here, and then under fluoroscopic guidance I deployed a 23 mm diameter x 15 cm long stent, this time completely crossing the gastrojejunal anastomosis as well as the GE junction. It extended down into the jejunum 5 or 6 cm. I was able to advance the scope through it into the jejunal channel. Abdomen was exsufflated and the scope was then pulled back.
Dr. Pomp and his team performed an extensive wound debridement which he will dictate separately. I was present for and performed the entire endoscopy and stenting.
DD:10/05/2012
DT:10/05/2012
Job:845048
Message Control: 845048
BRENDON STILES
ELECTRONICALLY SIGNED 10/11/2012 9:02
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