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