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 A flexible bronchoscope was introduced through the airway and the endotracheal tube was gradually withdrawn.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.

------------------------------------

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.

------------------------------------

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

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

_____________________________________________
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

Reconstruction of Roux-en-Y Gastric Bypass

Operative Note Summary

Patient:  Kang Wei Ko

MRN:  2492702

Encounter Date:  Sep 21, 2012

Operative Note:

PT NAME:  KANG WEI KO

MRN:  100554653

SURGEON NAME: Francesco Rubino, MD [6739R]

PROCEDURE DATE: 09/21/2012

ADMIT DATE: 09/21/2012

PREOPERATIVE DIAGNOSIS: S/P  Resection of gastrojejunostomy due to gastric ulcer beed after gastric bypass surgery, s/p end jejunostomy

POSTOPERATIVE DIAGNOSIS: Same

OPERATION: Esophagogastric-jejunal anastomosis and reconstruction of Roux-en-Y gastric bypass, extensive lysis of adhesions, feeding jejunostomy, closure of end jejunostomy, closure of iatrogenic enterotomy, closure of mesenteric defect to repair internal hernia, advancement flaps to close the abdomen, intra-operative upper endoscopy

ATTENDING SURGEON: Francesco Rubino, MD [6739R]

ATTENDING SURGEON: Alfons Pomp, MD [PO089]

ATTENDING SURGEON: Brendon Stiles

ASSISTANT SURGEON: Lindsay Cohen MD, Matthew Bott, 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. At the time 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, cervical esophagostomy and closure of abdominal wall with Alloderm. After an  Prolonged period of recovery and significant weight loss (>100 lbs) the patient has been scheduled for reconstruction of gastrointestinal anatomy. Pre-operative consent was obtained.Given the extreme complexity and technical difficulty of the case, Dr. Pomp assisted throughout this 7 hour procedure and Dr Stiles assisted intermittently  throughout the procedure but was present during the gastroesophageal dissection and anastomosis (principle parts of the procedure).

PROCEDURE: The patient entered the operating room. Following appropriate identification, he was placed in supine position on the operating table. Venodyne boots were applied. A surgical pause was performed in accordance with hospital regulations. Full general anesthesia was induced with orotracheal intubation. A Foley catheter was placed in the usual sterile fashion. The patient was prepped and draped in a supine position with appropriate padding and avoidance of hyper-extension of the extremities. Appropriate antibiotics were given intravenously.

An incision was carried down on the midline, in the lower abdominal area. With careful dissection the abdominal cavity was entered under direct vision and the laparotomy eventually extended cephalad to the xyphoid process. There were extensive adhesions between the small bowel and the abdominal wall requiring adhesiolysis. The adhesions were taken down using a lengthy and tedious dissection of over 3 hours (44005) with sharp and blunt instruments in order to entirely free the small bowel and allow mobilization of the jejunostomy. The jejunostomy was taken down under the jejunostomy using a linear stapler. The entire small bowel was examined, starting from the ileo-cecal valve and moving cephalad toward the ligament of Treitz. This maneuver allowed identification of the jejuno-jenunostomy and clear distinction of the biliary, alimentary and common limbs of the RY-anatomy. Dissection of bowel-to-bowel adhesions and intermesenteric adhesions was then performed to lengthen the alimentary limb and obtain its adequate mobilization for anastomosis. There was one small (2mm) enterotomy which was closed with 2 layers using 2-0 Vicryl.(44602) Next, the upper abdominal area was exposed using a Omnitrac retractor. There were extensive adhesions between the liver and the abdominal wall, the liver and the gastric remnant and the transverse colon and liver. This again required extensive adhesiolysis.Dissection of adhesions allowed clear identification of gastric remnant and transverse colon with its splenic flexure located high up in the left hypochondrium. The dissection also revealed a significant small bowel herniation through the tranverse mesocolon. The herniated bowel was reduced in the submesocolic space and the mesocolic defect closed with running suture (silk 2-0) (44050).

Next the left lobe of the liver was partially mobilized and dissected from the upper gastric pouch. This was clearly identified with the assistance of intraoperative esophago-gastroscopy (Dr Stiles). The left and posterior aspects of the gastric pouch were mobilized sufficiently to allow a gastro-jejunostomy. At this point, with the endoscope in the gastric pouch, a small gastrostomy was performed at the posterior lower part of the gastric pouch. A snare was pushed through the endoscope and passed through the gastrotomy into the abdominal cavity. A long silk suture was anchored to the snare and pulled all the way up to through the mouth and connected to the tip of an orogastric tube armed with the anvil of an EEA 25. This was passed by the anesthesiologist through the mouth into the proximal gastric pouch. The orogastric tube was removed, leaving the anvil in place. Two sutures (vicryl 2-0) were placed on both sides of the gastrotomy to further secure the anvil in place.

Following this, the staples on the distal jejunum were now removed to permit the introduction into the bowel of an EEA- 25. This was inserted for about 5 cm and the spike of the EEA was pushed through the anti-mesenteric side of the small bowel. The male and female parts of the EEA were drawn together to create an antecolic, antegastric, esophagogastro-jejunostomy (43340). The EEA was fired and removed. This was accomplished without problem. The anastomosis was without undue tension. The opening in the small bowel was closed with a GIA stapler (white cartridge). Several 2-0 Vicryl sutures were placed between the musculoserosa of the gastric pouch and the jejunum to complement the anastomosis on its right and left sides.

Another endoscopy performed to verify the integrity of the G-J from the inside. The anastomosis appeared adequate and the endoscope was advanced in the efferent jejunal loop. Then the bowel was occluded and an air-bubble test was performed. The test revealed no leaks at the gastric suture line, at the anastomosis, or at the closure of small bowel. This was entirely satisfactory. A JP 7fr drain was positioned along the gastro-jejunostomy, and secured to the right abdominal wall by a  silk suture.

The end jejunostomy was taken down by circumferentially dissecting out the mucosa-skin junction with electrocautery and then subcutaneously and then freeing this up from the fascia. The fascia was then approximated with #1 Vicryl. The skin was left open.

Next, a jejunostomy was performed (44015) on the initial part of the common limb, just caudal to the jejuno-jejunostomy. To do so, a Vicryl 2-0 purse string was placed and an enterotomy performed using ultrasound shears. A 22-Fr T-tube was then inserted in the bowel, the purse string suture was cinched and tied and the jejunostomy secured to the parietal peritoneum in the right hypochondrium with 2-0 silk sutures in the cardinal positions

The bowel was examined again and there were no obvious lesions. Hemostasis was verified.

With this being satisfactory, just enough of the abdominal fascial flaps were advanced on top of the rectus fascia (under the skin and fascia) to and incision at the junction with the obliques bilaterally; this was a dissection area of about 200 square cm (14301, 14302 X 5).  This allowed appropriate closure of the abdominal wall without undue tension. The abdominal fascia was then closed using #1 Maxon double loop sutures. At this point the wound was heavily irrigated and the skin was left open given the contaminated nature of this operation. Sterile dressings were applied. Anesthesia was well tolerated. The patient was left intubated on the table and accompanied by the surgical team to the recovery room. The lysis of adhesions took more than 3 hours overall.  The entire case took 7 hours and 15 min. Estimated blood loss was approximately 1300 cc., one unit of PRBC was transfused intraoperatively. Sponge, needle and instrument counts were reported correct to the surgeon.

Attestation: I was present and scrubbed during the entire procedure.

Francesco Rubino, MD [6739R]
_____________________________________________

Note electronically signed by Francesco Rubino on Wed Sep 26, 2012  1:36 PM

Attestation: I was present and scrubbed during the entire procedure.

Alfons Pomp MD

_____________________________________________

Note electronically signed by Alfons Pomp on Mon Sep 24, 2012  4:31 PM

Esophagoscopy

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:05/17/2012
SURGEON: Brendon Stiles, M.D.

CONSULTANT:
ASSISTANT:
PREOPERATIVE DIAGNOSIS: Bariatric surgery status post division of stomach with patient left in discontinuity.
POSTOPERATIVE DIAGNOSIS:
OPERATION: Esophagoscopy.
ANESTHESIA: Conscious sedation.
ANESTHESIOLOGIST: DR. NATALIA VASCHIA

BRIEF HISTORY:
Mr. Ko is a young man who had bariatric procedure which was complicated by postoperative bleeding necessitating division of his gastric pouch. He had been left in discontinuity. I had previously seen him and placed an esophagostomy drainage tube. I was asked to re-evaluate him today for quality of drainage and to make sure that his proximal gastric pouch was intact. The 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 where conscious sedation was induced. He was continuously hemodynamically monitored. Once he was adequately sedated, a GIF upper endoscope was advanced through his oropharynx and down his esophagus. We were able to easily visualize the NG tube and the esophagostomy. These were fine. I followed the tube down to the distal esophagus and into the gastric pouch. The gastric pouch seemed to hold air fine and had no evidence of a leak. It looked healthy. I advanced the tube down to approximately 40 cm just above the GE junction. The pouch was exploited and the scope was carefully pulled back. I performed the entire
procedure.

DD:05/18/2012
DT:05/18/2012
Job:931328
Message Control: 931328

BRENDON STILES
ELECTRONICALLY SIGNED 5/26/2012 6:25


  

Jenny's Update #2

Tony's surgery went well and is recovering smoothly. While he was drowsy after the surgery, he told me he just had a dream about transformer....he finds fun, as always. So no worries, that's the least thing I wish from all of you. He will be back on FB soon, I promise! 

- Jenny Ko

VAC Change & Abdomen Closure

Operative Note Summary

Patient:  Kang Wei Ko
MRN:  2492702
Encounter Date:  May 02, 2012

Operative Note:
SURGEON NAME: Francesco Rubino, MD [6739R]
PROCEDURE DATE:05/02/2012
ADMIT DATE:05/02/2012

PREOPERATIVE DIAGNOSIS: Discontinuity of GI Anatomy and Open Abdomen (Wound Vac) after Resection of Gastrojejunostomy for Endoluminal Bleed
POSTOPERATIVE DIAGNOSIS: Same

OPERATION: Abdominal Exploration and Washout; Closure of Abdomen with Alloderm + Wound Vac Placement + Esophageal Endoscopy and Cervical Esophagostomy Tube Placement

ATTENDING SURGEON: Francesco Rubino [6739R]
ATTENDING SURGEON: Brendon Stiles, MD
ASSISTANT SURGEON: Amanda Powers MD

The patient is a 35 yo male with morbid obesity, who underwent Roux en Y Gastric Bypass two months ago. He had two recurrent episodes of marginal ulcers with gastrointestinal bleeding successfully treated with endoscopic hemostasis. After a third recidivism of gastrointestinal bleeding last week with syncope he was admitted in critical conditions at another hospital in Queens. After a failed attempt to control GI bleed endoscopically, the patient 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. Last week the patient underwent abdominal exploration and washout with placement of feeding jejunostomy. The abdomen was left open due to significant edema of the viscera.

Patient's conditions and therapeutic plan have been discussed at length with his family, that consented for abdominal exploration, washout, abdominal closure, cervical esophagostomy, and possible reconstruction of gastrointestinal continuity.

PROCEDURE: The patient entered the operating room with orotracheal intubation. Following appropriate identification, he was placed in supine position on the operating table. Venodyne boots were applied. A surgical pause was performed in accordance with hospital regulations. Full general anesthesia was induced. The patient was prepped and draped in a supine position with appropriate padding and avoidance of hyper-extension of the extremities. Appropriate antibiotics were given intravenously.

Dr Stiles from thoracic surgery performed the left cervical esophagostomy with a 18F nasogastric tube on the left side of the esophagus (see his op note for details).

After removal of the Vac the abdominal cavity was washed copiously with saline. The position of the Jejunostomy tube was checked and was found to be securely in place in the Roux- limb. The JP drain was removed. The abdominal fascia was then separated from the subcutaneous tissue in a circumferential fashion leaving an edge of at least 2 cm. At this point the abdominal defect was evaluated and it was determined that it was not possible to close the abdominal wall safely. At this point the abdominal wall defect was measured. Then two pieces of Alloderm were assembled together appropriately to obtain a 32x20 cm mesh. This was secured to the fascial edges circumferentially with a running #1 Prolene suture. Then, white foam was placed against the alloderm and black foam layer was placedon top of the white foam. A  KCI Vac was placed under suction to -100mmHg.The J tube was left to gravity.

Sterile dressings were applied. Anesthesia was well tolerated. The patient was left intubated and accompanied by the surgical team to the recovery room. Estimated blood loss was approximately 50cc. Sponge, needle and instrument counts were reported correct to the surgeon.

I was present during the entire procedure.

Francesco Rubino, MD [6739R]
(Electronic signature on file)

_____________________________________________
Note electronically signed by Francesco Rubino on Fri May 25, 2012  5:23 PM

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