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

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

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

Hospital Transfer - FROM: New York Hospital Medical Center of Queens; TO: New York Presbyterian Hospital Weill Cornell Medical Center

After receiving emergency surgery in New York Hospital, it would be 5 more days before I was stable enough for them to transfer me back to New York Presbyterian Hospital so that my original surgeon could take over my case and continue my care. I have remained unconscious since late night of April 17th, I was unconscious during the transfer, and I remained unconscious for a few more weeks after arriving at NYP.

Discontinuity of Gastrointestinal Tract

THE NEW YORK HOSPITAL MEDICAL CENTER of QUEENS
OPERATIVE REPORT

NAME: KO, KANG WEI
MRN: 3197633
SURGEON: STEPHEN MEROLA, MD
DATE: 04/18/2012
---------------------------------------------------------------------------
ASSISTANTS: ROSENSTOCK. MD; OMAVRICK, MD

ANESTHESIOLOGIST: FELER, MD; HWANG, MD; HU, MD

PREOPERATIVE DIAGNOSIS: Massive gastrointestinal bleed from gastric pouch, from gastric bypass.

POSTOPERATIVE DIAGNOSIS: Same.

OPERATION: Exploratory laparotomy, takedown of gastrojejunostomy and resection of small bowel, resection of gastric remnant, fundus and resection of gastric pouch along with placement of ABThera device.

ANESTHESIA: General endotracheal.

SPECIMEN: A piece of fundus and small bowel and gastric pouch.
DRAINS: None.
COUNTS: Needle, sponge and instrument counts correct.
PATIENT CONDITION: The patient left the operating room in critical condition.

FINDINGS: The patient [was] explored and on opening had extremely distended bowel full of blood, almost all the small bowel, the colon and even the gastric remnant were all filled with blood. A bariatric Omni was placed and bowel decompressed just below the gastrojejunostomy to allow for a better manipulation, then ultimately divisions were done of the Roux limb of the gastric remnant to exclude the fundus, that was adherent to the gastric pouch and ** the gastric remnant.  Of note, endoscopy was performed by GI, that showed no bubbling, no evidence of any anastomotic of staple line leak.

Once this was completed. Due to instability and inability to close his abdomen, a ABThera was placed with plans to stabilize the patient, to likely change the ABThera in 2-3 days and the 2-3 days after that discuss closure and possible re-anastomosis in the same admission.

INDICATIONS: The patient is a 35-year-old male, who underwent a gastric bypass at Cornell University one month ago by Dr. Francesco Rubino.  The patient had two, if not three episodes of GI bleeding in the months since surgery, that were treated nonoperatively, without reoperation, but simply with EGD and injection. However, after a recent discharge, he now presented with syncope and dark stools and a hemoglobin of 7 and was found to have an additional GI bleed.

He was brought to the emergency room at NYCQ with plans to transfer to Cornell.  Ultimately, this transfer did not occur for reasons unclear. Although possibly due to discussion that the patient was unstable and the patient was admitted to the Critical Care Unit at New York Hospital Medical Center of Queens.  I was made aware of this patient at approximately 9:30, 10:30 AM on 04/18. I received a call from Dr. Alfonse Pomp telling me that the patient was in the hospital who has a massive GI bleed and was being intubated and bleeding to death.  He asked that I evaluate the patient.

I evaluated the patient in the Critical Care Unit with the Surgical ICU Team and felt the patient was hemodynamically stable at the time, was undergoing endoscopy with Dr. San Kim.  He placed a number of clips and epinephrine. In the end there still was some oozing, but no brisk bleeding.  The hematocrit at 10:30 in the morning was about 23, in the afternoon, about 1:30, it was the same and he was admitted to SICU for stabilization and possible transfer.

Discussion were made about possible transfer here if he remained stable and he received two additional units of blood and his hematocrit went to 26.5 up less than 4% with 2 units of blood.  I discussed with Dr. Pomp about transferring and he felt that he did not want the patient transferred while being transfused, although I did state the transfusion had been completed.  He was also unclear whether there were any Intensive Care Unit beds.  We talked to Surgical ICU at Cornell and there were two beds available.  However, by 6:30, 7:00 o'clock the patient had vomited blood and had become oliguric and at this point appeared to be going into shock and it was felt that this patient was now not stable [to] transfer.

I discussed with the family in detail. I felt that at this point the only option would be to operate on him, as he was having significant GI bleed and we could not simply try and stabilize him overnight with the hope to transfer.  There was no guarantee he would be transferred and he needed surgical treatment for his bleeding that included resection.

We discussed options including resecting the anastomosis and not putting it back together again possibly putting in a gastrostomy tube.  The possibility of needing reconstruction at a later date, either in days or months, possibly through the left chest.  Multiple risks related to procedure including the high likelihood of death, approaching at least a one-in-three change that he will ultimately die, if not necessarily the day of surgery, but in the recovery period from this big operation.

They deemed understanding and they gave written and verbal consent for this surgical procedure.

PROCEDURE: The patient was brought to the operating room, placed supine on the operating table. Cardiopulmonary monitoring was applied. IV was inserted. He was already intubated previously and after anesthesia was obtained, the abdomen was prepped and draped with ChrolaPrep. A time-out was performed and the skin was incised from the xiphoid to just below the umbilicus with a 10 blade scalpel.  Once the abdomen was entered, the bowel was quite distended and it was impossible to work due to the large distention.  Clearly the patent was not a candidate for laparoscopy, given this large distention.

I, therefore, ultimately opted to open the small bowel just distal to the gastrojejunostomy to decompress all the blood out of the small bowel.  Once this was done, I opted to divide the small bowel just below the anastomosis and then take the mesentery with the harmonic scalpel and staplers and this allowed the Roux limb to fall down to lower abdomen with antecolic anastomosis. I then evaluated the anastomosis by cutting back the small bowel and looking within the anastomosis. The clips could be palpated and seen through the anastomosis on the stomach side, and that was where they were placed.  Of note, the stomach was densely adherent to the gastric remnant and the gastric remnant was also quite distended.

I opened this up and found dark blood in the gastric remnant and what appeared to be a possible fistulation.  This could represent a leak from the previous anastomosis had eroded into the gastric remnant.  Given this finding, and the likely possibility of a small leak or small fistula in to the remnant, I opted to resect the upper part of the stomach.  I, therefore, cut the short gastrics with harmonic scalpel and resected the upper stomach with staplers and left the gastric remnant. This was quite mobile and it would be easy to place a gastrostomy tube, that he will need at some point.  At this point with the gastric remnant divided and removed, the Roux limb divided and attention was given to the anastomosis.

The anastomosis was evaluated and I opted to divide the pouch.  His stomach was quite small only about 2cm from the hiatus.  The bleeding was at least 1cm above that, leaving only about 1cm of stomach below the GE junction.  A stapler was applied and I had GI, Dr. Nussbaum, do intraoperative endoscopy.  It appeared that the way the staples sat there was no bleeding at that level.  In addition, blood had been emanating up his esophagus, sitting at the GE junction, just about 1cm distal to staple line and sitting up at the GE junction with no further bleeding coming up from the pouch, as the pouch was not filling up with blood, and again, the staple line was inspected with no significant bleeding.

I, therefore, at this point, fired the stapler, cut the end off and then I did note some bleeding from the staple line.  To [ensure] that this would not continue to bleed, I over-sewed this with 2-0 Prolene. In the end, it was felt that there was no significant bleeding in the pouch.

At this point with no bleeding in the pouch or esophagus, no bleeding in the jejunum, no bleeding in the gastric remnant, it appeared that his bleeding source was under control.  At this point, he had some bleeding in the upper abdomen, that was controlled with a combination of suturing and Evicel. In the end, there is no bleeding noted in the abdomen and, again, the bleeding point that caused him to have a massive bleed was stopped.

At this point, he had oliguria with low blood pressure and another 6-10 units of packed red blood cells were given.  Given the large volume of transfusion, at this point, 4-5 hours into the procedure, I felt that an attempt to do anastomosis in this large man with diabetes, hypertension and obstructive sleep apnea and atrial fibrillation just below his GE junction would be difficult and would be at risk of a leak, that clearly he would not survive.  I, therefore, placed an ABThera device, a vacuum dressing to his abdomen.  I did not feel the need to bring up the gastrostomy tube at this point, as he would have to come back for permanent closure and he will be transferred to the SICU for resuscitation. I would like to have the ABThera changed in 2-3 days and after diuresis and bowel decompression of all the blood that has been passed, his abdomen might likely be closed.  I will also stress the possibility of recreating the gastrojejunal anastomosis or possibly esophagojejunal anastomosis, possibly in the abdomen and if not possible in the abdomen, possible in the chest versus putting in a gastrostomy tube, closing his abdomen and planning for re-operation in a month or so when he is more stable and this will all be determined over the coming days.

I will touch base with the physicians at Cornell regarding their patient with a massive GI bleed, who underwent life-saving resection of the bleeding gastrojejunostomy.  I discussed the outcome with the patient's family outside the operating room at approximately 3:30 in the morning on 04/19.

STEPHEN MEROLA, MD

DICT: STEPHEN MEROLA, M.D. 04/19/2012
TRANS: ST/CJA 04/19/2012
JOB: 888573
---------------------------------------------------------------------------
Digitally signed on 4/21/2012 at 4:46:47 PM by Stephen Merola.

Discharged From the Hospital

After 3 days in the hospital, I was discharged and sent home to start my pureed food diet.

Roux-en-Y Gastric Bypass

My surgery day. I'm getting a laparoscopic Roux-en-Y Gastric Bypass. Not nervous at all. Extreme confidence in my surgeon and the medical team, as well as confidence in the hospital. Woke up with just a little bit of pain, as the surgery was minimally invasive.

Surgical Staple Removal

THE NEW YORK HOSPITAL
06-26-95

KO, KANG WEI

2492702



PREOPERATIVE DIAGNOSIS: STATUS POST EXCISION OF EXTENSIVE HEMANGIOMA OF THE LEFT POSTERIOR THIGH AND CALF, WITH SPLIT-THICKNESS SKIN GRAFT.

POSTOPERATIVE DIAGNOSIS: SAME.

OPERATION:

1. DRESSING CHANGE LEFT LEG.
2. REMOVAL OF SURGICAL STAPLES.
3. RANGE OF MOTION LEFT LEG.

SURGEON: LLOYD HOFFMAN, M.D.

CONSULTANT:

ASSISTANT: 

ANESTHESIA: INTRAVENOUS SEDATION.

ANESTHESIOLOGIST:

INDICATIONS:
The patient is status post excision of a large hemangioma which required extensive grafting.  The patient has numerous surgical staples which could not be removed without undue pain as an office procedure.  The patient's knee is getting stiff, and he requires closed manipulation of the knee.

PROCEDURE:
The patient was taken to the operating room where successful intravenous sedation was achieved.  The dressing on the left leg was changed, and there was 100% take of the graft.  There were small areas of hypertrophic granulation tissue, and these were cauterized with silver nitrate.

The surgical staples were then removed, and Bacitracin was applied.  The left hip, knee and ankle were then vigorously manipulated, and full range of motion was achieved.  A sterile dressing was applied.  The patient transported to the recovery room, having tolerated the procedure well.

LLOYD HOFFMAN, M.D.

T:8700  J:87001  D:06/27/95  T:06/29/95  RR/FJP  NY087001.629

Hemangioma Removal

THE NEW YORK HOSPITAL
05-25-95

KO, KANG WEI

249-27-02



PREOPERATIVE DIAGNOSIS: GIANT HEMANGIOMA, LEFT THIGH AND LOWER LEG.

POSTOPERATIVE DIAGNOSIS: SAME.

OPERATION:

1. EXCISION OF MASSIVE HEMANGIOMA, LEFT THIGH AND LEFT LOWER LEG.
2. SPLIT THICKNESS SKIN GRAFT GREATER THAN 200 SQ. CENTIMETERS.

SURGEON: LLOYD HOFFMAN, M.D.

ASSISTANT: SCHWARTZ, M.D.

ANESTHESIA: GENERAL ENDOTRACHEAL ANESTHESIA.

ANESTHESIOLOGIST:

INDICATIONS:
The patient is a 17 year old Asian male who has a massive hemangioma of the left posterior thigh and posterior calf as well as the popliteal fossa.  This hemangioma has been present since birth.  It was treated with herbal wraps and the patient subsequently developed a burn over the skin.  This area continually becomes infected and has often bled.  MRI reveals a deep hemangioma and the angiogram revealed normal vessels.

PROCEDURE:
The patient was taken to the Operating Room where he underwent extensive preoperative preparation including Foley catheterization, IV lines, warming blankets and he was rotated into position following the induction of endotracheal anesthesia. The patient is a massive individual weighing greater than 112 kilos.

The entire leg and left upper thigh and buttocks were prepped and draped in the usual fashion.  Consideration was given to the latissmus dorsi flap and this area was prepped in as well.  A tourniquet was applied to the left upper thigh and the left leg was exsanguinated as fully as possible.  The tourniquet was inflated to 350 mmHg.

Incision was designed involving the medial aspect of the upper thigh extending inferiorly encompassing a large ellipse of involved skin and then proceeding inferiorly to a straight line again.  The incision was made using a 10 blade and skin flaps were elevated.  Even the normal appearing skin was involved with the hemangiomatous component.  Extensive dissection was carried out sharply and bluntly to remove hemangioma from between muscle groups as well as fascia.  The semimembranosus and semitendonosus and gracilis muscles were dissected out as the popliteal fossa was crossed and the gastroc muscles came into view.  The fascia was removed with the specimen and hemostatis was achieved.  Following excision of this large mass and submission to Pathology, the remaining skin was trimmed using the scissors.

The defect measured approximately 12 centimeters in width by 48 centimeters in length.  The decision was not to use the flap and skin graft this area.  The dermis was then tacked down to muscle and skin harvested with the Padgett dermatome from the upper thigh and buttock area.

The skin was meshed and secured with staples and wet clips.  Carefully molded splint was prepared and the graft secured with moist cotton and Xeroform.

The patient tolerated this procedure well and was transferred to the Recovery area in stable condition.  The sponge and instrument counts were correct.  The estimated blood loss was 200 cc.

DICTATED BY: LLOYD HOFFMAN, M.D.

LH/FVB/RR

TAPE: 6714

D: 05-26-95

T: 05-31-95

531NY03.FVB