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
Friday, September 21, 2012
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]
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Note electronically signed by Francesco Rubino on Wed Sep 26, 2012 1:36 PM
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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
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Note electronically signed by Alfons Pomp on Mon Sep 24, 2012 4:31 PM
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