Meso-Rex Bypass CPT

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Joined: Wed Jun 03, 2015 10:18 am

Tue Jun 27, 2017 9:51 am

Good morning!

I'm hoping to find some help coding the CPT for the following procedure, I have not had luck googling. Any help is appreciated.

POSTOPERATIVE DIAGNOSIS:Portal vein stenosis status post living donor liver transplant.

DESCRIPTION OF OPERATIVE PROCEDURE: Under general anesthesia, the patient's abdomen was prepped and draped.The previous incision was opened in its entirety. There were dense adhesions between the anterior abdominal wall, liver and viscera and there were fair amount of continuous oozing. Anteriorly, there was a loop of intestine that was severely adherent to the inferior wall of the liver and two enterotomies were made as it appeared that the bowel wall had developed very intermittent relationship with the capsule of liver. When traced further, it appeared that this segment of bowel was part of the Roux that was well away from liver and may have represented a place where the choledochal tube had been exteriorized. A small segment of bowel was removed and reanastomosed with a single layer of 5-0 PDS.

As we approached the hilum, we separated the hepatic artery from the portal vein and the Roux loop with great care, taking care not to injure any of vessels. Using Doppler interrogation and ultrasound examination we were able to localize the portal vein and separate from the adjacent hepatic artery as well as the Roux loop. Vena cava was also found. The portal vein somewhere in the neighborhood of the proximal anastomosis of the vein graft to the donor portal vein was encircled.

We then went down into the root of the mesentery, localized the superior mesenteric vein and isolated it with vessel loops.

We then went to the child's left neck, and procured the left internal jugular vein in its entirety from the jugular foramen down to the thoracic inlet. Both ends were oversewn with running Prolene suture and all branches were tied and divided. The vein was flushed with heparinized saline and placed in preservative solution.

The neck was then closed in a single layer reapproximating the platysma with a running Vicryl suture and Monocryl stitch for the skin.

At this point, we went head and reconfirmed again using ultrasound interrogation, the nature of the portal vein. The vein was doubly clamped and divided. The proximal end was oversewn with running Prolene suture. Distally, the wide portion of the internal jugular vein was sewn end-to-end to the donor portal with a running 7-0 Prolene suture for the back wall and interrupted Prolene for the front wall.

We then tunneled the vein over the duodenum along the Roux loop down to the superior mesenteric vein, which had reached quite comfortably.

Anatomy was made on the anterior surface of superior mesenteric vein and the small end of the jugular vein graft was spatulated and sewn end to side superior mesenteric vein with running 7-0 Prolene suture.

After clamping, excellent flow was detected in the vein and measured approximately 300 to 350 mL per minute, which was more than what we have approximated the portal vein for to be body surface area.

The abdomen was then closed with some tension with series of interrupted 2-0 figure-of-eight PDS sutures and Monocryl suture for the skin. The gastrostomy tube was replaced at the end of the procedure.
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