Frequently Asked Questions and Answers about Esophagectomy

Frequently Asked Questions and Answers about Esophagectomy This blog lists some commonly asked questions and answers about esophagectomy, a common surgical procedure.

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Esophagectomy is a surgical procedure that involves removing the entire esophagus or a part of it. The esophagus is a muscular tube that connects the mouth and the top part of the stomach and is responsible for moving the food we eat to the stomach. The lymph nodes near the esophagus and the stomach may also be removed during this operation. Once removed, the esophagus is rebuilt from part of the stomach or part of your large intestine. In most cases, this surgical procedure is a common treatment for advanced esophageal cancer. The extent of the procedure and the amount of esophagus to be removed will depend on several factors, including the stage of the tumor, tumor size and its location. General surgery medical billing and coding is quite complex as there are several coding rules and code choices related to reporting the procedure accurately. General surgeons performing esophagectomy should correctly document the procedures performed in the patients’ medical records. Utilizing medical coding services is a practical solution for physicians to simplify their documentation process. Here are some frequently asked questions and answers about esophagectomy – Q: Why is Esophagectomy performed?

A: One of the common reasons for performing esophagectomy is to treat earlystage cancer of the esophagus before the cancer has spread to the stomach or other organs. It is also used to treat patients suffering from benign conditions like Barrett’s esophagus

- a tissue

metamorphosis associated with chronic

gastroesophageal reflux that has developed into cancer, or pre-cancerous changes called high-grade dysplasia. Other conditions requiring this procedure include –  Trauma to the esophagus  Swallowing of caustic, or cell-damaging agents such as lye  Chronic inflammation

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 Complicated muscle disorders that prevent the movement of food to the stomach  A history of unsuccessful surgery on the esophagus People whose esophagus has been injured by ingestion of caustic substances also are candidates for esophagectomy, as are people with [achalasia] – poor motility of food from the throat to the stomach.

Q: What are the different types of esophagectomy techniques?

A: The surgical removal of esophagus includes a number of variations. The type of surgery a person undergoes depends on the stage of cancer as well as the physical condition and other medical disorders a person suffers from.  Open esophagectomy – In this standard, open procedure, the surgeon makes one or more large incisions in the neck, chest or abdomen. Open esophagectomy involves the following types –  Transthoracic esophagectomy (TTE) – Also known as an Ivor Lewis esophagectomy, under this procedure part of the esophagus is removed through small incisions made in the abdomen or the chest.  Transhiatal esophagectomy (THE)–the main incisions are made in the abdomen or neck.  Three incision esophagectomy – wherein the tumor is removed through incisions in the neck, chest or abdomen.  Minimally invasive esophagectomy – In this minimally invasive surgical technique, the tumor is removed through small incisions in the abdomen and chest.

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 Robotic esophagectomy – This minimally invasive approach is performed using robotic arms that allow the surgeon complete range of motion and better precision than other types of surgery.

For either type of esophagectomy, nearby lymph nodes are also removed during the operation.

Q: What are the potential risks or complications involved?

A: The risks of surgery may be greater than normal for people who are obese, heavy smokers, older adults who are on steroid medications, people who have lost a lot of weight from cancer, people who received cancer drugs (chemotherapy) before surgery and people who have had a severe infection from the damaged esophagus/stomach.

Esophagectomy carries a risk of complications, which may include –  Lung complications, such as pneumonia  Swallowing difficulties (dysphagia)  Leakage from the surgical connection of the esophagus and stomach  Excess bleeding, blood clots in the lungs and infections  Cough  Hoarseness  Acid or bile reflux  Bowel obstruction  Breathing problems

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Q: Who performs the procedure?

A: In most cases, Esophagectomy is performed by a multidisciplinary team of physicians – consisting of thoracic surgeons, gastroenterologists, medical oncologists, radiation oncologists and general surgeons.

Q: How are patients evaluated prior to the surgery?

A: Determining which specific procedure best suits the patient is an important aspect of esophagectomy. In order to reach that decision, specialists use several diagnostic imaging tests such as computerized tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET), endoscopic ultrasound and fine-needle biopsies during endoscopy. A pre-operative medical exam will be performed to identify conditions that could potentially complicate the surgery to be performed. In addition, physicians may also recommend chemotherapy or radiation or both, followed by a period of recovery, before an esophagectomy.

Q: What are the medical codes used for documenting esophagectomy?

A: Thoracic surgeons, oncologists, gastroenterologists or general surgeons who happen to perform esophagectomy are reimbursed for the services provided to the patients. Correct medical codes must be used to document the diagnosis, screening and other procedures performed. Medical billing and coding services offered by reputable companies can help physicians use the correct codes for their medical billing process.

The following CPT codes are relevant with regard to esophagectomy –

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 43107 - Total or near total esophagectomy, without thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or without pyloroplasty (transhiatal)  43108 - Total or near total esophagectomy, without thoracotomy; with colon interposition

or

small

intestine

reconstruction,

including

intestine

mobilization, preparation and anastomosis(es)  43112 - Total or near total esophagectomy, with thoracotomy; with pharyngogastrostomy or cervical esophagogastrostomy, with or without pyloroplasty

(i.e.,

McKeown

esophagectomy

or

tri-incisional

esophagectomy)  43113 - Total or near total esophagectomy, with thoracotomy; with colon interposition

or

small

intestine

reconstruction,

including

intestine

mobilization, preparation, and anastomosis(es)  43116 - Partial esophagectomy, cervical, with free intestinal graft, including microvascular anastomosis, obtaining the graft and intestinal reconstruction  43117 - Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without proximal gastrectomy; with thoracic esophagogastrostomy, with or without pyloroplasty (Ivor Lewis)  43118 - Partial esophagectomy, distal two-thirds, with thoracotomy and separate abdominal incision, with or without proximal gastrectomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es)  43121 - Partial esophagectomy, distal two-thirds, with thoracotomy only, with or without proximal gastrectomy, with thoracic esophagogastrostomy, with or without pyloroplasty

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 43122 - Partial esophagectomy, thoracoabdominal or abdominal approach, with or without proximal gastrectomy; with esophagogastrostomy, with or without pyloroplasty  43123 - Partial esophagectomy, thoracoabdominal or abdominal approach, with or without proximal gastrectomy; with colon interposition or small intestine reconstruction, including intestine mobilization, preparation, and anastomosis(es)  43124 - Total or partial esophagectomy, without reconstruction (any approach), with cervical esophagostomy Three new CPT codes have been added for laparoscopic esophagectomy procedures as on January 2018 –  43286 - Esophagectomy, total or near total, with laparoscopic mobilization of the abdominal and mediastinal esophagus and proximal gastrectomy, with laparoscopic pyloric drainage procedure if performed, with open cervical pharyngogastrostomy or esophagogastrostomy (i.e., laparoscopic transhiatal esophagectomy)  43287

-

Esophagectomy,

distal

two-thirds,

with

laparoscopic

mobilization of the abdominal or lower mediastinal esophagus and proximal gastrectomy, with laparoscopic pyloric drainage procedure if performed, with separate thoracoscopic mobilization of the middle and upper mediastinal esophagus and thoracic esophagogastrostomy (i.e., laparoscopic thoracoscopic esophagectomy, Ivor Lewis esophagectomy)  43288 - Esophagectomy, total or near total, with thoracoscopic mobilization of the upper, middle, or lower mediastinal esophagus, with separate laparoscopic proximal gastrectomy, with laparoscopic pyloric drainage

procedure

www.outsourcestrategies.com

if

performed,

with

open

cervical 918-221-7769

pharyngogastrostomy or esophagogastrostomy (i.e., thoracoscopic, laparoscopic

and

cervical

incision

esophagectomy,

McKeown

esophagectomy, tri-incisional esophagectomy) Q: How to prepare for the surgery?

A: Before an esophagectomy, your physician will conduct a detailed physical examination to rule out other medical problems like diabetes, high blood pressure, and heart or lung problems that the patient suffers from and confirm whether these problems are under control. As part of the surgery preparation, patients will be given details /advice on –  The potential risks of surgery and what to expect before, during and after the surgery  Nutritional counseling  Consuming or stopping normal medications before the surgery  When to stop eating or drinking the night before the surgery  How to quit smoking at least a few weeks before the surgery (for patients who are smokers) Patients may also be asked to stop consumption of blood thinner medicines like Aspirin, Ibuprofen (Advil, Motrin), as well as Vitamin E, Warfarin (Coumadin), and Clopidogrel (Plavix), or Ticlopidine (Ticlid). It is important for patients to inform physicians if they are pregnant, have a habit of drinking alcohol and what other medicines or other vitamin supplements they are consuming.

Q: What to expect after the surgical procedure?

A: Physicians in most cases will recommend tube feeding (enteral nutrition) for at least 4-6 six weeks to ensure adequate nutrition. Patients may have to wear special

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stockings to prevent blood clots on the feet and legs. Pain medicine will be directly administered through an IV or pills. Patients will be given instruction to do breathing exercises to prevent lung infection. Once patients start recovering and resume a normal diet, they will need to eat more frequent, smaller quantities.

Generally, patients lose significant amount of weight after surgery.

In addition, patients may develop dumping syndrome soon after the surgery.

Dumping syndrome occurs when the stomach pushes food into the small bowel too fast causing symptoms of dizziness, flushing, sweating, nausea, cramping or vomiting (which can be effectively controlled with a special diet, low in carbohydrates). However, this syndrome usually disappears with time.

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