Frequently asked coding questions.

Current Procedural Terminology (CPT) coding is not an exact science. Although the CPT code set was developed to describe clearly and comprehensively services provided by health care professionals, the intended application of individual codes is not always clear. In addition, coding that may be correct in terms of CPT definitions and instructions may contradict instructions from payment policies set by insurers. This article provides answers to the gastroenterologists' most commonly asked questions and provides primary sources for coding and payment policies when possible. Answers to the questions are accurate as of the date of publication but may be subject to change.

Aggressive D2 lymphadenectomy is required for accurate pathologic staging of gastric adenocarcinoma.

The therapeutic efficacy of aggressive regional D2 lymphadenectomy as an adjunct to gastrectomy for adenocarcinoma of the stomach remains controversial. It is hypothesized that D2 lymphadenectomy compared with limited D1 lymphadenectomy increases nodal yield without adding to operative morbidity or mortality, and is necessary to allow accurate pathologic staging according to current American Joint Committee on Cancer (AJCC) criteria. A 10-year retrospective review of a consecutive series of 105 gastrectomies for adenocarcinoma at an urban public teaching hospital was performed. Of 69 intended curative gastrectomies, 55 (80%) included D2 lymphadenectomies, whereas of 36 palliative gastrectomies, only 9 (25%) included D2 lymphadenectomies (P = 0.0041). Only D2 and not D1 lymphadenectomy achieved the AJCC minimum guideline of the 15 lymph nodes required for accurate pathologic staging (mean 25.2 vs 12.4 nodes, respectively; P = 0.0001). For D2 cases, 86 per cent had greater than 15 nodes excised compared with only 20 per cent for D1 cases (P = 0.0002). The morbidity and mortality rates for D2 and D1 operations were 22 per cent and 2 per cent, and 41 per cent and 2 per cent, respectively. We conclude that there was no increased morbidity or mortality associated with D2 lymphadenectomy; that reliable harvesting of an adequate number of lymph nodes for accurate AJCC pathologic tumor staging requires D2 lymphadenectomy; and that D2 lymphadenectomy should be performed as part of virtually all gastrectomies for invasive adenocarcinoma having curative intent.

Classification and regression trees (CART) for estimation of prognosis in patients with gastric carcinoma.

A total of 961 patients who had received resective surgery for gastric carcinoma were grouped according to prognosis by classification and regression trees (CART). This grouping was compared to the present UICC stage grouping. For patients resected for cure (R0) the CART approach allows a better discrimination of patients with poor prognosis (5-year survival rates 15%-30%) from patients with a 5-year survival of 50%, on the one hand, and from patients with extremely poor prognosis (5-year survival rates below 5%) on the other. In the present investigation CART grouping was not influenced by the differentiation between pT1 and pT2 or between pT3 and pT4.

Comparison of anterior and geometric mean liquid and solid gastric emptying rates in dogs and in patients after partial gastrectomy.

OBJECTIVE: The purpose of this study was to determine if geometrical correction is necessary in the study of gastric emptying rate (GER) for liquids, using a low-energy radionuclide, such as 99mTc. Solid test meals were considered the reference. METHODS: Both solid and liquid GERs were investigated using regional analysis. Anterior data were compared with geometrically corrected values in 15 dogs and 9 partial gastrectomy patients. RESULTS: Anterior and geometrically corrected measurements differed significantly for solid food in the whole gastric region and in the antrum. Geometrically corrected values differed slightly from anterior data after partial gastrectomy. No difference was found for liquid food. Liquids redistributed much faster than solids within the stomach. CONCLUSION: Measurement of GER using a single-phase liquid meal does not require geometrical correction. This is due to the rapid intragastric redistribution of the liquid. Geometrical correction for solid food can be omitted only after partial gastrectomy.

Stomach tumors and gastric surgery.

Malignant and benign tumors of the stomach must be resected. Some can be removed endoscopically, but larger lesions must be removed via traditional surgical methods. This article provides an overview of malignant and benign stomach tumors and outlines the determination of diagnosis and the recommended treatment. It describes different types of gastric surgery and the RN first assistant's role in these procedures. A case study of a rare type of benign stomach tumor also is presented.

Association of radiographic morphology with early gastroesophageal reflux disease and satiety control after sleeve gastrectomy.

BACKGROUND: Variable gastric morphology has been identified on routine upper gastrointestinal series after laparoscopic sleeve gastrectomy. This test might give us useful information beyond the presence of leak and obstruction. The aim of this study is to standardize a morphologic classification of gastric sleeve based on water-soluble contrast upper gastrointestinal series, and to determine possible clinical implications. STUDY DESIGN: One hundred morbidly obese patients underwent laparoscopic sleeve gastrectomy and had routine upper gastrointestinal on postoperative day 1 or 2. Images were reviewed by 4 radiologists who were blinded to outcomes, and sleeve shape was classified as upper pouch, lower pouch, tubular, or dumbbell. Inter-observer agreement was calculated. Clinical outcomes including weight loss, satiety control, and reflux symptoms were recorded. Comparisons were determined by 1-way ANOVA and t-test. RESULTS: Mean age was 46 ± 12 years and mean BMI was 45.1 ± 6 kg/m(2). Overall inter-observer agreement level for the sleeve shape classification was 76.3%. Sleeve shapes were tubular in 37%, dumbbell in 32%, lower pouch in 22%, and upper pouch in 8%. Mean excess body weight loss at 1, 3, and 6 months was 16.8%, 29.9%, and 39.1%, respectively. Excess body weight loss was not associated with sleeve shape. Mean hunger score was 213 ± 97, and patients with dumbbell shape had higher hunger scores (p = 0.003). Mean reflux score was 5.7 ± 8. Upper pouch shape was associated with greater severity of reflux symptoms (p = 0.02). CONCLUSIONS: This study suggests a standardized radiographic classification of gastric sleeve morphology. Although sleeve shape is not correlated with weight loss, gastric sleeves with retained fundus result in lower satiety control and higher severity of reflux symptoms. An adequate resection of the gastric fundus might avoid this potential complication.

Relación entre el índice de Onodera pre-operatorio y las complicaciones post-cirugía R0 en el cáncer de estómago / Relation between preoperative prognostic Onodera’s Index and postsurgery complications in the R0 gastric carcinoma resection

Fundamento: En publicaciones asiáticas se postula que un Índice de Onodera (IO) bajo puede asociarse con una mayor frecuencia de complicaciones post-resección radical del cáncer gástrico, careciendo de resultados en áreas occidentales. En el presente trabajo se analiza la relación entre un IO pre-operatorio bajo con la frecuencia y la gravedad de las complicaciones post-cirugía R0 en el cáncer gástrico. Pacientes y métodos: Se revisaron 124 tumores gástricos con resección R0. Considerando patológicamente bajo un IO <45, estudiamos la frecuencia de complicaciones entre los grupos con IO menor y ≥45. En el análisis multivariante incluimos como variables de ajuste la edad mayor de 68 años, puntuación ASA, hemoglobina pre-operatoria menor de 12 g/dL, estadio pTNM, infiltración serosa, invasión ganglionar y tipo de gastrectomía realizada. Determinamos la relación entre IO <45 y la frecuencia y gravedad de las complicaciones, según la clasificación de Clavien-Dindo modificada. Resultados: Se registraron complicaciones leves en un 11,3%; graves 9,7% y exitus 2,4%. Los pacientes con IO <45 presentaron mayor frecuencia de complicaciones: 37,7% versus 12,7% [ odds ratio (OR) = 4,17; IC 95% = (1,71-10,20); p = 0,001], confirmada en el análisis multivariante: [OR = 4,17; IC 95% = (1,54-11,30); p = 0,005]. Los pacientes con IO <45 tuvieron más complicaciones graves-exitus: 20,8% versus 5,6% [OR = 4,39; IC 95% = (1,31-14,68); p = 0,011]. Conclusiones: También en un país occidental, los pacientes con IO pre-operatorio bajo (<45) muestran un mayor riesgo independiente de presentar complicaciones tras la resección R0 del carcinoma gástrico. Adicionalmente, las complicaciones registradas en los casos con IO <45, muestran una significativa mayor gravedad (AU)

Background: It has been postulated in the Asian literature that a low prognostic nutritional index (OI) could be associated with a higher rate of complications following radical gastric cancer surgery, but there is a lack of data concerning western countries. The aim is to analyze the relationship between a low preoperative OI and the frequency and severity of surgical complications in R0 gastric cancer resection. Patients and methods: In the present article, 124 cases of gastric cancer with R0 resection were reviewed. An OI <45 was considered pathologically low. The complication rate was compared between both groups: OI <45 vs OI ≥45. A multivariate analysis was performed adjusting for: age > 68 years, ASA score, preoperative hemoglobin level <12 g/dL, pTNM stage, administration of neoadyuvant therapy and type of gastrectomy. The relationship between a PNI<45 and the severity of complications graded according to the Clavien-Dindo classification was determined. Results: We registered mild complications in 11.3% of cases, severe complications in 9.7% and a mortality rate of 2.4%. Patients with a OI <45 showed a higher complication rate: 37.7% versus 12.7% [odds ratio (OR) = 4.17; CI95% = (1.71 - 10.20 p = 0.001)], confirmed by multivariate analysis: [OR = 4.17; CI95% = (1.54 - 11.30); p = 0.005]. Patients with OI <45 had more severe complication-exitus: 20.8% versus 5.6% [OR = 4.39; CI95% = (1.31 - 14.68); p = 0.011]. Conclusions: We confirmed that patients with a low preoperative OI show a higher independent risk of complications after a R0 gastric cancer resection in a western country as well. Complications, in these cases with OI <45, registered a significantly higher severity grade (AU)

Surgery: independent prognostic factor in curable and far advanced gastric cancer.

The hospital records of 639 patients affected by primary gastric cancer who were consecutively admitted to our unit during the period 1981-1995 were reviewed. Overall 220 underwent total gastrectomy (38 palliative), 12 had resection of the gastric stump, 195 had distal subtotal gastrectomy (55 palliative), 78 had bypass procedures, 72 had explorative laparotomy, and 62 had no operation. Univariate and multivariate analyses were used to evaluate 5-year survival with respect to the main clinical, pathologic, and treatment variables after both curative and palliative treatments. Overall the 5-year survival after curative treatment (320 patients-operative mortality excluded) was 55.5%: 91.1% for stage IA, 71.5% IB, 62.4% II, 37.5% IIIA, 31.5% IIIB. Among patients who underwent palliative treatment 5-year survival was 13.1% after gastric resection (total or distal subtotal), 4.9% after the bypass procedures, 0 after explorative laparotomy, and 0 after no operation. Univariate and multivariate survival analyses showed that variables independently associated with poor survival were advanced stage, upper location and D1 lymphadenectomy after curative treatment, tumor spread to distant sites, and nonresectional surgery after palliative treatment. Multivariate analysis showed that even though survival with gastric cancer depends on predetermined factors, the type of surgery can have a significant effect on prognosis after both curative and palliative treatment.

Carcinoma of the gastric cardia: surgical practices and short-term operative results in a defined Swedish population.

Adenocarcinoma of the gastric cardia has one of the most rapidly increasing incidence rates of all tumors in Western countries. The aim of this population-based investigation was to study surgical practices and postoperative morbidity and mortality during routine hospital care. The study comprised 176 patients given a new diagnosis of adenocarcinoma of the gastric cardia from February 1, 1989 to the January 31, 1995 in five Swedish counties. The tumor was resectable in 100 (57%) patients (in 36% of the women and 64% of the men), but only 46% of all patients could be offered a potentially curative operation. A total gastrectomy was performed in 54 patients and a proximal gastric resection in 44. Postoperative complications occurred in 39%: in 20% of the patients under age 60 years and in 47% of those aged 60 and over (p = 0.006). Seventeen operated patients (13%) died before discharge. The hospital mortality increased from 3% among those < 60 years of age to 18% among those > 69 years (p = 0.041). Surgical treatment of carcinoma of the gastric cardia carries substantial morbidity and mortality. No important progress seems to have taken place since the 1960s.

Gastric surgery does not increase the risk of developing Barrett's esophagus.

OBJECTIVE: Barrett's esophagus is currently believed to be related to severe and prolonged pathological acid gastroesophageal reflux. However, other factors have been discussed, especially pancreatic biliary reflux. To determine the importance of pancreatic-biliary reflux in the genesis of Barrett's esophagus, we assessed the prevalence of Barrett's esophagus in patients with an intact stomach and in those with previous gastric surgery. METHODS: This is a retrospective study in which 22,236 upper digestive endoscopy reports were reviewed and classified into two groups: intact stomach (n = 21,023) and operated stomach (n = 1,213). In turn, these two groups were divided into five subgroups according to surgical techniques. In each of the groups and subgroups, we calculated the percentage of patients with esophagitis, the percentage of esophagitis patients with Barrett's esophagus, and the percentage of Barrett's esophagus patients with complications. Results were compared by chi2 test. RESULTS: With regard to the prevalence of Barrett's esophagus, we found no significant differences between the study groups. CONCLUSIONS: We conclude that previous gastric surgery does not increase the risk that esophagitis patients will develop Barrett's esophagus.

Surgical mortality, survival, and quality of life after resection for gastric cancer in the elderly.

Although there were some studies on clinicopathologic characteristics, operative morbidity, and mortality in elderly patients with gastric cancer, no reports have specifically focused on survival and quality of life after resection. A total of 433 patients aged >/= 65 years (1987-1994) who underwent gastric resection for gastric adenocarcinoma were studied. Two groups were considered: patients aged 65 to 74 years and those > 74 years. Most of the patients (78.1%) had advanced diseases, and nearly half (41. 3%) had associated chronic disease(s). Resections with curative intention were performed in 362 patients (83.6%). The overall operative morbidity rate was 21.7% and mortality rate 5.1%. Although operative procedures were similar in both groups, patients aged >74 years had a higher mortality rate than those aged 65 to 74 years (10. 1% vs. 3.5%; p = 0.034). Age and extent of gastric resection were two independent factors negatively affecting mortality. The cumulative survival rates for patients who underwent curative resection were 86.2%, 72.4%, 67.2%, 62.9%, and 60.0% at 1, 2, 3, 4, and 5 years, respectively. Nearly all patients (96%) after surgery had normal work and daily activities. Some patients appeared to lack energy (16%) or experienced a period of anxiety or depression. There was no statistical difference in survival and quality of life assessed by the Spitzer index after curative resection between the two groups. Therefore resection with curative intention can be performed for the elderly with acceptable morbidity and mortality rates, possible long-term survival, and good quality of life, but a limited operation should be considered in the very elderly patients.

Borrmann's type IV gastric cancer: clinicopathologic analysis.

OBJECTIVE: To determine whether there is a specific pattern of clinicopathological features that could distinguish Borrmann's type IV gastric cancer from other types of gastric cancer. DESIGN: A retrospective study of patients with advanced gastric cancer treated between 1985 and 1995. SETTING: The Department of Surgery, Sendai National Hospital, a 716-bed teaching hospital. PATIENTS: The clinicopathologic features of 88 patients with Borrmann's type IV carcinoma of the stomach were reviewed from the database of gastric cancer. The results were compared with those of 309 patients with other types of gastric carcinoma. MAIN OUTCOME MEASURES: Gender, age, tumour size, depth of invasion, histologic type, cancer-stromal relationship, histologic growth pattern, nodal involvement, lymphatic and vascular invasion, type of operation, cause of death and 5-year survival. RESULTS: Women were afflicted as commonly as men in the Borrmann's type IV group. These patients tended to be younger and to have larger tumours involving the entire stomach than patients with other types of cancer. Histologic type was commonly diffuse and scirrhous, and serosal invasion was prominent with infiltrative growth. Nodal involvement and lymphatic invasion were more common in patients with Borrmann's type IV than in those with other types of gastric cancer. The disease was advanced in most instances and a total gastrectomy was performed in 55% of the patients. The survival rate of patients with Borrmann's type IV tumour was lower than for patients with other types of gastric cancer (p < 0.005, log-rank test). CONCLUSIONS: In Borrmann's type IV gastric cancer, early detection and curative resection are crucial to extend the patient's survival. Aggressive postoperative chemotherapy is recommended when a noncurative resection is performed.

Tratamiento quirurgico del cancer gastrico: una vision actualizada / Surgical treatment of gastric cancer: an update sight

La conducta adopatada en el Hospital de La Samaritana coincide con algunos preceptos actualmente preconizados por la Clinica Lahey (54), uno de los centros que en una epoca promulgaron la extirpacion radical y que mayor influencia produjeron en muchos paises del mundo, asi como con los preconizados por la Clinica Cleveland (55), institucion que ha modificado muchos de los tradicionales principios de radicalidad en la cirugia del cancer. 1. Todo paciente con cancer gastrico es sometido a exploracion quirurgica; 2. Si la lesion es resecable, se emprende una operacion "curativa", la cual comprende la reseccion del tumor con margenes suficientes, pero no excesivos, de tejido normal, tratando siempre de conservar un segmento de estomago proximal, y evitando la reseccion profilactica del bazo, epiplones y organos vecinos; 3. No se realiza la gastrectomia total sino en situaciones en las cuales esta es la unica forma de lograr la extirpacion total del tumor, y nunca como terapia paliativa; 4. Se realizan grandes resecciones solo para grandes canceres, y se realizan pequenas resecciones para tumores pequenos; 5. Cuando no es posible realizar una reseccion curativa, se procede con una reseccion paliativa si esta es facilmente realizable y no significa una reseccion heroica o masiva; especificamente se realizan resecciones paliativas para controlar hemorragia, obstruccion y dolor; nunca debe hacerse una gastrectomia total como procedimiento paliativo, y la gastroenterostomia, la gastrostomia o la yeyunostomia tienen muy escasa indicacion en la paliacion del cancer..

Cancer gástrico / Gastric cancer

El objetivo del presente trabajo es analizar la experiencia en un hospital general en el tratamiento del cáncer gástrico evaluando morbilidad, mortalidad y sobrevida a largo plazo. Entre enero de 1981 y diciembre de 1990 se operaron 176 pacientes con edad promedio de 70ñ9 años. Se realizó cirugía resectiva a 129 pacientes, de los cuales 79 con intención curativa. El tipo de resección fue RI en el 84// de los casos. Sólo el 29// de los pacientes pertenecían al estadio I o II. La morbilidad fue del 26// y la mortalidad global del 9//. El factor más importante de la supervivencia a largo plazo fue el estadio y el mejor tratamiento paliativo de la cirugia resectiva