Ask Dr. Z

I'm looking at a case trying to help another coder out and now I'm confused. SMA/portal vein confluence. I'm leaning towards an unlisted code at this point...your thoughts?

PREOPERATIVE DIAGNOSIS: Pancreatic cancer, status post neoadjuvant therapy. POSTOPERATIVE DIAGNOSIS: Locally advanced pancreatic head adenocarcinoma with invasion of the superior mesenteric vein, status post neoadjuvant therapy.. OPERATION PERFORMED: End to End reconstruction of the superior mesenteric and portal vein confluence. INDICATIONS: Mr. xx is a 53-year-old gentleman, who was undergoing a Whipple procedure by Dr. xx and was found to have a locally invasive pancreatic head adenocarcinoma involving the superior mesenteric vein. I was consulted in the operating room for the superior mesenteric vein reconstruction as it appeared that a portion of the superior mesenteric vein at the level of the confluence of the splenic vein was attached on the right lateral aspect to the pancreatic head cancer and could not be separated. Please refer to Dr. xx operative report relating to the indications for the Whipple procedure. OPERATION: The patient was already in the supine position and Dr. xx had performed the major portion of the Whipple procedure, other than the section where the pancreatic head cancer was attached along the right lateral aspect of the superior mesenteric vein at the level of the confluence of the splenic vein and at the start of the portal vein origin. There appeared to be a slight aneurysmal dilatation on the anterior wall of the superior mesenteric vein at the point of entry of the splenic vein. The patient was given heparin intravenously by Anesthesia and approximately 5 to 10 minutes later, the superior mesenteric vein, the portal vein, and the splenic vein were each individually clamped with 3 separate pediatric Potts clamps. Dr. xx excised an oval shaped section of the right lateral aspect of the superior mesenteric vein just across from the point of entry of the splenic vein. The Whipple specimen was then handed out for pathology. At that point, the vein was flushed with hep-saline solution and I divided the superior mesenteric vein by extending to the left aspect to just below the point of entry of the splenic vein. I then approximated the 2 cut ends using 5-0 prolene on either side. An end-to-end anastomosis was performed using a continuous suture of 5-0 Prolene involving first the posterior wall and then the anterior wall. A growth factor of approximately 1 to 1-1/2 cm was placed and the total reconstruction took 17 minutes. The clamps were removed and the superior mesenteric vein expanded through the growth factor. There was a small area of bleeding on the right lateral aspect and this was controlled with a U-stitch of 5-0 Prolene. An intraoperative duplex was obtained, which showed slight turbulence in the area of the aneurysmal dilatation just above the anastomosis at the confluence of the splenic vein. There did not appear to be any area of stenosis and there was excellent flow without evidence of any thrill distal to the anastomosis. Dr. xx went on to complete the operation with the assistance of Dr. xx and Dr. xx. I was only present for the consultation relating to the revision/reconstruction of the superior mesenteric vein at the point of confluence with the splenic vein. I left the operating room and Dr. xx continued with completion of the Whipple procedure.