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Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with transendoscopic stent placement (includes predilation)

CPT4 code

Name of the Procedure:

Small intestinal endoscopy, enteroscopy beyond second portion of duodenum, not including ileum; with transendoscopic stent placement (includes predilation).
Common name(s): Enteroscopy with stent placement

Summary

Enteroscopy with stent placement is a medical procedure where a flexible tube with a camera (endoscope) is inserted into the small intestine beyond the second portion of the duodenum. The procedure involves placing a stent (a small tube) to keep a narrowed or blocked section of the intestine open. Predilation, or the widening of the intestine, is included before the stent is placed.

Purpose

Medical Condition or Problem:

This procedure addresses obstructions or severe narrowings (strictures) in the small intestine that can cause symptoms like pain, vomiting, and difficulty digesting food.

Goals or Expected Outcomes:

The goal is to alleviate obstruction, improve food passage, relieve symptoms, and enhance the patient's quality of life.

Indications

Specific Symptoms or Conditions:
  • Chronic abdominal pain
  • Vomiting
  • Unexplained nausea
  • Severe weight loss
  • Malnutrition due to intestinal blockage
Patient Criteria:

Patients with confirmed small intestinal obstructions or strictures that cannot be managed with medication alone.

Preparation

Pre-procedure Instructions:
  • Fasting (usually for 8-12 hours before the procedure)
  • Adjustments to current medications as directed by the physician
  • Complete any prescribed bowel preparation solutions
Diagnostic Tests:
  • Blood tests
  • Imaging studies like a CT scan or MRI
  • Review of medical history and physical examination

Procedure Description

  1. Anesthesia: The patient is usually given conscious sedation or general anesthesia.
  2. Insertion: The endoscope is carefully inserted through the mouth and advanced beyond the second portion of the duodenum.
  3. Navigation: The endoscope’s camera allows the doctor to navigate through the intestines.
  4. Assessment: The narrowed area is located and assessed.
  5. Predilation: The area is dilated (widened) using a special balloon.
  6. Stent Placement: A stent is placed in the dilated area to keep it open.
  7. Confirmation: Placement is confirmed with imaging, and the endoscope is carefully withdrawn.
Tools, Equipment, Technology:
  • Flexible endoscope with a camera
  • Balloon dilator
  • Stent deployment system

Duration

The procedure typically takes between 1 to 3 hours, depending on the case complexity.

Setting

Enteroscopy with stent placement is performed in a hospital or an outpatient surgical center equipped with endoscopic facilities.

Personnel

  • Gastroenterologist or surgeon performing the procedure
  • Nurses or endoscopy technicians assisting
  • Anesthesiologist (if general anesthesia is used)

Risks and Complications

Common Risks:
  • Sore throat
  • Mild abdominal discomfort
Rare Risks:
  • Perforation (tear) of the intestine
  • Infection
  • Bleeding
  • Stent migration or occlusion
Management of Complications:

Complications are managed with medications, additional procedures, or surgery, if necessary.

Benefits

  • Relieves symptoms of obstruction
  • Improves nutritional absorption
  • Reduces pain and discomfort
  • Enhances overall quality of life ##### Realization of Benefits: Benefits are often realized immediately after the procedure with gradual improvement over days to weeks.

Recovery

Post-procedure Care:
  • Observational period in a recovery area
  • Pain management as needed
  • Gradual reintroduction of diet
Recovery Time:

Full recovery typically takes a few days, with most patients resuming normal activities within a week.

Restrictions and Follow-up:
  • Avoid strenuous activities for a few days
  • Follow-up appointments to monitor stent position and efficacy

Alternatives

Other Treatment Options:
  • Medication to manage symptoms
  • Surgical intervention to bypass or remove the obstruction
Pros and Cons:
  • Medications: Less invasive but often less effective for severe obstructions.
  • Surgery: More definitive but involves longer recovery and higher risk.

Patient Experience

During Procedure:

The patient may experience a sensation of pressure or discomfort initially, generally well-managed with sedation.

After Procedure:

Soreness in the throat or mild abdominal discomfort may occur. Pain is typically mild and managed with over-the-counter analgesics.

Pain Management:

Mild pain relief medications and supportive care ensure patient comfort during recovery.

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