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Technology still requires human input to ensure the integrity of automated front-end and back-end processes. Ten years ago, the healthcare industry was pushed into the digital world via the Health Information Technology for Economic and Clinical Health Act (HITECH); and while some healthcare professionals felt uprooted and/or poorly equipped for this change, others used it […]
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DESCRIPTION OF PROCEDURE: The patient was given general anesthetic. He was placed in Allen stirrups, prepped with Betadine solution and sterile towels. We probed the left lower quadrant site, passed a forceps and found that it seemed to go quite deep towards the pelvis, so I irrigated with saline solution and found that it did in fact tract and drained out through the rectum.
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I then used a curette to clean out as much as possible this sinus tract and then from below probed through the anus cleaning out the sinus tract above the rectum was opened and then cleaned out with a curette the sinus tract where the Penrose exit just lateral to the anus on the right hand side. Finally, the vascular clamp passed to have his drain through the left lower quadrant wound and brought it out to the apex of the rectum and brought outside the anus and then I sutured that drained to preexisting drain that went into the rectum and came out lateral to the rectum. I then cut the looped drain and pulled it through so that the drain now came out via the perineal opening and no longer leaking out to the anus. Finally, I made a second incision just anterior to the sphincter on the right-hand side and made a second incision through there and tunneled the drain, so it went from left lower quadrant out to wound just anterior to the scrotum. Each were sutured in place with nylon. Dry dressings were applied. Dr. XXXX examined the patient and confirmed proper positioning of the drains. He was taken to recovery.
:confused::confused:
Carol
Procedure:
The patient was placed in the supine position on the fluoroscopy table.
The skin over the left groin, left abdomen, and left upper quadrant was prepped and draped in the usual sterile fashion.
The largest pocket of ascites was identified in the left lower quadrant. 1% lidocaine was used to anesthetize the skin and subcutaneous tissues. Using a micropuncture needle and ultrasound guidance, the peritoneal cavity as accessed. The transitional dilator was placed and a Bentson wire was advanced into the peritoneal cavity under fluoroscopic guidance. Over the Bentson wire, a 5 Fr pigtail catheter was placed. Ascites was aspirated throughout the case. A total of 7.6 Liters of serosanguinous ascites was aspirated. The 5 Fr pigtail catheter was removed at the end of the case with
Attention was then turned to the spleen. Under ultrasound guidance, the inferior pole splenic vein was accessed using a 21 gauge Accustik needle. A splenic venogram was performed through the 21 gauge needle. There were prominent splenic varices. The major outflow was via mesenteric to lumbar collateral veins as well as left chest wall collateral veins. No large gastric varices were noted via the splenic venogram. Therefore, 21 gauge needle was removed and pressure was held for hemostasis.
The left common femoral was accessed using a micropuncture needle under ultrasound guidance and then upsized to a 5 Fr sheath over an Amplatz wire. A left common iliac / IVC venogram was performed which demonstrated a patent venous system.
Through the 5 Fr sheath, a 5 Fr C1 catheter and 0.035" glidewire was used to access the left renal vein and left gastrorenal shunt/phrenic vein. The C1 was exchanged for a 5 Fr glidecath which was used to access the left gastrorenal shunt/phrenic vein. A venogram was performed which demonstrated a small gastrorenal shunt measuring 8 mm into the left renal vein.
The glidecath was advanced to the apex of the left phrenic vein. A venogram was performed which demonstrated the left phrenic venous plexus with small connections to gastric veins. There were no large gastric varices. Additional venograms were performed of the left phrenic vein branches. The left adrenal vein was identified. There was no evidence of large gastric varices.
A 2.4 Fr progreat microcatheter with 0.014" fathom microwire was used to advanced into the phrenic venous plexus in an attempt to cross into the gastric veins. However, due to the tortuosity, this was unsuccessful.
At this point, the decision was made to end the procedure.
All catheters and wires were removed. The right groin sheath was removed and pressure held to hemostasis.
The patient tolerated the procedure well.
There were no apparent immediate complications.
Impression:
1) Splenic venogram with large draining veins/varices into mesenteric/lumbar collaterals as well as left chest wall collaterals. There were no large gastric varices that were amenable to treatment via the splenic venogram.
2) Patent common iliac vein and IVC
3) Gastrorenal shunt measuring 8 mm with connection to small gastric veins via the left phrenic vein venous plexus. There were no large gastric varices that were amenable to treatment via this retrograde venogram.
4) Uncomplicated paracentesis with a total of 7.6 Liters serosanguinous ascites aspirated.
Plan:
1) Continue monitoring for bleeding and transfuse PRN.
2) No indication for additional IR intervention at this time.
The Centers for Medicare & Medicaid Services (CMS) measures the fee-for-service (FFS) improper payment rate through the Comprehensive Error Rate Testing (CERT) program. According to a 2017 CERT report, CMS had a 90.5 percent proper payment rate and a 9.5 percent improper payment rate for all claims submitted July 1, 2015, to June 30, 2016. […]
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House plans to replace Obamacare through a proposed Congressional reconciliation bill would reduce federal deficits by$ 323 billion of on-budget savings and $ 13 billion in off-budget by 2026, but the human cost will be high, according to the Congressional Budget Office (CBO). The bipartisan agency said 14 more people would be uninsured in 2018 under
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