CPT® Code 43400

Official Description

Ligation, direct, esophageal varices

Common Language Description

The procedure described by CPT® Code 43400 refers to the ligation of esophageal varices, which are dilated veins in the esophagus that can lead to significant complications, including life-threatening bleeding. This surgical intervention is typically reserved for patients experiencing variceal bleeding that cannot be managed through less invasive methods such as pharmacologic treatments or endoscopic procedures. The ligation is performed through an open surgical approach, which is not commonly utilized due to the availability of alternative treatment options. In this procedure, the surgeon gains access to the esophagus by performing a right posterolateral thoracotomy, which involves making an incision in the skin and extending it through the underlying soft tissues. The scapula is retracted to facilitate entry into the thoracic cavity while ensuring that the pleura, the membrane surrounding the lungs, remains intact. A retropleural dissection is then carried out, allowing the lung to be retracted and the distal third of the esophagus to be exposed. Alternatively, a transhiatal abdominal approach may be employed, which involves accessing the esophagus through the abdominal cavity. Once the esophagus is adequately exposed, it is dissected free from surrounding tissues, and an incision is made to inspect the varices directly. The varices are subsequently ligated, or tied off, using sutures or bands under direct visualization. After successfully controlling the bleeding from the varices, the esophagus is repaired, and the surgical incisions are closed, marking the completion of the procedure.

1. Indications

The ligation of esophageal varices, as described by CPT® Code 43400, is indicated for patients who present with specific conditions related to esophageal varices. These indications include:

Variceal Bleeding Patients experiencing bleeding from esophageal varices that cannot be controlled through pharmacologic or endoscopic interventions.

2. Procedure

The procedure for ligation of esophageal varices involves several critical steps to ensure effective treatment. The steps are as follows:

Step 1: Surgical Access The procedure begins with a right posterolateral thoracotomy, where the surgeon makes an incision in the skin and extends it through the soft tissues to access the thoracic cavity. The scapula is retracted to provide a clear view and access to the esophagus while avoiding disruption of the pleura.
Step 2: Thoracic Entry and Dissection After gaining access to the thorax, the surgeon performs a retropleural dissection. This involves carefully retracting the lung to expose the distal third of the esophagus, allowing for a clear view of the varices that need to be treated.
Step 3: Alternative Approach In some cases, a transhiatal abdominal approach may be utilized. This method involves accessing the esophagus through the abdominal cavity, providing an alternative route for the procedure.
Step 4: Exposure and Inspection Once the esophagus is adequately exposed, the surgeon dissects it free from surrounding tissues and makes an incision to inspect the varices directly. This step is crucial for assessing the extent of the varices and planning the ligation.
Step 5: Ligation of Varices The varices are then ligated, or tied off, under direct vision using sutures or bands. This step is essential for controlling the bleeding and preventing further complications.
Step 6: Repair and Closure After successfully ligating the varices and controlling any bleeding, the surgeon repairs the esophagus. Finally, the surgical incisions are closed, completing the procedure.

3. Post-Procedure

Post-procedure care following the ligation of esophageal varices involves monitoring the patient for any signs of complications, such as bleeding or infection. Patients may require supportive care, including pain management and nutritional support, as they recover from the surgery. The expected recovery period can vary based on the individual patient's condition and the extent of the procedure performed. Follow-up evaluations are essential to ensure that the varices remain controlled and to assess the overall recovery process.

Short Descr	LIGATE ESOPHAGUS VEINS
Medium Descr	LIGATION DIRECT ESOPHAGEAL VARICES
Long Descr	Ligation, direct, esophageal varices
Status Code	Active Code
Global Days	090 - Major Surgery
PC/TC Indicator (26, TC)	0 - Physician Service Code
Multiple Procedures (51)	2 - Standard payment adjustment rules for multiple procedures apply.
Bilateral Surgery (50)	0 - 150% payment adjustment for bilateral procedures does NOT apply.
Physician Supervisions	09 - Concept does not apply.
Assistant Surgeon (80, 82)	2 - Payment restriction for assistants at surgery does not apply to this procedure...
Co-Surgeons (62)	1 - Co-surgeons could be paid, though supporting documentation is required...
Team Surgery (66)	0 - Team surgeons not permitted for this procedure.
Diagnostic Imaging Family	99 - Concept Does Not Apply
APC Status Indicator	Inpatient Procedures, not paid under OPPS
Type of Service (TOS)	2 - Surgery
Berenson-Eggers TOS (BETOS)	P1G - Major procedure - Other
MUE	1
CCS Clinical Classification	68 - Injection or ligation of esophageal varices