CPT® Code 43641

1. Indications

The procedure described by CPT® Code 43641 is indicated for patients experiencing conditions related to excessive gastric acid production. The following are specific indications for performing a highly selective vagotomy:

• Peptic Ulcers: Patients with recurrent peptic ulcers that are resistant to medical management may benefit from this procedure to reduce acid secretion.
• Gastric Hypersecretion: Conditions characterized by excessive gastric acid production, leading to complications such as gastritis or esophagitis, may warrant this surgical intervention.
• Gastric Outlet Obstruction: In cases where gastric outlet obstruction is caused by peptic ulcers, vagotomy combined with pyloroplasty can help alleviate symptoms.

2. Procedure

The procedure for CPT® Code 43641 involves several critical steps to ensure effective surgical intervention:

• Step 1: Incision and Exposure A midline upper abdominal incision is made to provide access to the stomach and the vagus nerve. This incision allows the surgeon to visualize and manipulate the necessary anatomical structures.
• Step 2: Identification of the Vagus Nerve The vagus nerve is carefully identified and freed from surrounding tissues. This step is crucial for ensuring that the nerve can be accurately dissected without damaging adjacent structures.
• Step 3: Highly Selective Vagotomy The surgeon follows the vagus nerve to the Latarjet's nerve branches, also known as the parietal cell branches. These branches are then divided starting at the esophagogastric junction and continuing along the lesser curvature of the stomach, effectively reducing acid production.
• Step 4: Pyloroplasty To address potential gastric motility issues, a pyloroplasty is performed. The pyloric sphincter is incised longitudinally, and the incision is repaired transversely to enlarge the opening from the stomach to the duodenum, facilitating gastric drainage.
• Step 5: Gastrostomy (if indicated) If a gastrostomy is required, two concentric purse-string sutures are placed around the planned incision site on the stomach. The serosa is incised, and a small portion of the inner mucosal layer is excised to create an opening. A balloon catheter is then inserted, inflated, and secured in place with the purse-string sutures.
• Step 6: Catheter Exteriorization The stomach is positioned against the abdominal wall, and a stab incision is made in the abdomen to exteriorize the catheter. The catheter is grasped and brought out through the abdominal wall, allowing for access to the stomach.
• Step 7: Closure Finally, anchoring sutures are placed on the internal abdominal wall, and the abdominal incision is closed in layers to ensure proper healing and minimize complications.

3. Post-Procedure

After the completion of the procedure, patients typically require monitoring for any complications related to the surgery. Post-operative care may include managing pain, monitoring for signs of infection, and ensuring proper gastric drainage. Patients may experience changes in gastric motility, and dietary modifications may be necessary during the recovery period. Follow-up appointments are essential to assess healing and the effectiveness of the procedure in reducing gastric acid production and preventing peptic ulcers.