CPT® Code 44137

Official Description

Removal of transplanted intestinal allograft, complete

Common Language Description

The procedure described by CPT® Code 44137 involves the complete removal of a transplanted intestinal allograft. This surgical intervention is typically necessitated by complications such as graft failure, which may occur due to chronic rejection of the transplanted tissue, or other serious issues like thrombosis affecting major arteries. The operation begins with the exposure of the abdominal cavity through a midline incision, allowing the surgeon to access the transplanted intestine and surrounding structures. During the procedure, any adhesions that may have formed are carefully lysed using both blunt and sharp dissection techniques to ensure a clear field of operation. The surgeon then retracts the intestine to expose the aorta, which is critical for identifying and managing the vascular connections made during the initial transplant. The aortic and venous grafts are meticulously dissected and controlled with vessel loops before being clamped and transected. The anastomosis sites, where the transplanted intestine connects to the native intestine, are identified, and the transplanted segment is divided and removed en bloc. Following the removal, the remnants of the aortic and venous grafts are sutured closed, and the distal stump of the native bowel is oversewn to prevent leakage. The proximal end of the native intestine is then exteriorized through a small incision made at the planned enterostomy site. This involves excising fat and opening the anterior rectus fascia to access the peritoneum. An opening of adequate size is created for the stoma, allowing the segment of small bowel to be brought out through the abdominal wall, everted, and sutured to the skin. Additionally, a gastrostomy tube is inserted and anchored to the abdominal wall to facilitate postoperative care. Finally, abdominal drains are placed to manage any potential fluid accumulation, and the surgical wound is closed, completing the procedure.

1. Indications

The procedure described by CPT® Code 44137 is indicated for the complete removal of a transplanted intestinal allograft due to specific complications. These include:

Graft Failure - This may occur as a result of chronic rejection of the transplanted intestine, where the recipient's immune system attacks the graft.
Thrombosis of Major Arteries - This condition can lead to compromised blood flow to the transplanted intestine, necessitating its removal.

2. Procedure

The procedure for the complete removal of a transplanted intestinal allograft involves several critical steps, each performed with precision to ensure patient safety and surgical success:

Step 1: Abdominal Incision - The surgeon begins by making a midline incision in the abdominal cavity to gain access to the transplanted intestine and surrounding structures.
Step 2: Lysis of Adhesions - Once the abdominal cavity is exposed, any adhesions that may have formed are lysed using both blunt and sharp dissection techniques, allowing for better visibility and access to the surgical site.
Step 3: Exposure of the Aorta - The intestine is carefully retracted to expose the aorta, which is essential for identifying the vascular connections made during the transplant procedure.
Step 4: Dissection of Grafts - The aortic and venous grafts that were constructed at the time of the transplant are dissected and controlled with vessel loops. They are then clamped and transected to facilitate the removal of the allograft.
Step 5: Division of Transplanted Intestine - The anastomosis sites where the transplanted intestine connects to the native intestine are identified. The transplanted intestine is then divided from the native intestine and removed en bloc.
Step 6: Closure of Graft Remnants - After the allograft is removed, the remnants of the aortic and venous grafts are sutured closed to prevent any complications.
Step 7: Oversewing of Native Bowel Stump - The distal stump of the native bowel is oversewn to ensure that there is no leakage from the remaining intestine.
Step 8: Exteriorization of Proximal Native Intestine - The proximal end of the native intestine is exteriorized through a small incision made over the planned enterostomy site.
Step 9: Creation of Stoma - A small incision is made through the subcutaneous tissue, and fat is excised to expose the anterior rectus fascia. The rectus muscle fibers are separated using blunt dissection, and the peritoneum is entered. An opening of sufficient diameter is created for the stoma, allowing the segment of small bowel to be brought out through the peritoneum and abdominal wall, everted, and sutured to the skin.
Step 10: Insertion of Gastrostomy Tube - A gastrostomy tube is inserted and anchored to the abdominal wall to assist with postoperative feeding and care.
Step 11: Placement of Abdominal Drains - Abdominal drains are placed to manage any potential fluid accumulation post-surgery.
Step 12: Closure of Surgical Wound - Finally, the surgical wound is closed, completing the procedure.

3. Post-Procedure

Post-procedure care following the complete removal of a transplanted intestinal allograft includes monitoring for any complications such as infection, bleeding, or issues related to the stoma. Patients may require nutritional support through the gastrostomy tube until they can resume normal oral intake. Regular follow-up appointments are essential to assess the healing process and manage any ongoing care needs related to the enterostomy. Additionally, the surgical team will provide instructions on stoma care and signs of potential complications that the patient should watch for during recovery.

Short Descr	REMOVE INTESTINAL ALLOGRAFT
Medium Descr	RMVL TRNSPLED INTESTINAL ALLOGRAFT COMPL
Long Descr	Removal of transplanted intestinal allograft, complete
Status Code	Carriers Price the Code
Global Days	XXX - Global Concept Does Not Apply
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	99 - Other OR gastrointestinal therapeutic procedures

82	Assistant surgeon (when qualified resident surgeon not available): the unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).
GC	This service has been performed in part by a resident under the direction of a teaching physician