DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS AND INDICATIONS: A patient with a long history of Crohn’s of the upper GI tract, status post multiple upper GI-related surgeries over nine years ago. Now, the patient has had a slow weight loss with poor nutrition with several significant strictures noted just beyond the stomach in the proximal jejunum.
POSTOPERATIVE DIAGNOSIS: Multiple Crohn’s-related strictures just distal to the stomach. The patient also had postsurgical changes. The significant strictures were dilated to 36 French with what was felt to be good results.
PROCEDURE PERFORMED: Panendoscopy and dilation.
MEDICATIONS: Fentanyl 200 mcg and Versed 2 mg.
DESCRIPTION OF PROCEDURE AND FINDINGS: The risks and indications of the procedure were discussed with the patient, who understood the risks and agreed to the procedure.
After sedation, the video endoscope was visually passed through the mouth into the esophagus. The esophagus was closely examined and revealed no abnormalities. The scope was passed into the stomach. There was some liquid and food debris in the stomach. The patient was status post antrectomy. His anatomy appeared to be most consistent with a Billroth II with afferent and efferent loops.
The area just past the stomach, which was felt to be jejunum, was markedly dilated. There was a stricture that was noted in this dilated segment. The scope was able to get through this stricture into a second dilated pouch of jejunum. There again was a second tight stricture in this area also.
With some manipulation, the scope was able to pass through this stricture and advanced another 10 or 15 cm. There was a third milder stricture, and then, when the scope was fully advanced to its limit, there did appear to be a mild to moderate fourth stricture. A wire and dilating balloon were able to easily pass beyond the fourth stricture. Initially, the fourth stricture was dilated to 30 French. The scope and balloon were then withdrawn, and dilation of the second stricture was also performed to 30 French.
At this point, the scope was further withdrawn, and the first most proximal stricture was dilated to 30 French. The scope was then advanced down to the fourth stricture. It was somewhat difficult to advance the scope beyond this for stricture. This was mostly related to tortuosity of the jejunum. Dilation was performed to 33 French.
At this point, the position of the scope was somewhat lost and no further dilation of the stricture was performed. The second stricture was next dilated again to 33 French and then 36 French. The scope was then further withdrawn and the most proximal stricture dilated to 33 French and 36 French. There did seem to be some significant improvement in these strictures. No complications were noted during the dilation. The procedure was then completed, and the patient’s immediate recovery was uneventful.
PLAN AND RECOMMENDATIONS: The patient was started on a clear liquid diet and slowly advance his diet. We will probably repeat the endoscopy and consider further dilation in six to eight weeks.
