Esophagectomy (Ivor Lewis / Minimally Invasive)

CPT 43117
Approach Open
Add-on / Variant CPTs
  • 43107 — Total or near total esophagectomy, transhiatal
  • 43286 — Laparoscopic esophagectomy with thoracoscopy
Preoperative Diagnosis:

[Esophageal adenocarcinoma / squamous cell carcinoma] — [lower / middle / GEJ] esophagus — [clinical stage IIA / IIB / III], following [neoadjuvant chemoradiation / chemotherapy]

Postoperative Diagnosis:

Same

Procedure Performed:

Ivor Lewis esophagectomy [/ minimally invasive esophagectomy — laparoscopic abdomen + thoracoscopic chest] with intrathoracic [/ cervical] anastomosis

Attending Surgeon:

[Attending name], MD/DO

First Assistant:

[Resident/PA name]

Anesthesia:

General endotracheal — double-lumen tube with single-lung ventilation for thoracic phase; epidural for post-operative analgesia

Indications:

The patient is a [age]-year-old [male/female] with [esophageal adenocarcinoma / SCC] of the [lower esophagus / GEJ / mid-esophagus] following [neoadjuvant CROSS protocol chemoradiation]. Clinical restaging demonstrates [response to treatment / no distant metastasis]. Surgical resection was planned for curative intent. The risks, benefits, and alternatives were discussed and informed consent was obtained.

Findings:

Abdominal phase: The stomach was [mobile / required division of gastrocolic omentum and short gastrics]. A gastric conduit was fashioned. The celiac, left gastric, and hepatic lymph nodes were dissected. Thoracic phase: The esophagus was mobilized from the carina to the hiatus. Mediastinal lymph nodes were dissected. The anastomosis was created at the level of the [azygos vein / thoracic inlet] without tension. Post-operative EGD confirmed [anastomotic patency / no leak].

Description of Procedure:

[ABDOMINAL PHASE:]
The patient was positioned supine. A midline laparotomy [/ laparoscopic port placement with Hasson technique] was performed. The greater omentum was divided from the transverse colon. The gastrohepatic ligament was divided. The left gastric artery and vein were ligated and divided at the celiac axis, with lymph node dissection. The short gastric vessels were divided. The gastric conduit was fashioned by stapling [4–5 cm] from the lesser curvature using [green load GIA staplers] from the antrum to the fundus, creating a [5-cm-wide] conduit based on the right gastroepiploic artery. A pyloroplasty [/ Botox injection / pyloromyotomy] was performed. A [12 Fr] jejunostomy tube was placed for enteral nutrition.

[THORACIC PHASE:]
The patient was repositioned to the left lateral decubitus position. A [posterolateral thoracotomy / VATS utility thoracotomy] was performed through the [right 5th] intercostal space. Single-lung ventilation was established. The azygos vein was divided with a [vascular load stapler]. The esophagus was mobilized circumferentially from the carina to the hiatus with mediastinal lymphadenectomy (stations [2R, 4R, 7, 8, 9]).

The specimen was extracted. The gastric conduit was delivered into the chest through the esophageal hiatus. A [circular / linear] stapled [or hand-sewn] intrathoracic anastomosis was constructed at the level of [the azygos vein level / thoracic inlet]. The anastomosis was tested — no leak on saline wash. [A nasogastric tube was positioned distal to the anastomosis.] A [28 Fr] chest tube was placed. The thoracotomy was closed.

Complications:

None

Specimens:

Esophageal resection specimen with gastric cardia, regional lymph nodes — sent to pathology. Request proximal and distal margin evaluation.

Estimated Blood Loss:

[X] mL

Drains:

[28 Fr] chest tube; Jackson-Pratt drain near anastomosis; jejunostomy tube

Disposition:

The patient was taken to the thoracic ICU intubated and sedated [/ extubated to the ICU]. Jejunostomy feeds were initiated on postoperative day 1. Contrast swallow study was performed on [postoperative day 5] to confirm anastomotic integrity prior to oral intake.

Epic SmartPhrase Version 
PREOPERATIVE DIAGNOSIS: Esophageal *** — *** esophagus, stage ***, post-neoadjuvant ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Ivor Lewis esophagectomy / MIE with intrathoracic anastomosis
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General, DLT; epidural

INDICATIONS: .PTAGE-year-old .PTSEX with *** esophageal cancer, post-neoadjuvant, no distant disease. Consent obtained.

FINDINGS: Stomach mobile, conduit fashioned. Celiac/LGA LND performed. Esophagus mobilized carina to hiatus. Mediastinal LND stations ***. Anastomosis at *** level — no leak.

PROCEDURE:
ABDOMINAL: Supine. [Midline/Laparoscopic] access. Greater omentum divided. Gastrohepatic divided. LGA/LGV ligated at celiac with LND. Short gastrics divided. Gastric conduit fashioned, right gastroepiploic based, *** cm wide. Pyloroplasty/Botox/pyloromyotomy. J-tube placed.
THORACIC: Left lateral. Right *** ICS [thoracotomy/VATS]. Single-lung ventilation. Azygos divided. Esophagus mobilized. Mediastinal LND stations ***. Conduit delivered through hiatus. *** anastomosis at *** level. Saline test — no leak. NGT placed distal to anastomosis. Chest tube *** Fr. Closed.

EBL: *** mL
SPECIMENS: Esophageal specimen + LNs to pathology
COMPLICATIONS: None
DISPOSITION: Thoracic ICU. J-feeds POD 1. Swallow study POD 5.

Signed: .ME, .MYDEGREE
.TODAY
Variants

Transhiatal Esophagectomy (THE)

A transhiatal approach was used, avoiding thoracotomy. The abdominal phase was performed as described. Cervical esophageal dissection was performed through a left neck incision, with the esophagus encircled and controlled. The thoracic esophagus was mobilized bluntly through the hiatus under direct vision to the level of the carina, then with a hand advanced through the hiatus. The conduit was pulled up to the neck and a cervical hand-sewn [/ stapled] anastomosis was constructed. THE is preferred for patients with prohibitive pulmonary function or when thoracotomy is contraindicated; cervical leak rates are higher but are generally less morbid than intrathoracic leaks.

Charting Tips
  • Document anastomotic tension assessment. A conduit under tension is the most common cause of anastomotic leak. Document 'the anastomosis was created without tension' and describe how conduit length was ensured (gastric conduit length, point of anastomosis relative to carina).
  • Document pyloromyotomy/pyloroplasty or pyloric intervention. Gastric emptying depends on pyloric drainage after vagotomy. Document which drainage procedure was performed and why. Gastroparesis is a significant source of postoperative morbidity.
  • Document mediastinal lymph node stations dissected. Adequate lymphadenectomy (≥15 nodes for adenocarcinoma per AJCC) is required for accurate staging and affects adjuvant therapy decisions. Document each station dissected by number.
Billing Tips
  • 43107 (transhiatal esophagectomy without thoracotomy, 50.75 wRVU) vs 43112 (total esophagectomy with thoracotomy, 60.45 wRVU): approach determines the code, not the extent of resection.
  • Partial distal esophagectomy: 43117 (without thoracotomy, 56.06 wRVU) or 43118 (with thoracotomy, 65.39 wRVU). Use for limited distal resections with intrathoracic anastomosis.
  • 43123 (partial esophagectomy with transthoracic approach + thoracotomy, 81.04 wRVU) covers the most complex three-field (Ivor-Lewis or McKeown) variants. Document approach in detail.
  • Two-surgeon billing: thoracic and abdominal components may be performed simultaneously by two surgeons billing with modifier -62 (co-surgery); both bill the same CPT with -62.
  • Global period is 90 days. Post-op dilation for anastomotic stricture within the global period is bundled unless performed under separate anesthesia (modifier -58).
  • Pyloric drainage procedure (pyloroplasty 43800, pyloromyotomy 43520) performed concurrently is separately billable. Document conduit preparation and drainage procedure.
  • Minimally invasive esophagectomy (laparoscopic/thoracoscopic): use the same CPT codes as open; payers do not have separate MIS codes for esophagectomy. Append modifier -22 only if complexity was genuinely exceptional.