DATE OF PROCEDURE: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: This is a (XX)-year-old woman who presents for her 2-month surveillance upper endoscopy due to a history of Barrett esophagus with low-grade dysplasia/indefinite for dysplasia. The patient has undergone 3 prior HALO procedures and now presents for her 2-month surveillance esophagogastroduodenoscopy with possible HALO.
POSTOPERATIVE DIAGNOSES:
1. Barrett esophagus with low-grade dysplasia/indefinite for dysplasia, status post HALO, radiofrequency ablation.
2. Small sliding hiatal hernia.
3. Minimal antral gastritis.
PROCEDURE PERFORMED:
EGD with focal ablation of the distal esophagus utilizing the HALO system.
ENDOSCOPIST: John Doe, MD
SEDATION: Monitored anesthesia care per anesthesiology department.
COMPLICATIONS: None.
DESCRIPTION OF PROCEDURE: The risks and benefits of the procedure have been discussed in the past with the patient during her prior procedures as well as in the office. All questions were answered and informed consent was obtained. The patient was placed in the left lateral decubitus position and sedated as outlined above.
The video endoscope was inserted through the mouth and advanced to the descending portion of the duodenum under direct visualization without any difficulty. Duodenoscopy revealed a normal-appearing postbulbar duodenum as well as duodenal bulb. The scope was then withdrawn into the stomach. Gastroscopy revealed minimal antral erythema, edema, and friability. Otherwise, the remainder of the visualized mucosa of the gastric body and retroflexed views of the gastric cardia and fundus were unremarkable. A small sliding hiatal hernia was noted. Scope was then withdrawn into the distal esophagus. The Barrett tissue was once again closely inspected. There continues to be one tongue of ectopic mucosa, which is approximately 1.4 to 2.2 cm in size. The top of the intestinal metaplasia is at approximately 40 cm and the top of the gastric folds is at approximately 42 cm.
The endoscope was then removed and reintroduced with the ablation electrode attached. The Barrett tissue was targeted, proximal to distal treatment of the ectopic mucosa. The ablation electrode was positioned under direct visualization so that the electrode was in contact with the Barrett tissue. Energy was applied twice at approximately 100 watts/sq. cm at a setting of 15 joules/sq. cm. Ablation was repeated until all visible Barrett tissue was ablated. A second ablation was done adjacent to the first one due to a very small tongue of ectopic mucosa. Once again, it was applied twice at the same settings as detailed above. The ablation zone was then cleaned of any coagulative debris. The ablation electrode and the endoscope were then removed. The patient tolerated the procedure well and there were no apparent complications noted.
IMPRESSION:
1. Barrett esophagus with low-grade dysplasia/indefinite for dysplasia, status post HALO, radiofrequency ablation x4 treatments.
2. Small sliding hiatal hernia.
3. Minimal antral gastritis.
PLAN:
1. Have contacted office to arrange for the patient to have a repeat upper endoscopy with biopsies in 2 months.
2. Will give the patient prescriptions today for Zofran, acetaminophen/codeine elixir, GI cocktail, as well as Carafate. Also advised her to continue taking her Prevacid.
3. Will also advise the patient to contact the office if she has any postoperative complications, including increasing abdominal pain, chest pain, bleeding, fevers, or chills.
Dr. Doe, thank you very much for allowing me to participate in the care of this patient. Should you have any questions, please do not hesitate to contact me.
