1st Physician:Procedure: Colonoscopy
Indications: Screening for colorectal malignant neoplasm
The Colonoscope was introduced through the anus and advanced to the cecum, The distal aspect of this lesion was located 11 cm from the anal verge. This lesion was not resected at this time.
- One 3 mm polyp in the descending Colon. Resected and retrieved.
- Few smal diverticula in the sigmoid colon.
Large polypoid lesion noted in the rectum as described above.
- Await pathology results.
- Repeat flexible sigmoidoscopy with wide endoscopic mucosal resection of this rectal lesion to be Attending Participation:- Large polypoid lesion noted in the rectum as described above. CPT 45380
2nd Physician same day
A flat polyp (Paris IIa + Is) was found in the recto-sigmoid colon. The polyp was 30 mm in size. After submucosal injection
of diluted epinephrine (1:20,000) stained with methylene blue, the polyp was resected in piecemeal fashion using snare
cautery polypectomy. The small amount of residual polypoid tissue at the resection edge was first removed with a jumbo
biopsy forceps and then ablated using a 7Fr, straight fire, APC probe at 30 Watts and 0.8 L/min. Two carbon black tattoos
were then placed (one on the proximal edge and one on the distal edge of the resection site) to aid future identification of
the site.
Impression:- One 30mm rectosigmoid colon polyp removed in piecemeal fashion with saline assisted EMR then ablated with APC.
- Location marked with Carbon Black for future identification.CPT 45339 & 45335