Esophagectomy (Ivor Lewis / Minimally Invasive)
4311743107wRVU: 50.75 — Total or near total esophagectomy, transhiatal43286wRVU: 53.63 — Laparoscopic esophagectomy with thoracoscopy
[Esophageal adenocarcinoma / squamous cell carcinoma] of the [lower / middle / GEJ] esophagus, [clinical stage IIA / IIB / III], following [neoadjuvant chemoradiation / chemotherapy]
Same
Ivor Lewis esophagectomy [/ minimally invasive esophagectomy (laparoscopic abdomen + thoracoscopic chest)] with intrathoracic [/ cervical] anastomosis
[Attending name], MD/DO
[Resident/PA name]
General endotracheal with double-lumen tube for thoracic phase; epidural for postoperative analgesia
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.
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].
[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 Heineke-Mikulicz pyloroplasty was performed [/ Finney pyloroplasty for scarred pylorus / Botox injection to pylorus / pyloromyotomy]. 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.
None
Esophageal resection specimen with gastric cardia, regional lymph nodes, sent to pathology. Request proximal and distal margin evaluation.
[X] mL
[28 Fr] chest tube; Jackson-Pratt drain near anastomosis; jejunostomy tube
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. Heineke-Mikulicz pyloroplasty performed [/ Finney / 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
.TODAYVariants
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 conduit viability before the anastomosis: conduit length, color and turgor at the tip, Doppler signal, and ICG fluorescence result if used. The note should show the surgeon assessed perfusion before constructing the anastomosis.
- Document anastomotic tension assessment. State the anastomosis was created without tension and how conduit length was confirmed adequate relative to the anastomotic level.
- Document mediastinal lymph node stations dissected by number. At least 15 nodes are required for accurate AJCC staging. 'Lymphadenectomy performed' without station numbers is inadequate.
- Document pyloric drainage intervention by name and technique. A 2025 ACS RCT demonstrated routine Heineke-Mikulicz pyloroplasty during esophagectomy significantly reduces early major complications (17.6% vs 27.1%) and delayed gastric emptying — making it the current standard for gastric conduit drainage. If pyloroplasty was performed, document the specific technique (Heineke-Mikulicz as standard; Finney for scarred pylorus). If Botox or pyloromyotomy was chosen instead, document the clinical rationale. Gastroparesis is the most common cause of prolonged hospitalization after esophagectomy.
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.