Surgical Timeline

Anderson Hospital 6800 State Route 162 Maryville, IL 62062 Operative Note SignedPatient: Towell,Alexander R MR#: M000499848 DOB: 08/04/1975 Acct:V00003688837Age: 48 ADM Date: 07/22/24 Loc: ANHSURGERY Attending Dr: Pei Chang Chung M.D.cc: Chung, Pei Chang MD; Suthan***, Nanthini MD~Procedure Note - DetailedDate of Procedure07/22/24Pre-op Diagnosis small-bowel adenocarcinomaPost-op DiagnosisSameProcedure Performed placement of left subclavian venous access device under fluoroscopic guidanceSurgeonPei Chang Chung, MDAnesthesiaMAC and LocalIndications 48-year-old male with small bowel adenocarcinoma status post right hemicolectomy now needing adjuvant chemotherapyFindings 1st stick left subclavianDescription of ProcedurePatient was brought into the operating room and placed in the supine position. After adequate induction of mac anesthesia, the patient was prepped and draped in normal sterile fashion. Time-out was then done to verify the patient's identity, as well as the procedure being performed. I began by making a small incision in the left chest, I then gained access into the left subclavian vein with an 18 gauge needle. I then placed the guidewire into the vein and confirmedplacement via fluoroscopic guidance. I then locally anesthetized the area in the left chest. I then enlarged the incision around the guidewire including making a subcutaneous pocket inferiorly to allow placement of the port itself. I then placed a dilating sheath over the guidewire into the left subclavian veinvia sterile Seldinger technique. This was once again done and confirmed via fluoroscopic guidance. I then removed the dilator and the guidewire, now just leaving the sheath in the vein. I then fed the previously flushed catheter intothe left subclavian vein under fluoroscopic guidance. At approximately 23 cm, the catheter was noted to be near the atrial caval junction. I then peeled awaythe sheath, now just leaving the catheter in the vein. I then was able to easily draw and flush from the catheter. The catheter was cut to fit and attached to the port itself. The port was placed into the previously made subcutaneous pocket and sutured in with 0 Ethibond suture. Final fluoroscopic view showed the termination of the catheter at the atrial caval junction with a nice smooth curvature back to the port itself. I was able to gain access to theport with a Huber needle and was able to easily draw and flush from the port. I then flushed 4 cc of a final heparin flush into the port. The incision was closed with 3 0 Vicryl suture in the subcutaneous tissue and the skin was closedwith 4 O Monocryl subcuticular suture. Dermabond was then placed on wound. Thepatient tolerated the procedure well and will be sent to the recovery room in stable condition.ImplantsL SCV VADEstimated Blood Loss5DrainsNoPackingNoPathologyNone sentComplicationsNo immediate complicationsConditionStableDispositionPACUAMG BillingSurgery - Charge Forward: Surgery BillingThis report may have been done utilizing a voice recognition system. Attempts have been made to correct errors. However, there may be uncorrected grammatical,spelling, and recognition errors present.Report Initialized date/time: Chung, Pei Chang MD 07/22/24 / 1557Electronically signed by: Chung, Pei Chang MD 07/22/24 1557

Anderson Hospital 6800 State Route 162 Maryville, IL 62062 Operative Note SignedPatient: Towell,Alexnder R MR#: M000499848 DOB: 08/04/1975 Acct:V00003676858Age: 48 ADM Date: 07/01/24 Loc: ANHSURGERY Attending Dr: Pei Chang Chung M.D.cc: Chung, Pei Chang MD; Suthan***, Nanthini MD~Procedure Note - DetailedDate of Procedure07/01/24Pre-op Diagnosissmall bowel cancerPost-op DiagnosisSameProcedure Performedhand assisted laparoscopic right colectomy c mobilization of hepatic flexureSurgeonPei Chang Chung, MDAnesthesiaGeneralIndications 48-year-old male presenting with adenocarcinoma of the terminal ileum. The patient has previous sigmoid colon cancer status post resection and adjuvant therapy.Findingspalpable mass in terminal ileum with noted masses in the mesentery consistent with lymph node spreadDescription of ProcedureThe patient was taken to the operating room and placed in the supine position. After adequate induction of general anesthesia, the patient was prepped and draped normal sterile fashion. A time-out was then done to verify the patient'sidentity as well as the procedure being performed. I began by making a hand port incision around the umbilicus. Of note, this was done through his previoushand port incision. This was carried down into the peritoneal cavity and there was noted adhesions to the lower anterior abdominal wall. These adhesions weretaken down under visualization with the bovie cautery. Once the abdominal wall was cleared, the hand port was then placed. I then insufflated the abdomen through the hand port. I then placed the camera through the hand port and under direct visualization, I placed 2 5 mm ports in right lower and right mid abdomen. Once this was done, I examined the right abdomen. It was noted that the patient had adhesions of the cecum and distal ileum to the pelvis. These adhesions were taken down both bluntly and with the ligasure under direct visualization. This adhesiolysis took approximately 30 minutes. There was a noted large mass in the terminal ileum approximately 5-10 cm from the ileocecal valve. There was also noted to be at least 2 large masses in the mesentery around this area consistent with lymph node spread. I then began my medial to lateral approach. I was able to identify the right colic vessels. I subsequently transected the right colic vessels with the LigaSure device. This was taken down near the base of the mesentery with the LigaSure. Once this was done, I carried this plane towards the hepatic flexure until I encountered the duodenum which was mobilized posteriorly. I then began taking down the lateral attachments of the terminal ileum and right colon including taking down the white line of Toldt and the hepatic flexure. Once this was done my medial and lateral dissection planes met. I was able to easily manipulate the right colon. at this point I extracorporealyzed the right colon and terminal ileum. I thentransected the terminal ileum approximately 10 cm proximal to the mass with a 55GIA stapler. I then transected the colon at the ascending colon making sure there was plenty of distal intestine to the mass. I then performed a side-to-side functional end-to-end anastomosis between the ileum and ascending colon with a 55 GIA stapler followed by a TL 60 stapler. The anastomosis was noted to be tension-free and widely patent. I closed the messenteric defect with a 2.0 silk suture. I then copiously irrigated the abdomen, no other pathology was noted. I then closed the hand port incision with a 0 PDS suture at the fascial level. The skin was closed with 4 O Monocryl subcuticular sutures including the 5 mm ports sites. Dermabond was then placed on all wounds. The patient tolerated the procedure well. He was extubated in the operating room postoperatively and will be transferred to the recovery room in stable condition.Estimated Blood Loss25DrainsNoPackingNoPathologyYesComplicationsNo immediate complicationsConditionStableDispositionPACUAMG BillingSurgery - Charge Forward: Surgery BillingThis report may have been done utilizing a voice recognition system. Attempts have been made to correct errors. However, there may be uncorrected grammatical,spelling, and recognition errors present.Report Initialized date/time: Chung, Pei Chang MD 07/01/24 / 1548Electronically signed by: Chung, Pei Chang MD 07/01/24 1548

ANESTHESIA ARTERIAL LINE PLACEMENT — 2025-05-14

ANESTHESIA INTUBATION — 2025-05-14

Cerumen Removal — 2023-07-25

colonoscopy — 2024-05-29

Colonoscopy — 2024-05-29

Colonoscopy with biopsy — 2021-12-12

CT, abdomen + pelvis, w/ contrast — 2021-12-08

CT, abdomen + pelvis, w/ contrast — 2023-12-27

CT, abdomen + pelvis, w/ contrast — 2024-10-14

CT, abdomen + pelvis, w/o contrast — 2023-04-30

CT, abdomen + pelvis, w/wo contrast — 2024-05-06

CT, abdomen + pelvis, w/wo contrast — 2025-03-12

CT, abdomen, w/ contrast — 2023-12-27

electrocardiogram — 2021-10-07

endoscopy — 2021-12-12

Esophagogastroduodenoscopy & Colonoscopy — 2021-11-22

Esophagogastroduodenoscopy with colonoscopy — 2021-11-22

Insertion Porta Cath (Left) — 2022-02-09

Insertion Porta Cath (Left) — 2024-07-22

Insertion, Port-A-Cath — 2022-02-09

July 1st, 2024 3:48pm

July 22nd, 2024 3:57pm

Lap Right Transverse Colon Resection (Right) — 2024-07-01

Lap Sigmoid Colon Resection (Left) — 2021-12-29

Laparoscopic left hemicolectomy or sigmoidectomy with creation of end colostomy and c — 2021-12-29

lobectomy of thyroid gland — 2022-10-20

MRI procedure (PROC) — 2025-05-26

NM, bone scan, whole body — 2024-05-21

Other — 2021-12-29

Other — 2022-01-20

Pei ChungAnderson HealthcareJuly 1st, 2024 3:48pm

Pei ChungAnderson HealthcareJuly 22nd, 2024 3:57pm

PERIPHERAL LINE — 2025-05-14

PET, limited — 2022-01-31

PET, limited — 2024-07-24

PR AN ELECTIVE ENDOTRACHEAL AIRWAY — 2025-12-18

PR AN PROCEDURE PLACEHOLDER — 2025-12-18

Removal Porta Cath (Bilateral) — 2024-01-17

resection of segment of liver

RF, guidance — 2024-06-30

US, chest wall — 2021-10-07

US, thyroid — 2022-03-09

XI LIVER RESECTION - LAPAROSCOPIC ROBOTIC ASSISTED SEGMENT 5 8 and 4B, INTRAOPERATIVE ULTRASOUND and TAP BLOCK

XI LIVER RESECTION - LAPAROSCOPIC ROBOTIC ASSISTED, TAP Block

XR, abdomen + pelvis — 2024-05-06

XR, abdomen + pelvis — 2024-05-07

XR, chest — 2022-02-08

XR, portacathogram — 2024-07-21

XR, wrist — 2023-07-25