Patient identification
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Diabetes Mellitus
Obstructive sleep apnea
CPAP use
Pulmonary / venous thrombosis
Vitamin deficiency
Metabolic syndrome
Cardiovascular disease
Mental heal condition
Hight blood pressure
Hypothyroidism
GERD
Smoking
Other (relevant disease)
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None
Hiatal hernia
Type I
Type II
Type III
Type IV
Esophagitis
LA classification
Grade A
Garde B
Grade C
Grade D
Gastropathy
Peptic ulcer
H. pylori
H. pylori erradicated
Duodenogastric reflux
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Planned primary procedure
Alternative procedure
Revision (Previous procedure)
Preop 3D-MDCT/IV-CT
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Horizontal stapler line distance from GEJ (pouch length)
Cardia stapler line distance
Blind loop length (G-J ostomy)
Alimentary limb length
Biliary limb length
G-J ostomy
Linear stapler
Circular stapler
Hand sewn
Reinforcement
Instrumentation
None
Tube
Other
Hiatal plication
None
Yes
J-J ostomy
Linear stapler
Hand sewn
Reinforcement
Mesenteric defect closure
Petersen
J-J ostomy
Other
Intraoperative adverse events
Leak
Bleeding
Perforation
Stenosis
Other
Treatment
Drain
No
Yes
Intraoperative test
Methylene blue
Endoscopy
Remarkable findings
Prophylaxis
Antibiotic
Antitrombotic
Intermittent pneumatic compression
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Major adverse events
None
Yes
Reintervention / endoscopy
Vital signs at discharge
BP:
/
HR:
RR:
Temp:
Drain removal
No drain
Yes (POD)
No, remains in place at discharge date
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Postoperative nutritionals recomendations
None
Yes
Verbal
In writing
Both
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