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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Pouch length
Cardia stapler line distance
Biliary limb length
Commom limb length
G-J ostomy
Laterlo-lateral anastomosis
Termino-lateral anastomosis
Linear stapler
Circular stapler
Hand sewn
Reinforcement
Instrumentation
None
Tube
Other
Hiatal plication
None
Yes
Antireflux mechanism
Latero-lateral gastro-enteric suture (length)
Other
Mesenteric defect closure
Petersen
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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