REVISION by cuiliqing


									                                                               REVISION                                                                  MBSC
                                       SECTION A: ADMINISTRATIVE INFORMATION
   A1. Site ID #: __ __                A2. Registry ID #: __ __/ __ __ __ __ __ __ A3. Patient’s initials: __ __ __

                                  SECTION B: PRE-OPERATIVE MEDICAL CONDITIONS
   B1. Time from original procedure to revision                                 (cont.)
              a.  <30 days post-op                                              B6. If done for a complication, please give the underlying diagnosis
              b.  > 30 days and < 90 days post-op                               b. Original procedure: Adjustable gastric band
              c.   > 90 days and < 1 year post-op                                     1.     Band slippage
              d.   1 year and < 5 years post-op                                       2.     Band erosion
              e.   > 5 years post-op                                                  3.     Band infection
                                                                                      4.    Port site infection
   B2. What was the original procedure?                                               5.     Food intolerance
            a.    Gastric bypass                                                      6.     Other (specify) ___________________________________
            b.    Adjustable gastric band                                       c. Original procedure: Sleeve gastrectomy
            c.    Sleeve gastrectomy                                                  1.     Non-healing leak from original procedure
            d.    Vertical banded gastroplasty                                        2.     Stricture/obstruction
            e.    Malabsorptive procedure (biliopancreatic diversion with             3.     Gastroesophageal reflux symptoms
                 or without duodenal switch)                                          4.     Chronic nausea
            f.   Jejunoileal bypass                                                   5.     Other (specify) ___________________________________
            g.    Other (specify)_________________________________              d. Original procedure: Vertical banded gastroplasty
                                                                                      1.     Stricture/ pouch outlet obstruction
   B3. What was the revisional procedure?                                             2.     Gastric staple line disruption/gastrogastric fistula
            a.    Revision of original operation                                      3.     Other (specify) ___________________________________
            b.    Conversion to another procedure:                              e. Original procedure: malabsorptive procedure (Biliopacreatic
                      i.   Gastric bypass                                           diversion with or without duodenal switch)
                     ii.   Adjustable gastric band                                    1.     Non-healing leak
                    iii.   Sleeve gastrectomy                                         2.     Malnutrition
                    iv.    Malabsorptive procedure (biliopancreatic                   3.     Small bowel obstruction
                           diversion with or without duodenal switch)                        i.    Internal hernia
                    v.    Reversal of original procedure (with return to                    ii.    Obstruction/stricture at enteroenterostomy
                           normal anatomy)                                                 iii.    Adhesive disease
                                                                                           iv.     Intussusception
   B4. Please list the primary indication for the revisional procedure:               4.     Obstruction with the gastric sleeve
              a.     Weight loss failure of original procedure                        5.     Refractory kidney stones
              b.     Complication of original procedure                               6.     Diarrhea
                                                                                      7.     Other (specify) ________________________________
   B5. If done for a complication, was the revisional procedure:                f. Original procedure: Jejunoileal bypass
             Check only one:                                                          1.     Malnutrition
              a.     Elective                                                         2.     Liver disease
              b.     Urgent (surgery required within days)                            3.     Small bowel obstruction
              c.     Emergent (surgery required within hours)                         4.     Refractory kidney stones
                                                                                      5.     Diarrhea
   B6. If done for a complication, please give underlying diagnosis                   6.     Other (specify) ________________________________
   Check all that apply:                                                        g. Original procedure: Other
   a. Original procedure: Gastric bypass                                             1.     Specify________________________________________
         1.     Anastomotic (GJ) stricture (causing obstruction)
         2.     Anastomotic (GJ) ulcer (causing bleeding, perforation, pain)    B7. If done for failed weight loss, what was the patient’s weight
         3.     Gastro-gastric fistula                                          prior to the original operation?
         4.     Non-healing leak from initial procedure                              a.    Actual ___________ lbs
         5.     Small bowel obstruction                                              b.    Estimated ____________lbs
                  i.   Internal hernia                                               c.    No/unknown
                 ii.   Obstruction/stricture at enteroenterostomy
                iii.   Adhesive disease
                iv.    Intussusception                                          Person completing the form (Please print):_______________________
         6.     Malnutrition
         7.     Peptic ulcer disease of remnant stomach/duodenum                Date form completed: ___ ___/___ ___/___ ___ ___ ___
         8.     Uncontrolled hypoglycemia/neuroglycopenia
         9.     Other (specify) ___________________________________

Confidential: For Quality Assurance Work Only                              1 of 1       REVISION                     Last modified:     6/9/2011

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