yes Source of data collection time of contact
Face to face interview with the patient
Phone call with the patient
A patient’s representative
Other physician
Record review

YesNo
YesNo
YesNo
yes Complication
Wound infection
Fascial dehiscence
Small bowel obstruction
Incisional/ventral hernia
Acute cholecystitis/ biliary colic
Cholangitis/ CBD stone
Stomal/gastric outlet obstruction
Staple line breakdown
Anastomotic stricture (gastrojejunostomy)
Anastomotic stricture (jejunojejunostomy)
Pancreatitis
Gastric band stenosis
Gastric band erosion
Gastric band slippage
Gastric band leakage
Port/tube malfunction
Gastric prolapse
Esophageal motility disorders/dilation
GE reflux
Early-onset dumping syndrome
Late-onset dumping syndrome
Nausea/vomiting
Flatulence
Persistent diarrhea
Constipation
Dehydration
Acute renal failure
Liver failure
MI
Cardiac arrest
Other complications requiring special treatments


YesNo
Intervention result Date
Abdominal redo operation
Re-intubation
Tracheostomy
Endoscopy
Subcutaneous drain placement
Anticoagulation for possible or definite DVT
Anticoagulation for possible or definite PE
Re-admission 1
Re-admission 2
Re-admission 3



Procedure result Date
a. Drain placement
b. Gastrostomy
c. Anastomosis repair
i. GJ
ii. JJ
iii. DJ
d. Band placement
e. Band/port repair
f. Wound revision
g. Exploration
h. Other procedures

yes Possible cause of complication
Anastomotic leak
Other abdominal sepsis
Intestinal obstruction
DVT
Pulmonary embolism
Pneumonia
Other respiratory failure
Wound infection/evisceration
Fluid or electrolyte depletion
Vomiting or poor intake
Gastric distension
Strictures
Bleeding
Infection/fever
Other