Endoscopic Sleeve Gastroplasty Procedure Note

Patient: [Patient name]    DOB: [Date of birth]    MRN: [Medical record number]    Date of Service: [Date]
Start Time: [HH:MM]    End Time: [HH:MM]    Location: [Facility/Endoscopy suite]    Setting: [inpatient / outpatient]
Primary Endoscopist: [Name, credentials]    Assistant(s): [Name(s), credentials]    Anesthesia Provider: [Name, credentials]

Procedures Performed

• [Diagnostic EGD / Upper GI endoscopy]
• [Endoscopic Sleeve Gastroplasty (ESG)]
• [Additional therapeutic maneuvers, e.g., hemostasis, clip placement, biopsy] (Only include if performed)

Diagnoses

Pre-procedure: [Primary indication(s) for ESG: obesity management with relevant metabolic comorbidities / bridge therapy / revision after weight regain]

Post-procedure: [ESG performed with technical outcome; key endoscopic findings, e.g., gastritis, hiatal hernia, erosions] (Do not infer findings not visualized.)

Indication and Clinical Context

[Brief statement of primary clinical reason for ESG, including baseline weight/BMI if available; relevant obesity-related comorbidities (e.g., T2DM, HTN, OSA, NAFLD); prior foregut or bariatric procedures impacting anatomy; presence/absence of contraindications evaluated (e.g., active gastric ulceration, large hiatal hernia)] (If specific data unavailable, enter "Not documented in record at time of note.")

Consent and Pre-procedure Verification

[Informed consent obtained prior to sedation, including discussion of risks (bleeding, perforation/leak, infection, aspiration, need for hospitalization or surgery, failure to achieve weight loss, need for repeat intervention) and alternatives.]
[Pre-procedure verification/time-out completed confirming correct patient, procedure, allergies, and anticoagulation status.] (Note anticoagulant/antiplatelet management if relevant.)
Prophylactic antibiotics: [Agent, dose, route, and timing relative to procedure start / Not administered]

Sedation/Anesthesia

Type: [moderate sedation / deep sedation / MAC / general anesthesia]
Administered by: [anesthesia service / endoscopy team]
[If endoscopist-directed sedation, list medications and doses; if anesthesia-managed, reference anesthesia record for details.] (Include notable sedation events only.)
Patient tolerance: [Tolerated well without events / Sedation-related event(s) and intervention(s) performed]

Equipment

• Gastroscope: [Manufacturer/model]
• Endoscopic suturing system: [Manufacturer/model]
• Accessories: [Tissue helix/retractor, overtube, distal cap, cinch/anchor device as applicable]
• Insufflation: [CO2 / room air]
• [Device lot/UDI identifiers] (Document here or per institutional policy.)

Pre-ESG Endoscopic Findings

[Extent and completeness of examination. If incomplete, state limitation and cause. Retroflexion and photo-documentation: performed / not performed with adequate / limited visualization.]

• Esophagus: [Mucosal appearance; presence/absence of esophagitis, varices, hiatal hernia]
• Stomach: [Fundus, body, antrum findings; presence/absence of ulcers, erosions, gastritis, polyps, retained contents] (Include pertinent negatives, e.g., "No gastric ulceration.")
• Duodenum: [Findings in bulb and second portion / Not examined with reason]

ESG Technique

[After diagnostic inspection confirmed no contraindications, ESG was performed transorally using the endoscopic suturing system to create full-thickness plications along the greater curvature, reducing gastric volume. Mucosal marking: performed / not performed.] (Provide concise narrative of plication sequence.)

• Suture pattern: [U / Z / triangular / site-specific] (Brief plain-language description.)
• Number of sutures/plications: [Total count]
• Start location: [e.g., distal body near incisura]    End location: [e.g., proximal body; fundus spared / partially included]
• Additional technical details: [Bites per suture, anchor/cinch usage if tracked]
• Hemostasis: [Adequate throughout / Intervention performed with modality and site]
• Final assessment: [Sleeve configuration; luminal patency confirmed with ability to traverse to antrum/pylorus]
• Technical success: [complete / partial / aborted] (If partial or aborted, state reason.)
• Deviations/Challenges: [None / Description of mucosal tearing, device issue, bleeding requiring therapy, altered pattern with troubleshooting and outcome]

Specimens

Specimens: [None / List each with site, method, jar/label, and indication (e.g., Gastric antrum biopsy, Jar A, for H. pylori testing)] (If specimens obtained, note plan for pathology review and patient notification.)

Estimated Blood Loss and Complications

EBL: [mL value / minimal]
Immediate complications: [No immediate complications noted / Description with timing, severity, intervention performed, and outcome] (Relevant complications: bleeding requiring endoscopic therapy, suspected perforation/leak, pneumoperitoneum, aspiration, hemodynamic instability, unplanned admission.)

Impression

• [Key diagnostic findings from pre-ESG EGD with pertinent negatives]
• [ESG performed: suture pattern, total plications, technical outcome]
• [Additional intra-procedural therapies if any]
• [Overall tolerance and immediate post-procedure status]

Post-procedure Plan

• Recovery and disposition: [Recovery location; same-day discharge / observation / admission with reason; written instructions provided]
• Medications: [Acid suppression (agent/dose/duration); antiemetics; analgesia; antibiotics if prescribed; anticoagulation hold/resume plan]
• Diet: [Staged progression per ESG pathway: clear liquids → full liquids → soft/pureed → small solid portions with timeframes]
• Activity: [Return-to-work guidance; lifting restrictions; NSAID and tobacco avoidance per program]
• Follow-up: [Bariatric endoscopy follow-up timeframe; nutrition/dietitian appointment; behavioral/physical activity program]
• Return precautions: [Severe/worsening abdominal pain, fever, persistent vomiting, hematemesis/melena, chest pain/shortness of breath, inability to tolerate liquids]    Contact: [Clinic number / After-hours number]

Communication

[Findings and plan reviewed with patient and/or family; questions addressed; report sent to referring provider] (Note interpreter use if applicable.)