Intragastric Balloon Placement/Removal Procedure Note

(Intragastric balloon procedure template. Include only sections that apply to the procedure type. Do not infer missing details—state "Not documented" with reference to where information may be found.)

Date/Time: [Procedure date and start time]

Location: [Facility and room]

Procedure Type: [Placement / Removal / Removal + Replacement]

Primary Operator: [Name, credentials]

Assistant(s): [Name(s) and role(s)] (Omit if none)

Anesthesia Provider: [Name, credentials] (State "Not documented" if unknown)

Indication: [Indication for procedure] (For removal: [scheduled end-of-therapy / early removal due to intolerance / early removal due to suspected leak or deflation / early removal due to suspected hyperinflation / early removal due to ulceration / early removal due to obstruction / other: [specify reason]])

Diagnosis: Pre-procedure: [Pre-procedure diagnosis]. Post-procedure: [Post-procedure diagnosis]

Pre-Procedure Verification

• Informed consent: [Obtained by name/role] (Document that risks, benefits, and alternatives were discussed, including aspiration, perforation, bleeding, device complications, and potential need for early removal.)
• Time-out: [Completed / Not documented]
• NPO status: [Duration]
• Antithrombotic management: [Held / Continued / Not applicable / Not documented] (Specify agent if applicable)
• ASA class: [I / II / III / IV / V]
• Pertinent comorbidities affecting sedation risk: [Relevant comorbidities] (Include only if applicable; otherwise omit line entirely)

Sedation/Anesthesia

• Sedation type: [none / minimal / moderate / deep / MAC / general]
• Provider: [Endoscopy team / Anesthesia service]
• Medications: [Agent(s) with dose and route] (If administered by anesthesia service: "See anesthesia record for medications, vitals, and airway management.")
• Patient tolerance: [good / fair / poor]

Device Information

(Required section. If identifiers are unavailable, state "UDI/lot not available at time of documentation.")

Existing Balloon (for Removal)

• Brand/trade name and model: [Brand and model]
• Balloon type: [liquid-filled / gas-filled], [single / dual]
• UDI and/or lot number: [UDI/lot number]
• Serial number: [Serial number]
• Expiration date: [Expiration date]
• Implant duration since placement: [Duration]
• Original fill medium: [saline / gas], [with / without] methylene blue dye
• Original fill volume: [Volume in mL]

New Balloon (for Placement or Replacement)

• Brand/trade name and model: [Brand and model]
• Balloon type: [liquid-filled / gas-filled], [single / dual]
• UDI and/or lot number: [UDI/lot number]
• Serial number: [Serial number]
• Expiration date: [Expiration date]
• Fill medium: [saline / gas], [with / without] methylene blue dye
• Target fill volume: [Volume in mL]
• Final fill volume: [Volume in mL]

Endoscopic Findings

(Use "Normal" only if examined and attested. If not examined, state "Not examined.")

Pre-Intervention Inspection

• Esophagus: [Normal / Not examined / Findings]
• Stomach: [Normal / Not examined / Findings]
• Duodenum: [Normal / Not examined / Findings]

Post-Removal Inspection

(Include only if removal performed)

• Esophagus: [Normal / Not examined / Findings]
• Stomach: [Normal / Not examined / Findings]
• Duodenum: [Normal / Not examined / Findings]

Procedure Technique

Placement Technique

(Include for Placement or Replacement)

• Introduction route/method: [Route and method of introduction]
• Confirmation of intragastric position prior to inflation: [Method of confirmation]
• Inflation technique: [Fill medium, method, volume infused, use of dye]
• Final position and mobility: [Position and mobility confirmation]
• Immediate mucosal trauma: [None / Description of trauma]

Removal Technique

(Include for Removal or Removal + Replacement)

• Access/puncture method and device: [Method and device used]
• Aspirated volume: [Volume in mL]; Fluid character: [clear / bloody / bilious]; Dye present: [yes / no / unknown]
• Retrieval method: [grasper / snare / overtube / net / other]
• Balloon integrity: [Retrieved intact and complete / Fragmented: [description]]
• Airway protection measures: [Measures taken / Not applicable] (Include if retained food/fluid present)

Complications and Disposition

• Complications: [None / Description with severity, management, and outcome]
• Estimated blood loss: [Volume in mL / Minimal / Not documented]
• Disposition: [Recovery unit / Discharged home / Admitted to [responsible service]]

Post-Procedure Plan

Medications:

• Acid suppression: [Agent, dose, frequency, duration]
• Antiemetic: [scheduled / PRN], [agent, dose, frequency]
• Antispasmodic: [Agent, dose, frequency] (Include only if prescribed)
• Avoid: NSAIDs and gastric irritants

Diet Progression:

• Same day: NPO until alert, then sips/ice chips
• Days 1–3: Clear liquids; hydration goals; avoid carbonation
• Days 4–14: Full liquids/protein shakes
• Weeks 2–3: Pureed/soft foods; portion limits
• After week 3–4: Regular textured foods in small portions
• After Removal: [Resume regular diet / Gradual re-advancement per mucosal findings] (Include for removal only)

Follow-Up:

• Early check-in: [Timeframe, typically 24–72 hours]
• Clinic visit: [Timeframe, typically 1–2 weeks]
• Ongoing: Monthly visits with bariatric team/dietitian
• Planned removal date: [Date or date range] (Required for placement; omit for removal-only procedures)

Return Precautions:

• Severe or worsening abdominal pain
• Persistent vomiting or inability to hydrate
• GI bleeding
• Fever or chills
• Chest pain or dyspnea
• Syncope
• Urine color change suggesting balloon leak (if dye-filled balloon)
• Sudden abdominal distension suggesting hyperinflation

Attestation

I attest that I personally performed and/or supervised this procedure as documented above.

Operator Signature: [Name, credentials, electronic signature] Date/Time: [Date and time]

(Reference anesthesia record and nursing documentation for additional intra-procedure details.)