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Long NameSurgery NCI Standard Template
DefinitionThe collection of CDEs used in the sugery modules.
ContextcaBIG
Protocol Long NameNCI Standard Template Forms
WorkflowDRAFT NEW
TypeCRF
Public ID3476625
Version1.0
Module Long NameModule InstructionsQuestionCDECDE Public IDCDE VersionQuestion InstructionsValue Domain Data TypeValue Domain Unit of MeasureDisplay FormatValid ValueForm Value Meaning TextForm Value Meaning Desc.
Mandatory Sugery Questions These items must be included when this data is collected for reporting.
DateSurgery Date20039861.0DATEDD/MON/YYYY
Surgical procedure typeSurgical Procedure Name31218091.0CHARACTER
WhippleWhipple ProcedureSurgical removal of part of the pancreas, duodenum, and distal part of the bile duct. Sometimes, the lower portion of the stomach and the gallbladder are also removed. This procedure is performed for pancreatic, ampullary, duodenal and distal bile duct cancers.
Total PancreatectomyTotal PancreatectomyPertaining to an entirety or whole, also constituting the full quantity or extent; complete.: Surgical removal of the pancreas. (Dorland, 28th ed)
Neck DissectionNeck Dissection(dye-SEK-shun) Surgery to remove lymph nodes and other tissues in the neck.
LumpectomyLumpectomyThe removal of a cancer as well as some of the breast tissue around the tumor and the lining over the chest muscles below the tumor. Usually some of the lymph nodes under the arm are also taken out. Also called segmental mastectomy.
Gross total resection without neck dissectionGross Total Resection Without Neck DissectionVisible to the naked eye.: Pertaining to an entirety or whole, also constituting the full quantity or extent; complete.: The act of cutting out; the surgical removal of part or all of a structure or organ. : Used to indicate the absence or lack of something or someone. (from Merriam-Webster OnLine): (dye-SEK-shun) Surgery to remove lymph nodes and other tissues in the neck.
Gross total resection with neck dissectionGross Total Resection With Neck DissectionVisible to the naked eye.: Pertaining to an entirety or whole, also constituting the full quantity or extent; complete.: The act of cutting out; the surgical removal of part or all of a structure or organ. : Used to indicate the presence of something or someone.: (dye-SEK-shun) Surgery to remove lymph nodes and other tissues in the neck.
Distal PancreatectomyDistal PancreatectomyRemoval of the body and tail of the pancreas.
AspirationAspirationRemoval of fluid or a sample of fluid and cells through a needle. (from medicinenet.com)
BiopsyBiopsyRemoval and pathologic examination of specimens in the form of small pieces of tissue from the living body.
CryosurgeryCryosurgery(KRYE-o-SIR-jer-ee) Treatment performed with an instrument that freezes and destroys abnormal tissues.
CystoprostatectomyRadical CystoprostatectomyThe simultaneous surgical resection of the urinary bladder and prostate gland with pelvic lymphadenectomy.
ExplorationExploratory Surgery(ek-SPLOR-uh-TOR-ee SER-juh-ree) Surgery to look inside the body to help make a diagnosis.
LobectomyLobectomy(lo-BEK-toe-mee) The removal of a lobe.
MastectomyMastectomyMastectomy
Modified Radical MastectomyModified Radical Mastectomy(mas-TEK-toe-mee) Surgery for breast cancer in which the breast, some of the lymph nodes under the arm, the lining over the chest muscles, and sometimes part of the chest wall muscles are removed.
Modified radical mastectomy after partial mastectomy as first attemptModified Radical Mastectomy after Partial Mastectomy as first attemptModified Radical Mastectomy after Partial Mastectomy as first attempt
Other, specifyOther SpecifyDifferent than the one(s) previously specified or mentioned.: Specify; be specific about something; define clearly.
Partial MastectomyLumpectomyThe removal of a cancer as well as some of the breast tissue around the tumor and the lining over the chest muscles below the tumor. Usually some of the lymph nodes under the arm are also taken out. Also called segmental mastectomy.
Partial mastectomy with re-exisionLumpectomy With Re-excisionThe removal of a cancer as well as some of the breast tissue around the tumor and the lining over the chest muscles below the tumor. Usually some of the lymph nodes under the arm are also taken out. Also called segmental mastectomy.: Used to indicate the presence of something or someone.: A surgical procedure to remove the remaining abnormal tissues from the body, not completely removed in an earlier attempt.
Partial mastectomy without re-exisionLumpectomy Without Re-excisionThe removal of a cancer as well as some of the breast tissue around the tumor and the lining over the chest muscles below the tumor. Usually some of the lymph nodes under the arm are also taken out. Also called segmental mastectomy.: Used to indicate the absence or lack of something or someone. (from Merriam-Webster OnLine): A surgical procedure to remove the remaining abnormal tissues from the body, not completely removed in an earlier attempt.
ProstatectomyProstatectomy(pros-ta-TEK-toe-mee) An operation to remove part or all of the prostate. Radical (or total) prostatectomy is the removal of the entire prostate and some of the tissue around it.
Radical MastectomyRadical MastectomyRemoval of the breast, pectoral muscles, axillary lymph nodes, and associated skin and subcutaneous tissue (from MeSH).
SegmentectomySegmentectomyResection of a segment of an organ or partial resection of a gland.
ThoracoscopyThoracoscopyThe use of a thin, lighted tube (called an endoscope) to examine the inside of the chest.
ThoracotomyThoracotomySurgical opening of the mediastinum.
Vein ResectionVein ExcisionA blood vessel that carries blood toward the heart.: Removal or excision by surgical measures.
Wesge ResectionWedge ExcisionAny shape that is triangular in cross section.: Removal or excision by surgical measures.
Surgical procedure type, Other specifySurgical Procedure Name Other Specify Text31218141.0CHARACTER
Conditional Surgery QuestionsThere are business rules to indicate situations under which these elements should be used on a case report form.
Surgical approachSurgical Procedure Approach Type24298401.0Use when surgical procedure requires documentation of surgical approach.CHARACTER
Transventricular Endoscopic Biopsy/ResectionTransventricular Endoscopic Biopsy/ResectionTransventricular Endoscopic Biopsy/Resection
Transnasal Endoscopic Biopsy/ResectionTransnasal Endoscopic Biopsy/ResectionTransnasal Endoscopic Biopsy/Resection
Stereotactic needle biopsyStereotactic Needle BiopsyNo value exists.: The removal of tissue or fluid with a needle for examination under a microscope. When a wide needle is used, the procedure is called a core biopsy. When a thin needle is used, the procedure is called a fine-needle aspiration biopsy.
Procedure not performedSurgical Procedure Not performedA diagnostic or treatment procedure performed by manual and/or instrumental means, often involving an incision and the removal or replacement of a diseased organ or tissue; of or relating to or involving or used in surgery or requiring or amenable to treatment by surgery.: No value exists.
Open Operation/Resection/BiopsyOpen Operation/Resection/BiopsyOpen Operation/Resection/Biopsy
Hand-assistedHand assisted laparoscopichand inserted at the beginning of the operation through an incision measuring less than 8 cm and the hand used only as a retractor for the pelvic portion of the procedure which must be done with laparoscopic techniques
LaparoscopicLaparoscopic SurgeryNo value exists.
Laparoscopic converted to openLaparoscopic converted to open.Laparoscopic converted to open.
Laparoscopic hand-assistedLaparoscopic hand-assistedLaparoscopic hand-assisted
Laparoscopic-assistedLaparoscopic assisted dissectionlaparoscopic dissection with removal of the specimen through a small incision and the transaction of the rectum and anastomosis performed through the small incision
Minimally InvasiveMinimum InvasiveThe smallest possible quantity.: Marked by a tendency to spread especially into healthy tissue.
openopenopen
OtherOtherOther
PrimaryPrimaryOccurring first in time or sequence; original; of greatest rank or importance or value.
Robot assisted laparoscopic (da Vinci)Robot Assistance LaparoscopyA mechanical device that sometimes resembles a living animal and is capable of performing a variety of often complex human tasks on command or by being programmed in advance.: The act of contributing to the fulfillment of a need or furtherance of an effort.: (lap-a-RAHS-ko-pee) The insertion of a thin, lighted tube (called a laparoscope) through the abdominal wall to inspect the inside of the abdomen and remove tissue samples.
Robotic-assistedRobotic-assistedA surgical procedure that uses a robot interface to help perform part or all of the procedure.
SalvageSalvageDefinition not available.
Thoracoscopy/Video-assisted (VATS)Video-assisted Thoracic SurgeryEndoscopic surgery of the pleural cavity performed with visualization via video transmission.
Thoracoscopy/Video-assisted (VATS), with conversion to thoracotomyThoracotomy Video-assisted Thoracic Surgery(thor-a-KAH-toe-mee) An operation to open the chest.: Endoscopic surgery of the pleural cavity performed with visualization via video transmission.
Surgical approach other specifySurgical Procedure Approach Other Specify Text31219201.0Use when surgical procedure requires documentation of surgical approach.CHARACTER
Optional Surgery QuestionsThere is no requirement for inclusion of these elements on the case report form. If the design and scientific questions posed in the study dictate the need to collect this type of data, these elements should be included.
Reason for surgical approachSurgical Procedure Approach Reason Text31219221.0CHARACTER
Resection typeSurgical Resection Procedure Type31225721.0CHARACTER
MinorMinorLesser or smaller in amount, extent, or size.
BiopsyBiopsyRemoval and pathologic examination of specimens in the form of small pieces of tissue from the living body.
Extensive SubtotalExtensive SubtotalLarge in quantity, range, or spatial extent.: The total of part of a series of numbers.
Gross totalGross TotalVisible to the naked eye.: Pertaining to an entirety or whole, also constituting the full quantity or extent; complete.
Optimal debulkingOptimum DebulkingThe best or most suitable; the greatest degree attainable. : Surgically removing as much of the tumor as possible.
OtherOtherDifferent than the one(s) previously specified or mentioned.
Partial debulkingPartial DebulkingPartial; being or affecting only a part; not total: Surgically removing as much of the tumor as possible.
SegmentalSegmentalSegmental
SMV/PV patchSuperior Mesenteric Vein Portal Vein PatchNo Value Exists: A short thick trunk vein that transports blood containing the absorbed products of digestion from the intestine directly to the liver.: No Value Exists
SuboptimalSuboptimalBeing below an optimal level or standard.
Suboptimal debulkingSuboptimal DebulkingBeing below an optimal level or standard.: Surgically removing as much of the tumor as possible.
Subtotalsubtotalsubtotal
Resection type other specifySurgical Resection Procedure Other Specify Text31226961.0CHARACTER
Surgeon NameSurgeon Name643443.0CHARACTER
Date of first postop bowel movementFirst Postoperative Bowel Movement Date31227161.0DATEMM/DD/YYYY
Date of first postop flatusFirst Postoperative Flatus Date31230411.0DATEMM/DD/YYYY
Estimated Blood Loss (cc)Total Estimate Blood Loss Amount639543.0NUMBER
Operative FindingsSurgical Procedure Operative Finding Text31230461.0CHARACTER
Final incision length (including if laproscopy was converted to open)Final Surgical Incision Length Performed Measurement31230541.0NUMBERcm
Tumor size longest diameter (as determined by surgeon)Longest Tumor Surgeon Diameter Measurement31230691.0NUMBERcm99.9
Surgical margin distance (as determined by surgeon)Surgical Margin Distance Surgeon Measurement31230791.0NUMBER
Residual Disease after SurgerySurgical Margin Resection Status Type31240811.0CHARACTER
Micro residualMicro ResidualA prefix indicating a quantity of one one-millionth, 10E-6.: Remaining or left behind.
No residualNo ResidualThe non-affirmative response to a question.: Remaining or left behind.
Not applicableNot ApplicableDetermination that a value is not relevant in the current context.
Is gross disease unifocal or multifocal?Gross Disease Foci Status21902641.0CHARACTER
MultifocalMultifocalArising from or pertaining to many locations.
UnifocalUnifocalArising from, pertaining to, or having a single location.
UnknownUnknownNot known, not observed, not recorded, or refused.
Operative conditions/proceduresOperative Procedure Condition Type31230981.0CHARACTER
Drain placedDrainage PlaceThe systematic withdrawal of fluids and discharges from a wound, sore or cavity.: The particular portion of space occupied by a physical object or intended for a physical object.
Drain removedDrainage RemovedThe systematic withdrawal of fluids and discharges from a wound, sore or cavity.: Removed; taken out of or separated from.
Ostomy placedOstomy PlaceSurgical construction of an artificial opening (stoma) for external fistulization of a duct or vessel by insertion of a tube with or without a supportive stent.: The particular portion of space occupied by a physical object or intended for a physical object.
Rectum intactRectum IntactThe terminal portion of the gastrointestinal tract, extending from the rectosigmoid junction to the anal canal.: Undamaged in any way; whole.
Sphincter preservedSphincter PreservationA ring-shaped muscle that relaxes or tightens to open or close a passage or opening in the body. Examples are the anal sphincter (around the opening of the anus) and the pyloric sphincter (at the lower opening of the stomach).: The activity of protecting something from loss or danger; a process that saves organic substances from decay; to maintain or keep intact.
Transfusion TypeTransfusion Component Procedure Type31251801.0CHARACTER
AutologousAutologous(aw-TAHL-o-gus) Taken from an individual's own tissues, cells, or DNA.
Donor DirectedDonor DirectedDonor Directed
HomologousHomologous RecombinationExchange of like DNA sequences on homologous chromosomes by recombination.
TotalTotalPertaining to an entirety or whole, also constituting the full quantity or extent; complete.
Transfusion ComponentBlood Component Transfusion Text Name21828632.0CHARACTER
Manipulated LymphocytesTreated (Primed) LymphocytesSubject to a process with the aim of readying for some purpose, improving, or remedying a condition.: (LIM-fo-site) A type of white blood cell. Lymphocytes have a number of roles in the immune system, including the production of antibodies and other substances that fight infection and diseases.
AlbuminAlbuminfamily of globular proteins found in many plant and animal tissues that tend to bind a wide variety of ligands.
CryoprecipitateCryoprecipitate Cryoprecipitate
FFPFresh Frozen PlasmaFreshly frozen PLASMA after the removal of PLATELETS.
No Blood ProductsNo Blood productNo administration of blood products
Packed RBCPacked Red Blood Cells TransfusionPacked Red Blood Cells Transfusion
Packed RBC, AutologousPacked Autologous Red Blood Cells TransfusionPacked Autologous Red Blood Cells Transfusion
Packed RBC, Autologous, IrradiatedPacked Autologous Irradiated Red Blood Cells TransfusionPacked Autologous Irradiated Red Blood Cells Transfusion
Packed RBC, Autologous, LeukoreducedPacked Autologous Leukoreduced Red Blood Cells TransfusionPacked Autologous Leukoreduced Red Blood Cells Transfusion
Packed RBC, IrradiatedPacked Irradiated Red Blood Cells TransfusionPacked Irradiated Red Blood Cells Transfusion
Packed RBC, Irradiated and LeukoreducedIrradiated Leukocyte-reduced Packed Red Blood Cell TransfusionTreated with radiation.: Reduced; made less in size or amount or degree.: White blood cells. These include granular leukocytes (BASOPHILS, EOSINOPHILS, and NEUTROPHILS) as well as non-granular leukocytes (LYMPHOCYTES and MONOCYTES).: Definition not available.
Packed RBC, LeukopoorPacked Leukopoor Red Blood Cells TransfusionPacked Leukopoor Red Blood Cells Transfusion
Packed RBC, LeukoreducedPacked Leukoreduced Red Blood Cells TransfusionPacked Leukoreduced Red Blood Cells Transfusion
PlateletPlatelet(PLAYT-lets) A type of blood cell that helps prevent bleeding by causing blood clots to form. Also called thrombocytes.
Platelets, HLA MatchPlatelets, HLA-MatchedPlatelets, HLA-Matched
Platelets, IrradiatedPlatelets, IrradiatedPlatelets, Irradiated
Platelets, Irradiated and LeukoreducedIrradiated Leukocyte-reduced Platelet TransfusionTreated with radiation.: Reduced; made less in size or amount or degree.: White blood cells. These include granular leukocytes (BASOPHILS, EOSINOPHILS, and NEUTROPHILS) as well as non-granular leukocytes (LYMPHOCYTES and MONOCYTES).: The infusion of platelets into the bloodstream.
Platelets, LeukoreducedPlatelets, LeukoreducedPlatelets, Leukoreduced
WBCWhite Blood CellsWhite Blood Cells, Leukocytes
WBC, IrradiatedWhite Blood Cells, IrradiatedWhite Blood Cells, Irradiated
Whole BloodWhole bloodWhole blood
Blood transfusionBlood Transfusion Timepoint Administered Type26855251.0CHARACTER
IntraoperativeIntraoperativeIntraoperative
PreoperativePreoperativeRelating to or occurring during the period immediately before a surgical operation.
Within 30 days post-operativeWithin 30 days post-operativeWithin 30 days post-operative
UnitsTransfuse Blood Component Units21828661.0NUMBER
Surgical documentation method(s)Surgical Procedure Documentation Method Type31231121.0CHARACTER
Medical recordMedical RecordA chronological written account of a patient's examination and treatment that includes the patient's medical history and complaints, the physician's physical findings, the results of diagnostic tests and procedures, and medications and therapeutic procedures. (dictionary.com)
VideoVideo RecordingThe storing or preserving of video images to be displayed later.
Number of surgeriesSurgical Procedure Required Total Number31232231.0NUMBER
Stop DateIntervention Occurrence End Date30287461.0DATEmm/dd/yyyy
Start DateIntervention Occurrence Begin Date30287441.0DATEmm/dd/yyyy
Start TimeStart Time20040953.0TIMETIME (HR(24):MN)
Stop TimeStop Time20041393.0TIMETIME (HR(24):MN)