Data dictionary: Liver and bile ducts - DHBA

Go back to Dutch Institute for Clinical Auditing Databases (DICA) (The Netherlands) page.

This is a summary of the variables available in the database. You can download the complete data dictionary. Click here to learn more.

Patient Identification Information

Health Facility
Unique Patient Number
Date of Birth
Gender
Date of Death (if applicable)

Comorbidities and Previous Conditions

Date of Comorbidities
Myocardial Infarction
Congestive Heart Failure
Chronic Pulmonary Disease
Peripheral Vascular Disease/Aortic Aneurysm
Cerebrovascular Disease (e.g., Stroke/TIA)
Dementia
Para-/Hemiplegia
Connective Tissue Disease (e.g., Rheumatic Diseases)
Gastrointestinal Ulcer Disease
Liver Disease
Liver Cirrhosis
Symptomatic Gallstone Disease
Primary Sclerosing Cholangitis
Diabetes Mellitus
Kidney Disease
HIV/AIDS
Malignancy (excluding PCC or BCC of the skin)

Surgical and Interventional Procedures

Date of Comorbidities
Previous Liver Resection/Ablation for this Condition?
Length in cm
Weight on the Day of Surgery (in kg)
Date of Recurrence Section Creation
Is there also a recurrence elsewhere besides the liver?
Date of Recurrence Diagnosis
Is this recurrence a locoregional recurrence of the previous ablation or resection?
Date of the Previous Liver Resection/Ablation of the Tumor which the Current Tumor is a Recurrence of (local or intrahepatic elsewhere)
Recurrence Treatment
CT Scan?
MRI Scan of Liver?
PET Scan?
CT Volumetry?
Hepatobiliary Scintigraphy?
Date of Last Imaging Regarding the Liver Prior to Liver Resection/Ablation
CEA Value in Blood? (ng/mL)
CA 19-9 Value in Blood? (U/mL)
Alpha Fetoprotein (AFP) Value, Unit μg/L
Total Bilirubin Value? (µmol/L)
Location of Tumor in Bile Ducts or Gallbladder
Clinical T Stage of Cholangiocarcinoma on Last Preoperative Imaging
Clinical N Stage of Cholangiocarcinoma on Last Preoperative Imaging
Clinical M Stage of Cholangiocarcinoma on Last Preoperative Imaging
Liver Resection Performed for Gallbladder Carcinoma?
Indication for Resection
Presence of Bilobal Disease
Bismuth-Corlette Type?
Diameter of Lesion
Number of Liver Tumors
Diameter of Largest Lesion in mm (prior to any Neoadjuvant Therapy)
BCLC Stage Known?
BCLC Stage
Presence of Tumor Satellites or Daughter Nodules?
Origin of Liver Metastases
Are there Extra-Hepatic Metastases?
Location of Extrahepatic Liver Metastases
Are there Other Abdominal Metastases?
Are there Lung Metastases?
Are there Metastases at Other Locations?
Date of First Resection of Primary Tumor
Pathological N-Classification According to TNM System of Primary Tumor
Was Preoperative Biliary Drainage Performed?
Biliary Drainage Technique?
Was Imaging (CT/MRI) Performed Prior to Biliary Drainage?
Was the Future Liver Remnant Drained?
Was Preoperative Portal Embolization Performed?
When was the Portal Embolization Performed?
Was a Liver Function Test Done?
Was a Prehabilitation Process Started?
Date of Operation/Ablation
ASA Score as Reported by the Anesthetist
Procedure
Reason for Irresectability?
Procedure
Is it Synchronous or Metachronous Liver Metastases?
Type of Treatment for Synchronous Liver Metastases?
Is the Operation Part of a Two-Stage Procedure?
Was a Two-Stage Procedure Performed According to the (Mini)-ALPPS Technique?
Ablation Procedure:

  - Radiofrequency Ablation (RFA)
  - Microwave Ablation (MWA)
  - Cryoablation
  - Irreversible Electroporation (IRE)

Type of Imaging During Ablation
Type of Anesthesia During Ablation
Which Specialist Performed the Ablation?
Number of Ablated Lesions/Metastases.
Size of Largest Focus Ablated (mm)
Was there Technical Success?
Was a Post-Ablation Contrast Scan Made?
What Procedure was Performed?
What Type of Liver Resection was Performed?

  - Wedge Resection
  - Right Hemihepatectomy
  - Left Hemihepatectomy
  - Extended Right Hemihepatectomy
  - Extended Left Hemihepatectomy
  - Segmental Resection
     * Segment 1
     * Segment 2
     * Segment 3
     * Segment 4a
     * Segment 4b
     * Segment 5
     * Segment 6
     * Segment 7
     * Segment 8

Size of Largest Focus for Resection (mm)
Was it a Major Liver Resection?
Operation Combined with Other Intra-Abdominal Procedure?
Additional Resections Due to Tumor Invasion?
Was Portal Resection and Reconstruction Performed?
Wedge Excision?
Segmental Resection?
How Many Metastases Were Removed?
How Many Bilio-Digestive Anastomoses Were Performed?
Number of Abnormalities
Size of Abnormalities
Vascular Unfavorable Location
Extra-Hepatic Abnormalities
Other
Unknown
What was the Blood Loss? (ml)
Was an Abdominal Drain Placed Perioperatively?
How Much Volume of the Original Did the Remaining Liver Have After the Operation?
Were There Complications Within 30 Days After Resection/Ablation?

  - Bile Leakage
  - Severity of Complication
  - Date of Complication
  - Was There a Reintervention Due to a Bile Leak?
  - Nature of Reintervention
  - Did this Reintervention Take Place Under General Anesthesia?
  - Post-Bleeding
  - Post-Bleeding Requiring Blood Transfusion or Intervention
  - Severity of Complication
  - Date of Complication
  - Was There a Reintervention Due to This Post-Bleeding?
  - Nature of Reintervention
  - Did this Reintervention Take Place Under General Anesthesia?
  - Liver Failure
  - Severity of Complication
  - Date of Complication
  - Was There a Reintervention Due to Liver Failure?
  - Nature of Reintervention
  - Did this Reintervention Take Place Under General Anesthesia?
  - Infectious Complication
  - Intra-Abdominal Infection/Abscess
  - Severity of Complication
  - Date of Complication
  - Was There a Reintervention Due to Intra-Abdominal Infections/Abscess?
  - Nature of Reintervention
  - Did this Reintervention Take Place Under General Anesthesia?
  - Pneumonia
  - Severity of Complication
  - Date of Complication
  - Was There a Reintervention Due to Pneumonia?
  - Nature of Reintervention
  - Did this Reintervention Take Place Under General Anesthesia?
  - Wound Infection/Abscess
  - Severity of Complication
  - Date of Complication
  - Was There a Reintervention Due to a Wound Infection?
  - Nature of Reintervention
  - Did this Reintervention Take Place Under General Anesthesia?
  - Other Infections
  - Severity of Complication
  - Date of Complication
  - Was There a Reintervention Due to Other Infections?
  - Nature of Reintervention
  - Did this Reintervention Take Place Under General Anesthesia?
  - Was There a Thromboembolic Complication?
  - Severity of Complication
  - Date of Complication
  - Was There a Reintervention Due to a Thromboembolic Complication?
  - Nature of Reintervention
  - Did this Reintervention Take Place Under General Anesthesia?
  - Was There a Cardiac Complication?
  - Severity of Complication
  - Date of Complication
  - Was There a Reintervention Due to a Cardiac Complication?
  - Nature of Reintervention
  - Did this Reintervention Take Place Under General Anesthesia?
  - Pleural Effusion
  - Severity of Complication
  - Date of Complication
  - Was There a Reintervention Due to Pleural Effusion?
  - Nature of Reintervention
  - Did this Reintervention Take Place Under General Anesthesia?
  - Ascites
  - Severity of Complication
  - Date of Complication
  - Was There a Reintervention Due to Ascites?
  - Nature of Reintervention
  - Did this Reintervention Take Place Under General Anesthesia?
  - Pneumothorax Requiring Reintervention
  - Severity of Complication
  - Date of Complication
  - Was There a Reintervention Due to a Pneumothorax?
  - Nature of Reintervention
  - Did this Reintervention Take Place Under General Anesthesia?
  - Skin Burns
  - Severity of Complication
  - Date of Complication
  - Was There a Reintervention Due to Skin Burns?
  - Nature of Reintervention
  - Did this Reintervention Take Place Under General Anesthesia?
  - Other
  - Severity of Complication
  - Date of Complication
  - Was There a Reintervention Due to Other Complications?
  - Nature of Reintervention
  - Did this Reintervention Take Place Under General Anesthesia?
  - Was There an Intervention Due to the Complication?
  - Did This Reintervention Take Place Under General Anesthesia?
  - Nature of Reintervention (Choose Most Invasive)
  - Reintervention Under General Anesthesia?
  - Number of Days in Intensive Care / PACU
  - What was the Reason for (Extended) IC Admission or Readmission to IC?
  - Was There Organ Failure?
  - Date of Discharge
  - Did the Patient Die During the Hospital Stay or Within 30 Days After the Operation?
  - Was the Patient Readmitted to the Hospital Within 30 Days After Discharge?
  - Was the Reason for Readmission a Complication?
  - Was the Patient Admitted to the Medium/Intensive Care Unit During Readmission?
  - How Many Days was the Patient Admitted to the MC/IC During Readmission?
  - Date of Readmission
  - Date of Discharge After Readmission
  - What is the Diagnosis?

pT Stage of Perihilar Cholangiocarcinoma According to Pathology Report
pN Stage of Perihilar Cholangiocarcinoma According to Pathology Report
pM Stage of Perihilar Cholangiocarcinoma According to Pathology Report
pT Stage of Gallbladder Carcinoma According to Pathology Report
pN Stage of Gallbladder Carcinoma According to Pathology Report
pM Stage of Gallbladder Carcinoma According to Pathology Report
pG Stage According to Pathology Report
Pathological T Stage of HCC According to Pathology Report
Pathological N Stage of HCC According to Pathology Report
Pathological M Stage of HCC According to Pathology Report
pT Stage of Intrahepatic Cholangiocarcinoma According to Pathology Report
pTN Stage of Intrahepatic Cholangiocarcinoma According to Pathology Report
pM Stage of Intrahepatic Cholangiocarcinoma According to Pathology Report
Number of Tumors in the Resection Specimen
Was the Tumor Radically Removed?
Irradicality at Liver Resection Level?
Irradicality at Distal Bile Duct Level?
Irradicality at Proximal Bile Duct Level?
What is the Image of the Unaffected Liver?
PA Number (TJJ-CCCCCC)
PA Laboratory
Was (Neo-)Adjuvant Chemotherapy Given for the Liver Abnormality or the Abnormality of the Bile Ducts or Gallbladder?
Induction for Downstaging
Neoadjuvant for Resectable Tumor
Adjuvant for Resectable Tumor
Is Patient Participating in a Trial?
The Doctor Can Check Here That the Patient's Data is Complete and Correct.

Date of Last Information on Survival Status (If the Patient is Deceased, This is the Death Date)

Health Facility
Hospital Patient Number
Is the Patient Deceased?
Is There a Recurrence After the Last Procedure?
Date of Recurrence Diagnosis
Was This Recurrence a Locoregional Recurrence of an Earlier Ablation or Resection?
Date of the Previous Liver Resection/Ablation of the Tumor which the Current Tumor is a Recurrence of (local or intrahepatic elsewhere)
Date of Last Information on Recurrence Status
Is This Recurrence Being Treated?
Nature of Reintervention

COVID-19 Related Variables

Was There a (Clinical) Suspicion or Test for a SARS-CoV-2 Infection from the Period Before Admission to 30 Days After Admission?
Admission Date or, If Not Available, Date of Treatment
Was the Patient Tested for a SARS-CoV-2 Infection by CT Thorax, RT-PCR, or Another Specific Lab Test?
Date of First Suspicion of SARS-CoV-2 Infection [ICD-10: U07.2 Date]
If Unknown: Was This Before Treatment or During/After Treatment?
Date of First Specific Test for SARS-CoV-2 Infection [ICD-10: U07.1 or U07.2 Date]
If Unknown: Was This Before Treatment or During/After Treatment?
Date of First Positive Lab Test for SARS-CoV-2 [ICD-10: U07.1 Date]
If Unknown: Was This Before Treatment or During/After Treatment?
IC Admission Date and Time
IC Discharge Date and Time
Destination After IC Admission
What Was the Ultimate Status Regarding SARS-CoV-2?
Are You Participating in the COVIDSURG II Snapshot Study for This Registration?
Was There a Clinical Suspicion or Test for SARS-CoV-2 Infection or COVID-19 Around the Time of the Surgery?
Symptoms Compatible with COVID-19?

  - Coughing
  - Fever
  - Dyspnea
  - Loss of Smell and/or Taste
  - Other

Number of Days of Symptoms Prior to Surgery
Did or Does the Patient Smoke?
Number of Packyears
What is the Patient's Height? (in cm)
What was the Patient's Weight at Admission? (in kg)
Was the Patient Tested for a SARS-CoV-2 Infection?
What Type(s) of Test(s) Did the Patient Undergo Preoperatively?

  - RT-PCR
  - X-ray or CT Thorax
  - Serology
  - Other

Number of Times Preoperative RT-PCR Test was Performed
Date of First Preoperative RT-PCR Test
Date of First Positive Preoperative RT-PCR Test
X-ray Thorax - Consolidations
CT Thorax - CORADS Score
Number of Preoperative CT Thoraxes with COVID-19 Question
Date of First Preoperative CT Thorax with COVID-19 Questioning
Date of First Preoperative CT Thorax with a CORADS Score of 4-5
Definitive Preoperative COVID-19 Status
Were There Pre-Operative COVID-Related Complications?
COVID-Related Complications?

  - ARDS
  - Acute Kidney Failure
  - Arrhythmias
  - Thrombo-Embolic Events
  - Other

Thrombo-Embolic Events?

  - Pulmonary Embolism
  - DVT
  - Bowel Ischemia
  - Other

Therapeutic Anticoagulation Prior to Embolic Event?
Therapeutic Anticoagulation Following COVID-Related Embolic Event?
Impact on Neoadjuvant Treatment?
What Impact on Neoadjuvant Treatment?

  - Abstained from Pretreatment
  - Type of Pretreatment Changed (e.g., Chemoradiation Instead of Chemo, Chemo Instead of Immuno)
  - Treatment Schedule/Dosage Changed (e.g., More or Fewer Courses, Higher or Lower Dose)
  - Same Type of Treatment, Different Drug (e.g., 5FU Instead of Docetaxel)
  - Other

Impact on Planning/Surgery Postponed?
Reason for Impact on Planning/Surgery Postponed?

  - Due to COVID Suspicion/Test
  - Due to Limited Healthcare Capacity COVID Crisis
  - Other Reason

Impact on Surgical Approach (Scopic/Robot/Open)?
Impact on Surgical Approach (Scopic/Robot/Open)?

  - Due to COVID Suspicion/Test
  - Due to Limited Healthcare Capacity COVID Crisis
  - Protection of Surgical Team
  - Other

Were There Postoperative Complaints Compatible with COVID-19?
What Complaints Compatible with COVID-19?

  - Coughing
  - Fever
  - Dyspnea
  - Loss of Smell and/or Taste
  - Other

How Many Days After Surgery Did COVID-19 Symptoms Begin?
Was the Patient Tested for a SARS-CoV-2 Infection Postoperatively?
What Type(s) of Test(s) Did the Patient Undergo Postoperatively?

  - RT-PCR
  - X-ray or CT Thorax
  - Serology
  - Other

Number of Times Postoperative RT-PCR Test was Performed
Date of First Postoperative RT-PCR
Date of First Positive Postoperative RT-PCR?
X-ray Thorax - Consolidations
CT Thorax - CORADS Score
Number of CT Thorax with COVID-19 Questioning
Date of First Postoperative CT Thorax with COVID-19 Questioning
Date of First Postoperative CT Thorax with a CORADS Score of 4-5
Definitive Postoperative COVID-19 Status
Were There Postoperative COVID-Related Complications?
COVID-Related Complications?

  - ARDS
  - Acute Kidney Failure
  - Arrhythmias
  - Thrombo-Embolic Events

Thrombo-Embolic Events?

  - Pulmonary Embolism
  - DVT
  - Bowel Ischemia
  - Other

Therapeutic Anticoagulation Prior to Embolic Event?
Therapeutic Anticoagulation Following COVID-Related Embolic Event?
Was There an IC Admission Around the Time of Surgery?
Was There a COVID-Related IC Admission?
Was COVID Diagnosed During the IC Admission?
What Respiratory Support During the IC Admission?

  - Prone Ventilation
  - ECMO

IC Admission Date
IC Discharge Date
Duration of IC Admission (Days)
Destination After Last IC Admission