Appendix

The gastrointestinal (GI) tract is part of the body's digestive system. It helps to digest food, takesnutrients (vitamins, minerals, carbohydrates, fats, proteins, and water) from food to be used by the body and helps pass waste material out of the body. The GI tract is made up of these and otherorgans:

1. Stomach.
2. Small intestine (duodenum, jejunum, and ileum).
3. Colon.
4. Rectum.

Gastrointestinal carcinoid tumors form in the lining of the gastrointestinal tract, most often in the appendix, small intestine, or rectum.

Gastrointestinal carcinoid tumors form from a certain type of neuroendocrine cell (a type of cell that is like a nerve cell and a hormone -making cell). These cells are scattered throughout the chest andabdomen but most are found in the GI tract. Neuroendocrine cells make hormones that help control digestive juices and the muscles used in moving food through the stomach and intestines. A GI carcinoid tumor may also make hormones and release them into the body.

GI carcinoid tumors are rare and most grow very slowly. Most of them occur in the appendix, small intestine, and rectum. Sometimes more than one tumor will form.

The three ways that cancer spreads in the body are:

1. Through tissue. Cancer invades the surrounding normal tissue.
2. Through the lymph system. Cancer invades the lymph system and travels through the lymph vessels to other places in the body.
3. Through the blood. Cancer invades the veins and capillaries and travels through the blood to other places in the body.

When cancer cells break away from the primary (original) tumor and travel through the lymph or blood to other places in the body, another (secondary) tumor may form. This process is called metastasis. The secondary (metastatic) tumor is the same type of cancer as the primary tumor. For example, ifbreast cancer spreads to the bones, the cancer cells in the bones are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.

Anything that increases a person's chance of developing a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. Talk to your doctor if you think you may be at risk.

Risk factors for GI carcinoid tumors include the following:

1. Having a family history of multiple endocrine neoplasia type 1 (MEN1) syndrome orneurofibromatosis type 1 (NF1) syndrome.
2. Having certain conditions that affect the stomach's ability to make stomach acid, such as atrophicgastritis, pernicious anemia, or Zollinger-Ellison syndrome.

Some gastrointestinal carcinoid tumors have no symptoms in the early stages.The growth of the tumor and/or the hormones the tumor makes may cause symptoms. Some tumors, especially tumors of the stomach or appendix, may not cause symptoms. Carcinoid tumors are often found during tests or treatments for other conditions.

Carcinoid tumors in the small intestine (duodenum, jejunum, and ileum), colon, and rectum sometimes cause symptoms as they grow or because of the hormones they make. Other conditions may cause the same symptoms. Check with your doctor if you have any of the following problems:

Symptoms of GI carcinoid tumors in the duodenum (first part of the small intestine, that connects to the stomach) may include the following:

1. Abdominal pain.
2. Constipation
3. Diarrhea.
4. Change in stool color.
5. Nausea.
6. Vomiting.
7. Jaundice (yellowing of the skin and whites of the eyes).
8. Heartburn.

Symptoms of GI carcinoid tumors in the jejunum (middle part of the small intestine) and ileum (last part of the small intestine, that connects to the colon) may include the following:

1. Abdominal pain.
2. Weight loss for no known reason.
3. Feeling very tired.
4. Feeling bloated.
5. Diarrhea.
6. Nausea.
7. Vomiting.

Symptoms of GI carcinoid tumors in the colon may include the following:

1. Abdominal pain.
2. Weight loss for no known reason.

Symptoms of GI carcinoid tumors in the rectum may include the following:

1. Blood in the stool.
2. Pain in the rectum.
3. Constipation.

The hormones made by gastrointestinal carcinoid tumors are usually destroyed by liver enzymes in the blood. If the tumor has spread to the liver and the liver enzymes cannot destroy the extra hormones made by the tumor, high amounts of these hormones may remain in the body and cause carcinoid syndrome. This can also happen if tumor cells enter the blood. Symptoms of carcinoid syndrome include the following:

1. Redness or a feeling of warmth in the face and neck.
2. Abdominal pain.
3. Feeling bloated.
4. Diarrhea.
5. Wheezing or other trouble breathing.
6. Fast heartbeat.

These symptoms and others may be caused by gastrointestinal carcinoid tumors or by other conditions. Talk to your doctor if any of these symptoms occur.

The following tests and procedures may be used:

1. Physical exam and history : An exam of the body to check general signs of health, including checking for signs of disease, such as lumps or anything else that seems unusual. A history of the patient€™s health habits and past illnesses and treatments will also be taken.
2. Blood chemistry studies : A procedure in which a blood sample is checked to measure the amounts of certain substances, such as hormones, released into the blood by organs and tissuesin the body. An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that produces it. The blood sample is checked to see if it contains a hormone produced by carcinoid tumors. This test is used to help diagnose carcinoid syndrome.
3. Tumor marker test : A procedure in which a sample of blood, urine, or tissue is checked to measure the amounts of certain substances, such as chromogranin A, made by organs, tissues, or tumor cells in the body. Chromogranin A is a tumor marker. It has been linked to neuroendocrine tumors when found in increased levels in the body.
4. Twenty-four-hour urine test: A test in which urine is collected for 24 hours to measure the amounts of certain substances, such as 5-HIAA or serotonin (hormone). An unusual (higher or lower than normal) amount of a substance can be a sign of disease in the organ or tissue that makes it. This test is used to help diagnose carcinoid syndrome.
5. MIBG scan : A procedure used to find neuroendocrine tumors, such as carcinoid tumors. A very small amount of radioactive material called MIBG (metaiodobenzylguanidine) is injected into a vein and travels through the bloodstream. Carcinoid tumors take up the radioactive material and are detected by a device that measures radiation.
6. CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-raymachine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
7. MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of areas inside the body. This procedure is also called nuclear magnetic resonance imaging
8. PET scan (positron emission tomography scan): A procedure to find malignant tumor cells in the body. A small amount of radionuclide glucose (sugar) is injected into a vein. The PET scannerrotates around the body and makes a picture of where glucose is being used in the body. Malignant tumor cells show up brighter in the picture because they are more active and take up more glucose than normal cells.
9. Endoscopic ultrasound (EUS): A procedure in which an endoscope is inserted into the body, usually through the mouth or rectum. An endoscope is a thin, tube-like instrument with a light and alens for viewing. A probe at the end of the endoscope is used to bounce high-energy sound waves (ultrasound) off internal tissues or organs, such as the stomach, small intestine, colon, or rectum, and make echoes. The echoes form a picture of body tissues called a sonogram. This procedure is also called endosonography.
10. Upper endoscopy : A procedure to look at organs and tissues inside the body to check forabnormal areas. An endoscope is inserted through the mouth and passed through the esophagusinto the stomach. Sometimes the endoscope also is passed from the stomach into the small intestine. An endoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove tissue or lymph node samples, which are checked under a microscope for signs of disease.
11. Colonoscopy : A procedure to look inside the rectum and colon for polyps, abnormal areas, or cancer. A colonoscope is inserted through the rectum into the colon. A colonoscope is a thin, tube-like instrument with a light and a lens for viewing. It may also have a tool to remove polyps or tissue samples, which are checked under a microscope for signs of cancer.
12. Capsule endoscopy : A procedure used to see all of the small intestine. The patient swallows a capsule that contains a tiny camera. As the capsule moves through the gastrointestinal tract, the camera takes pictures and sends them to a receiver worn on the outside of the body.
13. Biopsy : The removal of cells or tissues so they can be viewed under a microscope to check for signs of cancer. Tissue samples may be taken during endoscopy and colonoscopy.

The prognosis (chance of recovery) and treatment options depend on the following:

1. Where the tumor is in the gastrointestinal tract.
2. The size of the tumor.
3. Whether the cancer has spread from the stomach and intestines to other parts of the body, such as the liver or lymph nodes.
4. Whether the patient has carcinoid syndrome or has carcinoid heart syndrome.
5. Whether the cancer can be completely removed by surgery.
6. Whether the cancer is newly diagnosed or has recurred.

Staging is the process used to find out how far the cancer has spread. The information gathered from the staging process determines the stage of the disease. After a gastrointestinal carcinoid tumor has been diagnosed, tests are done to find out if cancer cells have spread within the stomach and intestines or to other parts of the body. The results of tests and procedures used to diagnose gastrointestinal carcinoid tumors may also be used for staging.

For many cancers it is important to know the stage of the cancer in order to plan treatment. However, the treatment of gastrointestinal carcinoid tumors is not based on the stage of the cancer. Treatment depends mainly on whether the tumor can be removed by surgery and if the tumor has spread.

Treatment is based on whether the tumor:

1. Can be completely removed by surgery.
2. Has spread to other parts of the body.
3. Has come back after treatment. The tumor may come back in the stomach or intestines or in other parts of the body.
4. Has not gotten better with treatment.

Treatment of gastrointestinal carcinoid tumors usually includes surgery. One of the following surgical procedures may be used:

1. Endoscopic resection: Surgery to remove a small tumor that is on the inside lining of the GI tract. An endoscope is inserted through the mouth and passed through the esophagus to the stomach and sometimes, the duodenum. An endoscope is a thin, tube-like instrument with a light, a lens for viewing, and a tool for removing tumor tissue.
2. Local excision: Surgery to remove the tumor and a small amount of normal tissue around it.
3. Resection: Surgery to remove part or all of the organ that contains cancer. Nearby lymph nodesmay also be removed.
4. Cryosurgery: A treatment that uses an instrument to freeze and destroy carcinoid tumor tissue. This type of treatment is also called cryotherapy. The doctor may use ultrasound to guide the instrument.
5. Radiofrequency ablation: The use of a special probe with tiny electrodes that release high-energy radio waves (similar to microwaves) that kill cancer cells. The probe may be inserted through the skin or through an incision (cut) in the abdomen.
6. Liver transplant: Surgery to remove the whole liver and replace it with a healthy donated liver.
7. Hepatic artery embolization: A procedure to embolize (block) the hepatic artery, which is the mainblood vessel that brings blood into the liver. Blocking the flow of blood to the liver helps kill cancer cells growing there.

Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactivesubstance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.

Radiopharmaceutical therapy is a type of radiation therapy. Radiation is given to the tumor using adrug that has a radioactive substance, such as iodine I 131, attached to it. The radioactive substance kills the tumor cells.

Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy).

Chemoembolization of the hepatic artery is a type of regional chemotherapy that may be used to treat a gastrointestinal carcinoid tumor that has spread to the liver. The anticancer drug is injected into the hepatic artery through a catheter (thin tube). The drug is mixed with a substance that embolizes (blocks) the artery, and cuts off blood flow to the tumor. Most of the anticancer drug is trapped near the tumor and only a small amount of the drug reaches other parts of the body. The blockage may be temporary or permanent, depending on the substance used to block the artery. The tumor is prevented from getting the oxygen and nutrients it needs to grow. The liver continues to receive blood from thehepatic portal vein, which carries blood from the stomach and intestine.

The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Hormone therapy with a somatostatin analogue is a treatment that stops extra hormones from being made. GI carcinoid tumors are treated with octreotide or lanreotide which are injected under the skin or into the muscle. Octreotide and lanreotide may also have a small effect on stopping tumor growth.

Treatment of carcinoid syndrome may include the following:

1. Hormone therapy with a somatostatin analogue stops extra hormones from being made. Carcinoid syndrome is treated with octreotide or lanreotide to lessen flushing and diarrhea. Octreotide and lanreotide may also help slow tumor growth.
2. Interferon therapy stimulates the body€™s immune system to work better and lessens flushing and diarrhea. Interferon may also help slow tumor growth.
3. Taking medicine for diarrhea.
4. Taking medicine for skin rashes.
5. Taking medicine to breathe easier.
6. Taking medicine before having anesthesia for a medical procedure.

Other ways to help treat carcinoid syndrome include avoiding things that cause flushing or difficulty breathing such as alcohol, nuts, certain cheeses and foods with capsaicin, such as chili peppers. Avoiding stressful situations and certain types of physical activity can also help treat carcinoid syndrome. For some patients with carcinoid heart syndrome, a heart valve replacement may be done.

Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells. Several types of targeted therapy are being studied in the treatment of GI carcinoid tumors.

Treatment of gastrointestinal (GI) carcinoid tumors in the stomach may include the following:

1. Endoscopic surgery (resection) for small tumors.
2. Surgery (resection) to remove part or all of the stomach. Nearby lymph nodes for larger tumors, tumors that grow deep into the stomach wall, or tumors that are growing and spreading quickly may also be removed.

For patients with GI carcinoid tumors in the stomach and MEN1 syndrome, treatment may also include:

1. Surgery to remove tumors in the duodenum (first part of the small intestine, that connects to the stomach).
2. Hormone therapy.

It is not clear what the best treatment is for GI carcinoid tumors in the duodenum (first part of the small intestine, that connects to the stomach). Treatment may include the following:

1. Endoscopic surgery (resection) for small tumors.
2. Surgery (local excision) to remove the tumor, for slightly larger tumors.
3. Surgery resection to remove the tumor and nearby lymph nodes.

Treatment of GI carcinoid tumors in the jejunum (middle part of the small intestine) and ileum (last part of the small intestine, that connects to the colon) may include the following:

1. Surgery (resection) to remove the tumor and the membrane that connects the intestines to the back of the abdominal wall. Nearby lymph nodes are also removed.
2. A second surgery to remove the membrane that connects the intestines to the back of the abdominal wall, if any tumor remains or the tumor continues to grow.
3. Hormone therapy.

Treatment of GI carcinoid tumors in the appendix may include the following:

1. Surgery (resection) to remove the appendix.
2. Surgery (resection) to remove the right side of the colon including the appendix. Nearby lymph nodes are also removed.

Treatment of GI carcinoid tumors in the colon may include the following:

1. Surgery (resection) to remove part of the colon and nearby lymph nodes, in order to remove as much of the cancer as possible.

Treatment of GI carcinoid tumors in the rectum may include the following:

1. Endoscopic surgery (resection) for small tumors.
2. Surgery (local excision) to remove slightly larger tumors that have not spread into the muscle layer of the rectal wall.
3. Surgery (resection) to remove the top part of the rectum and the left side of the colon, for slightly larger tumors that have may spread to the muscle layer of the rectal wall or nearby tissues. Nearbylymph nodes are also removed.
4. Surgery (local excision) to remove as much tumor as possible when the tumor has spread todistant parts of the body. This is palliative therapy to relieve symptoms and improve quality of life.

Treatment of distant metastases of gastrointestinal carcinoid tumors is usually palliative therapy to relieve symptoms and improve quality of life. Treatment may include the following:

1. Surgery (resection) to remove as much of the tumor as possible.
2. Hormone therapy.
3. Radiopharmaceutical therapy.
4. Radiation therapy for cancer that has spread to the bone, brain, or spinal cord.

Treatment of cancer that has spread to the liver may include the following:

1. Surgery resection to remove the tumor from the liver.
2. Hepatic artery embolization.
3. Cryosurgery.
4. Radiofrequency ablation.
5. Liver transplant.

Treatment of recurrent gastrointestinal carcinoid tumors may include the following:

1. Surgery to remove part or all of the tumor.
2. A clinical trial of a new treatment.

Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients withrecurrent gastrointestinal carcinoid tumor. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. General information about clinical trials is available from the NCI Web site.

Depending on your cancer type and stage, our goals for treatment are:

1. Cure : This is the most important goal of cancer surgery. In fact as a cancer patient you are also strongly willing to have cure of cancer for forever. For most of the Liver & Gastro-intestinal cancers perhaps surgery is the first step for cure. Radiation &/or Chemotheray may be advised as an additional tool to achieve this goal.
2. Control : If your cancer is at a later stage or if previous treatments have been unsuccessful, we aim to control your cancer by removing as much as safely possible. Once you recover from surgery, radiation or chemotherapy is advised as important tool to control your cancer.
3. Comfort : If you have an advanced stage of cancer or one that hasn't responded to treatments and having symptoms because of tumor i.e pain, jaundice, vomiting, bleeding either in vomitus or in stool, then our multi-specialist team work together to sure you are free of pain and other symptoms.

Surgery can be done for many reasons for treatment of cancer.

1. Curative surgery is done when cancer is found in only one area, and it’s likely that all of the cancer can be removed. In this case, curative surgery can be the main treatment. It may be used alone or along with chemotherapy or radiation therapy, which can be given before or after the operation.

1. This type of surgery is used to take out a piece of tissue (biopsy) to find out if cancer is present or what type of cancer it is. The diagnosis of cancer is made by looking at the cells under a microscope. Staging surgery is done to find out how much cancer there is and how far it has spread. The physical exam and the results of lab and imaging tests are used to figure out the clinical stage of the cancer. But the surgical stage (also called the pathologic stage) is usually a more exact measure of how far the cancer has spread. Examples of surgical procedures commonly used to stage cancers, like laparoscopy or laparotomy.

1. This type of surgery is used to treat problems caused by advanced cancer. It is not done to cure the cancer. For example, cancers of intestine may grow large enough to block off (obstruct) the intestine, or tumor is bleeding and unable to control bleed by medical/endoscopic technique. If this happens, surgery can be used to remove the blockage/control bleeding.

How surgery is performed? (Special surgery techniques): Open Or Laparoscopic

1. It is the Gold Standard approach for Liver & Gastro-Intestinal cancer. An incision is given on the belly depending upton the underlying location of tumor so that surgeon can directly approach the cancer on cutting the belly. Open Surgery help to remove tumor safely if its adherent to near by blood vessels or organ, that is otherwise difficult in laparoscopic surgery.

1. A laparoscope is a long, thin, flexible tube that can be put through a small cut (incision) to look inside the body. In recent years, doctors have found that by creating small holes and using special instruments, the laparoscope can be used to perform surgery without making a large cut. This can help reduce blood loss during surgery and pain afterward. It can also shorten hospital stays and allow people to heal faster.
2. The role of laparoscopic surgery in cancer treatment is not yet clear. Doctors are now studying whether it is safe and effective to use laparoscopic surgeries for cancers of the stomach, colon, rectum & liver. It may prove to be as safe and work as well as standard surgery while cutting less and causing less damage to healthy tissues (being less invasive).

Biopsy is procedure to confirm the presence of cancer. It’s not essential before surgery. Usually biopsy is performed when 1. Suspicion is cause other than cancer, 2. When surgery cannot be done for cancer due to advanced stage of cancer or 3. Patient is unfit to undergo surgery. In these situation, biopsy guides for further therapy.

There is variety of way to perform biopsies:

1. Fine needle aspiration (FNA) uses a very thin needle attached to a syringe to pull out small bits of tissue. The needle is guided into the tumor by looking at it using an imaging test, like an ultrasound or CT scan.
2. The main advantage of FNA is that there is no need to cut through the skin, so there is no surgical incision.
3. A drawback is that in some cases the needle can’t take out enough tissue for an exact diagnosis. A more invasive type of biopsy (one that involves larger needles or a cut in the skin) may then be needed.

1. This type of biopsy uses a larger needle to take out a core of tissue and done under guidance of imaging test like an ultrasound or CT scan. The advantage of core biopsy is that it usually collects enough tissue to find out whether the tumor is cancer.

1. For these biopsies, the surgeon remove the entire tumor (excisional biopsy) or a small part of the tumor (incisional biopsy).

Our expert team members shall help you to prepare you for surgery. You are strongly advised to stop smoking, stop drinking alcohol, try to improve your diet, lose weight, or actively exercise before surgery.

In most cases, you will need some tests before your surgery. The tests routinely used include:

1. Blood tests to measure your blood counts, your risk of bleeding or infection, and how well your liver and kidneys are working. Your blood group type is also be checked in case you need blood transfusions during the operation.
2. Chest x-ray and ECG (electrocardiogram) to check your lungs and your heart’s electrical system.
3. USG/CT scans/ MRI to look at the size and location of the tumors and see if the cancer looks like it has spread to nearby tissues.

Our expert team of Anaesthetist will ask you questions pertaining to your health and to assess your fitness for surgery. You are requested to tell them in detail about your current and past medical ailments, allergic reactions you’ve had in the past and current medicines that you are taking like blood thinning medicine. This medicine should be stopped 1 week prior to surgery.

Informed consent is one of the most important parts of “getting ready for surgery”. It is a process during which you are told about all aspects of the treatment before you give your doctor written permission to do the surgery.

Depending on the type of operation you have, there may be things you need to do to be ready for surgery:

1. Emptying your stomach and bowels (digestive tract) is important. Vomiting while under anaesthesia can be very dangerous because the vomit could get into your lungs and cause an infection. Because of this, you will be asked to not eat or drink anything starting the night before the surgery.
2. Laxative: You may also be asked to use a laxative or an enema to make sure your bowels are empty.
3. Shaving of Operative part: You need to have an area of your body shaved to keep hair from getting into the surgical cut (incision). The area will be cleaned before the operation to reduce the risk of infection.

Anaesthesia is the use of drugs to make the body unable to feel pain for a period of time. General anaesthesia puts you into a deep sleep for the surgery. It is often started by having you breathe into a face mask or by putting a drug into a vein in your arm. Once you are asleep, an endotracheal or ET tube is put in your throat to make it easy for you to breathe. Your heart rate, breathing rate, and blood pressure (vital signs) will be closely watched during the surgery. A doctor watches you throughout the procedure and until you wake up. They also take out the ET tube when the operation is over. You will be taken to the recovery room to be watched closely while the effects of the drugs wear off. This may take hours. People waking up from general anaesthesia often feel "out of it" for some time. Things may seem hazy or dream-like for a while. Your throat may be sore for a while from the endotracheal (ET) tube.

Your recovery right after surgery depends on many factors, including your state of health before the operation and how extensive the operation was performed.

You may feel pain at the site of surgery. We aim to keep you pain free after surgery with the help of latest and most effective technique or analgesic (pain relieving medicine).

1. You may also have Ryle’s Tube (tube going through nose to stomach) that drain out intestinal fluid. This tube helps to relieve nausea and vomiting after surgery and usually removed 1-2 day after surgery.
2. You may also have “Tube” (called a Foley catheter) draining urine from your bladder into a bag. This will be taken out soon after surgery, once you are comfortable enough to go to bathroom.
3. You may have a tube or tubes (called Drains) coming out of the surgical opening in your skin (incision site). Drains allow the excess fluid that collects at the surgery site to leave the body. Drain tube will also be removed once they stop collecting fluid, usually a few days after the operation.

As you are remains in bed on day of surgery, circulation of blood in leg become sluggish that may increase possibility of thrombo-embolism. To minimise it, you will be wearing leg stocking/ pneumatic compression boot to improve your leg circulation thus minimising the risk of thrombolism.

You may not feel much like eating or drinking, but this is an important part of the recovery process. Our health care team may start you out with ice chips or clear liquids. The stomach and intestines (digestive tract) is one of the last parts of the body to recover from the drugs used during surgery. You will need to have signs of stomach and bowel activity before you will be allowed to eat. You will likely be on a clear liquid diet until this happens. Once it does, you may get to try solid foods.

1. Our health care team will try to have you move around as soon as possible after surgery. They may even have you out of bed and walking the same day. While this may be hard at first, it helps speed your recovery by getting your digestive tract moving. It also helps your circulation and helps prevent blood clots from forming in your legs.
2. Our team shall also encourage you to do deep breathing exercises. This helps fully inflate your lungs and reduces the risk of pneumonia. You are advised to take deep breaths and cough every hour to help prevent lung infections. You will use an incentive spirometer (a small device used in breathing exercises to prevent complications after major surgery) 10-15 times every hour.

Once you are eating and walking, all tube/drains placed during surgery are removed, and then you may be ready to go home. Before leaving for home our health care team shall give you detailed guidance regarding diet, activities, medications & further plan of treatment.

There are risks that go with any type of medical procedure and surgery is no longer an exception. Success of surgery depends upon 3 factors: type of disease/surgery, experience of surgeon and overall health of patients. What’s important is whether the expected benefits outweigh the possible risks.

Doctors have been performing surgeries for a very long time. Advances in surgical techniques and our understanding of how to prevent infections have made modern surgery safer and less likely to damage healthy tissues than it has ever been. Still, there’s always a degree of risk involved, no matter how small. Different procedures have different kinds of risks and side effects. Be sure to discuss the details of your case with our health care team, who can give you a better idea about what your actual risks are. During surgery, possible complications during surgery may be caused by the surgery itself, the drugs used (anesthesia), or an underlying disease. Generally speaking, the more complex the surgery is the greater the risk. Complications in major surgical procedures include:

1. Complications related to Anaesthesia : Reactions to drugs used (anesthesia) or other medicines. Although rare, these can be serious because they can cause dangerously low blood pressures. Your doctors will watch your heart rate, breathing rate, blood pressure, and other signs throughout the procedure to look for this.
2. Complications related to underlying medical illness like heart disease, diabetes, kidney disease, obesity, malnutrition.
   1. Lung : Pneumonia, Atelectasis (collapse of lung), effusion (fluid in chest) can occur, especially in patients with reduced lung function, such as smokers. Doing deep breathing exercises as soon as possible after surgery helps lessen this risk.
   2. Thrombosis (blood clot) in leg & embolism (blood clot) in lung : Blood clots can form in the deep veins of the legs after surgery, especially if a person stays in bed for a long time. Such a clot can become a serious problem if it breaks loose and travels to another part of the body, such as a lung. This is a big reason why you will be encouraged to get out of bed to sit, stand, and walk as soon as possible.
   3. Cardiovascular : Myocardial infarction (heart attach), Arrhythmia (irregular heart beat), Stroke (cerebro-vascular accidents).
   4. Kidney & urinary tract infection, acute kidney failure if patient has uncontrolled/non-responding infection.
3. Complications related to Specific Operations
   1. There are specific complications related to type of surgery. You are encouraged with discuss in detail with our health care team before you give your consent for surgery.
   2. Bile leak
   3. Bleed
4. Complications related to Major Surgery
   1. Infection : Infection at the site of the wound, lung and urinary infection. Infection risk is more if intestine is perforated before surgery, operated for colon and rectum, stent in placed in bile duct to relieve jaundice or intestinal joint is leaking.
   2. Bleeding : The risk of bleeding during or after surgery is more if patient taking blood thinning medicine till day of surgery or having liver dysfunction. Bleeding during surgery that may cause you to need blood transfusions. There is a risk of certain problems with transfusions, some of them serious. Still, some operations involve a certain amount of controlled blood loss. Bleeding can happen either inside the body (internally) or outside the body (externally). It can occur if a blood vessel sealed during surgery opens up or if a wound opens up. Serious bleeding may cause the person to need another operation to find the source of the bleeding and stop it.
   3. Leakage from anastomosis (joint of anastomosis) & fluid collection in tummy.
   4. Blockage of intestine (Intestinal obstruction)

1. Following treatment, you may feel change in your taste. This improves over a time and we encourage having health food habit like fresh vegetables, fruits and high protein diet.

1. Along with healthy food habits, we also encourage for exercise. Exercise improves your health in different ways: It improves your heart and circulation, makes your muscles stronger & makes you feel happier. You should do your regular activities like walking, and rather increase day by day. Weight lifting and strenuous exercise are avoided for initial 2-3 months.

1. You'll need regular check-ups after treatment for liver cancer. This help to find out any change in your recovery. Sometimes liver cancer comes back after treatment. Our health care team will check for return of cancer. Checkups may include a physical exam, blood tests, ultrasound / CT scan.
2. If you have any health problems between checkups, you should contact our health care team. Report to our health care team, if you have any redness/ swelling or discharge of any type of fluid from your operative incision site, pain abdomen, vomiting or fever, breathing difficulty etc.