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Dr. Deepak Chhabra

Types of Colostomy Surgery

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A colostomy can be short-term (temporary) or life-long (permanent) and can be made in any part of the colon.

Transverse colostomy

A transverse colostomy is made from the transverse or the horizontal part of the colon. The transverse colostomy is in the upper abdomen, either in the middle or toward the right side of the body. Colon problems like diverticulitis, inflammatory bowel disease, cancer, obstruction (blockage), injury, or birth defects can lead to a transverse colostomy. This type of colostomy allows the stool to leave the colon before it reaches the further portion of colon called the descending colon.

When the problems are in the lower bowel, the affected part of the bowel might need time to rest and heal. A transverse colostomy may be used to keep stool out of the area of the colon that is inflamed, infected, diseased, or newly operated on – this allows healing to take place. This type of colostomy is usually temporary. Depending on the healing process, the colostomy may be needed for a few weeks, months, or even years. If you heal over time, the colostomy is likely to be reversed (closed) and you will go back to having normal bowel function.

The type of discharge from a transverse colostomy varies from time to time and from person to person. A few transverse colostomies discharge firm stool at infrequent intervals, but most of them move fairly often and put out a soft or loose stool. It is important to know that the stool contains digestive enzymes that are very irritating, so the nearby skin must be protected. Despite the colostomy, the resting part of the colon keeps making mucus that will come out either through the stoma or through the rectum and anus. This is normal and expected.

Your colostomy does not have a sphincter muscle or control mechanism like your anus does. For this reason, you will need to wear a pouch over your colostomy to collect the output. Your ostomy nurse or doctor will help you find a pouching system that is right for you. The pouch does not usually bulge, and it’s not easy to see under your clothes.

Sigmoid colostomy

A sigmoid colostomy is made from the lower portion of the intestine called Sigmoid colon. Because there is more working colon, it may produce more solid stool more regularly. The sigmoid colostomy is the most common type of colostomy.

The stoma or the opening of the end colostomy is either sewn flush with the skin or it is turned back on itself (like the turned-down top of a sock).

The stool of a descending or sigmoid colostomy is firmer than that of the transverse colostomy. It does not have as much of the irritating digestive enzymes in it. Output from these types of colostomies may happen as a reflex at regular, expected times. The bowel movement will take place after a certain amount of stool has collected in the bowel above the colostomy. Two or 3 days may go between movements. Spilling may happen between movements because there is no anus to hold the stool back. Many people use a lightweight, disposable pouch to prevent accidents. A reflex to empty the bowel will set up quite naturally in some people. Others may need mild stimulation, such as juice, coffee, a meal, a mild laxative, or irrigation.

While many descending and sigmoid colostomies can be trained to move regularly, some cannot. Training, with or without stimulation, is likely to happen only in those people who had regular bowel movements before they became ill. If bowel movements were irregular in earlier years, it may be hard, or impossible, to have regular, predictable colostomy function.

Many people think that a person must have a bowel movement every day. In truth, this varies from person to person. Some people have 2 or 3 movements a day, while others have a bowel movement every 2 or 3 days or even less often. Figure out what is normal for you.

Initially it is necessary to have colostomy bags for output from a descending or sigmoid colostomy but with proper irrigation care you may be able to avoid a colostomy bag altogether (see irrigation in colostomy care).

What is Pancreatic Cancer?

By Pancreatic Cancer

What is Pancreas?

Pancreatic Cancer Oncologist Dr. Deepak Chhabra Mumbai

The pancreas is a thin, lumpy gland that lies between your stomach and your spine. It is normally about six inches long and is shaped something like a thin pear, the organ is wide at one end and narrow at the other end and has three sections. The wider right end is called the head, the midsection is the body, and the narrow left end is the tail. It is joined by a duct (the ‘pancreatic duct’) to the first part of the small bowel (the duodenum) into a common opening with the bile duct called the ampulla.

The pancreas plays two major roles in your body’s digestive system.

  • It produces insulin, which controls the amount of sugar in your blood. If the pancreas does not produce enough insulin, you will develop diabetes.
  • Other parts of the pancreas produce substances called enzymes, which help you to digest food. These enzymes pass from the pancreas into your duodenum through the pancreatic duct. If the release of these enzymes is blocked for any reason, the body cannot absorb food completely and may result in diarrhoea and weight loss.

About

What is cancer of pancreas?

Cancer of the pancreas develops when healthy cells in the pancreas become abnormal and grow too quickly. The abnormal cells form a mass in the pancreas called a tumor. When a tumor has the ability to spread to other parts of the body, it is called malignant (cancer).
The most common malignant tumors of the pancreas, known as adenocarcinoma, come from cells involved in the production of enzymes for digestion and accounts for 95 percent of all pancreatic cancers. Sometimes mass develops in the specialised cells of pancreas called islet cells.

Islet cell carcinoma involves cells that can secrete a variety of hormones. These tumors can be functional and make abnormally high amounts of hormones or can be non-functional and not produce any hormones. Most islet cell tumors are malignant, but some are benign such as insulin-producing islet cell tumors.

Which part of the pancreas is affected with cancer?

Cancer can affect any part of the pancreas, the head, body or the tail but is more common in the wide right end or commonly called as the head of pancreas. Sometimes a common label of “periampullary cancer” is used indicating that the location of cancer can be either in the head of pancreas, at the common opening called ampulla, at the lower end of the bile duct or at the intestine where the pancreatic duct opens.

Pancreatic Cancer Surgery

By Pancreatic Cancer

Treatment

What is the treatment of pancreatic cancer?

Many years of treating cancer patients and testing treatments in clinical trials has helped doctors know what is likely to work for a particular type and stage of cancer. You will be advised on the best treatment for your cancer. This will depend on the type of cancer you have, where it is and how far it has spread and your general health.

Surgery

Surgery For Pancreatic Cancer

The main treatment for pancreatic cancer is surgery. Though cancer surgeries are extensive and take longer hours; with advanced medical care, surgeries have become safer and better equipments are now available to perform surgeries. Improved techniques of anaesthesia and post-operative monitoring have significantly contributed to overall safety of surgical procedures for cancers.

If you are found suitable for the surgery, you will be usually admitted one or two days prior to the proposed date of surgery. There may be dietary restrictions and you may be given laxatives to evacuate your bowels prior to surgery. Your blood group will be checked and blood is usually reserved for all major abdominal surgeries.

It is always a good idea to start with deep breathing exercises once you are admitted to the hospital. Your doctor may summon a physiotherapist to assist you with the same. You will have most of your body parts shaved for the surgery. You will be given a consent form for your signature.

The form would have details of the procedure to be performed on you by your treating surgeon. In case you have any doubts you should feel free to ask them to the surgical team.

Paliation

The surgeries for pancreatic cancers depend on the location of the tumor in the pancreas.

Majority of the pancreas cancer however are in the head region of the pancreas and the operation performed is “Whipple’s surgery”.

“Distal Pancreatectomy” is performed for tumors located in the tail or body portion of the pancreas and the surgery involves removal of the body and tail portion of the pancreas along with the spleen.

Whipple’s Surgery:

This major operation involves removal of:

  • part of the pancreas
  • part of the first part of the small bowel (duodenum)
  • part of the stomach
  • part of the gall bladder and part of the bile duct.

The diagram below shows what your surgeon removes

pancreas
(Not Verified)

The surgeon reconnects the remainder of the pancreas, bile duct and stomach to different sections of the small bowel so the digestive tract keeps working.

pancreas cancer

(Not Verified)

A feeding tube may be placed during the surgery to replenish nutrition to the patient after surgery.

Distal Pancreatectomy:

This operation is performed for certain types of pancreatic tumors located in the tail or body portion of the pancreas. This surgery involves removal of only the tail of the pancreas or the tail and a portion of the body of the pancreas. The spleen is usually removed as well.

distal pancreatectomy

(Not Verified)

Bypass Surgery:

Sometimes surgery may begin with the hope it will cure the patient, but the surgeon discovers this is not possible. In this case, the surgeon may continue the operation as a palliative / bypass procedure to relieve or prevent symptoms.

Cancers growing in the head of the pancreas can block the common bile duct as it passes through this part of the pancreas. This may cause pain and digestive problems because the bile can’t get into the intestine and patient develops jaundice and vomiting. The bile chemicals will build up in the body

There are 2 options for relieving bile duct blockage.

Surgery can be done to reroute the flow of bile from the common bile duct directly into the small intestine, bypassing the pancreas. Sometimes, the stomach connection to the duodenum (the first part of the small intestine) is rerouted at this time as well. Often, late in the course of pancreatic cancer, the duodenum becomes blocked by cancer, which can cause pain and vomiting that requires surgery. Bypassing the duodenum before this happens can help avoid a second operation.

stent

(Not Verified)

A second approach to relieving a blocked bile duct does not involve surgery. Instead, a stent (small tube) is placed in the duct to keep it open. This is usually done through an endoscope (a long, flexible tube) while the patient is sedated. The doctor passes the endoscope down the patient’s throat and all the way into the small intestine. The doctor can then insert the stent into the bile duct through the endoscope. The stent helps keep the bile duct open and resists compression from the surrounding cancer.

Drinking and eating after surgery.

After an anaesthetic, the movement of the bowel slows down and usually takes about 72 hours to get back to normal. After about 48-72 hours you will probably be ready to start taking small sips of water, however your doctors will tell you when it is appropriate for you to start drinking some fluids. This will be gradually increased after a couple of days until you are able to eat a light diet.

Going home.

You will probably be ready to go home in about 10-14 days after your operation and once your stitches have been removed. If deemed appropriate your doctor may send you home with stitches and call you later to remove the stitches. By and large you should be able to climb several flights of stairs after your discharge from the hospital and you will be given diet instructions.

Before you leave hospital you will be given an appointment for a post-operative check-up at the outpatient clinic.

Diet after pancreas surgery.

You will be transferred to the Intensive care unit after the surgery. Your recovery will depend on the magnitude of surgery performed. After the operation, the patient is usually monitored in the ICU for 48 to 72 hrs and the overall hospital stay (if no complications) is usually between 10–14 days.

Your pain and discomfort will be taken care of by the anaesthetic team. You will be given pain-killers and an intravenous infusion (drip) to replace your body’s fluids until you are able to drink and eat again after a few days. You will also have a naso-gastric (NG) tube in place.

This is a thin tube that passes down your nose into your stomach or small intestine and allows any fluids to be removed so that you don’t feel sick. It is usually taken out within 48 hours. Sometimes a small tube (catheter) is put into the bladder to drain your urine into a collecting bag.

After your operation you will be encouraged to start moving about as soon as possible. This is an essential part of your recovery. If you have to stay in bed the nurses will encourage you to do regular leg movements and deep breathing exercises. You will be seen by a physiotherapist who can help you to do the exercises.

At first, even tiny meals may make you feel uncomfortably full. You will need to eat very small amounts very often at first. Then, gradually increase the amounts and then the time between meals. At first, you may find you need to eat every hour or so in order to get enough nutrition.

There is no restriction on the type of food you eat after a pancreas surgery and you should be able to eat all that you did before surgery. Fizzy drinks can make you feel full – it is probably best not to drink with meals at all, as any liquid will fill you up.

Try keeping a food diary if you are having problems you think are related to your diet. Take a small notebook and draw a line down the centre of each page. Write down what you eat and when on the left of the page. Write down any symptoms you get and when on the other side of the page. After a few days, you may be able to spot which foods cause which symptoms.

Some people need to take tablets to help digest fat and proteins, and some people develop diabetes, which may require treatment.

Tests for GIST

By GIST

Tests

What are the tests carried out to diagnose GIST?

This section lists common tests for the cancers. It is not necessary for all the tests to be performed for a patient. Your doctor will select the tests that will assist him / her to have the maximum information about the tumor/ disease. Before referring you for tests, your doctor will take a full medical history and examine you. You may also have a blood test and chest x-ray to check your general health.

Computerised tomography (CT) scan

A CT scan is a type of x-ray that gives a picture of organs and other structures (including any tumours) in your body. It is used to see more details of a cancer and its relation to the surrounding organs in your body. It also gives information related to cancer spread into the lymph nodes, liver or lungs.

Endoscopy / Gastroscopy

In this test, a thin, flexible ‘telescope’ (called an endoscope) will be passed down your throat so that the doctor can examine your oesophagus, stomach and the upper part of your bowel. If anything unusual is seen, the doctor can put instruments down the endoscope and remove tissue to examine under a microscope (biopsy).

Endoscopic ultrasound scan (EUS)

This is similar to having an endoscopy and may be occasionally for people who may have stomach GIST. For this test, the endoscope has a small ultrasound probe on the end for more detailed information about the local spread of the tumor. It can help the doctor decide whether you should have some other modality of treatment before surgery.

Positron emission tomography (PET) scan

This test is combined with a CT scan by injecting a radioactive material in the body to highlight all areas where the tumor has or can spread. This test may be used to build up more information after an MRI or CT scan. PET-CT scan is not necessary for all patients. Your doctor will decide if you need to undergo this scan.

Biopsy

A biopsy is diagnosis made under a microscope by a pathologist using a small bit of tissue removed from a suspicious area or lump that is found to be abnormal.

Gastrointestinal stromal tumor (GIST) is a cancer that may be suspected from its appearance in imaging techniques such as CT scans, but the diagnosis can only be determined by a pathologist after examining tumor tissue from a biopsy, or from the entire tumor after it has been surgically removed (resected). The main role of the pathologist is to determine the type of tumor (diagnosis). This is done by judging the characteristics of tumor cells viewed under a microscope and the results from a series of tests. The pathologist also gives an opinion regarding the prognosis (the risk of recurrence or metastasis).

The pathologist selects and applies immunohistochemical tests (IHC studies) to tumor samples. These tests involve using antibodies to detect the presence of proteins that are expressed by the tumor cells. The pattern of proteins that are present or missing in a respective tumor in conjunction with the morphology of the tissue is taken into account for the final diagnosis.

The best immunostaining method for identifying GIST is to test for expression of KIT, also called CD117. Therefore, a positive result for KIT antibody testing is a strong indication of a GIST diagnosis.

Symptoms of GIST

By GIST

Symptoms

Many patients (mostly those with smaller tumors) have no symptoms.

Larger tumors may cause symptoms that are generally related to the increased mass being accommodated in the abdominal cavity, and such symptoms would not necessarily be different from those other types of tumors.

Symptoms include digestive discomfort, sensations of abdominal fullness, or abdominal pain.

Larger tumors may be detectable as a mass when feeling the abdomen, or as a visible enlargement of the abdomen.

Some patients experience vomiting or diarrhea or intestinal obstruction may occur in some patients.

Sometimes GISTs perforate the stomach or gut lining and bleed into the GI tract, resulting in black or tarry stools, or occasionally in vomiting of blood. Anemia (Low Haemoglobin) may result from chronic bleeding, leading to fatigue. Sometimes anemia may cause the patient’s heart to race (tachycardia). The patient may notice weight loss.

Very rarely a GIST may rupture, making its presence known with a medical emergency.

Though such symptoms are possible, most of them are rather indistinct and merely related to the additional mass that is present in the abdomen. Therefore, many GISTs are found incidentally through medical imaging for other purposes or through surgery for other conditions.

What is GIST(gastrointestinal-stromal-tumor)?

By GIST

What is GIST?

A gastrointestinal stromal tumor (GIST) is a type of tumor that occurs in the gastrointestinal (GI or digestive) tract, including the esophagus, stomach, gallbladder, liver, small intestine, colon, rectum, and lining of the gut. GISTs are different from other types of gastrointestinal tumors because of the type of tissue in which they start.

About

Originally, GISTs were thought to be either muscle or nerve tumors, but recent research points to GISTs starting in cells found in the walls of the GI tract, called interstitial cells of Cajal (ICC); these cells send signals to the GI tract to help move food and liquid through the system.

GISTs belong to a group of cancers called soft tissue sarcoma. Soft tissue sarcomas are a group of cancers that develop in the tissues that support and connect the body, and the sarcoma cells resemble the cells that hold the body together, including fat cells, muscles, nerves, tendons, joints, blood vessels, or lymph vessels.

It is important to note that GISTs can be either benign or malignant. Sometimes it may be hard for the doctor to tell immediately whether a GIST is likely to come back after treatment. As a result, the doctor will look at many factors to determine the best treatment, including the size of the tumor, whether it has already spread, how many dividing cells there are, and the tumor’s location.

Because GIST cancers arise from the GI tract wall, they are usually attached to the outside of the involved organ, growing outward; this is sometimes referred to as exophytic. Occasionally a GIST may grow inward through the muscle layer of the GI tract wall and then develop partly inside the digestive tract lumen; this is sometimes called endophytic.

More than half of GISTs start in the stomach. Most of the remaining start in the small intestine, but GISTs can be found anywhere in the GI tract.

How common is GIST?

GIST is one of the not so common tumors Most primary care physicians and many pathologists and oncologists go through their entire professional careers without seeing a single GIST. This is important to patients because misdiagnosis can delay the start of appropriate treatment.

Surgery for Appendix Cancer

By Appendix Cancer

Treatment

What is the treatment of appendix cancer?

Treating appendix cancer depends on the type of tumor, its location within the appendix and whether or not it has spread. Because these tumors are relatively rare, particularly the non-carcinoid tumors, most treatment strategies have not been tested in standard clinical trials. In general, patients will undergo surgery to remove the appendix and/or right colon.

Surgery

Surgery For Appendix Cancer

The majority of cases, carcinoid tumors are small (less than two centimeters) and have a very low risk of spread to nearby lymph nodes. Appendectomy (removal of the appendix) is adequate treatment in these cases. Larger tumors have a slightly higher risk of spreading to surrounding lymph nodes and the liver. Removal of the right colon and regional lymph nodes is recommended. (Right Hemicolectomy)

For patients with non-carcinoid tumors that have spread within the abdominal cavity, the most effective therapy appears to be a combined approach of cytoreductive (tumor debulking) surgery and hyperthermic intraperitoneal (i.e., in the abdominal cavity) chemotherapy.

Appendix cancer has often spread to the peritoneal surfaces of the abdomen by the time it is discovered. The surgery to remove as much of the cancer in the abdomen as possible, reducing the “bulk” of the cancer is called “debulking” or “cytoreduction” surgery. “Cyto” is a word root meaning cells, so cytoreduction means to surgically “reduce” number of cancer cells. Both terms mean the same thing and are usually used interchangeably.

Cytoreduction (debulking) surgery is often long , complicated and a major operation to remove all the tumor and mucin present within the abdominal cavity. This can often require removing involved organs such as parts of the intestine, gallbladder, spleen, ovaries, uterus and even the lining of the abdominal cavity (peritoneum). “Complete cytoreduction” or “complete debulking” means that all of the visible tumors are successfully removed during surgery. “Incomplete cytoreduction” or “incomplete debulking” means that all of the tumors could not be removed during the surgery and that visible tumors were left behind.

The factor most associated with long term survival is completeness of cytoreduction, or the removal of all visible tumors.

To destroy very small tumors and cancer cells left behind that are too small to be seen, and to prevent them from later growing into new cancerous tumors in the abdomen, the surgery can be followed by treatment with intraoperative Hyperthermic Intraperitoneal Chemotherapy or by treatment with early post-operative intraperitoneal chemotherapy (EPIC) at facilities that have the capability to provide these treatments.

These chemotherapy treatments may be effective on very tiny tumors that cannot be removed, but are not able to completely destroy larger tumors left behind.

HIPEC is performed only if a complete tumor debulking is achieved. During the surgery, the abdominal cavity is filled with a chemotherapy drug, which is heated to over 40 degrees Celsius. The patient’s abdomen is then gently rocked back and forth for 90 minutes to ensure that the chemotherapy bathes all areas of the abdominal cavity, killing any remaining tumor cells.

When intravenous chemotherapy (IV chemo) is indicated for the treatment of appendix cancer, the specific drugs used are usually the same as those used to treat colon cancer. Appendix cancer is so uncommon that clinical trials comparing the effectiveness of the various available chemotherapy agents have not been done. Since colon cancer and appendix cancer pathologies are similar, the effectiveness of these chemotherapy medications is assumed to be beneficial in the treatment of appendix cancer, and in many cases it has been demonstrated to be effective. Most often a combination of several drugs is used.

Tests for Appendix Cancer

By Appendix Cancer

Tests

What tests are carried out to diagnose appendix cancer?

Often, appendix cancer remains undiagnosed until it is unexpectedly found during or after abdominal surgery or when an abdominal mass is seen during a CT scan for an unrelated condition.

If appendix cancer is suspected during abdominal surgery, the surgeon would take a tissue sample (biopsy) for a pathologist to review. Otherwise, the cancer may be diagnosed after your abdominal surgery as part of the routine pathology reading. In that case, another surgery may be recommended to make sure all the cancerous tissue is removed.

Symptoms of Appendix Cancer

By Appendix Cancer

Symptoms

Most of the times there are no symptoms of appendix cancer until it has progressed and is advanced.

Cancer of the appendix may cause appendicitis or cause the appendix to rupture. Sometimes this is the first symptom of appendix cancer.

A ruptured appendix may cause a very serious condition called peritonitis, which is an infection of the lining of the abdomen and pelvis. A cancerous tumor of the appendix may also “seed” the abdomen with cancer cells. This may cause more cancerous tumors to develop in the abdomen before it is discovered.

Abdominal discomfort and bloating of the abdomen can be signs of advanced appendiceal cancer.

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