Best Liver Cancer treatment Centre in Ahmedabad

LIVER CANCER TREATMENT

The liver is the largest organ inside your abdomen. It's found behind your ribs on the right side of your body.

The liver does important work to keep you healthy:

The liver gets its supply of blood from two vessels. Most of its blood comes from the hepatic portal vein. The rest comes from the hepatic artery.

Cancer Cells

Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body.

Normal cells grow and divide to form new cells as the body needs them. When normal cells grow old or get damaged, they die, and new cells take their place.

Sometimes, this process goes wrong. New cells form when the body doesn't need them, and old or damaged cells don't die as they should. The buildup of extra cells often forms a mass of tissue called a growth, nodule, or tumor.

Growths in the liver can be benign (not cancer) or malignant (cancer). Benign tumors are not as harmful as malignant tumors:

Benign tumors:

are rarely a threat to life
can be removed and usually don't grow back
don't invade the tissues around them
don't spread to other parts of the body

Malignant growths:

may be a threat to life
sometimes can be removed but can grow back
can invade and damage nearby tissues and organs (such as the stomach or intestine)
can spread to other parts of the body

Most primary liver cancers begin in hepatocytes (liver cells). This type of cancer is called hepatocellular carcinoma or malignant hepatoma.

Liver cancer cells can spread by breaking away from the original tumor. They mainly spread by entering blood vessels, but liver cancer cells can also be found in lymph nodes. The cancer cells may attach to other tissues and grow to form new tumors that may damage those tissues. See the Stagingsection for information about liver cancer that has spread.

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Risk Factor

Studies have found the following risk factors for liver cancer:

Infection with hepatitis B virus (HBV) or hepatitis C virus (HCV): Liver cancer can develop after many years of infection with either of these viruses. Around the world, infection with HBV or HCV is the main cause of liver cancer. HBV and HCV can be passed from person to person through blood (such as by sharing needles) or sexual contact. An infant may catch these viruses from an infected mother. Although HBV and HCV infections are contagious diseases, liver cancer is not. You can't catch liver cancer from another person.
Heavy alcohol use: Having more than two drinks of alcohol each day for many years increases the risk of liver cancer and certain other cancers. The risk increases with the amount of alcohol that a person drinks.
Aflatoxin: Liver cancer can be caused by aflatoxin, a harmful substance made by certain types of mold. Aflatoxin can form on peanuts, corn, and other nuts and grains. In parts of Asia and Africa, levels of aflatoxin are high.
Iron storage disease: Liver cancer may develop among people with a disease that causes the body to store too much iron in the liver and other organs.
Cirrhosis: Cirrhosis is a serious disease that develops when liver cells are damaged and replaced with scar tissue. Many exposures cause cirrhosis, including HBV or HCV infection, heavy alcohol use, too much iron stored in the liver, certain drugs, and certain parasites.
Obesity and diabetes: Studies have shown that obesity and diabetes may be important risk factors for liver cancer.The more risk factors a person has, the greater the chance that liver cancer will develop.

Symptoms

Early liver cancer often doesn't cause symptoms. When the cancer grows larger, people may notice one or more of these common symptoms:

Diagnosis

If you have symptoms that suggest liver cancer, your doctor will try to find out what's causing the problems.

You may have one or more of the following tests:

Physical exam: Your doctor feels your abdomen to check the liver, spleen, and other nearby organs for any lumps or changes in their shape or size. Your doctor also checks for ascites, an abnormal buildup of fluid in the abdomen. Also, your skin and eyes may be checked for signs of jaundice.
Blood tests: Many blood tests may be used to check for liver problems. One blood test detects alpha-fetoprotein (AFP). High AFP levels could be a sign of liver cancer. Other blood tests can show how well the liver is working.
CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of your liver and other organs and blood vessels in your abdomen. You may receive an injection of contrast material so that your liver shows up clearly in the pictures. On the CT scan, your doctor may see tumors in the liver or elsewhere in the abdomen.
MRI: A large machine with a strong magnet linked to a computer is used to make detailed pictures of areas inside your body. Sometimes contrast material makes abnormal areas show up more clearly on the picture.
Ultrasound test: The ultrasound device uses sound waves that can't be heard by humans. The sound waves produce a pattern of echoes as they bounce off internal organs. The echoes create a picture (sonogram) of your liver and other organs in the abdomen. Tumors may produce echoes that are different from the echoes made by healthy tissues.
Biopsy: A biopsy usually is not needed to diagnose liver cancer, but in some cases, the doctor may remove a sample of tissue. The doctor inserts a thin needle into the liver to remove a small amount of tissue. CT or ultrasound may be used to guide the needle. A pathologist uses a microscope to look for cancer cells in the tissue.

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Complications

If liver cancer is diagnosed, your doctor needs to learn the extent (stage) of the disease to help you choose the best treatment. Staging is an attempt to find out whether the cancer has spread, and if so, to what parts of the body.

When liver cancer spreads, the cancer cells may be found in the lungs. Cancer cells also may be found in the bones and in lymph nodes near the liver.

When cancer spreads from its original place to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the primary tumor. For example, if liver cancer spreads to the bones, the cancer cells in the bones are actually liver cancer cells. The disease is metastatic liver cancer, not bone cancer. It's treated as liver cancer, not bone cancer. Doctors sometimes call the new tumor "distant" or metastatic disease.

To learn whether the liver cancer has spread, your doctor may order one or more of the following tests:

CT scan of the chest: A CT scan often can show whether liver cancer has spread to the lungs.
Bone scan: The doctor injects a small amount of a radioactive substance into your blood vessel. It travels through the bloodstream and collects in the bones. A machine called a scanner detects and measures the radiation. The scanner makes pictures of the bones. The pictures may show cancer that has spread to the bones.
PET scan: You receive an injection of a small amount of radioactive sugar. The radioactive sugar gives off signals that the PET scanner picks up. The PET scanner makes a picture of the places in your body where the sugar is being taken up. Cancer cells show up brighter in the picture because they take up sugar faster than normal cells do. A PET scan shows whether liver cancer may have spread.

Treatment

Treatment options for people with liver cancer are surgery (including a liver transplant), ablation,embolization, targeted therapy, radiation therapy, and chemotherapy. You may have a combination of treatments.

The treatment that's right for you depends mainly on the following:

the number, size, and location of tumors in your liver
how well your liver is working and whether you have cirrhosis
whether the cancer has spread outside your liver
Other factors to consider include your age, general health, and concerns about the treatments and their possible side effects.

Surgery
Surgery is an option for people with an early stage of liver cancer. The liver cancer specialist in Ahmedabad may remove the whole liver or only the part that has cancer. If the whole liver is removed, it's replaced with healthy liver tissue from a donor.

Removal of part of the liver (Hepatectomy)
Surgery to remove part of the liver is called partial hepatectomy. A person with liver cancer may have part of the liver removed if lab tests show that the liver is working well and if there is no evidence that the cancer has spread to nearby lymph nodes or to other parts of the body.

The surgeon removes the tumor along with a margin of normal liver tissue around the tumor. The extent of the surgery depends on the size, number, and location of the tumors. It also depends on how well the liver is working.

As much as 80 percent of the liver may be removed. The surgeon leaves behind normal liver tissue. The remaining healthy tissue takes over the work of the liver. Also, the liver can regrow the missing part. The new cells grow over several weeks.

Liver transplant
A liver transplant is an option if the tumors are small, the disease has not spread outside the liver, and suitable donated liver tissue can be found.

Donated liver tissue comes from a deceased person or a live donor. If the donor is living, the tissue is part of a liver, rather than a whole liver.

While you wait for donated liver tissue to become available, the health care team monitors your health and provides other treatments.

When healthy liver tissue from a donor is available, the transplant surgeon removes your entire liver (total hepatectomy) and replaces it with the donated tissue. After surgery, your health care team will give you medicine to help control your pain. You may need to stay in the hospital for several weeks. During that time, your health care team monitors how well your body is accepting the new liver tissue. You'll take medicine to prevent your body's immune system from rejecting the new liver.

Ablation
Methods of ablation destroy the cancer in the liver. They are treatments to control liver cancer and extend life. This may be used for people who can't have surgery or a liver transplant or for people waiting for a liver transplant . Surgery to remove the tumor may not be possible because of cirrhosis or other conditions that cause poor liver function, the location of the tumor within the liver, or other health problems.

Methods of ablation include the following:

Radiofrequency ablation: The doctor uses a special probe that contains tiny electrodes to kill the cancer cells with heat. Ultrasound, CT, or MRI may be used to guide the probe to the tumor. Usually, the doctor can insert the probe directly through your skin, and only local anesthesia is needed. Sometimes, surgery under general anesthesia is needed. The doctor inserts the probe through a small incision in your abdomen (using a laparoscope) or through a wider incision that opens your abdomen.Some people have pain or a slight fever after this procedure. Staying overnight in the hospital is not usually needed. Radiofrequency ablation is a type of hyperthermia therapy. Other therapies that use heat to destroy liver tumors include laser or microwave therapy. They are used less often than radiofrequency ablation.

Percutaneous ethanol injection: The doctor uses ultrasound to guide a thin needle into the liver tumor. Alcohol (ethanol) is injected directly into the tumor and kills cancer cells. The procedure may be performed once or twice a week. Usually local anesthesia is used, but if you have many tumors in the liver, general anesthesia may be needed. You may have fever and pain after the injection.
Embolization For those who can't have surgery or a liver transplant, embolization or chemoembolization may be an option. The doctor inserts a tiny catheter into an artery in your leg and moves the catheter into the hepatic artery. For embolization, the doctor injects tiny sponges or other particles into the catheter. The particles block the flow of blood through the artery. Depending on the type of particles used, the blockage may be temporary or permanent. Without blood flow from the hepatic artery, the tumor dies. Although the hepatic artery is blocked, healthy liver tissue continues to receive blood from the hepatic portal vein. For chemoembolization, the doctor injects an anticancer drug (chemotherapy) into the artery before injecting the tiny particles that block blood flow. Without blood flow, the drug stays in the liver longer. You'll need to be sedated for this procedure, but general anesthesia is not usually needed. You'll probably stay in the hospital for 2 to 3 days after the treatment. Embolization often causes abdominal pain, nausea, vomiting, and fever. Some people may feel very tired for several weeks after the treatment.

Targeted Therapy
People with liver cancer who can't have surgery or a liver transplant may receive a drug called targeted therapy. Sorafenib tablets were the first targeted therapy approved for liver cancer.Targeted therapy slows the growth of liver tumors. It also reduces their blood supply. The drug is taken by mouth. Side effects include nausea, vomiting, mouth sores, and loss of appetite. Sometimes, a person may have chest pain, bleeding problems, or blisters on the hands or feet. The drug can also cause high blood pressure. The health care team will check your blood pressure often during the first 6 weeks of treatment.

Radiation Therapy
Radiation therapy uses high-energy rays to kill cancer cells. It may be an option for a few people who can't have surgery. Sometimes it's used with other approaches. Radiation therapy also may be used to help relieve pain from liver cancer that has spread to the bones.

Liver cancer surgeon in Ahmedabad uses two types of radiation therapy to treat liver cancer:
External radiation therapy: The radiation comes from a large machine. The machine aims beams of radiation at the chest and abdomen.
Internal radiation therapy: The radiation comes from tiny radioactive spheres. A doctor uses a catheter to inject the tiny spheres into your hepatic artery. The spheres destroy the blood supply to the liver tumor.
The side effects from radiation therapy include nausea, vomiting, or diarrhea. Your health care team can suggest ways to treat or control the side effects.

Chemotherapy
Chemotherapy, the use of drugs to kill cancer cells, is sometimes used to treat liver cancer. Drugs are usually given by vein (intravenous). The drugs enter the bloodstream and travel throughout your body. The side effects of chemotherapy depend mainly on which drugs are given and how much. Common side effects include nausea and vomiting, loss of appetite, headache, fever and chills, and weakness.

Some drugs lower the levels of healthy blood cells, and you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team will check for low levels of blood cells. Some side effects may be relieved with medicine.

Overview of Cancer Surgery

Goal of liver cancer surgery
Depending on your cancer type and stage, our goals for treatment are:

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.
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.
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.

Role of Surgery for liver Cancer treatment
Surgery can be done for many reasons for treatment of cancer.

Curative Surgery
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.

Diagnostic & Staging Surgery
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.

Palliative Surgery
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.

Approach for Liver Cancer Surgery:
How surgery is performed? (Special surgery techniques): Open Or Laparoscopic

Open Surgery:
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.

Laparoscopic Surgery
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.

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 of Cancer before Surgery
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.

If all investigations suggest that cancer can be removed in totality from body, then biopsy can be avoided in to minimize the risk of spillage of cancer cell during biopsy procedure.

There is variety of way to perform biopsies:

Fine Needle Aspiration (FAN) biopsy
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.
The main advantage of FNA is that there is no need to cut through the skin, so there is no surgical incision.
- 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.
  Core Needle biopsy
  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.
  Excisional or Incisional biopsy
  For these biopsies, the surgeon remove the entire tumor (excisional biopsy) or a small part of the tumor (incisional biopsy).

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Preparation for Surgery

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.

Pre-operative testing

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

Anaesthetic Assessment before Surgery:

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

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.

Getting ready for Surgery

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

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.
Laxative: You may also be asked to use a laxative or an enema to make sure your bowels are empty.
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

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.

Recovery from Surgery

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

Pain

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).

Tube/ Drains

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.
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.
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.

Leg stocking / Compression boot

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.

Eating and Drinking

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.

Activity

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.

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.

Going home

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.

Risks and side effects of surgery

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:

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.
Complications related to underlying medical illness llike heart disease, diabetes, kidney disease, obesity, malnutrition.
- 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.
- 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.
- Cardiovascular: Myocardial infarction (heart attach), Arrhythmia (irregular heart beat), Stroke (cerebro-vascular accidents)
- Kidney & urinary tract infection, acute kidney failure if patient has uncontrolled/non-responding infection

Complications related to Specific Operations
- 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..
- Bile leak
- Bleed
Complications related to Major Surgery
- 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.
- 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.
- Leakage from anastomosis (joint of anastomosis) & fluid collection in tummy
- Blockage of intestine (Intestinal obstruction)

Life After Surgery

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

Nutrition

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.

Exercise

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.

Follow up care

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.
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.