Shah's Gastro, Cancer & Robotic Surgery Centre · Ahmedabad & Gandhinagar
Why a growth in the small intestine is not assumed to be cancer, and what is proved before any bowel is taken out. Apollo Hospital, Bhat, Gandhinagar · Gota OPD, Ahmedabad.
A mass or a narrowing in the small intestine is not, in Indian practice, most often cancer. Intestinal tuberculosis and lymphoma are both commoner, and both are treated with medicines rather than with an operation. Removing a length of small bowel for what turns out to be tuberculosis is a harm that a piece of tissue, sent for the right tests, would have prevented. So the question this page answers is not how the operation is done — it is what must be certain before the operation is agreed to at all. Where the diagnosis is adenocarcinoma, a neuroendocrine tumour or a GIST, surgery is the treatment that offers cure, and it is planned properly rather than hurried.
Shah’s Gastro, Cancer & Robotic Surgery Centre. Qualified in surgical gastroenterology specifically — a super-specialty training in the gastrointestinal tract rather than general surgery with an interest in it. The small intestine is difficult ground: long, mobile, hard to reach with a scope, and home to tumours uncommon enough that most surgeons meet them rarely. That rarity is why the diagnosis is worth slowing down for.
Dr Harsh Shah
MS, MCh (Surgical Gastroenterology), DrNB (Surgical Gastroenterology)
Small Bowel Cancer Surgeon · Apollo Hospital, Bhat, Gandhinagar · Gota OPD, Ahmedabad
Google rating 4.89 from 216 reviews at the Gota clinic, and 4.94 from 17 reviews at Apollo, Bhat.
The surgeon who reads your scan in the Gota OPD is the surgeon who operates at Apollo, Bhat. Every small bowel tumour is discussed at a tumour board — surgeon, medical oncologist, radiation oncologist, radiologist and pathologist together — before an operation is offered, and the board exists here for one particular reason: this is a rare cancer, and the alternatives to it are common.
In this part of the world the commonest cause of a stricture or a mass in the small intestine is intestinal tuberculosis. The second commonest is lymphoma. Neither needs a resection. Tuberculosis is cured with a full course of anti-tubercular treatment, and lymphoma is treated by the haemato-oncologist with chemotherapy. An operation for either removes healthy, useful bowel and treats nothing.
This is not a theoretical caution. Patients arrive at the Gota OPD already booked for a resection elsewhere, on a CT report that says “small bowel mass, likely malignant” and nothing more. The scan cannot tell these apart reliably: necrotic mesenteric nodes point towards tuberculosis, and bulky nodes with the bowel widened rather than narrowed, in a patient with fevers and night sweats, point towards lymphoma. But pointing is not proving, and the difference is the difference between tablets and losing a length of intestine.
Crohn disease produces the same picture again, and so does damage from long-term painkillers. The list of conditions that imitate small bowel cancer is longer than the list of small bowel cancers.
Small bowel tumours are found late because the symptoms are ordinary: colicky pain that comes and goes for months, tiredness from an anaemia nobody can explain, and eventually an obstruction. A great many are diagnosed for the first time on the operating table, during emergency surgery for a blockage.
There is one pattern that shortens the delay, and it is worth knowing because it is so often missed. A patient with iron-deficiency anaemia, or with bleeding that shows in the stool tests, who has had a gastroscopy and a colonoscopy that were both normal, does not need a third repeat of the same two tests. They need the small intestine looked at. That is the stretch of gut which neither of those scopes reaches, and it is where the answer lies.
The right test is a CT or MR enterography — a scan taken with the small bowel deliberately distended, which is a different study from an ordinary CT abdomen. Where a lesion is within reach, a balloon enteroscopy can take tissue and mark the spot for the surgeon.
A capsule endoscopy is useful for obscure bleeding, but only after a narrowing has been ruled out on a proper scan first. A capsule that lodges in a stricture becomes a second problem, and it is an avoidable one.
Three things, wherever the situation allows. Tissue — and tissue sent for the tuberculosis panel as well as for histology. Staging scans of the chest, abdomen and pelvis. And a tumour board decision. Where the patient is stable, none of these is skipped for speed.
The tuberculosis panel matters more than any single line on this page. A biopsy sent only to the histopathologist answers half the question. The same tissue must also go for an AFB stain, for a GeneXpert or similar molecular test, and for mycobacterial culture. These are ordered at the time the tissue is taken, because that tissue is obtainable once.
The same specimen is also tested for mismatch repair status. It identifies the families in which Lynch syndrome is running, and in advanced disease it identifies the minority of patients for whom immunotherapy works remarkably well. It is done for everyone, not for the ones who look likely.
The last piece is a deliberate search for an underlying condition — Crohn disease, coeliac disease, or an inherited syndrome such as Lynch, familial adenomatous polyposis or Peutz-Jeghers. Finding one changes the operation and the surveillance, and turns a single diagnosis into something the rest of the family needs to know about, with a genetics referral and testing offered to relatives.
Where the diagnosis is confirmed cancer, an operation is the only treatment that cures it. The segment of intestine carrying the tumour is removed together with the fan of tissue that carries its lymph nodes, and the two cut ends are joined. A tumour in the last part of the ileum, close to where the small bowel meets the colon, is removed with the right side of the colon instead — not because the colon is diseased, but because that is the only way to take the lymph nodes properly.
Two things are done at every one of these operations regardless of the tumour. The entire length of the small intestine is run through the fingers from end to end, because a second tumour elsewhere is not rare, particularly in the inherited syndromes and in neuroendocrine tumours. And the length of bowel removed, and the length left behind, are measured and written in the operation note — a number that matters for the rest of the patient’s life if further surgery is ever needed.
The lymph nodes are not an afterthought: a specimen that yields too few of them leaves the patient understaged, and the decision about chemotherapy afterwards is then taken on incomplete information. And where the tumour is stuck to something next to it, that structure is taken with it in one piece rather than peeled away — peeling risks leaving disease behind at exactly the point that matters.
The approach. Most planned resections are done laparoscopically. Some are better done open, and an operation that begins laparoscopically is converted if the view or the plane is not what it should be. This is decided during the operation, on what is found. Small bowel resection is not a procedure that is promised as robotic in advance, and a page that promised it would be selling the equipment rather than the operation.
When it is an emergency. A blockage that will not settle, or a perforation, is operated on urgently. Tissue is still taken and still sent for the full panel including the tuberculosis tests — the one thing an emergency does not excuse. The bowel is joined where the patient is stable and well nourished, and a stoma is made instead where the abdomen is contaminated or the patient is septic or malnourished, because a join made in those conditions is the one that leaks. If disease is found to have spread widely and unexpectedly, the right operation is a small one: biopsy, relieve the blockage, stop.
More than on almost any other operation, the histology can change the diagnosis after the surgery is over. The specimen is examined in full, and it may come back as tuberculosis, as lymphoma, or as Crohn disease rather than as cancer. Each of those is treated with medicines, so the report can replace the entire plan — and the family is told this before the consent is signed, not afterwards.
If the answer is tuberculosis, a full course of anti-tubercular treatment is started and completed, and it is completed even though the affected bowel has already been removed. If the answer is lymphoma, the patient goes to the haemato-oncologist and no further surgery is planned. If it is cancer and the lymph nodes are involved, chemotherapy is advised afterwards, and where it is advised it is given on a fluoropyrimidine-based regimen.
One caution belongs here because it affects treatment directly. Small bowel cancer is often managed as though it were colon cancer, because the two look alike under the microscope. They are not the same disease, and a class of drugs adopted on that assumption has not shown clear benefit and is being moved away from. Treatment here is chosen on the evidence for this cancer, not by analogy with a commoner one.
Recovery follows an enhanced-recovery pathway: out of bed the same evening, drinking early, eating the next day, and home in under a week where the operation was planned rather than emergency. Two things are different if the last part of the small intestine has been removed — loose stools, which are treatable, and vitamin B12, which the body can no longer absorb from food.
Most patients coming to this operation are already undernourished, after months of eating less because eating brought on pain. Nutrition and anaemia are corrected before a planned operation rather than after it — one of the few things that reliably changes how the recovery goes — and where a stoma is possible the site is marked on the abdomen before the patient goes to theatre.
After an ileal resection, watery stools come from bile salts reaching the colon and a simple medicine controls it. Vitamin B12 is checked and then replaced by injection for life, on a written schedule. Iron and weight are followed, and the remaining bowel length is carried forward in the record.
★★★★★
“(Translated by Google) We are deeply grateful to Dr. Harsh Shah, his coordinator Roshni Ma'am, and the entire team at Apollo Hospitals. During the treatment of my wife's neuroendocrine tumor, which was detected after an appendix operation, they not only demonstrated excellent surgical skills but also explained the entire disease and procedure to me and my family in clear and simple language. They patiently answered all our questions and made me feel confident that my wife was in safe hands. Under their guidance and care, my wife's tumor was completely removed. If you need a gastro oncologist surgeon, Dr. Harsh Shah and Apollo Hospitals, Gandhinagar, Gujarat, would be a great option.”
A Google review, quoted as written. It describes a neuroendocrine tumour found after an appendix operation — one of the ways a tumour at the far end of the small intestine comes to light.
The single most useful question before a planned small bowel resection is: has tuberculosis been excluded, and was the tissue sent for the tuberculosis tests as well as for histology? If the answer is that no tissue has been obtained and the plan is to resect and find out, that is the moment to ask for a second opinion.
Worth asking in the OPD, and worth writing down:
A second opinion is reasonable at any point before treatment starts, and most valuable in two situations: a resection planned without tissue, and an emergency operation already done elsewhere whose histology has come back as something other than cancer. Bring the images rather than the reports alone, bring the biopsy blocks or slides if any were taken, and expect to be examined.
There is no single price for a small bowel resection. It moves with the room category, the length of stay, whether the operation is laparoscopic or open, planned or an emergency, whether intensive care is needed, and whether a stoma is made. A written estimate is given before a planned admission, and the office states what is inside it and what is not.
Apollo Hospital, Bhat, is empanelled with the major insurers and cashless schemes, and the office handles pre-authorisation directly. Send the policy details along with the reports so the paperwork moves in parallel with the medical planning. Where a stoma is made and will later be closed, that second operation is a separate admission and is worth budgeting for from the start.
Bring on admission: imaging on a disc or drive, previous discharge summaries and operation notes, biopsy reports and slides, a list of medicines with doses, insurance card and identification, and one family member as the point of contact.
Not by itself, and in India it more often does not. Tuberculosis and lymphoma both produce the same appearance, and both are treated with medicines. A scan raises the question; tissue answers it.
Sometimes there is no choice — an obstruction that will not settle has to be operated on, and the diagnosis comes from the specimen afterwards. But where the patient is stable, resecting an undiagnosed mass to find out what it is means accepting the risk of removing bowel for a disease that tablets would have cured.
Because neither reaches the small intestine. Between the stomach and the colon there is a long stretch of gut that those two scopes cannot see, and it needs a CT or MR enterography, or an enteroscopy, instead of a third repeat.
Usually not for a planned operation — the bowel is joined. A stoma becomes likely when the surgery is an emergency with contamination, or the patient is septic or severely malnourished, because a join made in those conditions is the one that fails. Where a stoma is possible, the site is marked before theatre.
Usually laparoscopic, sometimes open. The approach is chosen for the patient and the findings, and an operation is converted from laparoscopic to open whenever that is safer. Nobody should choose a surgeon for this operation on the basis of the machine.
Yes. The full course of anti-tubercular treatment is completed even though the diseased segment has been removed, because the infection is not confined to the piece that was taken out. Contacts are screened as well.
Shah’s Gastro, Cancer & Robotic Surgery Centre — Gota, Ahmedabad
Consultations, examination, review of reports, follow-up and surveillance.
Google: Dr Harsh Shah · 4.89 from 216 reviews
Directions to the Gota clinic
Apollo Hospital — Bhat, Gandhinagar
Admission, surgery and inpatient care.
Google: Dr Harsh Shah – Robotic GI Surgeon · 4.94 from 17 reviews
Directions to Apollo, Bhat
Patients travel to Ahmedabad for small intestine surgery from across Gujarat — Gandhinagar, Mehsana, Nadiad, Anand, Banaskantha, Bhavnagar, Rajkot, Jamnagar and Kutch — and from southern Rajasthan and western Madhya Pradesh. Send the scan ahead on WhatsApp.
More on Dr Harsh Shah’s work in gastrointestinal cancer: cancer surgery services · colon cancer treatment · stomach cancer treatment.
Swasth Parivar: twice a month, practical advice on recovery, diet and warning signs. No advertising. Stop any time.
Your number is used for these updates and for the clinic to reach you. It is never sold or passed on. To stop, reply STOP on WhatsApp.
