Nutrition after gastrectomy

Malnutrition can develop because of removal of all or part of the stomach.  Important appetite cues are missing due to lack of hormones secreted by the stomach.  Even without this problem, survivors are unable to eat normal volumes due to the smaller pouch that is available.   The strategies used before surgery will also be helpful now, and you will need to eat small, frequent meals indefinitely.

• Try preschool sized amounts of soft foods, high in protein and low in fiber; 6 – 8 times a day until weight is stable. This can take up to six months, as the stomach capacity gradually increases.
• Chew foods thoroughly before swallowing
• Fluids can fill up the stomach’s limited volume and patients are encouraged to sip fluids with meals and take in additional fluid to maintain hydration between meals. Limit soups and liquids with meals to ½ a cup.

Surgical oncologists will often place a feeding tube in to the small intestines at the time of the surgery, known as a j-tube for the location in the jejunem of the small bowel.  Fiber free formulas such as Osmolite and Isosource HN are usually well tolerated, and may be run overnight to provide support as patients expand their diet during daytime hours.  J-tube feedings require a pump to allow the slow, gradual delivery of formula that is tolerated.  Rates of 65 – 80 cc an hour are typical, but variation above (to 125 cc/hour) and below that (30 cc/hour) have been seen as well.

“Dumping” is possible, especially if the pyloric sphincter is removed in surgery.  This lays at the bottom of the stomach and controls emptying from the stomach.  When it is missing, foods can pass through too quickly and small particles of nutrients, such as those found in simple sugars can create a cluster of symptoms that can lessen a patient’s desire to eat.  This does not always occur, so don’t restrict the diet unless the symptoms are present

• Symptoms of early dumping will happen within an hour, usually within 15 minutes after eating. Concentrated sugars entering too quickly into the small intestines can cause your body to pull fluids in to try to dilute the mixtures.  These fluids come from the blood stream, potentially dropping your blood pressure to drop and you may feel light headed.  It is also drawn from tissues in the wall of the small bowel.  The distention within the bowel can cause cramping, bloating, nausea and diarrhea.
  • Eat slowly and often, in small volumes at a time. Lying down for a few minutes after eating may help slow the emptying out of the stomach.
  • Avoid fluids for 30 – 45 minutes before eating and for 1 hour after eating to prevent these from washing food through too quickly.
  • Eat a good source of protein with each meal or snack. Fish, eggs, dairy products, smooth peanut butter and tender meats and poultry work well and can help slow stomach emptying.
  • Avoid high sugar foods including juice, sugar sweetened drinks of any kind, syrup/honey/jelly/jam/molasses, ice cream/sherbet/ices/gelato/jello, pastries or other sweet deserts. Some patients have noticed that even the amount of sugar in catsup or other sauces can be problematic. Check ingredients for sugar, corn syrup, fructose, honey, lactose and anything ending in –ose (other types of sugars).  Manufacturers often make these sound healthy by adding “organic” to the name.   Avoid any products with these sugars listed within the first three ingredients.
  • Unfortunately the sugar alcohol substitutes can create even more distress, so watch for sorbitol, mannitol, xylitol. Other sugar substitutes are tolerated, such as those in yellow (sucralose), blue (aspartame) or pink (saccharin) packets.
  • Be patient! Symptoms usually improve over a couple months. Slowly add back foods.  Journaling can help you follow any symptoms that develop and tell you whether you are tolerating the new food, and in what amounts.

• Late dumping happens much later, usually 2 – 3 hours after eating. It is the result of the rapid absorption of the sugar from the small bowel, causing your pancreas to make more insulin.  Sometimes insulin clears away too much blood sugar and your blood sugar levels can fall below normal, leaving you feeling irritable, weak and shaky, dizzy, uncoordinated and not thinking clearly.
  • In addition to avoiding significant amounts of sugar at one time, your best strategy is small mixed meals, spreading out the carbohydrate over time, like a gentle rain instead of a thunderstorm. No more than 3 servings of carbohydrates should be eaten in a single meal.
  • Combining the carbohydrate with protein and fat or soluble fiber (oats/barley, cooked vegetables) will slow the emptying of the stomach and slow the rate that sugars are absorbed into the blood.

Fat malabsorption can occur if smaller amounts of pancreatic enzymes are available because of surgical changes in the normal “geography” of the GI tract, or if there are problems with the signaling to the pancreas to release those enzymes.  Symptoms will include increased gas production in the colon, as food that hasn’t been absorbed is fermented by the probiotic bacteria that typically only receive fiber from the diet.  When unabsorbed fat is present in the stool it will cause bowel movements to float on the surface of the water in the toilet and these stools will have a uniquely foul odor.  Your doctor can provide you with a prescription for pancreatic enzymes that can be taken with every meal or snack that contains fat, improving the digestion of your food.  When needed, common doses include 16,000 – 24,000 units of lipase with a snack and double that with meals. If symptoms improve, but do not completely resolve the gas or odor, or if stools continue to float, check back with your team about increasing the dose of enzymes.

Lack of production of stomach acid will lead to altered absorption of the following nutrients that should be discussed with your physician and supplemented.

• Iron
• Calcium, risking osteoporosis.
• B12, requiring supplementation with sublingual forms of B12 or by injections.