Stomach Cancer

Eating after Gastrectomy Surgery

Having had part or all of your stomach removed, you will need to modify your diet. With part of your stomach removed you may feel full after very small amounts of food and fluid. It may therefore be difficult to obtain all the nutrients your body needs and you may lose weight.

Your small stomach or pouch should stretch over the next few months, and eventually you may not need to restrict the amount of food or fluid you can fit at one time. Immediately after surgery however, you will need to alter your eating pattern to avoid losing weight.

This resource will give you an outline of the nutritional factors involved with this procedure.

Before Surgery

Prior to your surgery, it is recommended that you have a supplement, called Impact Advanced Recovery. It improves your outcomes after surgery by reducing the risk of infections, enhancing your recovery and promotes a shorter stay in hospital. Each serve comes in a tetra pack.

You will need to have 3 servings of Impact Advanced Recovery every day, for 5 days before your surgery.It can be purchased at Atlas Health Care Edwardstown but you MUST ORDER FIRST over the phone (Ph: 08 8177 1600; Web; www.atlashc.com.au). Then, you can either choose to pick it up from their store, or have it delivered to your house for an additional fee of $5.50.

We also recommend you take Nutricia PreOp. It is a clear, lemon flavoured carbohydrate drink; designed to prevent you feeling hungry and thirsty just before your surgery. Take 2 of the 200 ml drinks the evening before surgery. And take another 2 of the 200 ml drinks two hours before admission on the day of surgery. You can buy Nutricia Preop from our office; SA Group of Specialists, Wakefield Clinic, 270 Wakefield Street, Adelaide 8359 2411.

In Hospital

While in hospital, your diet will have been graded from fluids to a soft diet. You should continue with soft foods for 4 weeks then slowly grade back to a normal diet as tolerated/directed by your dietitian or surgeon.

It is important to know that nutritional adequacy and eating behaviour are important factors in keeping you healthy and preventing unintentional weight loss. Below are dietary changes you’ll need to make.

Eat small frequent meals – Eat by the clock

• Instead of 3 large meals per day, eat 6 to 9 smaller meals per day.
• Graze throughout the day.
• If you feel full during a meal, don’t force yourself to eat more as this may cause vomiting.
• Eventually aim for 3 larger meals and 3 mid-meal snacks per day.

Eat at regular meal times

• Eat or drink every 2 to 3 hours.
• Avoid long periods without food.
• Carry nutritious snacks with you when you are on the go.

Don’t eat and drink at the same time

• Drinking fluids at mealtimes limits the amount of food that can be eaten and increases the chance of dumping syndrome, an unpleasant side effect.
• Drink fluids 30 minutes before and 30-60 minutes after meals.

Eat slowly and chew foods well. Chew all food thoroughly before swallowing. Avoid the following foods that are difficult to chew well:

• Asparagus stalks
• Stringy celery
• Dried/glace fruit
• Orange pith
• Nuts
• Persimmon
• Fruit pips
• Tough meat

Some people also find fresh white bread difficult.

Drink nourishing fluids

Aim to include at least 1500ml of fluid per day. Wherever possible drink nourishing fluids such as milk and fruit juices. Include cordial and soft drink to increase your energy intake. See separate information of a Nourishing Diet.

Nutritional Supplements

A multivitamin supplement is advised after surgery. We recommend you take 2 BN multivitamins every day for the first 6 months after surgery (available from our office). After 6 months Blackmores Conceive Well Gold may be a suitable option (dont worry its a pregnancy vitamin!). These are available at most chemist shops.

After Discharge - Potential Problems Following Surgery

The following may occur in some people who have had a gastrectomy.

Weight loss

Maintaining your weight following surgery can be difficult. Include small frequent meals and eat at regular meal times. See information on A Nourishing Diet.

Anaemia

Anaemia is caused as some vitamins or minerals are poorly absorbed, usually iron and B vitamins. Your intake of foods containing iron may also be reduced after surgery, which further increases the risk of anaemia. Your dietitian can give you advice on increasing your iron intake from foods. You may also need iron and/or Vitamin B12 supplements. Discuss with your dietitian or doctor.

Bone health

Bone disease following gastrectomy can be caused by a reduction in calcium, vitamin D and dairy intake, along with an altered absorption and metabolism. In addition to including calcium-rich foods in your daily diet, you are advised to take a calcium supplement following gastrectomy. If you have existing bone disease, a higher dose of calcium combined with vitamin D is required. Discuss with your doctor or dietitian.

Lactose intolerance

If you experience abdominal pains or cramps, boating, flatulence or diarrhoea after consuming lactose, it may be helpful to limit or avoid it. However, the tolerance is often dose-dependent, so you may find consuming small amounts of foods containing lactose throughout the day tolerable. Lactase enzymes can also be used to aid lactose digestion if you wish to continue having dairy products. Discuss with your dietitian.

Folate deficiency

Folate deficiency may develop following gastrectomy due to various factors, including malabsorption and impaired digestion of the nutrient. A daily multivitamin containing 100μg folate is recommended. If folate deficiency occurs, a daily dose of 5mg is recommended.

Dumping syndrome

Although it has a catchy name Dumping syndrome only occurs only very rarely. It occurs when undigested food, particularly very sugary food, passes too quickly out of the stomach and into the small bowel. This can cause sweating, nausea, dizziness and diarrhoea shortly after eating. The following can help reduce symptoms:

• Do not drink with meals – drink 30 minutes before and 30-60 minutes after eating
• Eat foods containing protein at each meal and snack such as meat, chicken, fish, eggs, cheese and milk
• Eat slowly and chew food well
• Sit upright when eating
• Choose high fibre foods when possible including wholemeal/wholegrain bread and pasta, fresh fruits and vegetables, legumes, high fibre cereals
• Avoid very hot or very cold foods
• Avoid any food you know causes symptoms
• Rest whenever symptoms occur
• Eat small meals often
• Limit sugary food and fluid eg. soft drink, cordial, lollies, chocolate, desserts.

Diarrhoea

This is usually a result of poor digestion or absorption, particularly of fatty foods. Malabsorption of fat causes pale, frothy stools, which float on water. Diarrhoea may also be caused by drinking large amounts of fluid with food (see Dumping syndrome above).

To manage diarrhoea you should avoid foods with a very high fat content such as fried food, pastry, cream, oil, chocolate, creamy or oil based salad dressing, butter, margarine, condensed milk, cream cheese or creamy soups. However, these foods provide significant calories and should be slowly reintroduced as tolerated.

Long Term Diet

Slowly you will be able to manage larger amounts of food, and you will need to eat less often. You can gradually introduce more solid food into you diet. Most people however find that they are not able to eat the amount of food they ate previously. You will probably always need to eat 6 times per day to obtain an adequate diet.

If you are not able to eat an adequate diet you will likely need a multivitamin and/or an iron supplement. This can be discussed in more detail at your 4 week review

References:

• DAA Manual 2009. Radigan, A E. Post-Gastrectomy: Mana