A gastrectomy is a surgical procedure for the total (total or total gastrectomy) or partial (subtotal gastrectomy) removal of the stomach. It is a form of surgical treatment of gastric cancer, a salvage procedure in severe forms of peptic ulcer disease, especially complicated by perforation, in gastric bleeding that is difficult to control by other means (mainly endoscopic). Due to its complex functions in the human body, gastrectomy is associated with numerous consequences, requiring the patient to be disciplined in the post-operative period and to change their lifestyle.
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Gastric functions
The stomach, as part of the gastrointestinal tract, temporarily stores ingested food, preparing it for further processing stages - digestion and absorption. The cells that make up the stomach wall produce an average of two litres of gastric juice every day in a healthy person. Its main constituent is water (99%), in addition to hydrochloric acid, digestive enzymes and mucus, electrolytes and components of the AB0 antigen system. A very important protein secreted in the stomach is the so-called Castle endogenous factor (produced by the cells lining the stomach), which binds and assists in the absorption of vitamin B12, involved in the synthesis and maturation of red blood cells.
The cells in the lining of the digestive tract also secrete hydrochloric acid, which has a bactericidal effect by lowering the pH in the lumen of the digestive tract, making the food sterile even in the first stages of digestion. The main cells of the gastric mucosa secrete pepsinogen, an inactive proenzyme which, under the influence of hydrochloric acid in the stomach, is converted into the enzyme pepsin, which is responsible for breaking down large protein particles - polypeptides - into smaller ones, starting their digestion process.
Other cells secrete mucus, which forms a barrier against self-digestion. The APUD cells, which belong to the group of diffuse endocrine cells, produce gastrin, a hormone that stimulates the secretion of hydrochloric acid and pepsin, gastric and intestinal motility and the contraction and emptying of the gallbladder. Gastrin also has a stimulating and trophic effect on cell renewal in the stomach, duodenum, jejunum, ileum and colon. The gastric wall is made up of muscles - as a result of their contraction, the food content in the stomach lumen is mixed with gastric juice and is actively passed on to further sections of the gastrointestinal tract.
All things considered, removal of the stomach is associated with numerous consequences. It requires discipline on the part of the patient in the post-operative period, in the long-term follow-up, to avoid distant complications - changes to lifestyle, dietary habits and acceptance of new recommendations sometimes eliminating the greatest culinary pleasures so far.
Management strategy after gastrectomy
Immediately after surgery, the gastrointestinal tract requires temporary relief. The created oesophageal-intestinal anastomosis, to ensure optimal healing conditions, must not be irritated, exposed to digestive enzymes, changing temperatures. For the first few days, the patient should therefore be fed into the jejunostomy, if such an access has been created. A microjejunostomy is a thin tube whose outlet is located in the jejunum (about 40 centimetres from the duodenum), the end of which is brought out onto the abdominal shell. It allows the delivery of a complete industrial diet directly into the small intestine, where the full spectrum of nutrients is digested and actively absorbed. The alternative remains parenteral nutrition, which is not practised in many hospitals or is reserved for patients with the highest risk of perioperative malnutrition.
If no early complications are observed, a so-called anastomotic tightness and patency test - usually radiological - is performed on postoperative day 4-5. During the X-ray of the chest and abdominal cavity, the patient is given a sip of water with dissolved safety contrast agent orally in the standing position and any leakage of contrast agent outside the lumen of the gastrointestinal tract from the mechanical suture site is assessed. If, on radiological assessment, the anastomosis is tight and passage through the anastomosis is not impaired, the oral diet is gradually extended, starting with a supply of water, followed by clear liquids, jelly, rice gruel or semolina. According to tolerance, the diet is extended with vegetable broths, mashed fruit, vegetables, light soups, white bread.
diet after gasterctomy, photo: panthermedia
The foods given should not be too sweet to avoid early post-resection syndrome. A week or so after surgery, with good tolerance of the previous diet, mashed potatoes and sources of complete protein can be introduced: soft-boiled eggs, lean cooked ground meats, dairy products.
Diet
The diet after gastrectomy should be balanced, rich in all the necessary nutrients in order to prevent, as far as possible, nutritional deficiencies arising from the stress of the operation, starvation and the impact of the cancer itself, as well as digestion and absorption disorders resulting from the removal of the stomach. The method of meal intake itself is very important. Three large meals per day should be avoided. It is advisable to give small food portions, but relatively often (5-7x a day), at regular intervals. The stomach physiologically collects, mixes and slowly passes portions of food to further sections of the digestive tract. In healthy individuals, uninterrupted gastric passage and its gradual emptying, in small portions, ensures a continuous supply of nutrients to the intestinal lumen, many hours after the meal is over. Frequent meals are in a way an attempt to mimic the physiological gastrointestinal passage, preventing the occurrence of discomforts: bloating, nausea, abdominal pain - common in patients after gastrectomy, after a more abundant, irrational meal.
It is safest, especially in the first postoperative weeks, to eat room temperature food to prevent irritation of the intestinal mucosa. The consistency of meals should be pulpy as far as possible - bites that are well-bitten or crumbled, grated or overcooked, but not completely liquid. A liquid diet shortens the intestinal transit time, can cause diarrhoea and consequently reduces the effective acquisition and absorption of nutrients from the meals consumed. For the same reason, it is not advisable to drink while eating and the liquids themselves should preferably be taken in small portions between meals (30-60 minutes before or after the meal).
The basis of the diet, at least in the first weeks after the surgical treatment, should be easily digestible products, introduced to the menu gradually, according to tolerance. The patient often feels a disturbed appetite after surgery or complains of a complete lack of appetite, and is sometimes afraid to start oral feeding quickly.
Meals, to encourage and stimulate the appetite, should be visually attractive, varied, have an appropriate, preferably tolerated by the patient, temperature - encourage the patient to eat despite the fact that the taste may be different than the favourite dishes consumed before surgery.
Vegetables causing intensive gas production (flatulent) should be excluded from the diet, i.e. leguminous vegetables such as peas, beans, broad beans, onions, garlic, cabbage. Mushrooms, sauces based on fatty meat broths, soups with thick cream or roux are contraindicated. Meat should be leaner, well-cooked and minced, and the digestive tract should not be overloaded with tough, fibrous pieces of meat - mutton, goose and duck meat, fatty pork and beef, and delicatessen products - sausages, salami, pâtés - should be excluded, mainly due to their often unreliable ingredients.
Dairy products can be poorly tolerated shortly after starting oral feeding, so dairy products should be introduced to the diet gradually. Yellow and processed cheeses, despite their high protein content, should also be replaced by light dairy products (less than 15% fat in dry matter).
diet after gastroectomy, photo: panthermedia
An important component of the diet is an adequate supply of protein. Adequate protein levels are an important factor for proper healing of wounds, surgical anastomoses and tissue regeneration based on physiological immune mechanisms.
The protein supply should not be less than 1.5 grams per kilogram of body weight per day. It is advisable that the greater part is a complete protein of animal origin. If, as is not uncommon, the patient cannot tolerate meat, it is a good idea to increase the proportion of fish in the diet. Fish protein is easily digestible, complete and easily assimilated.
In malnourished patients who do not meet their daily requirements with oral home diets, high-protein industrial preparations are included. In extreme situations, in order to ensure an adequate supply of fats, amino acids, carbohydrates, micro and macroelements and vitamins, parenteral hyperalimentation is included perioperatively in the hospital setting. It is reserved for a group of patients at high risk of malnutrition - the oral route is considered the most appropriate and, if possible, enteral nutrition should be preferred.
In the easy-to-digest diet, fat is also limited (to 50-70 grams per day), especially animal fats (lard, bacon). Vegetable oils, mainly olive oil, are a source of omega acids, the addition of which has proven immunomodulatory benefits.
In addition to the above, it is urged that coffee, cocoa, chocolate, alcohol and spicy, artificially seasoned foods be avoided. The taste of meals can be enriched by the addition of mild herbs and spices such as dill, marjoram, basil, vanilla, parsley.
diet after gasterctomy, photo: panthermedia
It should not be forgotten that gastrectomy surgery leads to deficiencies - observed years later, after the body stores have been depleted. The first component that always requires supplementation is vitamin B12. It is absorbed after binding to the protein carrier Castle factor, produced and secreted in the stomach. Vitamin B12 deficiency is observed 4-6 years after surgery without supplementation. The symptoms are many, involve various systems and organs, and can be reflected in the somatic as well as the psychological sphere of the patient. Often observed are weakness, rapid fatigability, concentration and attention problems, headaches and dizziness, mood changes, with increased - neurological symptoms, e.g. of the paresthesia type. Peripheral blood count shows macrocytic anaemia (increased red blood cell volume).
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