Gastroenterology - Having Gastric Surgery

This leaflet has four aims:

• To help you and your family become better informed and more involved in your care
• To explain the operation you will be having
• To describe what will happen after the operation
• To help overcome any worries you may have about the operation

What is the stomach?

The stomach is a “j” shaped bag at the end of your gullet (oesophagus) that receives food and liquids after swallowing. It helps in the digestion of the food you eat by grinding it into a liquidised state and adding acid. Once this process has occurred the liquid is delivered slowly into the small intestine.

What is a gastrectomy?

It is removal of part or all of the stomach. The consultant will advise on the extent of the surgery intended for you. This operation may be carried out as an open procedure or as keyhole (laparoscopic) surgery.

Why do I need an operation?

A gastrectomy is often needed to treat cancer of the stomach. You will already have had many investigations to show that in your case an operation is possible to remove the tumour in your stomach.
 
The operation is performed to remove the cancer in your stomach. It is hoped that this will be a curative procedure. In some cases where it is not possible to remove all of the tumour the procedure is carried out to help the stomach to empty and prevent obstruction.

Will I need any other treatment if I have surgery?

Sometimes patients are offered a course of chemotherapy before and after the operation to help treat the cancer.

Will I still be able to eat after the operation?

Yes, even though all or part of your stomach has been removed you will still be able to eat. You will not be able to manage large meals as you did before. The key is to eat little and often.

How is the operation performed?

• An incision is made in the top part of your abdomen in an open operation
• If you are having this by keyhole (laparoscopy) 5 small incisions are made in the abdomen
• Part of or all of the stomach is removed
• The small intestine is connected to the bottom end of the gullet or to the remaining part of the stomach
• The abdomen is then sewn back up

What will happen after the operation?

The first 24-48hours will be spent on the critical care unit (CCU). Here you can be closely monitored. If you are making good progress you will be transferred to the main surgical ward from CCU.

You will have several tubes attached to you when you come out of the theatre these will include:

• Epidural for pain relief
• Intravenous Infusion (a drip) to give you fluid and prevent dehydration
• Urinary catheter – this tube is in your bladder. Urine drains via the tube so that it can be measured accurately. It is removed when you are fully mobile
• Naso-gastric tube – this tube goes up your nose, down the back of your throat and the tip sits near to the site of your operation. The tube is placed to help stop nausea and vomiting. It is removed a few days after the operation
• Oxygen – you will be given oxygen via a mask to help you breathe
• Wound drains – these are tubes that drain any blood of fluid from inside the abdomen after the operation. They are removed after a few days following your operation

Enhanced Recovery after Surgery (ERAS)

The Upper GI team follow a programme of care to promote early recovery after surgery. The programme has input from a whole team (surgeons, anaesthetist, specialist nurses, physiotherapists and dietitians). Its aim is for you to recover from your operation as soon as possible.

How will my pain be controlled after the operation?

One of the important parts of the ERAS programme is good pain control, which will help you to be up and about as soon as possible (early mobilisation). Your pain will be controlled by an epidural. This is a fine tube placed in your back, through which pain numbing medicines are given. This is usually kept in for several days and removed painlessly.

Mobilisation/Physiotherapy

Early mobilisation (i.e., getting out of bed and walking around) is a very important part of your recovery. Most patients will get up the day of, or the day after their operation. You will be encouraged to sit out in a chair and walk short distances at least 4-6 times per day, with help from the nursing staff, physiotherapist and our specialist therapy assistants.

Having an operation has an effect on your breathing and your circulation. The physiotherapist and therapy assistants will see you and will be able to give you help and advice. The following exercises will help to reduce complications and speed your recovery.

Incentive Spirometer

You will be given an incentive spirometer to use. This is a small device that encourages you to take deep breaths by inhaling through a tube. It is important to use this before surgery (at home) and after surgery.

You will be given a separate information sheet on how to use this.

Deep breathing exercises

Following your operation you tend to breathe more shallowly and not expand your lungs at the bottom. These exercises help to improve your lung movement and clear phlegm off your chest.  Start these exercises as soon as you wake up, and continue hourly whilst awake, until you are up and about again.

• Sit in a comfortable position with your back well supported (upright in bed or in a chair), place your hand on the upper part of your stomach
• Relax your shoulders
• Take a slow deep breath in through your nose, concentrating on expanding the lower part of your chest
• Hold the breath for a count of 3, then slowly breathe out completely
• Repeat 3 or 4 times

Huffing

Coughing can be uncomfortable and tiring. It has been found that ‘huffing’ helps to move phlegm in preparation for coughing.

• Take a small breath in
• Open your mouth wide and squeeze the air forcefully out of your lungs as quickly as possible (as if steaming up a mirror)
• Your stomach muscles should contract but your throat muscles should not tighten
• The huff must be long enough to move phlegm from the airways

Coughing

Adequate pain relief and the correct coughing technique are essential to clear phlegm comfortably and effectively. Once phlegm has been loosened by ‘huffing’ try a supported cough.

• Position yourself either sitting in a chair, on the edge of the bed, or lying in bed with both knees bent up, to relieve the stretch on your tummy
• Place hands or pillow over your stomach
• Take a deep breath in and as you cough squeeze your hands in over your stomach in order to support it

Circulatory exercises

Good circulation in your legs helps to prevent deep vein thrombosis (DVT) or blood clots. You will be given a pair of special support stockings (TED stockings) to wear the morning you go to theatre. You will be encouraged to wear them throughout your hospital stay. These help push the blood back to your heart. Also remember not to cross your legs or ankles as this can make the circulation more sluggish.

• Ankle circling involves moving the feet clockwise and anti- clockwise in circles. Repeat 10 times
• Keeping your legs straight bend your feet firmly up and down at the ankles. Repeat 10 times
• Keeping your legs outstretched, press the back of your knees down into the bed and tighten your thigh muscles. Hold for a count of 3 and relax. Repeat 10 times

It would be helpful to practice these exercises before you come into hospital.
 
When will I be able to eat and drink after the operation?

You will not be able to eat or drink for three/four days after the operation to allow things to heal inside, this is known as being nil by mouth. You may be given special liquid feed through a vein if your consultant feels this is necessary. After three/four days of being nil by mouth you will then be able to start taking sips of water and if there are no problems build slowly up to free fluids and then soft diet. A dietician will monitor your food intake and offer advice regarding dietary supplements.

How long will I be in hospital?

You can expect to be in hospital for 7-10 days.

Are there any complications attached to this surgery?

Complications can occur after any surgical procedure. A gastrectomy is a major operation.

The main complications are:

• Chest infection. This is usually due to not being able to cough and breathe deeply because of the cut on your abdomen. The physiotherapist and nurses will encourage breathing exercises to prevent this and ensure that you have effective pain relief to carry them out. You will also be encouraged to give up smoking before the operation
• Cardiac problems. Some patients may already have heart problems, which may be exacerbated, by surgery. Having major operation can put stress on the heart
• Anastomotic leak (a leak from the site where the bowel is joined to the gullet) with any new join in the gut there is a small chance that there will be a leak. If a leak does occur, it is sometimes necessary to re-operate to repair the leak. However, sometimes leaks can be healed without reoperation, just by careful management on the ward, where you would need to be kept NBM and nutrition given into your veins by feed called TPN
• Wound infection. Sometimes the wound gets locally infected and may need treating with antibiotics
• Deep Vein Thrombosis. You will be given a special pair of elastic stockings to wear and a small injection once a day. These will help prevent clots from forming in your legs often caused by reduced mobility. You will continue on these injections for 28 days after your operation
• Bleeding. This may occur during or after the operation. Very occasionally it may be necessary to do a further operation to stop the bleeding. If a significant amount of blood is lost, you may require a transfusion
• Dumping syndrome. This occurs after a gastrectomy and may cause you to become sweaty, hot dizzy and slightly uncomfortable after eating a large meal. It occurs because food empties more rapidly than normal into the small intestine. It can be treated with a change in eating habits

Will I need further treatment?

It may be necessary for you to have vitamin B12 injections.

You may also need a course of chemotherapy.

You will also be prescribed a 28-day course of blood thinning injections; these are given to prevent you from getting a blood clot. These are given from day 1 of your surgery; you will complete the remainder of the 28-day course at home. You will be shown how to administer this yourself whilst in hospital.

What if I decide not to go ahead with the operation?

Your decision will be respected, and your doctor will discuss alternative treatments with you. The treatments would not cure the cancer and would only be palliative.

If the stomach is not emptying properly because of a blockage at the lower end a stent can be placed to help improve symptoms.

Life after gastric surgery

This part of the leaflet is to help answer any questions you may have when you are discharged from hospital.

Will I need to rest when I go home?

You have had a major operation that has resulted in a long stay in hospital.

Recovery from this type of surgery is not fast and it may be several months before you return to your normal activities of living. You may feel that life can never be the same again but with slight modifications it can be a very good life.

You must now learn to live with the changes in your system so that they affect your quality of life as little as possible.

What will I be able to eat after the operation when I’m at home?

You will be seen and assessed regularly by the specialist Upper GI dietician.

Will I be able to swallow normally?

Yes, you should have no trouble in swallowing normal food after the operation.

If you experience difficulty with swallowing when you are at home, you should contact the Upper G.I. Specialist Nurse or your
G.P. for advice.

Will I have problems eating after the operation?

• You may find you need to eat smaller amounts more frequently ie: little and often
• Eating large meals may cause you to feel dizzy, hot and slightly uncomfortable and have diarrhoea. This is known as dumping syndrome and can be treated with a change in diet. It may help to avoid very sugary foods
• Chew food well and relax after meals
• Sit upright when eating
• Initially it is advisable to eat slowly and have small portions until you know your own capacity
• If you do eat too much at one sitting you may feel uncomfortable, this is will ease with resting usually within 30 minutes
• It is advisable not to have a drink with your meal as the fluid may fill you up and make you feel bloated. You should take fluids approximately one hour before or one hour after eating

What should I do if I have problems with my appetite?

• Eat small portions of food frequently
• Try to have high calorie foods
• Stick to foods you like
• Try to have nutritious drinks such as milk shakes, milky coffee
• Use supplement drinks prescribed by dietician. There are a variety of these supplements available, and you should choose the one which suites you best
• If lack of appetite persists and you are losing weight contact the specialist dietician, nurse or your GP

How can I gain weight?

• The hospital dietician will give you advice before you go home
• It will be quite normal for you to lose a little weight when you first go home
• Try to have snacks in-between meals such as biscuits, chocolate, crisps, milky drinks, yoghurts
• Eat butter not low calorie spread
• Try to have at least one pint of full cream milk daily
• Add milk, butter, cream cheese to foods such as mashed potatoes, soups and vegetables and extra cream, sugar and jam to foods such as puddings and cereals
• Use supplement drinks e.g. Build-up or Complan

Will I be able to drink alcohol?

You can drink alcohol as long as it does not interfere with any of your medications.

When will I be able to start exercising when I go home?

You should be able to start light exercise as soon as you get home. Short walks or a little light housework should be possible within a few weeks. Progress may be frustratingly slow, and you should not push yourself to do too much in the early stages. As time progresses and you feel you have more energy increase the exercise as you feel able.

It is also beneficial to continue with the breathing exercises you were taught by the physio in hospital. This may help prevent chest problems once you are discharged.

Will I have pain when I go home?

Most patients will have little or no pain a few weeks after their operation. If you do have any pain it will be assessed before you leave the hospital and appropriate painkillers will be prescribed to take home with you.

Will I be followed up at the hospital after the operation?

Yes, you will be seen in the outpatient department approximately two weeks after discharge and then at regular intervals from then on.

Will I have any support when I go home?

Support will be available to you on discharge. You will be assessed by individual members of the team before you leave hospital to see if you need help and support when you go home.

The team includes:

• Medical staff
• Specialist Nurses
• Ward nursing staff
• Dietitian
• Physiotherapist

Any care you need will be provided and arranged before you leave hospital. If needed the team can arrange for you to be seen by the social worker and occupational therapist.

Is there a support group for patients who have had gastrectomy?

Yes, Salford Royal has a patient support group that is run every 2 months, ask your specialist nurse for further information about this.

For further advice or information please contact:

Upper GI Specialist Nurse - 0161 206 5062
Email: uppergi.nursingteam@nca.nhs.uk

Upper GI Surgical Secretaries
0161 206 5472
0161 206 5744
0161 206 5128
0161 206 0449

Macmillan Cancer Support Centre 0161 206 1455