Gastric

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Gastric Surgery

Gastric surgery (surgery on the stomach) may be performed for a variety of reasons. Ulcer disease may require surgery if medications fail, or if bleeding or perforation develop. Ulcers and other conditions may cause blockage of the outlet of the stomach which may need to be relieved. Bleeding for other reasons may require intervention. Benign or cancerous tumors may require removal. Regardless of the reason, if you are reading this it is likely you have been told you will need some type of stomach surgery.

The stomach has several functions. It stores and digests food, creates acid, controls the release of partially digested food into the intestine, and produces several hormones. Despite these important jobs, people can live without part or all of the stomach if needed. Depending on the type of condition affecting you, and the part of the stomach involved, your surgeon will decide how much of the stomach needs to be removed or altered, and will tell you what to expect from the procedure. Some examples of types of stomach surgery are shown.

HELLER MYOTOMY:

Strictly speaking this is a surgery on the esophagus, the muscular tube that carries food to the stomach. In some patients a condition develops for unknown reasons that causes the gradual failure of the bottom of the esophagus to relax and let food through. The result is a backup of food in the esophagus which can stretch it to very large proportions and may cause episodes of choking or pneumonia. At VSA we can perform a laparoscopic surgery, sometimes with robotic assistance, to release this blockage and let you swallow again. This procedure is called a Heller myotomy and is shown below. It generally requires 1 or 2 nights in the hospital and a week of recovery.

This procedure is usually successful, about 85% of the time, and is best done before repeated attempts at other treatments cause scarring of the area. Side effects include reflux (for this reason an antireflux procedure is usually added) and risks include perforation and leakage from the esophagus.

VAGOTOMY:

When the stomach produces too much acid, the nerves to the stomach (Vagus nerves) may need to be cut. This reduces the ability of the stomach to produce acid. It does not completely stop acid production, and may be combined with removal of a part of the stomach as well. These procedures can usually be performed with minimally invasive techniques, but in some circumstances open surgery may be needed. Some examples of vagotomy are:

GASTRECTOMY:

Removal of part or all of the stomach is called a gastrectomy. This is usually done for removal of a tumor, whether benign or cancerous, but might also be done for ulcer disease or other conditions. Different parts of the stomach can be removed, and the resulting pieces put back together in several ways. The more stomach that is removed, the more you can expect your eating habits will change. Several side effects may result, including weight loss, diarrhea, dumping syndrome (discussed later), or heartburn. Risks of this type of surgery include bleeding, infection, leakage from suture lines, recurrence of disease, or in rare cases death from heart issues or blood clots. Some different types of gastrectomy are shown:

REATTACHMENT (ANASTOMOSIS):

Once the portion of the stomach has been removed, we must reattach the ends to allow food to pass through the area again. Depending on how much was removed, this may require rearranging the remaining parts of stomach or intestine so that they can reach each other. Different techniques of reattachment have pros and cons that your surgeon will weigh in order to choose the correct method. Several examples are shown:

SIDE EFFECTS OF STOMACH RESECTION:

The side effects of having stomach surgery depend on the part of stomach that was removed, the amount and parts left behind, and the type of hookup you have.

Weight loss

The less stomach you have left, the more you will have trouble maintaining weight. An important function of the stomach is storage of food. If much of the volume of the organ is gone, you will only be able to eat small amounts. Eating small, frequent meals, and using supplements between meals, should help this problem.

Vitamin deficiency

If you have a Billroth II or Roux-en-Y anastomosis you may have trouble absorbing iron, calcium, and vitamin D. Supplementation may be needed. It is wise to take a multivitamin with these items in it daily after you have had this type of surgery.

Diarrhea

Loss of the nerves that control the stomach and intestine (vagus nerves) can lead to diarrhea. These nerves often must be cut during stomach surgery. This side effect occurs in up to 30% of people that have major stomach resections. It is usually only severe in 10%, and tends to decrease with time. With a combination of diet modification, over the counter products, and prescription medications it can usually be minimized.

Impaired emptying of the stomach

Cutting the vagus nerves and disrupting the normal intestinal attachments to the stomach can lead to slowing of the emptying of food from the stomach. This can become noticeable if the new connection to the intestine becomes scarred and narrowed over time. Occasionally this can be stretched by a After total gastrectomy, the Roux-en-Y technique can be used to attach the esophagus directly to the intestine esophagus gastroenterologist using a flexible endoscope through the mouth. Rarely, surgery might be needed if the narrowing is severe.

Dumping Syndrome

In some patients, the opposite problem may occur. Loss of the valve controlling the outlet of the stomach (pylorus) may lead to the stomach “dumping” all of its contents into the small intestine quickly after eating. This may cause nausea, sweating, flushing, diarrhea and lightheadedness. The rapid rise in blood sugar this causes will often lead to a “crash” of blood sugar later as the body produces insulin. Changes in eating habits are necessary to prevent these symptoms (see Post-Gastrectomy Diet). Avoiding large meals or high calorie liquids like sugary drinks and milkshakes, and separating liquids from solids when you eat are the main methods of controlling dumping syndrome.

PREPARING FOR SURGERY

OPEN SURGERY

Your doctor will talk with you about preparing for surgery. Follow all the instructions you’re given and be sure to:

The Day of Surgery

Arrive at the hospital at your scheduled time. You’ll be asked to change into a patient gown. You’ll then be given an IV to provide fluids and medication. You will be asked to sign consent forms to proceed. Shortly before surgery, an anesthesiologist will talk with you. He or she will explain the types of anesthesia used to prevent pain during surgery.

During the Surgery

An incision is made in the upper or central abdomen. The surgery is performed through this incision. Once everything is complete, the tissues are closed with sutures and/or staples. Dressings are applied. Sometimes surgical drains are used, which will exit the skin off to the side of the abdomen.

After Surgery

When the procedure is over, you’ll be taken to the recovery area to rest. Your blood pressure and heart rate will be monitored. You’ll also have a bandage over the surgical site. To help reduce discomfort, you’ll be given pain medications. You may also be given breathing exercises to keep your lungs clear. Later, you’ll be asked to get up and walk. This helps prevent blood clots in the legs. Once you have fully awakened, you will be sent to your room.

LAPAROSCOPIC SURGERY

Your doctor will talk with you about preparing for surgery. Follow all the instructions you’re given and be sure to:

Just Before Surgery

Arrive at the hospital at your scheduled time. You’ll be asked to change into a patient gown. You’ll then be given an IV to provide fluids and medication. You will be asked to sign consent forms to proceed. Shortly before surgery, an anesthesiologist will talk with you. He or she will explain the types of anesthesia used to prevent pain during surgery.

During the Procedure

After Surgery

When the procedure is over, you’ll be taken to the recovery area to rest. Your blood pressure and heart rate will be monitored. You may have a tube down your nose to keep your remaining stomach empty. You’ll also have bandages, tapes or glue over the surgical sites. To help reduce discomfort, you’ll be given pain medications. You may also be given breathing exercises to keep your lungs clear. Later, you’ll be asked to get up and walk. This helps prevent blood clots in the legs. Once you have fully awakened, you will be sent to your room.

AFTER YOUR GASTRIC SURGERY

Activity

We encourage resuming walking and light activity immediately; as soon as you are sure you are not going to have issues with dizziness or lightheadedness. You may resume driving when it is comfortable to walk up and down stairs. Don’t plan on any strenuous activities, like sports or going to the gym, until your postop appointment (and at least 2-4 weeks after open surgery). Your surgeon may have specific instructions to add to this; usually these are outlined to you before surgery. The bottom line: if it hurts, don’t do it! We generally recommend two weeks before air travel due to the increased risk of blood clots after surgery. This is a guideline and you may discuss this with your surgeon. Do not travel if you are still in pain. Ground travel is generally less a problem, and short distances may be undertaken within a week of surgery if you are comfortable. Longer distances (over 30 min) may need to wait two weeks unless you are told otherwise. Driving should not be attempted until you are off pain medications and able to go up and down stairs comfortably. You should be able to slam on the brakes to avoid an accident without causing any pain.

Care for the Incision

Usually surgical wounds will have either glue or steri-strips (butterfly tapes) on them, often covered with gauze. Glue, steri-strips, or waterproof plastic dressings can all get wet the day after surgery (unless your surgeon advises differently). Wounds with visible staples or sutures can get wet in the shower after 48 hours. Do not submerge your wound (tub bathing or swimming) for one week. While soap will not harm the wound, do not scrub it. Do not apply peroxide or other chemicals unless you have been told to do so by your doctor. After 48 hours, change or remove gauze dressings or Band-aids. Do not leave soiled or wet dressings on the wound beyond 48 hours. Most wounds can then remain uncovered, unless you have been told otherwise. Light gauze covering to prevent chafing is acceptable if you wish. You may notice a slight drainage (usually pink or reddish in color) from the incision site. This is normal and not a cause for concern. Light pinkness immediately surrounding the incision, and not spreading over time, is normal. Bruising is common and may extend for up to an inch. Spreading redness, progressive swelling with bruising, and malodorous drainage are not normal and should prompt a call to our office.

Diet

Generally for the first day or two you will not be able to take anything by mouth. As you recover in the hospital your surgical team will gradually progress your diet from clear liquids to thicker liquids, and then soft foods such as pudding, mashed potatoes, or bananas. Chew your food well. Avoid eating foods which must be swallowed in large pieces for two to three weeks. Also, avoid carbonated beverages during this period. Within two to four weeks, you should find your ability to eat returning to near normal. Refer to the detailed diet instructions in your discharge packet for any questions.

Elimination

Constipation is very common after surgery. We recommend staying well hydrated, and using Miralax, prune juice, or Milk of Magnesia for a few days at home until things are back to normal. If you are at all prone to constipation, or if you need several days of pain medicine, it may help to add Benefiber, Metamucil or similar bulk fiber agents for a few days as well. Do not let more than 48 hours go by without a bowel movement without starting the above medications. If they fail to help within another 24 hours, call our office. Diarrhea is common if you are taking antibiotics. If you have this problem, we would suggest either probiotics while you are on the antibiotics, or eating yogurt with active cultures. If diarrhea occurs more than 4-6 times daily for more than 48 hours, call us.

Medication

Prescription pain medications are there to help you recover comfortably, but stop them as soon as you are able. Side effects of nausea, vomiting, dizziness, fatigue, poor appetite, and above all constipation, are common. If you have these issues, try to use ibuprofen and Tylenol instead (see below). Do not use alcohol or drive if you are taking prescription pain medications.

Unless you are told differently by your surgeon or primary doctor, you can take 400 mg ibuprofen every 4-6 hours, or 800 mg every 8 hours, for the first 3-5 days after surgery, for a maximum dose of about 2400 mg/day (refer to the label for specific dosing based on age and weight). It is best if you can take some food with this medication. Tylenol is also acceptable to help with the baseline pain after surgery. It can be taken in conjunction with ibuprofen, and with your prescription (unless your prescription already contains acetaminophen--which is Tylenol). Be very careful not to exceed the dosage on the bottle. Taking more than 3 grams/day is not advisable. Blood thinners should only be restarted after surgery according to the plan discussed with you by your surgeon or prescribing doctor before surgery. If this was not made clear to you, call our office. All other medications should be resumed once you get home. Vitamins and supplements are not necessary to help you heal, unless you have a known deficiency, or unless your doctor suggests a multivitamin daily due to the type of surgery you had. You may resume any of these you normally take after you get home if you wish. We would suggest sleep aids not be used while you are on narcotic pain medications.

Follow up

You will be seen in our office 7 to 10 days after your discharge. Prior to surgery, you should have made an appointment for your first post-operative visit. If for some reason that appointment was not scheduled, please call our office at (703) 359-8640 as soon as your return home to schedule your appointment.

If Difficulties Arise

Please call our office immediately if you develop any of the following;

Please call us if other problems or questions arise. We can be reached any time, including evenings and
weekends, by calling our office number (703) 359-8640.

Risks and Complications

  • Injury to the liver, spleen, esophagus, or other organs
  • Infection
  • Leakage from a staple or suture line
  • Bleeding
  • Limited stomach capacity
  • Difficulty swallowing
  • Recurrence of tumor

POST GASTRECTOMY DIET

After a major stomach surgery, such as a proximal, distal, subtotal, or total gastrectomy (see above), your eating habits will need to change. The early transition from liquid to solid will occur in the hospital under the direction of your doctors and nurses. Once at home, there are a few guidelines that will help avoid problems with your eating.