Gastric/Stomach Surgery

What is the Stomach?

The stomach is an organ located on the left upper part of the abdomen. Swallowed food is received in the stomach, it is then mixed with acid and digestive enzymes made the cells of the stomach. The stomach is responsible for grinding and mixing food and is of the first organs of digestion. The stomach muscles contract and push digested food into the intestines.

Common Symptoms of Gastric Diseases

Gastric or stomach disease symptoms vary between benign diseases and cancerous diseases. Common symptoms depend on the nature of the problem but in general include:

Treating Gastric Diseases

Gastric Cancer – Gastric Tumors

Treatment of gastric cancer should be done by a team of specialists in various medical disciplines, including surgeons/surgical oncologists, medical oncologists, radiation oncologists, gastroenterologists, radiologists, nutritionists and support groups. Gastric cancer treatment is a multimodality treatment and includes surgery, chemotherapy and sometimes radiation therapy. Recent advances include immunotherapy if other treatments fail, in addition to palliative surgery/therapy.

Chemotherapy

Most gastric cancer patients will require chemotherapy at some point in their treatment. Chemotherapy can be given either before or after the tumor has been removed by surgery and depends on treatment team preference and stage of the disease. Surgery on these tumors is technically for curative intention.

If tumors are too large and involving surrounding organs, and/or have already spread to distant sites other than the stomach, then chemotherapy is given for palliative purposes. Surgery on these patients is also usually palliative and not curative.

Radiation Therapy

Similar to chemotherapy, radiation therapy is an important part of the multimodality approach to gastric cancer, it might be given before or after surgery depending on the stage of the disease and the treatment team preference.

Surgery

Surgery is done as a curative approach or a palliative approach in gastric cancer. As a curative surgery, the goal is surgically remove the cancer in its entirety. Palliative surgery is done of the tumor cannot be fully removed, then bypass procedures will be done to correct the stomach obstruction resulting from tumor growth.

Gastric Ulcer Diseases

Ulcers are sores or lesions in the inner lining of the stomach. They result from multiple factors, mainly increased acid production by the stomach in addition to weakened defense of the stomach lining. Multiple disease states or medications are linked to gastric ulcers and these include:

  1. Helicobacter Pylori (H. pylori) infection: H. pylori is likely the most common reason for the development of gastric and intestinal ulcers. It damages the lining of the stomach and the intestines and weakens its defense mechanism, allowing for stomach acid to burn through their wall. About 40% of Americans have H. Pylori in their system and most of them remain asymptomatic.
  2. Medications: Non-steroidal anti-inflammatory medications (NSAIDs), like Advil or Motrin or Ibuprofen damage the lining of the stomach allowing for the development of ulcers.
  3. Acid stimulating tumors: some tumors secrete substances that stimulate acid production, the most common example is Gastrinoma, a tumor growing in the stomach or intestines and secretes the Gastrin enzyme which stimulates extra acid production in the stomach, creating severe gastric and duodenal ulcers.

How are ulcers treated?

With the wide use of acid reducing mediations, surgery for gastric ulcer disease has become rare. Patients are treated with histamine receptor blockers (H2 blockers) or proton pump inhibitors (PPIs) to reduce the amount of acid and protect the stomach lining. For H. pylori infections, antibiotics and other medications to fight the bacteria and eradiate the bacteria are used. Obviously, if NSAIDs caused the peptic ulcer, a doctor will advise you on how to reduce their use.

Surgery for gastric ulcer disease is almost always nowadays limited to the complications of ulcer disease. If the ulcer is actively bleeding, multiple modalities are used to stop the bleeding and these include endoscopy or embolization of bleeding vessels. Surgery is used as a last resort if other attempts at stopping the bleeding fail. In cases that medication or endoscopic therapy does not work, your doctor may recommend surgery. If the ulcer becomes deep enough to cause a hole in the wall of the stomach, it becomes an emergency and surgery is most often required to repair the hole.

Surgery of the Stomach

The extent of surgery of the stomach is dictated by the location of the disease, whether done for tumors of the stomach or ulcer disease. Gastric surgery is one of the biggest and most involving surgeries in the abdomen, and that is due to the proximity of the stomach to vital organs, in addition to important blood vessels.

The stomach is divided into multiple parts: The cardia, fundus, body, antrum and pylorus.

The Gastrectomy Procedure

Surgery to remove part or most of the stomach is a very technically demanding procedure. The decision to remove part of the stomach depends on the location of the disease. A distal gastrectomy is removal of the lower part of the stomach and the pylorus. A total or subtotal gastrectomy is done if the tumor is located more superiorly in the stomach. National guidelines recommend a margin of 4-6 cm away from the tumor when removing a malignant gastric tumor. Depending on the experience and preference of the surgeon and the disease stage and involvement, gastrectomies can be performed either using the open technique of the minimally invasive laparoscopic or robotic technique.

Types of gastric surgery and mode of reconstruction:

Palliative Gastric Bypass

When tumors cannot be technically removed by surgery and they are causing a mechanical obstruction for the outflow of food from the stomach, palliative surgery is used to allow these patients to eat again and bypass the area of obstruction. This type of surgery is only done for palliative reasons and is not curative by any means.

Before Surgery

The Day of Surgery

Discharge Instructions after Gastric/Stomach Surgery

You just had gastric surgery and completed your hospital stay after the procedure. It is now safe to be discharged home. Your surgeon will be keeping a close eye on your progress even if are at home. Healing from a gastric surgery usually takes weeks.

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. 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!

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.

Eating:

The basic rule is take in what your body is telling you. It takes about two-three weeks at least after gastric surgery in order to resume a normal diet. Your stomach will be slow at digesting food especially after large portion of the stomach has been removed, this process might be faster if you had a small part of the stomach removed with the small incisions technique. Some find it easier to digest bland foods, light foods, or predominantly liquids. It is not uncommon that you will be discharged home on a liquid diet for the first two weeks after surgery. Make sure you stay hydrated, and avoid excessive caffeine. Raw fruits, raw vegetables, dairy products and carbonated beverages should be avoided as they cause gas pain. Alcohol is not allowed for a few weeks/months after gastric surgery. Some gastrectomy patients will have a feeding tube and will be sent home on tube feeds; very specific instructions will be given to you regarding the tube feed formula and the way these are administered. We strongly recommend being on supplements like Ensure or Boost after surgery for a few weeks.

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 until things are back to normal. 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. Make sure your doctor is aware of any chronic difficulties with urination (like prostate trouble) before surgery.

Wound care:

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. If you have a feeding tube, do not submerge in water until this tube is removed. If you have a surgical drain, do not submerge in water until that drain is removed. 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 Bandaids. 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.

Drains:

If you are sent home with surgical drains, you will likely be given instructions at the time of discharge for care of them, and a log sheet to record the output. It is important to note the daily output of the drain(s) so we will know when to remove them. Drains that empty into a suction bulb or attached bag can get wet in the shower. If there is gapping of the skin around the drain. Do not submerge the drain site underwater, such as tub bathing or swimming. Slight pinkish or yellowish drainage from around the tube is normal while it is in place, as is a small amount of redness at the site. Gauze over the site may help protect your clothing from staining. Foul smelling or copious drainage around the drain, or spreading redness around the drain, is not normal and should prompt a call to our office. If the drain reservoir fails to hold suction when you squeeze it, or if the drainage suddenly drops to near zero, call our office.

Normal care of drains includes emptying the fluid in the reservoir every 8 hours and recording the amount per 24 hour period. Bring this record to your postoperative appointment. The fluid may need to be emptied more frequently if the drainage is heavy. Fluid will often be red at first, then pink, then yellow as the wound heals. Stringy material in the tubing or reservoir is normal.

Medications:

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 should also be used around the clock 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 4 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. You may resume them after you get home if you wish. We would suggest sleep aids not be used while you are on narcotic pain medications.

If Difficulties Arise:

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

Call your doctor if you have any of the following:

  • Fever over 101°F or chills
  • Increasing pain, redness, or drainage at an incision site
  • Yellowing of the skin or eyes, or brown colored urine
  • Vomiting or nausea that lasts more than 12 hours
  • Prolonged diarrhea
  • Chest pain or shortness of breath
  • Inability to urinate within 8 hours of discharge