This information is about the problems people may have after surgery for stomach cancer. It may also be helpful to people who have had surgery for cancer of the gullet (oesophagus), as this may involve removal of part of the stomach.

The stomach acts as a storage chamber for food. It also mixes food with stomach juices, to begin the process of digestion.

There are two main types of surgery for stomach cancer:

• partial gastrectomy, in which only part of the stomach is removed
• total gastrectomy, in which the whole stomach is removed.

Other types of operation on the digestive system may also involve the removal of part or all of the stomach. For example, in a Whipple's procedure (pancreatoduodenectomy), the pancreas, part of the stomach and some of the small intestine are removed, whilst an oesophago-gastrectomy involves the removal of the gullet and part, or all, of the stomach.

People can have many different types of dietary problems after gastric surgery. These problems can generally be divided into two groups:

• early problems that occur straight away or soon after the surgery
• late problems that occur a few weeks or months after surgery.

These can include:

• feeling full after eating and drinking
• weight loss and malnutrition
• poor appetite
• indigestion and/or reflux (this can be continuous)
• dumping syndrome
• diarrhoea
• bilious vomiting.

Feeling full after eating and drinking

This is a sensation of fullness after meals and sometimes even after small snacks. The upper part of the stomach acts as a reservoir for food, and its muscle wall relaxes to accommodate a meal as a response to the sight or smell of food. This mechanism is controlled by the vagus nerve.

If surgery has made the stomach smaller and scarred (or if surgery has damaged or cut the vagus nerve), the stomach's capacity will be reduced. Food enters the stomach and puts direct pressure on the stomach wall, which makes it stretch (distend), and this gives a feeling of fullness.

Sometimes eating smaller, more frequent meals may reduce the sensation of fullness. Avoiding foods that are very high in fibre, such as large portions of fruit, vegetables and wholegrain cereals, is helpful, as high-fibre foods can make you feel full very quickly.

Whilst it is important to have enough fluid, it may be helpful not to drink large amounts just before mealtimes.

Weight loss and malnutrition

If you are not able to eat very much due to feeling full very quickly, you may find that you lose weight very easily and may not absorb all the nutrients that you need to keep healthy.

It is useful to build up your energy intake with small frequent meals and supplement drinks.

Your cancer specialist and dietitian can give you further advice on how to manage this problem.

Poor appetite

A poor appetite can be due to feeling full after meals or snacks. Eating little and often may help to stimulate your appetite. Again, you can ask your dietitian for further advice.

Indigestion

Indigestion and/or reflux (a backward flow of stomach juices into the gullet) can occur after any stomach surgery. Indigestion can also be caused by wind trapped in the digestive system.

Wind can be helped by taking peppermint water or charcoal tablets (available at local chemists) and by avoiding substances such as fizzy drinks, alcohol and spicy foods.

Reflux can cause soreness and inflammation of the lining of the gullet, and can be reduced by antacid medicines such as Gaviscon®, Maalox® and Aludrox®. Your GP or cancer specialist can prescribe antacid medicines for you.

Dumping syndrome

Dumping syndrome is divided into two types: early dumping syndrome and late dumping syndrome. Each of these has different processes and symptoms.

Early dumping syndrome often involves dizziness, a feeling of faintness and palpitations (a sensation of the heart beating faster) very soon after meals. It can last for approximately 10–15 minutes. Sometimes, the person's blood pressure drops.

Early dumping syndrome is caused when a meal rapidly enters the bowel from the stomach. The sudden high concentration of food in the bowel draws fluid from the surrounding organs and tissues and causes a drop in blood pressure.

Early dumping syndrome often gets better on its own over a few months, but it can be reduced by eating slowly and choosing small, frequent, dry meals. It is helpful to drink fluids between meals, rather than at mealtimes. It may also help to avoid high levels of refined sugars, which are found in foods that contain lots of sugar. It is important to eat some sugars as these are a good source of energy (calories), so try not to cut them out of your diet completely.

Some people find that resting for 15–30 minutes immediately after meals can reduce the effects of early dumping syndrome.

Late dumping syndrome usually occurs a couple of hours after meals or when a meal has been missed, and often involves a sudden attack of faintness that can be severe and may even lead to a loss of consciousness. The person may also have nausea and tremors (shaking).

Late dumping syndrome is caused by stomach contents that are high in carbohydrate being released into the small bowel. This causes a rise in the level of glucose in the blood as the carbohydrate is absorbed. Large amounts of insulin are released into the bloodstream as a response to this. The insulin levels continue to rise after the blood glucose levels have begun to fall. It is the high insulin level which causes the above symptoms.

If you experience this problem, you should follow the same advice given for early dumping syndrome, i.e. take small regular meals that are low in processed carbohydrates such as sugar. Glucose tablets can be helpful to take when the symptoms first start. Eating food and drinking fluid at different times may also be useful in preventing late onset dumping syndrome.

Diarrhoea

Diarrhoea can occur after any type of gastric surgery. It is more likely to occur after surgery involving the vagus nerve. If the vagus nerve has been cut during the surgery (vagotomy), the diarrhoea is often accompanied by a strong sense of needing to open the bowels urgently – which can be quite upsetting.

Immediately after surgery, diarrhoea can happen in short episodes for a few days or sometimes weeks, before the bowel returns to normal function. Everyone is very different, so it is difficult to predict how long it may last or how many times a day the diarrhoea will happen. Some people may have diarrhoea once a day, while for others it may be a few times a day.

Sometimes, taking an antidiarrhoea drug called loperamide (Imodium®) regularly in the morning can be helpful. As the diarrhoea is due to the effect of the surgery, it may not be possible to reduce it by changing the foods that you eat. If you find that some foods particularly affect your bowel it may help to avoid them, but it is best not to exclude too many foods from your diet.

Bilious vomiting

This usually occurs first thing in the morning. People find that they have stomach pain and a feeling of fullness when they wake up. This is relieved by vomiting clear fluid, which has some dark brown fluid (bile) in it.

Vomiting in this way can be very distressing for some people, but it only lasts for a short time. The cause is quite complex and it most often occurs after a partial gastrectomy (removal of part of the stomach).

Some drugs that act on the digestive system, such as domperidone (Motilium®) or metoclopramide (Maxolon®), may be helpful in controlling bilious vomiting. Some people find that any treatments they are given are not effective however, and they may need to learn to live with the condition. If the symptoms are severe and frequent, reconstructive surgery can sometimes be considered. Your surgeon can discuss the possible benefits and risks of further surgery.

Many of the problems mentioned above improve gradually over a period of time. You may need to make long-term changes to your daily eating patterns, such as eating smaller meals regularly, to reduce or control these problems. Your dietitian and clinical nurse specialist can give you further information, support and advice about this.

These can include:

• calcium malabsorption
• anaemia, caused by iron and vitamin B12 deficiency
• stricture of the anastomosis, which can make it difficult to swallow food.

Your surgeon will monitor you after your treatment and will see you on a regular basis every 6–12 months. This is because late side-effects can occur months or years after treatment.

Your specialist will investigate any problems that occur later on after stomach surgery, to see whether they are caused by your surgery.

Calcium malabsorption

Following surgery to remove the stomach (gastrectomy) it can be difficult for people to absorb enough calcium from their diet. This can cause a condition known as osteomalacia (a weakening of the bones). Osteomalacia can be prevented or reduced by taking vitamin D and calcium supplements regularly, as prescribed by your doctor.

Anaemia

Anaemia means that the blood is not carrying enough oxygen and can occur for several reasons. Iron-deficiency anaemia, the most common form, occurs if you do not have enough iron in your diet, or if you are not able to absorb iron from the foods that you eat. Iron is the main component of haemoglobin (Hb) which carries the oxygen in the blood.

There can be several reasons for an iron deficiency after gastric surgery. These are:

• changes in the way iron is converted from food, due to a reduction of stomach juices
• food moves more quickly through the intestine (bowel), reducing the time for absorption of iron
• if a small bowel (duodenal) bypass has been done, it reduces the normal surface area of the bowel so that less iron is absorbed.

Anaemia due to these reasons can be treated with iron supplements.

Lack of vitamin B12, which is needed to make red blood cells, can be another cause of anaemia. This can happen if part or all of the stomach has been removed, because the stomach produces a protein known as the 'intrinsic factor', which is needed for the absorption of vitamin B12. After stomach surgery, the body is no longer able to produce intrinsic factor, which leads to a reduction in the amount of vitamin B12 and folic acid absorbed. This can be treated with injections of vitamin B12. Everyone who has had a gastrectomy will need to have regular vitamin B12 injections from their GP.

Stricture of the anastomosis

When the stomach is removed, the lower end of the gullet (oesophagus) is joined to the upper end of the small bowel. The join is called an anastomosis. Occasionally the anastomosis can become narrowed which can make it difficult to swallow food. This is known as a stricture.

If you find that it is getting difficult to swallow food, you may become worried that the cancer has come back. It is a good idea to see your specialist as soon as possible, so that they can organise an endoscopy to look into your gullet. If you have a stricture, the doctor may be able to stretch it, making it easier for you to eat. Alternatively it may be possible to place a tube (a stent) into the narrowing to keep it open.

If you are having problems swallowing, you may find that you begin to lose weight quite quickly. It can be helpful to try eating soft or puréed foods and to have nourishing drinks.

A lot of people find it difficult coping with dietary complications after gastrointestinal surgery. Different feelings and emotions can arise, which can include feeling depressed due to not enjoying food or mealtimes any longer. Some people find it hard to adjust to the change in their body image due to surgery and/or weight loss.

Many people find that although their dietary problems may not disappear completely, they do learn to manage them so that they are not such a problem. Family and health care professionals can give support with this. It is often helpful to contact your hospital dietitian as soon as any dietary problems occur. Dietitians are experts in dealing with dietary problems, whatever the cause, and will be able to give you specialist advice regarding your diet and how to cope with associated problems.

This section has been compiled using information from a number of reliable sources including:

• Oxford Textbook of Oncology (2nd edition). Souhami et al. Oxford University Press, 2002.
• Cancer and Its Management (5th edition). Souhami and Tobias. Oxford Blackwell Scientific Publications, 2005.
• Gastrointestinal Oncology: Principles and Practice. Kelsen et al. Lippincott Williams and Williams, 2002.

For further references, please see the general bibliography.