Skip to content

Key Topics

What is a gastrectomy?

Gastrectomy involves removing all or part of the stomach with the draining lymph glands (these are small, bean-shaped glands that filter bacteria and disease from the lymph fluid).

The type of gastrectomy depends on the exact location of the cancer within the stomach. Cancers that are in the upper part of the stomach (proximal part, nearest to the oesophagus) are treated by removing the entire stomach. This is called an Extended Total or Total gastrectomy.

If the cancer is near to the exit of the stomach (distal part) a partial (distal/subtotal) gastrectomy is performed which means removing at least 50%-75% of the stomach. 

Your surgeon will discuss which type of operation is most suitable for you.

What does the surgery involves?

In this hospital, an extended total or total gastrectomy is an open operation which means it is performed by making an incision (a cut) in the abdomen. Partial gastrectomy operations are sometimes performed by keyhole surgery (laparoscopically) rather than an open operation.

Gastrectomy surgery is a major operation.

An extended total or total gastrectomy can take between 4-6 hours to perform.

A partial gastrectomy can take between 3-4 hours to perform.

You should be aware that there is a small chance (5% or 1 in 20) that a keyhole operation may need to be converted to an open procedure.

Position of wounds

If you would like to know where your operation incisions will be, please ask your Consultant Surgeon.

What are the possible risks and complications?

Before the operation your Surgeon will discuss the risks associated with the operation. The most common complications include the following:

  • Chest infection – Chest infection is quite common after an oesophagectomy. About a quarter of patients will require antibiotics for this. A smaller number of patients may have a chest infection that may require spending time on the Critical Care Complex (CCC). If you have chest problems to start with (asthma, chronic obstructive pulmonary disease or smoking-related chest problems) then a chest infection after the operation can be severe and life-threatening. Please note that the incidence of this is significantly higher in smokers (please see the section below on stopping smoking).
  • Bleeding – Bleeding can occur with any operation, it is uncommon for excessive bleeding to occur with gastric surgery but occasionally a further operation may be required if bleeding continues in the days immediately after surgery. Some patients may need a blood transfusion. If you have concerns about blood transfusion please let your Surgeon and Anaesthetist know before the operation.
  • Anastomotic leak – An anastomosis is a join between the small bowel and the lower end of the oesophagus (used for extended and total gastrectomy) or remaining part of the stomach (partial gastrectomy). On occasions the anastomosis doesn’t heal as well as it should and can leak in about 1 in 20 patients – this risk is particularly higher if you are still smoking. This can be life threatening and may require further surgery and a much longer hospital stay. 
  • Blood clots – Deep vein thrombosis (DVT) or pulmonary embolus (PE). This risk is reduced with injections (see below for more information on this).
  • Death from the operation – Unfortunately despite our best efforts there is a risk of death with a gastrectomy. The death rate for oesophagogastric cancer surgery is 1.3% (just over 1 in 100) at the NNUH and this compares favourably with the national average of 1.9% (National Oesophagogastric Cancer Audit (NOGCA) 2019).

Your preparation for surgery

Your preparation for surgery starts at the point you are told you will be having surgery as part of your treatment and continues on discharge home from hospital after your surgery.

It is absolutely essential to do everything possible to get you home safe and well after a gastrectomy. As a team we will do our utmost to perform the operation safely and look after you after your surgery. However we need you to adhere to the advice below regarding smoking cessation and cardiovascular exercise which if followed closely can greatly reduce the risk of complications and improve your chance of doing well. 

You must STOP smoking. 

If you smoke, it is essential to STOP SMOKING NOW. 

During the surgery your right lung is deflated for a whole afternoon, so it is essential to have as healthy lungs as possible to reduce the risk of breathing and chest problems after surgery.  As above, you have an increased risk of anastomotic leak if you continue to smoke. 

Nicotine patches or electronic cigarettes should NOT be used as these can also cause complications. You must adhere to this advice as it can make the difference between life and death.

For help on giving up smoking please contact “Smokefree Norfolk”, the stop smoking service in Norfolk, on 0800 0854 113 or via your GP or health centre. Your Doctor, Practice Nurse or Health Visitor can also give advice to help you stop smoking. 

Why is exercise before surgery vitally important?

You need to be as fit as possible before your operation as this will help you to recover more quickly afterwards and prevent life threatening complications. It can also mean that if you develop a complication you are much stronger to get better. Before surgery the fitness of your heart and lungs can be hugely improved by a small amount of exercise each day.

Any form of exercise which raises your heart rate and burns calories is beneficial. This can include the following:

  • Everyday activities:  walking, heavy housework, gardening.
  • Long walks, cycling, dancing.
  • Golf, swimming.

How much exercise will you be expected to do?

We recommend that during your chemotherapy (if you are having this) and the weeks before surgery you should try and do the following:

  • 30 mins of moderate exercise at least 5 days a week such as brisk walking or cycling at a comfortable pace.

Or

  • 20 mins of vigorous exercise 3 times a week such as jogging, swimming or cycling at a fast pace.

And

  • Complete strengthening activities on at least 2 days a week.

For more information refer to NHS website www.nhs.uk/live-well/exercise/

It is essential that you are well nourished leading up to surgery. You should be eating regularly throughout the day and if you are able include a variety of foods for each of the food groups; protein, carbohydrate, dairy, fruit and vegetables.

If you are still struggling with eating or losing weight, it is important to let us know so you can be given tailored nutritional advice and support to help. This may involve modifying the texture of your diet, fortifying your food and drink to increase the nutritional content and prescribing nutritional supplements.

The weeks leading up to surgery

You will receive an appointment to attend the preoperative assessment clinic to be screened for Methicillin Resistant Staph Aureus (MRSA) and to perform investigations such as heart rate, blood pressure and weight. You may have blood tests, a chest X-ray, and an electrocardiogram (heart test) and you will be seen by an Anaesthetist.

You will be given information about what to bring into hospital.

Please bring a list of all your current medication when you attend the clinic.

You may be given a medicine to take the night before and the morning of the operation to reduce the amount of acid in your stomach.

The Anaesthetist will see you to assess you and discuss the surgery and anaesthetic with you.

Some pre-operative assessments may be performed via telephone consultation – you will be informed of which style appointment you will have when the appointment date is confirmed with you. Please have a list of your current medication available for this pre-operative assessment telephone call.

A cardiopulmonary exercise test lets your Doctor see how your lungs, heart and muscles react together when you exercise. It involves you cycling on an exercise bike while we will measure how much air you breathe, how much oxygen you need, and how fast and efficiently your heart beats when you exercise.

To measure the amount of air that you breathe, you will need to wear a soft, comfortable facemask covering your mouth and nose. An ECG (electrocardiogram) will look at the rhythm and rate of your heart, a blood pressure cuff will measure your blood pressure throughout the test and a small peg on your finger will measure how much oxygen is in your blood.

What will happen on the day of surgery?

You will come in on the day of surgery via Same Day Admissions Unit (SDAU), where you will be taken to theatre. When you attend please bring in all your current medication.

The operation

  • The operation is performed under general anaesthetic (you will be asleep whilst the operation is performed).
  • Before the operation starts the Anaesthetist will spend time placing a spinal/epidural injection as well as starting the general anaesthetic.
  • While you are asleep, you will also have other tubes connected to you: a urinary catheter to drain urine, a tube down the nose to drain the stomach, and tubes in the abdomen.
  • After the operation, your Surgeon will telephone your next of kin to explain how the surgery went.

After the operation

What to expect whilst you are in hospital

Most people are in hospital for 5-10 days. If there are complications, your stay may be longer. After the operation particularly after an extended or total gastrectomy, patients will spend the first few days in the Critical Care Complex (CCC) to be monitored closely until stable enough to return to the ward. After a partial gastrectomy, patients routinely go back to the surgical ward.

After a gastrectomy you will experience some discomfort. This is usually controlled by the epidural method of pain relief. This involves inserting a thin plastic tube in your back just before the operation. It is attached to a pump to give you continuous pain-relieving medication until you are ready to take tablets. The Anaesthetist will discuss this with you before the operation.

It is important to make sure you have adequate pain relief so you can move around and cough to prevent complications. The Physiotherapists will work closely with you to help your lungs recover and prevent breathing complications. 

This is the most important part of your recovery process and it is very important that you follow their instructions and allow them to help you get going. The sooner you are able to stand and then walk (with help) the better for your recovery.

You will have one or usually two drains coming out of the abdomen. The drains are placed to allow fluid to drain from the abdomen. They are removed once the fluid stops draining – this is straightforward and easily done at the bedside.

You will have a urinary catheter placed into your bladder to monitor your urine output initially, and it is removed when you are able to walk to the toilet (after the epidural has come out). You will also have a small tube down your nose to drain any digestive fluids until the join (anastomosis) heals.

You will be advised when you can to start to drink and eat again; it usually takes 3-4 days. It is a gradual process starting with drinking small amounts of water. You may require an endoscopy or a barium swallow (an X-ray test that requires you to drink a liquid to show how it drains into the gut) before your Consultant is happy for you to start eating.

If there are no complications it is likely you will gradually build up to a soft diet by the time you go home. You should remain on a soft diet until you have been advised by your Consultant Surgeon to progress to solid food.

During your admission a Dietitian who will advise you about your diet and provide practical advice for your discharge home.

It is important to understand that you will no longer be able to eat large meals and will need to eat small and frequent meals. Your appetite will take a while to return and you may not feel the same hunger feelings as you did before surgery. It will take time to get used to this new way of eating.

Physiotherapy after surgery

The Physiotherapist will see you the morning after your operation and ensure you are able to breathe deeply and cough effectively. They or the nursing staff will assist you out of bed and to begin to mobilise. You will continue to be seen by the Physiotherapist daily to help you progress your exercise and walking until you are fully independent and able to continue by yourself.

Walking, deep breathing exercises and coughing

Breathing exercises are important following surgery and can help prevent chest infections and other lung problems. You should start them as soon as you wake up from surgery and practise them every half an hour.

  • Sit in a comfortable upright position with your shoulders relaxed.
  • Take a slow deep breath in (through the nose if possible) filling the bottom of your lungs.
  • Hold for 3 seconds and then relax and breathe out gently through your mouth.
  • Repeat 3 more times and then rest (more than this may make you feel dizzy or light headed).
  • Following deep breathing exercises it is important to cough and clear any phlegm that you produce.

Coughing

  • Support your wound (with a towel/pillow if required), cough as strong as possible to clear any phlegm from your chest.
  • It is normal for coughing to be painful initially, but if you are having difficulties deep breathing or coughing because of pain please let the nurse know
  • Coughing maybe more comfortable and effective if you sit forwards or bend your knees when you cough

Leg exercises

When in bed:

  • Point your toes and rotate your feet in a circular motion
  • Repeat 10 times on each leg
  • Tighten your thigh muscles by pushing the backs of your knees down against the bed, hold for 5 seconds
  • Repeat 10 times on each leg
  • Bend and straighten each leg 10 times
  • Keep your foot close to the bed but do not drag your heel on the sheet as this can make your heel sore

When in the chair:

  • Straighten one knee, pull toes up and hold for 5 seconds
  • Repeat 10 times
  • Repeat on the other side
  • March your legs in sitting, lifting each foot in turn
  • Aim to complete for 3 minutes

Walking

Walking will start on the first day after your operation. Drips and drains move with you and will not stop you getting out of bed and walking. The physiotherapy and nursing staff will help you until you can walk by yourself safely.

Once able to walk independently you will be responsible for walking regularly. We will aim for you to be walking 5 laps around the ward 4 times a day on day 4 after your surgery.  The more you do the better it is for you.

Histology and chances of cure

The histology report (the review of the cancer tissue removed) takes approximately 2-3 weeks to become available. The success of the surgery in terms of cure is dependent on how early the cancer has been detected. The removed part of the stomach is sent to the laboratory and examined to identify the stage of the cancer. 

The stage of cancer depends on how far the cancer has grown out from the wall of the stomach, into the surrounding lymph nodes. Sometimes more treatment is needed after surgery – this may involve radiotherapy and/or chemotherapy – to help to reduce a recurrence of the cancer. Your Consultant will discuss this with you after the operation if it is appropriate.

Tablets and drugs

Your usual tablets and drugs will be given to you when you are drinking properly. If they are important tablets, we can give them either down a feeding tube or intravenously (through a vein).

Dalteparin injections are routinely given through a tiny needle once a day to minimise the risk of a blood clot in the legs (DVT or deep vein thrombosis) and lungs (pulmonary embolism). This should be continued for 28 days after the operation and this will usually mean getting yourself or a family member to give it once you are home. The ward nurses will support you in learning how to use these injections before you are discharged.

What to expect when you get home

The following information will hopefully answer a number of common questions that many patients have about their care after an operation of the oesophagus.

For the first 2 weeks after surgery your Consultant Surgeon may instruct you to remain on a very soft diet. You should progress to eating most foods about 4-6 weeks after surgery but be guided by your Consultant, Dietitian and Nurse Specialist about when to progress to normal diet. 

Please refer to the diet sheet provided by the Dietitians for suggested meals and snack ideas.

Amount of food

After the operation you will need to significantly reduce the amount of food and drink consumed at one time. This will be a lifelong change. 

You should have been given a diet sheet by the ward Dietitian prior to going home. 

Depending on the type of stomach surgery, there is either no stomach reservoir (extended/total gastrectomy) or only a small remnant of stomach left (partial gastrectomy). This will mean you will become fuller much quicker than before. 

Therefore, it is very important that you eat small amounts regularly throughout the day. This will help to provide the nourishment your body needs in order to aid recovery and minimise weight loss.

Main points of advice are as follows:

  • Eat slowly and chew your food well.
  • Always sit upright when eating.
  • Use a small plate for your main meals. 
  • Do not drink before or during a meal (sips are ok)
  • Wait at least 30 minutes after a meal before having a desert.
  • As soon as you feel full – stop eating and drinking.
  • Walk around after a meal to help it move down.

Altered sensations when eating

In the first few months after surgery, you will feel full much more quickly after eating until the body adjusts to the changed anatomy. Sometimes, you may feel the food is sticking or there is a restriction in food going down, please contact your Nurse Specialist or Consultant Surgeon for advice if this happens. 

This may be a sign that the anastomosis has narrowed slightly or the exit of the remaining stomach has narrowed (after partial gastrectomy). This may require a gastroscopy to stretch it back. If this is needed it is a straightforward procedure which takes about 10-15 minutes and is done as a day case. 

For contact details please see below.

Appetite

It is common to have no or very little appetite after surgery. It may be difficult for you and your family/carers to cope with this. You may not feel like eating anything that is prepared for you and/or will not enjoy the taste of food. Not wanting to eat can cause a lot of stress and tension between you and your family as they worry about how you will recover if you do not eat. 

Remember to keep to small and frequent portions: you will not progress if you try to eat larger meals. The best way to recover and gain weight is to eat 4-6 small meals a day and have regular snacks. It takes several weeks before your appetite returns. Appetite and taste will improve after about 3 months but you may not regain the same level of appetite as you had before surgery.

Taste

After a gastrectomy it is normal for taste to change. We do not know what causes this but you will find that some foods you previously liked now don’t taste as nice. Similarly some foods you didn’t like before suddenly become tasty!

After extended/total gastrectomy

It is quite common for some people to experience some biliary reflux. As there is no longer a stomach, you will not produce stomach acid but can experience bile reflux. This happens because the oesophagus is joined to the small bowel and the valve that used to prevent stomach contents coming back up into the oesophagus has been removed.

Often it is a problem at night or when lying flat. Using extra pillows or a wedge pillow at night to raise your head may help to reduce this problem. Again eating frequent small meals and snacks may help.

Anti-acid medication such as lansoprazole will no longer be effective as you will not produce stomach acid. Bile reflux can be helped with liquid Gaviscon/Peptac.

Other helpful hints:

  • Avoid drinking or eating for at least 1- 2 hours before you go to bed.
  • Avoid lying flat or leaning over within ½ hr of eating or drinking.
  • Remember to eat and drink small portions and frequently.

If reflux is a persistent problem, discuss this with your Nurse Specialist or Consultant.

After a Partial gastrectomy

You can still experience acid reflux as there is some stomach remaining.

Anti-acid medication such as Lansoprazole can be helpful in relieving acid indigestion/heartburn symptoms.

Follow the above hints also to manage reflux symptoms.

Bed wedge/anti-reflux pillows

The Oesophageal Patients Association (OPA) has teamed up with Putman Pillows to provide their standard bed wedge acid reflux pillow at an approximate price of £27.

To take advantage of this offer please call or email the OPA first and they will give you a discount code.

Call on 0121 704 9860 or email: [email protected]

“Dumping syndrome” is a problem that can occur after stomach surgery. It can occur immediately after eating or within a few hours. 

Early Dumping Syndrome

This can occur within 30-60 minutes after eating. It is due to food moving too quickly into the small bowel. This draws a lot of water into the bowel and can cause a drop in blood pressure. This can result in nausea, vomiting, abdominal discomfort, feeling full, dizzy and diarrhoea.

Late Dumping Syndrome

This is can occur 1-3 hours after eating or of you have missed a meal. It is caused by food passing too quickly into the small bowel, resulting in a rise in the hormone insulin. This rise in insulin then causes your blood sugar levels to drop below normal. Symptoms can include sweating, flushing, dizziness, feeling faint, rapid heartbeat. In severe cases, some people can pass out.

Dumping syndrome is very common but can be reduced by the following:

  • Eating slowly and take your time over your meals.
  • Eating smaller meals but more often.
  • Reducing the amount of sugary foods that you eat.
  • Adding small amounts of fibre, protein or increase the fat content of your meals to replace the calories from sugars.

It is always worthwhile having a couple of sweets e.g. Lucozade/Dextrose energy tablets/jelly babies in your pocket if you do start to feel faint after you have eaten. One of these will help raise your blood sugar again. 

If none of the above helps, there is medication available that can be tried, which can dampen the sudden rise in insulin levels. You Nurse Specialist can advise you.

Diarrhoea is quite common after stomach surgery. Part of the operation to remove the stomach involves cutting a nerve called the vagus

nerve. (The nerve is stuck to the side of the oesophagus and the side of the stomach. It is not possible to avoid doing this.)  As a result of cutting this a few people can get quite bad diarrhoea. The diarrhoea can be very watery. It is a very annoying symptom to have and it can be quite difficult to treat.

The first line of treatment to try is obviously anti-diarrhoea medicine, which you can buy over the counter, such as Imodium. If this does not help you need to speak to your Consultant or your Nurse Specialist who can advise on other medication.

The colour of your bowel motions may change to be orange or pale brown in colour. This is very common in the first few months after stomach surgery due to changes in the speed of digestion and the timing of which digestive enzymes are mixed. If this continues after 3 months contact your Nurse Specialist/Dietitian for advice.

It is common to lose weight after stomach surgery, particularly within the first 3 months. It is important to minimise the amount of weight loss as much as possible in order to aid recovery and maintain fitness for any further treatment.

If you continue to lose weight after 6 months or if you are losing weight fairly rapidly please let your Nurse Specialist or Consultant know so an appointment can be made to review you.

After extended/total gastrectomy

After a total gastrectomy you will not be able to absorb vitamin B12. Your surgeon or specialist nurse will arrange for you to have 3 monthly injections at your GP surgery. This will continue for life.

In general, after stomach surgery

After both types of stomach surgery, you may be less able to absorb iron and some other vitamins and minerals. You will have regular blood tests at each follow up appointment to check for any deficiencies. You may need to take a course of supplements at intervals over time.

Taking multivitamins may help to prevent deficiencies.

Exercise when you get home

The best exercise after surgery is walking. As you exercise, even very gently the body recovers quicker. We advise that you continue to take regular walks and increase the distance that you walk every day.  It is recommended you walk daily for the first 3 months after the operation – there is a risk of DVT (blood clots) in that time. It is important to avoid heavy lifting and strenuous exercise for the first 6 weeks.

Most people have some swelling of their ankles and legs after major surgery. This is normal and should improve with gentle exercise, regular meals and time. 

Returning to normal activities

You should be able to go back to work after three or four months, though take the advice of your Doctor.

Driving is possible after about 2-4 weeks at home if you feel comfortable with doing an emergency stop.

Clinic appointments

You will normally be seen at within 4-6 weeks after the operation in clinic to check your wounds and to see how well you are getting on. It is usual to have another blood test at this appointment. Prior to this, you will have regular telephone contact with the Nurse Specialists.

If you have any questions about the surgery and further treatment then this appointment is the time to ask. 

If you are having a lot of problems with eating you should let us know prior to the clinic appointment.

Remember that your GP will be aware that you have had stomach surgery but may not know the full story so if you have any concerns please contact either your Consultant or Nurse Specialist.

After the first post-op clinic appointment you will normally be seen at 3-6 months after surgery and then at regular intervals thereafter.

Holidays

Providing you are eating OK and your weight is stable it is possible to go on holiday within 2 weeks of getting home. However, long-haul flights are not recommended in the first 3 months. If you are planning a long holiday let us know and we will fit your clinic appointments around the dates. You should check your travel insurance if you are flying in the first 3 months after your surgery.

Feelings and relationships after a major operation – please also refer to the ‘Coping with stress’ section below

After a major operation, it is usual for people to feel low in mood. This may be related to a number of factors such as lack of energy, poor appetite and a general feeling of frustration.

It is important to remember that it can take up to 3-6 months until you feel you have regained some strength and energy. It may be helpful to set small goals to achieve in the first few weeks after surgery rather than expecting to resume normal daily activities, which you may find you are not be able to do, leading to more disappointment and frustration.

Some people experience similar emotions after surgery to those felt at the time of diagnosis (e.g. anger, tearfulness) because of the impact that an operation can have temporarily on jobs, hobbies and relationships.

It can be difficult to talk to loved ones and explain our feelings or we often assume that they understand how we are feeling. Sometimes it seems easier to keep thoughts locked up but this can be difficult for family and friends. By sharing how you feel, you and those close to you are more likely to be able to support each other during stressful times in your recovery.

It is not uncommon for major surgery to cause a temporary drop in libido. Again, this is often due to lack of energy and physical strength. Try to talk openly with your partner about your feelings. Remember closeness and sexual pleasure can be shown in a number of ways, not just by the act of sex.

You should be able to resume sexual activity as soon as you feel physically able to.

Readmissions

On occasion, even after getting home, you may develop a complication such as a chest infection requiring admission to a hospital. Your GP may admit you to a different hospital or a different department within the NNUH. 

If this were to happen, please ask the team who are looking after you at the hospital to contact the Upper GI team at NNUH and please contact your Upper GI nurse specialist at the NNUH when you are home again so that we are aware of what is happening, where you are and what treatment is being offered.  We will like to continue to be involved in your care, as often other hospitals are not familiar with oesophagectomy problems. 

You will find contact telephone numbers at the end of this leaflet. 

Stress, anxiety and depression (CLICK to expand)

Useful contacts for further information

See link to our linked organisations page.

Your points of contact

Upper Gastrointestinal Nurse Specialists (Monday-Friday 9am-5pm)

Angela Longe and Tamara Taylor  Tel: 01603 288865

Surgeons: (Monday-Friday 9am-5pm)

Mr Michael Lewis FRCS                 Tel: 01603 287583

Mr Bhaskar Kumar FRCS               Tel: 01603 286418

Ms Loveena Sreedharan FRCS     Tel: 01603 287367

Mr Nick Penney FRCS                   Tel: 01603 286418

Mr Suheelan Kulasegaran              Tel: 01603 286418                          

* In an emergency please contact your GP or 999.