Essential Total Gastrectomy Diet Tips: What to Eat After Stomach Removal for Fast Recovery

A total gastrectomy, the surgical removal of the entire stomach, is a life-altering procedure often necessary for treating stomach cancer. While it allows patients to continue swallowing, eating, and digesting food, it requires significant adjustments to dietary habits to ensure proper nutrient absorption and overall health. This article provides a comprehensive guide to navigating the dietary changes following a total gastrectomy, drawing upon expert recommendations and practical advice to help patients thrive in their survivorship.

Understanding Gastrectomy and its Impact on Digestion

Gastrectomy involves the partial or total removal of the stomach. A partial gastrectomy removes a portion, usually the lower half, of the stomach, connecting the small intestine to the remaining section. A total gastrectomy, on the other hand, requires the surgeon to remove the entire stomach and connect the esophagus directly to the small intestine.

After a total gastrectomy, the digestive process is significantly altered. The stomach's roles in grinding food, storing large quantities, and gradually releasing food into the small intestine are lost. This necessitates a complete change in eating habits to compensate for these changes.

Immediate Post-Operative Diet: Healing and Reintroduction of Foods

In the initial days following surgery, the focus is on allowing the digestive system to heal. The diet typically begins with clear liquids, such as broth, gelatin, and clear juices, sipped slowly and frequently to minimize nausea and discomfort. As tolerance improves, the diet progresses to full liquids, including milk products, protein shakes, strained smoothies, and smooth soups.

Around 1-2 weeks post-op, soft or pureed foods are gradually introduced, aiming for 5-6 small meals each day. It is crucial to chew food thoroughly to aid digestion. At this stage, portion sizes are very small, often less than 1/4 cup, or about the size of an egg, as the opening that allows food to pass out of your stomach is also very narrow. Taking only two to three sips or bites at a time of any new food and then waiting 10 minutes before taking more will help you learn your limits and tolerance. Overeating or eating too quickly may cause nausea or pain.

Dietary Guidelines for Long-Term Management

Frequency and Size of Meals

One of the most critical adjustments after a total gastrectomy is eating smaller, more frequent meals. Aim for six to eight small meals a day, spaced every two to three hours. Without a stomach to hold large portions, smaller meals prevent overwhelming the digestive system and aid in nutrient absorption.

Calorie and Protein Intake

Consuming enough calories and protein is vital for healing and maintaining weight after surgery. Weight loss is common, especially in the first few months, due to reduced food intake and altered absorption.

Calories: Prioritize nutritious, high-calorie, low-sugar foods to maximize each bite's nutritional value. Nutrient-dense liquids can also provide needed calories and are sometimes easier to consume than solid foods.
Protein: Aim for a minimum of 65 to 75 grams of protein a day to preserve muscle tissue. High-protein foods include eggs, meats, fish, seafood, tuna, poultry, soy milk, tofu, cottage cheese, yogurt, and other milk products.

Food Choices and Tolerances

Eating a variety of foods is essential to ensure a balanced intake of nutrients. However, some foods may be poorly tolerated after a gastrectomy.

Fruits and Vegetables: Include a variety of fruits and vegetables, both cooked and raw, but introduce raw and high-fiber or gas-producing foods gradually, as these may cause discomfort.
Whole Grains: Incorporate whole grains for added nutrients and fiber, but be mindful of portion sizes to avoid feeling overly full.
Protein-Rich Foods: Choose lean protein sources and prepare them in a way that is easy to digest.
Dairy: Dairy products can be a good source of calcium and protein, but some individuals may develop lactose intolerance after surgery. If lactose intolerance occurs, try lactose-free products or smaller amounts of dairy.

Fluids

Proper hydration is crucial, but the timing of fluid intake needs adjustment.

Drink between meals: Avoid drinking liquids within a half hour before you eat and up to an hour after you eat. Fluids fill up your stomach quickly. They also move food even more quickly into the small intestine.
Stay hydrated: Drink at least 8 cups (1.9 liters) of fluids a day to avoid dehydration. All decaffeinated, sugar-free liquids (except alcohol) can count towards your fluid goal. Don’t wait until you feel thirsty to drink.

Supplements

Due to altered absorption, vitamin and mineral deficiencies are common after a total gastrectomy. The American Society for Metabolic and Bariatric Surgery (ASMBS) has established guidelines to prevent micronutrient deficiencies after stomach surgery, including gastrectomy.

Multivitamin: Take a bariatric formulated multivitamin every day.
Calcium Citrate: Take 1,200 to 2,000 mg of calcium daily to prevent calcium deficiency and bone disease. Calcium citrate is the form of calcium that can be absorbed without stomach acid. To enhance absorption, take the calcium in two to three divided doses throughout the day - for example, a 500 to 600 mg supplement taken three times a day.
Vitamin D: This total amount should be taken in divided doses of 400 to 500 IUs twice a day. Vitamin D should be taken with your calcium supplement.
Vitamin B12: If all of your stomach was removed, you need to have regular shots, or injections, of vitamin B12. Take 500 mcg of vitamin B daily.
Iron and Folic Acid: Some patients need additional folic acid or iron supplements, particularly women who are still menstruating.

Addressing Common Post-Gastrectomy Issues

Dumping Syndrome

Dumping syndrome is a common complication after gastrectomy, occurring when food passes too quickly into the small intestine. This can lead to a range of symptoms, including nausea, diarrhea, sweating, flushing, weakness, dizziness, palpitations, and abdominal pain.

Early Dumping Syndrome: Usually happens within 15-60 minutes of eating and can be triggered by eating or drinking a large portion at once, eating and drinking at the same time, or by ingesting food or drinks high in added sugar.
- Management: If you experience early dumping, sit upright in a chair or lie with the head of the bed at a 30-degree incline to slow the movement of food through your intestine. Examples include unsweetened yogurt, unsweetened peanut butter or unsweetened protein drink.
Late Dumping Syndrome: Occurs 1-3 or more hours after eating too much carbohydrate or added sugar. Your body quickly absorbs the carbohydrate or sugar, causing your blood sugar levels to rise quickly. When your blood sugar rises quickly, your body produces a lot of insulin (the hormone that regulates your blood sugar).
- Management: Avoid foods high in added sugar and refined carbohydrates.

Bile Reflux

Without a stomach, you do not produce stomach acid, so you will not have acid reflux. However, you are at risk of bile reflux. Bile reflux is when bile, the digestive liquid produced by your liver, backs up into your esophagus (the tube between your mouth and the rest of your digestive tract).

Management: Sleep with your head elevated at least 30 degrees, about 6 inches or more. You may want to purchase a wedge pillow to use at home. Maintain good posture and avoid leaning forward at the waist. If bile reflux continues despite taking these physical steps to avoid it, you may need medication.

Early Satiety and Anorexia

Early Satiety: Feeling full quickly. As your body adapts after surgery, you will gradually be able to increase portion sizes to child-size meals.
Anorexia: Not feeling hungry. After gastrectomy, your body does not have the usual signals to tell you to eat. If it has been more than two hours since your last meal or snack, nausea may be a hunger signal.

Dehydration

Dehydration can lead to constipation, electrolyte imbalances, fatigue, dizziness, confusion, and nausea.

Management: Talk to your dietitian about your fluid goal. Don’t wait until you feel thirsty to drink. All decaffeinated, sugar-free liquids (except alcohol) can count towards your fluid goal. If you think you are dehydrated, drink sugar-free fluids with electrolytes such as sugar-free sports drinks. Contact your health care team if you are unable to drink enough fluids to stay hydrated or if you experience severe dehydration.

Food Intolerances

After surgery, you may develop food intolerances you did not have before. Common intolerances include sugar, fat, and lactose. Identifying and managing these intolerances through dietary adjustments is crucial for comfort and nutrient absorption.

Adapting to the New Normal: Tips for Success

Eat Slowly and Chew Thoroughly: Since the stomach is no longer there to do the grinding and breakdown of food, it is important that patients take small bites and thoroughly chew the food.
Maintain a Food Diary: Record what you are eating and drinking, the amount, and any symptoms you have. Bring your food diary to follow-up appointments after surgery.
Weigh Yourself Regularly: Tracking your weight can help you identify potential problems early on.
Seek Professional Guidance: Consult with a registered dietitian or nutritionist to develop a personalized eating plan that meets your specific needs and addresses any challenges you may be facing.
Stay Active: Engage in regular physical activity to maintain strength and energy levels.

Sample Meal Plan (First 6-8 Weeks After Total Gastrectomy - Phase 1)

This example has at least 1500 calories and 100 grams of protein.

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Breakfast: 2 eggs/1tsp.
2 oz.
2 oz.

(Note: This is a sample meal plan and should be adjusted based on individual needs and tolerances.)

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