Republic of the Philippines

University of Northern Philippines

Tamag, Vigan City

GASTRECTOMY

In Partial Fulfillment of the Requirements

in NCM 104 (RLE)

Submitted to:

Marilou Asistin, R.N., MAN

CLINICAL INSTRUCTOR

Submitted by:

Rey Cris P. Adora

BSN IV-E

September 5, 2010
Gastrectomy Overview

Gastrectomy is the surgical removal of all or part of the stomach. This surgery is
performed as a treatment for stomach cancer and may also be indicated for a bleeding
gastric ulcer, a perforation (hole) in the stomach wall, and noncancerous polyps.
The stomach plays such a large role in digestion that it may be hard to believe that this
organ can be removed. Yet, a person can adjust to living without a stomach.
The stomach connects to the esophagus (tube that carries food from the mouth) on one
end and the small intestine (primary site of nutrient absorption) on the other end. When
part of the stomach is removed, the remaining portion continues its digestive function. If
the entire stomach is removed, the esophagus is attached to the small intestine, the
digestive process begins in the small intestine, and the body eventually adapts. Dietary
changes may be necessary.

Disadvantages

After having some, or all, of your stomach removed, it is possible to continue to eat a
normal diet. However, there are some disadvantages associated with a gastrectomy. These
are outlined below.

Vitamin deficiency
One of your stomach's functions is to absorb vitamins - particularly vitamin B12, vitamin C
and vitamin D - from the food that you eat.
If all of your stomach has been removed, you may not be getting all of the vitamins that
your body needs from your diet. This may lead to the development of certain health
conditions, such as those that are listed below.
 Anemia - the body requires vitamin B12 to help make healthy blood cells; without
enough healthy blood cells you could develop symptoms of anaemia, such as tiredness
and breathlessness.
 Increased vulnerability to infection - vitamin C helps to strengthen your immune
system. If you do not have enough vitamin C in your diet, you may find that you
develop frequent infections, and wounds and burns will take longer to heal.
 Brittle bones (osteoporosis) and weakened muscles - your body requires vitamin D to
help keep both your bones and muscles healthy and strong. If there is not enough
vitamin D in your diet, you could develop pain and weakness in your bones and
muscles.
 It may be possible to compensate for the loss of your stomach's ability to absorb
vitamins by making changes to your diet. For example, oily fish is high in vitamin D,
oranges are high in vitamin C, and meat, eggs and dairy products are high in vitamin
B12.
 However, even after changing your diet, you may still be required to take regular
vitamin supplements. This will usually be in the form of regular injections of vitamin
B12, which can be harder for your body to absorb from food compared with other
vitamins. See the 'recovery' section for more information about diet and
supplements.
Weight loss
Immediately after surgery, you may find that even eating a small meal makes you feel
uncomfortably full. This could mean that you experience weight loss. While losing weight
may be desirable if you have undergone a gastrectomy because you are obese, weight loss
can present a health risk to people who have been treated for stomach cancer.
Some people who have a gastrectomy find that they regain weight once they have adjusted
to the after effects of the surgery and have made changes to their diet. However, if you
continue to lose weight you should visit a dietitian who will be able to give you advice about
how you can increase your weight without upsetting your digestive system.

Dumping syndrome
Dumping syndrome is a term that is used to refer to a set of symptoms that can affect
people after a gastrectomy. It is caused when particularly sugary or starchy food moves
suddenly into your small bowel.
Before having a gastrectomy, your stomach would have digested most of the sugar and
starch. However, after surgery, your stomach is no longer able to perform this role, so
your small bowel has to draw in water from the rest of your body in order to help to break
down the food.
The amount of water that enters your small bowel can be as much as 1.5 litres (three
pints). Much of the extra water is taken from your blood, which means that you will
experience a sudden fall in blood pressure. The drop in blood pressure can cause symptoms
that include:
 faintness,
 sweating,
 palpations, and
 you may need to lie down.
The extra water in your small bowel will also cause symptoms such as:
 bloating,
 rumbling stomach,
 nausea,
 indigestion, and
 diarrhoea.
If you experience dumping syndrome, you may find it useful to rest for 20-45 minutes
after eating a meal. You can also ease the symptoms of dumping syndrome by:
 eating slowly,
 avoiding sugary foods, such as cakes, chocolate, and sweets,
 slowly adding more fibre to your diet,
 avoiding soup and other liquid-type foods, and
 eating smaller, more frequent meals.
Most people find that the symptoms of dumping syndrome improve over time. Only 5% of
people still experience symptoms of dumping syndrome a year after having a gastrectomy.

Morning vomiting
Following a partial gastrectomy, a small number of people may experience morning vomiting.
Vomiting occurs when bile and digestive juices build up in your duodenum overnight and
then spill back into what remains of your stomach. Due to its reduced size, your stomach is
likely to feel uncomfortably full, and it will trigger a vomiting reflex in order to get rid of
the excess fluids and bile.
Taking indigestion medication, such as aluminium hydroxide, may help to reduce the
symptoms of morning vomiting. However, you should see your GP if your symptoms become
particularly troublesome.

Diarrhea
Sometimes, during a gastrectomy, it is necessary to cut a nerve called the vagus nerve.
The vagus nerve helps to control the movement of food through your digestive system.
Although the nerve will heal after surgery, a small number of people will experience bouts
of severe diarrhoea. However, the bouts will usually only occur intermittently and should
pass within a day or so.
Taking an anti-diarrhoea medication, such as loperamide, in the morning, may help to
reduce your symptoms.

Gastrectomy Surgical Procedure

General anesthesia is used to render the patient unconscious, so they do not experience
pain and have no awareness during the operation. When the anesthesia has taken effect, a
urinary catheter is usually inserted to monitor urine output. A nasogastric tube (i.e., a thin
tube from the nose down into the stomach) is also put in. The abdomen is then cleansed
with an antiseptic solution.

The surgeon makes a large incision from just below the breastbone to the navel. If the
lower end of the stomach is diseased, the surgeon places clamps on either end of the area
and that portion of the stomach is removed. The upper part of the stomach is then
attached to the small intestine.

If the upper end of the stomach is diseased, the end of the esophagus and the upper part
of the stomach are clamped. The affected portion is removed, and the lower part of the
stomach is attached to the esophagus.

In a total gastrectomy, clamps are placed on the end of the esophagus and the end of the
small intestine. The stomach is removed and the esophagus is joined to the intestine.
Lymph nodes, a section of the pancreas, and the spleen are often removed in cases of
cancer.

The abdomen is sutured. The nasogastric tube remains in place and is removed during the
postoperative period. Surgery generally takes between 1 and 3 hours, depending on the
diagnosis and the extent of the disease.

Gastrectomy Preoperative Procedures

Prior to surgery, patients undergo preoperative testing, which may include x-rays, CT
scans, ultrasonography, blood tests, urinalysis, and an EKG.
Medications that "thin" the blood, such as aspirin, are discontinued several days prior to
the operation. Other drugs, such as insulin for diabetes, may be withheld the day of
surgery. As soon as the decision to undergo surgery is made, medication usage should be
discussed with the physician.
The stomach must be completely empty before the operation begins to avoid vomiting that
can occur during the procedure. Patients must abstain from solid food and liquid after
midnight on the evening before the operation.

Upon arrival at the hospital (usually the day before surgery), patients must sign an
informed consent form acknowledging that the procedure and risks have been explained
and that they are aware that they will receive anesthesia and possibly other medications.
The anesthesiologist (i.e., doctor who administers anesthesia) speaks to the patient prior
to surgery and performs a brief physical assessment. The anesthesiologist needs to know
about medications being taken, any history of allergies, and previous adverse reactions to
anesthesia. The patient's physical condition and history determines the choice and dosage
of anesthesia and whether special precautions need to be taken.

An intravenous (IV) is started in the patient's room or in the preoperative area. Sedation
is given by injection or through the intravenous to induce relaxation and cause drowsiness.
Anesthesia is administered in the operating room.

Postoperative Care after Gastrectomy

After gastrectomy surgery, most patients are taken to the postanesthesia care unit
(PACU) and are closely monitored by the nursing staff until the anesthesia wears off. They
may spend several hours in the PACU, depending on how quickly they recover from the
surgery. When they are stable, they are transferred to their room.

Some patients need closer monitoring and attention. Those who are having respiratory
problems, those who were very ill prior to the operation, and those who developed
complications during the procedure are taken to the surgical intensive care unit until they
are stable enough to be transferred to their hospital room.

Upon waking from anesthesia, patients have an intravenous line, a urinary catheter, and a
nasogastric tube. They are not allowed to eat or drink immediately following surgery.
Oxygen may also be delivered through a plastic mask that fits over the mouth and nose, or
through nasal prongs. Patients experience pain from the incision and medication is
prescribed to provide relief. Pain medication is usually delivered intravenously.

Intensive care patients are connected to a monitor that measures their heart rate and
breathing. Their blood pressure and blood oxygen level are continuously monitored. Some
patients require a respirator to breathe for them, and additional intravenous lines to
deliver medication and fluids.

Recovery is a gradual process. The nasogastric tube is attached to intermittant suction to

keep the stomach empty. If the entire stomach has been removed, the tube goes directly
to the small intestine and remains in place until bowel function returns. This generally
takes between 2 and 3 days and is determined by listening to the abdomen with a
stethoscope for bowel sounds (the passage of gas). A bowel movement also indicates
healing.

When bowel sounds return, clear liquids are offered. If they are tolerated, the
nasogastric tube is removed and the diet is gradually advanced from liquids to soft foods,
and then to more solid foods. Dietary adjustments may be necessary, as certain foods may
now be difficult to digest.

The urinary catheter is removed in a day or two, depending on recovery. When food and
liquid are tolerated, and urine output is normal, the catheter is removed. The intravenous
may also be removed, but it remains in longer if medications, such as antibiotics and
painkillers, have been prescribed.

The day after surgery, most patients can get out of bed. Getting up and moving around is
one of the best ways to prevent postoperative complications. Movement helps blood
circulation return to normal, decreases the risk for a blood clot, helps bowel function
normalize, and lowers the risk for lung infection. Getting out of bed can be painful and puts
pressure on the incision. Pain medication is prescribed and can be given before the patient
attempts to get up.

Diet may present a challenge, especially for those whose entire stomach was removed.
Food and liquids now enter the small intestine quickly, causing uncomfortable symptoms
that can usually be relieved by eating several small meals, eating more protein and less
sugar, and making other dietary changes. A nutritionist or dietician can help develop new
eating habits. The dietary changes may be temporary, until the digestive system adjusts,
or they may be permanent.

Vitamin B12 is absorbed in the stomach and must be supplemented with regular injections
by patients who underwent a total gastrectomy. Absorption may be impaired in those who
still have part of their stomach, so it is necessary to have B12 levels checked periodically.
Supplementation with folate, iron, and calcium may also be necessary to correct
deficiencies caused by the surgery.

The length of hospitalization varies. Full recovery may take several weeks or a few months,
especially if the patient has gastrointestinal problems such as diarrhea, which can be
debilitating. Recovery may also be prolonged by other treatments, such as chemotherapy.

Gastrectomy Postoperative Complications

Complications related to the surgical procedure or problems adjusting to an altered
digestive tract can occur.

Dumping syndrome is a common problem that occurs after gastrectomy. With all or much
of the stomach gone, food and fluids can pass too quickly into the small intestine, causing
symptoms including:
 Cramping
 Diarrhea
 Dizziness
 Nausea and vomiting
 Shortness of breath
 Sweating
Dumping syndrome may resolve on its own after a few months and is often be relieved by
dietary changes. Eating several small, frequent meals during the day, and eating foods
higher in protein and lower in carbohydrates usually relieves symptoms. If diarrhea and
vomiting worsen, the surgeon should be notified.
Other possible complications of gastrectomy include:
 Complications from general anesthesia (e.g., stroke, heart attack, brain damage)
 Infection at the incision site
 Internal bleeding
 Peritonitis (i.e., inflammation of the membranes lining the abdomen)
 Pernicious anemia (caused by vitamin B12 deficiently)
 Persistent nutritional and digestive problems
The surgeon should be notified if any of these symptoms appear:
 Fever of 101°F or higher
 Pain not relieved by medication or comfort measures
 Pain that worsens
 Redness, drainage, bleeding, or swelling at the incision site