Although you can eat by mouth after part or all of the stomach is removed, the amount you can eat and the way food moves through the digestive tract change. Large meals are replaced by smaller meals spread throughout the day, while weight and vitamin needs are monitored regularly.
Laparoscopic surgery uses a camera and instruments inserted through small incisions in the abdomen. The skin incisions are small. Inside, however, this is major surgery that involves reconnecting the digestive tract, so the recovery plan depends on how much has been removed, nutritional status and the need for further treatment.
How much of the stomach is removed?
Surgical removal of the stomach is called gastrectomy, and when the location and extent of the tumour allow, part of the stomach is preserved in a partial, or subtotal, gastrectomy. For some tumours in the lower part of the stomach, the affected section is removed and the remaining stomach is joined to the intestine so that food can pass through.
In a total gastrectomy, the entire stomach is removed and the oesophagus is joined to the small intestine. Food is no longer stored in the stomach. The choice of operation is not based solely on a wish to remove less tissue, because the aim is to remove the cancerous area without leaving tumour cells at the cut edges. For some patients, this requires removal of the whole stomach.
You can see how the different procedures are performed in the videos on partial gastrectomy and total gastrectomy. Both videos contain surgical footage intended for adults. The general approach is also explained on the laparoscopic surgery for stomach cancer page.
Why are lymph nodes removed?
Cancer cells can spread to the lymph nodes around the stomach, which are small tissue structures belonging to the body's immune system, so certain groups of lymph nodes are removed along with the tumour during surgery. This helps both to treat the disease and to establish more accurately how far it has spread.
The term D2 lymph node dissection refers to the removal of specific groups of lymph nodes around the stomach. It is not a cancer stage. The removed tissues are examined in a laboratory; findings about the depth of the tumour, spread to the nodes and the status of the cut edges influence decisions about further treatment.
Suitability for laparoscopic surgery is assessed according to the extent of the tumour and whether the operation can be performed safely. Sometimes open surgery through a larger incision is needed, or the surgeon switches to this approach during the procedure. The priority is to carry out the extent of surgery required by the cancer; the size of the incisions is no substitute for this.
The hospital stay and the first few days
A hospital stay of one or two weeks is often needed after removal of the stomach, although the extent of surgery and your individual recovery may shorten or lengthen this. The discharge date is decided individually. More important considerations are whether you can eat and drink, move around, manage pain with medication, and whether there are any complications.
In the first few days, if you cannot take enough fluid and food by mouth, support is given through a vein or a feeding tube. Progression to liquids, soft food and firmer foods follows the surgical team's plan. Another patient starting to eat sooner does not mean you should start at the same time.
Early movement with help from healthcare staff and breathing exercises are part of recovery. Staying in bed for a long time can increase the risk of blood clots in the leg veins and lung problems. Tiredness is expected, but increasing pain and breathlessness should not be treated as ordinary fatigue.
Possible complications include leakage from the new join, bleeding and infection. After discharge, fever, worsening abdominal or chest pain, repeated vomiting, inability to drink fluids and a rapidly deteriorating condition need urgent assessment. Sudden breathlessness, vomiting blood or loss of consciousness requires emergency medical care.
Eating habits and dumping syndrome
A plate of food you could comfortably eat before surgery may be too much afterwards. Eating small amounts, chewing slowly and having meals more frequently throughout the day can help you adjust to this change. Waiting until you feel hungry can sometimes mean you do not eat enough during the day.
Protein and energy are needed for healing. A dietitian, a specialist in nutrition, can adapt the type and amount of food to your needs, including foods such as eggs, fish, tender cooked meat and dairy products according to what you tolerate. Having most of your fluids between meals may reduce the feeling of fullness that comes on quickly; this does not mean reducing your overall fluid intake.
Food passing rapidly into the intestine can cause symptoms known as dumping syndrome. Abdominal cramps, bloating, diarrhoea, palpitations and dizziness may occur soon after eating. Sweating, trembling and weakness that occur later may be related to a drop in blood sugar. Not everyone experiences this.
Large portions and very sugary drinks may make symptoms worse. Splitting food into smaller meals and changing what you eat often helps; persistent symptoms may require further treatment. Keeping a record of which foods trigger symptoms and when they start makes them easier to discuss with your doctor, whereas severely restricting food out of fear can worsen weight loss and weakness.
B12 and long-term follow-up
The stomach produces a substance that helps the body absorb vitamin B12. After the whole stomach is removed, B12 replacement becomes an essential part of the long-term plan. It is often given by injection. Your doctor determines how and when it is given. Deficiency can also occur after partial gastrectomy.
Weight, anaemia, iron and other nutrient levels are monitored as needed. If swallowing becomes increasingly difficult, food gets stuck or weight loss continues, changing your diet alone may not be enough, because tests are needed to check for narrowing at the join or another problem. Follow-up appointments cover these symptoms as well as the plan for further cancer treatment and investigations.