Stomach removal surgery
A gastrectomy is a medical procedure where all or part of the stomach is surgically removed.
There are four types of gastrectomy:
total gastrectomy – the whole stomach is removed
partial gastrectomy – the lower part of the stomach is removed
sleeve gastrectomy – the left side of the stomach is removed
oesophagogastrectomy – the top part of the stomach and part of the oesophagus (gullet) is removed
The stomach is connected to the gullet (oesophagus) at its top and the first sections of the duodenum (small intestine) at its bottom. During the operation, the surgeon connects the oesophagus either to the small intestine or the remaining section of stomach. This means that you'll still have a working digestive system, although it won't function as well as it did before.
Why is a gastrectomy carried out?
A gastrectomy is often used to treat stomach cancer.
Less commonly, it's used to treat:
stomach ulcers (peptic ulcers)
After a gastrectomy
A gastrectomy is a major operation, so recovery can take a long time. You'll usually have to stay in hospital for one or two weeks after the procedure, where you may receive nutrition into a vein until you can eat and drink again.
You'll eventually be able to digest most foods and liquids. However, you may need to make changes to your diet, such as eating frequent, smaller meals rather than three large meals a day. You may also need vitamin supplements to ensure you're getting the correct nutrition.
In many cases, a gastrectomy is an effective operation. Studies show that survival rates for cancer after a gastrectomy are generally good. It's also been proven that people who have the operation to treat obesity lose a significant amount of weight afterwards.
Gastrectomy is usually an effective treatment for cancer and obesity.
Healthcare professionals use the phrase "five-year disease-free survival" to refer to people who are alive and well, and whose cancer hasn't returned five years after having surgery.
The five-year disease-free survival rate for people who have a gastrectomy for early-stage stomach cancer is estimated to be up to 90%.
The five-year disease-free survival rate for people who have a gastrectomy for advanced stomach cancer is estimated to be around 25%.
However, many people who have a gastrectomy for stomach cancer live for much longer than five years without the cancer returning.
The survival rate of oesophagogastrectomy to treat cancer isn't as good. Studies have shown five-year disease-free survival rates of around 25% for this type of operation. This may be because this operation is usually done if the cancer is discovered at a late stage and has already started to spread.
Sleeve gastrectomy has a good success rate for treating obesity.
Studies have found excess weight loss of up to 75% after surgery. Excess weight loss is a measurement based on your weight before surgery and your ideal weight.
Further research is needed to determine how effective sleeve gastrectomy is for the long-term treatment of obesity. Studies often show that average excess weight declines over time, which suggests that some people regain some of the weight they initially lost.
To get the best results from a sleeve gastrectomy, it's important to follow the instructions given by your healthcare team about diet and exercise.
As with any type of surgery, a gastrectomy carries a risk of complications, such as infection, bleeding and leaking from the area that's been stitched together.
A gastrectomy may also lead to problems caused by a reduction in your ability to absorb vitamins, such as anaemia and osteoporosis.
Why a gastrectomy is carried out
A gastrectomy can be used to treat a variety of conditions, including obesity and some types of cancer.
There are several types of gastrectomy that may be used, depending on the condition being treated.
A gastrectomy is one of the most effective ways of curing stomach cancer or slowing down the rate at which it spreads.
In most cases of stomach cancer, tumours are too large to be cured with non-surgical methods, such as chemotherapy orradiotherapy (although these treatments are sometimes used to help make surgery more successful).
However, removing some or all of the stomach can prevent cancer cells spreading to other parts of the body.
If you have small tumours in the lower part of your stomach, you may only need a partial gastrectomy. However, if you have larger tumours in the middle of your stomach, or if cancer cells have spread to nearby lymph nodes (small glands that are part of the immune system), it may be necessary to remove all of your stomach.
A gastrectomy isn't usually performed if the cancer has spread to other organs, such as the liver or lungs.
It may also be recommended if you develop a non-cancerous (benign) tumour in your stomach. Even though the tumour isn't cancerous, there's a risk it could become cancerous if it's not removed.
An oesophagogastrectomy may be used to treat oesophageal cancer (cancer of the gullet) when it's thought that the cancer may have spread from the oesophagus to the top of the stomach.
A sleeve gastrectomy can be used to treat people with potentially life-threatening obesity.
Potentially life-threatening obesity is defined as:
having a body mass index (BMI) of 40 or above
having a BMI of 35 or above and having another serious health condition that could be improved if you lose weight, such as type 2 diabetes or high blood pressure
Surgery involves reducing the size of the stomach by up to 75%, which means you can no longer eat large amounts of food, resulting in weight loss.
Sleeve gastrectomy is sometimes used when people are too obese to safely undergo other types of weight loss surgery, such as a gastric bypass.
Obesity surgery is usually only available if your obesity puts you at risk of developing life-threatening conditions, such as heart disease, and you've previously made significant efforts to lose weight with other methods.
A gastrectomy used to be a common treatment for stomach ulcers (peptic ulcers). Nowadays, other less invasive treatments are usually used instead.
A gastrectomy is only used to treat stomach ulcers in very rare cases, where they fail to respond to other treatments.
How a gastrectomy is performed
There are different types of gastrectomy, depending on which part of your stomach needs to be removed.
Types of gastrectomy
There are four main types of gastrectomy, all carried out under general anaesthetic (where you're unconscious):
During a partial gastrectomy, the surgeon makes a cut in your abdomen (tummy) before removing the lower half of your stomach.
If you have stomach cancer, nearby lymph nodes are also usually removed, as there's a risk the cancer may have spread to the nodes.
Your surgeon then stitches the upper part of your stomach to your small intestine.
During total gastrectomy, your surgeon makes a cut in your abdomen before removing your stomach. They will then connect your oesophagus (the tube between your throat and stomach that food passes down) directly to your small intestine.
During sleeve gastrectomy, the surgeon makes a cut in your abdomen before removing the left side of your stomach. This can reduce your stomach's volume by up to 75%, and is usually performed using keyhole surgery.
The remaining part of your stomach is pulled upwards and resealed using stitches. This creates a much smaller and longer stomach that looks like a banana.
An oesophagogastrectomy is used to remove the upper section of the stomach and part of the oesophagus.
The lower part of your stomach is pulled upwards and attached to the end of your oesophagus.
Techniques for gastrectomy
Two different techniques can be used to carry out gastrectomy:
open gastrectomy – where a large cut is made in your abdomen or chest
keyhole surgery (laparoscopic gastrectomy) – where several smaller cuts are made and special surgical instruments are used
A laparoscopic gastrectomy is also sometimes known as a laparoscopically assisted gastrectomy (LAG).
Open vs keyhole surgery
There are pros and cons of each type of surgery. People who have keyhole surgery usually recover quicker and have less pain after the procedure than those who have an open gastrectomy. You may also be able to leave hospital slightly earlier. Complication rates after keyhole surgery are similar to those for open gastrectomies.
Keyhole surgery is an advanced surgical technique requiring specialised training and equipment. The operation may take longer if it's carried out using keyhole surgery.
Open gastrectomies are usually more effective in treating advanced stomach cancer compared with keyhole surgery. This is because it's usually easier to remove affected lymph nodes (small glands that are part of the immune system) during an open gastrectomy.
Before you decide which procedure to have, discuss the advantages and disadvantages of both techniques with your surgeon.
Recovering from gastrectomy
A gastrectomy is a serious operation and recovery can take a long time.
After the operation
After having a gastrectomy, you may be fitted with a nasogastric tube for about 48 hours. This is a thin tube that passes through your nose and down into your stomach or small intestine. This will allow fluids produced by your stomach to be regularly removed, which will stop you feeling sick.
You'll also have a catheter placed in your bladder. This is to drain and collect urine, as your mobility will be reduced and passing urine may be more difficult while you recover.
Until you can eat and drink normally, nutrition will be supplied through a tube inserted directly into a vein (intravenously) or through a tube inserted through your abdomen (tummy) into your bowel. Most people can begin eating a light diet about a week after having a gastrectomy.
After the operation, you'll need to take painkillers for a few days. Tell your treatment team if the painkillers you're taking don't work, because alternative painkillers are available. You'll probably be able to return home one to two weeks after having a gastrectomy.
Adjusting to a new diet
Whatever type of gastrectomy you have, you'll need to make changes to your diet. It may be months before you can return to a more normal diet. A dietitian should be able to help you with this adjustment.
Food or drink you enjoyed before the operation may give you indigestion. You may find it helpful to keep a food diary to record the effects that certain types of food have on your digestion.
You'll probably have to eat smaller meals more frequently for a fairly long time after having a gastrectomy. However, over time your remaining stomach and small intestine will stretch and you'll gradually be able to eat larger, less frequent meals.
The Oesophageal Patients Association (OPA) has produced a guide to life after stomach surgery (PDF, 605kb), containing lifestyle advice for people after they've had a gastrectomy.
Avoid eating high-fibre foods immediately after having a gastrectomy, as they'll make you feel uncomfortably full. High-fibre foods include:
wholegrain bread, rice and pasta
pulses – which are edible seeds that grow in a pod, such as peas, beans and lentils
oats – found in some breakfast cereals
Over time, you'll be able to gradually increase the amount of fibre in your diet.
Vitamins and minerals
If you've had a partial gastrectomy, you may be able to get enough vitamins and minerals from your diet by eating foods that are high in these nutrients. In particular, eat foods that are high in calcium, iron, vitamin C and vitamin D.
If you've had a total gastrectomy, you may be unable to get enough iron, calcium, vitamin C and vitamin D from your diet, so you may require additional supplements.
Some people who have had a partial gastrectomy, and most people who have had a total gastrectomy, need regular injections of vitamin B12. This vitamin is difficult to absorb from food if your stomach has been removed.
After a gastrectomy, you'll need regular blood tests to check you're getting the correct amount of vitamins and minerals in your diet. If you don't have the correct nutrition, you can develop problems such asanaemia.
Complications of gastrectomy
As with any type of surgery, a gastrectomy carries a risk of complications. Problems can also occur because of changes in the way you digest food.
Gastrectomies to treat stomach cancer have a higher risk of complications, because most people who have this type of surgery are elderly and often in poor health.
Complications can also occur after a gastrectomy to treat oesophageal cancer. The oesophagus is the tube connecting your throat to your stomach.
Possible complications of a gastrectomy include:
leaking from where the stomach has been closed or reattached to the small intestine
stricture – where stomach acid leaks up into your oesophagus and over time causes scarring, leading to the oesophagus becoming narrow and constricted
blockage of the small intestine (small bowel)
An infection can usually be treated with antibiotics, but some other complications will require further surgery. Before your operation, ask your surgeon to explain the possible risks and how likely they are to affect you.
It's estimated that around 2 in 100 people who have a gastrectomy for cancer die from complications.
Possible complications of a gastrectomy for obesity include:
nausea and vomiting – which usually get better over time
internal bleeding – which can lead to blood clots forming
leaking from where the stomach has been closed
acid reflux – where stomach acid leaks back up into the oesophagus
It may be possible to treat some complications with medication, but others may need further surgery. Before your operation, ask your surgeon to explain the possible risks and how likely they are to affect you.
The risk of death from a gastrectomy for obesity is very low, estimated as less than 1 in 100.
One function of your stomach is to absorb vitamins, particularly vitamins B12, C and D, from the food you eat.
If your entire stomach has been removed, you may not get all the vitamins your body needs from your diet. This may lead to certain health conditions, such as:
The body requires vitamin B12 to 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 (the body's natural defence against infection and illness). If you don't have enough vitamin C in your diet, you may develop frequent infections. Wounds or burns will also take longer to heal.
Brittle bones and weakened muscles
Your body needs vitamin D to keep both your bones and muscles strong and healthy. If there isn't enough vitamin D in your diet, you could develop pain and weakness in your bones (osteoporosis) and muscles.
Changing your diet may help to compensate for your stomach's inability to absorb vitamins. However, even after changing your diet, you may need vitamin supplements. The healthcare professionals treating you can advise on this.
Immediately after surgery, you may find that eating even a small meal makes you feel uncomfortably full. This could lead to weight loss. Losing weight may be desirable if you've had a gastrectomy because you're obese, but it can be a health risk if you've been treated for cancer.
Some people who have a gastrectomy regain weight once they have adjusted to the effects of surgery and have changed their diet. However, if you continue to lose weight, see a dietitian (a healthcare professional who specialises in nutrition). A dietitian can give you advice on how to increase your weight without upsetting your digestive system.
Dumping syndrome is a set of symptoms that can affect people after a gastrectomy. It's caused when particularly sugary or starchy food moves suddenly into your small intestine.
Before a gastrectomy, your stomach digested most of the sugar and starch. However, after surgery your stomach can no longer do this, so your small intestine has to draw in water from the rest of your body to help break down the food.
The amount of water that enters your small intestine can be as much as 1.5 litres (3 pints). Much of the extra water is taken from your blood, which means you will experience a sudden fall in blood pressure.
The drop in blood pressure can cause symptoms such as:
a need to lie down
The extra water in your small intestine will cause symptoms such as:
If you have dumping syndrome, resting for 20-45 minutes after eating a meal may help. To ease the symptoms of dumping syndrome:
avoid sugary foods – such as cakes, chocolate and sweets
slowly add more fibre to your diet
avoid soup and other liquid foods
eat smaller, more frequent meals
Seek advice from your hospital team or dietitian if you have symptoms of dumping syndrome. For most people, the symptoms improve over time.
After a partial gastrectomy, a small number of people may experience morning vomiting.
Vomiting occurs when bile (a fluid used by the digestive system to break down fats) and digestive juices build up in your duodenum overnight, before spilling back into what remains of your stomach. The duodenum is the first part of your small intestine.
Due to its reduced size, your stomach is likely to feel uncomfortably full and this will trigger a vomiting reflex 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. See your GP if your symptoms are particularly troublesome.
During a gastrectomy, it's sometimes 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 vagus nerve will heal after surgery, a small number of people will experience bouts of severe diarrhoea. However, they usually only occur now and again, and should pass within a day or so.
Taking diarrhoea medication, such as loperamide, in the morning may help to reduce your symptoms.
Stomach removal surgery