47 yo M with Full Gastrectomy for Cancer Prevention

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    • #17125
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      Full Gastrectomy for Cancer Prevention – Advice Regarding Appropriate Diet and Supplementation

      47 year old female, history of double mastectomy, reconstructive surgery, Job’s disease. Both parents died of cancer. Prophylactic oophorectomy and gastrectomy advised by doctor. Client requires a nutritional program/advice following gastrectomy scheduled for next week.

      Medications: tamoxifen, clomipramine.

      Specifically need advice re., protein and mineral supplements that can be absorbed directly in to small intestine.

      Posted by Penny Priestley

    • #17127

      Hello Penny,

      Thank you for posing this complicated case here. I’m glad this woman has come to you for additional support with her health and post-surgery dietary management.

      I have not encountered anyone with a prophylactic gastrectomy, although I am assuming that one of her parents may have had an aggressive gastric cancer with a genetic association – an germline mutations in the E-cadherin (CDH1). In such settings the prophylactic total gastrectomy, despite its high level of potential complications, is a recommendation as the mortality risk is more than 80% at a young age with this genetic mutation. If such patients reject preventive total gastrectomy recommendations, they must be followed-up intensively by endoscopy every 6-12 months.

      Lewis FR, et al. Prophylactic total gastrectomy for familial gastric cancer. Surgery. 2001 Oct;130(4):612-7; discussion 617-9. http://tinyurl.com/z4fwcvl
      Schwarz A, et al. Preventive gastrectomy in patients with gastric cancer risk due to genetic alterations of the E-cadherin gene defect. Langenbecks Arch Surg. 2003 Mar;388(1):27-32. http://tinyurl.com/ju8k64e

      There are many different stages of recovery after such a surgery, and many potential complications of infection and gastrointestinal problems to consider when working with this client. I am sure that she has been given very specific directions to follow prior to this surgery by her surgical team potentially including a bowel prep and antibiotic prophylaxis. She also may have some specific guidelines for the acute time after this surgery.

      There are many variations of reconstruction after this surgery to attempt to create a reservoir in replacement of the stomach which was removed. Some aspect of pouch reconstruction appears to have better functional outcomes and improved quality of life compared with other types of reconstruction. Patients who had a gastric pouch reconstruction had a significantly decreased incidence of dumping syndrome (10.3 versus 19.6 percent), and improved quality of life compared with patients who did not undergo pouch reconstruction. Pouch reconstruction did not increase the incidence of adverse events or mortality or morbidity. In one trial, patients with pouch reconstruction regained preoperative quality of life within two years of their gastrectomy, compared with five years for those without pouch reconstruction.

      Gertler R, et al. Pouch vs. no pouch following total gastrectomy: meta-analysis and systematic review. Am J Gastroenterol. 2009 Nov;104(11):2838-51. http://tinyurl.com/j585wq6
      Fein M, et al. Long-term benefits of Roux-en-Y pouch reconstruction after total gastrectomy: a randomized trial. Ann Surg. 2008 May;247(5):759-65. http://tinyurl.com/jgx6xws

      Small intestinal reconstruction techniques attempt to preserve propulsion initiated by the duodenal pacemaker maintain antegrade flow of duodenal contents into jejunum. This also helps to maintain physiologic regulation of gastrointestinal hormones.

      Schwarz A, et al. Importance of the duodenal passage and pouch volume after total gastrectomy and reconstruction with the Ulm pouch: prospective randomized clinical study. World J Surg. 1996 Jan;20(1):60-6; discussion 66-7. http://tinyurl.com/z5tkwtw

      Patients are usually initially maintained on intravenous fluids and are not given anything to eat by mouth after the surgery. Standard enteral feeding can be initiated two to three days postoperatively and advanced according to the patient’s tolerance. After validating that there are no “leaks” internally at the surgical junction, they are started on foods by mouth. Oral feeding begins with a liquid diet and advances to a soft diet over 24 to 48 hours as tolerated.

      With the initiation of oral foods, there are dietary recommendations that help to minimize problems. Small frequent meals, high in protein and inclusive of fat, should be consumed approximately six times per day. Liquids may need to be taken separately from solids. Meals high in simple carbohydrates may contribute to dumping syndrome and may need to be avoided. Vitamin and mineral supplementation are also required, and weight loss is common.

      Dumping syndrome, or rapid gastric emptying is a state where ingested foods bypass the stomach very rapidly and enter the small intestine largely undigested. When this happens small intestine expands too quickly due to the presence of hyperosmolar contents, leading to a fluid shift into the gut lumen with plasma volume contraction and acute intestinal distention. There may be both “early” and “late” symptoms of this after a meal.

      Dumping syndrome is diagnosed clinically by typical symptoms. Early symptoms include diaphoresis, palpitations, and flushing 15 to 30 minutes after a meal, while late symptoms (similar symptoms) are 1 – 3 hours after meals. Late symptoms are possibly associated with hypoglycemiafollowing a postprandial insulin peak rather than hyperosmolarity. This syndrome often occurs after the more common gastric bypass (Roux-en-Y) surgery.

      There are many other potential complications that all should have some familiarity with when working with such a client. With some general familiarity if signs and symptoms of problems which may come up you will have a better understanding of when this client should be referred back to her gastroenterologist for further investigation. Chronic dysmotility symptoms should be worked up with an abdominal CT and upper endoscopy.

      Potential issues are anastomotic complications (leak, stricture, ulceration), or post-gastrectomy obstruction. Fortunately, symptoms suggestive of most of these usually manifest in the first two weeks after surgery and your client should still be closely followed by her gastroenterologist at this time. A leak will manifest with symptoms of acute infection, a stricture or obstruction presents with digestive symptoms which likely include nausea and vomiting, while a marginal ulcer presents with nausea, pain, bleeding and/or perforation. Longer term, many of the same risk factors for gastric ulcers apply (Helicobacter pylori infection, smoking, NSAID use), and such may occur at any time subsequent to the procedure.

      The most common symptom that post-gastrectomy patients with rapid transit report is diarrhea. In the post-gastrectomy period, diarrhea may be due to dumping syndrome or post-vagotomy diarrhea. The later issue, post-vagotomydiarrhoea, may occur if the hepatic and coeliac branches of the anterior and posterior vagal nerves are not preserved during the surgical procedure. There is also an increased risk of gallstone formation if the vagus nerve is not preserved appropriately.

      Nunobe S, et al. Laparoscopy-assisted pylorus-preserving gastrectomy: preservation of vagus nerve and infrapyloric blood flow induces less stasis. World J Surg. 2007 Dec;31(12):2335-40. http://tinyurl.com/hxy4vwg

      Most patients with dumping syndrome can be treated conservatively with dietary changes to include frequent small meals that are high in fiber and protein and low in carbohydrates as well as separation of liquid from solid during meals. Symptoms tend to resolve in most patients as they learn to avoid foods that aggravate the problem (eg, simple sugar). There are medications which may be used if dietary changes are not helpful, but these are rarely required. If the vagus nerve is not preserved with the surgery this also may present with diarrhea. If such is the case there may be need for a medication which binds bile salts and is called cholestyramine.

      Eagon JC, et al. Postgastrectomy syndromes. SurgClin North Am. 1992 Apr;72(2):445-65. http://tinyurl.com/hf9ux5p

      On the other end of the spectrum, gastric stasis can occur after a gastrectomy. This may be due to postsurgical atony, vagal denervation, or from a small gastric remnant following surgical resection. Symptoms may include early fullness, vomiting, pain, and weight loss. Again, sometimes these will improve with small, frequent feedings and time to allow the remnant stomach to accommodate. Prokinetic agents such as metoclopramide and erythromycin also may improve gastric atony.

      Gastric or duodenal ulcers can recur because of surgical or other common medical reasons as previously mentioned. Vagal stimulation of gastric acid production may not completely be completely abolished, which results in hyperacidity and recurrent peptic ulcer. A small percentage of patients also develop alkaline reflux gastritis, a syndrome of persistent burning epigastric pain and chronic nausea that is aggravated by meals.

      After gastric bypass surgery, patients will no longer be able to digest and absorb sufficient amounts of B12 and must take B12 in a form that directly enters the bloodstream more directly as opposed to through the digestive tract. Decreased calcium absorption post gastric bypass also is common as calcium is better absorbed in an acidic environment and gastric acid exposure is reduced with this procedure. Iron deficiency also is one of the most common nutritional problems following bariatric surgery. In addition to diminished absorption of these as well as many other nutrients, nutritional deficiencies may occur in these patients due to low nutrient intake, poor food choices, food intolerances, excessive vomiting, and limited portion sizes. Chewable or liquid formulas of nutrients also may be better as her digestion is compromised especially initially.

      Bifidobacterium spp. is a predominant flora in the large intestine, and has been shown to help prevent enteric infection. Lactobacillus also is a primary flora isolated from the large intestine, and has been shown to moderate infection and inflammation.

      Fukuda S, et al. Bifidobacteria can protect from enteropathogenic infection through production of acetate. Nature 2011 Jan;469(7331):543-547. http://tinyurl.com/kp5sys7
      Liévin-Le Moal V, Servin AL. Anti-Infective Activities of Lactobacillus Strains in the Human Intestinal Microbiota: from Probiotics to Gastrointestinal Anti-Infectious Biotherapeutic Agents. ClinMicrobiol Rev. 2014 Apr;27(2):167-99. http://tinyurl.com/pfaghxv

      Butyrate has been shown to promote healthy large intestinal flora and protect the mucosa from mechanical and chemical damage, as well as improve tissue integrity. A thorough article about the use of SCFAs for the management of colonic inflammation has been written by Michael Ash, and can be found on the Nutri-Link Clinical Education website http://tinyurl.com/odk2g3u

      Bloemen JG, et al. Butyrate enemas improve intestinal anastomotic strength in a rat model. Dis Colon Rectum 2010 Jul;53(7):1069-1075. http://tinyurl.com/n6cmrbd

      Obviously as your client is just going into this procedure, it is impossible to ascertain to what level she will experience gastrointestinal dysfunction in the future, but starting with the general recommendations of a gradual transition to solids, small meals, carbohydrate/sugar avoidance, separating solids from liquids, and supplementation with a multivitamin/mineral to include vitamin D is important. Later into recovery gradually increasing fiber (in soft food form) can be considered but initially it should be limited to 2g per meal.

      As time goes by subsequent to the surgery there definitely are other things that can be considered to improve gastrointestinal symptoms much like other chronic gastrointestinal case. Supporting healthy flora with a probiotic, as well as digestion with enzymes, and possibly colon health with butyrate would be further things to consider. Although the thought to include stomach acid replacement with betaine HCl may be intuitive, this should be avoided due to the common complication of a gastric ulcer.

      In the future (>6-12mo post procedure), you may wish to consider a comprehensive stool digestive analysis to determine how best to further support your client. Additionally, you may want to consider a comprehensive nutritional evaluation so you can better direct this support as well.

      Do see other discussions on the Clinical Education group pertaining to support post-gastrectomy, dumping syndrome, and Roux-en-Y gastric bypass surgery as these discussions offer insights on other considerations for your client as well – http://tinyurl.com/jc4m76v&http://tinyurl.com/gvj2kuf&http://tinyurl.com/jbvaggu.

      SUGGESTED SUPPLEMENTS

      The following supplements are suggested for you to consider in light of your relevant expertise and intimate understanding of the needs of your client or patient. They may be used in isolation or as part of a multi supplement strategy, but at all times the consideration of their use should be tied into the specific needs of the individual you are responsible for.

      • Aqueous Multi Plus (BRC): 1 – 2Tbsp daily. http://tinyurl.com/zkperuv

      • B12-2000 (BRC): 1 lozenge dissolved under the tongue daily. http://tinyurl.com/34rkax3

      • OsteoVi Min (ARG): 2 chewable tablets once a day. http://tinyurl.com/jvdmekeProvides additional calcium.

      • Vitamin D3 Complete (ARG): 1-2 tablets once a day.

      OR

      • Bio-D-Mulsion Forte (BRC): Consider 2 – 3 drops a day. Long term dosage to be determined by serum level. http://tinyurl.com/33a7ug8

      • Fe-Zyme (BRC): 1 tablet daily. http://tinyurl.com/kjz5so4

      • BioDoph-7 Plus (BRC): 1-2 per day with meals.http://tinyurl.com/36nr8fr. Contains inulin, multiple Lactobacillus and Bifidobacterium probiotic strains. Dose based upon tolerance and perception of benefit.

      • Caricol (ARG): 1 stick after meals. http://tinyurl.com/p5gjrkk. Supports normal digestive function.

      Please consider these suggestions in light of the other clinical information pertaining to this individual. If you have any more information about the specific problems this individual is experiencing, further refinement of these suggestions may be considered. I hope this information is helpful, and if you have any further questions or information specific to the problems this individual is experiencing, please do provide feedback.

      In health,
      Dr. Decker

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