Upper Tract Surgery
Surgery for the upper gastrointestinal (GI) tract is less common today. This is good news, avoiding the many physical and nutritional complications of surgery. Newer treatments for ulcers and gastroesophageal reflux disease (GERD) have been effective in treating serious cases that in previous years had required surgical intervention. However, for those whose disease does not respond to medication and lifestyle modifications, or for those who develop complications, surgery may be required.
Surgeries for Ulcer Disease
The use of powerful acid suppressing drugs such as proton pump inhibitors (PPIs) and the discovery of a treatable ulcer 'bug' (H. pylori bacteria), has greatly reduced the need for surgical treatment. Surgery is still required in some cases where an ulcer fails to heal or if complications occur. These are some of the more common surgical procedures for ulcer disease.
Description of Surgery
The vagus nerve (a nerve that transmits signals from the brain to the stomach and regulates stomach acid secretion) is cut to reduce the production of stomach acid. Newer procedures strive to leave part of the vagus nerve intact while cutting only the portion that controls the acid secreting cells of the stomach.
Stomach emptying may be impaired. Iron deficiency can result from decreased acid secretion. Diarrhea and dumping syndrome (food is released too rapidly from the stomach into the intestine) may occur. Risk of gallstones may be increased following gastric surgery.
Description of Surgery
The lower part of the stomach (antrum) is removed. The antrum produces a hormone that stimulates stomach acid secretion. Vagotomy is often done in conjunction with antrectomy.
Vomiting, delayed gastric emptying, dumping syndrome, decreased stomach capacity, diarrhea, nutrient malabsorption, cramps, and weight loss.
Description of Surgery
Pyloroplasty is another surgical procedure that may be performed along with a vagotomy. The pylorus, the opening from the stomach into the upper intestine (duodenum), is enlarged to allow stomach emptying to occur more easily.
Diarrhea, dumping syndrome, vomiting, delayed stomach emptying, reflux gastritis, (intestinal contents containing bile acids, digestive enzymes and bacteria reflux into the stomach and damage gastric mucosal cells), weight loss, and nutrient malabsorption.
Surgery for GERD
Only a small number of patients with GERD will require surgery. Surgery is usually only considered if medical management and lifestyle modifications have proven ineffective. The main objective of anti-reflux surgery is to strengthen or repair the lower esophageal sphincter (LES), the valve that helps to prevent the reflux of acidic stomach contents back into the esophagus. If a hiatal hernia (protrusion of the stomach above the diaphragm) is present, it is usually repaired at the same time.
Indications for surgical repair include esophagitis secondary to reflux, inadequate response to lifestyle and medical management, or symptoms that are significant enough to impair quality of life. One of the primary surgical procedures performed for GERD is called a Nissen Fundoplication. In this procedure, a portion of the upper stomach (fundus) is wrapped around the lower esophagus to strengthen the LES.
Research Digest reviewed a modification of this procedure, a laparoscopic partial posterior fundoplication. This modification leaves a portion of the esophagus uncovered and provided relief for some patients who were unable to undergo traditional Nissen fundoplication.
Avoiding traditional surgery for GERD is desirable due to the potential complications. Dysphagia (painful or difficult swallowing), bloating, recurrent or worsening reflux, an inability to belch or vomit, and gas can all result.
Nutritional Implications of Upper Gastrointestinal Surgery
Surgery performed on the digestive tract can directly affect one's ability to chew, swallow, digest or absorb food. The most common problems after esophageal surgery are swallowing difficulties. Altering the consistency of foods and fluids may be helpful. Thin liquids can be thickened to make them easier to swallow (there are commercial products available for this purpose) and solid foods can be moistened or pureed. If you are having difficulty swallowing, be sure to discuss this with your physician right away. Improper swallowing increases the risk of aspiration, the entrance of food into the wind pipe (trachea) or lungs during swallowing.
The intact GI tract usually allows measured spurts of food to pass from the stomach into the intestine. Following GI surgery, particularly when all or part of the stomach is removed or the stomach outlet (pylorus) is affected, a large volume of concentrated food may dump into the small intestine. Dumping may result in a number of symptoms including dizziness, sweating, heart palpitations, cramps, vomiting and diarrhea. Dumping may also result in a low blood sugar after the initial load of concentrated food contents stimulates a large insulin (a hormone) response.
Dietary Management of Dumping Symptoms
- Limit sources of concentrated sugar such as juices, regular soda, candy, and honey as these can move quickly into the small intestine and cause dumping.
- Eat small, frequent meals that contain adequate fiber and balanced proportions of carbohydrate, fat, and protein. Including fat and protein with every meal increases calories and slows stomach emptying.
- Separate liquids from meals. Eat meals dry and take fluids 30-60 minutes before or after eating to slow stomach emptying.
- Eat slowly and lay down for 20-30 minutes after eating. This helps to keep food in the stomach longer. (Avoid if experiencing heartburn).
Decreased stomach capacity, dysphagia, diarrhea and vomiting can all contribute to post-surgery weight loss. Eating frequently, using nutritional supplements, and consulting with a dietitian may be helpful. If severe weight loss occurs and intake of calories cannot compensate, intravenous feedings may need to be considered.
Vitamin and Mineral Deficiencies
Surgery to reduce acid production can result in iron and vitamin B12 deficiency as gastric acid is an important facilitator of the absorption of these nutrients. If bacterial overgrowth occurs in the GI tract after surgery, the absorption of fat-soluble vitamins may be impaired.
Vitamin B12 injections may be necessary if gastric resection involves removal of the stomach areas that secrete intrinsic factor. Ask your doctor about your risk for vitamin B12 deficiency if you've had a partial or total gastrectomy.
Points to Remember
Surgery can provide lifesaving intervention in the case of severe ulcer disease or if complications such as bleeding, perforation, or obstruction occur. Surgery can also provide relief for individuals whose symptoms are unresponsive to nonsurgical interventions. However, any surgical procedure can result in complications and should generally be considered only after medical management and lifestyle modification has proven ineffective.