Nutrition and Gastrointestinal Issues After GIST Surgery

GIST Support International (GSI) posed questions about nutritional concerns following surgery for gastrointestinal stromal tumor (GIST) to Khursheed N. Jeejeebhoy, M.D., F.R.C.P.(C), Ph.D.

Dr. Jeejeebhoy is Professor Emeritus of three departments (Medicine, Nutritional Sciences, and Physiology) of the Faculty of Medicine at the University of Toronto. Dr. Jeejeebhoy is an extremely experienced physician who has focused much of his research on the nutritional needs of surgical patients. He has published prolifically and lectured around the world. Since his mandatory retirement from the University of Toronto’s Faculty of Medicine, Dr. Jeejeebhoy has continued to see patients at St. Michael’s Hospital, and to teach a clinic about home parenteral nutrition.

Below are Dr. Jeejeebhoy’s replies to our questions.

1) Considering the entire GI tract, which organs are most important for DIGESTING (breaking down) which types of food, and which GI tract organs ABSORB which nutrients?

Functions of the organs of the gastrointestinal tract.
Organ	Digestive Enzymes and Factors Secreted	Nutrients Broken Down	Nutrients Absorbed
stomach	pepsin, intrinsic factor	protein	alcohol
duodenum	trypsin, amylase, lipase and other minor ones	protein, fat, and carbohydrates	calcium, iron
gall bladder	bile	emulsifies fatty acids and monoglycerides	not applicable
pancreas	same as duodenum	same as duodenum Dissociates vitamin B12 from R protein and allows binding to intrinsic factor in small bowel	not applicable
jejunum	peptidases, lactase, sucrose, and maltase	peptides and disaccharides	all nutrients
ileum	same as jejunum	same as jejunum	all nutrients plus bile salts and vitamin B12
colon	not applicable	fermentation of fiber and carbohydrate to short chain fatty acids	short chain fatty acids, water

2) Are there particular problems with different types of sugar (fructose, lactose, etc.) after gastrectomy? Why do sugary foods cause "dumping" and how can patients prevent this?

Normally the intact pyloric mechanism controls the output of sugar to a rate which allows complete absorption of the sugar as it is delivered to the intestine. After surgery the stomach empties by gravity without any control which overwhelms the absorption and increases intestinal osmolarity so that water is sucked into the bowel, there is excessive distention, release of kinins causing dumping.

3) How can patients cope with the acid indigestion and / or acid reflux after gastrectomy? Is this problem more likely after certain types of surgeries?

There is no simple answer and need to be considered by your physician individually. The general comments given below is not for everyone. Indigestion has many causes but is not due to excessive acid unless the esophageal sphincter to the stomach is resected (upper gastrectomy or esopahgogastectomy) . In this case drugs of the family of Proton Pump Inhibitors may be used. In other cases small solid meals with complex carbohydrates, avoiding sugars and separating fluids from solids should be considered. The advice depends on the details of the clinical state.

4) Which patients (based on type of surgery, organs removed) might benefit from which types of digestive enzyme supplements? For example, some patients with gastrectomy have reported benefit from taking pancreatic enzyme supplements even though the pancreas was not altered.

Enzymes may be necessary where bile and pancreatic juice is diverted to the jejunum.

5) What sorts of food are easiest to digest for a patient with gastrectomy? Are there "indigestible" foods that should be avoided? What is your advice on what to eat?

In patients with a partial gastrectomy, vegetable and fruit fibre may form so called bezoars (balls of undigested plant fiber) in the remnant stomach. Again there is no generalization possible. Many patients ultimately can eat most foods.

6) Some gastrectomy patients have profound nausea for months and months post-gastrectomy. What strategies can help these patients begin to eat again?

The problem is a combination of great sensitivity to dumping in some persons and slow motility with retention in others. Each person needs to be investigated to determine if there is retention or not. Depending on the findings the treatment should be directed to Dumping or to slow motility.

7) Does the remnant stomach after partial gastrectomy "expand" to accommodate more food eventually?

Yes, most people become more tolerant with time.

8) What nutrient monitoring tests should be done to detect whether post-GI-surgery patients are adequately nourished? What nutritional supplements are a good idea?

The main deficiencies are iron, Vitamin B12 and, if the duodenum is bypassed, then Vitamin D and calcium. (The duodenum absorbs Calcium under the influence of Vitamin D. The Vitamin itself is absorbed in the small bowel.)

9) What drugs may sometimes be helpful for patients after GI surgery (for example, metoclopramide), and are these a temporary "jumpstart" or a permanent aid?

This depends upon the problem. Slow motility responds to metoclopromide, but this drug may cause neurological symptoms. In intractable dumping, octreotide may help.

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One Grateful Patient’s Testimonial

One patient (also an MD) recounts his success with Dr. Jeejeebhoy’s advice after his surgery:

"I found that the advice from the nutritionists in the hospital after surgery was useless. They had very little experience dealing with gastrectomy and partial gastrectomy patients, since it is a relatively rare operation these days, compared to when it was a routine treatment for stomach ulcers.

Their main advice at first was ‘Boost’ high protein drinks, which I could keep down, but which, in retrospect, gave me severe dumping syndrome with sweating and/or diarrhea due to the high sugar content. The nutritionists didn’t know what else to suggest, so even after going home, I was still losing weight, and didn’t know what to eat without feeling sick in one way or another. In fact, I was beginning to worry that I would waste away due to the inability to eat without feeling very unwell.

Fortunately, I was referred to Dr. Jeejeebhoy, who was already a world famous expert on post-surgical nutritional issues back when I was a medical student in the 1970’s! At that time, gastrectomies and partial gastrectomies were very common (for stomach ulcers), and Dr. Jeejeebhoy developed a great deal of experience in understanding the nutritional needs of such patients.

Obviously every patient is unique, but for me, his advice was a lifesaver!

He said that I should eat primarily ‘digestible solids’, such as mea
t, chicken, fish, eggs, pasta, white bread, potatoes and rice, while avoiding ‘indigestible solids’ (including most fruits and vegetables, whole wheat bread, etc.), excess liquids, and especially anything with significant sugar (including many fruits that have natural sugar, sauces like honey garlic or Teriyaki, etc).

It may be a bit boring, but I can add spices or hot sauce, and ever since I started this diet, I have been doing really well. I stopped losing weight almost immediately, and even gained back a few pounds, albeit still a lot skinnier than before my surgery (145 lbs vs 170).

Also, he said that because I now have decreased absorbtion of most foods, I’ll never have to worry again about my cholesterol, so if I want to eat a burger and fries three times a day, I can. It is essentially the exact opposite of the ‘healthy eating’ habits that we were all taught growing up. However he does recommend an easily absorbed form of multi-vitamin, B12, Vit D, iron and calcium every day (avoid slow-release or other highly encapsulated products, as they won’t be absorbed properly), as well as getting regular bone density scans. For anyone that needs extra digestive enzymes to help digest their food, he recommends Viokase powder.

He also mentioned that when the stomach is (mostly) removed, we don’t have graelin, the chemical that stimulates the feeling of hunger when the stomach is empty, so it is important to force ourselves to eat regularly throughout the day, since our bodies won’t tell us to do so."