Dietary Recommendations After a Total Gastrectomy

It is recommended to consume about 1.5 litres of liquid per day, but because that is not always easy, it is preferable to try to reach the maximum that each person can tolerate.

In many cases, water alone is not well tolerated, so other liquids should be drunk, such as broth, diluted juice or diluted vegetable and fruit smoothies. Jellies and popsicles are also an option.

It is advisable to always drink outside of meals and in small amounts, and not to drink within 30 to 60 minutes before and after meals. It is best to start with small volumes and sips.

Sugary, carbonated and alcoholic beverages should be avoided.

Because the stomach is no longer available to receive and digest food before it goes on to the small intestine, there is a general sense of feeling full very quickly and losing your appetite. Therefore, the amount of food per meal should be much smaller. It is important to eat more meals per day to ingest different foods and a higher proportion of nutrients. Thus, at a minimum, the feeding should be divided into breakfast, mid-morning snack, lunch, afternoon snack, dinner and after-dinner snack.
In some cases, even more small meals eaten every two hours may be needed. Even if you do not feel hungry, you should eat several times a day to maintain adequate weight and nutrition. This will also help the digestive system to adapt to the new situation.

It is essential to chew food very well and mash it into a purée before swallowing.

It is important to learn to listen to the body, its sensations and reactions when eating, and to stop eating before feeling full to avoid discomfort later.

Fruits, dairy, starchy foods (cereals, tubers, legumes*, etc.), protein-rich foods (eggs, fish, meat, tofu, tempeh, seitan, texturised protein) and healthy fats (virgin olive oil, nuts**), depending on tolerance and dietary progression.

Incorporate vegetables in small amounts at the beginning, since they are very filling and provide few calories.

*Legumes should be incorporated in puréed form (creams, purées, etc.) or mashed with a fork to facilitate digestion.

** Nuts should be incorporated ground or crushed.

It is common for the patient to eat a liquid diet during the hospital stay and then to progress to a puréed diet when released. At home, a diet with soft-textured foods can be started, which can be mashed if they are not tolerated in a solid form. The type of food and textures needed may progress day to day, depending on the specifications of the medical team.

Because the stomach capacity is reduced, it is necessary to eat little amounts frequently. It is advisable to avoid prolonged fasting, so ideally you should have a snack before bedtime in order to lower the fasting time.

Always ensure the presence of starchy, protein-rich foods, vegetables in small amounts and fruit at lunch and dinner, even in small amounts, as indicated in the plate method. A dessert dish can be used as the basis for a main course, a first or second course or a tapas-style meal.

It is preferable to incorporate the food groups according to the instructions below.

White rice, pasta, potatoes, cooked carrots, bread, oatmeal or legumes:

• Puréed legumes
• Bread is usually better if it is toasted
• Thoroughly cooked pasta and rice. Do not leave it al dente, and always serve it with sauce.
• Avoid wholegrain or wholemeal versions (brown rice, wholegrain pasta, wholegrain bread, etc.)

Initially after surgery, it is advisable to avoid very fibrous or flatulence-causing vegetables, such as leeks, asparagus, artichokes, cauliflower or broccoli.

After a while, other cooked vegetables can be introduced in small amounts, and new ones, like salads, can be added depending on tolerance to raw vegetables.

Keep in mind that vegetables provide few calories, so it is important to consume them in small amounts and always well-seasoned and/or accompanied by more nutritious foods.

Meat, fish, seafood, eggs and soy are the highest quality protein-rich foods. At least the main meals should contain these proteins: at lunch and dinner, eat any dish containing white fish, seafood, meat (mainly lean), eggs, soy or soy by-products (tofu, texturised soy, etc.), depending on tolerance. Other foods that are also a good source of protein, such as dairy products, can be included in other meals, depending on tolerance.

It is preferable to avoid very tough or fibrous meats, as they tend to be poorly tolerated. Texture is important, so dishes based on minced meat, mixed with sauce, etc. are usually better tolerated (high-quality hamburgers, meatballs with sauce, etc.).

Include oily fish (sardines, mackerel, salmon, etc.), as other foods become tolerated and digestion has stabilised.

Examples of protein-rich foods:

People who follow an exclusively plant-based diet, with very little or no animal-based food (vegan, strict vegetarian, etc.), should check with their referring dietician-nutritionist to study how to adequately cover the proteins, vitamins and minerals that the organism needs to deal with the whole oncological process.

Adapting the diet to a texture that helps to facilitate digestion during the first few days may be necessary in some cases, but in general it is best to normalise the diet as soon as possible to avoid weight loss, since mashed diets provide fewer calories and nutrients.

During the first week it is advisable to prioritise mild cooking with little fat, such as boiled, microwaved, baked en papillote or very mild stews.

Subsequently, baked and low-fat stews and casseroles can be incorporated, and finally grilled food.

Try to avoid battered, breaded, fried and very fatty stews.

In many cases, room-temperature dishes (neither too cold nor too hot) are best tolerated.

Try to start with lactose-free dairy products. Subsequently, tolerance to natural skimmed yoghurt and later to natural yoghurt, cottage cheese and fresh cheese can be tested. Finally, tolerance to other dairy products can be tested.

Try to incorporate protein-rich natural yoghurt (with or without lactose, depending on tolerance and progression).

Sugary dairy products, such as sweetened or flavoured yoghurt, custard, flan, mousse, etc., should be avoided.

It is important to consume two or three pieces of fruit a day. Initially they should always be cooked, mashed (without skin or seeds) or in a compote. Later, test tolerance to small amounts of fresh fruit (without skin and seeds), such as apples, grapes, pears and bananas.

Avoid acidic fruits (pineapples, oranges, grapefruits, tangerines, strawberries). Small amounts of fruit and vegetable smoothies can also be eaten.

• Follow the above recommendations and the table below of recommended and inadvisable foods to start home feeding after a total gastrectomy.

Once weight loss slows down or stabilises and food is well tolerated, other foods and new dishes with a higher fibre content can be introduced (fresh fruits, vegetables, nuts, legumes and whole grains one at a time and in small amounts, to test tolerance).

It is advisable to continue using a food journal to check tolerance to the new foods introduced.

Just as in the first few weeks, keep in mind:

• Eat at least 6-8 small meals a day.
• Eat slowly and in a relaxed manner.
• Chew food thoroughly before swallowing.
• Avoid drinking during meals. Drink 30 to 60 minutes before or after eating, and always in small amounts.
• Consume protein-rich foods at every meal.
• Ensure a sufficient intake of iron, calcium and vitamin D.
• Avoid consuming simple and added sugars.
• Avoid alcohol.

The following table provides ideas on how to enrich meals that are suitable after a total gastrectomy.

• Avoid drinking one hour before or after meals.
• Lie down for about 30 minutes after meals (if you have acid reflux, recline without lying prone).
• Avoid alcoholic beverages, caffeinated beverages (coffee, stimulating soft drinks) and tea, because they increase the speed of gastric emptying.
• Avoid eating foods with simple sugars:
  • Do not add sugar (white or brown sugar, honey, agave, syrup, etc.) to dishes.
  • Avoid foods containing simple sugars (white or brown sugar, honey, agave, syrup), such as commercial juices, soft drinks, cakes or pastries, commercial sauces, sweetened yoghurt or dairy desserts (flan, custard, mousse, ice cream, etc.).
  • Limit the intake of natural fruit juices.