A GUIDE TO LIFE AFTER GASTRIC SURGERY

A GUIDE TO LIFE AFTER

OESOPHAGEAL/GASTRIC SURGERY

(Oesophagectomy/Gastrectomy)

CONTENTS

1. Introduction

2. The Operation

- Oesophagectomy

- Gastrectomy

- Keyhole Surgery

3. Speed of Recovery

4. Eating and Drinking

- Swallowing

- Appetite

- Mealtimes

- Little and often

- Drinking

- Gaining weight

5. Some Possible Problems

- Dumping Syndrome

- Gastric retention and sickness

- Food Sticking

- Acid Regurgitation (reflux)

- Flatulence

- Diarrhoea

6. Summary of Nutritional Guidance

7. Lifestyle After Surgery

- The first few weeks

- At home

- Driving

- Eating out

- Sleep

- Psychological effects and support

- Relationships and sex

- Smoking

- Getting back to normal

- Three to six months on

- Back to work

8. Appendix - Healthy eating

- Adding calories

- Snacks and small meals

- Nutritious drinks

- After recovery

1. INTRODUCTION

You have had a major operation and feel that life can never be the same again.

It can, with slight modifications, and it can be a very good life.

The objective now must be to learn to live with the changes in your system so

that they affect your quality of life as little as possible.

There is no need for a special diet, you can eat and drink anything you like, but

some guidelines may influence the way you eat. For example, for the first 4-6

weeks you should eat food which is soft and well cooked, and adopt a little and

often regime. Almost certainly you will develop a greater interest in healthy

eating and that will be better for you too.

The recovery period is slow, but slow steady improvement is best. It is possible

for people to return to their former fitness level in time, including running

marathons!!

In the UK the most common reason for the operation you have had is cancer,

but it can also be a result of a rupture of the oesophagus, a long- term hiatus

hernia, a development from Barrett‟s oesophagus, or because of a congenital

condition. Continuing research is being carried out on both the causes and

treatment.

You may wonder, in the early days, if you will ever recover from this operation

which has left you feeling as if you have been under a steam roller. Initially you

will need a lot of rest and may feel exhausted by the slightest exertion, but you

will notice a gradual improvement. Your recovery will take place over a number

of months and some people will take longer than others.

This booklet will help you. It is based on the experiences of people who have

had the same operation as you, with valuable input from health professionals.

2. THE OPERATION

Oesophagectomy

This operation involves removal of part, or most of the oesophagus (gullet) and

part of the stomach, the amount of each varying according to the position of the

tumour. The stomach is then moved into the chest and joined to the remainder

of the oesophagus. The join may be near the neck or slightly lower and all or

only part of the stomach may be in the chest. To help healing of the join you

may have been fed in hospital through a tube up the nose and into the stomach,

or perhaps directly into the small intestine (the jejunum) where most of our

digestion of food takes place.

Gastrectomy

In this operation, if all of your stomach has been removed (total gastrectomy),

the top part of the small bowel (the jejunum) is joined on to the bottom of the

gullet (oesophagus). If only part of the stomach has been removed the small

bowel is joined to the remaining part of the stomach. This means that the food

you eat will pass almost immediately from the stomach into the small bowel. As

after oesophagectomy, to help healing of the join you may have been fed in

hospital through a tube up the nose and into the stomach, or perhaps directly

into the small intestine (the jejunum) where most of our digestion of food takes

place. In the future you will need to have regular injections of vitamin B12 from

your GP.

Ask your clinical/medical team for more detail if you need to better understand

your condition. You may find that a clearer understanding will help you cope.

Keyhole surgery

Some people have part or all of their surgery performed using keyhole surgery.

This means that although the same operation is performed you do not have a

large wound. You may therefore recover more quickly, but you should

remember that although there is little to see on the surface your body still has to

recover and heal and this will take time.

If your feeding tube is still in place when you are discharged you will be taught

how to care for it before you leave.

3. SPEED OF RECOVERY

Your GP will be informed when you are leaving hospital. It is quite likely that the

district nurse will also be informed especially if you still have a feeding tube in

place.

Recovery from a major operation involving digestive organs is not fast. It can

take months for the digestive system to adapt after surgery although some

patients are quicker than others. It will be some months before you are at your

peak again and you will have off days along the way. Try not to be impatient -

enjoy the new lease of life.

Initially you will feel very tired, possibly exhausted at times and plenty of rest is

needed. Sometimes the tiredness may come on very quickly; don‟t feel you

have to fight it An afternoon nap in bed is helpful for the first 5/6 weeks to

prevent you getting overtired, or you may find you need to go to bed for several

hours during the day and still need to go to bed early in the evening. Take some

gentle exercise as soon as you can - walking to start with for just a little further

each day - it will help stimulate the appetite. It will also stimulate your breathing,

helping the chest to expand and restore its suppleness.

Diarrhoea can be a problem from the early days (see the section on this below).

You may also have a dry cough, perhaps when talking a lot or too loudly. This

can be helped by sipping a cold drink or sucking a boiled sweet. It disappears in

time, but may take a year or more.

4. EATING AND DRINKING

Depending on exactly what surgery you have had, you may now have no

stomach at all, or you may have a much smaller stomach. This means that you

no longer have the capacity for large amounts of food, but this may gradually

increase. The digestion process will be different and it will take a while for you

to become used to this. You will feel “full up” more quickly, but the sensation will

probably be different. At first it will be easy to over eat and it will take you a

while to judge when you have had enough. You will also find that your sense of

taste keeps changing during the initial weeks. You may find that one week you

like something and the next you don‟t. Keep eating a wide variety of foods.

SWALLOWING

The act of swallowing should not be impaired but some trepidation about food

entering the „new arrangements‟ can make it feel a little difficult and lumpy at

first. Staying on a liquid diet should not be necessary. Gradually move onto a

normal diet as you feel able. Avoid hard or sharp food pieces during the first six

weeks, but well-cooked meat (white in particular) can be included as well as fish

without bones. You should be able to manage a normal diet within about six

weeks to three months. However, crispy foods such as crispbreads and toast

may be easier to manage than soft bread since they don‟t absorb as much

saliva and become a doughy mass.

Do not be alarmed if in the early weeks you have problems with swallowing.

This often occurs due to the join being swollen and tender. See under “Food

Sticking”

APPETITE

Many people find they have poor appetite during the early stages of recovery so

concentrate on things you like. Initially your sense of taste may be affected with

food and drink not tasting of much and possibly a bit unpleasant. You may

prefer more sweet or savoury foods than you did before. As said earlier an

operation on the digestive system does have major effects, but these vary from

one person to another so different solutions are needed. Something not easily

digested or liked in the early days may become so after a while. There may

have been certain foods or drinks that did not agree with you in the past for

whatever reason and these are not likely to change following surgery.

Stimulating the appetite

A small drink of sherry or other aperitif, or even a small beer, before a meal may

help to stimulate your appetite and improve taste.

Relax and avoid rushing meals.

Try using a smaller plate and serve meals which are attractive and colourful.

If you are too tired to prepare a meal, have a ready meal instead.

If food has no taste, try highly seasoned or marinated food.

If hot food upsets you, eat it at room temperature or cold.

If you find cooking smells a problem, avoid the kitchen or use cold or

microwaved foods. Perhaps someone else can prepare your food for you.

However, for some, the smell of food will tempt the appetite.

If you do not feel like eating you may supplement a snack with a milky drink;

you can fortify the milk by adding dried milk powder to it. Alternatively, have a

food supplement or try one of the nutritious drinks listed in the appendix.

MEALTIMES

In the early days talking during meals may affect ease of swallowing. You may

like to sit at the table to eat, or prefer to sit in an armchair with a tray on your

lap. Some people find it easier to eat with a distraction such as reading or

watching TV. Sitting upright helps to avoid any tendency to choke on food.

A microwave oven is useful for reheating food which has gone cold, as may

happen if you are eating slowly.

Sit for a while after a meal.

LITTLE AND OFTEN

The key to eating well after surgery is not to eat large meals, but to eat smaller

amounts regularly. You may find this difficult at first, but try to eat SIX times a

day; three small meals and nourishing snacks in-between. Eat slowly and chew

your food well. This will help you digest your food and prevent you feeling full

too quickly. You will feel uncomfortable if you eat too much at one time. You will

gradually get to know what is the right amount for you.

Eating more frequently can be a pleasure - biscuits with coffee in the morning; a

scone or cake with tea in the afternoon; a gap between courses of the main

meal of the day be it midday or evening; - one is always eating! Try to make it

an enjoyable activity - you now have time for conversation, and there‟s no need

to grumble at slow service when you are eating out!

DRINKING

Drinking is important and you should make sure that you drink plenty of fluids.

However, you must be careful not to fill yourself up before or during a meal or

you will not want to eat your food. When eating, just take sips of fluid.

There is no reason why alcohol should not be taken but the effect may be felt a

little earlier than hitherto - so beware! Moderation in all things! (Remember

certain medicines can react with alcohol - look at the label).

GAINING WEIGHT

Often people have lost weight prior to surgery and it is quite common to

continue losing weight after leaving hospital, maybe for some months, and

many people never return to the weight they were prior to their illness. You will

establish a new „fighting weight‟ in due course. It may take a long time - a year

or longer - and by eating little and often you should be able to maintain a good

calorie intake. However, if you feel that you need to gain weight there are ways

of adding calories to food. See appendix.

5. SOME POSSIBLE PROBLEMS

Following your operation it will take your body a while to settle down and you

may initially encounter some unexpected experiences. Most of these will

subside with time. For instance, if milk seems to be making you ill you can use

soya milk instead but consult your dietician as you may need to add a food

supplement to maintain your nutrition levels. Keep trying a little milk as the

problem should not last more than a few months when the enzyme needed to

digest milk starts being produced again.

DUMPING

A sensation known as Dumping Syndrome occurs when the food you have

eaten passes rapidly through the system and may give rise to some of the

following symptoms: dizziness, possibly fainting, feeling very hot, sickness and

pain in the abdomen. Diarrhoea or frequent bowel movements may follow. It

can be unpleasant and distressing, but is not serious and generally the

frequency of attacks becomes less. The effects normally disappear in half an

hour or so. For oesophagectomy patients it generally occurs an hour or more

after eating (late Dumping). Those who have had a gastrectomy may be more

prone to dumping, and this may occur sooner after eating (early Dumping).

In late dumping the sugar content of the food or drink causes insulin to be

released by the pancreas. A slight excess of this gives rise to the feelings and

some patients have found that quickly having a glucose tablet or sweet can

relieve the symptoms

Dumping is a fairly complex subject and we have factsheets available which

give more detail.

GASTRIC RETENTION AND SICKNESS

Conversely, food can sometimes remain in the stomach rather too long, causing

you to feel sick and bloated, with burping. This may occur as you begin to eat

slightly bigger meals. It is very common and your GP will be able to give you a

medicine (for example,metoclopramide or domperidone) which you should take

half an hour before each main meal to improve the motility of the system. You

will not need it forever - just until the body gets used to the new arrangements.

Major nerves are severed in doing the operation and this is the cause of the

problem.

If you suffer more persistent sickness which is not relieved by the above

medicines mint or ginger products, the traditional remedies for nausea and

sickness, may be helpful.

FOOD STICKING

If you feel that a little food is stuck, try a fizzy drink, which may help to loosen it.

If food does become stuck for more than a couple of hours ring for advice from

the ward at the hospital where you were treated. Normal eating of solids should

not be a problem, given that they are well chewed and obviously not too large.

After surgery scar tissue at the join in the oesophagus may restrict the flow of

food or even cause it to stick. This can be worrying and a reminder of the

original trouble but it is alleviated fairly easily by dilating it a little in hospital. It is

a routine procedure and may only have to be carried out once but a few patients

need to have it done several times in the early months. Do not persist with the

problem too long; it is better to treat it early. Consult your doctor/ surgeon if you

feel this aspect could be improved.

ACID REGURGITATION (REFLUX)

Sometimes an extremely unpleasant feeling in the stomach may come over you

for a short while, particularly first thing in the morning. Although there may be no

acid burning in the throat the trouble appears to be caused by acid in an empty

stomach. The remedy is to spit out as much fluid as you can or, if caught in

time, drink some water to dilute the effect and encourage it to go downwards. It

should become less frequent in time, but there may always be a possibility of it

occurring.

Keeping some food in the system may help to prevent acid or bile from the

stomach area actually encroaching on the throat and even into the mouth,

which is very unpleasant. It occurs most commonly at night or in the early

morning. Some food in the stomach or gut helps to absorb the acid and there

are also medicines which can help to prevent its regurgitation (prokinetics) or

reduce its formation (proton pump inhibitors - PPIs). Mints or ginger biscuits

may make you feel more comfortable.

Extra pillows or raising the bed head by about 4 - 6 inches with blocks of wood

or a house brick can be very beneficial, and a pillow under the knee area may

prevent slipping down during the night. Electric beds are now available much

more cheaply than in the past. If you have had an oesphagectomy, whether you

sleep flat or propped up may be affected by the position of the join between the

remainder of the oesophagus and the smaller stomach. The higher this is the

less reflux may be experienced.

FLATULENCE

You will probably experience a tendency to burp rather more than before.

Sometimes it can almost be involuntary but with practice some control is gained

and embarrassment can be avoided. Discomfort is relieved and it has to be

tolerated since it may remain a long-term effect. You may also find that wind

gets trapped in the stomach area. This can be painful and worrying, but it does

improve fairly quickly.

DIARRHOEA

Due to the surgery you may suffer from diarrhoea, particularly in the first few

months after the operation. It may be accompanied by rather severe colicky

pain.

This problem generally eases in time and medicine from your GP can help, but

it often seems to occur for no apparent reason, i.e. it cannot be related to

anything you have eaten. You could take a note of what you have eaten that

day, just to see if it is food related. It may be wise to reduce intake of high fibre

foods and milk for a day or two while affected, i.e. less fruit, green vegetables,

pulses (beans and lentils), high fibre cereals and wholemeal bread. A diet with

more meat, fish, eggs and potatoes is likely to be useful in controlling the

condition. It‟s a nuisance but don‟t worry about it, and learn the method of

control that suits you best. Diarrhoea can have other causes of course. See

your doctor if it persists.

6. A SUMMARY OF NUTRITIONAL GUIDANCE

Try to eat often –graze throughout the day.

Sit upright, eat slowly and chew your food well, this will help you digest your

food and prevent you feeling full too quickly. Eat soft food (not liquidised) for 4-6

weeks following surgery. Then, normal consistency should be suitable. Ordinary

bread can be a problem for a while - try toast, crackers or crisp breads.

Sip a drink with food if you like, but don‟t drink much before meals – it will fill

you up. A small aperitif may help such as sherry.

What you like is best – it stimulates the gastric juices.

After eating sit still for half an hour and don‟t bend down soon (you may

regurgitate your food)

Your last snack of the day should be at least an hour before bed – it can help to

absorb stomach acid.

Food supplements (on prescription) can be useful – good nutrition in small

volume – find ones you like. There are many – ask your dietician.

Do not put too much emphasis on weight gain – it will come in time. It is normal

to lose weight after surgery, as you will not eat much for a few weeks. Then it

should become stable and gradually increase, but not usually to your original

weight. If you are still losing weight after two months or if food sticks on

swallowing, speak to your specialist nurse or consultant.

If you have no appetite speak with your doctor – a short course of steroids may

help.

Further ideas for food are in the appendix.

Some patients find probiotics (eg Yakult, Actimel, etc) helpful with reflux and

digestive problems.

Nutritious drinks can be very valuable in the diet. Make milky drinks (eg coffee,

cocoa, hot chocolate, Horlicks, etc) with full fat milk. You can also purchase

Complan, Build-up or supermarket/chemist own brand nutritional drinks, which

are available in sweet and savoury flavours.

7. LIFESTYLE AFTER SURGERY

Your aim after getting over your operation may be to become fitter than you

were before. However, in the immediate post-operative period, exercise is the

last thing you feel capable of doing. Muscles, bones and organs have all been

affected in the chest, abdomen, and often the throat. Recovery takes some

time; if you were working you are going to be off for some months and it could

be more than 12 months or so before you are really at your best, although

hopefully you will feel pretty well long before that.

THE FIRST FEW WEEKS

You start exercising very quickly after the operation; the physiotherapist has to

get your lungs going again, expelling fluid that can gather as a result of the

operation and anaesthetic. This is a rather painful process but effort put in at

this time is well worthwhile. As you get out of bed and feel so weak you see the

challenge. Walking (or staggering) is about all you can do at this stage. Any

effort exhausts you and going up stairs is like climbing Everest, but try walking a

little further each day and it will get easier.

Progressive exercise during this early period should be taken by increasing

speed or distance - not both. Bear in mind that outdoor walking is more difficult -

there may be slopes, a wind and heavier clothing to wear - and don‟t forget the

return journey!

Look after yourself at this stage, not the housework. Continue the breathing

exercises given in hospital - six deep breaths each held for a count of 3 and

gently exhaled. Do this 5 or 6 times a day. It can be done sitting up straight or

standing. (If there is still sputum coming up you may have been given extra

exercises to do - don‟t neglect them).

AT HOME

Progress may seem slow, but pushing it too hard will possibly do more harm

than good. Don‟t try to prove anything; it‟s not worth it, the body will take its own

time. During this early stage coughing, perhaps occasional sickness, and

movement generally will be painful and you may feel that things will come apart

inside. Be assured - they will not. If you have had an open oesophagectomy the

ribs do take time to repair and it will be a month or two before you can sleep on

the side affected. Muscles too have been stitched together but these heal well

in about two months; bones and cartilage take rather longer. Nerves, which are

necessarily severed in any operation, repair very slowly indeed and some areas

around the wound may remain numb.

Surface pain at the wound may occasionally occur for years. Nothing to worry

about - it‟s the raw nerve endings.

You may feel able to tackle the odd bit of housework after a few weeks but don‟t

aim to complete it all in one go.

You may find that your ability to concentrate has been affected. This can be

very frustrating, but it will gradually return. It may help to take up a new hobby

that is not so demanding while you have got time on your hands.

DRIVING

It is probably wise to inform your motor insurance company that you have

undergone major surgery before you start driving again. You must be capable of

performing an emergency stop. Have a practice run first. There are mental as

well as physical aspects to consider and you must feel safe. There will be some

pulling on healing muscles, depending on the size of car and ease of steering.

EATING OUT

Eating with others is a very social occasion and there is no reason why you

should not continue to do this. Friends and family should be aware that you only

eat small portions, and in a restaurant ask for a child‟s portion or have a starter

as a main course. Do not worry about leaving food. If you wish you may explain

to a member of staff that it is no reflection on their cooking, but you do not have

to do this. The Oesophageal Patients Association has produced a card which

states that for medical reasons you can only eat small portions.

SLEEP

It may take several weeks to establish your normal sleeping pattern. To avoid

pain waking you it may help to take a painkiller before you go to bed.

As already stated, you may feel totally exhausted and an afternoon nap for the

first 5/6 weeks is helpful. Some people like to go to bed, others nap in the chair.

Hallucinations and dreams

Some patients may „see‟ or dream about things they know cannot be

happening. This may be related to medication and should gradually happen

less. If you find this disturbing it may help to talk to your family or GP.

PSYCHOLOGICAL EFFECTS AND SUPPORT

Now that you are recovering you may find that you have an emotional reaction

to the events which have taken place. If this is a problem for you try talking to

family and friends or your GP. Many patients find it very helpful to talk to

somebody who has also had the surgery and the Oesophageal Patients

Association will be able to put you in touch with a knowledgeable former patient.

There are groups around the country and you can be told about the one nearest

to you.

RELATIONSHIPS AND SEX

The trauma of being diagnosed with cancer and undergoing surgery often alters

our relationships with others. Feelings for our closest family are enhanced and

couples may need extra love and reassurance.

Both partners may be worried about having sex after surgery. It is normal to

feel anxious, but sex should be possible and as enjoyable as it was before. It

may be best to wait 4-6 weeks, but allow yourself plenty of time if you feel

uneasy about resuming sex. Treat it like any other activity; if you are tired and

tense wait until you are ready.

SMOKING

If you are a smoker you will have stopped smoking in hospital, so try not to start

again. If you need help to stop smoking contact your GP. For further information

on the internet look at www.givingupsmoking.co.uk

GETTING BACK TO NORMAL

You should be seen by your surgeon within two months of your surgery. Further

appointments may then be made but some hospitals leave it to the patient to

make contact if they feel the need. Clinic procedures also vary; some doctors

will always examine you but others only do so if there is a problem. It is natural

for you to worry about the cancer recurring but in time your confidence will

grow. If you have any concerns see your GP or contact your specialist nurse.

THREE TO SIX MONTHS ON

We are all individuals but somewhere within this period you should be able to

tackle exercise. Perhaps swimming, which is a very good exercise for all ages.

Take someone with you to give you confidence and the benefits will soon show.

For the non-swimmer (though it‟s never too late to learn) walking is good all

round exercise as long as you walk far enough and at a fair pace. Cycling and

dancing are also suitable as they need not be too strenuous, and as you

become stronger any sport that you enjoy can be added, but don‟t start with

competitive games like squash and badminton and avoid lifting weights. These

and sports like running can be added later (up to marathon standard if you are

really determined - one of our former patients has run several). If you were

previously overweight, now is your chance to keep that new slim figure by

taking up a sport that you used to find too energetic.

Activities which involve bending down may cause acid regurgitation. This would

apply to some yoga exercises and to gardening (usually weeding) where it can

be avoided by squatting or kneeling, and using long-handled tools.

The most important things about exercise are that it should be taken regularly,

be strenuous enough to make you puff, and be enjoyable.

BACK TO WORK

The timing of a return to work depends on many factors; age, type of work,

effort put into regaining fitness. In any event it may be some months before you

do, but we are all individuals. Heavy work makes more demands and might in

fact not be suitable if much bending and lifting is involved. Hopefully your

employer may be able to help by using your skills and knowledge for lighter

work. Initially travelling in rush hour traffic may be stressful and shorter hours for

a few weeks will enable you to “run in”. Remember to plan to be able to take

nourishment when you need it - little and often. Remember too that for some

time you may tire more quickly so if driving or working with machinery is

involved extra care and planning may be necessary.

8. APPENDIX - HEALTHY EATING

The following are suggestions only and do not have to be followed. If you

have to follow a special diet for medical reasons, you should not change your

diet without consulting your health professional.

ADDING CALORIES

Add extra sugar or glucose to drinks, cereals, desserts and fruit.

Add honey, syrup or jam to porridge and desserts.

Melt butter on vegetables, meat and fish and add to sauces and milk puddings.

Add grated cheese to mashed potato, vegetables and soup.

Have mayonnaise on salads and in sandwiches, cream in soups, sauces and

desserts, and cream cheese on bread and biscuits.

Put minced meat or flaked fish into soups.

Make fortified milk (4 tablespoons milk powder mixed into a pint of milk) and use

this for your drinks and in cooking in porridge, sauces, soup and milk puddings.

SNACKS AND SMALL MEALS

Keep snacks to hand so you can nibble throughout the day.

Nuts, Bombay mix, pasteurised cheese, pate, peanut butter, biscuits, crackers,

breadsticks, dips – such as hummus or tarasamalata, crisps, nachos, tortilla

chips, pepperoni, cheese dippers.

Fresh and canned fruit, popcorn, yoghurt, muesli bars, chocolate, sweets, dried

fruit, breakfast cereal eg crunchy nut cornflakes.

Teacakes, muffins, crumpets, croissants

Sandwiches

These can be made from sliced bread, toast, bagels, baguette, chapatti or pitta

bread. Fill with cold meats, tinned fish, pate, dhal, hummus, egg, bacon, cheese

or peanut butter. Add mayonnaise, pickles, chutneys, salad or avocado to make

them more interesting.

On toast

Baked beans, cheese, sardines, eggs – poached, scrambled or fried. Add

plenty of butter or margarine and top with grated cheese.

French toast (eggy bread) or omelette.

Add cheese / mushrooms/ ham

Jacket potatoes

With butter and fillings such as cheese, beans, tuna mayonnaise, chilli con

carne, coleslaw, bolognaise sauce, hummus or sour cream.

Ready made meals

Can be frozen, chilled, tinned or boil in bag

Nutritious Soups

If having soup as a meal, choose one that contains meat, fish, cheese, lentils

peas or beans. Make soup with milk or add cream and serve with a roll.

Pasta

Instant or microwaved pasta with added cheese or ham

Puddings

Milk puddings such as rice or semolina. Add jam, fresh or tinned fruit or

cinnamon and sultanas and brown sugar. Thick and creamy or custard style

yoghurt, fromage frais, fruit mousse or fool, trifle. Tinned sponge pudding,

jelly with tinned fruit and ice cream or cream. Add raspberry or chocolate sauce.

Hot or cold pie or crumble with cream, ice cream or custard. Waffles or pancake

with maple syrup and cream or ice cream. Cheesecake or sweet pastries with

cream.

Baked apple or banana with brown sugar and sultanas. Serve with custard,

cream or ice cream.

Whisk a small tin of evaporated milk into a cooled jelly made with 1/2pt water to

make a milk jelly.

Use custard and stewed or pureed fruit to make a fruit fool.

Banana and chocolate or other confectionery can be chopped into Angel

Delight.

Full fat Greek yoghurt with honey and soft fruit. This can be topped with brown

sugar and grilled to make crème brulee.

Adding cream to any pudding will boost the energy content. For convenience try

aerosol creams. These keep well in the fridge. Long life cream is also useful.

NUTRITIOUS DRINKS

To tempt the appetite, serve chilled in a tall glass or tumbler with a straw.

Milkshake

1 cup milk

1 packet Build Up or Complan – flavour of your choice

1 scoop ice cream

Blend all ingredients together and serve.

Fruit Milkshake

1 cup milk

1 cup tinned fruit (drained) or fresh fruit

1 packet vanilla Build up, Complan or full cream milk

1 teaspoon sugar (optional)

Liquidise the fruit. Add other ingredients. Blend and serve.

Coffee Calypso

1 cup milk

1 packet Build up, Complan or full cream milk

1 teaspoon instant coffee (vary amount according to your taste)

1 scoop ice cream

Dissolve coffee in a little hot water. Add to other ingredients. Blend and serve.

Choc-mint surprise

1 cup milk

1 packet chocolate Build up or Complan

2 table spoons single cream

Few drops peppermint essence (vary to taste)

1 scoop ice cream

Blend or whisk all ingredients together except the ice cream. Pour into glass,

add ice cream and serve.

Yoghurt smoothie

1 pot full fat yoghurt, flavour of your choice

1 banana

1 packet Build up or Complan

1 cup milk

1 teaspoon sugar (optional)

Blend all ingredients together

Sherbet fizz

1 packet vanilla Build up, Complan or full cream milk

1 scoop ice cream

150mls lemonade

Blend all ingredients together and serve immediately

AFTER RECOVERY

It can take up to six months for the digestive system to adapt after surgery.

When you feel fully recovered from your operation and you are more fit and

active you may want to return to a lower fat diet and include more fibre, fruit and

vegetables.

If you are still losing weight or experiencing difficulties with eating at this time,

contact your dietician or GP.

The balance of good health plate

ACKNOWLEDGMENTS

We gratefully acknowledge the contribution of consultants, research nurse,

clinical nurse specialist and dieticians, together with former patients in compiling

this booklet.

Particular thanks to the Trustees of United Bristol Healthcare Trust who funded

work in Bristol and to Bristol University and Birmingham Heartlands Hospital.