Colorectal enhanced recovery programme

An important part of an enhanced recovery programme is that you are as healthy as possible in the lead up to your operation; you play the leading role in achieving this. Please take note of the following pre surgery recommendations to improve your chance of a speedy recovery.

Pre-assessment

Your pre-assessment will occur after you have been listed for surgery. The aim of pre-assessment is to assess and improve your fitness for anaesthetic. You will be seen by a nurse or healthcare assistant, who will ask you about your medical history, current medications, previous operations and screen for various risk assessments. If there are any issues of concern regarding your social circumstances, please discuss them with the nurse at your pre-assessment as well.

You will have measurements taken (including height, weight, blood pressure, pulse and heart rate), MRSA (methicillin resistant staphylococcus aureus) swabs from the nose, mouth and groin and potentially an ECG (heart tracing). You will also be given six bottles of drinks before the operation (unless you are diabetic) and, if your surgeon has prescribed it, bowel preparation. This is a drink used to cleanse the bowel before surgery and is usually combined with oral antibiotics. You will receive written and verbal instructions stating exactly how and when to take these.

The information you provide, along with the tests taken, will be reviewed by the nursing team to determine if there are any additional requirements before admission. For example, some patients with a more complex medical history may be asked to return to see an anaesthetist, or the PRIME team for review. The PRIME clinic (Perioperative review informing management of elective surgery) is a multidisciplinary team based at our hospitals. This service is dedicated to patients over the age of 65, and who may be frailer than the general population. The aims of the PRIME Service are to get you as fit as possible for your surgery; medically, physically and functionally; reduce the risks of post-operative complications and get you home as soon as possible. Also, anaemic patients may be asked to return for an intravenous iron infusion, and patients with poorly controlled medical conditions such as diabetes or hypertension (high blood pressure) may be asked to see their general practitioner (GP).

Carrying out this assessment before surgery is important as it highlights information that your surgeon and anaesthetist need before the day of your surgery. This minimises the risk of cancellation, due to an unknown/ poorly controlled medical condition and identifies patients who might be at risk.

At present the pre-assessment unit is located within the ATC (Addenbrooke’s Treatment Centre), which is adjacent to the DSU (Day Surgery Unit). This is where you should also come on the morning of your surgery, unless stated otherwise in your admission letter.

Physiotherapy

Before your operation, you will receive guidance and help with physiotherapy to increase your fitness. We especially focus on your heart and lungs, to help recovery following your operation. It is very important that you participate in the physiotherapy programme to reduce the risk of post-operative complications. Ensuring you are as fit as possible gives you the best chance at a quick recovery.

Exercise prior to surgery

Prior to being admitted it is beneficial to start practising breathing exercises (see these online video resources (opens in a new tab)). This will help to remove any sputum (phlegm) you may have at present, and mean you are familiar with breathing exercises for after your operation. As well as optimising your lungs, it is essential to improve your physical fitness as much as possible before your operation. Some patients will undergo chemotherapy and/or radiotherapy before their surgery, which alongside a decreased appetite may lead to weakness. It is still safe to continue with gentle exercise like walking while you are undergoing chemotherapy/ radiotherapy.

Once your chemotherapy and/or radiotherapy has been completed you should aim, where possible, to gradually increase your exercise before the operation. This will mean you are stronger going into the operation and will help you recover more quickly after the operation. Walking is an effective form of exercise. Other means of exercise may include swimming, cycling or dancing. The national recommendation for exercise is 30 minutes five times per week; this is a good aim to achieve before your surgery. The amount of exercise you are able to do may depend on the amount you can eat and how you feel following your pre-admission treatment.

Stopping smoking

We recommend you stop smoking as soon as possible. Smoking puts you at an increased risk of developing serious complications. You should stop smoking at least four weeks prior to admission for surgery. There is a chance that you could be tested to check if you have been smoking on the day of your pre-admissions assessment, or when you come in for surgery. If you continue to smoke, your surgery may be cancelled. If you are finding it difficult, you can speak to your GP for help and advice about smoking cessation. You can also contact the NHS Smoke free helpline on 0800 022 4332. Your local pharmacy may provide, or can direct you to a pharmacy that does provide, free ‘one-to-one’ support to help you stop smoking.

Limit alcohol

You must also try to limit the amount of alcohol you drink and aim to not exceed the current UK recommendations, which are to drink no more than 14 units of alcohol per week for both men and women. We also recommend that you have two alcohol-free days per week. If you take any other recreational drugs, please inform your consultant or nurse specialist so that they can offer you appropriate help or refer you to the appropriate services.

Eating and drinking before colorectal surgery

Prior to your surgery you will be able to eat and drink as normal unless you are required to take medication to clear the contents of your bowel, or if you have been advised to follow a special diet, for example a low‑fibre diet. If this applies to you, it will be discussed with you at either your pre-operative assessment or with your surgeon.

If you are eating well and have not lost any weight recently, it is important to maintain a stable weight to aid recovery and allow your body to heal after your operation. Try to eat as normally as possible leading up to your surgery. We suggest eating three meals a day, and snacks if required. You should aim to include a wide variety of foods. We also recommend that you drink at least 1.5 to 2 litres of fluid every day in the days before surgery. By eating and drinking well, you are giving your body the nutrients it needs to heal, fight infection and cope with any side effects of your surgery. You may find it useful to prepare and freeze meals ready for your return home.

You might be asked a few questions about your diet and weight at either your appointment with your surgeon or by the nurses at your pre-assessment clinic. If it is necessary you may be referred to the dietitian, for example if you have lost a lot of weight unintentionally and/or you have not been eating well. If you have any concerns about your diet before coming in for your operation, please speak to either your surgeon or one of the nurses.

You will also be required to take special carbohydrate drinks called ‘pre‑op’ before your surgery; these will be given to you at your pre-assessment visit. You will require two of these drinks the night before and two drinks on the morning of your operation. You may continue to eat for up to six hours before your operation and drink clear fluids (eg water, dilute squash) for up to three hours before, unless advised otherwise.

Bowel preparation and use of pre‑operative antibiotics

There is now increasing evidence that having an empty bowel and taking oral antibiotics prior to bowel surgery may reduce some of the risks of surgery, in particular, wound infections. If required, bowel preparation and oral antibiotics will be discussed with you at your clinic appointment.

The day before your operation you will need to drink a laxative medication to help clear the content of your bowel. This should be taken at 14:00 (2pm) and 19:00 (7pm). Pre‑operative antibiotics can be collected from the pharmacy on the day of your outpatient appointment. Your prescription will include Metronidazole 400mg and Neomycin 500mg; you will need to take both antibiotics the day before your operation in addition to the laxative medication.

You will be required to drink plenty of ‘clear’ fluids (any drink which you are able to see through) during this time.

With enhanced recovery we aim to remove your tubes and attachments as quickly as possible. This aids mobility, independence and reduces the length of stay as an inpatient.

The attachments you may have are as follows:

Urinary catheter

A urinary catheter may be placed into your bladder during the operation. This allows us to accurately measure your urine output. We aim to remove this by day 1 or 2. Removing the catheter at an early stage allows you to become more independently mobile.

Intravenous lines

When you wake up, you will have one or more intravenous cannulas in your arm. We will use these to administer intravenous fluids, analgesia and anti-sickness medication as required. We will be able to remove them when you are tolerating oral fluids and medications.

Bowel function

Your bowels may stop working for a period of time after your operation. This is common, but for some patients this can last a few days; this is known as ileus. Having ileus can make you feel sick, and you may vomit. Please tell your nurse if you feel sick. If ileus occurs, it is usually necessary to rest your bowel, by reducing your oral fluid and food intake, and restarting a drip so that you do not become dehydrated. This can be a frustrating time, but please be patient – it will resolve itself.

Expect to have loose watery stools, with some urgency when your bowel function first returns after surgery.

Nasogastric tubes and abdominal drains

With enhanced recovery we aim to avoid the use of nasogastric tubes (which pass through your nose to your stomach) and abdominal drains where possible. If you do wake up with either of these in place, they will be reviewed on a daily basis by the surgical team and removed as soon as they are no longer deemed necessary.

Stoma (ileostomy / colostomy / urostomy)

If your consultant has informed you that they may need to form a stoma (where the bowel is brought out to the skin), you will see a stoma specialist nurse in clinic, or on admission before your surgery. At this appointment the stoma specialist nurses will give you detailed information about having a stoma, mark the site where the stoma will be and give you practice packs.

After your operation you can expect to see a stoma specialist nurse on the ward; they will give you a patient diary and show you how to care for your stoma. The ward nurses will be heavily involved in your stoma care too. You will be expected to participate in your stoma care on the first day after your operation. Participating early allows you to feel more confident when it comes to going home and adjusting to life with your stoma.

• Day 1: your stoma care and bag change will be demonstrated by a stoma care nurse or ward nurse.
• Day 2: you will empty and change the bag in the morning and evening with assistance from nursing staff or your stoma care nurse
• After day 2: increasing your participation in stoma care. We aim for full proficiency by days 4-5.

You should be able to eat and drink normally after your surgery unless advised otherwise. Returning to your regular diet after surgery will help your bowel function return more quickly, improve your energy levels and aid wound healing. We would recommend that you try to eat whilst sitting in your chair rather than in bed. This can prevent bloating and nausea, and it is how you would eat when you are at home.

• Day 0: If you are able to, you can eat and drink as normal unless advised otherwise.
• Day 1: Build up eating and drinking as tolerated. Have three bottles of Fortisip Compact*.
• Days 2-5: Continue to eat and drink normally. Drink two litres of fluid. Have three bottles of Fortisip Compact each day.

* (Fortisip Compact is a ready‑made, high energy, high protein, milkshake-style drink and is available in a variety of flavours including strawberry, vanilla and chocolate.)

If you are struggling to finish your meals, try eating smaller portions more frequently and include more snacks and nourishing drinks. Try to take the three Fortisip Compact drinks as advised.

Protein is particularly important after surgery as it helps to promote wound healing and rebuild muscle function and strength. Examples of foods containing protein are meat, fish, eggs, yoghurts, cheese, soya and soya products, tofu, milk and hot milky drinks. You can ask family and friends to bring in snacks from home. The ward staff can label them and put them in the fridge for you if needed.

If you have been advised to follow a special diet, such as a low‑fibre or low‑residue diet, please follow the advice that you have been given. If you have a stoma, we recommend that you gradually reintroduce fibre-containing foods to ensure that you do not experience any unpleasant symptoms. This includes foods such as fruits, vegetables, salads, nuts, seeds, potatoes with skins, wholegrain breads and cereals, and wholemeal pasta and rice. For more information about eating with a stoma please refer to the information given to you by the stoma nurses or ask to speak with a dietitian.

We aim to give you advice on exercises following your operation in order to aid and speed up your recovery.

The lungs following surgery

After your operation, your lungs will be affected from the anaesthetic, pain and immobility. Many people find they have a cough after the anaesthetic and it is important that you start to clear any sputum immediately after your operation. If any sputum remains in your lungs, it creates the ideal environment for infections to develop.

It is important that your pain is controlled well enough for you to take deep breaths, cough and move around. Most patients will have patient-controlled analgesia (PCA). If you are still in pain, it is important that you speak to your doctor, nurse or physiotherapist.

Deep breathing exercises

You should start deep breathing exercises straight away after the operation. While doing breathing exercises, try to sit as upright as possible and ensure your pain is well controlled.

1. Take a slow, deep breath in through your nose if possible.
2. Hold your breath for a count of three.
3. Gently breathe out through your mouth.
4. Repeat this three to five times. Do not do too many at once as this may make you lightheaded.

Aim to do two sets of three to five deep breaths every waking hour.

You may want to watch our video to help with your breathing exercises (opens in a new tab).

‘Huff’ and cough

It is not harmful to your wound to ‘huff’ or cough after the operation. To make your ‘huff’ and cough stronger and more comfortable, you can use a pillow or towel over your wound to support it. To loosen the sputum, you may wish to do a huff before a cough. A ‘huff’ is a deep breath in followed by a forced breath out through an open mouth – as if you were trying to steam up a mirror. It is vitally important that you cough as frequently as is needed to clear your sputum.

Bed mobility

We advise and encourage you to get out of bed and sit in the chair/ move around as soon as possible after your operation. This might be as early as the same day or day after your operation. The ward physiotherapists and/or nurses will help you with this initially. The most comfortable way of getting out of bed initially is to bend up your knees with your feet flat on the bed, then roll onto your side. Once you are on your side, put your legs over the edge of the bed and push up through your elbow.

Circulation exercises

It is important to start circulation exercises immediately after the operation to reduce swelling and to prevent blood clots. Move your feet backwards and forwards briskly 10‑20 times every 30 minutes. Try also circling your feet and squeezing your buttocks together.

Postural advice

Initially following the operation you may find you tend to bend forward towards your wound. It is important, however, that you maintain a good upright posture to help wound healing and to prevent back and neck pain. It is also important to stand as straight as possible when you are walking.

Walking

This is an excellent form of exercise after your operation. The benefits of early mobilisation (walking) are to promote independence and reduce the risk of developing chest infections and blood clots. You will be assisted in getting out of bed and into the chair the day after your surgery. We will also assist you to have a walk if possible. All of your drips and drains are portable and will run on battery power where appropriate. The distance and frequency that you walk should be increased daily. You will initially require assistance in doing this due to your attachments. The aim is to regain your independence as soon as it is safe to do so. If your mobility is restricted in the early post-operative period, for example by low blood pressure, it is even more vital that you continue with your breathing and leg exercises regularly. Once you are able to mobilise independently you should aim to have a short walk on the ward every two hours. The physiotherapist will do a mobility assessment with you prior to discharge if required.

Blood clot prevention

Dalteparin is part of a group of medicines called anticoagulants (blood thinners). An anticoagulant medicine prevents blood clots forming in your blood vessels by making your blood take longer to clot. Dalteparin reduces your blood clot risk. A blood clot can develop in the large veins of the body, usually in the legs. This is called a deep vein thrombosis (DVT). Sometimes, a blood clot can break free and travel through your blood vessels. If a clot lodges in the blood vessels of your lungs it is called a pulmonary embolism (PE). A PE can cause chest pain, difficulty breathing and, if severe, can cause death. Rarely, a clot may move to the brain and cause a stroke.

After surgery there is an increased risk of blood clots forming. Evidence shows that following bowel cancer surgery, an extended period of treatment with dalteparin reduces this risk. You will need to inject dalteparin for 28 days after your surgery. You will be shown how to do this by a member of the team.

Your expected date of discharge should be communicated with you throughout your admission. If you are unsure of this, please ask a member of staff.

Transport

We advise that you arrange a method of transport home prior to being ready for discharge. Please do let a member of staff know if this is not possible.

Help at home

You might need assistance for activities of daily living for the first couple of weeks following your discharge. Please arrange for family or friends to help you with tasks such as shopping, preparing food and cleaning for this period. If this is not possible, please alert a member of staff.

Hobbies and activities

The aim of our enhanced recovery programme is to get you back to your normal life as quickly as possible.

Exercise advice on discharge

Although the aim of our enhanced recovery programme is to get you back to your normal life as quickly as possible, we recognise that, in the initial stages after your operation, rest is important, as well as exercise. It is common to feel tired after the operation for some time, and you may wish to have a rest in the afternoon. Let your family/ friends help with daily activities where required and try to pace your activities evenly throughout the day. To prevent strain on the healing wound, it is important to avoid extremes of exercise, such as heavy housework and lifting or heavy gardening, for 8‑12 weeks. Try to avoid lifting items heavier than 2kg during this time. If you must lift, push or pull an object, try to do it with both hands to avoid uneven strain on the abdomen.

Try to increase the duration and distance of your walking weekly. You should be aiming to walk between 20 and 30 minutes at least five times per week at around six weeks post-operatively (if you were able to do this before the operation). Discuss this with your consultant before returning to specific activities.

Eating and drinking when you get home

You may find that it takes some time to get your appetite back after your operation, so try eating small meals several times a day. This should include plenty of protein. It is also a good idea to try to drink plenty of fluids which can include milk, soup, hot drinks and juice.

Advice may differ if you have a stoma. You should seek advice from your stoma specialist nurse if you have queries as they will be able to offer you specific advice. If you continue to struggle with your diet approximately one month after you are discharged home and are not seeing a dietitian, please speak to your GP.

Bowel function expectation

In the early weeks following surgery to remove part of your bowel, if you have not had a stoma created, your bowel habit is likely to change. Bowel movements may become looser, or you may become constipated. A well-balanced diet that includes high calorie, high‑protein foods will aid your recovery. Try to eat small regular meals three to four times a day. You might find some foods upset you and can cause loose and more frequent bowel movements. You may wish to avoid these foods for the first few weeks, but you should try to re-introduce them early on in your recovery. When re‑introducing foods, it is sensible to add a small amount, chew it well and see how it affects you. Please try not to skip meals; have a snack or nourishing drink if you can’t manage a main meal. Have a selection of easy‑to‑prepare foods in case you do not feel like cooking.

Try to drink adequate amounts of fluid and take regular walks each day, especially during the first two to three weeks after surgery

Please contact the specialist colorectal nursing team on 01223 217923 if you are experiencing prolonged constipation or diarrhoea (after three weeks) or have discharge, bleeding or excessive pain from your back passage.

Follow‑up clinic appointment

Cancer patients will be seen in clinic approximately six weeks after the operation. This is a nurse‑led follow up clinic, run by the specialist colorectal nursing team. You will also receive a post-discharge follow up phone call around 3‑5 days following surgery and again two weeks after discharge. During these calls, a member of the clinical team will discuss the results of your cancer surgery and whether you require any further cancer treatment in the form of chemotherapy. We will also discuss your recovery, bowel function and any concerns you may have. If you wish to discuss your results face-to-face we will try to accommodate your request by arranging an appointment as soon as possible.

As a cancer patient you will remain under the care of the colorectal nursing service for life. We will also co‑ordinate your cancer surveillance.

Non-cancer patients follow‑up schedule will be decided by the consultant on the day of discharge.

Patients with a stoma will receive a phone call approximately two days after discharge and an initial appointment with the stoma specialist nurses two weeks after discharge. Ongoing appointments will then be discussed and arranged. Patients from outside the Addenbrooke’s catchment area will be referred to their local stoma nursing service.

Details of your follow‑up plan will be available in your discharge letter.
Please ask a member of staff if you have any queries.

The stoma nurses have a telephone hotline and are accessible via MyChart (which is a downloadable app to your smartphone or accessed via a computer). Please contact them if you have any concerns – do not wait for your appointment if you are having problems.

Please see below for your discharge checklist.