Introduction
Coming into hospital to have major surgery is stressful. Fear of the unknown and a loss of control are both factors cited by our patients, and the aim of this document is to give you and your family relevant information about what to expect. It also gives you achievable targets for your recovery so you can monitor your progress and help influence the outcomes. We hope you find it useful. We are committed to continuous improvement and your feedback about your experience is welcome.
Meet the Team
Consultant surgeons
- Peter Safranek
- Andrew Hindmarsh
- Vijayendran Sujendran
- John Bennett
- Stavros Gourgiotis
- Robert O’Neil
- Ayesha Noorani
Dieticians
- Sam Grimes, principal dietitian
- Claire Lamb, specialist upper GI dietitian
- Tania Cimonetti, upper GI dietitian
- Chloe Siu, upper GI dietitian
Upper GI specialist nurses
- Benjamin Smith, lead upper GI digestive diseases nurse
- Nyarai Chinyama, upper GI nurse practitioner
- Natalie Lee, upper GI specialist nurse
- Simple Joshi, upper GI support nurse
Consultant anaesthetists
- Famila Alagarsamy
- Petrus Fourie
- Vibhay Kakhandki
- Anand Jain
- Lisa Grimes
Physiotherapist
- Edain Martin, team Lead and clinical specialist
- Bridget Mason, senior clinical specialist practitioner
Summary of the patient journey
- Prehabilitation clinic – getting you fit for surgery
- Pre-assessment and consent
- Admission on day of surgery – Ward L2
- After surgery-overnight intensive recovery (OIR)
- Day 1 Post Op Move to High dependency Critical Care area
- Day 5 Post op Move to enhanced recovery area-M4
- Home
- Outpatient clinic two weeks post discharge
A dietitian will call you in one week. Specialist nurses are available for telephone support.
Before your surgery
As part of the enhanced recovery programme, you will be able to play an active role in your care. Prior to coming in for surgery it is important you are as healthy as possible. This cannot be emphasised enough. The following are areas that will need to be addressed by you and the team looking after you. You will be invited to attend the pre-habilitation clinic where you will be seen by a physiotherapist, a dietitian and a specialist nurse.
Physiotherapy
You will receive guidance and help with physiotherapy to increase your fitness, specifically for your heart and lungs to help following your operation. It is very important that you participate in the physiotherapy programme to try to prevent complications after your operation. Ensuring you are as fit as possible helps with your recovery.
Exercise prior to surgery
Prior to being admitted it is beneficial to start practising breathing exercises. This will help to remove any sputum 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 optimise your physical fitness as much as possible prior to 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 such as 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 tolerance again prior to the operation. This will mean you are stronger going into the operation and help you recover more quickly after the operation.
Walking is a very good form of exercise. Other forms of exercise may include swimming, cycling, dancing. The national recommendation for exercise is 30 minutes five times a week; this is a good aim to achieve prior to 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.
Smoking cessation
We recommend you stop smoking as soon as possible. This should be at least four weeks prior to coming in 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. Smoking puts you at an increased risk of developing serious complications so it is important you speak to your specialist nurse (01223 596383) or GP for help and advice on giving up if you are finding it difficult. You can also contact the NHS smoke free helpline on 0800 022 4332 or you can ask your local pharmacist, if they have a trained advisor you can see for free ‘one-to-one’ help and support.
Limit Alcohol
You must also limit the amount of alcohol you drink and not exceed the national recommendations, which are currently no more than two units per day for men and women. It is also recommended that you have two alcohol-free days per week. If you take any other types of recreational drugs please inform your consultant or nurse specialist so that they can offer you appropriate help or refer you to other services. No more than two units per day.
NHS Eatwell guide
The “Eatwell Guide” shows how much of each food group you should eat to achieve a healthy and balanced diet. This covers everything you eat and drink during the day, including snacks.
Nutrition
Your body needs to be well-nourished in order to fight infections and heal. It is important that you continue to eat a healthy balanced diet and maintain your weight. You need to eat a variety of foods from the following groups in addition to any other supplements that your dietitian or doctor may have advised you to take.
Starchy foods (breads, cereals, rice, pasta, potatoes, and chapatis): eat a portion of these with every meal.
Meat, poultry, fish, eggs, nuts, peas, beans and lentils: eat a portion of any of these foods at two of your daily meals.
Fruits and vegetables including juice: try to eat five portions per day. A portion is roughly the amount you can fit in your hand
Milk and dairy
Have three portions per day. A portion could be a cup of milk, pot of yoghurt or a matchbox-sized piece of cheese.
Foods containing fats and sugar
These foods should be eaten in moderation. However, if you have a poor appetite or your weight is low, they can be eaten as additional snacks or added to foods to provide more energy. Foods such as crisps, biscuits, cakes, chocolate, mayonnaise, cream, sugar, butter and oil are ideal.
Eating will be different post operatively as your capacity will be limited due to the surgery, the focus will be on smaller more frequent meals. You will be guided in terms of texture progression by both your surgeon and Dietitian. We encourage you to consider implementing 5-6 smaller meals or snacks prior to surgery in order to make the transition after surgery easier.
If your swallowing starts to get more difficult, or you are of low weight or losing weight prior to your surgery, it is important that you contact the dietitian at your local hospital. Alternatively, you can speak to a dietitian at Addenbrooke’s on telephone number 01223 216655.
After an oesophagectomy, you will require additional tube feeding for a few weeks which will start in hospital and continue after you are discharged. To prevent delays to your discharge from hospital, you will be contacted before your admission to arrange training on how to use a feeding pump and how to care for your feeding tube after surgery. If you are having difficulty eating and maintaining your weight please call the dietitian.
In-patient Journey
Day of surgery
On the day of your operation, you will be admitted to ward L2 at 07:00 unless we advise you otherwise (see below for directions). Please do not have anything to eat from midnight. You can have a small amount of water to drink until 05:00 and your carbohydrate drink should be taken two hours prior to surgery. Your nurse or surgeon will inform you when to take this.
Your surgeon will also see you to answer any final questions and ensure that the consent form is signed. You will be seen by an anaesthetist to discuss your anaesthetic and postoperative pain control.
Below is a checklist for you to complete prior to your surgery
Pre-surgery checklist
☐ I have drunk Nutricia Pre-Op two hours prior to my surgery time
☐ I have seen the surgeon and have discussed the planned surgery
☐ I have seen the anaesthetist and discussed the anaesthesia
☐ The estimated date of discharge has been discussed with me
☐ I have discussed any concerns/anxieties with my nurse/surgeon
Your operation will be carried out under a general anaesthetic. Whether you have open surgery or key hole surgery our aim is to remove the cancer with as little upset to you as possible. With careful anaesthesia, meticulous surgery, attention to pain relief, and careful post-operative care, we aim to get you through your hospital stay safely and swiftly.
By the nature of the surgery being undertaken, complications can arise and occasionally these can be serious. (Please refer to your consent form for possible complications). We are always vigilant and aim to treat any potential complications quickly and effectively.
A typical patient journey
Day of admission
You will be admitted to ward L2. You will be escorted to theatre after you have been seen by your surgeon and anaesthetist.
You will then undergo a final safety check in the anaesthetic room with the surgical and anaesthetic team
Your anaesthetic
Your surgery will be done under a general anaesthetic. For open surgery (as opposed to keyhole) you will be offered an epidural for pain relief.
The epidural will be placed before you are put to sleep. This forms the cornerstone of your pain relief, and will be used for up to five days following your surgery (see the separate information leaflet that explains this in more detail, including the specific benefits and risks). In addition you will probably have a pain pump connected to your drip that you can use as you need.
The anaesthetist will attend to you throughout the procedure supporting your organs, while making sure you are unconscious and pain-free. Prior to surgery (but after you have been put to sleep) the anaesthetist will place a neck line and wrist line to monitor your vital signs and administer strong drugs. All of this will be discussed with you in the morning prior to coming to theatre.
At the end of the operation, the surgeon will give your relative or friend a call if you would like them to.
Overnight Intensive Recovery (OIR)
After your surgery you will be transferred to overnight intensive recovery where you will spend your first night.
OIR is located on level 3 of the main hospital inside the main theatre block. There is a buzzer for your visitors to press to be allowed entry.
Once inside the theatre block there is an entrance on the right hand side to OIR.
Whilst you are in OIR you will be carefully monitored by nurses and doctors.
OIR
Following your operation, it is important that you are monitored closely. The equipment can sometimes feel a little overwhelming but please remember that it is there to keep you safe. The diagram explains a little more about what some of the equipment is. Not all patients will require every piece of equipment.
- Monitor for pulse/blood pressure/oxygen
- Epidural for pain relief
- Patient Controlled Analgesia (PCA) button for pain relief
- Chest drain − to drain fluid/air from the chest
- Urinary catheter − to measure urine output
- Abdominal drain − to drain fluid from the abdomen
- Nasogastric (NG) tube − to drain the stomach
- IV fluids − fluids administered through the vein
- Central line − for blood tests, medication and monitoring
- Arterial line-to measure blood oxygen levels
Our previous patients wanted to share some quotes with you to help you on your journey, following your operation.
You will perform some breathing exercises when you have come round from your surgery. This is essential on the evening of your operation to try and help your lungs to function better.
“Your recovery journey has just begun. Start it with confidence and conviction. If things do not go well today, tomorrow is another day’.
Day of Surgery goals
- Breathing exercises
- Incentive spirometry
Day one post surgery
You will be reviewed by your surgeon, pain specialists and physiotherapists. The physiotherapist and the nurses will assist you with getting up, walking and sitting in your chair
Later in the day you will be transferred to the Critical care high Dependency Area where nurses and doctors will continue to monitor you closely.
“You may feel as if a bus has run over you and the thought of standing, let alone walking with help, seems impossible, have faith in yourself, the least you can do is try…”
Day one goals
- Breathing exercises
- Incentive Spirometry
- Sit in chair
- Stand with assistance
- Walk with assistance
Day two to four
You will stay in the Critical Care high dependency area where you will continue to be monitored closely. Most of your tubes and attachments will also be removed whilst you are here. The physiotherapist and nursing staff will help you to start moving frequently throughout the day. “The idea of more physiotherapy may still be daunting so soon after surgery. Keep trying, there is a reason why your health care professionals are advising you to do the things they are advising you to do. The people are experienced and see the greatness within you, even when you do not see it yourself.” “The reality of what you have been through might be starting to set in. Each task seems harder than before. Remember; recovery is a process; it takes time, it takes patience and sometimes it takes everything you have, keep going until you get there. “ “The nurses and physiotherapists are giving you more freedom and the expectations of what you are able to do are getting higher, it’s not how quick you achieve these goals, what matters is attempting to complete them “.
Day Two Goals
- Breathing exercises
- Incentive spirometry
- Sit in chair
- Stand with assistance
- Walk with assistance
Day Three Goals
- Breathing exercises
- Incentive spirometry
- Sit in chair
- Stand with assistance
- Walk with assistance
Day Four Goals
- Breathing exercises
- Incentive spirometry
- Sit in chair
- Stand with assistance
- Walk with assistance
Day five to six
By this stage we expect you to be well enough to be transferred to the ward M4. Once transferred, you will continue to be monitored closely. However, this will now be at less frequent intervals. By now your level of independence should be increasing and we will start encouraging you to use your pump feed (oesophagectomy patients).
This is what a surgical jejunostomy (feeding tube) looks like. It is attached to a pump which supplies you with food until you are able to eat again. It is placed in the abdomen.
“You may be feeling a lot more confident in your recovery. The words ‘going home’ may have even been mentioned. Don’t lose sight of your goals. If it is safe to do so, ask family or friends when they visit to help you with that afternoon walk up and down the corridor. It’s the little things you and your family do that aid a quick recovery.”
Day Five Goals
- Breathing exercises
- Incentive spirometry
- Sit in chair
- Walk with assistance if still required
- Oesophagectomy patients: start giving own water flushes down jejunostomy tube
“Walking or doing some activities independently may not be something you envisaged doing on day six. Now you are there! All your hard work is paying off. Keep practising the goals you have been given. They are the things that will make your life at home easier.”
Day Six Goals
- Walk Independently
- Ward exercise bike
- Set up pump feeding with assistance
- Blood thinning injection training
Day seven to eight
You will remain on the ward and at this stage we will start working towards your discharge. We aim to be ready to discharge you from hospital, so you can go home on day eight after your surgery.
- Get washed and dressed independently
- Walk Independently
- Ward exercise bike
- Perform blood thinning injection training
- Set up pump feeding with assistance (oesophagectomy patients)
- Make plans for discharge
“It’s almost time for you to go home. You have done the hard part but more recovery time is yet to follow. Face each day as it comes. It is a big change, so be realistic in your expectations, and be gentle with yourself. Be nice to whoever is looking after you at home. Things will get better but it will take time. If things are not going well; ask your healthcare team to help or advise you.”
Day Seven Goals
- Get washed and dressed independently
- Walk Independently
- Ward exercise bike
- Perform blood thinning injection training
- Set up pump feeding with assistance (oesophagectomy patients)
- Make plans for discharge
Physiotherapy after your surgery
Introduction
We aim to give you advice on exercises following your operation in order to aid and enhance your recovery.
The lungs following surgery
Your lungs will be affected after your operation 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 (phlegm) immediately after your operation. If any sputum remains in the 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 an epidural or patient controlled analgesia (a button they can press to control their pain relief). If you are still in pain it is important 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.
- Take a slow, deep breath in through your nose if possible.
- Hold your breath for a count of three.
- Gently breathe out through your mouth.
- Repeat this three times. (Do not do too many at once as this may make you lightheaded).
Aim to do one to two sets of five deep breaths every waking hour.
Why not watch our video to help with your breathing exercises?
Video information: Upper GI (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. This is a 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 required 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 may be as early as the same day or day after your operation). The ward physiotherapists 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 help reduce swelling and to prevent blood clots. Move your feet backwards and forwards briskly 10 to 20 times every 30 minutes. Try also circling your feet, and squeezing your buttocks together to increase your circulation.
Postural advice
Initially following the operation you may find you lean towards the operation side due to the wound. It is important however that you maintain a good upright posture in order to help with wound healing and 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. If your mobility is restricted in the early post-operative period, for example by low blood pressure, it is even more vital you continue with your breathing and leg exercises regularly. Once you are able to mobilise independently you should aim to have a short walk every two hours on the ward. The physiotherapist will do a stairs assessment with you prior to discharge if required.
Shoulder mobility
Following your surgery you may be reluctant to move your shoulder, especially on your operation side due to the wound and chest drains. It is important you follow the following exercises on the side of your operation to increase your range of movement and reduce stiffness.
Sit in a good upright position to complete the exercises:
- Shrug your shoulders up towards your ears then relax back
- Gently roll your shoulders forwards then backwards
- Place your hand on your shoulder then gently lift your elbow out to the side then back down
- Keeping your hand on your shoulder then gently lift your elbow forwards then back down
- Raise your hand in the air towards the ceiling
Complete each exercise five times, three times a day.
You should aim for a gentle stretch sensation. If the exercises are causing you any pain or discomfort stop immediately and discuss with your physiotherapist.
Bed exercises
- While lying in the bed briskly move your ankle backwards and forwards. Repeat this 20 times on each leg.
- While lying in the bed gently rotate your ankle clockwise and anti-clockwise. Repeat this 10 times in each direction on each leg.
- While lying in the bed squeeze your bottom cheeks together, hold for the count of three then relax. Repeat this 10 times
- Sitting up in the bed pull your ankle up towards you then push your knee down into the bed. Hold your leg there for five seconds then relax. Repeat this five times on each leg.
- Sitting up in the bed place a rolled up towel under your knee. Pull your ankle up towards you, push your knee into the towel then gently lift your leg up. Try to hold your leg there for five seconds.
Chair exercises
- While sitting in the chair bend and straighten your ankles, alternating between lifting your toes and heels off the floor Repeat this 10 times.
- Rotate your ankles then change direction. Repeat this 10 times.
- Pull your toes up towards you, tighten your thigh muscle and straighten your knee. Hold it there for five seconds then slowly relax your leg. Repeat this five times on each leg.
- Lift your leg up off the seat keeping your knee bent. Return to the starting position. Repeat this five times on each leg.
Finding the wards
Ward L2
Ward L2 can be found on the ground floor of the Addenbrooke’s treatment centre (ATC). From the main hospital entrance, to access the Atrium and the ATC reception desk, continue down the ‘museum’ corridor on level 2, walk past the Rosie turning and into the Atrium.
If you are visiting a patient who is likely to be hospitalised for two weeks or more, you can get a discounted parking ticket from the main reception. This allows you to exit from the car parks for 14 consecutive days from the day you validate the ticket.
Enquiries: 01223 256584
Overnight Intensive Recovery Unit (OIR)
The main recovery unit can be found on level three at the entrance of the Main Theatre department. Overnight Intensive Recovery (OIR) is located within Recovery. Access is via security swipe cards and automatic doors.
Visiting: Open visiting. Please call the OIR before coming in.
Maximum of two visitors per patient.
Enquiries: please call 01223 256054
Critical care high dependency area
Enquiries: 01223 217873
About the ward
The critical care high dependency area is a nurse-led unit with all patients admitted remaining under their current medical teams. The critical care high dependency area provides close monitoring during the initial period after major surgery, for patients stepping down from intensive care or for patients entering an acutely ill phase. The Critical care high dependency area is located on Wards D3 and D4.
Ward Numbers:
D3- 01223 217494
D4- 01223 348144
For security, there is an intercom at the ward door.
Visiting times: 12:00-19:00
Patients can tire if they have too many visitors. If the patient is not well enough, the nurse in charge might ask visitors to restrict the length of their visit. To help us prevent the spread of any infections, we ask visitors to use the hand rub at the entrance to the ward on arrival and on leaving.
All patients are tested for MRSA on admission to the Critical care high dependency area. We will take every precaution to prevent the spread of infection during your stay. We ask that to reduce the risk of infection the belongings that patients bring into the ward are kept to a minimum.
You will be reviewed at least daily by your own team of doctors. Please do not hesitate to ask if you require any further information regarding your progress. During out of hours (after 17:30 and at weekends) there will be an ‘on call’ team on duty.
As your condition improves and you no longer need the close monitoring, you will be transferred to a ward. You may notice at first that there are fewer nursing staff and less equipment. However, this is a natural progression towards discharge from hospital. Unfortunately, due to emergency admissions, you may be transferred to a ward at short notice and at any time of the day or night.
Ward M4
Ward M4 can be found on level 4 of the Addenbrooke’s Treatment Centre. From the main hospital entrance, to access the Atrium and the ATC reception desk, continue down the museum’ corridor on level 2, walk past the Rosie turning and into the Atrium.
The passenger lifts are situated across the Atrium on the right hand side, opposite the new Patient Advice and Liaison Service (PALS) office.
Located off the Atrium are two sets of stairwells; one is located through the set of double doors adjacent to the passenger lifts, the other is situated on the other side of the Atrium opposite the payphones.
Take the stairs or lift to level 4. The reception desks for ward L4 and M4 are located in the hall outside of the lifts.
Enquiries
Telephone:
Visiting times: 11:00 to 20:00
Support groups
Upper GI cancer support group
The Cambridge Upper GI cancer support group is for anyone who has had or is about to undergo oesophagostomy or gastrectomy for cancer.
This simple act of sharing can make an enormous difference to the way you feel and help you through the difficult times you may be facing.
The group will be run by a cancer support specialist from Maggie's and a nurse specialist from your clinical/surgical team. The group will also welcome guest speakers on a variety of subjects such as chemotherapy, nutrition, dumping syndrome, mindfulness and enhanced recovery.
Friends, relatives and carers are also welcome to attend.
Dates
Second Tuesday of alternate months. 10:30an - 12 noon
Location
Maggie's Cambridge
21 Milton House
Puddicombe Way (on Addenbrooke's campus)
Cambridge CB2 0AD
Reduced parking tickets available.
For more information or to register your interest call: 01223 249220
Maggie's website (opens in a new tab)
Registered charity number: SC024414
We are smoke-free
Smoking is not allowed anywhere on the hospital campus. For advice and support in quitting, contact your GP or the free NHS stop smoking helpline on 0800 169 0 169.
Other formats
Help accessing this information in other formats is available. To find out more about the services we provide, please visit our patient information help page (see link below) or telephone 01223 256998. www.cuh.nhs.uk/contact-us/accessible-information/
Contact us
Cambridge University Hospitals
NHS Foundation Trust
Hills Road, Cambridge
CB2 0QQ
Telephone +44 (0)1223 245151
https://www.cuh.nhs.uk/contact-us/contact-enquiries/