Colorectal Enhanced Recovery Programme

Enhanced Recovery Programme booklet – Colorectal

Introduction
This booklet is intended for patients undergoing a bowel resection. The aim of the booklet is to provide you with information regarding the time leading up to your planned surgery, admission to hospital and what you can expect during your stay and discharge from hospital.

There are a variety of bowel operations, both open and keyhole, therefore not all sections will apply to everyone.

Enhanced recovery is a modern evidence-based approach that helps people recover more quickly after having major surgery. Your care will follow this programme.

The enhanced recovery aims to ensure that patients:

• are as healthy as possible before receiving treatment
• receive the best possible care during their operation
• receive the best possible care while recovering

Having an operation can be both physically and emotionally stressful. The enhanced recovery programme supports you to get back to full health as quickly as possible.

Research has shown that the earlier a person gets out of bed and starts mobilising, eating and drinking after having an operation, the quicker their recovery time will be.

The aim of this programme is to help you to recover safely and return to your normal activities as soon as possible following surgery.

The usual length of stay can be individual and usually ranges between 3-7 days depending on your operation.

To enhance your recovery from surgery, it’s important that you play an active role in your own care.

Pre-assessment
Your pre-admission assessment is an ideal opportunity for you to be involved in planning your care and for you to tell us your needs and circumstances. As part of your pre-assessment you will be seen by an enhanced recovery nurse and a pre-assessment nurse, who will discuss your medical history and ensure you are fit for surgery.

It is important for your health to be as good as possible before having the surgery. This may include cutting down on, or giving up, smoking and alcohol. This will speed up your recovery and reduce your risk of developing complications.

Before your operation you may be required to follow a special diet. A diet sheet will be provided if necessary. In addition to this you may also be given instructions on taking a laxative or enema to prepare your bowel for surgery.

You may also be given Nutricia Pre Op drinks; These are a clear, lemon flavoured drink that contains nutrients and energy to help aid your recovery. Pre Op drinks maybe stored in the fridge or drank at room temperature.

Most people will have a small blood thinning injection the evening before admission. You will be asked to administer this yourself. The injection is given into the skin on your tummy to reduce the risks of blood clots (thrombosis) by thinning your blood.

You may be required to wear surgical stockings, which will also help reduce the risk of thrombosis.

You may also be required to take bowel preparation such as Moviprep at home the day before or an Enema which you will have on the day of admission.

All of the above will be discussed with you if appropriate at your pre-assessment visit.

Enhanced Recovery Programme requirements – you will be given further information and instructions by your clinician about the following:-

• Following a Low Fibre Diet for 5 days before your operation
• Taking Senna tablets each night for 5 nights before your operation
• Drinking Nutricia Pre Op drinks (day before your operation)
• Inhixia Injection 6 pm Evening before
• Nuticia Pre Op drinks the morning of your operation
• Moviprep

Admission to hospital

What to bring

• Any medication your currently taking
• Books, magazines
• Comfortable clothes to get dressed in each day.
• Night clothes
• Dressing gown
• Slippers
• Toiletries

We encourage you to try to care for yourself as much as you are able whilst in hospital to help maintain your independence and to encourage mobility. However, the nursing staff will happily help you with any needs that you may have. We will encourage you to wear your own day attire where possible.

Stoma
Depending on the operation that you are having, you may require a stoma. If this is the case, our stoma specialist nurses will see you regularly to teach you how to manage this.

Discharge arrangements
You will be assessed daily throughout your stay by one of the doctors to ensure your safe progress and discharge. Once your discharge is agreed you will be asked to leave the ward and transfer to the discharge lounge whilst your discharge letters and tablets to take home, if necessary, are prepared. We aim to discharge patients from the ward by 10am. You will need to arrange for someone to collect you.

Before you are sent home from hospital you will:

• Be able to eat and drink
• Be mobile and independent
• Have passed flatus (wind)
• Have your pain controlled with pain killers
• Have a normal temperature

After care
Once you are discharged you will receive regular support calls from the enhanced recovery nurses for up to 10 days after discharge. Following this you will have arrangements to see your consultant.

Diet

• A balanced, varied diet is recommended (some foods may upset your stomach and cause loose bowel motions, this is usually temporary).
• Eat little and often with snacks between meals when able.
• Try to eat an adequate amount of protein and calories to allow your body to heal.
• If your appetite is poor you may benefit from high calorie supplements that can be purchased from most supermarkets, or can be available on prescription from your GP.
• Drink plenty of water.

Sometimes if you are losing weight after surgery you may require a referral to a dietitian (this can be discussed with you consultant or your GP).

Exercise
We encourage you to be mobile from the first day after your surgery, ideally walking several times per day. It is important, however, not to undertake any strenuous exercise that will put strain on your wounds for a period of 6 weeks to allow full healing; this includes contact sports and heavy lifting. Once pain free you can start to do gentle exercise. You may be expected to wear surgical stockings, alongside blood thinning injections, for up to 28 days post discharge, or until your mobility has returned to what is was before the surgery.

Driving
We advise no driving for 4 weeks following major bowel surgery. It is important that you are able to perform an emergency stop if necessary. For some patients it may take longer than four weeks. It is important that you should inform your insurance company before you start to drive again.

Work
Many patients are fit to return to work after 4 weeks, but if your work involves manual work or heavy lifting you should refrain from work for at least 6 weeks or see if your employer can offer you light duties. In the home a gradual return to light duties such as light housework is recommended.

Sexual activity
It is safe to have sex as soon as you feel able to do so without pain or discomfort. Some surgery may affect the nerves that are important for sexual function. Please contact your GP if any problems persist.

Bowel function after surgery
Your bowel habit may well change after surgery. It is common to get diarrhoea or constipation. If symptoms persist you may require medication to keep your bowel function under control. Occasionally diarrhoea could be due to other issues such as infection or a collection in the abdomen which can irritate the bowel.

Constipation is also common following bowel surgery and can be due to certain pain relief. If you are constipated it is important to drink plenty of fluids, walk regularly and increase the fibre in your diet.

However, if concerned, please discuss the symptoms with your enhanced recovery nurses or your GP.

Passing urine
Following bowel surgery, most people will have a urinary catheter which is usually removed before you are discharged home. Sometimes this can cause people to develop urinary tract infections. Signs include pain on passing urine, urinary frequency and incontinence. Some types of bowel surgery can affect the nerves that control bladder function. This can result in bladder irritability, a degree of incontinence or difficulty in passing urine. Often these symptoms will improve over time. If you have any of these symptoms you will need to see your GP. Rarely some patients can develop urinary retention (unable to pass urine) if this happens you should seek urgent medical assistance.

What if you feel unwell?
Most people who are discharged home improve day by day. There are certain signs and symptoms that should prompt an emergency review in hospital. These include.

• Abdominal pain – By the time you are discharged your pain should be controlled with simple analgesia. You may experience some colic or gripping pain that last a few minutes at a time. If your pain is getting worse, you should contact us.
• Vomiting – Occasional vomiting after surgery is not uncommon. However, if you develop persistent vomiting that’s preventing you from eating a normal diet you should contact us.
• Fever – Fever in combination or abdominal pain and vomiting could indicate that you also need to be reviewed. Chest and urine infections are not uncommon following surgery.
• Wound problems – You may be sent home with clips in place, these are often removed between 10-14 days after surgery with your practice nurse at your GP surgery. If your wound develops a discharge or redness then it is important to contact the enhanced recovery nurses.

If any of these issues occur during the first 10 days after discharge you should contact your enhanced recovery specialist nurse or your colorectal specialist nurse. The contact details are at the back of this booklet. If you have concerns out of office hours, you should contact GP out of hours 111 service, who will guide you to the service which is best suited for your needs.

Research
We are involved in various national/international research studies that are aiming to improve the care of colorectal patients. You may be asked if you would like to be involved in one or more studies before or during your hospital stay. We will always explain what the studies involve and you are free to choose whether you would like to be involved. For further information, please ask you CNS or consultant.

Low Fibre diet – Information for patients, relatives and carers

Food Type	Food ALLOWED	Food to AVOID
Bread, cereals and grains	Refined breakfast cereals such as: Rice Krispies®, Coco Pops®, Weetos®, Frosties®, Cornflakes®, Sugar puffs®, Ready Brek®. Products made from white flour for example white bread, white pasta, crumpets, English muffins, wraps, pitta bread, bagels. Well cooked white rice, rice noodles, egg noodles, white noodles. Plain naan bread, plain chapatti, poppadoms. Rice pudding, semolina, tapioca, plain couscous and Polenta.	Wholemeal cereals. Cereals containing nuts, seeds or dried fruit. Muesli, fruit and fibre, shredded wheat, bran flakes, Crunchy Nut Cornflakes® Any bread products or biscuits containing coarse grains, seeds or nuts or dried fruit such as multigrain bread, seeded batch, rye crispbread, rough oatcakes, hobnobs, muesli bars, flapjacks, teacakes, scones, fruit loaves. Brown rice, brown pasta, quinoa, pearl barley.
Meat, poultry and fish	Soft and tender meats or poultry without visible fat and with skin removed such as poultry, lamb, beef, pork, veal and ham. Plain tofu, textured vegetable protein, Seitan, Quorn®. All types of eggs. Fish without bones such as cod, salmon. Seafood (ensure prawns and shrimps are peeled).	Tough, gristly meat or skin including pork scratchings. Fish with bones like sardines or with edible bones like whitebait.
Dairy products, fats and oils	Limit all types of milk including nut and plant-based milks to no more than half a cup a day. Any dairy alternatives are also allowed, in the same quantities.	Cheese containing dried fruit, onions or nuts. Yoghurts or fromage frais containing fruit pieces, dried fruit, nuts, seeds or cereal
Vegetables	Well-cooked or pureed root vegetables such as carrots, parsnips, turnips or swede. Tomatoes without skins or seeds such as tomato juice canned deseeded tomatoes, passata, tomato puree. Well-pureed hummus, lentil soup sieved to remove skins. Vegetable juices or soups – sieved to get rid of any seeds/skins. Avocado. Mashed potatoes or well-cooked potatoes without skin, for example jacket potato, boiled potato. Potato gnocchi is also allowed. Potatoes can be made into chips but NOT deep fried. (Fatty foods are difficult to digest and may cause discomfort)	All vegetable stalks, skins, seeds and peel. Sweet corn, broad beans, runner beans, mange tout, sugar snap peas, sweetcorn, spinach. Raw vegetables such as peppers, radishes and celery, tomatoes, cabbage, leeks, onions, lettuce, spinach and salad leaves. Firm beans and pulses with thick skins like kidney beans, baked beans, haricot beans, barlotti beans, soybeans, puy lentils, mushy peas or chickpeas. Potato skins. All curries made with lentils, beans, legumes/pulses.
Fruits	Fruit juice (no seeds / pips / skins / piths). Cooked or stewed fruit without skin. Melon, banana, canned pears, peaches or apricots, canned citrus fruit with no pith, skin or pips such as mandarins or grapefruit. Pureed fruit / fruit coulis (sieved).	All dried fruit. Any fruit skins, pips or seeds, strawberries, raspberries, blueberries, blackcurrants, gooseberries, passion fruit, pineapple, kiwi, mango, apricots.
Desserts	Clear jelly only.	Coloured jelly e.g. red jelly. Ice cream containing fruit and nuts, cakes, puddings and pies containing any of the following: Wholemeal flour, dried fruit, nuts, dried coconut and any fruits you have been advised to avoid.
Drinks	Fruit and vegetables juices with no bits. UHT Clear Apple juice (This is an excellent choice to drink alongside the sachets of bowel prep) Water, soft drinks, tea and coffee, herbal tea.	Fruit and vegetable juices/smoothies with pulp and seeds.
Other	Clear or strained soups. Sugar, honey, golden/maple syrup, seedless jam, marmalade. Dark/milk/white chocolate, boiled sweets, marshmallows, toffee	Chocolate with fruit or nuts. Nuts, seeds, coconut and desiccated coconut. Marmalade with peel, jam with seeds.

Contact Details:

Enhanced Recovery Nurses
Tel: 01527 503030 Ext: 44513 Bleep 587
Aimee Summers
Helen Morgan
Emma Coleman

Enhanced Recovery Lead Consultant
Pamela Sivathondan

If your symptoms or condition worsens, or if you are concerned about anything, please call your GP, 111, or 999.

Patient Experience
We know that being admitted to hospital can be a difficult and unsettling time for you and your loved ones. If you have any questions or concerns, please do speak with a member of staff on the ward or in the relevant department who will do their best to answer your questions and reassure you.

Feedback
Feedback is really important and useful to us – it can tell us where we are working well and where improvements can be made. There are lots of ways you can share your experience with us including completing our Friends and Family Test – cards are available and can be posted on all wards, departments and clinics at our hospitals. We value your comments and feedback and thank you for taking the time to share this with us.

Patient Advice and Liaison Service (PALS)
If you have any concerns or questions about your care, we advise you to talk with the nurse in charge or the department manager in the first instance as they are best placed to answer any questions or resolve concerns quickly. If the relevant member of staff is unable to help resolve your concern, you can contact the PALS Team. We offer informal help, advice or support about any aspect of hospital services & experiences.

Our PALS team will liaise with the various departments in our hospitals on your behalf, if you feel unable to do so, to resolve your problems and where appropriate refer to outside help.

If you are still unhappy you can contact the Complaints Department, who can investigate your concerns. You can make a complaint orally, electronically or in writing and we can advise and guide you through the complaints procedure.

How to contact PALS:
Telephone Patient Services: 0300 123 1732 or via email at: [email protected]

Opening times:
The PALS telephone lines are open Monday to Friday from 8.30am to 4.00pm. Please be aware that you may need to leave a voicemail message, but we aim to return your call within one working day.

If you are unable to understand this leaflet, please communicate with a member of staff.

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