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Bowel Surgery – The Enhanced Recovery Programme

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The Enhanced Recovery Programme
The Enhanced Recovery Programme aims to promote your quick recovery after bowel surgery so that you may return to full health as soon as possible. There is evidence to suggest that the earlier you get out of bed and start to eat and drink after bowel surgery, the better. This will help to reduce complications related to the surgery and reduced activity. Other aspects of the programme include good control of your pain and reducing the stress of the operation on your body.

Before your operation
You will have met your Consultant Surgeon in clinic who will talk to you about the reason you need an operation, the benefits and any associated risks. It is important that you understand the information you have been given. If not, please contact your specialist nurse or the enhanced recovery nurse. Your consultant will arrange for you to be seen by a nurse in the pre-assessment clinic. Pre-assessment will assess your fitness for surgery and arrange any further tests that may be needed. This can include an ECG (tracing of your heart rhythm) and blood tests.

Getting ready for admission
There are steps you can take to prepare yourself for surgery and improve your chance of a quick recovery. These include stopping smoking. Your GP or pharmacist can advise you on nicotine replacements and support if you feel this would help. Other steps such as eating a healthy diet and cutting down on alcohol intake can help reduce the risk of complications after your surgery.

Planning for discharge
It is a good idea to start planning for your discharge before you come in.
• Is there someone who will be able to collect you from hospital when you are ready to go home? Will they be able to stay with you for a day or two?
• Can someone do some shopping for you and make sure you have everything you need for the first couple of weeks after you return home?
• Perhaps you or a friend or relative could make some meals in advance that could be placed in the freezer or buy in some ready meals or convenience food.
• If you are able, complete the washing and ironing and change the bed sheets before you come in. This means returning to a clean tidy home afterwards. If you live with your partner or family, ask them to make sure the house is clean and tidy before you return home.
• Think about whether you need help with children or pets, not just when you are in hospital but also for a couple of weeks after discharge.

After your surgery you will be encouraged to get dressed in your normal clothes when you are able to. This may be after a couple of days. Please try to ensure you have some comfortable clothes to bring in with you. Jogging bottoms or leggings and a t-shirt or casual shirt are ideal. Please feel free to discuss any of this with your specialist nurse, consultant or pre-assessment nurse.

The day before your operation
You will have been advised if you need to clean your bowel before surgery. This may be a drink you have twice a day which will act as a powerful laxative. You may need an enema to clean out the
lower end of your bowel and this will be done when you come into hospital for your operation. Unless you have been told otherwise, you may eat and drink normally up to 6 hours before your
operation and drink water until 2 hours before your operation.

In pre-assessment you will be given “pre-load” drinks. These are sachets that are mixed with water and drunk the evening before and the morning of your surgery. Pre-load drinks are high carbohydrate drinks that reduce the stress on your body caused by fasting before and during your operation. You may be asked to administer a small injection in to your tummy the day before surgery. This is a medication which helps prevent clots from forming in the veins of your legs. (Deep Vein Thrombosis)

The day of your operation
Most people are now admitted on the morning of their operation. You will be asked to come to the Same Day Admissions Unit (SDAU) which is based in The Treatment Centre at Milton Keynes
University Hospital. The nurses in the unit will welcome you and help you to get ready for your operation. It is important to keep warm whilst you are waiting to go to the operating theatre so please bring a dressing gown and slippers or warm socks to wear whilst you are in the SDAU.

Your belongings will be taken care of and taken to the ward when you have had your operation. Please avoid bringing anything valuable in to hospital with you. You will go to theatre from the SDAU. After your operation you will be taken to ward 20 where you will be cared for until you are ready to go home. This is usually between 3-7 days depending on the operation you have had and your recovery.

After your operation
You will be cared for and closely monitored in recovery until you have fully woken up and your pain is well controlled. When nursing staff are happy with your progress, you will be transferred to
the ward. Some people will need to be more closely monitored in the Intensive Care Unit for a day or two before moving to the ward.

Pain and sickness
The anaesthetist will discuss pain relief with you before your operation. You may be offered an injection of a long lasting pain killer into your back just before the operation. When you wake you will have pain relief given through a drip attached to a pump that you control. (PCA – Patient Controlled Analgesia). This pump will stay with you for a day or two after your operation. When you are drinking and starting to eat, you will be offered pain relief to take by mouth. It is important that you are comfortable enough to get out of bed and walk around. Please let your nurse know if you have pain and they can give you extra pain relief.

Modern general anaesthetics don’t tend to cause sickness but having bowel surgery can lead to feelings of nausea. You will be given anti-sickness medication to prevent this but please let your nurse know if you do feel sick after your operation. It is normal after bowel surgery to experience some bloating and discomfort in your abdomen. This will improve over several weeks.

Eating and drinking after your operation
A few hours after your operation you will be able to start drinking. Usually you will start by drinking water and your nurse will guide you on how much. You will be offered nutritional drinks three times a day whilst you are staying in hospital. It is important that you try to drink these as it helps your body recover and heal. These supplement drinks are called Ensure Plus and are available in different flavours. Please ask if you would like to try a different flavour. You do not need to continue taking these supplements once you have been discharged home. The day after your surgery, unless the Consultant has advised otherwise, you can start to eat and you should be offered breakfast, lunch and supper. We recommend that you start with small portions of a low fibre diet for the first few days after your operation. If you have a stoma, the stoma nurse will offer you specific advice on this.

Some examples of suitable foods to choose are:
Breakfast
Cornflakes or rice Krispies with milk
Yoghurt
White bread/toast with butter and jam.
Lunch and supper
Mashed potato and gravy
Omelette
Sandwich on white bread
Jacket potato without the skin with cheese or tuna.
Plain chicken or fish (can be ordered by the ward for you)
Milk puddings,
Cheese and biscuits.
We can provide you with further guidance on this if you need it.

After 4-5 days you can start to build back up gradually to your normal diet. You may need to introduce high fibre foods slowly but we would anticipate you would be enjoying your usual meals
within a couple of weeks. Sometimes after bowel surgery, the bowel can “go on strike”. This means that the bowel does not work properly and this can cause you to feel bloated and sick. You may vomit and if this happens you may need a tube passed into your stomach to drain fluid and stop you from vomiting. If this happens your bowel will need to be rested and you will not be able to eat and drink. You may need a drip to make sure you receive enough fluids. This is usually temporary and the bowel should start to work again after 24 or 48 hours.

Drains and tubes
During your operation, you will have a small tube inserted into a vein in your hand or arm. This is called a cannula and the anaesthetist gives you medication and fluids through this. You will return to the ward with a drip connected to the cannula. The drip will be taken down when it has finished. You will be encouraged to drink water to make sure you are well hydrated. You may also need oxygen given via a face mask or small tubing that sits just under your nose. This will be taken away when it is no longer needed. You will have a catheter inserted in to your bladder and this will be removed within 48 hours.

Getting out of bed
You will be able to get out of bed around 6 hours after your operation. This may not be until the morning after you return to the ward. The physiotherapist or nursing staff will assist you. It is normal to feel a little lightheaded when you first get out of bed. This feeling will pass quickly. It is very important that you get out of bed as soon as you are able. This prevents complications such as chest infection or clots in the veins of your legs. It has also been shown to promote recovery for the bowel so that you can tolerate food and drink. The day after your operation, you will spend at least 6 hours out of bed. Some of this time can be spent out of bed in the morning and some in the afternoon. The day after your operation, you will be encouraged to walk about 60 metres 4-6 times a day. The physiotherapist or nurse will walk with you until you feel confident.

You will be encouraged to do deep breathing exercises regularly when you wake up from your operation.
1.Sit upright and hold a towel over your abdomen with your arms to give you support
2.Breathe in deeply through your nose and out through your mouth slowly 5 times.
3.Whilst holding the towel against your tummy, give a good cough if needed.

You should aim to repeat steps 1-3 every hour until you settle for the night. You will be given a daily injection whilst you are on the ward which helps to reduce the risk of developing a blot clot. Some people need to continue these daily injections at home for 2 or 3 weeks. If you need to go home with the injections, the nurse on the ward will show you or your carer how to administer these. Please don’t worry if you don’t feel able to do this yourself as we can arrange district nurses to visit you at home to do this.

Your bowels
It is not unusual for it to take several days for you to open your bowels after surgery. This will not necessarily delay your discharge home. You may find your bowel habit is different after your
operation. You may find you go to the toilet to open your bowels more often and your stools may be looser. Occasionally people find they become constipated.

Your bowel function usually improves over time but this can take many weeks. If you are worried please speak to your specialist nurse, GP or consultant. If you need a stoma forming as part of your operation, the stoma care nurses will provide information and support for you after your surgery.

Going Home
When you are ready to go home the nurses will make sure you have everything you need. You may be advised to wear your anti embolism stockings at home for 2 -3 weeks. You should be given a spare pair to take home with you. You will be given enough painkillers to last for 2 weeks. It is important that you take these regularly for the first few days at home. As you recover, these can be reduced. If you feel you need further painkillers after this time your GP can review this for you. If you need advice on this please contact your Specialist Nurse or the Enhanced Recovery Nurse.

Your wound
Your wound or wounds will have been closed using stitches under the skin and a special “glue” to close the skin. Your wound may be slightly red and uncomfortable for a couple of weeks after your operation. If your wound becomes swollen, more painful or begins to leak fluid, please contact The Enhanced Recovery Nurse or your GP. Your nurse will advise you on bathing and showering after your surgery.

Rest and Exercise
It is very common to feel tired after bowel surgery. Everybody is different but it can take up to 2 months for your energy levels to return to normal. You should aim to get up and get dressed each
day. You may need a nap in the afternoon and this is normal. You should avoid heavy lifting such as shopping bags or strenuous physical exercise for around 6 weeks.

After 2 weeks you can begin to increase your activity levels. Walking is a good way to increase your stamina and general health. If you need advice please contact your specialist nurse or GP.

Driving
If you have had laparoscopic surgery you should be able to start driving after 2-3 weeks. If you have had an open operation, you will need to wait around 6 weeks to commence driving. In both cases you will need to be able to perform an emergency stop comfortably. It is advisable to check with your insurance company before you start driving again.

Work
This depends on your type of work. If your job involves heavy manual work you will need to allow at least 6 weeks before returning to work. If you are office based you may feel ready to go back to work after 4 weeks. You may find that returning on a part time basis or working shorter days is helpful for the first few weeks. If you need a sick certificate, please ask the nursing staff or doctors on the ward who can arrange this for you.

Follow–up
The ward will arrange your follow–up appointment to see your Consultant. This will normally happen around 2 weeks after you go home. You will be contacted at home by phone or letter with your appointment.

For further information please go to the hospital website www.mkuh.nhs.uk and search for “Enhanced Recovery”. Here you will find a short video explaining how the Enhanced Recovery
Programme works here at Milton Keynes University Hospital.

References
Royal College of Anaesthetists (2012) Guidelines for patients undergoing surgery as part of an Enhanced Recovery Programme (ERP) www.rcoa.ac.uk