Surgery

Patient information for Translation

Colorectal Enhanced Recovery Pathway (ERP)

Pre and post-operative patient information booklet

The Enhanced Recovery Pathway (ERP) is a programme of care that aims to help you recover quickly and safely, and puts you the patient at the centre of your pre and post-operative treatment.

This booklet is designed to increase your knowledge of the programme and how you can play an active role in your recovery.

There is an inpatient diary for you to refer to your daily goals.

Please bring this booklet into hospital with you as a reference to your daily goals.

If there is anything you are unsure about, please ask a member of the colorectal team. Contact details can be found at the back of the booklet.

What is the Enhanced  Recovery  Pathway? (ERP)

The ERP aims to get you back to full health as quickly as possible after your surgery.

Research suggests the earlier you get out of; bed; start eating, drinking and moving the quicker your recovery will be and the less likely you are going to develop complications.

The ERP has a number of goals to follow for quicker and successful recovery after surgery

• Reducing post- operative stress
• Ensuring your pain is well controlled
• Ensuring you mobilise as soon as you are able post-operatively.
• Ensuring you eat and drink as soon as you are able post-operatively.
• Early discharge home

Preparing for your operation

Before your operation it is important that you look after your health, this will help you recover quicker and reduce post-operative complications.

Exercise

Exercising before your operation can be a great way to teach your body how to cope with stress. Being physically active before your operation will help you recover quicker.  If you are someone who exercises regularly, we recommend you increase your daily exercise regime. If you are someone who does not exercise regularly, we recommend increasing your daily activity. For example taking a short walk daily, walking upstairs rather than taking the lift or even walking further to catch the bus.

Deep breathing exercises

Strengthening your breathing muscles can reduce your chance of acquiring a chest infection post-operatively and can speed up your recovery time. Deep breathing exercises are recommended daily both before and after your operation.  These exercises will be demonstrated to you during your enhanced recovery pre-operative session.

Leg exercises

It is also important to point your feet up and down and circle your ankles to reduce the risk of blood clots in your legs. It is advisable to practice these exercises and perform them post-operatively.

Eating and Drinking

It is important that you are well nourished before your operation as this will help in the healing of your wounds, reduce your risk of infection and generally improve your recovery. We recommend you cut red meat out of your diet and follow a diet high in protein. Reducing the amount of fibre (the undigested parts of plant foods) in your diet prior to surgery is also advisable. This will help reduce

the size and number of times you pass stools.  This diet is being recommended to reduce your stools prior to your surgery.  You can also take multivitamin tablets to help supplement nutrition.

Smoking

If you are a smoker it is advisable for you to stop.  Smoking increases your risk of getting a chest infection and reduces your body’s ability to heal quickly and fight infection.  We can provide you with a smoking cessation referral or you may wish to access www.nhs.uk/smokefree for help and support to quit smoking. 

Alcohol

Alcohol can affect your body’s response to surgical stress.  We recommend that you reduce/stop drinking alcohol up to 4 weeks before your operation.  If you are a heavy drinker, we recommend that you do not stop drinking suddenly as it may not be safe to do this.  Please advise the team looking after you.  We can provide you with information for local support services if you need help reducing/stopping alcohol. 

Oral hygiene

Oral hygiene is important as bacteria from the mouth can be spread during your operation causing complications. We advise that you keep your mouth as clean as possible, brush your teeth at least twice a day, use antiseptic mouthwash and floss daily.

It may be advisable to visit the hygienist or Dentist before your surgery.

Relaxation

Before your operation it is important that you take time to relax and do things that you enjoy. Being relaxed before your operation can lead to a good recovery

Stoma

If your operation involves you having a stoma, you will be referred to the stoma team. The stoma team will arrange to see you before your operation to discuss living with a stoma, answer your questions and show you the use of the stoma appliances.

You and the stoma team will arrange an agreeable time to mark the stoma site before surgery. The stoma team will continue to support you after your operation.

Preparation at home

After your operation you may still have a lot of recovering to do and tire easily. You may not be able to do everything yourself straight away.

It may be beneficial to do some of the following before your operation:

• Get up to date with house chores
• Make some extra portions of food to freeze or purchase a few ready meals that you can freeze to use in the first couple of weeks at home.
• Arrange with relatives or friends to collect you when you are medically fit for discharge.
• If you have children, arrange childcare provision for at least 7 days
• Arrange care for pets if necessary

Pre-assessment

The primary role of the pre-assessment clinic is to ensure you have a safe anaesthetic during your operation.  During your pre-assessment appointment, you will meet an experienced qualified nurse, who will have a discussion with you around your general health. You will be asked questions about your medical and anaesthetic history, current medications and any allergies you may have. During the appointment you will have an ECG (Electro-cardiogram) to check the rate and rhythm of your heart, as well as your blood pressure, oxygen saturations and height and weight check.  MRSA screening and a blood test will also be done whilst in the pre-assessment clinic and you will be given an appointment for your CPET (Heart and Lung exercise test). If you are taking regular medications, the nurse will advise you if you need to omit any medication prior to the operation. 

Enhanced recovery surgical school

After your heart and lung exercise test you will attend the enhanced recovery surgical school. At this appointment you will meet your enhanced recovery nurse who will talk to you about preparation for your surgery including advice on diet and increasing activity. The enhanced recovery pathway, and how you can achieve your daily recovery goals, will be discussed as well as post-surgery care, anticipated length of stay and discharge plans.

Admission

It is usual to be admitted on the day of surgery to the elective surgical ward at 7am. When you arrive on the ward you will be welcomed by nursing staff and then you will meet with your anaesthetist and one of the surgical team performing the operation. All necessary paperwork will be completed, and nursing staff will perform any admission procedures. From Hope Ward you will go to theatre and after your operation you will be transferred to one of the surgical wards (Rowan, Primrose, and Poplar) or the intensive care unit.

What to bring into Hospital

We advise that you do not bring a lot of property into hospital and valuables are left at home.

The following items may be useful

• All your medication in the original packet
• Wash bag - toothbrush, toothpaste, soap, shampoo
• Comfortable clothing suitable to wear after your operation – shorts and t-shirt, loungewear, slippers, trainers - all suitable for you to mobilise in.
• High energy snacks – Crackers
• Chewing gum
• Entertainment – puzzle books & reading material

Bowel Preparation

It may be necessary to prepare your bowel prior to surgery and this will depend on what operation you are due to have. For some patients this may require you to take medication to help to clear out your bowel. This is usually given the day prior to surgery and will give you very loose stools. It is important that you drink plenty of fluids such as water, black tea and black coffee to replace what is lost. Avoid fizzy drinks and drinks with milk. Some patients may have an enema to help clear the lower part of the bowel on the morning of their surgery and sometimes bowel preparation is not required at all. This will be discussed with you prior to admission by your pre-assessment or ERP Nurse.

You will be given oral antibiotics tablets to take the day before surgery.

Low Molecular Weight Heparin (LMWH)

• This is a small injection into the skin 5cm away from your tummy button all around.
• It helps reduce the risk of a blood clot (thrombosis) by thinning the blood.
• The injection is given at home the night before surgery. Teaching on how to administer this will be given by your Pre-assessment nurse. If for any reason this is not appropriate for you, an alternative arrangement will be made.
• You will continue to have this daily while you are in hospital and will go home administering these yourself for 28 days from the day of your surgery.

Pre-operative drinks

As a part of the ERP you have to drink 2x pre-operative drinks on the morning of your surgery.

These drinks are carbohydrate (sugary) drinks and therefore patients with Diabetes will not be given these drinks. The drink will be given by the Pre assessment nurse.

Eating and drinking

• You can eat until Midnight the day before your operation (Unless you are having oral laxative bowel preparation).
• You can drink water up to 6am on the morning of your operation.
• You must not have anything to drink for two hours before your surgery. 
• If you have a hiatus hernia or suffer from severe heartburn, you should not have anything to drink for four hours before your operation.
• A few hours after your operation you should be able to start drinking and may be offered sips of water in recovery.
• It is important that you eat after your surgery (your ERP team will advise you when to start). Your body needs nourishment to help heal your wounds, reduce the risk of infection and generally help you to recover. We recommend that you follow a little and often approach and start with low fibre light meals and regular snacks. You will be given a nourishment drink like shake or soup. 

Pain control

It is important that your pain is well controlled so you can breathe deeply, cough and mobilise comfortably. You are likely to be offered a spinal injection into your back to control your pain. This will be done prior to general anaesthesia when you are awake. A small number of patients receive an epidural, which is a small tube inserted into your back to provide continuous pain relief. You may also have a very small tube inserted into your abdominal wall whilst you are asleep – this is known as rectus sheath catheter and allow you to receive more analgesia in the post-operative period. Alternatively you may have a patient controlled analgesia (PCA), which is a button you can press to administer pain relief via a drip. You will be visited by the pain team to ensure your pain is well controlled.  In some cases, you may receive only oral pain killers. It is advisable to take regular pain killer for a few days after your operation.

Sickness

After your surgery you may feel sick or vomit. This is usually caused by the anaesthetic drugs used. You will be given medicine during and after surgery to help reduce this. If you continue to feel sick it is important to let your nurse know so that they can give you medicine to relieve your sickness.

Tubes and drips

During your surgery a tube (catheter) will be placed into your bladder so that we can measure how much urine you are making and check that your kidneys are working well. This will be removed as soon as possible, usually within 48 hours after surgery.

You will have a tube in your nose to relieve pressure and remove fluids from the stomach.  This should be removed at the end of your operation.

You will have a drip in your arm and fluid will be given through this to stop you getting dehydrated. This should be removed once you are drinking.

You may also have some drains. These will help drain away any old blood or fluid from inside your operation site, down the tubes and into a bag or bottle. The drains would usually be removed two to three days after surgery.

Monitoring

During your recovery the nurses will monitor the following regularly

• Blood pressure, pulse, respiratory rate and temperature
• Fluid and  dietary intake
• Urine output
• Level of pain
• When you pass flatus / your bowels or stoma start working properly
• TED stockings -These are compressions stockings to help reduce the risk of blood clots.  They will be given to you prior to surgery and to be worn until discharge from hospital.

Enhanced recovery daily diary

Please find below your enhanced recovery daily diary, we would like you to complete the diary in order to fulfil the programme goals and ensure you have a quick and problem free recovery.

Day before the operation

You will have been informed what you will need by pre-assessment/ enhanced recovery nurse

Bowel preparation Yes/No

Picolax 10am and 4pm

Oral Antibiotics

Neomycin 1gm and metronidazole 400gm three times a day

Low molecule weight heparin (LMWH injection)

Injection 6pm

Day of surgery

You will have been informed what you will need

Bowel preparation – Enema on admission Yes/No

Carbohydrate pre-op drink

05:30am        06:00am

I am diabetic – NO carbohydrate pre-op drink

Evening of surgery (Day 0)

Deep breathing exercises every waking hour

Limb exercises every waking hour

Changed position to relieve pressure on bottom every 2 hours

Started drinking

Sat out of bed

First day (Day1) after surgery

Deep breathing exercises every waking hour

Limb exercises every waking hour

Changed position to relieve pressure from your bottom every 2 hours

Reported any pain or nausea

Sat out of bed in the morning for 2 hours

Sat out of bed in the afternoon for 2 hours

Sat out of bed in the evening for 2 hours

Walked 60m (assisted) morning

Walked 60m (assisted) afternoon

Walked 60m (assisted) evening

Drinking oral fluids 2L

Eaten Breakfast

Eaten lunch

Eaten supper

Eaten snacks between meals

Day 2 after surgery

Deep breathing exercises every waking hour

Limb exercises every waking hour

Changed position to relieve pressure from your bottom every 2 hours

Reported any pain or nausea

Had wash and dress in your usual clothes

Sat out of bed in the morning for 2 hours

Sat out of bed in the afternoon for 2 hours

Sat out of bed in the evening for 2 hours

Walked 60m (supervised) morning

Walked 60m (supervised) afternoon

Walked 60m (supervised) evening

Walked 60m (independently)

Drinking oral fluids 2L

Eaten Breakfast

Eaten lunch

Eaten supper

Eaten snacks between meals

Day 3 after surgery

Deep breathing exercises every waking hour

Limb exercises every waking hour

Changed position to relieve pressure from your bottom every 2 hours

Reported any pain or nausea

Had wash and dressed in your usual clothes

Sat out of bed in the morning for 2 hours

Sat out of bed in the afternoon for 2 hours

Sat out of bed in the evening for 2 hours

Walked 60m (independently) morning

Walked 60m (independently) afternoon

Walked 60m (independently) evening

Walked 60m (independently)

Eaten breakfast

Eaten lunch

Eaten supper

Eaten some snacks between meals

Discussed discharge plans with team

Day 4 after surgery

Deep breathing exercises every waking hour

Limb exercises every waking hour

Changed position to relieve pressure from your bottom every 2 hours

Reported any pain or nausea

Had wash and dressed in your usual clothes

Sat out of bed in the morning for 2 hours

Sat out of bed in the afternoon for 2 hours

Sat out of bed in the evening for 2 hours

Walked 60m (independently) morning

Walked 60m (independently) afternoon

Walked 60m (independently) evening

Walked 60m (independently)

Eaten breakfast

Eaten lunch

Eaten supper

Eaten snacks between meals

Day 5 after surgery

Deep breathing exercises every waking hour

Limb exercises every waking hour

Changed position to relieve pressure from your bottom every 2 hours

Reported any pain or nausea

Had wash and dressed in usual clothes

Sat out of bed in the morning for 2 hours

Sat out of bed in the afternoon for 2 hours

Sat out of bed in the evening for 2 hours

Walked 60m (independently) morning

Walked 60m (independently) afternoon

Walked 60m (independently) evening

Walked 60m (independently)

Eaten breakfast

Eaten lunch

Eaten supper

Eaten some snacks between meals

Discussed discharge plans/ arranged transport home

Discharge

We aim to get you home as soon as possible after your surgery this is usually when you are passing wind/opening your bowels and eating and drinking adequately.

Complications from your surgery do not happen very often but it is important that you know what to look out for.

Abdominal pain

It can be normal to experience abdominal pain for the first few weeks after surgery. This should decrease as time goes by. If you have increased severe abdominal pain, you should contact the colorectal team on the number provided or contact NHS 111/999.

Sickness

You may have occasional nausea in the first few weeks after surgery.  If you have persistent nausea or vomiting please contact the colorectal team.

Wound care

Your wounds should heal fairly quickly and dressings are usually removed prior to discharge. You are able to shower and get your wounds wet but do not apply soaps to your wounds. Pat the area dry and if advised re-apply dressings. Your wound may be uncomfortable and slightly red for the for the first 1-2 weeks, if your wound becomes

• Painful
• Swollen/ hard under the wound surface
• Feels hot
• Fluid/pus discharging

Please contact the colorectal team

Bowel function

Your bowel function is likely to change after surgery and this is likely to take some time to settle. You may find that your bowels are opening more frequently. It is important that you don’t become constipated, you may be prescribed a laxative as part of your discharge medication.

If you have persistent diarrhoea or constipation please contact the colorectal team.

If you have a stoma your stoma nurse will advise you what to do if you become constipated or have diarrhoea.

Exercise/Activities

It is not unusual to feel tired for up to six weeks after your operation.  It is important to do daily gentle exercises to build up your muscle strength and lift up your mood. 

Start going for a short walk daily and increase the distance by a small amount each day. 

You will be able to return to your normal activity and work when you feel well enough. 

Do not lift anything heavier than a kettle full of water, for up to six weeks after surgery. 

If you are planning to restart a routine exercise such as jogging or swimming you should wait until six weeks after your operation and start gradually. 

Work and driving

It is advisable that you do not drive for at least 4 weeks after your operation; you must feel safe to drive and check with your insurance company that you are covered following surgery. When you return to work is largely dependent on your occupation. We would advise you to return to work at the earliest 6 weeks post-operatively and usually after your outpatient follow up appointment.

Diet

Following your surgery, you may have to adjust your diet slightly depending on your bowel pattern. It is advisable to follow a low fibre diet for the first couple of weeks after surgery.

Eat food with high calorie and protein to help with wound healing and fighting infection.

Eat small meals with regular intervals

Drink plenty of fluids in between meals

Avoid spicy food

Food Diary    

Further information

If you require any further information, please contact the following:

Ring 020 8539 5522 and ask to bleep

Stoma nurses

Lisa Moothoo                          bleep 2888

Stacy Clarke                            bleep 2138

Colorectal Cancer Nurses

Waveney Stanford                   bleep 2548

Rachel Hooper                        bleep 2676

Enhanced Recovery Practitioner

Priya Koungampillil                 bleep 2669 Or Direct line 020 8535 6563

NOTES

Large print and other languages
This information can be made available in alternative formats, such as easy read or large print, and may be available in alternative languages, upon request. For more information, speak to your clinical team.
 

এই তথ্যগুলো সহজে পড়া যায় অথবা বৃহৎ প্রিন্টের মত বিকল্প ফরম্যাটে পাওয়া যাবে, এবং অনুরোধে অন্য ভাষায়ও পাওয়া যেতে পারে। আরো তথ্যের জন্য আপনার ক্লিনিক্যাল টিমের সাথে কথা বলুন।

Na żądanie te informacje mogą zostać udostępnione w innych formatach, takich jak zapis większą czcionką lub łatwą do czytania, a także w innych językach. Aby uzyskać więcej informacji, porozmawiaj ze swoim zespołem specjalistów.

Macluumaadkaan waxaa loo heli karaa qaab kale, sida ugu akhrinta ugu fudud, ama far waa weyn, waxana laga yabaa in lagu heli luuqaado Kale, haddii la codsado. Wixii macluumaad dheeraad ah, kala hadal kooxda xarunta caafimaadka.

Bu bilgi, kolay okunurluk veya büyük baskılar gibi alternatif biçimlerde sunulabilir, ve talep üzerine Alternatif Dillerde sunulabilir. Daha fazla bilgi için klinik ekibinizle irtibata geçin.

یہ معلومات متبادل فارمیٹس میں دستیاب کی جا سکتی ہیں، جیسا کہ پڑھنے میں آسان یا بڑا پرنٹ  اور درخواست پر متبادل زبانوں میں بھی دستیاب ہو سکتی ہیں۔ مزید معلومات کے لیے، اپنی کلینکل ٹیم سے بات کریں'۔

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Reference: BH/PIN/1047

Publication date: Nov 2020

All our patient information leaflets are reviewed every three years.

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