The aim of this information is to provide information for patients undergoing bowel surgery and/or their family members to help reinforce discussions with the treating doctors.
Enhanced Recovery After Surgery (ERAS) refers to the multidisciplinary team approach to your care before, during and after undergoing major bowel surgery (bowel resection). The team includes your surgeon and anaesthetist as well as the nurses, dietitians, physiotherapists and other team members involved in your care. They all work together with you to reduce the risk of potential complications and to help you achieve a short hospital stay and an uneventful recovery. You are encouraged to be an active member of this team and to be in charge of your own journey to recovery.
Consent: You will be asked to sign a form where you request and give permission for the surgery to take place. The consent must include a correct understanding of the procedure, the need for it, its aims, its potential complications and alternatives, if any.
Prepare for your discharge home before your admission to hospital. You may want to consider organising someone to do the housework for a few weeks after your surgery, cooking extra meals and freezing them and/or having a family member to come and stay with you for a few days after you go home. If you are the main carer for a family member, arrangements must be made for that care to continue during your absence and recovery. Speak to the social worker, the cancer-coordinator and/or your doctors about available options.
Before Surgery Care
You will be contacted to attend the Pre-Admission Clinic (PAC) at the hospital. An assessment of your perioperative risk and how this can be best managed will be undertaken by the anaesthetist. You will also be interviewed by a nurse to further discuss your admission and discharge planning. You will be sent to pathology for blood tests. The potential need and options for an iron infusion and pain management and your medication instructions (including blood thinners) will be discussed if applicable. Further referrals may be needed.
This visit also serves as an Education Session regarding the aspects of ERAS.
If you smoke it is extremely important that you stop. Your GP can assist you in this regard. It is advisable that you also minimise alcohol intake prior to surgery.
Exercise regularly to improve your general health – walking is a very simple form of exercise to improve your heart and lung health in preparation for surgery. Walk as much as you can.
Talk to your GP about improving any chronic conditions that you may have, such as diabetes or asthma before the surgery.
Synbiotics are a combination of prebiotics and probiotics (e.g. Inner Health Plus). Probiotics are the good gut bacteria and prebiotics are the substances that promote the growth of those good bacteria. It is recommended that synbiotics are used for two weeks prior to the surgery. No script is required.
For the three days prior to your operation you are required to consume a low fibre diet. ERAS Low Residue Foods include tender meat, fish, poultry and eggs. They also include low-fibre breads, biscuits, pasta, white rice and some vegetables such as peeled potato, zucchini, onions, mushrooms, lettuce and asparagus. Avoid seeds and pulp. Increase your fluid intake except if advised otherwise by your doctor(s).
Except if advised otherwise, daily “Movicol-Half” is also recommended for the three days prior to surgery. No script is required. Your surgeon will tell you if further bowel preparation is required.
At the PAC, you will also be given 6 x 200ml tetra packs, containing flavoured carbohydrate drink. You must drink 4 packs the evening before surgery and the last 2 packs, 2 hours before your arrival time. No solid foods, chewing gums/ lozenges should be consumed from midnight, the night before surgery. Clear fluid drinks such as water, black coffee or tea (without milk) and clear (not cloudy) apple juice are encouraged up to 2 hours before the surgery.
Skin preparation includes clipping (not shaving) abdominal hair when required. Please don’t attempt to shave your abdominal hair. Shower with a pre-op wash one night before surgery and the morning of surgery. Before admission but do not apply creams, powder or deodorant. Keep Warm this is very important.
Bring all recent x-rays and scans with you on the day of Admission. Make sure you bring all your prescribed medications with you.
This is a good time to ask any questions or raise concerns.
You will change into a theatre gown and firm stockings (TED’s). Your skin will be prepared and you may be given an enema.
You will then be transferred to the anaesthetic bay where the anaesthetist, anaesthetic technician or nurse will insert a drip. You will receive some of the anaesthetic medicines through that drip. The drip is usually required to remain in place for two or three days after the surgery.
The Surgery takes about 2 to 4 hours. When you wake up, you will receive oxygen through a mask on your face, or via small nasal clips, and you will be connected to an intravenous drip and to a urinary catheter. Wound drains and nasogastric tubes are only used under certain circumstances but not routinely. You will spend about an hour or two in the Recovery Room. Pain relief may be achieved by using an epidural catheter, a wound soaking device, injections and/or a patient-activated device for an average of three days as well as medicines such as panadol. The use of opioids (drugs such as morphine, which have a number of side effects) is reduced to a minimum in order to encourage bowel recovery.
After Surgery Care
After the Surgery, you may be transferred to the Intensive Care Unit (ICU) for monitoring, before going to the Surgical Ward. Your family will be able to visit you. You will be looked after by a team of doctors, nurses, physiotherapists and other members of the care team. If you have a stoma formed you will be followed up by a Stoma Nurse for stoma management/education.
You will receive blood-thinning injections to prevent blood clots. The injections may continue to be required after discharge from hospital.
Your lungs may not have full function due to:
- General anaesthetic;
- Your lying down position for the operation and
- Hesitance in taking deep breaths due to pain from the surgery.
To promote normal lung function immediately after your operation, you may be asked to take regular deep breaths as well as hold your breath for a few seconds before breathing out – this is to encourage smaller airways of the lungs to re-fill with air.
The ERAS regime requires that you move out of bed and sit upright in a chair, for periods of at least an hour and a maximum of 2 – 4 hours on the day of your surgery if you are medically safe to do so. Early mobilisation (which includes standing and walking) is critical in the prevention of complications.
The day after your surgery, it is beneficial to continue sitting in a chair for period throughout the day and to start walking short distances. All these forms of movement are intended to promote heart, lung and bowel functions, helping to prevent blood clots (DVTs and/or PEs), pneumonia and bowel obstructions respectively. Nursing and physiotherapy staff will provide re-assurance and assistance where needed.
Medications are readily given to stop nausea and vomiting. The ERAS method of care allows you to drink fluids when you can tolerate them. You will also receive two protein drinks per day, commencing about six hours after your operation.
Movicol-Half will be given to help your bowels get started and to keep them going as you recover. A Bowel Movement Chart will be kept and filled in, by the nursing staff.
You will commence a normal diet as soon as you can tolerate it. You will be encouraged to sit upright in a chair to eat your meals.
A Fluid Balance Chart will be used to monitor your daily intake (oral or intravenous) and output of fluids.
On Day Two or three, the epidural catheter or the wound soaker (whichever is applicable) will be removed and the oxygen mask will be taken down. The drip in your arm will be removed if you are tolerating fluids and a normal diet. The urinary catheter will be removed. You will be able to take a shower, with assistance if required. Your wound will be monitored daily and covered with a dressing.
A cancer coordinator assists with all aspects of cancer care if applicable.
The dietitian will oversee your dietary requirements when needed.
A physiotherapist may continue to review your progress during hospital, until you are able to walk enough distances to maintain general health. You may also be referred for an outpatient physiotherapist appointment at 6 weeks, if you have a new stoma formed.
The discharge planner will assess your needs for when you are discharged from hospital. You may need help around the house for the first few weeks. You should expect to be discharged from hospital around day five. You will need to be picked up by a family member or a friend.
Before you leave hospital, you will be given the telephone numbers to contact in case of an emergency. An appointment will need to be made for you to visit your surgeon for Follow Up Care. You may have skin staples that will need to be removed, pathology results to discuss and any other treatment plans such as chemotherapy or radiotherapy to be organised.
When you go home, avoid leafy vegetables (e.g. cabbage) for about 7 days as they contain a large amount of fibre. Continue walking for Exercise with frequent breaks. Avoid straining or heavy lifting for 6 to 12 weeks (nothing over 5 kg).
At Home Surgery Care
You may need to take medications to stimulate your Bowel Movements. Movicol-Half is recommended if you have not opened your bowels for longer than a day. If in doubt, consult your doctor. If unwell, attend the Emergency Department.
Gentle Sexual Activity is safe, as soon as you feel up to it. It would not cause damage. Initial fear and anxieties are part of the normal healing process. Some patients experience Sexual Dysfunction because of the pelvic nerves being compromised by the surgery. Consult your surgeon regarding available treatment options.
If your job does not involve strenuous activity or heavy lifting, you may be able to Return to Work after four weeks. If your job involves heavy duties, your surgeon will advise you as to when you could return to work.
You should not drive for at least two weeks.
You should attend the Emergency Department if:
- There is redness or swelling of the wound.
- You develop a discharge from the wound.
- Your stomach becomes unusually bloated or painful.
- You have a fever or feel unwell or repeatedly vomit.
- You have an ileostomy that has not functioned for 6 hours, or you have a colostomy that has not functioned for 3 days.
It may be a good idea to write down the questions you want to discuss with your doctor, for example, using complementary medications or alternate therapies.
If complications arise, your surgeon may convert your care from the ERAS regime to the traditional methods of care to ensure the best possible outcome for you.
If in doubt, ask questions!