Enhanced Recovery Programme
How to Recover
Quickly from Major
Colorectal Surgery
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Patient Information
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INTRODUCTON
We look forward to welcoming you to Ashford and St. Peter’s
Hospitals for your operation.
Our mission is for you to come into hospital as strong as possible,
ready for your surgery, and to make a quick recovery. In order
to achieve this, we will use an Enhanced Recovery Programme
to optimise your nutrition, mobility and pain relief around the
time of the operation. There is strong evidence that by following
an Enhanced Recovery Programme you will recover faster from
your operation, with fewer complications.
Enhanced Recovery involves staff caring for you, (anaesthetists,
nurses, dieticians, physiotherapists and surgeons) helping you
to follow a clearly defined programme and most importantly
requires your participation to make it work.
Together we will use as many parts of the programme that are
suitable for you to achieve the best recovery.
The key parts are:
Further Information
We endeavour to provide an excellent service at all times, but should you have
any concerns please, in the first instance, raise these with the Matron, Senior
Nurse or Manager on duty. If they cannot resolve your concern, please contact
our Patient Advice and Liaison Service (PALS) on 01932 723553 or email
[email protected]. If you remain concerned, PALS can also advise upon how
to make a formal complaint.
Author: Mr J Trickett
Department: Colorectal Surgery
Version: 2
Published: Sept 2012
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Review: Sept 2014
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Having nutritional high energy drinks before and soon
after your operation leading to early return to a normal diet.
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Having good pain relief.
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Getting out of bed and having assistance to walk, soon
after your operation.
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Getting home as soon as possible. Your Consultant
should have already discussed this with you, or you should
ask how long you will be in hospital at pre-assessment.
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ADMISSION PREPARATION
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It is important for you to be thinking about planning your
discharge, before you go into hospital. You can prepare by
arranging help and support before you come in such as:
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Make sure you know who can come and collect you from
hospital, please bring their contact details with you.
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Ask friends and relatives if they can come to stay or visit
to help around the house when you get home.
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Arrange for a friend or relative to do some shopping for
your or make extra portions of food to freeze, or purchase
ready meals and convenience foods that you can freeze
for use in the first couple of weeks.
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Get up to date on your housework before you come into
hospital, this will help reduce the load when you get home.
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Arrange additional childcare or help with the school runs
where necessary.
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Arrange care for your pets, if necessary
If you have any requirements that need to be put in place before
you go home, or any concerns or queries, please talk to your
clinical nurse specialist, key worker, pre-assessment nurse or
doctor before you come into hospital.
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Cakes, puddings made with white flour and that are nut
and fruit free
Jelly ice-cream, milk puddings, custard, sorbet
Honey, sugar, syrup, ‘jelly’ type jams
Tomato ketchup, brown sauce, mayonnaise
Salt, pepper, herbs, spices
Boiled sweets, chocolate, toffee and fudge without nuts or
fruit
Tea, coffee, fruit squash, smooth fruit juice (orange, apple
or grape) fizzy drinks, hot chocolate or malted milk drinks,
Bovril, Marmite
Free fluids / meals in liquid form
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Omit all solid food and take your meals in liquid form
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Includes thick soups without solid bits (clear soups,
Consommé, Bovril, Marmite), milk based puddings,
custard, ice cream, jelly, yoghurt.
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Boiled sweets, pastilles & peppermints are allowed.
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Drinks, tea & coffee (milk & sugar allowed), smooth fruit
juices, squash and milky drinks (Horlicks, Ovaltine, drinking
chocolate).
Clear fluids
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Water / plain or flavoured
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Clear soups, Bovril, Oxo & Marmite (dissolved in hot
water),
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Squashes without added fruit juice, black tea or coffee,
boiled sweets, pastilles
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DIET INFORMATION
BEFORE YOUR OPERATION
Low fibre diet
Getting fit for surgery:
Bread, other cereals and potatoes
• White bread, white chapatti, white pitta and white flour
• White pasta, White rice
• Refined cereals e.g. Rice Krispies, Cornflakes
• Cream crackers, rice cakes
• Boiled, mashed or roast potatoes (no skin)
Yams, sweet potato (no skin)
Anaemia: We will check you blood count prior to your operation.
If we find that you are anaemic (low in red blood cells) we may
organize for you to have a blood transfusion or see your GP to
start on oral iron tablets to help produce more blood cells before
your operation.
Fruit and vegetables
• Fresh, tinned or stewed fruit but remove any skin, pith or
pips
• Vegetables but remove any skins, stalks or seeds
Alcohol: You should reduce alcohol consumption prior to your
operation. Ideally you should not have any alcohol up to 1 week
prior to your operation.
Pulses and nuts
• None
Meat, fish and eggs
• Meat, poultry
• Fish
Milk and dairy products
• Milk, cream
• Plain or fruit yoghurts
• Cheese, butter
Smoking: If you are a smoker you are strongly advised to stop
smoking prior to your operation.
Exercise: It is important that you are as physically fit as possible
prior to your operation. If you are a person who regularly
exercises, just continue your current exercise plan. If you
undertake regular walks with a dog or friend continue, and try to
walk for longer, faster and more often.
If you are limited in the type and / or amount of exercise you are
able to do, use daily activities as a mode of exercise e.g. increase
the number of times your climb stairs etc. Please ensure you
take some form of daily exercise such as walking or light gym
practice/swimming.
Fats
• Margarine, oils
Others
• Plain biscuits e.g. Rich Tea, Morning Coffee
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Eating and Drinking
It is important that you are well nourished and not unintentionally
losing weight before your operation. This will assist the healing
of your wounds and reduce the risk of infection as well as
improving your general recovery.
You will need to follow a specific diet and schedule of nutritional
high energy drinks and prepare your bowel for surgery. We will
see you in an assessment clinic approximately 2 weeks before
your operation.
You will be prescribed nutritional high energy drinks, which will
need to be taken the day prior to and on your day of surgery.
This drink is called a preload and is a key aspect of your
Enhanced Recovery Programme.
These drinks have several benefits to your recovery. They will:
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Give you energy to help you recover
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Reduce the risk of nausea (sickness)
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Help your wounds heal
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Reduce the risk of infection
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Generally aid your recovery
Preload – Preparation Guidelines
Step 1 – Pour 400ml of water into cup
Step 2 – Add the contents of the sachet/s of preload
into the cup and stir
Six to eight weeks after your operation you should be back to
your normal level of activity. Do not undertake any heavy lifting
until six weeks following surgery and avoid standing for long
periods of time. Common sense will guide your exercise and
rehabilitation.
If your wound is uncomfortable go easy with your exercise. Once
your wound is pain free, you can undertake most activities.
Work
You should be able to return to work four to six weeks after
your surgery depending on the type of job you do. A member of
your health care team or your GP will be able to advise you.
Driving
You should not drive until you are confident that you can drive
safely. A good indicator for this is when you have got back to
most of your normal activities. Usually this will be within two to
four weeks of surgery. It is important that any pain has resolved
sufficiently to enable you to perform an emergency stop and
turn the wheel quickly.
If you have any problems after you go home please contact:
Lynn de Snoo
Carol Katte
Sally Tyte
Colorectal nurse
Stoma care nurse
Stoma care nurse
01932 723245
01932 722636
01932 722636
You should expect to have a call from our team within 24 hours
of discharge.
Step 3 – Drink as directed below
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if you are worried about any of the following please phone the
telephone numbers on this leaflet (page 15) If you cannot contact
the people listed then ring your GP, or the ward direct.
When should I take the preload?
Following discharge from hospital, after surgery it is normal to
experience some abdominal discomfort from the wound. This
will gradually improve over several weeks. You should continue
taking the pain relieving drugs, which have been prescribed
for you at the hospital, until you feel comfortable. If you need
further supplies or your pain is not adequately controlled you
should see your GP.
By 9pm: 2 sachets of preload in 400ml of water
Your Wound
If your surgery is scheduled for the afternoon have nothing
except a small amount of water and your carbohydrate drink
up to 2 hours before your operation – 1 sachet of preload in
400mls water to be finished by 10.30am.
It is not unusual for your wound to be slightly red and
uncomfortable during the first 1-2 weeks. Please let us know if
your wound is:
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Becoming inflamed, painful or swollen
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Starting to discharge fluid
Bowels
Evening before surgery
Day of Surgery
If your surgery is scheduled for the morning you should have
nothing to eat after midnight, but you may have a small amount
of water and your carbohydrate drink, up to 2 hours before
your operation – 1 sachet of preload in 400mls water to be
finished by 6am.
YOUR OPERATION
Your bowel habit may change after part of your bowel is removed.
You will be informed before you are discharged of what to expect.
We will discuss with you the sort of operation you require. This
will determine which of two ways we prepare your bowel for
surgery and if you require a stoma bag.
Returning to Normal Activities
You will be given the right sort of instructions tailored to your
particular operation.
For the first two weeks at home you should rest, relax and
continue the exercises that you did in hospital. Go for a walk
each day and gradually increase the amount you are doing.
Regular exercise combined with regular rest periods should help
you to return to normal activities as soon as possible.
If you need a stoma bag, a specialist stoma nurse will help you
by explaining what is involved and familiarising you with the
bags and general care before your operation.
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GUIDELINES FOR PATIENTS HAVING FULL BOWEL
PREPARATION FOR SURGERY
single injection in your back at the time of surgery (spinal). In
addition, you will be given other pain relief by mouth as required.
Four days before operation: Avoid foods that are high in fibre;
(brown rice, cereals, vegetables), choose low fibre alternatives
instead.
Tubes and Drips
Three days before operation (fluids only): Omit all solid food
and take your meals in liquid form.
NB: See pages 16 & 17 for further details on diet and free fluids
Two days before operation (clear fluids and nutritional
supplement drinks only).
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Aim to drink 2-3 glasses of clear liquid every 2 hours
during the day; e.g. water based drinks, squash, no milk,
no fruit juice.
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Please take one sachet of bowel prep at 08.00 hours.
This needs to be dissolved in one cup of water, stirred for
2-3 minutes and then drunk (please take care as the cup
may get hot).
NB: This medication will clear your bowels so you will need to be
close to a toilet.
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At 14.00 hours please take the second sachet of bowel
prep as instructed.
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Please drink 2 Fortisips 200ml cartons (1 in the afternoon
and 1 in the evening).
During your surgery a tube (catheter) will be placed in your
bladder so that we can check that your kidneys are working
well and producing urine. This will be removed as soon as
possible, usually within 48 hours after your surgery. You will have
a drip put into your arm and fluid will be given through this to
ensure you get enough fluid and do not become dehydrated.
This should be removed once you are drinking.
Occasionally, following surgery you may have a wound drain;
this is a plastic tube coming from your wound into a bottle or
bag to remove any excess fluid from your wound site. Depending
on the fluid in the bag these drains tend to be removed within
the first 24-48 hours after your operation.
Your participation in your recovery is extremely important, and
will help to reduce the chance of complications (such as infections
and blood clots in your legs) and will help your bowel function
return and get you home sooner.
Important Discharge Information
Our aim is to discharge you from hospital after 3/4 days for
colon operations and after 5 days for more complicated pelvic /
rectal surgery.
When You Leave Hospital
Complications do not happen very often but it is important you
know what to look out for. During the first two weeks after surgery
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First day after operation: Aim to drink 2 litres of fluid including
cartons of Fortisips and, with the aid of the nurses and
physiotherapists, participate in your walking programme. If you
feel hungry start a soft diet. If you are mobile and have not had
pelvic / rectal surgery we may remove your urinary catheter
NB: Please note that whilst Fortisips are not a clear fluid, the
benefits of taking them outweigh the need to have a totally
clear fluid diet before surgery.
One day before operation:
Second and subsequent days after operation: Continue to
drink 2 litres of fluid and, if you can manage it, start a normal
diet. We also want you to continue walking about as much as
possible. We will start to remove catheters and drips to help
“free you up” to walk.
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Continue to drink plenty of clear fluids all day.
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Please drink 4 cartons of the Fortisips throughout the day
(total 800ml).
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On the evening before your operation drink 2 dissolved
50g sachets of your Preload.
Sickness
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If you are admitted to hospital the day before your
operation, please bring the Fortisips with you.
Sometimes after surgery a person may feel sick or be sick. This
is usually caused by the anaesthetic agents or drugs we use. You
will be given medication during surgery to reduce this, but if
you feel sick following surgery, please speak to your nurse
who will be able to provide medication to help you. It is important
to relieve sickness in order to allow you to feel better so that
you can eat and drink normally which will aid your recovery.
Pain Control
It is important that your pain is controlled; you will not be pain free
but should be comfortable so that you can walk about, breathe
deeply, cough, eat and drink, feel relaxed and sleep well. You
will receive a number of different medications to control your
discomfort. You may have an injection in your back (epidural)
which allows a continuous supply of pain relieving medicine by
infusion or alternatively a PCA (Patient Controlled Analgesia),
which allows you to control the amount of pain medication that
you receive via a machine. Alternatively you may be given a
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Day of operation:
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Drink 1 dissolved 50g sachet of Preload 2-3 hours before
the scheduled operation time.
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If your operation is scheduled for the afternoon, drink 2
sachets of Preload during the morning.
NB: You are allowed water up to 4 hours before the
operation. (Approx 1 glass water per hour). It is important
you do not become dehydrated.
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GUIDELINES FOR PATIENTS HAVING AN ENEMA TO
PREPARE THEIR BOWELS FOR SURGERY
The nursing staff on the admission ward will explain and
administer the enemas when they are required
Two days before operation:
Avoid foods that are high in fibre, (brown rice, cereals,
vegetables), choose low fibre alternatives instead. (Please see
section on pages 16 & 17 for further advice).
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Please drink 2 Fortisips 200ml cartons (1 in the afternoon
and 1 in the evening).
GUIDELINES FOR ALL PATIENTS AFTER SURGERY
On the day of your operation
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When you wake up after your operation it is important you
start deep breathing exercises. Breathe in through your
nose and slowly our through your mouth. This should be
done at least five times an hour and this should reduce
the risk of a chest infection. If you need to cough use your
hands or a pillow to support your wound as this should
make coughing more comfortable. It is important that you
do not try to stop your self coughing if you feel you need
to. It is also important to point your feet up and down and
circle your ankles to reduce the risk of clots in your legs.
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1 carton of Fortisips (200ml) should be consumed every 6
hours.
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Once you have been back from surgery the staff will help
you out of bed and you will be encouraged to spend time
sitting out of bed in a chair. On the following days you will
be expected to sit out for at least four hours and your will
also be encouraged to walk 3-4 times a day.
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Being out of bed in a more upright position and by walking
regularly improves lung function and there is less chance
of chest infection as more oxygen is carried around the
body to the tissues. Try and wear your day ‘comfortable
‘clothes after your surgery as this can help you feel positive
about your recovery.
One day before operation (fluids and nutritional
supplements only).
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Continue to drink plenty of fluids all day.
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If you are admitted to hospital the day before the
operation, please bring the Fortisips with you.
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On the evening before the operation drink 2 dissolved
50g sachets of Preload.
Day of operation:
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Drink 1 dissolved 50g sachet of Preload 2-3 hours before
the scheduled operation time.
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If your operation is scheduled for the afternoon, drink 2
sachets of preload during the morning.
NB: You are allowed water up to 4 hours before the
operation. (Approx 1 glass water per hour). It is important
you do not become dehydrated.
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