Enhanced Recovery Programme Discharge Information - Colorectal Surgery

Ask three questions

As you prepare to leave hospital you may need to get certain things organised. To help you with your planning, make sure you get the answers to these three questions:

1. What are my options?
2. What are the possible benefits and risks of those options?
3. What help do I need to make my decision?

For further information please speak to the staff looking after you.

Your estimated discharge date

The Enhanced Recovery Nurses will discuss your discharge date with you.

When you leave hospital

Complications should not happen very often, but it is important that you know what to look out for.

During the first two weeks after surgery, if you are worried about any of the following, please phone the telephone numbers at the bottom of this page. You should be able to reach a member of staff on the ward at anytime. If you cannot contact the people listed, you will need to contact your GP or the NHS 111 service.

Abdominal pain

It is not unusual to suffer gripping pains (colic) during the first week following removal of a portion of bowel. The pain usually lasts for a few minutes and will go away completely in between spasms.

Severe pain that lasts for several hours may indicate a leakage of fluid from the area where the bowel has been joined together. This can be a serious complication, which fortunately, happens only rarely. Should this occur, it may be accompanied by a fever. On occasion leakage may occur which makes you feel generally unwell, causes a fever but is without pain.

If you have severe abdominal pain lasting more than 1-2 hours and/or have a fever and feel generally unwell, you should contact us on the telephone numbers provided immediately.

Vomiting

Occasionally after surgery you can experience some nausea which is not unusual. Persistent nausea and vomiting however is not to be expected as this could be a sign of obstruction. If this happens to you it could be a sign of obstruction which needs to be treated.

If you experience severe nausea and vomiting please contact us immediately on the telephone numbers provided.

Your wound

The ward nurses will check your wound dressing before discharging you home.

If you have had key hole surgery you might have paper stitches (steristrips) which may be left directly on the wounds. You can continue to bathe or shower and you can pull these off after 7 days during a soak in the bath. You shouldn’t need further dressings after this.

For other wounds it is possible that either dissolvable stitches or a special adhesive will be used and again you may continue to take light showers or baths. If you require a dressing for a longer period of time then the nursing staff will advise you.

It is not unusual for your wounds to be slightly red and tender during the first 1-2 weeks. You may also notice bruising.

Please let us know if your wound:

• Becomes more red, painful or swollen.
• Starts to discharge fluid/pus.
• Your wound edges separate.

As this may indicate an infection. You may also wish to contact your GP or practice nurse at your surgery for advice.

Your bowels

In the early stages following surgery to remove part of your bowel, your bowel habit may change and may either become loose or constipated. This can continue for up to 2-3 weeks.

Try to eat regular meals three or more times per day, drink adequate amounts, and take regular walks during the first two weeks after your operation. This will help improve bowel function.

Please note that if you have an ileostomy it is normal to pass loose stools more frequently than 3 times per day into the Stoma bag. The stoma nurse specialists will discuss this with you.

Please seek advice from the Enhanced Recovery Nurses, your GP or by contacting one of the telephone numbers at the bottom of this page if you are experiencing any of the following:

• Prolonged constipation or diarrhoea.
• Discharge, pus or bleeding from the back passage.
• If you are needing to empty your ileostomy pouch more than 6 times per day and if it is of a very loose, watery consistency.

Passing urine

Sometimes after bowel surgery you may experience the feeling of a full bladder.

This usually resolves, however if you experience ANY of the following problems please ring for advice:

• Unable to pass urine.
• Bladder pain or discomfort on passing urine.
• Excessive stinging when passing urine, as you may have an infection which will require treatment.
• Difficulty in emptying your bladder fully.

Diet

A balanced, varied diet is recommended and particularly eating 3 or more times a day. You may find that some foods upset you and cause loose bowel motions. If that is the case you should avoid those foods for the first few weeks following your surgery. You may find a low residue diet will help in the first two weeks after your operation.

If you are finding it difficult to eat it is still important to obtain an adequate amount of protein and calories to help your body heal. You may benefit from having three to four high protein, high calorie drinks such as Build-up or Complan (available in supermarkets and chemists) to supplement your food, or continue with the Fortisip or Fortijuce drinks which can be prescribed by your GP.

It is important to drink plenty of water. If you are suffering from diarrhoea then it is important to replace the fluid loss and to drink extra fluid.

If you are losing weight without trying or are struggling to eat enough you may benefit from a consultation with the dietitian, please contact any of the numbers provided below and someone will be able to help you, or ask your GP or consultant to refer you.

Helpful suggestions

• Eat small nourishing snacks between meals.
• Try not to skip meals, have a snack or nourishing drink if you cannot manage a main meal.
• Have nourishing drinks during the day. Avoid drinks up to 30 minutes before meals, as they may fill you up.
• If you are not eating as much as you normally would, try fortifying foods to make them more nourishing. See more information below on fortifying foods.
• Have a selection of easy-to-prepare foods in case you do not feel like cooking.
• Make use of your freezer and cupboards to store convenience foods.
• Aim to try and have 5 daily portions of fruit and vegetables to ensure a good vitamin and mineral intake. You may find it easier to digest if you remove the skin.

Important foods

Try to include high calorie and high protein foods at each mealtime.

High Protein Foods

• Meat and fish
• Eggs
• Soya
• Milk, yoghurt, cheese
• Nuts, beans, lentils

High Calorie Foods (if your appetite is poor)

Fatty and sugary foods such as:

• Biscuits and cakes
• Crisps and chocolate
• Puddings
• Cream and butter

Snack ideas

Try these snack ideas which are high in energy or protein:

Savoury

• 'Cream of’ soups
• Bombay Mix
• Individual cheeses
• Crisps and dips
• Peanut butter, nuts
• Quiche, cocktail sausages and pork pies.
• Cheese and biscuits
• Sandwiches
• Instant noodles

Sweet

• Milk puddings, rice pudding, mousse and custard
• Tea cakes and malt loaf
• Pastries and biscuits
• Cakes and muffins
• Trifle and ice cream
• Crumpets
• Full fat yoghurt
• Chocolate

Nourishing drinks

Milky drinks are high in energy and protein. Choose from the following:

• Full cream milk.
• Milkshakes and smoothies.
• Hot chocolate and malted drinks.
• Milky coffee and tea.
• Yoghurt drinks.
• Complan and Build Up.

If you dislike milk, try these high energy alternatives:

• Sugary fizzy drinks e.g. Lucozade, cola, lemonade.
• Complan and Build Up Soups.
• Fruit juice.
• Soya drinks e.g. OY or Provamel.
• ‘Cream of’ soups.

Fortifying foods

The following suggestions may help to add extra energy and protein to everyday foods if you have lost weight or are not eating much:

Milk

• Try using full cream milk instead of lower fat milks in tea, coffee, soups, sauces, jellies, milk puddings, porridge, custard.
• Add ice-cream or creamy yoghurt to milkshakes and smoothies.
• Try using condensed or evaporated milk.

Breakfast cereals

• Use full cream milk.
• Add extra dried fruit or nuts.
• Sprinkle extra sugar on top.
• Add jam, honey or syrup to yoghurt, porridge or cereals.

Toast

• Spread butter or margarine on whilst the toast is still hot.
• Spread jam, marmalade, honey or peanut butter on thickly.
• Try the above with crumpets, muffins and teacakes.    

Sandwiches

• Add mayonnaise or salad cream to fillings such as egg, tuna, cheese or meat.
• Spread butter or margarine thickly.

Soups

• Use ‘Cream of’ varieties.
• Add grated cheese.
• Add dumplings, baked beans or pasta.
• Add croutons.

Mashed potato

• Add butter, margarine, cream, grated cheese or extra milk.
• Mash hard boiled egg with potato and margarine or butter taste.
• Add flaked fish/corned beef/minced beef/fried onions.

Vegetables

• Melt butter or margarine on top.
• Sprinkle with grated cheese or chopped egg.
• Serve with a sauce e.g. cheese or hollandaise sauce.

Puddings

• Try to have a pudding after each main meal or as a snack in-between if your appetite is poor.
• Add cream, ice-cream, yoghurt, condensed or evaporated milk to puddings such as milk puddings, fruit or instant desserts.
• Add sugar, honey or syrup to ice-cream or other puddings.
• Make fruit fool using custard or double cream and pureed fruit.

Sample meal ideas

Breakfast

• Creamy scrambled egg with buttered toast.
• Porridge/cereals with honey/jam.
• Crumpets with butter and jam.
• Muesli with whole cream milk and natural yoghurt.

Main meal

• Shepherds pie with grated cheese topping and buttered vegetables.
• Chicken curry or dahl with rice or chapatti spread with butter or margarine.
• Cauliflower cheese made with fortified milk with grated cheese topping.
• Fish in cheese sauce with creamed potatoes and buttered vegetables.

Snack meals

• Beans on buttered toast with grated cheese topping
• Buttered jacket potato with tuna mayonnaise filling.
• Ham or cheese omelette, chips and salad with mayonnaise.
• A creamy soup with grated grated cheese and croutons.

Pudding Ideas

• Milk pudding e.g. rice/tapioca/ semolina.
• Baked egg custard.
• Crumble with ice-cream.
• Trifle with cream.
• Jelly made with fortified milk.

Exercise

We encourage activity from day one following surgery. You should plan to undertake regular exercise several times a day and gradually increase during the 4 weeks following your operation until you are back to your normal level of activity.

The main restriction we would place on exercise is that you do not undertake heavy lifting 4 - 6 weeks following your surgery. In addition, if you are planning to restart a routine exercise such as jogging or swimming that you wait until 2 weeks after surgery and start gradually.

Common sense will guide your exercise and rehabilitation; in general if the wound is still uncomfortable modify your exercise. Once the wounds are pain free you can undertake most activities.

Work

Many people are able to return to work within 2 - 4 weeks following their surgery. If it involves a heavy manual job then we would not advise heavy work until 6 weeks following surgery.

Driving

It is advised that you do not drive until you are confident that you can drive safely. Usually this is when you are doing most of your normal activities. In general this will be after 4 weeks of surgery. It is important that any pain has resolved sufficiently to enable you to perform an emergency stop. You should contact your insurance company to check their terms or you may not be fully insured.

Hobbies and activities

In general it is advised that you take up your hobbies and activities as soon as possible again after surgery. It enables you to maintain your activity and will benefit your convalescence.

We would not advise restricting these unless they cause significant pain or involve heavy lifting within the first 6 weeks following surgery.

Sexual activities

Feeling tired and weak after an operation or illness naturally affects your sex drive. As you gradually start to feel well again and your energy levels return to normal so should your sex drive. It is important for you and your partner to discuss your feelings openly.

Sexual intercourse can be resumed as soon as you feel comfortable, generally about two to four weeks after surgery. Occasionally, following surgery or radiotherapy to the rectum or lower colon, nerve and blood vessel damage can occur. In men this may cause ejaculatory problems or result in difficulty and/or maintaining an erection. In women, discomfort or vaginal dryness may occur.

These problems are usually temporary, due to inflammation and swelling after surgery, but in some instances may be permanent. If you do experience problems of this nature, please discuss it with your surgeon or colorectal nurse specialist, as specialist help is available.

Medications

You may continue with your normal medicines unless directed to stop by your doctor. You will be given a new supply of these if you do not have enough at home. You will also be given pain killers and any other medicines required, to take home.

It is a good idea to have a supply of non-prescription pain killers, such as Paracetamol, at home as a back up.

If you are required to continue with the ‘Clexane’ injections at home, you will be given enough pre-filled syringes to complete the course (usually for four weeks after your operation) and a ‘sharps bin’ to put the used syringes into. Your GP or local chemist will be able to advise you on how to dispose of the bin in your area.

Clinic follow up appointments

If you are under the care of one of the colorectal nurse specialists, your follow up appointment will be arranged by them. They will discuss this with you as soon as the biopsy results are available. This will usually be approximately two weeks after discharge home. Otherwise an appointment will be sent through the post as directed by the consultant.

Follow up appointments allows the team to see how you are and talk through any further treatment. Please do not hesitate to contact any of us on the numbers provided below if you need any help or advice following surgery.

If your surgery was planned (not an emergency) the enhanced recovery nurse will phone you at home each day for approximately four to five days to check on your progress. In between times, if you have any concerns, you can contact them on the number provided, or out of hours contact the ward.

When to seek urgent advice

If you experience any of the following please seek urgent advice by contacting us on the numbers below.

• Severe or uncontrolled abdominal pain.
• Persistent nausea and vomiting.
• Unable to eat and drink sufficiently.
• Urgent or serious wound problems.
• High stoma output (if you have a stoma following surgery).
• Persistent loose stools/ diarrhoea.
• A new difficultly passing urine.

References and further information

www.nhs.uk/conditions/enhanced-recovery

www.nbt.nhs.uk/erp

www.gov.uk/government/organisations/department-of-health-and-social-care

How to contact us

Enhanced Recovery Nurses

Telephone: 0117 414 3610

Telephone: 0117 414 3611

Colorectal nurses

Telephone: 0117 414 0514

Stoma Care Nurses

Telephone: 0117 414 0270

Surgical Admissions Unit

Gate 32B Brunel building

Southmead Hospital

Bristol

BS10 5NB

Telephone: 0117 414 3233

Telephone: 0117 414 3234

www.nbt.nhs.uk/erp