Useful information for patients who have been in the Intensive Care Unit and their relatives

The ICU Follow Up service contact details are:

ICUfollowup@nbt.nhs.uk

0117 414 1400

This telephone number is to ICU Reception please request to leave a message for the follow up team and we will try and get back to you as soon as possible.

View our ICU Follow Up website page for more information.

The ICU Follow Up Team are:

• ICU Senior Sister: Mo Maddock
• ICU Senior Sister: Jordan Sumner
• ICU Consultant: Dr Ben Walton
• ICU Consultant: Dr Andy Ray
• ICU Physiotherapist: Hannah Marychurch
• Clinical Psychologist: Nick Ambler
• Clinical Psychologist: Hannah Golden

Due to the nature of our work our time is predominantly spent working clinically however we endeavour to answer messages as soon as possible.

If you have an emergency

Please call 999, or if you require urgent advice contact your GP or utilise the NHS 111 service, over the phone or online.

Introduction

This information has been designed to assist patients and their relatives in their recovery following a period of critical illness. It aims to offer advice and provide an understanding of some of the challenges and worries that patients may experience during recovery. In the first few days after leaving ICU, you may find this information a little overwhelming and tiring to read, the information is also relevant to your relatives to allow them to gain a better understanding of what you are going through.

After critical illness, it is common for it to take a significant period of time for you to feel like your normal self. This will be different for everyone and can be dependent on your length of stay in hospital, and what caused you to be admitted in the first place.

This information aims to explain some of the more common challenges experienced by patients after critical illness, such as changes to your sleep, energy levels, appetite, mood, and family relationships.

You likely won’t experience all of the problems described here, but if you do suffer from any of them, we hope that you will find the relevant advice helpful.

Please be reassured that there is every chance you will return to your previous state of health and your symptoms will pass with time.

ICU follow up clinic

When you are discharged from hospital after being critically ill, there will be a period of physical, mental and emotional recovery that will likely take some time. We feel it is important to ensure you are not alone during this.

Our follow up clinic aims to provide somewhere for you and your family to be supported through this journey after hospital. All patients admitted to NBT ICU are entitled to attend our follow up clinic, however, as one of the largest ICUs in the country we treat on average 250 patients a month. As you can appreciate this creates a huge volume of potential visitors to our follow up clinic. For us to manage these numbers there are certain patient groups we will actively contact, based on their length of stay and condition. That doesn’t mean we don’t welcome everyone else, but instead, ask that you contact us via our email address if you feel the need to discuss your time with us in ICU, we’d love to hear from you.

For those who we actively contact, we aim to get in touch approximately 8 weeks after being discharged from hospital. We ask you to complete a health questionnaire allowing us to gain more information about how you are getting on post-discharge. Once completed and returned to the follow up clinic, a member of the team will contact you to discuss the questionnaire in more detail and establish whether you would benefit from more input. In this instance, you will be invited back to the hospital for a face-to-face or virtual meeting with the team, where we will aim to establish any current issues and attempt to assist you in dealing with these or signpost you to support available. You may also wish to look at the helplines listed near the bottom of this page.

Going to the ward

Going to the ward is a big step in your recovery from critical illness and gets you one step closer to going home. However, it is a big change in your care and therefore very normal to feel apprehensive. The ICU routine and staff may have become familiar to you and the thought of meeting new people and learning a new routine can make you feel anxious.

There are fewer nurses for each patient on the ward and this can sometimes feel as though you are waiting slightly longer for assistance. However, this also reflects the fact you are now able to do more for yourself, and you will continue to be closely monitored. The staff on wards have lots of experience in caring for patients recently discharged from ICU and will be able to assist you with any concerns you may have.

When first transferring to a ward some patients may still be experiencing episodes of delirium or acute confusion. This can be quite common and although very scary for both the patient and the relatives experiencing it, this should improve and settle with time. There is no magic treatment to stop this, however, as relatives, you can support your family member by trying to reorientate them to the date, time of day, and where they are. Also helpful is acknowledging that it can be very scary for the patient not being able to understand or remember where they are or what is happening to them, and providing reassurance.

The ICU steps website has an information booklet on Delirium that may be of help.

Exercise and mobility

Eating normally again

Sleeping

Changes in mood

Your family and relationships

Changes in appearance or voice

Stress and relaxation

Post traumatic symptoms

Patient diaries

Energy levels

Patient Advice and Liaison (PALS)

Further information

Feedback

© North Bristol NHS Trust. This edition published July 2022. Review due July 2025. NBT003494

What is trans anal surgery?

Trans anal surgery involves the removal of a rectal growth through the anus. It has been performed since the mid-1980s. For many years it has been a specialist operation only available in a few centres. More recently, there have been advances in technology to allow more surgeons to be able to use this technique.

When is trans anal surgery performed?

It is usually indicated in patients who have a benign polyp that is deemed too large to be removed in the endoscopy department. It may also be recommended for removal of a rectal polyp where the endoscopist has recommended that the polyp should be removed in one piece. This ‘one piece’ excision may not be possible endoscopically.

The benefits of removing a polyp in one piece is that when it is looked at under the microscope, the pathologists will be able to truly say whether the polyp has cancer in it or not. This evaluation is not possible when a polyp is removed in several pieces.

A small percentage of patients who are diagnosed with rectal cancer may be offered trans anal surgery. This may be in combination with radiotherapy. This would be as an alternative to major surgery which usually requires patients to have a stoma bag.

What other tests are necessary before the operation?

Usually it will be necessary to perform a flexible sigmoidoscopy or colonoscopy prior to trans anal surgery. This will allow us to gain accurate information about the growth we are trying to remove. If we are worried about the possibility of an underlying rectal cancer, we will arrange a CT and MRI scan.

Most patients are prescribed medication to cleanse the bowel on the day prior to the operation. This will involve taking 2 sachets of powder which is mixed with water. Other drinks such as orange squash and cordial can be mixed with it to improve the taste which some may find unpleasant. The reason for cleansing the bowel is to ensure that there are clear views of the growth during the operation.

What does the operation involve?

The operation is performed under general anaesthetic by keyhole surgery and takes between 1 and 2 hours.

All patients have a temporary urinary catheter inserted at the start of the procedure. A 4cm flexible port is inserted into the anal canal to allow the surgeon to use standard keyhole equipment. As with a colonoscopy, gas is used to keep the rectum widely open to allow the operation to proceed.

For benign polyps, the growth is essentially ‘skinned’ from the bowel muscle wall in one piece. For cancers, a full thickness excision is performed with a good rim of healthy tissue around. Occasionally this internal wound is stitched closed; however, sometimes we leave this wound open to heal slowly.

What is the recovery like after surgery?

It is usually a day case procedure and so you will be able to go home later that day. As with a colonoscopy procedure, your abdomen will feel bloated and gas filled when you come around from the anaesthetic. It is important to get up as soon as possible and walk around. We usually recommend a quick trip to the toilet to let off the gas.

Over the next 2-3 days you may experience some anal discomfort and pain. You may also experience some spot bleeding from the rectum. In most cases this settles within a week. If it gets worse rather than better we would recommend attending A&E or contact your healthcare provider for referral to surgical hot clinic for a review.

A small percentage of patients experience a temporary fever. We recommend taking paracetamol for a few days if this occurs.

Your bowels may take up to a week to start working. This is because of the bowel preparation taken before your operation. You can return to a normal diet straight away. You may be fit to drive after 1 week and to return to work after 2-4 weeks. You will be issued with a discharge summary and a copy will go to your GP. Pathology results from the removed growth will usually take 2 weeks.

Normal follow up after this procedure will involve a flexible sigmoidoscopy in the endoscopy department, usually by the surgeon who has performed the operation. This will happen three months after surgery. You will be given a phosphate enema to prepare your bowel for this follow up test.

What are the results like from surgery?

For patients with benign polyps, the surgery is usually curative. Patients under 75 years can expect to be invited for an endoscopy ‘screening’ programme as they may be at risk of developing further polyps in future.

For patients with rectal cancer, this operation can be curative for very early cancers. For more advanced rectal cancers that are still small in size, this operation is not standard. Usually major surgery would be recommended. Currently there are trials underway evaluating the safety of this technique in such cancers. Some patients with more advanced but small, rectal cancers have opted for this technique as an alternative to major surgery. In North Bristol we have treated a small percentage of patients with rectal cancer in this way. At this early stage, the risk of developing recurrent rectal cancer in patients undergoing this surgery is low.

We cannot predict which patients, if treated this way, will develop a recurrence and need further surgery. For these patients a close follow up programme is offered involving regular flexible sigmoidoscopy, MRI and CT scans.

What are the risks and long term effects of surgery?

This operation is usually well tolerated by patients, regardless of age. Patients can expect to be discharged the same day and are usually back to their normal selves within a week.

All surgery has risks and it is important to be aware of these risks before agreeing to surgery.

Specific complications

• Bleeding (usually spotting for 3-5 days then should stop).
• Pain around rectum/anus (common, should settle).
• Abdominal bloating (should settle in 24 hours).
• Infection (rare), transient temperature (more common).
• Urinary retention (increases with age, occasionally may need to be discharged with a catheter).
• Faecal urgency (this usually settles after 1 week).
• Faecal incontinence (rare).

Cancer patients

This biggest risk of choosing this operation over standard abdominal surgery is the risk of the cancer coming back either in the scar or spreading to nearby lymph nodes. For most patients with rectal cancer, this risk is low. For a small group of patients this risk may rise to 30%. All patients are offered a close follow up programme.

International studies have suggested that it should be possible to still perform major surgery if a cancer returned in the rectum after undergoing trans anal surgery. This issue will be discussed with you in depth prior to undergoing this procedure.

Is anyone not suitable for surgery?

We have operated on patients ranging in age from 35 to 90 years. It is well tolerated in all age groups. Sometimes it may not be possible to perform trans anal surgery. This may be because the growth is too large to be safely removed using this technique.

In a small percentage of cases we would need to perform major abdominal surgery (anterior resection) to remove your rectum instead. This operation carries significant risks – stoma formation (40%), anastomotic leak(<8%), damage to other structure in the abdomen and death (<2%).

Is there an alternative to trans anal surgery?

Yes, many centres recommend major abdominal surgery in order to remove the rectum/growth. This is standard treatment however carries significant risks with regard to recovery and longer term bowel function.

Is the operation painful?

As with all operations, you should expect some pain; usually this is localised to the anus. Taking over the counter painkillers such as paracetamol regularly will help. Your discomfort should settle down after a week.

If you have any concerns about ongoing symptoms or you are unsure about anything after surgery, contact your healthcare professional for advice.

How to contact us

Enhanced Recovery Nurses

Monday - Friday, 7:30am - 3:30pm

Telephone: 0117 414 3610 or 0117 414 3611

Telephone: 07808 201713

© North Bristol NHS Trust. This edition published July 2022. Review due July 2025. NBT003237

This leaflet has been provided to give you information about the reversal of your small bowel stoma (ileostomy) or large bowel stoma (colostomy).

Your stoma is a connection between the bowel and the skin, which was formed temporarily at your previous bowel surgery.

Temporary stomas are created for a minimum of six weeks. It takes this time to allow for the swelling of the tissues to settle down. Some stomas may not be reversed for several months for various reasons including your general health and recovery from the surgery. If your operation was performed for cancer, further treatment such as chemotherapy may also delay the reversal.

Closing or reversing the temporary stoma is no doubt something you are eagerly awaiting. Many people see it as an indication of getting back to normal. Whilst this operation may be more straightforward and much shorter than your initial operation, there are still a few things to consider before surgery. It is important to be prepared for any potential side-effects which could develop after the operation and for you to know what to do if they occur.

Ideally, as many people as possible will have their bowel joined back up, but there could be reasons why your surgeon may be reluctant to do so. This will be discussed with you in person if this is the case.

The main considerations for the stoma reversal are:

• The doctors must be happy that you are fit enough for another operation.
• The bowel that your temporary stoma was created to protect has healed or improved since the first operation.
• The anal sphincters which control the flow from your bowels are working, so that loss of control of your bowels (faecal incontinence) will not develop afterwards.

Depending on what operation you have had, the surgeon may need to perform a rectal examination, and possibly arrange some further tests before making this decision.

What does the operation involve?

The closure of your stoma is ‘technically’ not as demanding as your previous surgery when the stoma was created.

This operation involves making a cut around the stoma, to free it from the abdominal wall and stitching the bowel back together to restore continuity, the stitching may be referred to as an anastomosis. The joined bowel is dropped back inside the abdominal cavity. This is followed by the stitching of the abdominal wall muscles and skin. It is still considered a significant operation.

Very occasionally it is necessary to reopen the original laparotomy wound scar to be able to reverse the stoma.

Alternatives to surgery

The alternative to this surgery is not having the stoma reversed and keeping the stoma. Around 1 in 12 patients who have had a planned temporary stoma for cancer of the rectum will keep a permanent stoma.

Preparation for your surgery

Before coming into hospital you will attend a pre-admission clinic. At this appointment you will be asked questions about your general health and you might have a chest x-ray, ECG (heart tracing) and blood samples if necessary. Most concerns can be addressed at this appointment but if you have further questions relating to your operation, you can contact your colorectal specialist nurse or one of the stoma team (contact numbers are at the bottom of the page).

You will be admitted on the day of your operation. You must not eat anything for 6 hours prior to your surgery, you can continue to drink water up to two hours before your operation. It is important that you drink plenty of fluids and eat well during the previous day.

The operation usually takes around 90 minutes. After your operation you will be taken to the recovery area for close observation before returning to your hospital ward.

What to expect after surgery

You may have a drip in your arm to give you fluids until you are drinking. Once you are awake you can eat and drink normally, you may find small, light, low fibre meals are better tolerated.

Most people are moderately sore at the reversal site afterwards, but this can be managed with pain killers. You may feel distended following the procedure, some patients describe this as a feeling of being “bruised and bloated” but as the swelling decreases this discomfort will ease.

On discharge from hospital you will be given some pain killers and a low fibre diet sheet to take home with you. You will also be provided with contact numbers for who to call if you encounter any problems.

Possible complications following surgery

As with any surgery, the operation to close your stoma has some risks which you need to be aware of. Your surgical team will take all possible steps to prevent them from happening.

General complications that can happen after surgery include:

• Deep vein thrombosis (DVT) is a blood clot in the leg which can occasionally move through the blood stream and into the lungs causing a pulmonary embolism (PE). Whilst you are in hospital you will have an anti-clotting injection daily and support socks to prevent this happening.
• Chest infection.
• Urinary tract infection (UTI).

These complications are avoided by early mobilisation and deep breathing. Getting up and walking around and out of hospital quickly can help prevent these problems.

• Wound Infection.
• Bleeding from the operation site.
• Formation of a fluid or blood collection under the scar (seroma or haematoma).

These complications are not serious but are the most common. Infection would be treated with antibiotics and a collection of fluid will either be reabsorbed by your body or discharged through the wound. Wound infection would usually occur after you have gone home so if the wound becomes hot, red and sore please see your GP or practice nurse for further advice.

Complications following reversal of stoma

Hernias

A hernia occurs when the bowel protrudes through the muscles of your abdomen causing a bulge beneath the skin. The hernia may reduce or increase in size when lying, sitting, or standing. Hernias occur at sites of potential weakness (the stoma reversal site or at the scar of the first operation). The risk of a hernia formation is small but is more likely in frail, older and overweight patients. Its also seen more frequently in those who have strained their bodies or have undertaken too much exercise in the first few weeks following surgery. Management includes supporting your hernia with a belt or binder. This helps with decreasing the protrusion and assists in maintaining a good posture.

Most hernias appear over subsequent months, generally developing within the first two postoperative years. Surgical repair may however be necessary in a proportion of patients.

Less common complications

Anastomotic leak

A leak from the stitching where the bowel is joined back together. This happens in 1 in 250 cases of stoma reversals. This is a more serious complication which usually requires further surgery. If this happens your stoma might need to be reformed. This does not mean that it will be permanent as depending on your general health, it is still possible for another attempt at reversal in the future.

If there is a leak, you will probably experience a dull pain in your pelvis (the area below your belly button and above your hips), have a fever, and feel lethargic.

This complication usually presents within a few days after the operation and can make you feel generally unwell.

Abdominal collection

This refers to a collection of infected fluid inside the abdomen and presents as worsening pain and bloating. You may also have a high temperature and either frequent loose stools or the bowels stop working. The management of this condition involves antibiotics and drainage of the collection using either an ultrasound or CT scan.

Ileus and bowel obstruction

Initially after the surgery there is the risk of the bowel not working properly. This is because of a delay in the bowel movement or contractions known as peristalsis. The cause of this condition is generally due to the handling of the bowel during the surgery and the bruising which creates swelling. It can take a few days before the bowel movements occur normally again and you start to pass both wind and stool from your back passage.

If an ileus or bowel obstruction occurs and your bowels temporarily stop working you may experience increased bloating, abdominal pain, nausea and vomiting. This can be managed by stopping dietary intake and allowing your bowel to rest. It may also be necessary to pass a small tube through your nose into your stomach to relieve the symptoms. Keeping mobile and chewing gum will help prevent an ileus. You can return to normal diet once your bowels start working again. We will not expect you to necessarily have opened your bowels before you go home, but we would expect you to be eating and drinking without significant abdominal bloating, nausea or vomiting.

Similar symptoms may occur in patients who develop a blockage in their bowel (bowel obstruction). An obstruction after surgery is generally caused by adhesions (sticking of bowel tissue) or kinking of the bowel. In most cases the initial management is the same as described above for an ileus. In the majority of cases the bowel obstruction will also settle down on its own. A small percentage of patients will require a further operation or intervention.

If you are at home and are worried about any of the symptoms or complications described please contact us on the numbers provided in this leaflet for further advice. Readmission to hospital may be necessary if your symptoms are causing you to feel unwell and there is a suspected deterioration in your health, such as you can no longer tolerate fluids.

Fistula formation

A fistula is an abnormal connection between two parts of the body, in this case it is often from the bowel to the surface of the skin. In rare cases problems from the join made during the first operation can occur once the stoma is reversed and continuity of the bowel is restored. The most common problem is caused from an infection around the rectal anastomosis (join) which can present as a fistula. Some fistulas can heal on their own but surgery may be considered if the fistula does not close within a few months.

Possible side effects after stoma reversal

Diarrhoea

After the reversal it is common to experience liquid bowel motions for the first few days up to a few weeks before it settles down. In a small percentage of patients it can take up to 6 months before the bowel motions become more firm. It is fairly common to pass looser and more frequent stools than you may have been used to previously. Adjusting the food you eat and taking bowel slowing medication can help with this.

Frequency and urgency

It is normal to have erratic bowel movements for several weeks after this operation. You may find that you need to go to the toilet more urgently and also more often. This can be more of a problem for those who have had a low join or anastomosis in the bowel and for those who have had pelvic radiotherapy and/ or were already suffering from a weak sphincter muscle. The patients who have weak pelvic floor and anal sphincter muscles may leak gas, liquid or solid stools.

Performing pelvic floor exercises may help to regain continence but need to be practiced at least five times a day and over a few months to be of benefit. (Separate leaflets on how to exercise the pelvic floor are available). When done correctly, these exercises can build up and strengthen the muscles to help you to hold both gas and stool in the back passage.

Good hygiene and a light barrier cream may be useful to prevent the skin becoming sore if you are experiencing loose and frequent stools.

How long will you stay in hospital?

Our aim is that most patients who have an ileostomy reversal would go home after staying one night in hospital. You will be seen by your team of doctors the morning after your operation and a decision will be made to send you home if you are ready for discharge. This would usually be in the afternoon or early evening, but this may be earlier if you are well.

As long as you are tolerating fluids and a light diet, are mobile, have passed urine and are reasonably comfortable on pain killing tablets then you can go home.

Symptoms to look for once discharged home

Occasionally patients need to be re-admitted to hospital following discharge home due to complications such as an anastomotic leak, abdominal collection or obstruction.

Acute and persistent symptoms will require further observation and investigation.

The symptoms which should alert you include:

• Progressive and worsening abdominal pain.
• Increased bloating and abdominal discomfort.
• Persistent nausea and vomiting.
• High temperature.
• Breathing difficulties.
• Feeling generally unwell.
• Unable to eat and drink sufficiently.
• Persistent loose stools and diarrhoea.
• New difficulty with passing urine

Early detection of a serious complication leads to a better recovery, so if you feel unwell please contact The Enhanced Recovery Team for advice (contact numbers are at the bottom of the page). Out of office hours, please contact the surgical admissions unit.

We would prefer that you talk to us in the first week after discharge rather than your GP so we can identify problems early and bring you back to hospital if needed. Where possible, we will ask your GP to help to save you a trip to hospital.

Eating and drinking

Once you are home you should gradually build up to a normal diet. In general, you are advised that for the first couple of weeks after your operation you should reduce the amount of fruit, salad and vegetables that you eat. These types of food contain fibre and will be hard for your bowel to digest initially. Meal snacks like crisps and biscuits are good to nibble on when you start eating. The main advice is to eat little and often until your appetite returns to normal and you feel able to return to a healthy balanced diet.

You may find your sense of taste and smell is altered following the surgery. This can be because of the antibiotics, anaesthetics and painkillers. Be reassured that your taste and appetite will return to normal within approximately six weeks.

A good fluid intake of eight cups a day (some of which should be water) is advised. However if you experience constipation, you may need to drink more.

If any particular food does seem to cause problems (such as frequency) just stop eating it for a while, then try again at a later date.

Caring for your wound

It is good idea to inspect your wound daily once you are home. Keeping the wound dry and clean will help prevent infection. You may apply a dry dressing for the first week, which is usually changed after showering. The nursing staff will be able to provide you with a small supply if required.

If you are worried about possible infection, please call the ward for advice.

Signs of infection could be:

• Increased pain, swelling or inflammation.
• Redness around the wound.
• Discharge of fluid or pus from wound.

Exercise

It is very important that you start to walk around as soon as you can after the surgery, as this helps your breathing and circulation, as well as helping you to regain your strength. It is normal to feel tired after surgery so consider what help or support you may need when you go home.

When you first get home after your operation, initially plan your day to have a rest in the afternoon. It takes time to regain your normal strength, so try to build up to the amount of exercise you do slowly. Some people find it helpful to set goals to reach each week, for instance start by going for a short walk each day and increase this distance once you feel able. The level of exercise you will be able to do will vary dependent on your level of fitness before surgery. If you participate in strenuous sports or exercise, you should generally wait six weeks and then introduce this back into your lifestyle gradually.

Having had surgery on your abdomen, you are advised not to lift for the first six weeks. It is important that you do not do any heavy lifting (no heavier than a half-filled kettle) for at least two weeks following the operation, and build up gradually. The concern is that if you put too much stress on your abdominal muscles, you may cause a permanent weakness, which may lead to a hernia in the old stoma site.

Driving

You can drive as soon as you are able to concentrate fully and can make an emergency stop without discomfort in your abdomen. A minimum of two weeks is suggested however it is advisable to check with your own insurance policy as some insurance companies state that you will not be covered for six weeks after any abdominal surgery.

Returning to work

You can return to work when you feel ready to. However you may be surprised at how tired you feel after this operation, so it is advisable to consider returning to work on a part-time basis for a few weeks. If you have a physically demanding job or involves heavy lifting, it is preferable not to consider going back to work for six weeks, and to request lighter duties if possible. This will initially allow you to build up to your stamina and strength for normal duties.

Resuming sexual intimacy

The anxiety and all the stress your body has been through with this operation often reduces your sex drive. This is quite normal and in time it should return. It is important that you and your partner share time talking about your feelings, being close and enjoy being intimate without necessarily having penetrative sex. Once your body feels fitter and more relaxed, you may feel more confident resuming your usual sexual activity again. If you do experience any problems in having sex with your partner, please do discuss this with your doctor.

Follow up care

When you are initially discharged home, some people find it helpful to have family member or friend to stay. Extra help for this first week at home will allow you to rest when you will feel tired and may help you recover sooner. After this, you may still need help with the shopping, cooking and cleaning for a couple more weeks. But remember it is important for you to stay as active as possible.

If you have any queries or questions, do not hesitate to contact your surgical team or GP.

How to contact us

• Enhanced Recovery Nurses: 0117 414 3610 / 0117 414 3611 or 07808 201713
• Stoma Office: 0117 414 0270
• The Surgical Admissions Unit, Gate 32B: 0117 414 3233
• Switchboard: 0117 950 5050

© North Bristol NHS Trust. This edition published January 2024. Review due January 2027. NBT002926

Your estimated discharge date

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

Introduction

This information aims to increase your level of understanding of how you can play an active part in your recovery, after your emergency surgery. If there is anything that you are unsure about, please ask. It is important that you understand how you can help yourself recover, so that you, your family and friends can be involved.

Enhanced Recovery is a programme offered by North Bristol NHS Trust for patients undergoing emergency bowel surgery. Having surgery as an emergency can be stressful, and this information will help your recovery.

What is Enhanced Recovery?

The aim of Enhanced Recovery is to get you back to full health as quickly as possible after your operation.

Research indicates that after surgery, the earlier we get you out of bed, exercising, eating and drinking, your recovery will be quicker and it will be less likely that complications will develop.

Some of the benefits include:

• A quicker return of normal bowel function.
• Reduced chest infections.
• A quicker return to usual mobility.
• Decreased fatigue.
• Reduced risk of developing blood clots after surgery.

In order to achieve this we need you to be partners with us, so that we can work together to speed up your recovery.

Before your surgery

There is evidence to suggest that keeping warm, before surgery, helps prevent infection. Please ensure you have a warm dressing gown or similar item of clothing to wear immediately before your operation.

If possible, please ask a relative or friend to also bring you a supply of comfortable ‘day clothes’ for after your operation. You will be encouraged to return to normality as quickly as possible, and this includes getting dressed.

Eating and drinking

In preparation for your operation, if you are allowed to eat and drink normally, you should aim to take 3 of the Fortisip or Fortijuce supplement drinks per day. The drinks will be supplied by the ward for two days before your surgery.

The supplement drinks are important to help with wound healing, to reduce the risk of infection and aid with your overall recovery. It is important that you also continue to have a variety of other non-fizzy drinks during your hospital stay.

As well as the supplement drinks mentioned, you will also be required to take special carbohydrate drinks called ‘Pre Op’. You will require two drinks the night before and 2 drinks on the day of your operation, three hours before surgery. If your operation is very urgent, you may only be given two ‘Pre Op’ drinks before surgery.

You may continue to eat for up to six hours before your operation and drink fluids for up to three hours before, unless otherwise directed by your doctor.

A few hours after your operation you will start to drink and eat if you wish. It is important that you eat and drink early after your surgery, however if your operation was for a blockage in the bowel, early eating may not be appropriate. The ward staff will help and advise you. You will be expected to recommence the supplement drinks to help build up your strength. The drinks will either be given to you by the ward staff or you can help yourself to the drinks from the patients fridge.

Studies show that chewing gum after an operation can be helpful towards improving your recovery by assisting the bowel to return to its normal function.

Please ask a relative or friend to bring some chewing gum in for you. After your operation chew gum for 15 minutes, three times a day, until your bowel function returns to normal.

Preparing for theatre

On the day of your operation you may be given an enema to empty your bowel contents.

In order to help prevent blood clots you will be required to wear special support stockings (TEDS). The nurse will need to measure your legs to obtain the correct size.

You will also be given a small injection called ‘clexane’ at approximately 6pm each day you are in hospital. This helps reduce the risk of blood clots by thinning the blood.

Some patients who are at higher risk of experiencing blood clots may have to continue with the injection once home. This would only be for a few weeks after surgery and will be fully discussed with you when you are in hospital. Most patients are able to administer the injection themselves or with the help of a relative or carer. The nurses on the ward will show you how to use the injection during your hospital stay. If you have any problems with administering the injection an appointment can be made with your practice nurse to carry this out each day, or we will arrange for a District Nurse to visit you if you are unable to leave the house.

It is important that you keep yourself warm before your operation and you are advised to dress accordingly, (warm dressing gown, socks, slippers, blankets). You will be asked to remove the warm clothing when it is time for your operation as you will be required to wear a hospital gown.

After your operation

Mobilising and exercising

Following your operation when you wake up, it is important that you do deep breathing exercises (as prevention against chest infection). You will need to do 5 deep breathing exercises every hour. To do these you will need to:

• Be in an upright position.
• Take a deep slow breath in (feel your stomach gently rise).
• Hold the breath for 3 seconds.
• Breathe out slowly.
• Repeat 5 times.

You should cough regularly to make sure your lungs are clear of secretions. To do this, place a towel or pillow over your abdomen and wound. Support it with your hands and cough.

When you are sitting in the chair or lying in bed, you should also do frequent leg exercises, (as prevention against blood clots) pointing your feet up and down and moving your ankles as if making circles can achieve this.

Depending on what time you come back to the ward, the staff will help you out of bed about six hours after your operation. You may sit out of bed for up to two hours on the day of surgery and then up to six-eight hours out of bed on each subsequent day after surgery if you can manage this.

You will be encouraged to walk at least 60 metres four to six times per day after your surgery if you can manage this. By being out of bed in a more upright position and by walking regularly, lung function is improved and there is less chance of a chest infection after surgery. Circulation is also improved, reducing the risk of a blood clots and helping bowel function return to normal.

Try wearing your day clothes as soon as you feel able after your operation as this can help you feel positive about your recovery.

Pain control

It is important that your pain is controlled so that you can walk about, breathe deeply, eat and drink, feel relaxed and sleep well. Please let us know if your pain is not manageable so that we can help you.

It is also important for us to know if you are either allergic or sensitive to certain pain killers.

You may be given one of, or a combination of the following methods of pain relief, to keep you comfortable after surgery:

• Patient controlled analgesia (PCA). This is an intravenous pain killing medication, delivered by a machine, which is set up so that you can control it yourself. You will be given instructions on how to do this.
• Tap block. This is an injection given at the time of your operation to temporarily numb the abdomen and keep you comfortable immediately afterwards.
• Spinal block. This is an injection given at the time of your operation that will temporarily numb you from the waist down and will keep you comfortable afterwards.
• Ketamine infusion. This is a continuous intravenous pain killing medication which will run up to 24 hours after surgery.

The anaesthetist may discuss these options with you and explain more about it whilst you are in hospital, before your operation.

Alongside this, the doctors will prescribe other types of pain relieving medicines, which work in different ways. You will be given these regularly (three or four times per day) and you should feel more comfortable.

If the pain worsens at any time, please tell the nursing staff immediately and they will be able to help you.

Sickness

Sometimes after an operation it is not uncommon to feel nauseated and occasionally vomit. You will be given medication during surgery to reduce this, but if you feel sick following surgery please tell a member of staff who will be able to help.

Tubes and drips

During your operation a tube (catheter) will be placed into your bladder so that we can check that your kidneys are working well and your urine output can be measured. This tube will be removed as soon as possible.

You will have an intravenous drip put into your arm to ensure you do not become dehydrated. The drip will normally be removed the day after surgery, but you may still have the intravenous port (venflon) in place for a couple of days in case we have to give other drugs through it.

It is possible you may return from your surgery with a tube in your nose. The tube may stay in a few days which will help drain your stomach if your surgery was due to a blockage or an emergency. We aim to remove the tube as soon as possible. Please wait until the tube is removed before trying to eat. Staff can advise.

You may also be required to breathe extra oxygen for a short while after your operation.

Monitoring

Many different things will be monitored during your treatment including:

• Observations (blood pressure, pulse, temperature).
• Fluid in.
• Fluid out.
• Food eaten.
• When your bowel first starts working or you pass wind.
• Pain assessment.
• Number of walks achieved.
• Time spent out of bed.

You may be asked to tell us about what you eat and drink and what you pass so that we can record it.

Whilst you are in hospital you will be asked to participate in maintaining a daily diary / log (provided by the ward), so that you can keep a record of how well you are managing. This will help us monitor your progress.

Please remember playing an active part in your recovery will help you get better sooner. If you have any questions regarding your recovery please do not be afraid to ask a member of staff.

References and further information

For further information on the Enhanced Recovery Programme you may access the following websites:

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

How to contact us

Brunel building
Southmead Hospital
Bristol BS10 5NB

Surgical Admissions Unit
Gate 32B
Telephone: 0117 414 3233

Enhanced Recovery Nurses
Telephone: 0117 414 3610
Telephone: 0117 414 3611

Colorectal nurses
Telephone: 0117 414 0514

Stoma Care Nurses
Telephone: 0117 414 0270

© North Bristol NHS Trust. This edition published January 2024. Review due January 2027. NBT002721

What is cell salvage?

Cell salvage is a method of collecting blood you have lost during an operation, so that it can be given back to you.

The blood collected is washed and filtered to remove any contaminants. This blood can then be given back to you if the doctor thinks a blood transfusion is required. It is sometimes called autologous blood transfusion (using your own blood).

Cell salvage is a technique that is well established in many types of surgery and is regularly used at Southmead Hospital.

Why might I need a transfusion?

It is normal when having major surgery to have some blood loss during the procedure. In some cases this can be a large amount and will require the blood to be replaced by giving a blood transfusion. Blood used for these transfusions can either be:

• A supply of donor blood from volunteers; or
• Your own blood (by using cell salvage blood).

What are the benefits of using cell salvage blood?

Use of cell salvage can reduce the need for a blood transfusion using donor blood, which is in short supply and expensive.

Although the risk associated with receiving a blood transfusion from a donor are low, there are still a very small risk of infections being passed on (1:500,000 for Hepatitis B, 1:30 million for Hepatitis C, 1:5 million for HIV, less than 1:2 million for vCJD). Having your own blood returned to you removes these risks.

Likewise donor blood is stored before transfusion and this affects its properties. For instance, stored blood does not carry oxygen as well. Having your own blood returned to you straight away reduces these problems.

The cell salvage technique is sometimes seen as an acceptable alternative for those who for religious reasons will not accept a blood transfusion using donated blood.

Why isn’t it suitable for everyone?

Not all operations result in enough blood loss to enable cell salvage to be used. For some operations cell salvage is not recommended e.g. some bowel surgery.

What does this mean for you?

This information aims to help you make an informed decision on whether you would prefer cell salvage blood should you need a blood transfusion during your operation.

If you have any questions about cell salvage which are not answered by this information, please discuss them with your anaesthetist.

The following video will show you how to use P 6 acupressure to prevent or treat post-operative nausea and vomiting. It has been proven, by statistically summarising the results of 40 trials including 4858 patients, that this technique is as good in preventing or treating post-operative nausea and vomiting as taking an anti sickness medication. That does not mean that it will work for every patient, but it is worth trying first before you use some anti-sickness medication. 

• To find your acupressure points, you can take your index, and middle finger and place it on your wrist at the base of your palm.
• Alternatively, you can find them by identifying the two tendons in your wrist going in the middle of these and either going two or three finger widths from the crease in your wrist; this is your acupressure point.
• Take your thumb and your index or middle finger and press firmly on the points on both sides of the wrist. Do this when you feel nauseous and you should get relief within ten to thirty seconds, sometimes it can take a bit longer, up to five minutes.
• Alternatively, you can tap your wrists together gently at the acupressure points whilst taking deep breaths.   

Your estimated discharge date

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

Ask three questions - preparation for your appointments

We want you to be active in your healthcare. By telling us what is important to you and asking questions you can help with this. The three questions below may be useful:

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?

Introduction

This information aims to increase your level of understanding of how you can play an active part in your recovery after your surgery. If there is anything that you are unsure about, please ask. It is important that you understand how you can help yourself recover, so that you, your family and friends can be involved.

This is the programme offered by North Bristol NHS Trust for patients undergoing planned bowel surgery. There may be circumstances where the programme will not be appropriate for some patients and if this is the case, you will be fully informed.

What is the Enhanced Recovery Programme?

The aim of the Enhanced Recovery Programme is to get you back to full health as quickly as possible after your operation.

Research indicates that after surgery, the earlier we get you out of bed, exercising, eating and drinking, your recovery will be quicker and it will be less likely that complications will develop.

Some of the benefits include:

• A quicker return of normal bowel function.
• Reduced chest infections.
• A quicker return to usual mobility.
• Decreased fatigue.
• Reduced risk of developing blood clots after surgery.

In order to achieve this we need you to be partners with us so that we can work together to speed up your recovery.

What will happen?

Before you come into hospital the consultant will see you in the outpatients department to explain your operation.

Following this you will be sent a date to attend the pre-operative assessment clinic, where trained staff will carry out routine tests that are required to ensure you are fit and safely prepared for surgery. Please note all patients are routinely screened for potential infections at this time.

The specialist enhanced recovery nurse will see you when you attend the pre operative assessment clinic and will explain the programme to you and your family. You will be provided with written information and given plenty of opportunity to ask questions.

You may be referred to the anaesthetist, colorectal nurse specialist and stoma nurse specialist as necessary.

The nurse will discuss your arrangements at home so that together we can plan for any help you may need after your operation. The nurse will also discuss diet and exercise with you and if necessary you will be referred to the dietitian. (For example if you have lost a lot of weight or your appetite is poor). If you have concerns about your appetite or diet before coming in for your operation please speak to the nurses at your pre-assessment visit. What you eat is important, as good nutrition now will help you recover faster from your operation.

You will be given the opportunity to sample special nourishing supplement drinks: these are called ‘fortijuce’ and ‘fortisip’. You will be given some of the drinks to take home with you even if your weight and appetite are normal. You can choose from a variety of flavours.

It is important to keep as active as you can before your operation and if you are a smoker you should stop now. This helps reduce breathing problems after surgery. You can see your GP or pharmacist for advice on products to help you stop smoking.

Please bring a supply of your own medications into hospital with you. These will be stored safely on the ward and will be returned to you on discharge.

Please also bring a supply of comfortable ‘day clothes’ as you will be encouraged to return to normality as quickly as possible after your operation, and this includes getting dressed.

Eating and drinking

Prior to your surgery you will be able to eat and drink as normal unless you are required to take medication to clear the contents of your bowel. If this applies to you it will be discussed with you at pre operative assessment.

In preparation for your operation and in addition to your normal diet, you should aim to take three of the “Fortisip/Fortijuce” supplement drinks per day, for each of the 2 days before admission. Each drink can be sipped over a few hours.

When you are admitted to the ward after your operation, the supplement drinks will continue to be available to you, and you will need to continue with three per day.

The supplement drinks are important to help with wound healing, to reduce the risk of infection and aid with your overall recovery. It is important that you also continue to have a variety of other non-fizzy drinks during your hospital stay.

As well as the supplement drinks mentioned, you will also be required to take special carbohydrate drinks called ‘Pre Op’. You will require two drinks the night before and two drinks on the morning of your operation.

You may continue to eat for up to six hours before your operation and drink clear fluids for up to three hours before.

A few hours after your operation you may start to drink and eat if you wish. It is important that you eat and drink early after your surgery. Staff will help and advise you. Initially some patients may find a low fibre diet more tolerable. You will be encouraged to help yourself to the supplement drinks from the fridge. You will be expected to recommence the supplement drinks to help build up your strength following surgery.

Recent studies show that chewing gum after an operation can be helpful towards improving your recovery by assisting the bowel to return to its normal function. On the day you come into hospital bring some chewing gum with you. After your operation chew gum for 15 minutes, three times a day, until your bowel function returns to normal.

Preparing for theatre

Before your operation you may need 1-2 enema(s) to empty your bowel contents. Some patients may be required to take medication the day before in order to achieve this. This will be fully explained if this applies to you.

In order to help prevent blood clots you will be required to wear special support stockings (TEDS). The nurse will need to measure your legs to obtain the correct size.

There is also evidence to suggest that keeping warm, before surgery, helps prevent infection. Please ensure you bring a warm dressing gown, socks, slippers, blankets or similar item of clothing to wear immediately before your operation. (You will be asked to remove the warm clothing when it is time for your operation as you will be required to wear a hospital gown.

After your operation

Mobilising and exercising

Following your operation when you wake up, it is important that you do deep breathing exercises (as prevention against chest infection). You will need to do 5 deep breathing exercises every hour. To do these you will need to:

• Be in an upright position.
• Take a deep slow breath in (feel your stomach gently rise).
• Hold the breath for three seconds.
• Breathe out slowly.
• Repeat five times.

You should cough regularly to make sure your lungs are clear of secretions. To do this, place a towel or pillow over your abdomen and wound. Support it with your hands and cough.

When you are sitting in the chair or lying in bed, you should also do frequent leg exercises, (as prevention against blood clots); pointing your feet up and down and moving your ankles as if making circles can achieve this.

Depending on what time you come back to the ward, the staff will help you out of bed about six hours after your operation. You may sit out of bed for up to two hours on the day of surgery and then up to six-eight hours out of bed on each subsequent day after surgery if you can manage this.

You will be encouraged to walk at least 60 metres 4 – 6 times per day after your surgery if you can manage this.

By being out of bed in a more upright position and by walking regularly, lung function is improved and there is less chance of a chest infection after surgery. Circulation is also improved, reducing the risk of blood clots and helping bowel function return to normal.

You will also be given a small injection called ‘clexane’ at approximately 6pm each day you are in hospital. This helps reduce the risk of blood clots by thinning the blood. Some patients who are at higher risk of experiencing blood clots may have to continue with the injection once home. This would only be for a few weeks after surgery and will be fully discussed with you when you are in hospital.

Most patients are able to administer the injection themselves or with the help of a relative or carer. The nurses on the ward will show you how to use the injection during your hospital stay. If you have any problems with administering the injection an appointment can be made with your practice nurse to carry this out each day, or we will arrange for a District Nurse to visit you if you are unable to leave the house.

Try wearing your day clothes as soon as you feel able after your operation as this can help you feel positive about your recovery.

Pain control

It is important that your pain is controlled so that you can walk about, breathe deeply, eat and drink, feel relaxed and sleep well. Please let us know if your pain is not manageable so that we can help you.

It is also important for us to know if you are either allergic or sensitive to certain pain killers.

You may be given one of, or a combination of the following methods of pain relief, to keep you comfortable after surgery:

• Patient controlled analgesia (PCA). This is an intravenous pain killing medication, delivered by a machine, which is set up so that you can control it yourself. You will be given instructions on how to do this.
• Tap block. This is an injection given at the time of your operation to temporarily numb the abdomen and keep you comfortable immediately afterwards.
• Spinal block. This is an injection given at the time of your operation that will temporarily numb you from the waist down and will keep you comfortable afterwards.
• Ketamine infusion. This is a continuous intravenous pain killing medication which will run up to 24 hours after surgery.

The anaesthetist may discuss these options with you and explain more about it when you are in hospital.

Alongside this, the doctors will prescribe other types of pain relieving medicines, which work in different ways. You will be given these regularly (three or four times per day) and you should feel more comfortable.

If the pain worsens at any time, please tell the nursing staff immediately and they will be able to help you.

Sickness

Sometimes after an operation it is not uncommon to feel nauseated and occassionally vomit. You will be given medication during surgery to reduce this, but if you feel sick following surgery please tell a member of staff who will be able to help.

Tubes and drips

During your operation a tube (catheter) will be placed into your bladder so that we can check that your kidneys are working well and your urine output can be measured. This tube will be removed as soon as possible.

You will have an intravenous drip put into your arm to ensure you do not become dehydrated. The drip will normally be removed the day after surgery, but you may still have the intravenous port (venflon) in place for a couple of days in case we have to give other drugs through it. You may also be required to breathe extra oxygen for a short while after your operation.

Monitoring

Many different things will be monitored during your treatment including:

• Observations (blood pressure, pulse, temperature).
• Fluid out.
• Fluid in.
• Food eaten.
• When your bowel first starts working or you pass wind.
• Pain assessment.
• Number of walks achieved.
• Time spent out of bed.

You may be asked to tell us about what you eat and drink and what you pass so that we can record it.

While you are in hospital you will be asked to participate in maintaining a daily diary/log (provided by the ward) so that you can keep a record of how well you are managing. This will help us monitor your progress.

Please remember playing an active part in your recovery will help you get better sooner. If you have any questions regarding your recovery, please do not be afraid to ask a member of staff.

You will be seen, during your hospital stay, by the Enhanced Recovery Nurses (Monday – Friday) who will support you and advise you on your journey through the Enhanced Recovery Programme.

References and further information

For further information on the Enhanced Recovery Programme:

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

How to contact us

Enhanced Recovery Nurses

0117 414 3610

0117 414 3611

07808 201713

Colorectal nurses

0117 414 0514

Stoma Care Nurses

0117 414 0270

© North Bristol NHS Trust. This edition published January 2024. Review due January 2027. NBT002214

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

GMC Number: 7215355
Year & location of first qualification:
2010, Faculdade de Ciencias Medicas, Universidade Nova de Lisboa, Lisbon, Portugal

Specialty: Neuroradiology
Clinical interests:
Diagnostic Neuroradiology, Vascular and Skull Base pathology, Inflammatory and Autoimmune diseases

Secretary: Caroline Hawkins
Telephone number: 0117 414 9009

Dr Alves Rosa undertook core medical training in the West Midlands prior to radiology training in the Severn Deanery.

He completed a nationally competitive diagnostic and interventional neuroradiology fellowship at the tertiary neurosciences centre of North Bristol NHS Trust.

His qualifications include MRCP Lon (2014), FRCR (2018), and the European Diploma in Neuroradiology (2022). He also completed all modules of the European Course in Minimally Invasive Neurological Therapy in 2020.

Dr Alves Rosa has presented research at a national and international level and published in peer reviewed journals.

He is a fellow of the Royal College of Radiologists and an advisory editor for Clinical Radiology.

Email address: joao.alvesrosa@nbt.nhs.uk