What is The Enhanced Recovery Programme?

This leaflet helps you to understand what is involved in the Enhanced Recovery Programme, what you can expect from us and what is expected from you. It is likely that the care described here is very different to what you might expect after major bowel surgery, or surgery in other hospitals. This programme incorporates changes to traditional care based on best available research evidence to improve and speed-up recovery after your operation. Some other hospitals also run a similar programme. Your co-operation and commitment to the programme will aid your recovery process. If there is anything you are not sure about, do not hesitate to ask a member of staff or call one of the numbers at the end of this leaflet.

Preparing for your operation

A laxative medication to clear out the contents of your bowel is used only in a few instances for major bowel surgery at The West Middlesex Hospital and you wil be informed about this by your consultant or nurse specialist. If you are having surgery on the left side of your bowel then you will have an enema two hours before the operation to clear the lower end of the bowel. You will be clearly told about this during your pre-assessment visit. Only in a few select cases is full bowel preparation required (as you had for your colonoscopy – if you had one).

You can eat until six hours prior to your operation. After this time you can drink until two hours before the operation, but only clear fluids that do not contain fat. You may be given 2 cartons of a supplement drink called ‘PreOp’ to drink four hours prior to your operation. This will be discussed with you at your pre-assessment appointment.

Moving around & exercise after your operation

Following your operation, when you wake up, it is important that you perform deep breathing exercises. Breathe in through your nose and out through your mouth. This should be done at least five times an hour. This helps keep the lungs fully inflated reducing chest infections.

The staff will help you out of bed some hours after your operation. You will spend up to two hours out of bed on the day of surgery and then at least four hours out of bed on the day after surgery, and six to eight on each subsequent day. You will be encouraged to walk about as much as possible at least four to six times a day after surgery. By being out of bed in a more upright position and by walking regularly, lung function is improved and there is less chance of chest infection. Movement also reduces the risk of blood clots forming and minimises muscle weakness. By complying with these exercises your recovery is likely to be faster.

In order to reduce the risk of blood clots you will be given a small injection. This helps by thinning the blood. This will be given to you each day while you are in hospital. You will be required to wear compression stockings (TED) whilst in hospital as an additional measure to prevent clots.

Try and wear your normal clothes and not the hospital gowns after your operation as this can help you feel positive about your recovery and make it easier to walk around the hospital and the hospital gardens.

Drinking liquids after surgery

As soon as you are awake you will be allowed to drink freely. You can have whatever fluids you wish other than fizzy drinks, which may make you feel sick. You will also be given nourishing drinks after your operation. It is important that you drink at least 2-4 of these drinks each day after your operation as your body needs more nourishment to help heal your wounds, reduce the risk of infection and help your overall recovery.

Eating after surgery

You will be encouraged to eat the day after your operation. If you wish to eat earlier than this then just ask the nurses. A ‘soft’ diet is recommended initially – advice will be available from the ward nurses and dieticians if you are unsure. The nourishing drinks should be continued until you are eating normally. They are not a substitute for solid food, but an addition to help speed your recovery.

Pain control

The team of doctors and nurses looking after you will do everything they can to make sure that your recovery is as pain free as possible. It is important that you let us know if you have any pain or discomfort.

Good pain control improves your recovery as you can walk about, breathe deeply, eat and drink, feel relaxed and sleep well. Pain control after major bowel surgery is given either in the form of a tiny tube in your back (epidural) which allows a continuous supply of the pain relieving medication to be given, or as a needle in your arm and a button you can press (Patient controlled analgesia - PCA) to give yourself pain killing medication when needed.

You will be given the opportunity to discuss the type of analgesia you wish with the pre-assessment nurse and the anaesthetist prior to your operation. In addition you will be given other pain killers by mouth as you come off the above and your recovery speeds up. The epidural or PCA will be removed 2-3 days after your operation but you will continue on the other pain relieving medication.

Feeling sick & vomiting

Sometimes after an operation you may feel sick. This is usually caused by the anaesthetic or drugs we use. 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 give you something for this.

If you are sick after surgery, or a few days after your operation after you have commenced eating, it does not mean that you need to be ‘nil-by-mouth’, but you should reduce the amount and volume you are taking by mouth. Little and often for both fluids and food is best in this situation. If vomiting persists despite these measures then the medical team will be on hand to deal with it.

Tubes and drips

Whilst in theatre a tube (catheter) will be placed into your bladder to allow your urine to drain into a bag. This allows us to monitor your level of hydration. This tube will be removed as soon as possible – usually 2-3 days after surgery.
You will have a drip put into your arm and fluid will be run via this to ensure you do not become dehydrated. The fluids given to you through the drip in your arm will normally be removed the day after surgery.

You may also have a tube in your nose that goes into the stomach. If you do wake up with one of these tubes then it is usually removed within 24-hours.

After you leave hospital

Complications do 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 end of this leaflet. If you cannot contact the people listed, then ring your GP.

Abdominal pain

It is not unusual to suffer gripping pains (colic) during the first week or two following major bowel surgery. The pain usually lasts for a few minutes and will come and go away in spasms
If the pain becomes severe and lasts for several hours it may indicate a leakage of fluid from the area where the bowel has been joined together. This can be a serious complication that can occur within the first 2-weeks after surgery. This happens only very rarely (3-5% of all major bowel operations, but can be higher in diabetic patients and those with Crohn’s disease). Should this occur, it may be accompanied by a fever and sweating. You should contact us on the telephone numbers provided.

Wound infections

It is not unusual for your wounds to be slightly uncomfortable during the first one to two weeks. Please let us know if your wound becomes inflamed, painful or swollen, or starts to discharge fluid.

Bowel habits

Your bowel habit may change after removal of part of the bowel and may become loose or constipated, particularly in the first few weeks after surgery. Make sure you eat regular meals three to five times a day, drink adequate amounts, and take regular walks during the first two weeks after your operation. If constipation lasts for more than three or four days then taking a laxative is advised. If you are passing loose stools more than three times per day for more than four days we may advise taking medication such as Loperamide or Codeine Phosphate. Contact us for guidance.
If you have had surgery on the left side of your bowel then it may take a while for your bowel habit to settle down to a more established pattern. You may return to your previous bowel pattern or be a little more frequent than before. If this is not the case then please contact us on the numbers provided.

Passing urine

Sometimes after bowel surgery you may experience a feeling that your bladder is not emptying fully, especially after the catheter is removed after the operation (see above). This usually improves with time. If it does not, or if you have excessive stinging when passing urine, please contact us or your GP as you may have an infection.

Diet

A balanced, varied diet is recommended and particularly eating three 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. 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. If you are suffering from diarrhoea then it is important to replace the fluid loss and to drink extra fluid. The non-fizzy sports drinks such as Lucozade Sport are very useful in these circumstances.

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 four 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 until six weeks following your surgery. In addition, if you are planning to restart a routine exercise such as jogging or swimming that you wait until two to four weeks after discharge 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 normally undertake most activities.

Work

Many people are able to return to work within two to four weeks following their operation. If your job is a heavy manual job then take advice from the medical staff about when to return to work.

Driving

You should not drive until you are confident that you can drive safely. Once you have got back to most of your normal activities you should be able to drive. However, we recommend that before driving for the first time, sit in the driver’s seat and hit the brake pedal hard as if you are performing an emergency stop. If you get any abdominal pain when performing this then do not drive. It is important that any pain has resolved sufficiently to enable you to perform an emergency stop and turn the wheel quickly in an emergency. If you are unsure please contact your insurance company or speak to the staff.

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 you 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 2-4 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.

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