Colorectal Surgery: Instructions for before and after your surgery

Duke University Medical Center Division of Colorectal Surgery 919-681-3977  

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This information is to help you understand: • The surgery that you are about to undergo • What you can expect during your hospital stay • What you can expect when you return home Please read over this information. Feel free to talk about these matters with the doctors, ostomy nurses or nurse practitioner. This booklet should give you a general idea of things to do to help you get well after your surgery.

My Ostomy nurse is: I can contact Dr.

and can be contacted at: at

Monday-Friday 9:00 am – 5:00 pm

After hours and weekends please call 919-684-8111 and ask for the surgical resident on call to be paged. IMPORTANT PLEASE READ

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Information provided by this pamphlet is for educational purposes. It is not intended to replace the advice or instruction of a professional healthcare practitioner, or to substitute medical care. Contact a qualified healthcare practitioner if you have any questions concerning your care

TABLE OF CONTENTS

Digestive Function . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Hemicolectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Tansverse Colectomy and Colorectal anastamosis. . . . . . . . . . . . . . . . . . . . . . . 6 Abdominal perineal resection and Low anterior resection. . . . . . . . . . . . . . . . . 7 Low anterior resection and proctocolectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Ileocolic anastamosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 What is an ileostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 What is a colostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 What can I expect before my surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Bowel preparation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 What can I expect after my surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 What can I expect when I get home . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 When should I call the doctor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Changes in bowel function after colorectal surgery . . . . . . . . . . . . . . . . . . . . . .20 How to adjust the dose of loperamide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Ostomy internet resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Learning to live with an ileal J-pouch . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

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Digestive Function

Let us look at the normal digestive system so you can understand the type of surgery you are having. Food travels to the belly through a long tube called the esophagus. Enzymes in the belly break the food into smaller pieces. By the time the food has moved into the small intestine, it is mostly liquid. The small intestine absorbs the nutrients from this liquid. What is not needed passes into the large intestine (the colon). The primary function of the colon is to absorb water and make the waste (stool) more solid. Some vitamins are absorbed in the colon. Stool then passes through your rectum and out of your body through your anus.

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Your surgeon has told you that you need to have surgery on your bowel or rectum. This surgery could involve your small or large intestine or rectum. Some types of surgery that you may have include:

Right or left hemicolectomy (remove the right or left part of your colon)  

Segmental resection (remove a section of your colon)

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Transverse colectomy (remove the transverse part of your colon)

Colorectal anastomosis or reconstruction (remove part of your colon and join it to your rectum)

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Abdominal perineal resection (APR) with colostomy (remove part of your colon, all of your rectum and anus)

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Low anterior resection with coloanal anastomosis and J pouch construction (remove part of your rectum and make an area to replace it (J pouch construction)

Proctocolectomy (remove your rectum or all or part of your colon)

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Ileocolonic anastamosis

Sometimes your doctor may be able to join the good sections of your bowel or rectum together after the diseased part has been removed (anastomosis). Sometimes your doctor may have to bring a portion of your bowel out to your belly so that you can get rid of body wastes in this way (ostomy).

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What is an ostomy? An ostomy is a surgical procedure that makes an opening (stoma) in your belly for the elimination of body wastes. You can have an ostomy for urinary or bowel problems. The type of ostomy that you have will depend upon which body part is affected: urine (urostomy), small bowel (ileostomy) or colon (colostomy).

What is an ileostomy? This is an opening (stoma) in your belly where the surgeon has brought a part of your small bowel to the outside. An ileostomy may be temporary or permanent.

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What is a colostomy? This is an opening (stoma) in your belly where the surgeon has brought a part of your colon to the outside. The location of the stoma on your belly depends on what part of the colon is removed. A colostomy may be temporary or permanent.

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What can I expect before my surgery Once you have a date for your surgery, you can expect: • You may be given an appointment to be seen for a visit at Duke South Clinic 2D before

your surgery or get a phone call • At this appointment or phone call, someone will look at your past medical history and the medicines that you take now. Please bring all of your medicines that you take with you to

this appointment • You may be told that you will need some blood work , Xrays or see a special doctor like a Cardiologist (heart doctor) or Pulmonologist (lung doctor) before your surgery • You will be told what you need to do on the day of your surgery and where you need to go on the day of your surgery • You will be told what changes you may need to make in your diet before your surgery

• You may meet with someone from anesthesia who will discuss with you the way that will be used to help control your pain during your surgery

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• You will be told what medicine, if any, you can take with small sips of water on the day of your surgery. Do not take any medicines except what you are told to take on the day of your surgery • If you take blood thinners, like aspirin, naproxen, ibuprofen, clopridogrel (Plavix®), warfarin (Coumadin®) or Pradaxa®, you will be told when you must stop them before your surgery. If you take any of these medicines and no one has mentioned when

to stop taking them, please ask your doctor’s office about them before your surgery • On the day of your surgery, you may be given a 20 ounce bottle of Gatorade to drink

about 30 minutes before your surgery

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Bowel Prep before your surgery

Only take if directed by your doctor’s office to do this prep Purchase these over the counter laxatives: 1. GATORADE (64 ounces) of lemonade or other CLEAR Gatorade (two 32 oz. bottles). 2. DULCOLAX 5mg tablets (four tablets) 3. MIRALAX BOTTLE 238 grams (medium size, over the counter only) The DAY BEFORE your colon surgery: Clear Liquids ONLY No Solid Food Examples of CLEAR LIQUIDS: Water, clear fruit juices such as apple or white grape, chicken or beef bouillion, jello (no RED or PURPLE), clear Gatorade, popsicles (No RED or PURPLE), clear soft drinks, coffee without cream or sugar. NO MILK OR MILK PRODUCTS, NO ORANGE JUICE, NO RED OR PURPLE JELLO OR JUICES. 2 PM: Drink 8 ounces of clear liquids 3 PM: Take 2 DULCOLAX tablets 4 PM: Drink 8 ounces of clear liquids 5 PM: Mix the entire bottle of MIRALAX into the 64 ounces of GATORADE. (Put half the bottle in each 32 ounce bottle). Shake the solution until fully dissolved. Drink an 8 ounce glass every 15 minutes until the solution is gone. 7 PM: Take the last 2 DULCOLAX tablets. 8 PM & 9 PM: Drink 8 ounces of clear liquids. • If you develop discomfort or bloating, stop drinking the solution for 30 minutes then restart the prep. Nausea, cramping, and abdominal fullness are the most common adverse reactions with the bowel prep. NOTHING BY MOUTH AFTER MIDNIGHT The DAY OF your colon surgery: You may take the medicines you were told to take with a sip of water but nothing to eat or drink   14  

What can I expect after surgery? When you wake up in the Recovery Room (PACU) you can expect: • A needle in your hand that will drip fluids into your veins (an IV).

• Pads on your chest and be connected to a monitor that will check your heart rate

• A monitor on one of your fingers that will see how well you are circulating the oxygen that you breathe in. • To spend at least one hour in the PACU and then move to your room on the nursing unit. • If you received an ostomy, you will have a pouch (appliance) over it. It is normal to see some bloody drainage in the bag. • You may have a dressing over your incision that hooks to another machine. This machine works like a vacuum. It keeps the normal fluids that accumulate after surgery

from causing a seroma (fluid collection). • You will have a tube into your bladder to drain the urine. This tube may stay in for several days after your surgery.

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• You will be out of bed on the night of your surgery. You should be walking in the halls of your nursing unit the day after your surgery. You should be out of your bed more than

you are in your bed during your stay.

How will you control my pain? • You may have a needle in your back that will administer pain medicine to you (an epidural catheter) • You may receive some pain medicines through your IV line. • Before you leave, you will start on the pain medicines that you will take by mouth when you go home

What will I get to eat? • The day of your surgery, you can have ice chips or clear liquids. • You can have a regular diet (post surgical bland) by the time you go home. • Your diet should avoid foods that are high roughage foods such as lettuce and beans for four weeks after your surgery. Your diet should also avoid foods that are spicy or fried

for four weeks after surgery. You should have softer meats such as chicken, fish or ground beef rather than harder meats like steak or pork chops for four weeks after your surgery

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Will I have to eat certain foods after my surgery? • If you have had an ileostomy, you may have to avoid some foods for a while that may cause stool to back up. Your ostomy nurse will give you a list of these foods after your surgery. • If you have had a colostomy, you may want to avoid some foods that may cause gas or odor. Your ostomy nurse will give you a list of these foods after your surgery.

What can I expect when I get home? • BLEEDING o It is normal to have some old bloody discharge or sometimes stool coming from your rectum after this surgery in the first few days. o Your ostomy should be moist and red or pink in color. o If you have had an ostomy, it is normal for there to be some bleeding, especially in the first few days after surgery. o If you had an ileostomy, it is normal to have a high output several days after your surgery

• STOOL OUTPUT: o You may be sent home from the hospital before you had your first stool after surgery. This should happen within a few days after you go home. If you stop passing gas from your bottom, or don’t have stool pass from your bottom within three days of being sent home, call the doctor’s office to find out if they wish to have you do something else. o For both an ileostomy and a colostomy, you may have liquid stools coming from your ostomy at first. o The stool from a colostomy will become paste-like sooner than from the ileostomy.

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• ACTIVITY: o You should get up and walk around the house several times a day. If it feels good, then do it! You may go up and down stairs as needed o No lifting anything heavier than 10 pounds (about 1 gallon of milk) for 6 weeks after surgery o No soaking in water (no swimming, no baths, and no hot tubs) until your doctor

says that it is ok for you to do this. You may take a shower. Lightly pat dry any incision that you may have. o No driving as long as you are taking anything for pain stronger than Tylenol™ (acetaminophen)

• WOUND CARE: o If you have an incision, you may notice a small amount of fluid draining from between your staples/sutures. It is ok if it remains the color of a light beer or light pink. Call your doctor and let them know if this happens and they will tell you if you should do something else. o Staples will come out about two (2) weeks after your surgery. You may have an appointment made to see your doctor’s nurse before you leave the hospital. If you live very far away, you may also have your family doctor or the home health nurse remove these staples/sutures. If no one discussed this with you before you left the hospital, please call your doctor’s office to set this up. o If you go home with an open incision, you will learn how to care for this incision before you leave the hospital. You may be able to have Home Health Services come into your home to help you. Someone will discuss this with you before you leave the hospital.

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When should I call the doctor? • BLEEDING: o It is not normal to have bright red bleeding in large amounts coming from your ostomy or old dark blood from your rectum that continues beyond a few days. o You should let your doctor know if this happens.

• STOOL OUTPUT: o It is not normal to have several loose stools from your rectum in a day several days in a row. Please call your doctor’s office if this happens. o If you have started taking imodium because of high output from your ileostomy, you should be concerned if the output from your ostomy remains greater than 1.5 liters in a day. Call your doctor’s office.

• DEHYDRATION: Sometimes after surgery, you may take in less food and fluids than you need. If you notice the following, call your doctor. o Your tongue and mouth are dry o You are not going to the bathroom during the day as much as you were o You feel dizzy when you stand up or you cannot think clearly

• SUDDEN NEW ABDOMINAL PAIN: o If your pain worsens and the pain medicine that you have been taking does not manage your pain, please notify your doctor’s office

• WOUND: o If you notice any cream colored, green or yellow drainage coming from your wound or a foul smell or redness and tenderness around the outside of your incision, please notify your doctor’s office.

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Changes in Bowel Function after Colorectal Surgery How will my bowel function change after surgery? You may have: • Loose stools, leakage of stool • More frequent urges to have a bowel movement (BM) • Trouble completely emptying your rectum • A strong desire to have a BM while eating These symptoms can be worse if you have had bowel radiation treatments.

Why is this happening? • • • •

Reduced length or absence of colon after surgery causes faster transit time Decreased intestinal surface for absorbing fluids Decreased capacity of rectum or surgically created pouch Eating and drinking stimulate the gastrocolic reflex

How long does it take for bowel function improves? You may see improvement in the first few months after surgery. For others it may take up to a year.

What can I do to help? Do not avoid eating or drinking in hopes of preventing problems. This will only complicate your recovery. 1. Firm up your stool. These foods help make the stool firmer and less frequent. • • • • •

bananas, applesauce cheese boiled white rice tapioca pudding creamy peanut butter

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white potatoes white pasta pretzels marshmallows

Which Foods Make Stool Softer and More Frequent? • • • • • • • •

green leafy vegetables fruit and vegetable peels fruit juice spicy or greasy food beer and red wine chocolate caffeinated beverages sorbitol and mannitol artificial sweeteners

Which foods may contribute to anal irritation? • • • • • • • • •

certain raw fruits and vegetables (e.g. oranges, apples, coleslaw, celery and corn) popcorn chinese/oriental vegetables nuts coconut dried fruits (e.g. raisins, figs) foods with seeds spicy foods coffee and tea

2. Include soluble fiber that can firm up and slow down stool. Examples: • Oats, barley, and rye • Lentils, kidney beans, and chickpeas Start with 1 teaspoon of a single product below. Slowly increase dose until stool firms up. Drink the recommended amount of water with it. • Psyllium husks (e.g. Metamucil™) • Methylcellulose (e.g. Citrucel™) • Wheat dextrin (e.g. Benefiber™) 3. Avoid drinking large amounts of hot or cold liquids very quickly or with meals. Get your daily fluid intake by drinking smaller amounts of cool fluids in between meals throughout the day and evening. 21  

4. Ask your doctor about antidiarrheal medicines such as Imodium™ or Lomotil™. These are taken about 30 minutes before meals and at bedtime. 5. Empty your bowels correctly • Hold off going to the toilet until the urge is very strong. • If you have to sit and wait, you sat down too soon. • Keep your knees higher than your hips (unless you just had hip surgery – check with your MD). Point your toes to raise your knees. • Lean forward with your elbows on your knees. • Do not strain. This weakens your pelvic floor muscles.

6. Avoid heavy lifting, squatting, or intense physical activity while your stool is liquid to avoid leakage. 7. Practice pelvic floor muscle exercises to strengthen your anal sphincter. • Begin by doing the exercises lying down with your feet elevated or your knees bent. Later you can do the exercises sitting and standing as well. • Tighten the muscles you would use if you were trying to hold your urine or stop from passing gas. You should have a sensation of lifting these muscles up and then relaxing to let them go down. • Do not tighten your abdominal muscles or your buttocks at the same time. • Tighten the muscle and hold for a count of 5, work up to a count of 10. • Relax the muscles slowly and completely. Rest for a count of 3. • Repeat the tightening and relaxing. Start with a set of 5 repetitions and work up to 10 repetitions. • Start slowly and increase gradually to avoid overstressing the muscles.

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How to Adjust the Dosage of Loperamide

Start this if your ostomy output is greater than 1200 ml What is loperamide? • Loperamide is an anti-diarrhea drug that can be used to slow down the output from an ileostomy. • It is an over-the-counter drug.

• It is also know by the brand name Imodium® but the store brand may be less expensive. How do I take it? 1. Start with one 2 mg pill before breakfast, lunch, dinner, and at bedtime 2. Measure your stool for 24 hours 3. If the total output is still more than 1200 ml, take two 2 mg pills before breakfast, lunch, dinner, and at bedtime • Never take more than 8 pills (or 16 mg) in 24 hours • You can reduce the amount of pills you take once your output is below 1200 ml per day

How much does this drug cost? • The cost of this medicine should be less than $20. • This medicine may not paid for by insurance, Medicare or Medicaid • Let your doctor or ostomy nurse know if you cannot afford this drug.

What if my output stays more than 1200 ml per 24 hours while taking 8 pills a day? • Call your surgeon

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Ostomy Internet Resources What are websites that can tell me about my ostomy and supplies? • ConvaTec: Information and support. http://www.convatec.com/en/cvtus-ostomyus/cvtportalhpo/0/portalacc/1961/1433/0/ostomy.html • Coloplast: http://www.coloplast.com/Pages/home.aspx • Hollister: Information and support. Click on any of the topics in the learning center. http://www.hollister.com/ • Great Comebacks: A program which recognizes inspirational people with ostomies. http://www.greatcomebacks.com/ • Nu-Hope: http://nu-hope.com/ How can I order ostomy supplies through the mail? • Byram Health Care: http://www.byramhealthcare.com/ • Edgepark Surgical Supplies: https://www.edgepark.com/ • Liberty Medical Supplies: http://www.libertymedical.com/ostomy-supplies How can I locate a support group? Crohn’s, Colitis and Ostomy Meeting Place: http://www.ccomp.org/ Evansville Ostomy News: http://www.ostomy.evansville.net/ The International Ostomy Association: http://www.ostomyinternational.org/ Triangle Ostomy Association: http://www.raleighuoa.org/ United Ostomy Associations of America, Inc: http://www.uoaa.org/supportgroups.shtml • Bladder Cancer Advocacy Network: http://www.bcan.org/ • Bladder Cancer Web Café: http://blcwebcafe.org • • • • •

What are the names of some companies that offer special clothing? • Options: Undergarments with built in ostomy support system. www.optionsostomy.com • Ostomy Secrets: Stylish underwear for both men and women who are wearing a pouch. http://www.ostomysecrets.com/ • Yentls Secrets: Covering for any shape or brand of ostomy pouch in various colors. http://www.yentlssecrets.com/Home_Page.html An excellent 16 minute video on Living with an Ostomy can be viewed at: http://www.ostomy.org/living_with_an_ostomy.shtml 24  

This page is only for people who have a J-pouch Learning to Live with your Ileal J-pouch What can I expect at first? • At first you may have up to 15 small bowel movements (BM) a day. • You may have some leakage and need to get up several times at night. • You may have trouble telling the difference between gas and stool. What can I expect later on? • Eventually, most patients have about 6 BMs daily, do not have significant leakage, and are not troubled by night time incontinence. • It may take up to a year to train your Ileal J-pouch. • You may need to take anti-diarrheal medicine (Imodium™ or Lomotil™). • 95% of patients are very satisfied with their choice of an ileal J-pouch after a year. What can I do to help? • Practice Pelvic Muscle Exercises to help your J-pouch hold stool without leaking (see Page 4). o Start practicing before surgery o Ask your surgeon when you can resume the exercises after your surgery. • Perform Perianal Skin Care to prevent skin irritation. o Gently cleanse and pat dry skin thoroughly at least once a day. o Use pH-balanced skin cleanser and warm water. o Alcohol-free moist wipes or soft tissues are ideal for cleansing and are less abrasive than toilet paper. o Use of a barrier product is essential to protect perianal skin. § An ointment with petrolatum, dimethicone, or zinc oxide. • It is not necessary to clean it all off after each bowel movement. Remove only the soiled layer and apply a fresh coat on top. § Or an alcohol-free barrier film wipe (e.g. 3M Cavilon) • One application will last 24 hours o Pads or panty liners should be changed frequently to keep skin clean and dry.

• Train your pouch o You should not respond to every urge to have a BM. This will help to increase the size of the J-pouch. Start by waiting a few minutes. Build up to waiting an hour. o You can also help to control pouch function with diet and, if your doctor agrees, anti-diarrhea medication. 25  

What is Pouchitis? • Pouchitis is a poorly understood inflammation of the J-pouch. • A small number of patients will experience this. • Symptoms include: • Feeling that you constantly need to have a BM • Diarrhea • Pelvic pain • Bloody stools • Fever • Loss of appetite • Feeling weak and tired How is it treated? • Your doctor may use medications such as: • Antibiotics • Steroids • Non-steroidal anti-inflammatory drugs • Probiotics powder

 

• If you have multiple episodes of pouchitis, your doctor may recommend regular pouch irrigation

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Pelvic muscle exercises Please do not start these exercises until your doctor says it is ok Why do I need to do these exercises? • You will use these muscles after surgery to help you to hold your stool, especially when you stand up, cough, or sneeze.

How often should I do the exercises? • Do these exercises 3 times a day until you have good control of your urine during the day and night.

How do I find the correct muscle? • Tighten the muscles you would use if you were trying to hold your urine or stop from passing gas. You should have a sensation of lifting these muscles up and then relaxing to let them go down. • Do not tighten your abdominal muscles or your buttocks at the same time.

What position should I be in? • Begin by doing the exercises lying down with your feet elevated or your knees bent. • Later you can do the exercises sitting and standing as well.

How do I do the exercises? • Tighten the muscle and hold for a count of 5 seconds, work up to a count of 10. • Relax the muscles slowly and completely. Rest for a count of 3. • Repeat the tightening and relaxing. Start with a set of 5 repetitions and work up to 10 repetitions • Start slowly and increase gradually to avoid overstressing the muscles.

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