Preparing For Your Surgery www.cpmc.org/learning

Multidisciplinary Care for Colorectal Surgery

Welcome to California Pacific Medical Center. We are a Center of Excellence for Colorectal Cancer Surgery and Patient Care. Our goal is to give you a safe and rapid recovery. The following information will help you prepare for your surgery and hospital stay. We want you to take part in the decisions about your care. If you have family members, caregivers, or friends caring for you, please have them read this also. Each person is unique. If you have any questions, please ask the doctors and nurses caring for you.

Table of Contents Multidisciplinary Care at CPMC

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What is colorectal cancer surgery?

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How do I prepare for colorectal cancer surgery?

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Before Your Surgery

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The Day of Your Surgery

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Your Care During your Hospital stay

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When can I go home?

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At Home

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More Ways to Learn

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Multidisciplinary Care at California Pacific Medical Center Your treatment and recovery from colorectal cancer surgery at California Pacific Medical Center will be centered on multidisciplinary care given by a team of highly-skilled and experienced medical professionals from different disciplines. The goal is to help you recover faster and with fewer complications, letting you to go home sooner. The care plan used by these different healthcare providers will help you with physical recovery, return to eating and drinking, and will help control your pain using mostly non-narcotic medicines. We invite you and your family to take part in your recovery process. Knowing your plan of care and being part of it will help you recover faster. As with any surgery, the recovery period will not be pain free, but this method of caring for you will give you with the best pain control possible. Who is a part of the multidisciplinary team? Your surgeon leads the team by directing every step of your care. The following is a short description of other team members’ roles: Anesthesiologist: An anesthesiologist is a medical doctor trained in the relief of pain and in the care of the patient before, during, and after surgery. An anesthesiologist will meet with you prior to surgery to discuss the medication used during the surgery. Colorectal Cancer Nurse Navigator: The Colorectal Cancer Nurse Navigator specializes in the care of the colorectal cancer surgery patient. He or she will contact you before your surgery and is available for you if you have any questions or concerns about your care. The Colorectal Cancer Nurse Navigator can assist you with coordination of appointments, supportive service referrals including genetic assessment, clinical trials, counseling, integrative therapies, and other information. You can contact the Colorectal Cancer Nurse Navigator/Coordinator at (415) 6005880 before your surgery, during your hospital stay and/or after you go home. Clinical Nurse Specialist in Wound and Ostomy Care: A clinical nurse specialist will see you if you have a colostomy or ileostomy placed during surgery. He or she will assist you with how to care for your ostomy at home and how to order supplies. Discharge Planner: A discharge planner, also known as a case manager, will assess your needs prior to you going home. He or she will speak with your doctors and nurses on a regular basis to see whether there is a need for you to have special medical supplies or services at home. Genetic Counselor: A genetic counselor can help you and your family understand the genetic risks connected with colorectal cancer. The genetic counselor will work with families to identify members who are at risk. If appropriate, he or she will discuss genetic testing, coordinate testing, 2

interpret test results and will review all additional testing, follow-up, surgical, or research options that are available to family members. You can reach the genetic counselor at (415) 600-3073. Nurse: Nurses are your advocates. They will work with your surgeon and other members of the healthcare team to provide you with comprehensive and compassionate care. A nurse will care for you before, during and after your surgery. He or she will guide you through your recovery and provide ongoing education to meet your needs. Nutritionist: Your surgeon may ask a nutritionist to help you during your hospital stay. A nutritionist will help you with the dietary recommendations made by your surgeon. A nutritionist can educate you on good nutrition and healthy eating habits. Physical Therapists: Your surgeon may order physical therapy (PT) as part of your recovery. A physical therapist can help you with problems of strength and movement after surgery. They can also provide you with a personal home exercise program. Wellness and Support Services: There are support services at California Pacific Medical Center. A chaplain is available to give spiritual support during your hospital stay. Massage therapy can be ordered for you during your recovery. You can call the Institute for Health and Healing at (415) 600-3939 for information on services they offer or contact a patient navigator at (415) 600-3081 to coordinate these referrals for you.

What is colorectal cancer surgery? Colorectal cancer surgery is a surgery used to treat cancer in your large intestine, also known as your colon and rectum. Figure 1 is a detailed drawing of the colon and rectum.

Figure 1

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Colorectal cancer surgery can be done through an open cut (incision) on the abdomen or through laparoscopy, which requires several small cuts on your abdomen. Laparoscopy is possible for only some types of colorectal cancer surgery. Your surgeon will decide which method is best. Some laparoscopic surgeries may need to be changed to an open incision operation. In open incision surgery, your surgeon operates through a cut which is closed with staples or sutures (see Figure 2). In laparoscopic surgery, your surgeon operates through several small cuts using instruments placed through long, hollow tubes and guided by a camera (see Figure 3). Figure 3 shows four small cuts; an additional separate, small cut is usually made to take out the part of the colon or rectum that is being removed (resected). This cut may be made anywhere on your abdomen.

Figure 2

Figure 3

Colorectal cancer surgery may include different procedures: segmental colon resection, low anterior resection or abdominal perineal resection. A common surgery for rectal cancer is a low anterior resection (LAR) (http://en.wikipedia.org/wiki/Rectal_cancer). A LAR is done for cancer in the upper two-thirds of the rectum and leaves the anal sphincter intact. This allows you to retain bowel control. This surgery may also be possible for some patients with lower rectal tumors. If this approach is not possible in your case, your surgeon will discuss the possibility of a permanent colostomy with you. The wound and ostomy clinical nurse specialist will also meet with you and give education and counseling.

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How do I prepare for colorectal cancer surgery? Use the following information as you plan for your surgery. Schedule your surgery: Your surgeon's office will schedule your surgery and let you know the time and location. Make an appointment with your primary care doctor: You will need to make an appointment for a physical exam before your surgery. Discuss this with your surgeon’s office staff. One week before your surgery is the best time for you to have your physical exam. However, physical exams up to one month before your surgery will be accepted. Your primary care doctor will make sure you are fit for surgery.

Schedule a pre-operative education session with the Colorectal Cancer Nurse Navigator by calling (415) 600-5880 During the education session, the nurse will give you useful information about preparation for and recovering from surgery. The nurse will assist you with coordinating all of your appointments and follow-up care. He/she will visit you while you are in the hospital to help you with your recovery and discharge home.

Pre-registration is a two-step process that you must complete before having a surgery, test, or procedure at California Pacific Medical Center. 1. Health History. Please call (415) 600-2500 within 1- 2 weeks before your procedure to speak with a Pre-admission Testing nurse who will take your health history, answer your questions, and explain what testing is necessary before your surgery, test, or procedure. Based on your health status, the nurse may send you to complete any required testing before you come to the hospital. The nurse will tell you where you can go for your test(s). 2. Pre-Registration. The nurse will connect you to the Patient Access Center to complete the pre-registration process. Please be sure to have your insurance card information ready when you begin. About Your Medicines: Ask your surgeon or primary care doctor if and when you should stop taking any of your regular medicines. Your surgeon or primary care doctor may request that you bring all of your medicines in the original containers to the hospital.

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Note: For your safety, please give any and all medicines from home to the nurse. Medicine brought in from home will not be used during your stay in the hospital unless it is not available from the hospital pharmacy. Your medicines will be returned to you when you are ready to go home. If you are taking vitamins, herbal supplements, or over-the-counter drugs, please discuss this with your surgeon and primary care doctor as well as the nurse you speak with during pre-registration. Some of these supplements and drugs may need to be stopped before surgery. Fill new prescriptions, including pain medicine, before you have surgery. Review the list of your current medicines with the nurse coordinator. They will discuss the oral medicines you may need on the day of your surgery. These medicines should be taken with only a sip of water. Most patients will receive anticoagulation therapy before their surgery to help lower the chance of developing a blood clot. You will receive either Enoxaparin (Lovenox) or Heparin Sodium in the form of an injection. Please stop taking all antiplatelet medicines 7 days before your surgery. If you are taking Coumadin, please stop taking it 4 days before your surgery unless you are instructed to do otherwise. If you are taking medicines for diabetes, such as Glucophage (Metformin), Micronase (Glyburide), or Glucotrol (Glipizide), ask your surgeon or primary care doctor when you should stop taking these medicines before your surgery. If you are taking insulin for diabetes, ask your surgeon or primary care doctor about the amount and type of insulin you should take, or whether you should stop taking your insulin prior to the surgery.

Before Your Surgery Call your surgeon at once if you have any changes in your health, such as a fever or cold, within 23 hours before your scheduled surgery. Be sure to tell your surgeon if you are pregnant. Before colorectal cancer surgery, your surgeon will give you instructions for preoperative bowel preparation which may include being on a clear liquid diet and taking laxatives. Follow them carefully. Do not eat or drink anything after midnight the night before your surgery unless told otherwise by your doctor or nurse. 6

Please arrange for a friend or family member to be your “recovery coach.” This approach requires you to take an active role in your recovery. Most patients do better if they have a friend or family member who can spend time with them and encourage them to do what their healthcare providers ask. Your nurses will be able to explain to this person how to best help you. You will not be able to wear contact lenses in the operating room. It is a good idea to bring an old pair of glasses to the hospital to take into the operating room if you have very poor vision. Do not smoke or drink alcohol 24 hours before your surgery. Leave your valuables at home the day of surgery. Do not wear jewelry, including rings and body piercings.

The Day of Your Surgery Arrival: Please go directly to the specific campus where your surgery is scheduled. You will be asked to register at one of our Same Day Care units (ambulatory care). Please arrive 1.5 hours before your scheduled surgery. This time is needed by our staff to help prepare you for surgery. The Same Day Care staff will keep you informed of any possible delays. Inside the Surgical Suite: Once the Same Day Care staff have completed their tests and preoperative documentation, you will be taken to a surgical suite. In this suite you will meet with the anesthesiologist to discuss what it feels like to receive anesthesia and what to expect. The anesthesiologist will also give you information on how your pain will be managed after surgery. Your family may not accompany you into this unit. However, they are welcome to wait in one of our designated surgical waiting areas. Our staff will direct your family and friends to the designated areas and keep them informed. You will be asked a series of questions prior to surgery by your nurses, surgeon and other members of the team. Some of the questions may be: Do you know why you are having surgery? On what part of your body are you having surgery today? Do you have any allergies? Can you please tell me your name and date of birth? All of these questions are being asked for your safety. The Post-Anesthesia Unit (PACU): Immediately after surgery you will be transferred to the post-anesthesia unit. The nurses on this unit will monitor all of your vital signs and will make sure that your pain control plan is effective. Once you are stable, the nurses will take you to a nursing unit in the hospital. The surgeon will talk with your family and friends during this time. Your family will be told what room you will be in as soon as it is known. 7

Your Care During Your Hospital Stay Our goal after surgery is to start taking actions that will help your organs return to their normal function. The rest of this patient education handout will focus step by step on what you can expect after surgery. Please remember that these are general guidelines that may be changed to meet your specific needs. The specialists at CPMC will help you recover from surgery by attending to your nutrition, physical rehabilitation, and pain management. Managing your pain: As mentioned before, recovery will not be pain free. However, using all of the ways listed below, we hope to manage your pain well. Your doctors will decide the best pain management plan for you. You and your multidisciplinary team will decide the best way to provide you with the right amount of pain medicine. Medicine can be given in different ways. You may have an epidural catheter placed during surgery or you may have pain medicine given directly into your veins through an IV. Your pain management plan will include a combination of the following medicines:

Oral Pain Medicine

Intravenous Pain Medicine

Acetaminophen/ Hyrdrocodone (Norco)

Ketorolac (Toradol)

Acetaminophen (Tylenol)

Acetaminophen (Ofirmev), this is Tylenol that may be given via your IV

Please note that some pain medicines, such as narcotics, can slow the function of your body organs. During and after your surgery, your pain will be controlled using mostly non-narcotic medicines. Patient Controlled Analgesia (PCA). This form of pain management may be used in combination with either epidural or IV medicine. A PCA is a medicine pump that has a button that allows you to control the amount of pain medicine you receive. You will need to press the button to have medicine given to you. However, you cannot over-medicate yourself because the device is programmed to give you safe amounts over a period of time. During your hospital stay, your team of specialists will ask you about your pain regularly. They will ask you to rate your pain using a Pain Scale. This will help your team understand the severity of your pain. Below you will find the most commonly used pain scale. Please be familiar with this 8

scale before surgery. The team will ask you about your pain score often. This will help the team make adjustments to your pain medicine schedule. A score of 0 means you have no pain. A score of 10 means you have the worst pain imaginable.

There are many different things that may affect our ability to manage your pain. It is important that you do all of your physical rehabilitation exercises to help us control your pain. We will also encourage you to breathe deeply and cough. Deep breathing and coughing will help expand your lungs and will help prevent complications such as pneumonia.

Physical Rehabilitation: After surgery, the team will start preparing you to get out of bed. Being out of bed means sitting in a chair, standing, walking, or a combination of these actions. The goal is to increase the time you spend out of bed every day. These actions will help your colon return to its normal functions, which include taking in water and minerals and the forming and elimination of stool. On the day of surgery, we would like you to spend time out of bed at least two times. On the following days we will ask you to gradually increase the amount of time you spend out of bed.

Nutrition: Eating and Drinking: You will be offered clear liquids to drink soon after your surgery. This will help your bowel recuperate. Clear liquids include clear broth, jello, popsicles, and clear juices. We recommend that during this time you do not drink carbonated drinks or drink from a straw because these can bring air into your colon. The air may cause bloating and nausea, which can be painful and uncomfortable. 9

Post-Operative Care Plan after Colorectal Cancer Surgery *There will be exceptions to your post-operative care plan if you have a low anterior resection and/or an abdominal perineal resection. PostOperative Day

Nursing Activities The nurse should discuss and explain your pain medicine plan.

Day 1 After Surgery

You and your nurse should come up with a plan to get out of bed. Your urinary catheter will be removed.* The nurse will start preparing you for discharge.

Day 2 After Surgery

Day 3 After Surgery

Please inform your nurse if you are having any difficulties with bowel movements or nausea or inability to tolerate fluids.

The nurse will continue to prepare you for discharge. This should include discussion of your current pain level and the medicines being used to treat your pain.

Pain Management Your pain will be controlled with an IV nonnarcotic and/or PCA and oral pain medicines. Please let us know if we are controlling your pain. If you had an epidural catheter, the medicine will be stopped today.

Time Out of Bed Please attempt to get out of bed a total of 3 times.

Drink 6 to 7 eightounce glasses of clear liquid as tolerated.

The 3 times can be sitting in a chair during meal time, but we also encourage you to walk.

Clear liquids include clear broth, jello, popsicles, and clear juices.

We recommend that you spend a total of 4 hours out of bed.

Your diet will consist of solid foods as tolerated. We suggest that you begin with small, but frequent meals at this time.

Please try to increase the amount of time you are walking.

The epidural catheter will be removed once we have controlled your pain with oral medicines.

Please discuss with your nurse any difficulties you have.

At this time your pain will be managed with oral pain medicines only.

We recommend that you spend a total of 6 hours out of bed. Please increase the amount of time you are walking. Please discuss with your nurse any difficulties you are having.

Please inform your nurse if you are having any difficulties with bowel movements or nausea or inability to tolerate fluids.

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Nutrition

You may order small snacks between your breakfast, lunch and dinner. We suggest that you avoid too many seasonings or sauces. Your diet will consist of solid foods. We suggest that you continue with small, but frequent meals. You may order small snacks between your breakfast, lunch and dinner. We suggest that you avoid too many seasonings or sauces.

When can I go home? The multidisciplinary team will begin preparing you to go home on the second day after surgery. Your ability to complete the post-operative care plan activities will define when you can go home. Your doctor will want you to be able to do the following before sending you home: Tolerate the diet that was prescribed for you Pass gas and/or have bowel movements Spend at least 6 hours out of bed Be able to manage your pain with oral pain medicines only

At Home Your recovery care plan must continue at home. You will need to follow your discharge instructions, which will include the following: Take all of your prescription medicine as ordered by your doctor. Please make sure that prior to being discharged you understand how to take your pain medicine. Maintain a diet plan as recommended by your doctor. You may continue to follow the recommendations of eating small, but frequent meals throughout the day. Maintain a level of activity that will allow you to spend the majority of your day out of bed. Schedule a follow-up appointment with your surgeon. The surgeon will let you know how soon he would like to see you. Call your doctor if you experience any of the following: • Increasing abdominal pain or bloating • Nausea or vomiting lasting longer than 4 hours • Temperature greater than 101˚F or shaking or chills • Shortness of breath (difficulty breathing) • Chest pain 11

• Diarrhea that lasts more than 24 hours (6 or more episodes per 24 hours) You may receive follow-up phone calls from several of your healthcare providers. A nurse will contact you 30 days after surgery to assess how you are doing and to ask questions regarding your hospital stay.

More Ways to Learn Colorectal Cancer Nurse Navigator/Coordinator: Weekly classes will be held in group sessions or one-on-one to assist with any clinical needs. The nurse coordinator is available to you before surgery, while you are in the hospital and after you go home as often as you need. You can reach the Colorectal Nurse Navigator by calling (415) 600-5880.

Community Health Resource Center: Services include classes and written information on a wide variety of health topics. 2100 Webster Street, San Francisco. Telephone: (415) 923-3155 Institute For Health and Healing: Ask about their Personalized Research Service. A fee will be charged for this service. 2040 Webster Street at Sacramento Street, San Francisco Telephone: (415) 600-3681 Visit these Web sites: •

California Pacific Medical Center at www.cpmc.org/learning

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American College of Surgeons at www.facs.org/patienteducation

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National Institutes of Health at www.health.nih.gov

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Wikipedia Page on Rectal Cancer: http://en.wikipedia.org/wiki/Rectal_cancer

Produced by the staff and physicians at California Pacific Medical Center in association with Community Health Education. Last updated: 03/15. © 2015 California Pacific Medical Center Note: This information is not meant to replace any information or personal medical advice which you get directly from your doctor(s). If you have any questions about this information, such as the risks or benefits of the treatment listed, please ask your doctor(s).

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