Download Enhanced Recovery After Surgery Colorectal Surgery

Dumfries & Galloway Royal Infirmary
Enhanced Recovery After Surgery
Colorectal Surgery
Patient information booklet
Please bring this booklet into hospital with you
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Introduction
The aim of this booklet is to provide you with some general information about our
enhanced recovery programme. It is important that you are aware of what to
expect before and after your colorectal surgery in terms of how you prepare for
your operation and your recovery.
This booklet is only intended as a guide, as treatment is always planned on an
individual basis. Please ask a member of the healthcare team if anything remains
unclear, or you have any questions or concerns at pre-assessment, during your
stay in hospital or at home.
Please bring this booklet into hospital with you.
You have a very important part to play in your recovery so it is essential to follow
the advice given to you.
Patients and health professionals are realising the benefits of a shorter stay in
hospital, therefore we will work with you in your recovery to keep your stay as
short as possible. You should expect to be in hospital for approximately 7 - 10
days.
You should make your own transport arrangements to and from hospital.
Ambulances can be arranged for medical reasons only on the
recommendation of the doctor looking after you.
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Pre-assessment
Who will I see at the pre-assessment clinic?
• Pre-assessment nurse
• You may also see an Anaesthetist
The pre-assessment nurse will:
• assess how fit you are for surgery and anaesthetic to ensure that you will
be in the best health prior to your operation.
• discuss your general health and record your medical history.
• ask you about your current medication including all prescribed and any
other medication that you have purchased and take regularly. This will
include tablets, inhalers, creams, eye drops. Please bring a list with you
• you will have some tests carried out including blood pressure, pulse, weight
and height
• you may also have blood tests, ECG (heart tracing), MRSA swab. You
may also be asked to provide a urine sample. Other tests may be required
depending on your medical history and the pre-assessment nurse will
inform you if these are needed.
The pre-assessment nurse may arrange for an appointment with the Anaesthetist
who may need to do some further tests before your operation to assess how
safe a general anaesthetic is for you. These tests will allow the healthcare
team to decide if there is anything they may need to do differently. The tests
will vary but may include the following.
• blood tests to look for anaemia (your body not producing enough healthy
red blood cells), the balance of salts in your blood, the level of sugar in your
blood or how well your blood clots.
• lung-function tests, which may be appropriate if you have asthma,
bronchitis, emphysema or unexplained shortness of breath.
Sometimes, after examining you or because of the results of your investigations,
the Anaesthetist may recommend that you are seen by your GP or another
specialist to improve your medical condition before surgery. This often happens
with people who have high blood pressure, angina, asthma or anaemia which is
not well controlled. The Anaesthetist will also discuss the type of anaesthetic you
require for your operation and the type of pain relief you will have after your operation.
Some of your regular medication may need to be stopped prior to surgery but the
pre-assessment nurses will advise you if this requires to happen.
A key aspect of your enhanced recovery programme is that you will be given
some cartons of clear lemon flavoured carbohydrate drinks (called ‘preOp’) to take
the night before and the morning of your surgery. These drinks will help to
maintain hydration and provide some energy during the time you are fasting (not
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eating). These will be supplied at your pre-assessment. It is important to eat well
before your surgery as this helps you to recover quicker. Being well nourished is
essential for healing and minimising your chances of developing an infection. If
you have concerns about your diet, the pre-assessment nurse will be able to
provide you with some information and refer you to the dietician if necessary.
More information on diet can be found further on in this booklet.
If , you are to be admitted to hospital on the day of surgery, you will be given
bowel preparation at pre-assessment which you should administer yourself at
home. The pre-assessment nurse will give you full instructions on how and when
to use this.
If you are to be admitted to hospital the day before surgery then, if required, bowel
preparation will be administered to you by nursing staff.
Bowel preparation is a laxative drink which helps clear the contents of your bowel.
What we expect from you
Your pre-assessment clinic appointment is an opportunity for you to tell us about
your individual needs and circumstances. It is important that you tell us as early
as possible if you have any concerns about whether you will be able to manage
your daily activities when you are discharged after your surgery. You should also
let us know if any of your social circumstances change during your admission.
We have a multidisciplinary team of professionals who can help to organise any
social support you may need. These include, discharge coordinators, social
workers, occupational therapists and physiotherapists.
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 you get out of bed and start eating and drinking the better. This will speed
up your recovery making it less likely that complications will develop. To achieve
this we need you to be a partner with us so that we can work together to speed up
your recovery.
The pre-assessment clinic allows us to provide the information, support and
education you need to take an active role in your treatment. At this visit you may
also raise any concerns you have.
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Preparing for you operation
Do I need bowel preparation?
Some patients will not require bowel preparation. You will be told by the nurse in
the pre-assessment clinic whether you will need bowel preparation or not.
If bowel preparation is required:
The day before your operation, you may be asked to drink a laxative medicine to
help clear the contents of the bowel. If this is necessary you need to have a low
fibre/low residue diet on the day before the bowel preparation. The table below
highlights the foods you should choose and the foods you should avoid:
Low fibre foods to choose:
Bread, biscuits: white bread or rolls, cream
crackers, tea biscuits, plain scone, plain sponge.
High fibre foods to avoid:
Bread, biscuits: Wholemeal, granary or oatmeal
bread, rolls or scones, cream or chocolate
biscuits, cheese flavoured biscuits, shortbread,
rich fruit cake and chocolate cake. Gingerbread
or baked goods with added dried fruit or nuts.
Doughnuts, Danish pastries, Croissants,
Digestive biscuits, Crispbreads, Bran type
biscuits Oat biscuits
Meat: Sausages, haggis, black and white
puddings, Scotch egg, pies, sausage rolls,
bridies.
Fish: Mackerel. Fried fish (battered or crumbed)
Meat: Lean meats – beef, lamb, pork, rabbit,
ham, bacon, veal, liver, kidney, chicken or turkey.
Fish: White fish – cod, haddock, sole, (steam,
baked, grilled, poached or microwaved) Oily fish
– herring, sardines, pilchards, tuna, salmon.
Vegetables: Potatoes (boiled or mashed – no
skins) asparagus, cauliflower florets, courgettes,
(no skin) mushrooms, radish, swede, tomatoes
(flesh only) turnip, clear soups made with the
vegetables listed above
Vegetables: Potatoes, (fried, roasted, sauté,
crisps, chipped (including oven chips) fritters)
Fried vegetables, vegetables coated in sauce.
Vegetarian dishes.
Cabbage, sprouts, onion, broccoli, peas, sweet
corn, beetroot, all kinds of beans, soups
containing vegetables listed above, broth, lentil,
split pea
Fruits: Fruits eaten with their skins intact, fruits
with pith (e.g. oranges), pips or seeds, fibrous
foods like bananas
Cereals: Bran type cereals, Weetabix, Shredded
Wheat, Oatmeal, Muesli.
Puddings: Pastries, pies, suet puddings
Fruits: Stewed apples, tinned pears, tinned
peaches, tinned pineapple, tinned fruit cocktail,
melon. Fruit juices
Cereals: Corn Flakes, Rice Krispies. White rice or
pasta
Puddings: Milk pudding – custard, rice,
blancmange, semolina, sago, meringue shells,
table jelly, sorbet, fruit (as above) yoghurt or
fromage frais (not muesli or fruit pieces)
Miscellaneous: Bovril, Oxo, Marmite, weak tea,
coffee, lemonade ,fruit squash, malted drinks,
Boiled sweets, fruit gums, pastilles,
marshmallows, peppermints, fondants, Seedless
jam, jelly, marmalade, honey, syrup, treacle,
sugar
Miscellaneous: Olives, nuts (including coconut).
Pickles and Spices. Strong black coffee or tea,
Marzipan, sweets or chocolate containing fruit or
nuts, Peanut butter, jam or marmalade with
seeds or skin.
Additionally high fibre and highly coloured foods (e.g. red jelly, beetroot, coffee,
tea and red fruit juices) are NOT recommended.
The bowel preparation gives you loose, watery stools. It is important that you
drink plenty of clear fluids but not fizzy drinks to replace the fluid you are
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losing. This should stop you from feeling dizzy, sick or getting a headache. You
should aim for around 2 litres of clear fluids per day (8-10 glasses). Some people
may require a drip (intravenous fluids) which the nursing staff will advise you
about. If necessary, some patients will be given an enema before the operation to
clear out the lower bowel.
Other preparations for your surgery
If you are able to eat the day before surgery it is a very good idea to have a meal
the evening before the operation.
If you are in hospital the day before your surgery you will be given a small
injection into the skin the evening before surgery. This helps reduce the risk of
blood clots (thrombosis) by thinning your blood. This will be given to you each
evening while you are in hospital. You will be asked to wear elastic stockings
which you must wear whilst in hospital and for 10 days after discharge, these also
help to prevent clots.
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Preparing for your hospital stay
Pre operative advice
When you leave hospital you may return to your home, or stay with family or
friends. This decision will be made by you, along with the medical, nursing and
therapy team responsible for your care. The decision will depend on your home
situation, the amount of help you need at home and the rate of your progress and
physical condition.
After the operation you will need to change the way in which you carry out some
daily activities and may need some help from other people at first.
There are a few simple things you can do before coming into hospital, which might
make things easier when you get home again:
• have your house ready for your arrival back home. Clean and do the laundry,
and put it away. Put clean sheets on the bed.
• in the kitchen in particular, but also throughout your home, put the things you
use often somewhere between waist and shoulder height to avoid having to
bend down or stretch too much to reach them.
• bring downstairs the things you are going to use often during the day.
• buy a stock of food and other things which you need frequently as you may find
shopping difficult when you first go home. Stock up on ready-prepared meals.
• cut the grass, tend to the garden and other necessary outside work.
• arrange for someone to collect your post and take care of pets and loved–ones
if necessary.
• arrange for a repeat prescription of your regular medication.
What to bring into hospital
Please be aware there may be a lot of waiting around if you are admitted the day before
your operation, therefore, bring a good book to read. There is a bedside personal phone
and TV for your use whilst you are in hospital. You can purchase cards from the vending
machine in the core areas of the hospital. You may need to sit in the day room until your
bed is ready.
Day and night clothing
Please bring in comfortable loose fitting clothing for during the day as you will be
encouraged to dress in day clothes after your operation. Comfortable, flat
supportive shoes (not backless shoes e.g. mules) also socks and stockings rather
than tights are best. You will need to bring in suitable nightwear and a dressing
gown (if you wish) for the duration of your stay (approx 4 – 7 days).
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Toiletries
Please bring in all the toiletries that you feel you will need for the duration of your
stay. A towel will be provided by the hospital.
Medicines
You should bring all your usual medication into hospital with you and these will be
locked away in a medicine locker beside your bed. You must store and bring them
in their original containers rather than decant them or bring in single strips.
This is so that we can check your dosage instructions and positively identify them
as belonging to you. If there have been any changes to your medication since
pre-assessment please make nursing staff or the doctor are made aware.
Entertainment
It is advisable to bring in reading material, personal music player with
headphones, money for newspapers, magazines, and confectionary.
You must bring in
ƒ Your patient guide
ƒ Your medication guidelines
ƒ Your advanced directives/living will (if you have made one)
Do not bring valuables
Please avoid bringing valuables with you. If you cannot avoid bringing jewellery or
valuables with you we would strongly recommend that you hand them over to the
nurse, who will give you a receipt and then put them in the hospital safe.
Personal property and valuables are brought into the hospital premises at the
owner’s risk.
NHS Dumfries and Galloway will not be responsible for any loss of, or damage to
any property of patients, staff or visitors unless valuables have been handed in to
staff for safe keeping and a receipt obtained.
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Educational information
Anterior Resection – During this operation the sigmoid and upper part of the
rectum are removed. The remaining ends are joined together. Occasionally a
temporary stoma may be performed.
Sigmoid colectomy – During this operation the sigmoid colon is removed. The two
remaining ends are joined together. Or occasionally a temporary stoma is formed.
If a stoma is being considered, you will be supplied with a pre-operative pack at
your pre-assessment meeting. The pack will contain information about a stoma,
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an appliance, and a DVD. This will enable you to read and see what a stoma is
and what you can expect to deal with post operatively. The pack contains the
contact details of the Stoma Nurse whom you should phone and arrange to see in
order to discuss any questions or worries you may have.
If you require a temporary or permanent stoma you will meet with the Stoma
Nurse on the day of your admission who will place a mark on your tummy where
the surgeon will bring out a piece of the bowel to form your stoma. At this visit the
nurse will discuss the most appropriate site which will allow you to see, apply and
manage your stoma.
Right hemicolectomy – during this operation the right side of the large bowel is
removed and the end of your small bowel is joined to your large bowel.
Left hemicolectomy – during this operation the left side of the large bowel is
removed. The end of your bowel which passes from left to right across your
abdominal space is then joined to the lower end of your large bowel.
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What are the risks?
The healthcare team will make your operation as safe as possible, however,
complications can happen. Some of these can be serious. You should ask your
doctor if there is anything you do not understand.
General complications
Blood clots
A blood clot in the veins of the leg or pelvis is called a thrombosis. .
The longer you are in bed, the greater the risk of blood clots forming, which is why
you will be encouraged to get up as soon as possible after the operation. While
you are in bed you should do circulatory exercises regularly to prevent the blood
flow from becoming sluggish. The physiotherapist will show you what to do.
Pain
There is usually some pain related to a major operation but modern methods of
pain control mean that we are able to keep it to a minimum. Management of pain
following your surgery is dealt with later in this section.
Bleeding
Bleeding during or after surgery may mean you will require a blood transfusion.
If for any reason you do not wish to have a blood transfusion please make
nursing staff or medical staff aware.
Chest infection
Minor breathing problems which get better on their own are common. Chest
infection is less common. The risk is increased if you are a smoker, have a chest
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or lung disease or are having chest or abdominal surgery. The physiotherapist
will advise you on how to prevent developing a chest infection.
Infection
It is not uncommon for wounds to be slightly uncomfortable during the first two
weeks following surgery. Please let us know if your wound becomes inflamed,
painful, swollen, or starts to discharge fluid. Nursing staff will monitor your wound
for signs of infection whilst you are in hospital.
Post operative nausea and vomiting
Occasionally after an operation you may feel sick. During surgery you will be
given medication to reduce this, however, if you do feel sick after surgery please
tell a member of staff who will be able to give you medication for this.
If you are sick after surgery, or when you have started to eat, 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 continues then the medical team will be on hand to deal with
it.
Postoperative ileus
This is quite common following surgery and is more common after colorectal
surgery. This is when the bowel temporarily loses its motility and food and gas
are no longer able to pass through the intestinal tract. There are various methods
of treatment which your surgeon can discuss with you. A post-operative ileus
usually resolves spontaneously after two to three days.
Anastamotic leak
This is a serious complication which may happen if the join (anastamosis)
between the ends of the bowel fails to heal thus leaving a hole. Bowel contents
leak into the abdomen, leading to pain and serious illness. This often needs
another operation.
Death
Death occasionally occurs with colorectal surgery. The risk, however, is less the
fitter you are.
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Admission to hospital
Day of admission
You will receive a letter giving you the date and time of your admission. Please
follow the instructions carefully. If you are being admitted on the day of your
surgery please wash with an antibacterial wash in the morning. You will be asked
to report to the main reception desk after which you will be shown where to go
next.
You will be required to fast (stop eating) for a period of time prior to your surgery.
This is to reduce the risks of complications of being sick during surgery. You will
be required to fast for approximately 6 hours. This will allow sufficient time for
your stomach to empty prior to surgery.
You will be encouraged to have clear fluids up to 2 hours before your surgery, it is
important that you try to drink lots of clear fluids until then. This will help you to
stay well hydrated and will make you less likely to be thirsty or suffer from
headaches after surgery.
Specific guidelines are outlined below:
If your surgery is in
the morning:
If your surgery is in
the afternoon and
you have had bowel
preparation:
If your surgery is in
the afternoon and
you haven’t had
bowel preparation:
Allowed food until:
12 midnight the night before surgery
Allowed clear fluid until:
06.30am
12 midnight the night before surgery
11.30am
07:30am the day of surgery (you
may be allowed a light breakfast
before 07:30am, e.g. black tea and
toast made with white bread)
11:30am
At your appointment a few weeks prior to your surgery you will be given some drinks to
take home. These are called preOp. This is a clear carbohydrate lemon-flavoured drink
which will help to maintain hydration and provide some energy during the time you are
fasting.
Please note: these drinks are not suitable for diabetic patients due to their high
carbohydrate content. If you are diabetic please refer to the guidelines on fasting
only.
Diabetics should increase their clear oral fluids to replace the fluids they would
have received if they had taken preOp
You should have a total of 4 drinks the evening prior to your surgery and the final
2 drinks approximately two hours before your surgery.
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More specific guidelines are outlined below:
If your surgery is in the morning you should have:
• 4 cartons of preOp the evening before surgery
• A further 2 cartons during the night or early in the morning on the day of
surgery (these final 2 should be finished by 06.30am – do not take any
preOp after this time)
If your surgery is in the afternoon you should have:
• 4 cartons of preOp the evening before surgery
• A further 2 cartons early in the morning on the day of surgery (these final 2
should be finished by 11.00am – do not take any preOp after this time)
Please bring your remaining drinks into hospital with you on the day of your
admission.
What happens when you arrive at the hospital?
On the ward
The nurse will check your details and discuss your care with you. He or she will
ensure you are ready for your surgery and keep you informed every step of the
way.
Your consultant (surgeon) or the doctor working for your consultant will see you
before your operation. He/she will discuss the surgery with you and once you
have all the information required to make a decision about your surgery he/she
will ask you to sign a consent form. This form gives the surgeon your consent to
carry out your operation. He/she will then mark the area of your surgery.
Your Anaesthetist will discuss the types of anaesthesia available and what would
be the best choice for you. He/she will discuss the benefits, risks, any
complications and side effects of different types of anaesthesia.
Your surgery
If you are admitted the day before surgery, you will be asked to take a shower on
the day of surgery using an antibacterial wash. You will be given a theatre gown
to wear.
The doctor may also visit you again to have a brief chat and answer any questions
you may still have.
The staff on the ward will accompany you to the theatre, either walking with you,
taking you in a wheel chair or on your hospital bed. Here you will be met by the
nurses in the recovery room who will be taking care of you before and after your
operation. From here you will be taken to the anaesthetic room and then into
theatre.
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Anaesthesia
During surgery
What does my Anaesthetist do?
Your Anaesthetist is responsible for your comfort and well being before, during
and immediately after your surgical procedure. In the operating room, the
Anaesthetist looks after your body’s vital functions, including heart rate and
rhythm, blood pressure, temperature and breathing. The Anaesthetist is also
responsible for fluid and blood replacement when necessary.
What types of anaesthesia are available?
For colorectal operations, you will be given a general anaesthetic.
This is frequently combined with an epidural which is usually inserted before you
are given the general anaesthetic.
General Anaesthesia
What is a general anaesthetic?
A general anaesthetic is a combination of drugs which causes a deep sleep and is
used for operations or medical procedures. This causes a loss of sensation
and makes you unaware of what is happening to you or going on around you.
Afterwards you will not remember anything what has happened. Your
anaesthetic will be given to you by an Anaesthetist.
Why do I need a general anaesthetic?
You and your surgeon have agreed that you need to have a particular operation.
In order for your surgeon to perform the operation safely, you will need to be in
a state where you do not move and your muscles are relaxed hence the need
for a general anaesthetic.
How is the anaesthetic given?
Most people are sent to sleep by injecting the drugs through a drip (small tube)
into a vein. This takes about 30 seconds to take effect.
For some people, it may be more appropriate to go to sleep by breathing in an
anaesthetic gas through a face mask. This also takes about 30 seconds to
take effect.
You will be kept asleep for as long as is needed either by giving you more of the
same drug into the vein or by breathing anaesthetic gases. Your Anaesthetist
may also give you drugs to reduce pain and sickness after the procedure.
Through out your operation the Anaesthetist will monitor you closely.
Following the operation the anaesthetic will wear off thus allowing you to wake
up again.
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Is a general anaesthetic safe?
A general anaesthetic is safe for most people. Death after an operation is almost
always because a person’s body cannot cope with the surgery. The risk is
higher for those with ill health and for emergency surgery.
What complications can happen?
Your Anaesthetist will make your anaesthesia as safe as possible. However,
complications can happen. Some of these can be serious and can even cause
death (risk of anaesthesia contributing to death: 1 in 60,000, risk of death directly
due to anaesthesia: 1 in 200,000). The possible complications of a general
anaesthetic are listed below. Any numbers which relate to risk are from studies of
people who have had a general anaesthetic. Your Anaesthetist may be able to
tell you if the risk of complication is higher or lower for you.
1. Minor complications (not disabling or life-threatening)
• Feeling or being sick after the operation (risk: 1 in 4). This risk
increases with some people and certain operations, but this can be
reduced with drugs given by either the Anaesthetist at the time of your
anaesthetic or the ward doctor following the operation. If you think you
may be prone to being sick, you should let your Anaesthetist know.
• sore throat, which gets better quickly (risk: 1 in 6).
• headache (risk: 1 in 20). This is not usually severe and will get better.
Paracetamol or other simple painkillers may help.
• muscle and back pains due to the drugs used or being in one position
during the operation ( risk: 1 in 20). If you know that certain positions
are likely to cause problems, let your Anaesthetist know.
• dental damage affecting the front teeth or crowns (risk: less than 1 in
100). Your Anaesthetist will always ask to look inside your mouth,
however, you should let your Anaesthetist know if you have any loose
teeth, crowns or bridgework.
Overall around 4 in 10 people report some problem following a general
anaesthetic.
2. Serious complications
• loss or change of hearing (risk: 1 in 10,000). In most cases this gets
better on its own.
• eye injury (risk of short term blurred vision: 1 in 20, risk of serious damage
needing further treatment: 1 in 1,000, risk of loss of sight: 1 in 125,000).
• nerve injury (risk: 1 in 1,000). Usually the nerve that gets damaged is the
ulnar nerve that runs just behind your elbow. Any damage is usually mild
and gets better on its own. However, the damage may be permanent.
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• heart attack (myocardial infarction). This is unusual in a person who is fit
before the operation. Heart attack is more common, but still unusual, in
people with heart disease, diabetes or high blood pressure.
• stroke, which is a loss of brain function resulting from an interruption of the
blood supply to the brain. This is unusual in a person who was fit before the
operation. Stroke is more common, but still unusual, in people with heart
disease, diabetes, high blood pressure or a history of strokes.
• chest infection or other breathing problems. Minor breathing problems
which will get better on their own are common (risk: 1 in 20). Chest
infection is less common. The risk increases if you smoke, have a chest or
lung disease or are having a chest or abdominal operation.
• allergic reaction to the drugs used in your anaesthetic.
Your
Anaesthetist is trained to detect and treat any reactions which might
happen. However, an allergic reaction can be life-threatening (risk: 1 in
10,000). You should discuss these possible complications with your
Anaesthetist if there is anything you do not understand.
How will my Anaesthetist know that I am really asleep?
There is not a monitor available that can reliably say that someone is asleep. The
Anaesthetist continuously monitors the amount of anaesthetic in your body to
make sure that it is extremely unlikely you are aware of what is happening.
Summary
General anaesthesia is usually a safe and effective way for you to have your
operation. Most people do not have any problems and are satisfied with their
anaesthesia, however, complications can happen. You need to know about them
to help you make an informed decision about your anaesthetic.
Epidural anaesthesia/analgesia
An epidural anaesthetic (or epidural) involves injecting drugs into an area called
the epidural space, near the spinal cord. The drugs numb your nerves to give
pain relief in certain areas of your body. Epidurals can be used either on their
own while you are awake, or together with a sedative or general anaesthesia.
They can also be used after your operation to give effective pain relief. Your
anaesthetic will be given to you by an Anaesthetist.
How does an epidural work?
An epidural works by temporarily numbing your nerves to give pain relief. A fine
catheter (small tube) is inserted into the epidural space. Most of your nerves pass
through this space. Local anaesthetics and other painkilling drugs are inserted
down the catheter into the epidural space to numb your nerves.
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The epidural can be maintained by giving extra doses when needed or by giving a
continuous low dose (an infusion). Your Anaesthetist will monitor you closely.
What will happen if I decide not to have an epidural?
There may be clinical reasons not to use an epidural, such as having an allergy to
any of the drugs or materials used, or an infection at the site where the epidural
catheter will be inserted.
If you decide not to have an epidural, your Anaesthetist will suggest other
methods such as using a general anaesthetic alone, or using other types of
painkiller, such as morphine, after your operation.
What does the procedure involve?
To insert the epidural catheter, your Anaesthetist will ask you either to sit up or lie
on your side. You will need to curl up and arch your back as much as possible as
this makes it much easier for the Anaesthetist to find the right place.
Your Anaesthetist will inject local anaesthetic into the area where they will insert
the epidural catheter. This stings for a moment but will make the area numb,
allowing your Anaesthetist to put the catheter in with much less discomfort for you.
Your Anaesthetist will insert the epidural catheter using a needle. They will pass
the catheter through the needle. Once the catheter is in position, they will remove
the needle and you will simply have the catheter in your back.
Your Anaesthetist will then inject a small amount of drug through the catheter to
check the position. Once they have completed this check, they will give more of
the drug until the epidural is working properly.
Sometimes when your Anaesthetist is passing the catheter through the needle,
you may get an electric shock-like feeling or tingle in your back or in one of your
legs. If this happens, let your Anaesthetist know. This feeling should go away
fairly quickly. It does not mean anything is wrong.
You can help your Anaesthetist by keeping still while they are inserting the
epidural catheter. It should not be painful, although it can be uncomfortable. If
you feel pain, you should let your Anaesthetist know.
What effect does an epidural have?
The effect of the epidural can be varied by changing the type and amount of drug
given. The more drugs you are given, the more numb you will be. An epidural
has three main effects.
1. Pain relief – the epidural numbs the sensory nerves responsible for pain and
touch. This gives pain relief but can also make the area feel numb or heavy.
Pain nerves are easier to block than touch nerves. This means that, although
you may be able to feel someone touching or pulling you, it should not hurt.
Sensory nerves are more easily affected than movement nerves, so
sometimes you can be numb but still able to move your legs.
2. Low blood pressure – the nerves that help to control blood pressure are the
most easily affected. You may not be aware of this happening, but the
18
Anaesthetist will be monitoring you closely for any problems with low blood
pressure.
If you are having an operation using only epidural anaesthesia, the
operation will not start until the Anaesthetist is satisfied that the epidural is
working well. If your epidural does not work well it can usually be corrected.
Epidurals give good pain relief but, like other forms of pain relief, cannot
guarantee that you will be pain-free.
What complications can happen?
Your Anaesthetist will make your anaesthesia as safe as possible, however,
complications can happen. A serious complication happens in about 1 in every
10,000 epidurals. The possible complications of an epidural anaesthetic are listed
below. Any numbers which relate to risk are from studies of people who have had
an epidural anaesthetic. Your Anaesthetist may be able to tell you if the risk of
complication is higher or lower for you.
• failure of the epidural (risk: 1 in 20). About 9 out of 10 epidurals work well
first time. Of those that do not, about half are adjusted and then work well.
If the epidural is still not working, your Anaesthetist will discuss with you if
you should have a general anaesthetic instead. The pain relief provided by
an epidural is better than with other techniques.
• low blood pressure (risk: 1 in 30). The risk depends on your medical
condition, the site of the epidural and the surgery being performed. It is
easily treated and you will be closely monitored during your operation by
your Anaesthetist and afterwards by the nursing staff on your ward.
• headache, this is quite common after any operation. However, there is a
particular type of headache which can happen if the bag of fluid around the
spinal cord is punctured (risk: 1 in 100). This can vary from mild to severe
and can be treated if needed.
• respiratory depression, where your breathing slows down too much (risk:
1 in 400). Nurses will closely monitor your oxygen levels and will give you
oxygen if you need it.
• itching, if morphine or similar drugs are given (risk: 1 in 10). The effect is
usually mild, although it can occasionally be more severe. This can be
alleviated if certain drugs care changed. The itching always goes away.
• bladder emptying problems because the nerves to the bladder are
numbed. A catheter (tube) is often passed into your bladder to drain the
urine. This will be taken out when you no longer need it.
• leg weakness is common and can vary from being almost unnoticeable to
not being able to move your legs at all. This always goes away. If leg
weakness is causing a problem during the operation or procedure, the
epidural can sometimes be adjusted to make your legs more mobile. You
may need someone to stay with you and help you for a few hours after the
epidural.
• backache, which is quite common after an operation. It is quite common to
have a bruised feeling for a few days at the site where the epidural was
19
inserted, but this will settle. There is no evidence that having a
straightforward epidural causes long-term backache and epidurals are
commonly used to treat people with long-standing back pain.
• infection around the spine (abscess or meningitis) causing permanent
damage (risk: 1 in 30,000)
• cardiovascular collapse (where the heart stops)
• seizures, due to local anaesthetics (risk: 1 in 10,000). These are usually
temporary.
• unexpected high block, if the local anaesthetic spreads beyond the
intended area. This can make breathing difficult, cause low blood pressure
and, rarely, cause unconsciousness.
• nerve damage (risk: 1 in 50,000). Usually any damage is not serious and
gets better on its own. Sometimes the damage can be permanent
• blood clot around the spine (risk: 1 in 20,000).
• damage to nerves supplying the bladder and bowel (risk: 1 in 30,000)
• Paralysis or death (risk: 5 in 100,000). This can be caused by infection,
bleeding near the spinal cord or injury to the spinal cord.
You should discuss these possible complications with your Anaesthetist if there is
anything you do not understand.
If you have an epidural infusion, you will be monitored closely on the ward, in the
high dependency unit or in the intensive care unit after your operation to check for
any problems.
Late complications
A complication may happen after the epidural has been removed. If you
experience any of the following problems, you or your doctor should contact the
hospital straightaway.
• pus, redness, tenderness or pain where the epidural was inserted.
• high temperature
• feeling unwell, even after recovering from the operation itself.
• discomfort when in a bright room or sunlight (photophobia)
• neck stiffness
• difficulty moving or feeling your legs
• difficulty passing water
• bowel incontinence
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Summary
An epidural can be used for most people and usually gives a safe and effective
form of pain relief both during and after your operation. However, complications
can happen, therefore, you need to know about them to help you make an
informed decision about your anaesthetic
What can I do to make the operation a success?
• Keeping warm
It is important to keep warm around the time of your operation. The hospital
may be colder than your home, so you should bring in extra clothing or a
dressing gown. If you become too cold you may have an increased risk of
developing complications such as infection in the surgical wound, or heart
problems. Let a member of the healthcare team know if you feel cold.
Your Anaesthetist will take steps to keep you warm when you are having your
operation.
• Lifestyle changes
If you smoke then stopping smoking several weeks or more before an
operation may reduce your chances of getting complications and will improve
your long-term health.
Try to maintain a healthy weight. You have a higher chance of developing
complications if you are overweight
Regular exercise should help prepare you for the operation, help with your
recovery and improve your long-term health. Before you start exercising, ask a
member of the healthcare team or your GP for advice.
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What you should expect following your surgery
Immediately after your operation
After your operation you will spend time in the recovery room where you will be
looked after by a team of specialist nurses, you may then be transferred back to
the ward you came from when you are awake.
You may be transferred to the SHDU (Surgical High Dependency Unit). This is a
small 4 bed unit for patients who require high levels of nursing care. You would
be transferred to SHDU for a short period when extra monitoring is required.
Once your condition improves and you no longer need close observation you will
be transferred to a general ward.
You may have a small tube (catheter) in your back for the next few days to
provide you with continuous pain relieving medicine (epidural)
You will have a tube (catheter) in your bladder. This is so that we can monitor
how well your kidneys are working and how much urine you are making.
You will be given extra oxygen to breath via a mask
You will have a drip in your arm giving you fluid.
A few hours after your operation you will be able to start to drink. You will be
given two nutritious drinks on the evening after your operation. This is to provide
you with the nutrients necessary for healing.
The nursing staff or physiotherapist will help you out of bed.
You will have been fitted with stockings. These encourage the blood circulation in
your legs and reduce the chance of a clot. You will need to wear these throughout
your stay in hospital and for 10 days after discharge. The nurse will check your
temperature, pulse and blood pressure regularly when you first come back to the
ward.
Only close friends or relatives are advised to visit on this day and only for a short
period.
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Pain control following surgery
How is pain assessed?
After your operation your pain will be assessed regularly. Pain will be measured
by using a score and you will be asked to describe where the pain fits on a scale
of 0-10. You may find it easier to describe your pain as mild, moderate or severe,
either way is acceptable.
Pain Score
How would you describe your pain?
0
No pain
at all
1
2
Pain
increasing
Dull
Dull
Ache
Ache
3
4
5
Hurts on
Movement
6
Moderate
pain all
the time
7
8
Severe
pain all
the time
9
10
Worst pain
ever had
Mild pain all
the time
Pain assessment is necessary to identify, measure and plan your pain relief. It is
essential that you are able to take deep breaths, cough and move.
Prevention or early treatment of pain is far more effective than trying to treat
established or severe pain – don’t wait until it is too late.
It is important to let your nurse know if the pain you are experiencing is
unbearable.
Effective pain control is achieved by taking painkillers regularly
Good pain relief is necessary for you as you will require to do some gentle
exercises under the instructions of the physiotherapist and nursing staff. Taking
your prescribed pain medication regularly will give you good pain relief. Stronger
painkillers are not given routinely but are always available for you to ask for if you
need them. This regime will help you to recover quickly from your surgery.
What are the side effects of pain killers?
These may include nausea, vomiting, constipation, headache, dizziness, feeling
sleepy or mild confusion. These side effects can be reduced with anti-sickness
drugs and drinking lots of fluids. Addiction will not occur as the painkillers are
being used to relieve your pain.
Please let the nurses know if you feel any of these side effects.
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What type of pain relief is available?
Paracetamol
After your operation you should use simple painkillers regularly such as
paracetamol. This may not completely treat your pain but if taken regularly they
can reduce the amount of other stronger painkillers you might need.
It is important that you let your Anaesthetist know before your operation if you
have had any problems with painkilling drugs before, or if you have a history of
stomach ulcers, kidney damage, bleeding or asthma.
What complications can happen?
The risks with simple painkilling drugs are small.
• Paracetamol is safe in normal doses
Morphine
For more severe pain you may be prescribed morphine or similar drugs.
Intravenous delivery (using a drip)
The most common intravenous delivery is a technique known as patient-controlled
analgesia or PCA. This involves connecting a special pump, containing the drugs,
to a drip (small tube) in one of your veins. The pump has a button which you will
be given to hold and when you press the button a small dose of drugs will be
given. The pump has several features which do not allow you to overdose by
accident. These drugs tend to make you sleepy, so if you do have more than you
need, you are likely to fall asleep and not press the button for a while.
It is very important that you are the only person to press the button. A nurse will, if
possible, show you the pump before you have the operation so that you can be
confident in how to use it. If you think you may not be able to press the button (for
example, if you have arthritis), let the nurses know as they may be able to provide
a button which is easier to use.
Using a PCA is simple. If you are in pain, or you think you might be in pain soon,
press the button. If you are comfortable, do not press the button.
What complications can happen?
Although they are effective painkillers, morphine and similar drugs do have side
effects.
• itching is common but not usually severe. It can often be treated if it is a
major problem
• constipation is common but responds well to normal laxatives or increased
diet of fruit and vegetables.
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• feeling or being sick is more common after certain operations than others
and can usually be treated. There is no benefit in stopping taking the drugs
which are giving you pain relief as pain itself can make you feel sick. It is
usually better to take anti-sickness medication along with the drugs for pain
relief.
• respiratory depression, where your breathing slows down too much.
Serious complications are rare. Nurses will closely monitor you oxygen
levels and will give you oxygen if you need it.
• confusion is quite common after operations and morphine may contribute
to this. This is more likely in elderly people. Any confusion caused by
painkillers will not be permanent.
Epidural anaesthetics/analgesia
Some people may be offered epidural pain relief after their operation. This has
been mentioned previously under the anaesthetics section of the booklet.
Epidurals provide good pain relief but, like other forms of pain relief, cannot
guarantee that you will be pain-free.
Sometimes the drugs are injected continuously (called an infusion) and, if needed,
the dose varied by the nurses. As well as continuous infusion you can sometimes
have a button that allows you to ‘top up’ the epidural by giving a small, safe dose
when you need it. This system is designed to prevent too much being given.
Pain after an operation is a common problem but there is no need for you to be in
a lot of pain. Pain relief after surgery is usually safe and effective, however,
complications can happen. You need to know about them to help you make an
informed decision about surgery and pain relief.
If you are taking other medications or have had a reaction to a medication in
the past please let us know.
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The days following your surgery
The doctors and nurses continue to monitor your progress. Part of this monitoring
will involve blood tests being taken.
You will be encouraged to eat and drink soon after your surgery and you will also
be provided with high calorie/high protein drinks to aid your recovery. This is
important as your body needs nourishment to help heal wounds, minimise the risk
of infection and generally help your recovery. You should aim to increase your
dietary intake over a few days.
Pain relief will continue as you need it.
The nurses will continue to record your temperature, pulse and blood pressure
and assist you to move in bed at regular intervals.
Occupational Therapy
If you or your family have any concerns about how you will manage any aspects
of your daily living activities when you return home from hospital, you can be
referred to the OT who will discuss these with you. He/she will discuss activities
such as the physical layout of your home environment, washing, dressing, meal
preparation, shopping, domestic tasks and driving. An assessment can be carried
out on the ward and in the OT Department prior to discharge home (this can
include washing, dressing, getting on or off a chair or the toilet, in or out of bed
and basic kitchen tasks) depending on what problem areas have been identified.
The OT can refer you on to other agencies as necessary.
Washing – You may find it helpful to have a chair or stool in the bathroom to sit
on to wash to conserve energy.
Dressing – It is a good idea to sit on a chair or on the side of the bed to get
dressed. Loose, comfortable clothes that are easy to fasten and flat, supportive
shoes which allow for the fact that your foot may swell after the operation (but not
backless shoes, e.g. mules) are best.
Getting on or off a chair or bed – If you have difficulty with this the OT can practice
with you the best technique which suits you.
Meal Preparation – If you were able to prepare your own meals before your
operation, you should be able to manage when you return home. You may
become tired more easily when working in the kitchen so think about how you can
conserve energy, e.g.
• Prepare easy meals which require limited preparation, or use readyprepared meals (your OT can give you catalogues for these).
• Pace yourself if you are preparing a longer meal
• Position items used a lot within easy reach.
• Keep a seat or stool handy on which to rest if necessary.
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• Do not over stretch to high or very low cupboards – if possible ask someone
to move items to worktop level.
• Slide items along the work surface rather than carrying.
Housework – Avoid heavy housework such as vacuuming or moving furniture for
4 – 6 weeks after your operation
Private agencies can assist with housework and laundry – Social Services or your
OT can provide you with a list of approved local agencies if required.
Shopping – Consider having shopping delivered initially when you return home,
or ask friends or family to assist. Most major supermarkets offer an on-line store
which will deliver to your home for a small delivery charge. If you do not have
internet access, it may be possible for your family to do this for you. Information
on the Food Train Service within Dumfries and Galloway is provided at the back of
this booklet – they can deliver your weekly shopping to you. If you do your own
shopping, do not attempt to lift/carry heavy bags – use a trolley or light back pack.
Your OT can give advice about help with shopping and other household tasks if
you have any concerns.
Energy Conservation – If you find you are tired out by basic day to day tasks,
your OT can discuss ways of helping you to conserve your energy and discuss
ways to be as independent as possible during your recovery.
Physiotherapy
Day zero:
If surgery is in the morning you will be encouraged to sit up out of bed for 1-2 hours that
evening.
Day One:
You will be encouraged to sit up out of bed for at least 6 hours
The physiotherapist will listen to your chest and teach you some breathing and
circulation exercises which are to be practised every 30 minutes during the day.
The physiotherapist will also assist you to walk in the ward on day one. You will
also be encouraged to mobilise independently a further 2 to 3 times. These things
will help decrease the risk of chest infections and blood clots, improve oxygen
delivery to tissues to aid the healing process, will help the bowel function get back
to normal, help get rid of wind, help decrease post-op pain and help prevent
muscle weakness.
Day 2 onwards:
Continue to practice breathing and circulation exercises and gradually increase
the distance walked. Sit out of bed for at least 6 – 8 hours daily and aim to have 3
– 4 walks per day
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On discharge:
Continue to practice breathing exercises 3 – 4 times a day until wound pain has
gone and aim for 3 – 4 walks per day.
Gradually build up the distance walked daily and slowly return to normal activities
but remember that early in the recovery period short daytime rests are needed
too.
No heavy lifting for 2 months after surgery.
Do not drive for 4 - 6 weeks after abdominal surgery or until your surgeon says
that you are safe to drive. The DVLA advises that insurance companies are
informed when driving is restarted.
Please note that visits, particularly in the afternoon, will be interrupted for
treatment purposes.
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Going home: being discharged from hospital
Discharge
You should be able to leave hospital about 4 –7 days following your operation.
We will not discharge you from hospital until we are sure you are ready. This
means we will make sure your pain is well controlled, you are able to eat and
drink, your bowels are functioning and there is someone at home to help you.
Before you go home you will be given a copy of your discharge letter and a supply
of any medication you may require. If you should require further pain killers you
should contact your GP before your supply finishes. Your district nurse, or
practice nurse at your GP’s surgery will remove your clips 10 days after your
operation. Some patients have stitches under the skin, which do not need to be
removed.
When you are discharged you will receive a courtesy call from either, the
colorectal nurse specialist, stoma nurse specialist or ward staff. You will receive
these calls daily for up to 10 days after your surgery.
This allows the nursing staff to check on your progress and gives you the
opportunity to discuss any problems that you may be experiencing.
Your out-patients appointments
You will be sent an appointment to attend the out-patient clinic with your
consultant or registrar about 6 weeks after you go home. This is an ideal
opportunity for you to ask any questions you may have (it is a good idea to write
your questions down so you don’t forget them before coming to the clinic).
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Questions and problems?
This provides information about your discharge from our Enhanced
recovery after surgery programme following your colorectal surgery. If you
have any further questions please ask a member of staff.
What if I feel unwell?
Complications do not happen very often, but it is important for you to know what to
look out for should you feel unwell. If you are concerned about anything in this
booklet, contact details are available at the end.
Bowel function
After your operation your bowel function will take several weeks to settle down
and may be slightly unpredictable at first. Your motions may become loose or you
may be constipated. Make sure you eat regular meals, drink plenty of fluids and
take regular walks during the first two weeks after you operation. If constipation
lasts for more than two days then taking a laxative such as Lactulose is advised.
If you are passing loose stools more than three times per day for longer than four
days please contact the Colorectal Nurse Specialist and ask for advice.
Abdominal pain
It is not unusual to suffer gripping pains (colic) during the first week following
removal of a portion of your bowel. This pain usually lasts for a few minutes but
goes away between spasms.
If you have severe pain lasting more than 1 – 2 hours or have a fever and
feel generally unwell, you should contact us on the given numbers.
Urinary function
After bowel surgery you may get a feeling that your bladder is not emptying fully,
this usually resolves with time. If you have excessive stinging or burning when
passing urine please contact your GP as you may have an infection.
Wound care
For the first 1-2 weeks following your surgery your wound may be slightly red and
uncomfortable. If your wound is inflamed, painful, swollen or discharging
fluid please contact your GP.
Diet
You may find that for a few weeks following your operation you may have to make
some slight adjustments to your diet depending on your bowel pattern. You
should try to eat a balanced diet which includes:
• Fruit and vegetables (lower-fibre varieties may be tolerated better initially,
see p.7)
• Some milk and dairy foods which are a good source of protein to aid wound
healing
• Some meat, fish, eggs, beans which are also very good protein sources
• Plenty of bread, rice, pasta, potatoes and other starchy foods (lower-fibre
varieties may be tolerated better initially, see p.7)
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• Plenty of fluids-aim for at least 8-10 cups per day-this includes water, fruit
juice, squash, teas/coffee and milk (regular milk is encouraged as a good
source of nutrients to aid your recovery). Drinking plenty is especially
important if you have loose stools (diarrhoea).
You may find some foods can cause loose stools. If this happens you should
avoid these foods in the first few weeks after surgery then try them again, one at a
time.
If you are struggling with your diet/appetite try to eat little and often, choose higher
calorie versions and try to make the most of times when you feel hungry. If you
have any concerns that your appetite is not improving or you are unintentionally
losing weight, ask your GP or nurse if you would benefit from a consultation with
the dietician.
Hobbies/activities
Walking is encouraged from the day following your surgery. You should plan to
undertake regular exercise several times a day and gradually increase this during
the four weeks following your operation until you are back to your normal level of
activity. The main restrictions we would place on exercise are that you do not
undertake heavy lifting and contact sports until six weeks following your surgery.
You can return to hobbies and activities soon after your surgery. This will help
you recover. If you are unsure contact your Colorectal Nurse Specialist for
advice.
Gradually increase your exercise during the four weeks following your surgery
until you are back to your normal level of activity.
Once your wound is pain free you can return to your usual activities.
Work
You should be able to return to work within two to four weeks following your
operation. If your job is a heavy manual job then it is advised heavy work should
not be undertaken until six weeks after your operation. However, you should
check with your employer regarding rules which may be relevant to your return to
work.
You will need to provide your employer with a fit note from your GP after 7 days of
absence. A fit note must be signed by your GP. On the fit note, your GP can
advise that: you are ‘not fit for work’ or that you ‘may be fit for work’.
Resuming sexual relationships
You should be able to resume a normal loving relationship once the discomfort of
the operation has subsided and you have recovered from your operation. It is
important you talk to your partner about how you are feeling.
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Some people undergoing operations to the pelvis may have specific
bladder/sexual problems. Some men may experience problems with erection and
ejaculation. This is the result of damage to some of the nerves in the pelvis by
radiotherapy or by surgery. It is usually possible to keep the operation well clear
of these nerves but occasionally they may be damaged. Women may experience
pain during intercourse.
It is important to remember that emotions and worries can also have a direct effect
on not only how you feel about yourself but also in having an intimate relationship.
Talking about your feelings with your partner will help lessen your anxieties.
It is important to talk to your doctor, Sister Williams or Sister Kearney if you are
having problems as they can help you find the best way to deal with them. They
may choose to refer you to a specialist nurse who may be able to help you.
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Notes
Please use this blank space to write down any questions you have about your surgery.
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Useful telephone numbers / contacts
Dumfries and Galloway Royal Infirmary
01387 246246
Out–patients appointments (local rate)
0845 602 2812
Isabel Williams - Colorectal Nurse Specialist
Monday – Friday 08:30 – 16:30
01387 241380
Hazel Kearney – Stoma Nurse Specialist
01387 241284
Ward 6
01387 241358
Ward 3
01387 241359
Admission Desk
01387 241407
Pre-assessment Clinic
01387 241366
Physiotherapy Department (D&GRI)
01387 241452
Occupational Therapy Department
01387 241587
01387 241022
Pharmacy
01387 241557
The Food Train Service Dumfries and Galloway
For help with shopping and small jobs around the house.
www.thefoodtrain.co.uk
Dumfries Area:
01387 270800
Stranraer & Rhins Area
01776 704831
Newton Stewart & Machars Area
01988 402633
Annandale & Eskdale Area
01461 207778
Stewartry Area
01557 332444
Mid & Upper Nithsdale Area
01659 58778
Carer Information
You may wish to know where you can get information and support, or how to contact a
support group:
The Princes Royal Trust for Carers
2/6 Nith Street
01387 248600
34
Dumfries
DG1 2PW
www.carers.org
The Princes Royal Trust for Carers provides information, advice and support for carers
and young carers.
Carers Scotland
The Cottage,
21 Pearce Street
Glasgow
G51 3UT
www.carerscotland.org
0141 445 3070
Carers Scotland provides information and advice to carers on all aspects of caring.
Crossroads: Care for the Carer
Stranraer and District
Newton Stewart and Machars Area
Stewarty Area
Mid and Upper Nithsdale
Dumfries and Lower Nithsdale
Annan and Eskdale
01776 703216
01988 402003
01557 331638
01659 50005
01387 248686
01461 204240
www.crossroads-scotland.co.uk
Crossroads provides practical support to carers.
Dumfries and Galloway Council
First point of contact with the Council’s social services (part of Adult Services) is through
the local area office. These are based at:
Dumfries
Castle Douglas
Kirkconnel
Annan
Newton Stewart
Stranraer
01387 260872
01556 504101
01659 67601
01461 203411
01671 403933
01776 707272
Other useful contacts
British Digestive Foundation (CORE)
Website : www.corecharity.org.uk
Tel No. 020 7486 0341
Post : CORE
or
CORE
Freepost
3 St. Andrews Place
LON4268
London
London
NW1 4LB
NW1 0YJ
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The Cancer Information and Support Centre
The centre is situated in the MacMillan Centre of the hospital and offers free information
and support to anyone affected by cancer. It is open Monday – Friday from 10 am until 4
pm. Contact details are as follows:
Cancer Information and Support Centre
The MacMillan Centre
Dumfries and Galloway Royal Infirmary, Banked Road, Dumfries DG1 4AP
Tel No. 01387 241979
Cancer Information for South East Scotland (SCAN)
Dumfries and Galloway is part of a managed clinic network called SCAN. You can visit
our comprehensive website, which provides up to date information about cancer and
local services in South East Scotland. Website: www.scan.scot.nhs.uk
Cancer BACUP
30 Bell Street, Glasgow G1 1LG
Tel No. 0141 553 1553
Helpline Tel: 0808 800 1234
Website: www.cancerbacup.org.uk
Colon Cancer Concern Scotland
Department of Surgery and Molecular Oncology
Ninewells Hospital and Medical School, Dundee, DD1 9SY
Tel: 00383 662816
Information line Tel: 08708 50 60 50
Website: www.coloncancer.org.uk
Beating Bowel Cancer
39 Crown road, St. Margarets, Twickenham, Middlesex TW1 3 EJ
Tel : 020 8892 5256 Helpline Tel : 020 8892 1331
Produced by the ERAS Team Jan. 2012
Review date 2013
Review date 2013
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