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We appreciate and encourage feedback. If you need advice or


are concerned about any aspect of care or treatment please
speak to a member of staff or contact the Patient Advice and
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Freephone: 0800 183 0204
From a mobile or abroad: 0115 924 9924 ext 65412 or 62301
E-mail: pals@nuh.nhs.uk
Letter: NUH NHS Trust, c/o PALS, Freepost NEA 14614,
Nottingham NG7 1BR
www.nuh.nhs.uk

Enhanced recovery after


surgery (ERAS)
Total Gastrectomy
Information for patients
Digestive Diseases Directorate
General Surgery

The Trust endeavours to ensure that the information given here


is accurate and impartial.

This document can be provided in different languages and


formats. For more information please contact:
Upper GI Surgical Department
City Hospital campus
Hucknall Road, Nottingham
Tel: 0115 8404716
Cathy van Baalen, Upper GI Surgical Department January 2015. All rights reserved.
Nottingham University Hospitals NHS Trust. Review January 2017. Ref: 1246/v2/0115/AM

Public information

Aim of the leaflet

Notes

The aim of this booklet is to help you understand what enhanced


recovery is and how you can and will play an active part in your
recovery. It outlines what you can expect to happen on a daily
basis after your operation and gives some general discharge
advice.

Introduction
When you saw your consultant or doctor in clinic, they would
have given you an information leaflet about the operation you
will be having. The leaflet gives details of possible complications
of the surgery and lifestyle adjustments you will need to make
after the operation. It is important that you read this information
carefully.
It contains a lot of information but is split into sections to make it
easier for you. We ask you to read it carefully, bring it with you
when you attend the pre-operative assessment unit, to the ward
and to your initial appointment after your operation.
Section 1: Enhanced Recovery
Section 2: Before your operation
Section 3: Admission to hospital
Section 4: After your operation
Section 5: Criteria for discharge
Section 6: Your first two weeks after discharge
Section 7: Two weeks to three months

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Day 6

You can take a shower


You can wear your own clothes
You will be able to walk independently
You will be able to climb stairs
You will flush your feeding tube

Transport and car parking


You are expected to arrange your own transport to and from
your hospital appointments and admission. In exceptional
circumstances you can arrange hospital transport by calling the
ambulance office. They work to a strict criteria and may decide
that you do not qualify for this service.
Ambulance enquiries: 0115 8405898

Day 7

You can take a shower


You can wear your own clothes
You will be able to walk independently
You will flush your feeding tube
You may go home
Your feeding tube will be removed in outpatients

There is a free park and ride Medilink bus service that links the
two main hospital sites and the park and ride sites at Wilkinson
Street and Queens Drive. It is a free service and runs every ten
minutes from Monday to Friday from 8am to 6pm.
There are a number of car parking areas within the City Hospital
campus if you decided to come by car.

Note: These milestones may need to be delayed in certain


circumstances such as when your blood pressure is low or if
you feel faint on standing up. They resume when your
condition allows.

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Section 1: Enhanced recovery


Patients who are following the enhanced recovery pathway may
have their operation either by laparoscopic or open surgery.

Daily milestones
Day 1

The aim of enhanced recovery is to improve your recovery from


surgery and enable you to return to normal activities as early as
you are able to.
The key principles of enhanced recovery are that:

You will be able to eat and drink from day four of your
operation.

You will sit out of your bed the following day after your
operation and will be assisted to walk varying distances from
day one or two onwards.

You will sit out of bed


You will be transferred to ward
You will walk at least 30 metres
Nurse will flush your feeding tube
You will have nothing to eat or drink

You will sit out of bed


You will walk the length of the ward x 2
Nurse will flush your feeding tube
You will have nothing to eat or drink

You will sit out of bed


You will walk the length of the ward x 3
You will be given fluids
Nurse will flush your feeding tube

You will walk in the ward


You can take a shower
You can commence graduated fluids at 8am
You will commence oral painkillers
You will be given soup and ice cream at 6pm
Your drips and drains will be taken out
Your epidural will be taken out
Your urinary catheter will be taken out

Day 3

will be able to return home earlier than usual i.e. seven


to eight days after your operation.

However, forward planning for an early discharge does need to


be considered in advance of coming into hospital. Please read
the information in this leaflet as this will tell you what to expect
throughout the enhanced recovery process.

You will be in Critical Care


You will sit out of bed and walk a short distance as
able

Day 2

You

Provided you do not need on-hand medical care we believe your


recovery is improved when you are in the comfort of your own
home. If you develop any complications after your operation it
may be necessary for you to stay in hospital a littler longer.

Day 4

Day 5

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Section 7: Two weeks to three months


Physiotherapy and going home
You will need to look after your wounds by avoiding lifting (e.g.
small children, heavy shopping), pushing lawn mowers,
gardening and vacuuming for at least eight weeks.
Slowly increase your activity as you feel able, returning to
activities such as swimming after six weeks when your wounds
have healed. Activities such as golf and tennis can start to be
introduced after 10 - 12 weeks unless you are otherwise
advised. You should increase your activity as your body allows.
If you feel pain or discomfort on performing an activity, please
stop.
These times are guidelines only. If you are at all unsure,
please seek advice before you begin activities.
It is important to try and maintain a good upright posture to
ensure the scars heal in the correct way. Bad posture can lead
to neck and/or back pain.
You should continue with your walking gradually increasing the
amount you do each day. You can measure it in either time or
distance walked. Continue to do any stretches you have been
given by your physiotherapist.
During the day you should take time for a rest, perhaps in the
afternoon. Try and pace yourself each day as some days you
will feel more energetic than others. Try not to do too much on
these days but keep your activity level steady.

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Section 2: Before your operation


There are several things that you can do before your operation
to help speed up your recovery afterwards.
Stop smoking
You should stop smoking as soon as possible. The longer you
are smoke-free before your operation, the smaller your risk of
developing a chest problem after your operation. Stopping
smoking will also improve your blood circulation and your bodys
ability to heal.
We can refer you to the New Leaf Team who will help you with
giving up smoking or you can contact them directly on
Freephone 0800 5612121. Alternatively, see your GP.
Daily exercise
The amount of exercise that you can do will vary depending on
how much you can eat, and how you feel during your
chemotherapy, but you should aim to do some exercise every
day. Doing some exercise daily or at least five days a week will
help you get fitter and will also help you to get up and about
quicker after your operation.
Below are some examples of activities you can do which will
exercise your heart, lungs and muscles:
Walking, dancing, swimming, cycling, climbing stairs
When you exercise, you should be a little out of breath but not
so much so that you cant speak. If your physiotherapist
prescribes a specific exercise plan for you, it will be written at
the back of this booklet.

Healthy lungs - breathing exercises before your operation


Having an anaesthetic can make you produce phlegm which you
need to clear once you are awake after your operation. The
breathing exercises below will help you open up your lungs and
clear any phlegm. You should practice the breathing exercises
daily for one to two weeks before your operation.
Breathing exercises
Take four or five slow, deep breaths (through your nose or
mouth) making each one bigger than the one before. Hold
each breath in for three seconds before slowly letting the air
fall out of your lungs.

Breathe normally for 30 seconds with shoulders relaxed

With your mouth wide open, take a small breath in then


push the air out of your lungs fast and strong as if steaming
up a mirror. Do this three times.

Do a good, strong cough. (Make sure you cough from the


bottom of your chest and not just from the back of your
throat).

Rest and repeat the exercises once more.

Complications
Complications rarely happen but it is important that you know
what to look out for. During the first two weeks after surgery if
you develop any of the following symptoms:
Sudden onset of abdominal pain
Fevers/shivers
Vomiting
Feel generally unwell
Please contact the team between 8am and 4pm, Monday to
Friday, on the numbers below:
Specialist Nurse
0115 8404716 or page via hospital switchboard on
0115 969 1169
Mr Welchs secretary
0115 9691169 ext 54589
Mr Parsons secretary
0115 9691169 ext 54386
Mr Cattons secretary
0115 9691169 ext 54386

Your spirometer
You may be given a device called a spirometer to help you
perform these exercises correctly. Your physiotherapist will tell
you how to use this. This is a device that will help you to perform
your breathing exercises effectively.

Winifred 2 ward
0115 9691169 ext 56457

You should use this to do the deep breathing part of the


exercises above. You will be provided with information on how
to use the device if you are given one.

Critical Care 1-10 / Critical Care 11-16


0115 9691169 ext 54035 / ext 56671

Please bring it with you when you are admitted for your
operation.
6

Elective admissions lounge


0115 9691169 ext 56127

Your can also contact your GP for advise and assistance with
any problems you may encounter. In addition, you can also
contact NHS Direct for advice on 0845 4647.
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Section 6: Your first two weeks after discharge


Prior to going home you will receive a discharge sheet from the
ward staff explaining what to expect after your operation.
Please read this carefully. You will be seen by the dietician who
will give you and your family advice about diet and eating after
your surgery. The dietician will also provide you with an
information sheet.
The pharmacist or nurse will give you instructions about the
medications that you will take home. You will also be provided
with a pain management sheet with advice about how to
gradually reduce your intake of painkillers after you leave
hospital.
Dont hesitate to ask any questions.
After you leave hospital, you can get advice about pain relief
from your GP.
You will be given an appointment during discharge (or it will be
sent to you) to see your consultant in clinic within two weeks of
discharge.
You will be contacted by telephone seven days after your
discharge by the upper GI specialist nurse. The nurse will
check that you are progressing as you should be.

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Eating
Many people diagnosed with stomach cancer have problems
with poor appetite and eating and drinking. They may
experience symptoms of acid indigestion, reflux and vomiting.
This may result many in patients not eating enough and losing
weight. If you are eating less, it is important to eat as nourishing
a diet as possible. You may need to alter the texture of your diet
so that you can manage to eat it. Below are some tips you may
find helpful.

Eat small, frequent meals every two to three hours. This is


often easier than three main meals and can be just as
nourishing.

Eat what you fancy and eat any time you are hungry.

Try to avoid cooking smells if these are putting you off


eating.

Avoid drinking a lot of liquid with your meals as it may fill you
up and put you off your food.

Do not rush meals and eat slowly if you need to.

Make the most of good days and prepare foods which can
be used when you dont feel like cooking.

Try to include high energy foods such as full cream milk,


cheese, cream, full fat yogurt and ice cream.

Try to include high protein foods such as eggs, meat, fish,


beans and nuts.

Tube feeding before surgery


Some patients with swallowing difficulty prior to surgery may
need to have a puree or liquid diet.
Some patients with very severe swallowing problems are fed a
liquid feed through a tube. The feed is usually given via a
jejunostomy tube inserted into your small bowel or a
nasojejunal tube which is passed down through the nose into
the small bowel (jejunum). This usually requires a short inpatient
stay to establish the tube feed.

Section 5: Criteria for discharge


Although you may not know your date of discharge yet we are
keen to prepare you for it as early as possible for when you
leave hospital. We will start planning for your discharge as early
as your pre-assessment. It may be difficult to give a precise
date so the ward staff will estimate a discharge date.
Discharge will depend upon the following:

The doctors looking after you feel you are medically fit for
discharge.

You need to be eating and drinking.

Your pain is under control with painkillers.

You are able to mobilise safely on your own.

We will confirm with you the time and date you will need to come
in for your operation. This is a chance for you to ask the team
any questions you may have about your forthcoming operation.

Your wounds can be managed by the district nurse.

When to stop eating and drinking

The ward nurse will give you the necessary documents for you,
your GP and the district nurse.

Pre-assessment
Once a date for your operation has been decided an
appointment will be made for you to attend our pre-assessment
clinic. This allows us to assess your fitness for having a general
anaesthetic for your operation. We will also arrange any further
tests that your doctor or anaesthetist feels necessary.

Date of operation: ......................................................................


Last solid food at: ......................................................................

You will need to arrange your own transport home.

They will also give you your medication and explain how to take
it.

Last drink at: ..............................................................................

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Tubes, drips and drains


During your operation a tube will be placed into your bladder so
that we can check that your kidneys are working well. You will
have a fluid drip in your neck. You will have a drainage tube in
you abdomen. These tubes will be removed once your doctors
decide you no longer need them.

Section 3: Admission to hospital

Tube feeding and eating and drinking


During your operation a tube will be placed into your stomach
via your nose. The nurses will aspirate this tube at regular
intervals. You will not have anything to eat or drink by mouth for
approximately four days. The tube will be removed once you are
eating and drinking.

Please only bring essential items into hospital. There is limited


storage space on the ward. The following is a list of items to
bring with you:

At the time of your operation a feeding tube may be inserted into


your small bowel (jejunum). This will be used to provide nutrition
as a liquid feed, until you are able to eat and drink again.
The jejunostomy tube is removed at your first clinic appointment
after surgery if you are eating and drinking well.

If the tube stays in when you go home it will need to be kept


clean by flushing with water. Flush twice each day with 50ml
water which has been boiled and allowed to cool (boil some
water freshly each day).
Use a new syringe each time.

Unless otherwise stated, you will be admitted at 7am on the


morning of your operation to the elective admissions lounge
(EAL) which is located upstairs on the north corridor. If you have
not seen the anaesthetist at your pre-assessment you will meet
them on the day of your operation.

All your current medications


Nightwear, slippers and dressing gown
Toilet bag and toiletries
Books/magazines
Coins/cash for newspapers
Clothes for wearing on the ward/going home

Please do not bring in anything valuable into hospital with you.


Nottingham University Hospitals NHS Trust cannot accept
responsibility for loss of or damage to property that is not
handed in for safe keeping.
Visitors
Visitors are welcome. Visiting times are 2.30pm - 8.30pm. Any
visits outside of these times must be approved by the ward team
in advance.

The nurses on the ward will show you how to do this and will
give you a supply of syringes to take home.

We work hard to maintain a clean environment in our wards. If


you are visiting someone:

The dietician will see you whilst you are on the ward to give you
advice on eating and drinking after your surgery. You will also
be given a dietary information sheet to take home.

12

Please apply the alcohol gel available outside the ward to


their hands before entering and on leaving the ward.
Please do not sit on the hospital beds.
Please do not bring flowers or plants onto the ward as these
have been shown to be an infection risk.
9

Section 4: After your operation


All patients who are having a total gastrectomy will spend the
first 24-48 hours in critical care. During your stay in critical care
a nurse will be allocated to look after you. This is necessary to
allow us to monitor you closely. You may hear noises from
alarms and machines. There is nothing to be concerned about
as this is normal. You will be transferred back to the ward when
your doctors are happy with your condition.
Pain relief
It is important that your pain is controlled after your operation so
that you can:
Breathe deeply
Walk about
Feel relaxed
Sleep
Following your operation strong painkillers called Opioids will be
used to control your pain. They include Morphine, Oxycodone
and Fentanyl. Your pain relief will initially be by be in the form of
a continuous infusion or you can control the intravenous PCA
yourself.
Some people may experience side effects - the most common
include feeling sick, vomiting, itching, constipation, and
drowsiness. Larger doses may lead to breathing problems and
low blood pressure. You can experience hallucinations. You will
be monitored closely by the nursing staff for these side effects.
Any side effects can be treated effectively with other drugs. Antisickness medication can be given if you feel sick. Regular
laxative medication is given to prevent constipation.
You will be asked about your pain as part of your regular
observations, but it is important that you tell those who are
caring for you if you are in any pain at any other time.
10

Your pain relief is very important if you have pain, you


must tell someone or you may have difficulty deep
breathing, coughing or moving about. Failure to do
so may lead to breathing complications and may
lengthen your recovery.
Physiotherapy
A physiotherapist will visit you on the day after your operation.
They will help you with your breathing exercises and will assist
you out of bed if you are not already sitting out when they arrive.
They will also remind you to do your breathing exercises every
hour.
After your operation, the physiotherapist will come and help you
to get moving. They will also encourage you to do your
breathing exercises. The reason for this is that during your
operation, your breathing is shallow. This means that the
bottoms of your lungs are squashed and need opening up once
you are awake.
Mobilising and getting out of bed
After your operation you will be encouraged to spend several
hours out of bed each day. During the week that follows, the
physiotherapist will assist you to increase your mobility by
helping you to walk up and down the ward gradually going
further each day.
You will be encouraged to do your breathing
exercises each hour that you are awake. It is important for your
recovery that you get mobile as quickly as possible. This helps
your lungs to work more effectively and there is less chance of
getting a chest infection or blood clots in legs - see daily
milestones at the end of booklet.
At the end of your stay, your physiotherapist may ask you to you
climb a flight of stairs to check your balance, strength and
general fitness ready for discharge from hospital.
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