Team Sheldon: Patient teaching for the big surgery by Dr. Keith Fournier

Hyperthermic Intraperitoneal Chemotherapy

About Your Surgery.................................................................................2 Preparing for Surgery..............................................................................3 Day of Surgery ......................................................................................... 5 Recovery ..................................................................................................7 Home Care and Follow-Up ......................................................................8 Resources ................................................................................................9

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About Your Surgery

Welcome

Throughout your treatment, you will follow a specific plan of care. Your plan will depend on your individual diagnosis. The following pages provide an overview of your care plan. Although this material covers standard procedures, each patient receives individualized care.

Health Care Team

Many different health care providers will take care of you in the outpatient clinic and in the inpatient unit. Your primary health care team includes:

 Your attending surgeon and other doctors, including surgical fellows. Fellows are board

certified surgeons who have finished medical school and residency. They are receiving

additional training at MD Anderson to learn about cancer surgeries.

 Advanced practice providers including physician assistants (PAs) and nurse practitioners

(APNs)

 Nurses

 Dietitians

 Patient service coordinator (PSC)

 Patient advocates can help solve problems or address concerns you may have.

 Also on staff and available to help you:

- A genetic counselor can discuss your family’s health history with you.

- A social worker and chaplain can address your psychosocial and spiritual concerns.

 Other health care team members will address your specific needs and concerns when you are

admitted to the hospital as an inpatient.

The Surgery

Your doctor recommends that you have a cytoreductive surgery or tumor debulking. This may be combined with a procedure called hyperthermic intraperitoneal chemotherapy (HIPEC) depending on your discussion with your surgeon. Cytoreductive surgery is a major operation that requires an experienced surgical team. An attending surgeon with many years of experience will perform your surgery.

The goal of surgery is to remove all of the visible tumor in the abdominal cavity (this space lies between the abdominal muscles and abdominal organs). Removing the tumor may require removing involved organs such as parts of the intestine, gallbladder, spleen, ovaries and uterus and the lining of the abdominal cavity. Your surgeon may need to create a temporary diverting ileostomy during surgery. This requires wearing a temporary bag to collect stool that comes out along your abdominal wall. If you have a tumor in your pelvis that requires removal of your lower colon, then a diverting ileostomy is necessary to allow that area to heal. If you are eating well and maintaining your weight, the ileostomy is reversed at a later date, typically 6-8 weeks after surgery.

For patients whose tumors can be completely or nearly completely removed by surgery, HIPEC treatment has been shown to improve survival. Chemotherapy is given only if a complete or nearly complete tumor debulking is performed, or if used for palliative purposes to treat fluid in

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the cavity. During the surgery, the abdominal cavity is filled with a chemotherapy drug, which is heated to over 42°C. The patient's abdomen is then rocked back and forth for 60-90 minutes. This ensures that the chemotherapy bathes all areas of the abdominal cavity. The goal is to kill all remaining tumor cells. The surgery combined with HIPEC usually takes about 10 hours.

When to Arrive in Houston

You will need to arrive in Houston several days before your surgery for pre-op appointments and testing. Your arrival date depends on your specific case and varies from patient to patient. See below for more information.

 All patients should hand carry copies of results from any pre-operative testing or lab work done at home.

 Some patients need clearance through our specialty centers such as Internal Medicine, Cardiology, Endocrinology and Urology. If this is your case, you will need to arrive in Houston 2-5 days before surgery.

 For patients not needing clearance from other areas, plan to arrive in Houston 2 days before surgery. You will have appointments with your surgical team, anesthesia team and with the lab for blood work if needed. You will also sign consent forms for treatment and other procedures if needed. These will be explained to you by your health care team.

 If your surgery requires additional assistance from other departmental physicians, you will also have appointments with these providers. Examples of these providers include a plastic surgeon, urologist, a colorectal surgeon, specialized nurses etc. We arrange these appointments as conveniently as possible for you. Providers have specific days when they see patients in clinic. In order to coordinate all aspects of care for multiple providers and appointments, patients must arrive in Houston at least 2-3 days before surgery.

Hospital Stay

The average hospital stay is 14 days, but can vary from 7-17 days. Your discharge date will be determined by how well you recover after surgery.

Stop Smoking Immediately

Smoking increases your chances of complications, slows recovery and may prolong your hospital stay. Because your body will undergo a major operation, we need you to do all you can to assist in your recovery.

Programs are available to help you and/or your loved ones stop smoking. For more information, ask your doctor or nurse.

Preparing for Surgery

Diagnostic Tests

Your doctor may request a number of diagnostic tests 2-4 weeks before surgery. These are helpful in planning the surgery and can include:

 Blood tests

 Electrocardiogram (ECG) – This is a test that records the electrical activity of your heart.

 Possibly a stress ECG – This is an ECG done while you exercise on a bike or treadmill, or an

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exam by a cardiologist.

 X-ray of your chest – These are film images that are produced with low doses of high-energy

radiation.

 Computerized tomography (CT) scan – A test that uses an x-ray machine and a computer to

create detailed pictures of the body, including 3-D images. Do not eat for at least 4 hours before the CT scan. For more information, ask your nurse for a copy of “Computerized Tomography (CT) Scan.”

 Clearance from needed subspecialties (Cardiology, Endocrinology, etc.)

Preoperative Teaching

A nurse will teach you and your care giver how to prepare for your surgery, how to prepare your bowels the day before surgery and how to care for yourself afterward. You will meet with your team before surgery to review these instructions.

About Anesthesia

Anesthesia is a drug-induced state that produces a loss of feeling with or without a loss of consciousness. You will see an anesthesiologist, a doctor trained to give anesthetics (drugs that cause a loss of feeling with or without a loss of consciousness) who supports patients during surgery.

Before surgery, the anesthesiologist will talk to you about anesthetics and what to expect from anesthesia. He or she will also talk to you about the use of an epidural catheter for pain management. An epidural catheter is a small tube placed in your lower back that gives you continuous doses of medicine.

Tell your anesthesiologist about all medicines that you take, including over-the-counter medicine, vitamins, herbs and herbal supplements. For at least 2 weeks before surgery do not take herbs or herbal supplements. These include ginkgo biloba, garlic, ginger, ginseng, St. John's Wort or kava-kava. These products can cause excess blood loss or prolong your anesthesia.

If you take any blood thinners or anti-platelet drugs, you must discuss with your team when to stop taking these before surgery. You may need to stop taking these 1-10 days prior, but if you do not stop at the correct time, your surgery may be cancelled. These medicines include:

 Aspirin or aspirin products

 Blood thinners or anti-platelet drugs, such as Xarelto®, Coumadin® (warfarin), Pradaxa®,

Eliquis®, Plavix®, Aggrenox, Fragmin, etc.

 Lovenox or heparin injections

 Anti-inflammatory medicine (such as ibuprofen products like Advil®, Aleve®, and Motrin®)

unless instructed by your doctor.

Your anesthesiologist may allow you to take your regular medicines with a small amount of water on the day of surgery. Talk to your doctor or nurse about this.

Packing for the Hospital

Bring these items with you:

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 These educational materials

 Basic toiletries, such as comb, toothbrush and toothpaste

 Slippers and a robe

 Optional items: ear plugs and eye mask

Do not bring credit cards, money or jewelry. If you bring valuables, ask family or friends to keep them until you return to your hospital room after treatment. If no one is able to help, ask the nurse to store your valuables. MD Anderson is not responsible for lost or stolen items.

Admission Information

Check into the hospital on the day of your surgery. You will be given the telephone number to hospital admissions at your anesthesia appointment. Call this number after 5 p.m. the day before surgery to receive instructions on what time and where to report the day of surgery. You will need to have a place to stay in the Houston area 1-2 days before your surgery.

Preparing Your Bowels for Surgery

The nurse will give you instructions during your clinic appointment on how to prepare your bowels. Do not eat or drink anything after midnight the night before your surgery.

Visitors

You may have 1-2 family members/friends stay with you in the holding area before surgery. Afterwards, they will be directed to the surgery waiting area. This area is staffed by volunteers who will assist them. Family and friends are not allowed in the operating room. You may have only 1 person stay with you overnight in your hospital room. All patient rooms are private rooms with their own bathroom. Overnight visitors are not permitted to stay in the waiting room areas or lobby.

Day of Surgery

Getting Ready

 The day of your surgery, report to the hospital as directed.

 You will wear a hospital gown during the surgery.

 Do not wear anything that can come off during surgery, such as dentures or partial plates,

eyeglasses or contact lenses, jewelry, bobby pins, hair clips, wigs or any removable

prosthesis, such as an artificial eye or leg.

 Go to the bathroom and empty your bladder.

 You may receive medicine to help you relax.

 You will be helped onto a stretcher and moved to the holding area or the operating room.

In the Holding Area

The holding area is a patient waiting room near the operating room. An IV will be placed in a vein in your hand or arm. An IV is a small tube through which you receive medicine and fluids.

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In the Operating Room

 You will lie on an operating table. You will be secured while you are on the table.

 If you feel cold, ask for a blanket.

 The staff will monitor your heart rate.

 You will receive the anesthetic through a vein in your arm (IV).

 After you are asleep, a tube will be placed down your throat to help you breathe.

 Then you will have a Foley catheter placed in your bladder to drain urine.

 You may have stents placed in your ureters if ordered by your surgeon (if so, you would have

met with the urology team before surgery).

After Surgery

 You will most likely wake up with no breathing tube in place in the overnight recovery area. Although very infrequent, some patients need to keep their breathing tube in place after surgery. If this is your case, you will wake up in the intensive care unit (ICU) with your breathing tube attached to a ventilator. A ventilator is a machine that helps you breathe.

 You will be moved to a hospital room in about 24-72 hours. It can take longer to get to your private room if a bed is not available on a surgical floor. Your doctor wants your room to be on a specific floor for patients who have had similar surgeries.

 A nasogastric tube (NG-tube), a thin tube that passes from your nose into your stomach to help control nausea, will still be in place. Depending on the tubes you have, you may not be able to talk. After they are removed, you may have a sore throat for a few days.

 You may not see clearly when you first wake up because of a protective lubricant that was put in your eyes before surgery. Your eyesight will get better soon.

 After the breathing tube is removed, you will be able to sit up on the side of your bed or in a chair with the help of your nurse. You will be instructed to take deep breaths and cough every hour. For more information, see your copy of “Breathing Exercise Using the Incentive Spirometer.”

 Your nurse will show you how splinting (using a pillow to support your incision) will make the breathing exercise less painful.

After the surgery you can expect to have the following:

 An oxygen monitor, a sensor that looks like a clothespin, is slipped over a fingertip to

monitor the oxygen level of your blood

 An IV to give you fluids

 A Foley catheter to drain your bladder

 Compression boots and support hose to prevent blood clots

 Stitches (sutures) or metal clips (staples) to hold the edges of your incision together. Your

nurse will check your incision regularly to make sure there is no bleeding or infection.

 Tubes/drains you may or may not have depending on your needs:

 A Jackson Pratt (JP) drain for future fluid drainage.

 A chest tube(s) may be in place to help keep fluid off of the lungs. This is sometimes

needed if the diaphragm (the muscle below the lungs) is scraped during surgery due to

removing tumors from this area.

 Possibly an N/G tube still in your nose or a G tube out of your stomach

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Your health care team will:

 Monitor your general condition and vital signs

 Weigh you using a bed scale

 Draw blood in the early morning as needed and possibly take a chest x-ray

 Monitor and check your nutritional needs

 Care for your chest tubes and Foley catheter

 Give you IV fluids and medicines as needed

 Give you chest physiotherapy to help loosen mucus in the lungs. This is therapy performed

with a small machine placed on your chest and back that gently vibrates.

 Give you breathing treatments while the breathing tube is in place. Breathing treatments

include medicine that will keep your air passages open.

Recovery

Pain Management

You will receive medicine to help relieve or decrease your pain so that you can move around and recover faster.

During the procedure, your doctor will insert a special nerve block (called TAP) to help reduce pain in your abdomen area. This block will help manage pain for the first few days. Afterwards you will be able to give yourself doses of pain medicine as needed by a patient controlled analgesia (PCA) pump. The PCA pump is a push-button pump that provides small doses of pain medicine through your IV when you need it.

Tell your nurse how you are feeling and if the medicine you are taking helps. It is important for your team to know if you are having other reactions to the medicine besides pain relief. Many different pain medicines are available, and this information will help your doctor prescribe the best medicine for you.

Team Member Roles

 Your primary nurse will watch your progress and make sure you are well prepared when it is time to go home.

 A case manager will meet with you before you are discharged to help make arrangements.

 A dietitian may meet with you to discuss your dietary plan.

 The discharge nurse will give you and your care giver instructions on home care.

 Your doctor, the surgical fellow and advanced practice providers will follow your

progress. Please ask questions and tell them about any problems you have.

Nutrition and Activity

Although appetite loss is normal, nutrition plays an important role in your recovery. You may receive total parenteral nutrition (TPN). This is full nutrient and fluid requirements given through an IV. Some patients have TPN for a short while in the hospital; others are discharged on TPN pending their ability to eat all the calories they need.

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Your health care team will track your progress, and you will be weighed every day. Getting out of bed and walking several times a day will speed your recovery and aid in digestion.

Symptoms to Report

Report the following symptoms to your health care team:

 Nausea or vomiting

 Abdominal pain that is not well controlled with your pain medicine

 No passing of gas for 24 hours

 Rapid, irregular or skipped heartbeats

Home Care and Follow-up

After discharge, you will have follow-up appointments scheduled. If you live out of town, you must plan to remain in the Houston area for at least 1 week after leaving the hospital. Your medical team will check you 1-2 times before you may leave the Houston area.

Activities of Daily Living

When you arrive home, do not expect to do everything you did before surgery. Your body will need 3-6 months to return to a normal activity level. You will tire easily, but activity such as walking will help. Follow the guidelines below.

 Take frequent rest breaks.

 Avoid any strenuous physical activity or heavy housework, until approved by your doctor.

 Do not lift anything weighing more than 5 pounds (2.3 kg) for at least 6 weeks after surgery.

Gradually build up to more weight by adding 5 pounds each week.

 Wear clean, loose clothing over your incision.

 Walk a little more each day.

 Continue your breathing and coughing exercises.

 Eat a well-balanced diet. Use tube feedings if needed.

 Weigh yourself every day and report weight loss to your doctor or nurse.

 Drink at least 2 quarts (8-10, 8-ounce glasses) of fluids per day to help prevent constipation.

 Do not take laxatives unless instructed by your doctor.

 Resume sexual activities whenever you wish. Be careful to prevent strain on your belly

muscles for a least 6 weeks.

 If you must smoke after surgery, wait at least 1 day after leaving the hospital before you

smoke, unless your doctor gives you different instructions.

Caring for Your Incision

It is important to inspect your incision site daily for signs and symptoms of infection. If you have any of the symptoms listed below, contact your doctor immediately.

 Swelling, increased pain or tenderness in your abdomen or incision area

 Increased redness or heat

 Separation of the skin

 Drainage containing pus

 Drainage with a bad odor

 Temperature of 101°F (38.3°C) or higher

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Unless otherwise instructed, clean your incision once a day and as needed with soap and water. Pat the area dry with a clean towel. Avoid baths or submerging the incision in water until it is fully closed. You may take showers.

Precautions After Surgery

Do not drive for 2 weeks after you go home and until you are off all prescription pain medicine. After 2 weeks, continue to avoid driving if your incision is painful or if you are taking prescription pain medicine. Your reflexes may be slower than you think. A deployed air bag can cause you harm if you were in an accident. Do not drink alcohol as long as you are taking pain medicine.

After surgery you may have fatigue, diarrhea, weight loss, nausea on and off, a metallic taste in the mouth when eating and a full feeling that does not go away. These feelings will gradually improve. In the meantime try to eat small, frequent meals and stay well hydrated with fluids.

Return Visits

You will have a follow-up visit with your surgeon and medical team within a week after you are discharged. Plans for further therapy will be discussed then.

In general, your long term follow-up visits will be dependent on the final pathology results, as well as the overall results of surgery. At each of these follow-up visits, you will be scheduled for blood tests, a CT scan of your abdomen and pelvis and possibly a chest x-ray or CT scan of your chest.

Resources

Gastrointestinal (GI) Center

Main Building, Floor 7, near Elevator A Monday through Friday, 8 a.m. to 5 p.m. 713-792-2330

Anesthesia Assessment Center

Main Building, Floor 6, near Elevator A 713-792-6133

Emergency Center

In case of an emergency, please call 911, or go to the nearest emergency center. MD Anderson’s Emergency Center is open 24 hours a day, every day. From Holcombe Boulevard, turn at Entrance Marker 3. The entrance is on Bates Street near Garage 2. From inside the Main Building, go to Floor 1, Room P1.3000.

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