Sugarbaker Oncology Associates
Your Surgery & Hospitalization:
What to Expect

Preoperative

In preparation for your upcoming surgery, a patient information packet and a video have been created to provide you with some useful information. The information was put together with the input of various health care professionals, patients and families. We realize that this is a lot of information, but the surgery you will be undergoing is very involved and we want you to feel as prepared for this event as possible.

The surgical procedures most often performed are called "cytoreductive surgery". The basic principles involved are to surgically remove most or all of the visible tumor in your abdomen and then follow up immediately with chemotherapy placed directly into your abdomen. By doing this, residual tumor cells that persist after the surgery will hopefully be destroyed by the chemotherapy.

The procedure itself is very lengthy and often extends into the evening. Due to the length of the surgery and the amount of manipulation of your abdominal contents, your recovery period is also quite lengthy. We want you to be fully aware of what to expect so that you can actively participate in your recovery. Please feel free to contact the Sugarbaker Oncology Associates office at (202) 877-3908 or one of the clinical managers from one of the following units, should you have any questions about your surgery or your hospital stay.

Main Operating Room - (202) 877-6404
2NW Patient Unit - (202) 877-7824
3G Surgical ICU - (202) 877-3071

Most likely, you wil be admitted the day before your surgery. You will probably have a room on the 2 North-West Surgical floor. You may or may not have a private room, depending on availablity. Your preoperative day will be a busy one for you. You may need some preliminary lab work, x-rays, and a CT scan. You will also need to prepare your bowel for surgery.

You should anticipate drinking approximately one gallon of a special bowel prep solution called Golytely. Golytely is a clear liquid that has electrolytes and is very useful in cleansing the bowel prior to surgery. Golytely tastes a little salty, so please let your nurse know if you would prefer it to be iced or at room temperature.

Depending on what time you arrive on the 2NW unit and what preliminary work has been ordered, you may have time to take a tour of the Surgical Intensive Care Unit (SICU), the surgical waiting room, and other key sites around the hospital. Please let your nurse know when you arrive, if you are interested in taking a tour.


Day of Surgery

The Operating Room
On the morning of your surgery (or possibly the evening before), an intravenous (IV) line may be started. Your surgery will be scheduled to begin at either 6:00 a.m. or 9:00 a.m.

You will probably be going to the Surgical Intensive Care Unit (SICU) after your surgery, so your family needs to take your belongings with them when you go to the operating room. There is a family waiting room located just outside of the operating rooms on the ground floor of the North Addition. Your family should register with the receptionist at the waiting room desk. Our surgeons will look for them there to give periodic progress reports throughout the surgery. Further information will come from the OR nursing staff, recovery room personnel or a computer monitor located at the desk. A volunteer is usually at the desk until 4:00 p.m. After 4:00 p.m., communications will be delivered via the nursing staff.

This is a short day for you, but it is usually a very long, draining day for your family. You may be asleep in the operating room for a very long time. To help pass the time, we encourage the family to bring something to do (i.e. books, crafts, etc.).

Recovery Room
The main Post Anesthesia Care Unit (PACU) is located on the ground floor, across from the OR. The PACU is also sometimes called the Recovery Room. A postoperative cytoreduction patient may go the PACU or immediately to the Surgical ICU, depending on bed availability. The PACU is an open unit, meaning that curtains divide about 20 patient cubicles. Usually, there is one nurse to every one or two patients. Visiting the patient by family members is restricted due to the confined space and the transcient stay of patients in the PACU. If you were to stay in the Main PACU for a prolonged period, a concerted effort will be made to bring family members in to see you, but this can not be guaranteed.

You will probably be intubated, meaning that a breathing tube inserted into your mouth and throat will be attached to a ventilator to assist you with respiration. The ventilator will provide you with forced breaths, so it is important for you to try not to resist or "fight" the ventilator. You will not be able to talk when intubated since the tube disrupts the vocal cords when in place. To communicate you may want to do any of the following:

• Nod your head yes or no to questions asked by your nurse.
• When you are awake enough, mouth words. Your nurse may be able to read your lips.
  

After you are off of the ventilator, you can expect to be placed on oxygen either by a face mask or by a nasal cannula.

Numerous IV lines will be in place. These are necessary for fluid replacement, pain medication and nutrition. Also present will be an abdominal catheter for intraperitoneal chemotherapy infusion. Due to the numerous lines and the presence of the breathing tube, your hands will be restrained to prevent you from accidentally dislodging lines until you are fully awake and/or your breathing tube has been removed.

Immediately after your surgery, we will begin flushing your abdomen with a plain electrolyte solution. When the flushing begins, you may experience a warm, full feeling in your abdomen.

During your stay in the recovery room, your nurse will be quite busy settling you in after surgery. However, every attempt will be made to make you as comfortable and to reassure you as to where you are and how you are doing.

Surgical Intensive Care Unit (SICU)

The next step in your hospital course will probably include a stay in the surgical itensive care unit (SICU). The SICU can be a frightening and overwhelming experience. The average stay for a post-cytoreductive patient is 2-7 days.

On admission to the SICU, you will be placed in a private room, though it may appear to be a convention center to you. Many SICU staff members will assist you with your admission, including several SICU nurses. Your first memories of the SICU may be ones of many hands poking and prodding you, with amplified voices, buzzes, beeps and rings. The nurse will be doing a physical assesment of your condition, which involves touching and talking to you. You may feel cold and uncomfortable at first, but hang in there! They will complete the assesment in about 30 minutes. Our next step will be to make you as comfortable as possible. You will find that you have three different nurses during a 24-hour period. Every effort will be made for you to have the same nurses on a day to day basis caring for you. Your nurse will be caring for you, and often, one other person during his/her shift. You will see many lights flashing and hear alot of talking, beeps and buzzes. Each nurse has specific tasks to perform during the shift and will need to manipulate lines, drains, tubes and various mmonitoring devices more frequently than you imagined. The staff attempts to give you quiet time or rest time with the lights turned off, between the commotion. The many monitors in your room are used to alert the nurse to any changes. Remember, the sound of an alarm rarely means you are in danger. More often, it is a reminder for your nurse to complete a task.

In the SICU, we work as a team. Nurses, respiratory therapists, pharmacists, dieticiiians and doctors all strive to give you the most comprehensive medical care. The many team members involved in your care will be examining you throughout the day and night. This means that you will see many unfamiliar faces.

The care you need during your stay in the SICU fills most of the day. Therefore, visiting hours are limited from 1:00 p.m. - 1:30 p.m.; 5:00 p.m. - 5:30 p.m.; and 7:30 - 8:00 p.m.; and to two visitors at a time. It is helpful if you choose one member of your family to be a spokesperson. With your permission, information concerning your condition will be given to that person. This approach assists us in spending more time with you and it protects your rights to privacy.

Our main concern is for your health and safety. The questions you have may not be answered immediately, but we will try to meet all of your needs as soon as possible. You will not be able to speak because of the breathing tube in your mouth and throat. Please keep in mind that:

• The breathing tube is necessary for your recovery from the anesthesia.
• It is only temporary and you will be able to speak immediately after the tube is removed.
• You will be able to communicate by mouthing words, nodding your head to yes or no quesations and by hand signals.
  

You will find that your body has multiple tubes, applicance, and attachments present. Listed below are a few definitions of the tubes and terms frequently used for our cytoreductive patients. Each patient is different; therefore, all of these terms may not apply to you.

ET Tube:

Endotracheal Tube (breathing tube). Located in your mouth and throat. The ET tube is connected to a ventilator and will help you breathe.

NG Tube:

Nasogastric Tube. Located in your nose and goes down into your stomach. The purpose of this tube is to drain your stomach contents until your bowel starts functioning again.

TPN and Intralipids:

Total Parenteral Nutrition (TPN) and a liquid fat mixture (intralipids). This is nutrition that is administered directly into your veins. You will need this to help your body heal until you are able to eat again.

IV Catheters:

Intravenous Catheters are use for administration of medication and fluids directly into your veins. IV lines are usually located in your arms, hands and neck.

Central Line:

An IV line that is placed in a large vein leading to your heart during surgery. The purpose of this line is to provide a long-term access for your nutrition (TPN) until your bowel has healed, and for IV medications.

J.P. Drain:

Jackson-Pratt Drains are also known as closed suction catheters and they are used to drain blood, body fluids and chemotherapy out of your abdomen. The small plastic ball on the end of the drain provides very gentle suction to remove any accumulated fluids.

Tenckhoff Catheter:

This an intraabdominal catheter with a curled end, that is used to administer chemotherapy to your abdominal cavity.

Chest Tubes:

Chest tubes are placed through the skin and into the chest cavity. They are used to drain fluid and air from the area around your lungs. Chest tubes are often placed if your surgery involves you diaphragms.

Venodyne Compression Stockings:

Venodynes improve the blood circulation in your legs and prevent blood clots from forming. They are worn in addition to support hose. Venodynes are intermittently compressed around your legs and feel something like a blood pressure cuff inflating.

Dianeal Solution:

An electrolyte solution. Dianeal is given through your Tenckhoff catheter after surgery to "wash" your abdomen of any surgical debris so that the chemotherapy can begin. It usually takes about 24 hours to completely cleanse your abdomen.

Intraperitoneal Chemotherapy:

Chemotherapy solution that is administered directly into your abdomen. The purpose is to destroy cancer cells that remain in your abdominal cavity.

PCA Pump:

The Patient Controlled Analgesic pump is a special pump that delivers a prescribed amount of pain medication at a continuous rate into your vein. The PCA pump also allows you to push a button to receive additional medication when you need it.


Transfer to 2 North-West

The amount of time that the post-cytoreductive patient spends in the SICU varies from patient to patient. Your surgeons will decide when you are ready to transfer from the SICU. You will probably be transfered to 2 North-West (2NW) postsurgical floor. Once you are transfered, you will be followed by our surgeons, our Physician Assistant (Gary Edwards), and a number of residents.

When to transfer to 2NW, you will be moved to a private or semi-private room. You will still have all of the tubes and IV lines, with the exception of the breathing tube, that you had in the SICU. You will probably be receiving your intraperitoneal chemotherapy. Once your 5 days of chemotherapy are complete, your Tenckhoff catheter will be removed. The rest of your tubes will come out slowly but surely as the amount of drainage decreases. Each individual is different and it is difficult to predict how one person will progress compared to another. There will probably be patients on the unit who have undergone the same procedure as you, but try not to compare your progress with their progress. Some of your tubes mat be in longer or vice versa, but that does not necessarily indicate that one person is doing better than the other.

When you first come out of the SICU, you will be assigned to a primary nurse. Your primary nurse will be the person who coordinates your plan of care with you and your family, and he/she will coordinate your care throughout your hospitalization. We encourage you to actively participate in your recovery and to communicate your needs to your primary nurse. On the shifts that your primary nurse is not your direct caregiver, another nurse will be assigned to you and will be carrying out the plan of care developed by you and your primary nurse. Your postoperative care after you are stable, resting comfortably on 2 North-West Surgical Unit, and receiving chemotherapy will consist of the following:

• Maintenance of adequate nutrition with Total Parenteral Nutrition (TPN) via a central line catheter.
• Strict decompression of your stomach and bowels with a nasogastric (NG) tube through your nose and into your stomach.
• Pain management using a Patient Controlled Analgesic (PCA) pump and other medications as needed. Completion of your early postoperative intraperitoneal chemotherapy.

After your chemotherapy is completed on postoperative day 5 or 6, the process of removing chest tubes and intraabdominal drains will begin. Usually, by postoperative day 10 or 11 all of the tubes into your abdomen will be removed. Your nasogastric tube, however, will be required for several more days. It is extremely important to remove the secretions produced by your stomach until your bowels are capable of functioning again. This often takes 21 to 28 days after surgery, but each patient is different and it sometimes takes longer. The nasogastric tube will gradually be weaned over 24 to 72 hours. This will occur when:

• The output changes color from greenish to white.
• The 24 hour output falls to less than one liter.

You begin to pass gas - indicating that your bowel has begun to function again.

It is important to keep in mind the tremendous amount of manipulation that your bowels endured during your surgery. In order for our surgeons to remove the tumor, your bowel needed to be handled and moved around. This procedure, along with the chemotherapy, causes a degree of inflammation and irritation. Your intraabdominal surfaces will also be extremely abraded from the surgery. It takes a lot of time for your body to heal after an event such as this. It is of paramount importance that the NG tube NOT be taken out too early as this could cause some serious complications. Your bowels have a "mind of their own", and they will not start functioning until they are good and ready!

After your nasogastric tube is out, you may need to continue on TPN for a while. Once,you are able to take adequate nutrition by mouth, the TPN will be weaned and discontinued. You may continue to receive narcotics for discomfort and pain until you are able to tolerate a liquid diet and take oral pain medications.

Your emotional response to this significant event is as important as your body's physical response. Our philosophy is to treat the whole person, not just the disease. One of our oncology social workers will be working with you, along with your nurses and doctors, to assist you in coping with your recovery and any other issues you may choose to explore. Working through feelings and towards realistic, positive atrtitudes can maximize your recovery.

At the time of discharge you will be tolerating a normal diet, advancing your physical activities, and ahving normal bowel and bladder function. You will be discharged with adequate pain medication and arrangements for home care if necessary.

This is a general sketch of what to expect postoperatively. The postoperative course varies with each patient. Complications can, and do, occur from time to time. Complications can cause a prolonged hospitalization stay or discharge with significant home care needs. Every effort will be made to minimize the risk of having a complication; and to help you cope if a problem occurs.


If you have additional questions about Sugarbaker Oncology Associates, gastrointestinal cancer, or about this web site please contact us at:

Sugarbaker Oncology Associates
Washington Cancer Institute, CG-175
110 Irving St., NW
Washington, D.C. 20010

Phone 202-877-3908
Fax 202-877-8602