Abdominoperineal Resection of the Bowel (APR)

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1 Abdominoperineal Resection of the Bowel (APR) Cancer of the anus or lower rectum requires one surgery in two parts. First, the surgeon loosens the colon and rectum in the abdomen. The colon is cut and the upper part of the colon is pullethrough an opening on your lower belly. This opening is a colostomy. Then, the lower end of the colon, including the rectum, anus, and lymph nodes are removed. The anus is closed with stitches. Getting Ready for Surgery Full Bowel Prep Using Bisacodyl/GoLytely 2 days before surgery, eat a light breakfast but then drink only clear liquids. There is no limit on the amount. You will be on clear liquids for 2 days before surgery. Water Clear Jell-O (nothing added) made at home from powder, not pre-made. Popsicles Sparkling water or soda Broth Juice with no pulp (apple, grape) Hard candy Weak coffee or tea, no creamer Gatorade Resource or Boost Breeze No alcohol or dairy products of any kind Mix GoLYTELY by adding lukewarm drinking water to top of line on bottle. Recap bottle and shake to dissolve the powder. The mixture will be clear. Do not add any flavorings to the mixture. Store in refrigerator. Use within 48 hours. 1 day before surgery, drink only clear liquids until midnight. 9am: Take 4 Bisacodyl tablets with water. Do not chew or crush them. Do not take within 1 hour of taking an antacid. 10am-3pm: When you have a bowel movement, start drinking the GoLYTELY. If you have not had a bowel movement by 3 pm, start drinking at 3 pm. Drink one 8-ounce glass every 10 minutes until half the bottle is gone. You may want to add Sugar Free Crystal Light Lemonade Powder to each glass to flavor. Do not sip slowly. It works better if you drink quickly. When half of the GoLYTELY is gone,

2 and if your stools are clear, you may stop drinking. What does clear mean? Clear means, no solid matter in what you are passing into the toilet. If you see sand-like fragments that fall to the bottom of the toilet, you need to drink another glass and reassess. Clear does not mean clear no color. Clear can be clear mustard color, clear brown or look like rice in the water. If you have a recent history of rectal bleeding or hemorrhoids, this prep may irritate these areas and you may see blood streaks in what you are passing. This is normal. If you do have a history of rectal bleeding, you may choose to not eat or drink clear liquids with red dye. If you eat or drink clear liquids with red dye, the dyed stool may appear to look like blood. Do not be alarmed by this. If you feel you are bleeding bright red blood, please call. 7pm: Take the first dose of antibiotics: metronidazole 500 mg. and neomycin 1 gram (1000 mg). 8pm: Take the second dose of antibiotics. 10pm: Take the last dose of antibiotics. Nothing to eat or drink after midnight. Keep drinking clear liquids until bedtime. Shower before going to bed. Morning of surgery - at least 1 hour before leaving home Give yourself a sodium phosphate enema. Shower again. Note: You may feel some cramps in your lower abdomen while drinking the GoLYTELY. If you have severe, steady stomach pain, get light-headed or dizzy, don t have any bowel movements at all, or can not drink the GoLYTELY, call the clinic at (608) After hours, weekends or holidays ask for the doctor on call or ask for Dr. Harms, Heise, Kennedy, or Foley. Tell the doctor you are doing bowel prep for surgery and explain your problem. The toll free number is (855) Do not take any of your scheduled pills for 1 hour before or after drinking. You will be called and told if you need to take any potassium.

3 After Surgery You will have a colostomy. Part of the colon connects to an opening in your abdomen where stool drains out. Stool collects in a pouch attached to the abdomen which is changed when needed. Your nurse will teach you how to care for your colostomy. You will also have a home health nurse visit you at home. It may seem hard to do at first, but your skill at taking care of your colostomy will improve over time. Learning a new skill takes time, practice, and patience. Risks of Surgery Your doctor will talk to you about these possible risks. Bleeding that requires a blood transfusion Bowel obstruction Hernia at the wound site Infections of the wounds (either belly or anal wound) Kidney infection Sexual problems o Men may have semen back up into the bladder o Men may have problems with erections o Women may have pain with intercourse Trouble passing urine Wound healing that takes a long time Going Home Plan to be in the hospital about 7days. When you go home you will be slowly adding foods to your diet as you can tolerate them. You will have little pain. Stool will pass through your colostomy. Walking daily will help you to feel better and help your body heal. Wound Care You will be able to shower in 2-3 days. You can wash your wounds with mild soap and water. You may not need to wear a bandage on your wound. If you do, we will show you how to change it. Do not use ointments, powders, or lotions on your wounds unless your doctor tells you to do so. Do not soak in a hot tub, bathtub, or swim until your doctor says it is okay. Stoma Care The bowel that comes through your belly is a stoma. A healthy stoma is pink and shiny, like the inside of your mouth. It is important to maintain the health of this skin and not allow the stoma or the skin around it to get sore and red. Your nurses will teach you how to care for your stoma and pouch system.

4 Pain Expect to have some pain after surgery. You will have medicine to take for it. Work with your nurse to get the most relief from your pain. Remember, we want you to work to keep your pain level mild. To do this, you will need to take your medicine when you first start to feel it. Rectal Healing Healing of the anal wound may take months. There may be drainage from this wound. You will need to wear a pad. Changing positions often helps the wound to heal. Drains put in during surgery will also help you heal. They come out through your abdomen. They are removed 3-5 days after surgery. Diet A nasogastric (NG) tube is not routinely used during this surgery, but it may be needed in some cases. Once your bowel action returns, you can drink clear liquids and you can slowly advance to regular food. As your bowel heals and you are able to eat more fiber, the stool from your colostomy will become more formed like a normal bowel movement. At home, you will start with the diet you had in the hospital and then slowly add more foods to your diet. Drink plenty of fluids (eight 8-ounce. glasses a day) to help your body heal. Bowel Movements After surgery, stool collects in the pouching system. The system is airtight; it does not allow any air, fluid, or smells to leak to the outside. The pouches need to be changed regularly and the skin around the stoma needs special care. At home, expect to have at least one bowel movement a day. Because your bowel action is still sluggish when you go home, it is possible for you to get constipated. There are four factors to think about to prevent this problem. 1. Water is essential for you. Drink 8-10, eight-ounce. glasses of a non-caffeine fluid each day. 2. Fiber in your diet will help. You will increase your intake of fiber as you can tolerate it. But, without enough water, more fiber may lead to constipation. 3. Exercise helps regulate bowel activity. 4. Narcotic pain pills slow bowel action. Remedy this side effect with the above actions. At home you will be taking stool softeners (2 or more a day) to help prevent constipation. If you do not have at least one bowel movement a day, call us. We can help you get more regular.

5 Activity Most people are off work for 6-8 weeks, sometimes longer. You will need to plan rest periods at home. Walk at least twice a day. It helps you gain strength and you will feel better. Do nothing more strenuous than walking until your doctor says it is okay. No lifting more than 10 pounds for 4-6 weeks. No intercourse until okayed by your doctor. When to Call the Doctor Shortness of breath or chest pain, call 911 Pain, tenderness, swelling, or redness in feet, legs, or arms Pain in lower legs, calves, thighs, or arms Trouble passing urine Painful bloating or cramping Bulge at wound site Unable to pass gas or stool Skin soreness at or around the stoma Signs of a wound infection: o Increasing redness or warmth at the wound o Temperature over F. by mouth, for two readings taken 4 hours apart o Bleeding or pus from wound o Pain not controlled by pain pills Phone Numbers Digestive Health Center: (608) After hours, weekends or holidays this number will be answered by the paging operator. Ask for the doctor on call or ask for Dr. Harms, Heise, Kennedy, or Foley. Leave your name and phone number with area code. The doctor will call you back. If you live out of the area, call (855) Copyright 4/2013. University of Wisconsin Hospitals and Clinics Authority. All rights reserved. Produced by the Department of Nursing HF#6148