About Your Abdominal Perineal Resection (APR) Surgery

This guide will help you get ready for your APR surgery at MSK. It will also help you know what to expect as you recover.

Use this guide as a source of information in the days leading up to your surgery. Bring it with you on the day of your surgery. You and your care team will use it as you learn more about your recovery.

About your APR surgery

Your digestive system

Understanding how your digestive system works can be helpful as you get ready for and recover from your surgery.

Your digestive system is made up of organs that break down food, absorb nutrients, and remove waste from your body (see Figure 1). They include your:

• Mouth
• Esophagus (food pipe)
• Stomach
• Small intestine
• Colon (large intestine)
• Rectum
• Anus

After you chew and swallow your food, it moves into your esophagus. Your esophagus is a long, muscular tube that carries food from your mouth into your stomach. Once the food enters your stomach, it mixes with stomach acids. These acids start to digest (break down) the food.

When the food leaves your stomach, it moves into your small intestine. There it continues to be digested, and many nutrients are absorbed. Anything that isn’t absorbed is called waste.

The waste then moves to your colon, where some water is reabsorbed (taken back) into your body. The remaining waste enters the end of your colon, which is called your rectum. Your rectum serves as a holding area for the waste until it leaves your body through your anus.

Abdominal perineal resection

APR is a surgery that’s done to treat anal or rectal cancer. To remove the cancer, your surgeon will remove all of the following:

• The lower part of your colon
• Your rectum
• Your anus

An APR can be done using different techniques. Your surgeon will talk with you about which options are right for you. Depending on what type of surgery you have, your surgeon will make 1 or more incisions (surgical cuts) in your abdomen (belly).

• When 1 long incision is made on your abdomen, this is called open surgery.
• When several small incisions are made on your abdomen, this is called minimally invasive surgery. Small surgical tools and a video camera are put into the incisions to remove the cancer. Some surgeons use a robotic device to assist with the surgery.

Your surgeon will also make 1 incision in your perineal area. Your perineal area is the area between your vagina and anus or scrotum and anus.

When your surgeon removes your rectum and anus, a large empty space will be left between your buttocks. The space will be closed by sutures (stitches). While the space is healing, there will be restrictions on how you sit, lie down, and do some of your usual activities. Your doctor or nurse will talk with you about these restrictions. When the area has healed, other people will not notice anything different about you. You’ll be able to go about your daily activities.

Colostomy

Because your rectum and anus will be removed, you’ll need a new place for your stool (poop) to leave your body. During your surgery, the lower end of your colon will be brought outside your body through the skin on your abdomen. This is called a colostomy.

You’ll see the lining of your colon on the outside of your abdomen. This is called a stoma. Your stoma will be pink or red and look shiny and moist. Colostomy stomas are usually placed on the lower left side of the abdomen, about 2 inches away from the belly button (see Figure 2).

After your surgery, your stool will leave your body from your stoma. You’ll wear a colostomy pouch over your stoma. This pouch will collect your gas and stool. A wound, ostomy, continence (WOC) nurse will teach you how to change your pouch and care for your stoma. No one will know you have a colostomy unless you tell them.

Before your APR surgery

This section will help you get ready for your surgery. Read it when your surgery is scheduled. Refer to it as your surgery gets closer. It has important information about what to do to get ready.

As you read this section, write down questions to ask your healthcare provider.

Getting ready for your surgery

You and your care team will work together to get ready for your surgery. Help us keep you safe by telling us if any of these things apply to you, even if you’re not sure.

• I take an anticoagulant (blood thinner), such as:

  These are examples of medicines. There are others.
  
  Be sure your healthcare provider knows all the medicines you’re taking.
  • Aspirin
  • Heparin
  • Warfarin (Jantoven^®, Coumadin^®)
  • Clopidogrel (Plavix^®)
  • Enoxaparin (Lovenox^®)
  • Dabigatran (Pradaxa^®)
  • Apixaban (Eliquis^®)
  • Rivaroxaban (Xarelto^®)
• I take an SGLT2 inhibitor, such as:
  • Canagliflozin (Invokana^®)
  • Dapagliflozin (Farxiga^®)
  • Empagliflozin (Jardiance^®)
  • Ertugliflozin (Steglatro^®)
• I take prescription medicine(s), including patches and creams. A prescription medicine is one you can only get with a prescription from your healthcare provider.
• I take over-the-counter medicine(s), including patches and creams. An over-the-counter medicine is one you can buy without a prescription.
• I take dietary supplements, such as herbs, vitamins, minerals, or natural or home remedies.
• I have a pacemaker, automatic implantable cardioverter-defibrillator (AICD), or other heart device.
• I have sleep apnea.
• I have had a problem with anesthesia (A-nes-THEE-zhuh) in the past. Anesthesia is medicine to make you sleep during a surgery or procedure.
• I’m allergic to certain medicines or materials, including latex.
• I’m not willing to receive a blood transfusion.
• I drink alcohol.
• I smoke or use an electronic smoking device, such as a vape pen or e-cigarette.
• I use recreational drugs, such as marijuana.

About drinking alcohol

It’s important to talk with your healthcare providers about how much alcohol you drink. This will help us plan your care.

If you drink alcohol regularly, you may be at risk for problems during and after your surgery. These include bleeding, infections, heart problems, and a longer hospital stay.

If you drink alcohol regularly and stop suddenly, it can cause seizures, delirium, and death. If we know you’re at risk for these problems, we can prescribe medicine to help prevent them.

Here are things you can do before your surgery to keep from having problems.

• Be honest with your healthcare providers about how much alcohol you drink.
• Try to stop drinking alcohol once your surgery is planned. Tell your healthcare provider right away if you:
  • Get a headache.
  • Feel nauseous (like you’re going to throw up).
  • Feel more anxious (nervous or worried) than usual.
  • Cannot sleep.

These are early signs of alcohol withdrawal and can be treated.

• Tell your healthcare provider if you cannot stop drinking.
• Ask your healthcare provider questions about drinking and surgery. All your medical information will be kept private, as always.

About smoking

If you smoke, you can have breathing problems when you have surgery. Stopping for even a few days before your surgery can help.

Your healthcare provider will refer you to our Tobacco Treatment Program if you smoke. You can also reach the program by calling 212-610-0507.

About sleep apnea

Sleep apnea is a common breathing problem. If you have sleep apnea, you stop breathing for short lengths of time while you’re asleep. The most common type is obstructive sleep apnea (OSA). With OSA, your airway becomes fully blocked during sleep.

OSA can cause serious problems during and after surgery. Tell us if you have or think you might have sleep apnea. If you use a breathing device, such as a CPAP machine, bring it on the day of your surgery.

Using MyMSK

MyMSK (my.mskcc.org) is your MSK patient portal. You can use it to send and read messages from your care team, view your test results, see your appointment dates and times, and more. You can also invite your caregiver to make their own account so they can see information about your care.

If you do not have a MyMSK account, you can sign up at my.mskcc.org. You can get an enrollment ID by calling 646-227-2593 or your doctor’s office.

Watch How to Enroll in MyMSK: Memorial Sloan Kettering's Patient Portal (www.mskcc.org/pe/enroll_mymsk) to learn more. You can also contact the MyMSK Help Desk by emailing [email protected] or calling 800-248-0593.

About your MyMSK Goals to Discharge Checklist

After your surgery, you’ll focus on getting well enough to leave the hospital. We’ll send a Goals to Discharge Checklist to your MyMSK account to help you track how you’re doing.

You can use your MyMSK Goals to Discharge Checklist to see the goals you need to meet before leaving the hospital. You can also update your progress throughout the day. Your updates send alerts to your surgical team about your progress.

To learn more, read Frequently Asked Questions About the MyMSK Goals to Discharge Checklist (www.mskcc.org/pe/goals_discharge_checklist).

About Enhanced Recovery After Surgery (ERAS)

ERAS is a program to help you get better faster after your surgery. It’s important to do certain things before and after your surgery as part of the ERAS program.

Before your surgery, make sure you’re ready by:

• Reading this guide. It will help you know what to expect before, during, and after your surgery. If you have questions, write them down. You can ask your healthcare provider at your next visit or call their office.
• Exercising and following a healthy diet. This will help get your body ready for your surgery.

After your surgery, help yourself recover more quickly by:

• Reading your recovery pathway. This is an educational resource your healthcare provider will give you. It has goals for your recovery. It will help you know what to do and expect each day.
• Starting to move around as soon as you can. The sooner you get out of bed and walk, the quicker you can get back to your usual activities.

Within 30 days of your surgery

Presurgical testing (PST)

You’ll have a PST appointment before your surgery. You’ll get a reminder from your surgeon’s office with the appointment date, time, and location.

You can eat and take your usual medicine(s) the day of your PST appointment.

It’s helpful to bring these things to your appointment:

• A list of all the medicines you’re taking, including prescription and over-the-counter medicines, patches, and creams.
• Results of any medical tests done outside of MSK in the past year, if you have them. Examples include results from a cardiac stress test, echocardiogram, or carotid doppler study.
• The names and telephone numbers of your healthcare providers.

You’ll meet with an advance practice provider (APP) during your PST appointment. They work closely with MSK’s anesthesiology (A-nes-THEE-zee-AH-loh-jee) staff. These are doctors with special training in using anesthesia during a surgery or procedure.

Your APP will review your medical and surgical history with you. You may have tests to plan your care, such as:

• An electrocardiogram (EKG) to check your heart rhythm.
• A chest X-ray.
• Blood tests.

Your APP may recommend you see other healthcare providers. They’ll also talk with you about which medicine(s) to take the morning of your surgery.

Meet with a Wound, Ostomy, Continence (WOC) nurse

You’ll meet with a WOC nurse before your surgery. A WOC nurse is a registered nurse who specializes in wound and ostomy care. They’ll teach you and your family how to care for your new colostomy and help you become more independent. A WOC nurse will also show you a colostomy pouch so you can become familiar with it.

Identify your caregiver

Your caregiver has an important role in your care. Before your surgery, you and your caregiver will learn about your surgery from your healthcare providers. After your surgery, your caregiver will take you home when you’re discharged. They’ll also help you care for yourself at home.

For caregivers

‌  Caring for a person going through cancer treatment comes with many responsibilities. We offer resources and support to help you manage them. Visit www.msk.org/caregivers or read A Guide for Caregivers (www.mskcc.org/pe/guide_caregivers) to learn more.

Fill out a Health Care Proxy form

If you have not already filled out a Health Care Proxy form, we recommend you do now. If you already filled one out or have any other advance directives, bring them to your next appointment.

A health care proxy is a legal document. It says who will speak for you if you cannot communicate for yourself. This person is called your health care agent.

• To learn about health care proxies and other advance directives, read Advance Care Planning for People With Cancer and Their Loved Ones (www.mskcc.org/pe/advance_care_planning).
• To learn about being a health care agent, read How to Be a Health Care Agent (www.mskcc.org/pe/health_care_agent).

Talk with a member of your care team if you have questions about filling out a Health Care Proxy form.

Buy bowel prep supplies

You’ll need to do a bowel prep (clear the stool from your body) before your surgery.

Your healthcare provider will give you a prescription for antibiotics to take as part of your bowel prep. You’ll also need to buy these supplies:

• 1 (238-gram) bottle of polyethylene glycol (MiraLAX^®). You can buy this at your local pharmacy. You don’t need a prescription.
• 1 (64-ounce) bottle of a clear liquid. For examples of clear liquids, read the “Follow a clear liquid diet” section.
• Extra clear liquids to drink while you’re following a clear liquid diet.

Buy acetaminophen (Tylenol^®) and ibuprofen (Advil^® or Motrin^®)

Acetaminophen and ibuprofen are over-the-counter pain medicines. You’ll use them after your surgery to help manage your pain at home.

It’s helpful to buy these medicines ahead of time if you don’t already have them. You can get them at your local pharmacy without a prescription.

7 days before your surgery

Follow your healthcare provider’s instructions for taking aspirin

Aspirin can cause bleeding. If you take aspirin or a medicine that has aspirin, you may need to change your dose or stop taking it 7 days before your surgery. Follow your healthcare provider’s instructions. Do not stop taking aspirin unless they tell you to.

To learn more, read How To Check if a Medicine or Supplement Has Aspirin, Other NSAIDs, Vitamin E, or Fish Oil (www.mskcc.org/pe/check-med-supplement).

Stop taking vitamin E, multivitamins, herbal remedies, and other dietary supplements

Vitamin E, multivitamins, herbal remedies, and other dietary supplements can cause bleeding. Stop taking them 7 days before your surgery. If your healthcare provider gives you other instructions, follow those instead.

To learn more, read Herbal Remedies and Cancer Treatment (www.mskcc.org/pe/herbal_remedies).

2 days before your surgery

Don’t shave or wax your abdominal area starting 2 days before your surgery. This will lower your risk of getting an infection.

Stop taking nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs, such as ibuprofen (Advil^® and Motrin^®) and naproxen (Aleve^®), can cause bleeding. Stop taking them 2 days before your surgery. If your healthcare provider gives you other instructions, follow those instead.

To learn more, read How To Check if a Medicine or Supplement Has Aspirin, Other NSAIDs, Vitamin E, or Fish Oil (www.mskcc.org/pe/check-med-supplement).

1 day before your surgery

Follow a clear liquid diet

You’ll need to follow a clear liquid diet the day before your surgery. A clear liquid diet includes only liquids you can see through. You can find examples in the “Clear liquid diet” table.

While you’re following a clear liquid diet:

• Try to drink at least 1 (8-ounce) cup of clear liquid every hour you’re awake.
• Drink different types of clear liquids. Do not just drink water, coffee, and tea.
• Do not drink any liquids you can’t see through, such as milk or smoothies.
• Do not drink sugar-free liquids unless you have diabetes and a member of your care team tells you to.
• Do not eat any solid foods.

How to follow a clear liquid diet if you have diabetes

Ask the healthcare provider who manages your diabetes:

• What to do while you’re following a clear liquid diet.
• If you need to change your dose of insulin or other diabetes medication, if you take them.
• If you should drink sugar-free clear liquids.

Check your blood sugar level often while you’re following a clear liquid diet. If you have questions, talk with your healthcare provider.

Start your bowel prep

The morning of the day before your surgery, mix all 238 grams of MiraLAX with 64 ounces of clear liquid until the MiraLAX powder dissolves. After that, you can put the mixture in the refrigerator if you want to.

At 5 p.m. on the day before your surgery, start drinking the MiraLAX mixture. It will make you have bowel movements often, so make sure you’re near a bathroom.

• Drink 1 (8-ounce) cup of the mixture every 15 minutes until it’s gone.
• When you finish the MiraLAX mixture, drink 4 to 6 cups of clear liquids.
• Put zinc oxide ointment (such as Desitin^®) on the skin around your anus after every bowel movement. This helps prevent irritation.

At 7 p.m. on the day before your surgery, take your antibiotics as instructed.

At 10 p.m. on the day before your surgery, take your antibiotics as instructed.

You can keep drinking clear liquids, but you don’t have to.

Note the time of your surgery

A staff member will call you after 2 p.m. the day before your surgery. If your surgery is scheduled for a Monday, they’ll call you the Friday before. If you do not get a call by 7 p.m., call 212-639-5014.

The staff member will tell you what time to get to the hospital for your surgery. They’ll also remind you where to go.

Shower with a 4% chlorhexidine gluconate (CHG) solution antiseptic skin cleanser (such as Hibiclens^®)

4% CHG solution is a skin cleanser that kills germs for 24 hours after you use it. Showering with it before your surgery will help lower your risk of infection after surgery. Your nurse will give you a bottle to use before your surgery.

The night before your surgery, shower using a 4% CHG solution antiseptic skin cleanser.

1. Wash your hair with your usual shampoo and conditioner. Rinse your head well.
2. Wash your face and genital (groin) area with your usual soap. Rinse your body well with warm water.
3. Open the 4% CHG solution bottle. Pour some into your hand or a clean washcloth.
4. Move away from the shower stream. Rub the 4% CHG solution gently over your body from your neck to your feet. Do not put it on your face or genital area.
5. Move back into the shower stream to rinse off the 4% CHG solution. Use warm water.
6. Dry yourself off with a clean towel.

Do not put on any lotion, cream, deodorant, makeup, powder, perfume, or cologne after your shower.

Instructions for eating and drinking: 8 hours before your arrival time

Stop eating 8 hours before your arrival time, if you have not already. Your healthcare provider may tell you to stop eating earlier. If they do, follow their instructions. 8 hours before your arrival time, do not eat or drink anything except these clear liquids: Water. Soda. Clear juices, such as lemonade, apple, and cranberry juices. Do not drink orange juice or juices with pulp. Black coffee or tea (without any type of milk or creamer). Sports drinks, such as Gatorade®. Gelatin, such as Jell-O®. You can keep having these until 2 hours before your arrival time.

The day of your surgery

Remember, starting 8 hours before your scheduled arrival time, do not eat or drink anything except the things listed above.

Instructions for drinking: 2 hours before your arrival time

Stop drinking 2 hours before your arrival time. This includes water.

Take your medicines as instructed

A member of your care team will tell you which medicines to take the morning of your surgery. Take only those medicines with a sip of water. Depending on what you usually take, this may be all, some, or none of your usual morning medicines.

Shower with a 4% CHG solution antiseptic skin cleanser, such as Hibiclens

Shower with a 4% CHG solution antiseptic skin cleanser before you leave for the hospital. Use it the same way you did the night before.

Do not put on any lotion, cream, deodorant, makeup, powder, perfume, or cologne after your shower.

Things to remember

• Wear something comfortable and loose-fitting.
• If you wear contact lenses, wear your glasses instead. Wearing contact lenses during surgery can damage your eyes.
• Don’t wear any metal objects. Remove all jewelry, including body piercings. The equipment used during your surgery can cause burns if it touches metal.
• Leave valuable items at home.
• If you’re menstruating (have your monthly period), use a sanitary pad, not a tampon. You’ll get disposable underwear, as well as a pad if needed.

What to Bring

• A pair of loose-fitting pants (such as sweatpants).
• Brief-style underwear that’s 1 to 2 sizes larger than you normally wear.
• Sneakers that lace up. You may have some swelling in your feet. Lace-up sneakers can fit over this swelling.
• Your breathing device for sleep apnea (such as your CPAP device ), if you have one.
• Your Health Care Proxy form and other advance directives, if you completed them.
• Your cell phone and charger.
• Only the money you may want for small purchases (such as a newspaper).
• A case for your personal items (such as eyeglasses, hearing aid(s), dentures, prosthetic device(s), wig, and religious articles), if you have one.
• This guide. Your healthcare team will use it to teach you how to care for yourself after surgery.

Where to park

MSK’s parking garage is on East 66^th Street between York and 1^st avenues. If you have questions about prices, call 212-639-2338.

To get to the garage, turn onto East 66^th Street from York Avenue. The garage is about a quarter of a block in from York Avenue. It’s on the right (north) side of the street. There’s a tunnel you can walk through that connects the garage to the hospital.

There are other parking garages on:

• East 69^th Street between 1^st and 2^nd avenues.
• East 67^th Street between York and 1^st avenues.
• East 65^th Street between 1^st and 2^nd avenues.

Once you’re in the hospital

When you get to the hospital, take the B elevator to the 6^th floor. Check in at the desk in the PSC waiting room.

You’ll be asked to say and spell your name and birth date many times. This is for your safety. People with the same or a similar name may be having surgery on the same day.

When it’s time to change for surgery, you’ll get a hospital gown, robe, and nonskid socks to wear.

Meet with a nurse

You’ll meet with a nurse before surgery. Tell them the dose of any medicines you took after midnight (12 a.m.) and the time you took them. Make sure to include prescription and over-the-counter medicines, patches, and creams.

Your nurse may place an intravenous (IV) line in one of your veins, usually in your arm or hand. If your nurse does not place the IV, your anesthesiologist (A-nes-THEE-zee-AH-loh-jist) will do it in the operating room.

Meet with an anesthesiologist

You’ll also meet with an anesthesiologist before surgery. They will:

• Review your medical history with you.
• Ask if you’ve had any problems with anesthesia in the past. This includes nausea (feeling like you’re going to throw up) or pain.
• Talk with you about your comfort and safety during your surgery.
• Talk with you about the kind of anesthesia you’ll get.
• Answer questions you have about anesthesia.

Get ready for surgery

When it’s time for your surgery, you’ll take off your eyeglasses, hearing aids, dentures, prosthetic devices, wig, and religious articles.

You’ll either walk into the operating room or a staff member will bring you there on a stretcher. A member of the operating room team will help you onto the operating bed. They’ll put compression boots on your lower legs. These gently inflate and deflate to help blood flow in your legs.

Once you’re comfortable, your anesthesiologist will give you anesthesia through your IV line and you’ll fall asleep. You’ll also get fluids through your IV line during and after your surgery.

During your surgery

After you’re fully asleep, your care team will place a breathing tube through your mouth into your airway. It will help you breathe. They’ll also place a urinary (Foley) catheter in your bladder. It will drain your urine (pee) during your surgery.

Once they finish your surgery, your surgeon will close your incisions with stitches, staples, Steri-Strips^™ (thin pieces of surgical tape) or Dermabond^® (surgical glue). They may also cover your incisions with a bandage.

Your care team will usually take out your breathing tube while you’re still in the operating room.

After your APR surgery

This section will help you know what to expect after your surgery. You’ll learn how to safely recover from your surgery both in the hospital and at home.

As you read this section, write down questions to ask your healthcare provider.

In the Post-Anesthesia Care Unit (PACU)

You’ll be in the PACU when you wake up after your surgery. A nurse will be keeping track of your temperature, pulse, blood pressure, and oxygen levels. You may get oxygen through a tube resting below your nose or a mask over your nose and mouth. You’ll also have compression boots on your lower legs.

Pain medicine

You’ll get medicine to control your pain and keep you comfortable. There are different ways pain medicine can be given:

• Epidural catheter: Some people get pain medicine through an epidural catheter (thin, flexible tube in their spine).
• Nerve block: Some people get a nerve block before or during surgery. With a nerve block, your healthcare provider injects medicine into some of your nerves to reduce pain after surgery.
• IV medicine: Some people get pain medicine into a vein through their IV line.

You’ll have 1 or more of these after your surgery. They’re all effective ways to control your pain. Your healthcare provider will talk with you before choosing the best one(s) for you.

Tubes and drains

You’ll have 1 or more of the tubes and drains below. Your healthcare providers will talk with you about what to expect.

• You’ll have a Foley catheter in your urethra going into your bladder. This tube drains urine from your bladder so your care team can keep track of how much urine you’re making.
• You’ll have 1 or 2 drains in your lower abdomen. These drain extra fluid from the area. They’re usually removed after a few days. If you’ll go home with a drain, your nurse will show you how to care for it.

Moving to your hospital room

You’ll stay in the PACU until you’re awake and your pain is under control. Most people move to their hospital room after a few hours in the PACU, but some people stay in the PACU overnight for observation.

After your stay in the PACU, a staff member will take you to your hospital room.

In your hospital room

The length of time you’re in the hospital after your surgery depends on your recovery and the exact surgery you had. Your care team will tell you what to expect.

In your hospital room, you’ll meet one of the nurses who will care for you during your stay. A nurse will help you out of bed and into your chair soon after you get there.

Your care team will teach you how to care for yourself while you’re healing from your surgery. You can help yourself recover more quickly by:

• Reading your recovery pathway. We will give you a pathway with goals for your recovery if you do not already have one. It will help you know what to do and expect on each day during your recovery.
• Starting to move around as soon as you can. The sooner you get out of bed and walk, the quicker you can get back to your usual activities.

You can use your MyMSK Goals to Discharge Checklist to track your progress during your recovery. To learn more, read Frequently Asked Questions About the MyMSK Goals to Discharge Checklist (www.mskcc.org/pe/goals_discharge_checklist).

Read Call! Don't Fall! (www.mskcc.org/pe/call_dont_fall) to learn what you can do to stay safe and keep from falling while you’re in the hospital.

Managing your pain

You’ll have some pain after your surgery. At first, you’ll get your pain medicine through an epidural catheter, nerve block, or IV line. Once you can swallow liquids, you’ll get oral pain medicine (pain medicine you swallow).

Your healthcare providers will ask you about your pain often and give you medicine as needed. If your pain isn’t relieved, tell one of your healthcare providers. It’s important to control your pain so you can cough, breathe deeply, use your incentive spirometer, and move around. Controlling your pain will help you recover better.

Many people find their pain is controlled with over-the-counter medicines alone. If you need stronger pain medicine in the hospital, one of your healthcare providers will give you a prescription before you leave. Talk with your healthcare providers about possible side effects and how to taper (slowly stop taking) your medicine.

Moving around and walking

Moving around and walking will help lower your risk for blood clots and pneumonia (lung infection). It will also help you start passing gas and having stool (poop) in your ostomy pouch.

Read your recovery pathway to learn about your specific moving and walking goals. Your nurse, physical therapist, or occupational therapist will help you move around, if needed.

To learn more about how walking can help you recover, read Frequently Asked Questions About Walking After Your Surgery (www.mskcc.org/pe/walking_after_surgery).

Exercising your lungs

It’s important to exercise your lungs so they expand fully. This helps prevent pneumonia.

• Your nurse will give you an incentive spirometer. Use it 10 times every hour you’re awake. Read How To Use Your Incentive Spirometer (www.mskcc.org/pe/incentive_spirometer) to learn more.
• Do coughing and deep breathing exercises. A member of your care team will teach you how to do them.

Eating and drinking

Most people can start eating solid foods again on the day after their surgery. Your healthcare provider will tell you if you need to wait longer. Read your pathway and talk with your care team for more information.

Your healthcare provider will give you dietary guidelines to follow after your surgery. A clinical dietitian nutritionist will visit you in your hospital room to go over these guidelines with you before you leave the hospital.

Caring for your incisions

Your care team will check your incisions daily. Keep your incisions clean and dry. You may notice small amounts of light pink fluid leaking from your perineal area. This is normal. You can wear Depends^® or another type of shield to protect your clothing from stains.

For several weeks after your surgery, there will be restrictions on how you sit, lie down, and do some of your daily activities. You will not be able to sit for long periods of time and you’ll need to sleep on your side. Your healthcare providers will go over these restrictions with you.

Caring for your colostomy stoma

Your nurses, WOC nurse, or both will check your stoma every day. You’ll have a pouch in place to collect the stool that comes out of your stoma.

Your WOC nurse will visit you in your hospital room to teach you how to care for your colostomy. To learn more, read Caring for Your Ileostomy or Colostomy (www.mskcc.org/pe/caring_ileostomy_colostomy).

Leaving the hospital

By the time you’re ready to leave the hospital, your incisions will have started to heal. Before you leave, look at your incisions with one of your healthcare providers. Knowing what they look like will help you notice any changes later.

On the day of your discharge, plan to leave the hospital between 8 a.m. and 11 a.m. Before you leave, one of your healthcare providers will write your discharge order and prescriptions. You’ll also get written discharge instructions. One of your healthcare providers will review them with you before you leave.

If your ride isn’t at the hospital when you’re ready to be discharged, you may be able to wait in the Patient Transition Lounge. A member of your care team will give you more information.

At home

Read What You Can Do to Avoid Falling (www.mskcc.org/pe/avoid_falling) to learn what you can do to keep from falling at home and during your appointments at MSK.

Filling out your Recovery Tracker

We want to know how you’re feeling after you leave the hospital. To help us care for you, we’ll send questions to your MyMSK account. We’ll send them every day for 10 days after you’re discharged. These questions are known as your Recovery Tracker.

Fill out your Recovery Tracker every day before midnight (12 a.m.). It only takes 2 to 3 minutes to complete. Your answers to these questions will help us understand how you’re feeling and what you need.

Based on your answers, we may reach out to you for more information. Sometimes, we may ask you to call your surgeon’s office. You can always contact your surgeon’s office if you have any questions.

To learn more, read About Your Recovery Tracker (www.mskcc.org/pe/recovery_tracker).

Managing your pain

People have pain or discomfort for different lengths of time. You may still have some pain when you go home and will probably be taking pain medicine. Some people have soreness, tightness, or muscle aches around their incisions as they recover. This doesn’t mean that something is wrong. If it doesn’t get better, contact your healthcare provider.

Follow these guidelines to help manage your pain at home.

• Take your medicines as directed and as needed.
• Call your healthcare provider if the medicine prescribed for you does not help your pain.
• Do not drive or drink alcohol while you’re taking prescription pain medicine. Some prescription pain medicines can make you drowsy (very sleepy). Alcohol can make the drowsiness worse.
• You’ll have less pain and need less pain medicine as your incision heals. An over-the-counter pain reliever will help with aches and discomfort. Acetaminophen (Tylenol^®) and ibuprofen (Advil or Motrin) are examples of over-the-counter pain relievers.
  • Follow your healthcare provider’s instructions for stopping your prescription pain medicine.
  • Do not take too much of any medicine. Follow the instructions on the label or from your healthcare provider.
  • Read the labels on all the medicines you’re taking. This is very important if you’re taking acetaminophen. Acetaminophen is an ingredient in many over-the-counter and prescription medicines. Taking too much can harm your liver. Do not take more than one medicine that has acetaminophen without talking with a member of your care team.
• Pain medicine should help you get back to your usual activities. Take enough to do your activities and exercises comfortably. You may have a little more pain as you start to be more active.
• Keep track of when you take your pain medicine. It works best 30 to 45 minutes after you take it. Taking it when you first have pain is better than waiting for the pain to get worse.

Some prescription pain medicines, such as opioids, may cause constipation. Constipation is when you poop less often than usual, have a harder time pooping, or both.

Preventing and managing constipation

Talk with your healthcare provider about how to prevent and manage constipation. You can also follow the guidelines below.

• Exercise, if you can. Walking is an excellent form of exercise.
• Drink 8 to 10 (8-ounce) cups (2 liters) of liquids daily, if you can.
  • Choose liquids such as water, juices (such as prune juice), soups, and ice cream shakes.
  • Avoid liquids with caffeine, such as coffee and soda. Caffeine can pull fluid out of your body.
• Both over-the-counter and prescription medicines are available to treat constipation. Talk with your healthcare provider about which one is best for you.

If you have questions about constipation, contact your healthcare provider.

Caring for your incisions

• Redness
• Swelling
• Increased pain
• Warmth at the incision site
• Foul-smelling or pus-like drainage from your incision
• A fever of 100.5 °F (38 °C) or higher

To keep from getting an infection, don’t let anyone touch your incisions. Clean your hands with soap and water or an alcohol-based hand sanitizer before you touch your incisions.

Abdominal incisions

If you go home with staples or sutures in your incisions, your healthcare provider will take them out during one of your appointments after surgery. It’s okay to get them wet. If you go home with Steri-Strips or Dermabond on your incisions, they’ll loosen and peel off by themselves. If they haven’t come off after about 14 days, you can take them off.

Perineal incision

The sutures in your perineal incision will either dissolve over time or need to be taken out. Your healthcare provider will tell you if they need to be taken out.

The time it takes the perineal area to heal is different from person to person. It usually takes about 3 months. Your discomfort will decrease over time.

Showering

Shower every day. Taking a warm shower is relaxing and can help ease muscle aches. You’ll also clean your incision when you shower.

Take off your bandages before you shower. Gently wash your incisions with a fragrance-free, liquid soap. Don’t scrub or use a washcloth on your incisions. This could irritate them and keep them from healing.

When you’re finished with your shower, gently pat your incisions with a clean towel. Let them air dry completely before getting dressed. If there’s no drainage, leave your incisions uncovered.

Don’t take tub baths or go swimming until your healthcare provider says it’s OK.

Eating and drinking

Follow the instructions in Diet Guidelines for People With a Colostomy (www.mskcc.org/pe/diet_colostomy). If you need to reach a clinical dietitian nutritionist after you go home, call 212-639-7312.

Physical activity and exercise

When you leave the hospital, your incisions may look like they’re healed on the outside, but they will not be healed on the inside. For the first 6 weeks after your surgery:

• Don’t lift, push, or pull anything heavier than 10 pounds (about 4.5 kilograms).
• Don’t do any strenuous activities (such as jogging and tennis).
• Don’t play any contact sports (such as football).

Walking is a good way to increase your endurance. You can walk outside or indoors at your local mall or shopping center. You can also climb stairs, but try to limit how often you do this for the first week you’re home. Don’t go out by yourself until you’re sure of what you can do.

It’s common to have less energy than usual after surgery. Recovery time is different for everyone. Do more activity each day as much as you can. Always balance activity periods with rest periods. But if you can’t sleep at night, it may be a sign you’re resting too much during the day.

Driving

Driving may cause discomfort while you’re healing because you use your abdominal muscles (abs) when you brake. Ask your healthcare provider when you can drive. Don’t drive while you’re taking pain medicine that may make you drowsy.

You can ride in a car as a passenger at any time after you leave the hospital.

Sexual activity

Your healthcare provider will tell you when you can start having sexual activity.

The nerves that control sexual function are in your pelvis. You may worry they’ll be damaged after your surgery. Surgeons at MSK have special training to lower this risk. Only a small number of people have changes in sexual function after their surgery. If you have any concerns about sexual function, talk with your healthcare provider.

Changes in urinary function

The nerves that control urination are also in your pelvis. There’s a small chance you may have changes in urinary function after your surgery. Your surgeon will do everything they can to protect these nerves. Even so, a small number of people lose urinary control for a short time after surgery.

If this happens to you, you may need to use a catheter for a longer time after your surgery. Permanent loss of urinary control is uncommon. Your surgeon will talk with you about this risk. You can also speak to your other healthcare providers.

Going back to work

Talk with your healthcare provider about your job. They’ll tell you when it may be safe for you to start working again based on what you do. If you move around a lot or lift heavy objects, you may need to stay out a little longer. If you sit at a desk, you may be able to go back sooner.

Getting your test results

After your surgery, the tumor and the tissue around it will be sent to a pathologist. Your test results will be ready about 7 business days after your surgery. Your surgeon will talk with you about the results of the tests and whether they recommend any additional treatments.

Follow-up appointments

Your first appointment after your surgery will be 1 to 3 weeks after you leave the hospital. Call your surgeon’s office to schedule it after you’re discharged.

It’s important to go to all your follow-up appointments after your surgery. You can call your healthcare provider if you have questions between these appointments.

Managing your feelings

You may have new and upsetting feelings after a surgery for a serious illness. Many people say they felt weepy, sad, worried, nervous, irritable, or angry at one time or another. You may find that you cannot control some of these feelings. If this happens, it’s a good idea to seek emotional support. Your healthcare provider can refer you to MSK’s Counseling Center. You can also reach them by calling 646-888-0200.

The first step in coping is to talk about how you feel. Family and friends can help. We can also reassure, support, and guide you. It’s always a good idea to let us know how you, your family, and your friends are feeling emotionally. Many resources are available to you and your family. We’re here to help you and your family and friends handle the emotional aspects of your illness. We can help no matter if you’re in the hospital or at home.

When to call your healthcare provider

Call your healthcare provider if:

• You have a fever of 100.5 °F (38 °C) or higher.
• You have pain in your abdomen, nausea, and vomiting.
• There’s no stool in your pouch for 3 days.
• You have any of the following signs of infection in your incision:
• Redness
• Swelling
• Increased pain
• Warmth at the incision site
• Foul-smelling or pus-like drainage
• You have trouble urinating (peeing).
• You have pain at your incision that is not eased by pain medicine.
• You have any questions or concerns.

Contact information

Monday through Friday from 9 a.m. to 5 p.m., call your healthcare provider’s office.

After 5 p.m., during the weekend, and on holidays, call 212-639-2000. Ask to speak to the person on call for your healthcare provider.

Support services

This section has a list of support services. They may help you as you get ready for your surgery and recover after your surgery.

As you read this section, write down questions to ask your healthcare provider.

Ostomy support services

The Ostomy Association
www.ostomy.org

Wound Ostomy Continence Organization
www.wocn.org
Go to this website to find a CWOCN in your area. The website also has information on resources, suppliers of ostomy products, and support groups.

MSK support services

Admitting Office
212-639-7606
Call if you have questions about your hospital admission, such as asking for a private room.

Anesthesia
212-639-6840
Call if you have questions about anesthesia.

Blood Donor Room
212-639-7643
Call for information if you’re interested in donating blood or platelets.

Bobst International Center
332-699-7968
We welcome patients from around the world and offer many services to help. If you’re an international patient, call for help arranging your care.

Counseling Center
www.msk.org/counseling
646-888-0200
Many people find that counseling helps them. Our Counseling Center offers counseling for individuals, couples, families, and groups. We can also prescribe medicine to help if you feel anxious or depressed. Ask a member of your care team for a referral or call the number above to make an appointment.

Food Pantry Program
646-888-8055
We give food to people in need during their cancer treatment. Talk with a member of your care team or call the number above to learn more.

Integrative Medicine Service
www.msk.org/integrativemedicine
Our Integrative Medicine Service offers many services to complement (go along with) traditional medical care. For example, we offer music therapy, mind/body therapies, dance and movement therapy, yoga, and touch therapy. Call 646-449-1010 to make an appointment for these services.

You can also schedule a consultation with a healthcare provider in the Integrative Medicine Service. They’ll work with you to make a plan for creating a healthy lifestyle and managing side effects. Call 646-608-8550 to make an appointment for a consultation.

MSK Library
library.mskcc.org
212-639-7439
You can visit our library website or call to talk with the library reference staff. They can help you find more information about a type of cancer. You can also visit the library’s Patient and Health Care Consumer Education Guide.

Nutrition Services
www.msk.org/nutrition
212-639-7312
Our Nutrition Service offers nutritional counseling with one of our clinical dietitian nutritionists. Your clinical dietitian nutritionist will talk with you about your eating habits. They can also give advice on what to eat during and after treatment. Ask a member of your care team for a referral or call the number above to make an appointment.

Patient and Community Education
www.msk.org/pe
Visit our patient and community education website to search for educational resources, videos, and online programs.

Patient Billing
646-227-3378
Call if you have questions about preauthorization with your insurance company. This is also called preapproval.

Patient Representative Office
212-639-7202
Call if you have questions about the Health Care Proxy form or concerns about your care.

Perioperative Nurse Liaison
212-639-5935
Call if you have questions about MSK releasing any information while you’re having surgery.

Private Duty Nurses and Companions
917-862-6373
You can request private nurses or companions to care for you in the hospital and at home. Call to learn more.

Rehabilitation Services
www.msk.org/rehabilitation 
Cancers and cancer treatments can make your body feel weak, stiff, or tight. Some can cause lymphedema (swelling). Our physiatrists (rehabilitation medicine doctors), occupational therapists (OTs), and physical therapists (PTs) can help you get back to your usual activities.

• Rehabilitation medicine doctors diagnose and treat problems that affect how you move and do activities. They can design and help coordinate your rehabilitation therapy program, either at MSK or somewhere closer to home. Call Rehabilitation Medicine (Physiatry) at 646-888-1929 to learn more.
• An OT can help if you’re having trouble doing usual daily activities. For example, they can recommend tools to help make daily tasks easier. A PT can teach you exercises to help build strength and flexibility. Call Rehabilitation Therapy at 646-888-1900 to learn more.

Resources for Life After Cancer (RLAC) Program
646-888-8106
At MSK, care does not end after your treatment. The RLAC Program is for patients and their families who have finished treatment.

This program has many services. We offer seminars, workshops, support groups, and counseling on life after treatment. We can also help with insurance and employment issues.

Sexual Health Programs
Cancer and cancer treatments can affect your sexual health, fertility, or both. MSK’s sexual health programs can help you before, during, or after your treatment.

• Our Female Sexual Medicine and Women’s Health Program can help with sexual health problems such as premature menopause or fertility issues. Ask a member of your MSK care team for a referral or call 646-888-5076 to learn more.
• Our Male Sexual and Reproductive Medicine Program can help with sexual health problems such as erectile dysfunction (ED). Ask a member of your care team for a referral or call 646-888-6024 to learn more.

Social Work
www.msk.org/socialwork
212-639-7020
Social workers help patients, families, and friends deal with common issues for people who have cancer. They provide individual counseling and support groups throughout your treatment. They can help you communicate with children and other family members.

Our social workers can also help refer you to community agencies and programs. If you’re having trouble paying your bills, they also have information about financial resources. Call the number above to learn more.

Spiritual Care
212-639-5982
Our chaplains (spiritual counselors) are available to listen, help support family members, and pray. They can contact community clergy or faith groups, or simply be a comforting companion and a spiritual presence. Anyone can ask for spiritual support. You do not have to have a religious affiliation (connection to a religion).

MSK’s interfaith chapel is located near Memorial Hospital’s main lobby. It’s open 24 hours a day. If you have an emergency, call 212-639-2000. Ask for the chaplain on call.

Tobacco Treatment Program
www.msk.org/tobacco
212-610-0507
If you want to quit smoking, MSK has specialists who can help. Call to learn more.

Virtual Programs
www.msk.org/vp
We offer online education and support for patients and caregivers. These are live sessions where you can talk or just listen. You can learn about your diagnosis, what to expect during treatment, and how to prepare for your cancer care.

Sessions are private, free, and led by experts. Visit our website to learn more about Virtual Programs or to register.

External support services

Access-A-Ride
web.mta.info/nyct/paratran/guide.htm
877-337-2017
In New York City, the MTA offers a shared ride, door-to-door service for people with disabilities who can’t take the public bus or subway.

Air Charity Network
www.aircharitynetwork.org
877-621-7177
Provides travel to treatment centers.

American Cancer Society (ACS)
www.cancer.org
800-ACS-2345 (800-227-2345)
Offers a variety of information and services, including Hope Lodge, a free place for patients and caregivers to stay during cancer treatment.

Cancer and Careers
www.cancerandcareers.org
646-929-8032
A resource for education, tools, and events for employees with cancer.

CancerCare
www.cancercare.org
800-813-4673
275 Seventh Avenue (Between West 25^th & 26^th Streets)
New York, NY 10001
Provides counseling, support groups, educational workshops, publications, and financial assistance.

Cancer Support Community
www.cancersupportcommunity.org
Provides support and education to people affected by cancer.

Caregiver Action Network
www.caregiveraction.org
800-896-3650
Provides education and support for people who care for loved ones with a chronic illness or disability.

Corporate Angel Network
www.corpangelnetwork.org
866-328-1313
Offers free travel to treatment across the country using empty seats on corporate jets.

Good Days
www.mygooddays.org
877-968-7233
Offers financial assistance to pay for copayments during treatment. Patients must have medical insurance, meet the income criteria, and be prescribed medicine that’s part of the Good Days formulary.

HealthWell Foundation
www.healthwellfoundation.org
800-675-8416
Provides financial assistance to cover copayments, health care premiums, and deductibles for certain medicines and therapies.

Joe’s House
www.joeshouse.org
877-563-7468
Provides a list of places to stay near treatment centers for people with cancer and their families.

LGBT Cancer Project
www.lgbtcancer.com
Provides support and advocacy for the LGBT community, including online support groups and a database of LGBT-friendly clinical trials.

LIVESTRONG Fertility
www.livestrong.org/we-can-help/fertility-services
855-744-7777
Provides reproductive information and support to cancer patients and survivors whose medical treatments have risks associated with infertility.

Look Good Feel Better Program
www.lookgoodfeelbetter.org
800-395-LOOK (800-395-5665)
This program offers workshops to learn things you can do to help you feel better about your appearance. For more information or to sign up for a workshop, call the number above or visit the program’s website.

National Cancer Institute
www.cancer.gov
800-4-CANCER (800-422-6237)

National LGBT Cancer Network
www.cancer-network.org
Provides education, training, and advocacy for LGBT cancer survivors and those at risk.

Needy Meds
www.needymeds.org
Lists Patient Assistance Programs for brand and generic name medicines.

NYRx
www.health.ny.gov/health_care/medicaid/program/pharmacy.htm
Provides prescription benefits to eligible employees and retirees of public sector employers in New York State.

Patient Access Network (PAN) Foundation
www.panfoundation.org
866-316-7263
Gives help with copayments for patients with insurance.

Patient Advocate Foundation
www.patientadvocate.org
800-532-5274
Provides access to care, financial assistance, insurance assistance, job retention assistance, and access to the national underinsured resource directory.

Professional Prescription Advice
www.pparx.org
888-477-2669
Helps qualifying patients without prescription drug coverage get free or low-cost medicines.

Red Door Community (formerly known as Gilda’s Club)
www.reddoorcommunity.org
212-647-9700
A place where people living with cancer find social and emotional support through networking, workshops, lectures, and social activities.

RxHope
www.rxhope.com
877-267-0517
Provides assistance to help people get medicines they have trouble affording.

Triage Cancer
www.triagecancer.org
Provides legal, medical, and financial information and resources for cancer patients and their caregivers.

Educational resources

This section lists the educational resources mentioned in this guide. They will help you get ready for your surgery and recover after your surgery.

As you read these resources, write down questions to ask your healthcare provider.

• Call! Don't Fall! (www.mskcc.org/pe/call_dont_fall)
• Caring for Your Ileostomy or Colostomy (www.mskcc.org/pe/caring_ileostomy_colostomy)
• How To Check if a Medicine or Supplement Has Aspirin, Other NSAIDs, Vitamin E, or Fish Oil (www.mskcc.org/pe/check-med-supplement)
• Herbal Remedies and Cancer Treatment (www.mskcc.org/pe/herbal_remedies)
• How to Be a Health Care Agent (www.mskcc.org/pe/health_care_agent)
• How to Enroll in MyMSK: Memorial Sloan Kettering's Patient Portal (www.mskcc.org/pe/enroll_mymsk)
• How To Use Your Incentive Spirometer (www.mskcc.org/pe/incentive_spirometer)
• Frequently Asked Questions About the MyMSK Goals to Discharge Checklist (www.mskcc.org/pe/goals_discharge_checklist)
• Liquid Intake and Ostomy Output Log (www.mskcc.org/pe/intake_output_log)
• What You Can Do to Avoid Falling (www.mskcc.org/pe/avoid_falling)