Nursing care of patients operated-on for CRC Tsilimigra Despoina, RN, Msc, Iaso General Horpital

Colorectal cancer Colorectal cancer (CRC) is the second most common cause of cancer death in Europe and has wide variation in outcomes among countries. Increasing numbers of older people are contracting the disease, and treatments for advanced stages are becoming more complex. A growing number of survivors also require specialist support

Screening Colonoscopy Sigmoidoscopy Computed tomography (CT) Biopsy and imaging/pathology reports confirm a diagnosis and the stage of the disease − like most cancers, CRC is categorized into four clinical stages according to Union for International Cancer Control(UICC) classification, from localized to the lining of the colon (stage 1) to spread to other organs (stage 4), or metastatic disease.

Symptoms lead to diagnosis Change in bowel habit Anaemia Fatigue Rectal bleeding and an abdominal mass. As most patients are asymptomatic, screening is of great importance.

Essential aspects of the nursing role Have a insight into each patient’s experience of their disease, treatment and side-effects. Provide information and education to the patient and family Be the point of contact for them- act as case managers. Act in the best interest of the patient and their family to help coordinate the diagnosis, treatment and after-care of a person with CRC Represent the patient’s psychosocial needs and preferences within the MDT. ECCO Essential Requirements for Quality Cancer Care: Colorectal Cancer

Patient’s concerns Worry, anxiety or fear Information needs Fatigue Constipation or diarrhea Making plans Pain Sleep problems Tingling on hands and feet Quality of Life of colorectal cancer survivors in England (2015)

Nursing interventions which decrease worry Informed consent prior to treatment Assessment of need Adequate information & explanation Symptom management Post-treatment monitoring –supported self- management 10TH ESO-EONS MASTERCLASS IN ONCOLOGY NURSING

Preoperative nursing interventions Evaluate health status Preparation before surgery Inform Educate

Postoperative surgical complications Surgical site infection (SSI) 2-25% BMI ≥ 30, creation/revision/reversal of an ostomy perioperative transfusion, male gender ASA Score ≥ III wound contamination Kirchhoff et al. Patient Safety in Surgery 2010

Postoperative surgical complications Anastomotic leakage 2.9- 15.3% At least one third of the mortality after colorectal surgery is attributed to leaks. Risk factors: male gender (OR = 3.5). previous abdominal surgery (OR = 2.4). Crohn’s disease (OR = 3.3). rectal cancer < or = 12 cm from the anal verge (OR = 5.4) . prolonged operating time (P = 0.05 as a continuous variable and P = 0.01 when prolonged operative time was >120 min). Kirchhoff et al. Patient Safety in Surgery 2010

Postoperative surgical complications Postoperative bleeding is a rare complication, the risk depends on the performed surgical procedure, the co-morbidities of the patient and in individual cases on an impaired clotting system Ileus It prolongs hospital stay, increases morbidity, and adds to treatment costs. The pathophysiology of postoperative ileus is multifactorial. The operating time and intraoperative blood loss are independent risk factors for a postoperative ileus . Kirchhoff et al. Patient Safety in Surgery 2010

Top physical needs after treatment Time from surgery* Ranked concerns 3 months 9 months 15 months 24 months 1 Urinary frequency (48%) Impotence(51%) Impotence (47%) Impotence (45%) 2 Urinary frequency (37%) Urinary frequency (32%) Urinary frequency (34%) 3 Fatigue (38%) Fatigue (33%) Stool frequency (24%) Fatigue (24%) 4 Insomnia (26%) Stool frequency (26%) Fatigue (23%) Stool frequency (22%) 5 Stool frequency (25%) Flatulence (23%) Flatulence (22%) Flatulence (20%) Data from ColoREctal Wellbeing (CREW) cohort study

Monitoring Continuing pain that does not go away with usual painkillers, or is severe, or is persistent more than 2 weeks. Unexplained lumps, bumps, or swellings around your scar or stoma Unexplained change in normal bowel habit -especially if you are waking up in the night with loose stools. Unexplained loss of appetite, weight loss or increasing abdominal girth. Any new and unexplained bleeding from your back passage or from your stoma, or in your urine. Unexplained shortness of breath or cough which lasts for more than a few weeks. Bleeding or discharge from your wound site.

Multidisciplinary team Establishing MDTs for colorectal cancer care can lead to more complete preoperative evaluation and higher rates of access to multimodal therapies. MDTs can improve the quality of pathology reports, provide suitable recommendations for adjuvant chemotherapy, and increase overall survival in patients with colorectal cancer.