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Date: May 2022 

Review: May 2024

Ref: A-107 v4

PDF:  Liver surgery for HCC primary liver cancer final April 2022 v3[pdf] 519KB

Introduction

On the advice of your surgeon, you are coming into hospital for an operation on your liver. Specifically, this booklet is about surgical removal of primary liver tumours.

We appreciate that life may feel like an emotional roller coaster at the moment. You may have many questions and anxieties regarding the operation, your hospital stay, and financial concerns.

This booklet has been prepared to address many of these questions and more. It will hopefully supplement the information given to you by your doctors, ward nurses and specialist nurses. It may not cover all your concerns so if you have any other questions or worries after reading this booklet, please don’t hesitate to contact one of the staff listed on the last page.

This booklet is also meant for your relatives and close friends, to answer their questions and concerns, and to help them understand the treatment you will be undergoing.

Primary Liver Cancer

Primary liver cancer is quite rare in the UK and the rest of the western world, but the number of people developing it is increasing.

The most common kind of primary liver cancer is called Hepatoma or Hepatocellular Carcinoma (HCC) and arises from the main cells of the liver (the hepatocytes). This type is usually confined to the liver, although occasionally it spreads to other organs. There is also a rarer sub-type of hepatoma called Fibrolamellar hepatoma, which may occur in younger people and is not related to previous liver disease.

Causes of Primary Liver Cancer

In the western world, most people who develop hepatoma usually also have a condition called cirrhosis of the liver. This is a fine scarring throughout the liver which is due to a variety of causes. However, only a small proportion of people who have cirrhosis of the liver develop primary liver cancer.

Infection with either hepatitis B or hepatitis C virus can lead to liver cancer, and can also be the cause of cirrhosis, which increases the risk of developing hepatoma.

People who have a rare condition called haemochromatosis, which causes excess deposits of iron in the body, have a higher chance of developing hepatoma.

Signs and symptoms

In the early stages of primary liver cancer there are often no symptoms.

People sometimes notice a vague discomfort in the upper abdomen that may become painful. This is due to enlargement of the liver. Pain can sometimes also be felt in the right shoulder. This is known as referred pain and is due to an enlarged liver stimulating the nerves beneath the diaphragm which are connected to nerves in the right shoulder.

Loss of appetite, weight loss, feeling sick and weakness and tiredness are common symptoms. Some people may also develop a high temperature and feel shivery.

Jaundice If the bile duct becomes blocked, bile produced by the liver will flow back into the bloodstream, causing jaundice. This will cause the skin and whites of the eyes to go yellow and may make the skin very itchy. The itching may sometimes be relieved by antihistamine tablets or other drugs, which your doctor can prescribe. Sometimes the jaundice itself can be relieved. This is done by inserting a narrow tube called a stent into the bile duct to keep it open and to allow the bile to flow normally into the intestine.

Other signs of jaundice are dark-coloured urine and pale stools (bowel motions).

Treatment

Your plan of treatment will take into account a number of factors:

• If the cancer is a primary or secondary liver cancer

• Your general health

• The type, size, and number of tumours

• If it has spread beyond the liver

• If the liver is affected by any other disease, such as cirrhosis

The available treatment options for primary liver cancer are: Liver Transplant, Liver surgery, Chemoembolisation, Microwave Ablation, SABR and Systemic Therapies.

Liver surgery

Surgery is the most effective treatment for primary liver cancer, but this is not always possible due to the size, position and/or number of tumours. It is also not possible to operate if the cancer has spread beyond the liver.

If only certain areas of the liver are affected by the cancer and the rest of the liver is healthy, it may be possible to have an operation to remove the affected part: this is called a liver resection. If the liver is severely damaged by cirrhosis it may not be safe to have surgery.

The liver has a unique ability to repair itself. Even if up to three-quarters of the liver is removed it will start to re-grow very quickly and may be back to near normal size within a few weeks.

Portal Vein Embolisation

Portal Vein Embolization (PVE) is a procedure which is carried out in the Radiology department. It assists with the treatment of cancer of the liver. PVE is carried out when the liver cancer is suitable for surgical removal, but the remaining liver would be too small to work well afterwards. It can be done 4 to 5 weeks before the operation.

PVE works by blocking the blood flow to the affected part of the liver from the bowel ( portal venous flow). The blood flow from the bowel to the liver is then redirected to the healthy part of the liver, which is expected to stay after surgery. The aim of this procedure is to shrink the part of the liver affected with cancer, whilst allowing the remaining healthy liver to grow bigger.

Staged liver surgery

Sometime if the healthy part of the liver that is going to remain after surgery is not big enough the surgeon might offer you a two-step operation called ALPPS procedure (associated liver partitioning and portal vein ligation for staged liver surgery).

In the first stage, your surgeon will tie off a branch of the portal vein that supplies the section of the liver to be removed.

The liver will be divided completely, in preparation for removal, however the surgeon will not remove this part. Instead, the affected part of the liver will be left in place and still supplied with blood from the hepatic artery. This means it will still be able to work.

The blood flow from the portal vein is then increased to the healthy part of the liver, which enables it to grow.

The second stage of ALLPS is usually carried out 6-10 days after stage one. This stage involves removing the affected part of the liver. You will need a general anaesthetic for both stages and will normally stay in hospital between both operations.

Liver Transplant

Removing the whole liver and replacing it with a liver from another person (liver transplant) is another possible form of treatment for primary liver cancer but can only be done in a very few cases when the tumour is small.

Chemoembolisation

Chemoembolisation is a specialised procedure in which powerful anti-tumour drugs are delivered directly to the growth by means of the blood vessels (arteries) supplying it. The aim of the procedure is to reduce the size and symptoms from growths within liver. This treatment can be repeated several times. It is carried out in the x-ray department and usually needs a stay in hospital of 24-48 hours. This is a relatively safe procedure but does have risks associated with it. This treatment is not curative and can also be used to downsize tumours prior to other treatments.

Laparoscopic Microwave Ablation(MWA)

Microwave ablation(MWA) destroys liver tumours using heat generated by microwave energy. A thin microwave antenna needle is placed into the tumour under ultrasound or CT guidance, is done under a general anaesthetic and sometimes laparoscopically in a theatre. The microwave antenna generates heat which destroys(ablates) a carefully calculated zone of tissue that includes the tumour cells and a small margin of normal liver around the tumour. Once the antenna is in place, the ablation usually takes less than 10 minutes.  A biopsy (obtaining a small sample of abnormal cells) may be performed immediately prior to the ablation. A hospital stay of 24-48 hours is usually required after this procedure.

Stereotactic ablative radiotherapy (SABR)

This is a type of external radiotherapy that uses high energy rays, such as x-rays to treat cancer. It destroys cancel cells in the area where the radiotherapy is given. It aims to stop the cancer cells growing and either shrink the tumour or completely destroy it. It is usually given over 10 days, 5 fractions in total delivered every other day.

Systemic Therapies

Systemic therapies are the use of anti-cancer growth blocker drugs to destroy cancer cells known as targeted therapies. These are sometimes used to treat primary liver cancers that cannot be removed or other treatment options have not been successful. This group of drugs can help prolong survival in some patients. This option is evolving rapidly as new drugs are developed. Your Specialist Nurse will go through possible treatment side affects.

When is surgery an option?

Liver surgery is a major undertaking and for some patients with other health problems the risks may be too high, so that one of the other options may be more suitable. It is important that you discuss any questions you may have with your doctor either in the outpatient clinic prior to admission or when the doctors see you on the ward before surgery.

People who you will meet

A Doctor (Surgeon): Will examine you and ask questions about your illness. He/she will explain the operation to you and ask you to sign a consent form. This indicates that you agree to the operation so make sure you have discussed it fully with the doctor and understand what is involved.

An Anaesthetist: Is the doctor responsible for your anaesthetic. He/she will ask you questions about your medical history, what drugs you are on and if you have any allergies. They will also discuss the types of pain control available.

Hepatology Nurse Specialist: She will be your key worker throughout your surgical experience and during your follow- up. She is available for advice and information about any queries you have about your surgical journey. She is the main means of communication between all parties involved.

Ward Nurses: Will show you around the ward on arrival, help you settle in, and will discuss factors regarding preparation for your operation. They will provide expert surgical nursing care during your hospital stay and will also facilitate your discharge home.

A Physiotherapist: If it is clinically indicated the Physio will teach you important deep breathing and coughing exercises, which you will be encouraged to do after your operation. These exercises will help your lungs re-expand and help prevent chest infections from occurring. Following the operation the physiotherapist can also help you mobilise out of bed and assist you with your walking, posture, and climbing stairs.  He/she will help you to become as fit as possible before going home.

A Dietitian: If it is clinically indicated a dietician can advise you on how to maintain a good dietary intake before and after your surgery.

Risks associated with your surgery

Giving your consent

Before you have any treatment, your doctor will explain the aims of the treatment to you and you will be asked to sign a form saying you give permission for the hospital staff to give you the treatment. No treatment can be given to you without your consent and before you are asked to sign you should have been given full information regarding the risks and benefits of the proposed treatment, plus possible alternatives.

Liver resection is a major undertaking, and it is important that you understand the risks before undergoing this operation. It is also important that family members are aware of the risks.

Serious complications can occur due to the injury to the liver. These include leakage of bile (a yellow liquid produced by the liver) into the abdomen and post-operative bleeding.  Bile leaks can usually be controlled by a drainage tube but a technique called ERCP may be necessary to encourage internal drainage of bile.

Bleeding after a liver resection is a rare problem which may require a second operation and the administration of blood products to promote blood clotting.

Blood transfusion during Liver surgery can be more common due to the blood loss during the operation.

Occasionally after removal of more than half of the liver a period of liver failure may occur. This sometimes causes a temporary period of jaundice (yellow discolouration of your skin, eyes and urine).

Minor complications are common and readily treated.  These include wound infections and infections in the chest and bladder which usually respond to antibiotics.

These complications are rarely serious or fatal.  However, like all major operations liver resection has a risk of death.

Risk to life

The majority of people recover fairly well from liver surgery and are ready for discharge from hospital within 4-7 days depending on the surgery. Most complications are relatively minor and just slow down your recovery a little, but some can be much more serious and may mean you stay in hospital for much longer than you expected.

There is a very small risk that a combination of some of the complications described above may lead to an extended hospital stay and might ultimately lead to you dying as a result of liver surgery.

If you are in reasonably good general health then the risk to your life is about 0-2%; put the other way round, your chances of surviving the operation are 98-100%.

What will happen if I don’t have the surgery?

Left untreated the cancer cells will continue to grow, and could possibly spread to other organs. It is therefore a potentially fatal disease. If you decide not to have the operation, it maybe possible to shrink the tumour by use of Chemoembolisation or Microwave ablation. If this the preferred option, size and location of the tumour would guide this option.

Pre-habilitation preparing for surgery

How can I prepare for the surgery?

Having major surgery such as a Liver surgery will put a lot of strain on your body, particularly on your heart and lungs. You will have a lot of tests to help assess whether you are able to have surgery, but there are some things that you can do to prepare yourself. The three important areas for you to work on are:

1. Stopping smoking and alcohol

2. Eating healthily

3. Exercising regularly

Stopping smoking

In addition to the general health risks associated with smoking, research has shown that smokers are more likely to suffer complications during and following surgery. There is evidence to suggest the following benefits if you stop smoking before surgery:

1. Reduced risk of heart and lung post-operative    complications

2. Faster wound-healing

3. Reduced length of stay in hospital

Even stopping smoking for three to four weeks before surgery will decrease your risk of getting complications. The longer before surgery you can stop the better. Help is available through the NHS so please talk to your GP or Specialist Nurse.

Stopping alcohol

If you drink a lot of alcohol, we recommend that you reduce the amount that you drink prior to your surgery. Alcohol can reduce the function of your heart and can affect your liver. It can also cause mild dehydration. However, reducing high alcohol intake suddenly when you come into hospital can also cause serious health problems, so it is better to cut down well in advance. Help is available through the NHS so please talk to your GP or Specialist Nurse.

Eating healthily

It is important that you are not malnourished when you have surgery. You may have lost weight because of a decreased appetite, jaundice, an inability to eat and/ or digestion problems resulting in pale loose stools. If this is the case, and if you are underweight, then we will help you with nutritional advice and provide dietary booklets to help you stabilise your weight and hopefully put weight back on prior to surgery. You may require supplement drinks, to help or referral for treatment if you are jaundiced as this can affect your appetite and energy levels. Specialist dietitian support is available prior to your surgery if required.

Exercising regularly

Keeping fit and active as much as possible before the Liver surgery will help your recovery afterwards. For example, walking 2-3 miles (on the flat/hill depending on your fitness level) every day will help keep your heart and lungs working well, and keep you in good condition ready for your operation. If this is not possible even walking up the stairs a couple of times a day and ‘getting out of breath’ can make a difference to your heart and lung function.

Respiratory (breathing) exercises

Respiratory exercises performed before and after surgery can help reduce the risk of lung problems by opening up your airways and moving phlegm. Respiratory exercises, coughing and walking after surgery can prevent post-operative chest infections and reduce your length of stay in hospital.

Practising respiratory exercises before your operation will make it easier to perform them afterwards. Here is a five-step guide to breathing exercises:

1. Sit upright in a supported chair.

2. Breathe in and out normally.

3. Take a slow deep breathe in so that your ribs expand      sideways, and your lungs fill up with air and then breathe out.

4. Take a slow deep breathe in and expand your lungs, hold that breathe for three seconds and then slowly breathe out.

5. Repeat three times.

If you feel dizzy or tired, return to breathing in and out normally.

Practice these respiratory exercises prior to surgery. After your operation you should do them every one to two hours.

Psychological wellbeing

We know that providing good quality personalised information for you and your relatives’ leads to reduced anxiety, improved patient experience and better surgical results. We aim to give you information and support during all stages of your surgical experience. Information is normally provided by your Surgeon, Specialist Nurses, ward nurses and the allied health professions. It is important for us to consider how you are thinking, feeling and coping with your diagnosis and treatment at all times. Everyone in the team will be open to discussing these aspects with you at any time. Hopefully you will get a lot of reassurance from speaking openly and feeling understood by your healthcare professionals. There is added psychological and counselling support in your local Cancer Centres. Please see section on Cancer Support Centres.

Preparing your return home

Before your operation, it’s a good idea to start thinking about transport arrangements and how you will manage at home after surgery, especially in the first few days and weeks. We encourage patients to have a relative stay with them for the first week or so after returning home if possible. If you live alone or require additional support then please speak to the Surgeon/ Specialist Nurse and/ or ward nurses. The sooner we know this, the sooner we can start arranging something for you with the Ward Discharge Team. Talk to your close family, friends and GP to see what options you have.

Enhanced Recovery Programme

We have developed an Enhanced Recovery After Surgery (ERAS) programme for the Whipple operation. This process aims to ensure that you are discharged as early and as safely as possible with the best possible outcome. You will be given leaflets before surgery about your role and recovery in hospital post-surgery. This will help you understand what to expect and when to expect it.

Hearts Together Hospital Hotel accommodation

For patients and relatives who have a long way to travel there are a number of local hotels including ‘Hearts Together Hospital Hotel’ formerly ‘The Lodge’. Hearts Together provides accommodation for relatives, friends and carers of patients undergoing treatments in University Hospitals Plymouth. The accommodation is of a very high standard at affordable prices. There are self-catering facilities and breakfast is provided. There is a small but excellent team who are both helpful and supportive. Hearts Together is within walking distance of Derriford Hospital (10 minutes) and a courtesy bus is provided for guests during the week at specified times. It is situated on the edge of a local nature reserve. Take a stroll through the gardens or relax on the balcony, taking in the beautiful views. Their telephone number is provided at the back of this booklet.

Cancer Support Centre: The Mustard Tree (Derriford Hospital)

If you are having the Whipple operation as a result of a cancer diagnosis and you or your family would like the opportunity to talk to someone about how you feel or just want a break from the usual routine we invite you to contact the Mustard Tree. The centre is available to anyone affected by cancer at any stage of the illness and offers a comfortable space where you can share your concerns, ask questions and receive support. It is staffed by professionals and trained volunteers many of whom have a personal experience of cancer.

The centre is open Mon–Fri 09.00–5.00 and is located on level 3 of University Hospitals Plymouth by the Royal Eye Infirmary entrance. Their telephone number is provided at the back of this booklet.

Other Cancer Support Centres in Devon and Cornwall if you are not local to Plymouth are as follows. Telephone numbers for these can be found via the Specialist Nurse or the Mustard Tree Cancer Support Centre[1]

Triangle Centres

Kingsbridge Hospital (Tue 10.00-4.00)

Liskeard Hospital (Thur 10.00-4.00)

Tavistock Clinic (Fri 10.00-4.00)

The Cove Treliske Hospital, Truro.

The Force Royal Devon and Exeter Hospital, Exeter.

The Lodge South Devon District Hospital, Torbay.

The Over and Above Fern Centre- North Devon District   Hospital (under construction).

Pre-assessment

Before your operation and anaesthetic we will need to know about your general health, any previous or current illnesses and your medication. You will have an appointment at our pre-assessment clinic where several members of the team will assess your health and prepare you for the operation and anaesthetic.

Healthcare Assistant

A healthcare assistant will measure your height, weight, blood pressure and may carry out an ECG (electronic tracing of your heart). They will also take bloods to check your iron levels and the function of your kidneys and liver. You will also have swabs taken to screen for MRSA (Methicillin Resistant Staphylococcus Aureus).

Nurse

The nurse will ask you a number of questions to assess your fitness for a general anaesthetic and the Whipple operation. The nurse will ask about the medicines you are taking, including herbal remedies and any supplements that you may be taking. Please bring a current list of your medications with you. Some medications (including Aspirin, Warfarin or Clopidogrel) make your blood thin and may result in you experiencing excessive bleeding during the operation. You may be asked to stop these medications a few days before the operation to allow their effects to wear off. You may be given an alternative treatment for those days.  The nurse will also give you verbal and written information about preparing you, your family and friends for your operation and stay in hospital. They will check you have information on the ‘ERAS’ pathway after surgery. The ‘Planned Surgery’ booklet will also be given, which explains some practical aspects of coming into University Hospitals Plymouth for an operation.

Anaesthetist

The anaesthetist will review the information gathered by the healthcare assistant and nurse and will discuss the anaesthetic and pain relief options with you. You will be asked to do a Cardiopulmonary Exercise Test (CPET). This will involve a test on a static exercise bike; you will have been sent an information sheet explaining this. This is to see how well your heart and lungs are working. It gives the anaesthetist immediate information on your fitness and the anaesthetist will discuss the risks of surgery for you at this appointment. This discussion will determine the level of care you will need directly after the operation, for example a High Dependency Unit bed or a Level 1 bed on Stonehouse or Wolf wards. If there are any concerns about the results of your test the surgeons may want to see you in clinic again before you proceed to surgery.

COVID Swab

You will be required to have a COVID swab 24-48hrs before the operation. This can be done at your local hospital if you let us know in advance, otherwise this will be arranged at Derriford hospital.

Day of Operation

You will be asked to come into University Hospitals Plymouth, the Planned Care Treatment Ward on the day of your surgery for 7am.

You will have received information about when to stop eating and drinking in your operation notification letter. If you are diabetic a special regimen of glucose and insulin will be given through a drip and your blood glucose level will be closely monitored.

Consent

Your surgeon will discuss your operation with you again including the expected benefits and the potential risks involved. It’s important that you understand the benefits and risks involved in the operation before you sign the consent form. If you have any questions or concerns, please ask the surgeon before the operation. It is never too late to have second thoughts, but the hope is that all of your questions will have already been answered either when you came to clinic or subsequently by your Specialist Nurse.

The Operation

You will be asked to put on a theatre gown. You will be taken to the anaesthetic room in the operating department by one of the nurses. After the operation, you will be taken to the recovery area adjacent to the operating theatre for about 2 hours while you fully wake up. If the Consultant Surgeon has met your relative on the day of surgery and has a contact number there may be an opportunity for the Surgeon to let your relative know how the operation went and how you are progressing. This is only possible if you give your consent. All the tissue that is removed by the surgeon during your operation will be sent to the Histopathology Department to be analysed. This is where specialist doctors look at the tissue under the microscope to determine the exact cell type. The results of this usually take at least 4-5 weeks and will be discussed with you at your follow up telephone or face to face clinic appointment. Sometimes this may take longer if further work on the specimen is required.

Post operation: hospital stay

After your time in the recovery area, you will be transferred to the High Dependency Unit or the Level 1 facilities on Stonehouse Ward or Wolf Ward depending on your pre-operative level of fitness and how well you have been during the operation. If you go to High Dependency Unit you will usually stay there for specialist care and monitoring for 12-48 hours. When the Surgeon and the High Dependency Unit Consultant are satisfied that you no longer need intensive nursing care you will go to the Level 1 facilities on Stonehouse or Wolf Ward. There are a number of checks, which are normal and are part of the routine care for anyone having Liver surgery. The ward nurses will regularly monitor the following:

Breathing and Oxygen Levels

Following your anaesthetic, you will require some extra oxygen to help you recover. This will either be given through a face mask or nasal prongs. Your oxygen levels will be monitored with a small probe that sits on your finger. It is important to carry out your breathing exercises and cough, which will keep your lungs clear and prevent a chest infection developing. Your stomach may hurt, so please ask the nursing staff for pain relief if you are unable to breathe deeply or cough easily. You may be more comfortable to cough if you lean forward when sitting up and support your wound firmly with a pillow or a rolled-up towel.

Blood pressure, pulse and temperature

Your blood pressure and pulse will be closely watched to check for any signs of complications after your operation. Your temperature will be monitored to check for any signs of infection. A sharp rise in your temperature may indicate that you have an infection although it is normal within the first 24 hours of surgery for your temperature to increase slightly as part of your body’s normal response to your surgery.

Tubes/ drains

When you wake up after your operation you will have some tubes attached to you. These will have been placed whilst you were asleep under anaesthetic. They may be uncomfortable at times, but they are essential and we will remove them as soon as you recover.

You may have some or all of the following tubes:

1. A thin tube (drip) in the vein in your neck to give you fluid and certain medications (central venous catheter).

2. A tube (drip) in your vein in your arm to give additional fluids and medication (peripheral venous catheter).

3. A tube that passes through your nose and into your stomach (nasogastric tube). This collects excess acid and bile from your stomach to prevent you feeling   uncomfortable or sick.

4. Near to the site of the operation (your wound), you may find a drainage tube (abdominal drains) that go through the skin into the abdomen. They collect excess fluid from the operation site.

5. A urinary catheter (fine tube) will have been placed into your bladder to collect urine into a bag.

The tubes and drains are usually removed at the earliest opportunity according to your progress.

Pain control medication in hospital

Depending what you and your anaesthetist have discussed at your pre-assessment appointment will determine the type of pain control you will have during and after your liver operation. The amount of pain you will experience is variable and individual, but we will work with you to ensure that pain is kept to a minimum. It is important you tell the nursing staff if you have pain, discomfort, or if there is any change in the amount of pain you feel. It is essential that you are comfortable after your operation to allow you to breathe properly and to help you move about as soon as possible.

Patient Controlled Analgesia (PCA)

This is a way of giving you pain relief after the operation that allows you to control the pain relief yourself. You will be connected to a pump containing a pain-relieving medication, usually morphine. The pump is linked to a handset that has a button. When you press the button, you will receive a small dose of morphine. This will stop when you no longer need it (able to eat and drink). You will be given pain relief tablets/ liquid instead. This change usually happens 2 to 4 days after the operation.

Oral liquid morphine

This is usually given 2-4 hourly when you are able to drink and the PCA and LAI have been removed.

Personal Hygiene

Initially you will require help with your personal hygiene, but in a few days you will regain your independence. Once your drains have been removed and you are feeling well enough you will be able to have a shower.

Mobilisation

If possible you will be encouraged to get out of bed and sit in the chair on the day after your operation with support. Then short walks at frequent intervals will be encouraged daily with support. This will help prevent stiffness, bed sores, constipation, blood clots and help keep your chest clear.

Reducing the risk of blood clots

You will be given a daily injection of a blood thinning medicine (Clexane) which you will need to carry on having for 28 days after the operation. You or your relative will be shown how to give these injections but if this is a problem we shall arrange for a District or Practice Nurse to do this for you.

Wound

The wound can be closed with stitches that resemble ‘staples’ and are called clips. Glue is also used sometimes, more commonly in Laparoscopically procedures. Dressings around your drains may be renewed daily or often removed completely. It is important to report if there is any discharge from your wounds so that it may be treated appropriately. We sometimes use special “suction” dressings which can increase the speed of wound healing if the wound has opened up a little.

Diet and fluids

You will be encouraged to start drinking sips of water as soon as you feel able after your operation. From the second day after the operation you can eat and drink normally Initially, you might prefer to eat little and often.

During your hospital stay and after, you may require supplement drinks (Fresubin, Aymes) in addition to food to increase your daily calorie intake.

Your ability to eat and drink may be affected by feelings of sickness. This is quite normal and nothing to be unduly concerned about. Please tell the nurse looking after you and they will provide you with medication for the sickness.

Bowel function

You may experience altered bowel habits for a while as a result of your surgery, lack of mobility, change in diet and strong pain killers. This is normal post Liver surgery. You may need to take a laxative temporarily to help you pass stools.

Planning your hospital discharge

You should expect a hospital stay of 3-7 days depending on the type of operation and approach. Do not worry if you need to stay in hospital for longer than this. Recovery is very individual.

Transport

Please think about transport arrangements for discharge; if you have any problems with this the nurse on the ward can arrange transport, but there may be a charge. You may be transferred to the Discharge Lounge (level 3) on the day of your discharge where you can be collected by your family or arranged transport.

Wounds

You may be discharged home with wound clips or sutures. You should be sent home with a clip remover and wound dressings. Either the ward nurse will arrange, or you may be asked to arrange, a practice nurse or district nurse to remove the clips. These will need to be removed between 10-14 days after surgery.

Drains

If you are discharged with an abdominal drain in place, you will have a follow up clinic for assessment of the drain in 1-2 weeks. You will be taught how to empty the bag. When the bag is emptied please make a note of the amount drained so that the surgeons can make an assessment of whether to remove it at the post operation clinic appointment. Please ask for a replacement drainage bag. The ward nurse will arrange for a practice nurse or district nurse to check the skin around the drain and replace the bag if necessary.

Medication

We endeavour to arrange for your medication to be ready for you to take home in a timely manner. Unfortunately, there may be a 4-6 hour wait for this from pharmacy. Some of your usual medications may have been stopped and some new ones started in hospital, but a nurse will go through them with you before you leave. You will be sent home on the pain medication that you are taking in hospital. You may feel you need to take this regularly to enable you to regain full mobility and be comfortable to resume normal activities. If you find that once at home you have increased discomfort because you are more mobile, please talk to your GP for advice. Some painkillers may cause constipation, in which case it may be helpful to take a gentle laxative.

Sick certificate

If required, please ask the nursing staff to organise a sick certificate which will cover the time spent in hospital. Please ask your GP to organise a further sick certificate to cover post discharge from hospital.

Written discharge summary

You will be given a copy of your discharge summary. This includes information about your operation, scans and if you need follow up with the GP for further tests. Your GP will be sent a copy via the post or the ward nurse may ask you to deliver this to your GP if you are happy too.

Feeling unwell at home

If you feel unwell (symptoms of increased pain, temperature or vomiting) you should contact your Specialist Nurse, GP or out of hours service. In life threatening circumstances please visit your local Emergency Department. If you are admitted to a hospital other than University Hospitals Plymouth please ask them to inform us of your admission.

Post-operation at home

The following information has been designed to assist you after your hospital discharge. It covers the main questions commonly asked by patients. After any major operation it takes time to get back to feeling yourself again. Once all the tubes and drains have been removed you will still tire easily and feel emotionally upset. This is normal and as time passes you will begin to feel more like yourself again. Try to be patient with yourself and allow yourself time to recover.

Rest, mobility and activity

You may feel tired and insecure when you first go home. You can also feel frustrated if you are not able to do all the things you could do prior to your hospital admission. This is normal, and so it is important to make a plan and slowly increase the things you do over the following weeks and months. It is important to be aware that it can take 3-6 months before you feel completely back to normal.

Initially, you should avoid heavy tasks which involve lifting, stretching and pulling, e.g. pushing a shopping trolley or lifting and carrying children for at least 6 weeks. It is often helpful to plan a rest period during the day at a time when you will not be disturbed. Depending on your home circumstances, you may need to accept some help from family, friends and neighbours until you have regained your strength.

While rest is a vital part of the recovery process, being active is also an important part of your progress at home. Being active will enable you to regain your previous level of independence and will also help you to avoid the complications that can occur with reduced activity after surgery.

Being inactive and immobile, in many instances, can be harmful and is associated with complications such as deep vein thrombosis. Therefore, we encourage you to walk daily as a good form of exercise to recover after surgery, increasing in distance over a period of weeks/ months.

Blood Clot: Deep Vein Thrombosis (DVT)

To help prevent the postoperative complication of DVT:

• When resting, your legs should be raised, ideally above the level of your hip. The limbs should be supported along their entirety (pillows should not be placed solely under the knees or heels).

• Active movement of your feet whilst resting should be carried out for five minutes every hour.

• Avoid standing or sitting in one position for long periods.

Alcohol

There should be no reason why you cannot drink alcohol but the effect may be felt faster than before, so be careful. Remember that certain medications can react with Alcohol, always read the label.

Driving

Generally you should not resume driving until your levels of concentration, strength and mobility have improved enough for you to drive safely. It is important to ensure you are able to perform an emergency stop and any other physical manoeuvre should be practised in a stationary car when you feel ready. It is advisable to check with your insurance company prior to driving, particularly if you are returning to a job that involves driving.

Sexual Activity

You may resume sexual intercourse once you feel confident and comfortable. Medication, hormones, chemotherapy and your general condition physically and mentally can alter your desire for and response to sex. There is no correct time to return to sexual activity but if you experience problems or have questions, ask your Specialist Nurse or Doctor.

Wound Healing

Healing of your wound will take place over a period of time as all wounds progress through stages of natural healing.

• Do not pull off scabs as these protect new tissue underneath.

• Look for signs of infection, for example areas of redness, swelling, discharge, odour, increased pain and increased body temperature.

• It is normal for the wound to tingle, itch or feel slightly numb.

• It is normal for the wound to feel slightly hard and lumpy.

• It is normal to experience a slight pulling around the wound.

Please adhere to the rest, mobility and activity section discussed earlier as you have an increased risk of an incisional hernia. In time, if you feel this is the case, please see your GP.

Change in bowel habit

You may experience some changes in bowel habit. Diarrhoea, constipation and excess wind are common. These can be relieved with a review of your diet, medication to firm up stools (Lopermide). Both severe diarrhoea and constipation can be treated so be sure to tell your Specialist Nurse or GP.

Fatigue (Feeling exhausted most of the time), emotional impact

Everyone has good days and bad days, but fatigue is a very common experience post Whipple operation. This can last for several weeks or months after treatment is complete. There are many ways of combating fatigue and many strategies which can help you manage your everyday activities. Similarly fear, anxiety, depression and changes in mood are all possible for patients undergoing this operation. Your life may feel like it has been turned upside down, and that all your future plans are on hold. Everyone needs support through difficult periods in their life. For advice and support please contact your specialist nurse or GP.

Back to Work

How quickly you can return to work after Liver Surgery will depend on the type of work you do. It can take any time between three to six months. It’s normal to get tired very quickly in the first few months after surgery, and concentration and decision making may be difficult to start with. It’s best not to rush back to full-time work too soon as it may slow down your recovery. We advise you to ask if you can work part-time or on light duties for a few weeks initially. If you are self-employed, you may be able to do short spells of work much sooner after surgery, but please do not overdo it.

Please visit your GP to continue your sick certificate from hospital. If you need advice regarding work and benefits, ask your Specialist Nurses who can arrange for you to see a Benefits Advisor in a Cancer Support Centre.

When can I fly?

You will need to discuss this with your surgeon. It is not normally recommended until you are fully recovered from your surgery. Your insurance company will need to be informed of your plans for travel.

Who can I contact if I have any questions?

The team at University Hospitals Plymouth are always willing to answer any questions you have, in an open and honest manner. The team includes your surgeon, anaesthetist, pre-assessment and ward nursing staff, dietitian and potentially a Cancer Specialist Nurse. Any member of the team can be contacted via the numbers listed in the booklet. They are available to you, your relatives and close friends for any questions, concerns or worries throughout the whole of your treatment and after your treatment has ended at University Plymouths Hospital.

Helpful contacts

Surgeons’ secretaries 01752 432071

Hearts Together Hospital 01752 315900 Hotel accommodation

Mustard Tree (Cancer Support Centre) 01752 430060

Pre-assessment 01752 439067

High Dependency Unit 01752 431439

Stonehouse ward 01752 431489

Wolf ward 01752 439677

Diabetic Specialist Nurse 01752 430170

Dietitian department 01752 432243

Cancer Specialist Nurses

Plymouth (Derriford)                               01752 431962

Cornwall (Treliske)                                 01872 252177

Royal Devon and Exeter (Wonford)       01392 402775

North Devon                                           01271 314147

Torbay                                                   01803 655890

Further information

www.plymouthhospitals.nhs.uk

www.nhs.uk NHS Choices (England)

www.macmillan.org.uk

www.britishlivertrust.org.uk

www.mysunrise.co.uk

My sunrise app (mobile phone)