You as a patient should frankly ask the doctor this question. Doctors are humans too and bringing them into a setting of family will lead to honest answers in most cases. So this can be regarded as a little trick you can apply as a patient to get the most honest answer.

The doctor should give you information about a normal course of action after surgery and how long it normally takes to be discharged.

They should tell you how long it takes for you to get back to work or to a normal life. They should also tell you about rehabilitation and the care steps that are necessary for the first 1 to 2 years after surgery, like imaging, the potentially needed chemotherapy/radiation, endoscopy, change in medication and other screening that will be necessary.

If there is no requirement for any kind of further care they should also tell you and why.

The really good institutions will give you an outline on when something goes wrong and you experience complications, as this is critical for you and the treating doctors.

This question should be answered honestly by every doctor and if it is a procedure that is done rarely then they should tell you that. Some indications are rare and you will not find a surgeon that does a lot of them per year. It is important that you know that there is a  board certified consultant in the operating room when you undergo major surgery.

Doctors should always inform you about all treatment options if there are more that are equal or have a beneficial risk benefit assessment. In general doctors make a recommendation and a proposal for a treatment and should give you an opportunity to decide.

As the patient you should always ask if there are alternatives and what the alternatives could mean for you.

• Centers and especially certified centers must have multidisciplinary boards.
• Multiple experts from various disciplines such as radiology, radiotherapy, oncologists, pathologists, specialized surgeons and others discuss your individual case and look for the best individual treatment for you based on medical evidence.
• Multidisciplinary boards increase your quality of care.
• If there are multiple options for treatment and if the best treatment is not yet clarified, clinical studies are a good way to get the potentially best treatment in a very systematic way.

Pathology report

Pathology reports can be very hard to read for a lay person. Look at signal words like malignancy, inflammation and tumor. The word tumor normally only describes a lesion. It does not tell you if it is just a plus of tissue or cancer.

Cancers are classified in accordance with the TNM classification.

• T describes the tumor and its size.
• N the number of positive or potentially positive lymph nodes
• M tells us if there is suspicion of metastasis in other places.

There should be a G stadium as well.

• G tells us about the grading.

This means the tumor is either G0/1 very well differentiated or at higher stages G3/4 very weakly differentiated, which means it has only little similarities with the tissue (e.g. colon) it has originated from and is very aggressive.

Radiology report

Imaging is very important in the planning of your surgery!

• Get all radiology imaging and the reports.
• Ask your GP/referring doctor if there is an automated transfer of images to the hospital – if not, make sure to get a CD.
• Ask your doctor or surgeon to show you the images and explain what something means.
• Ask the doctor if they need any other diagnostics.

Ask your doctor if there are multidisciplinary boards in their facility. Multidisciplinary boards or tumor boards have been shown to increase the quality of care and outcomes. Choose experts for your treatment!

The hospital should be certified for what they do. It may be that there is no certificate for specific treatments in general but mostly there is.

A certificate is in general provided by large societies like national or international cancer societies, and surgical societies.

A certificate shows that the hospital and the staff have gone through a quality process.

A certificate does not only give information about the department itself but also about the whole infrastructure that is necessary to treat you in case that there are complications. This requires a lot of expertise that is available 24/7.

Research has shown that this clearly increases the quality of your treatment and your results.

Ideally, the doctor that talks to you is your surgeon as well. In larger settings there is a group of specialists that perform surgeries, like on the liver or the colon.

You can always get one! And it is recommended by patients’ and doctors’ associations to get more expert opinions although these may very well differ from each other. In some situations there are more ways than one, and all are medically correct.

If you have a good center, they will be open to discussing the recommendations of other centers with you as well. So it clearly empowers you as patient to be critical about the recommendations you get.

This is a very important question. However, please listen to your doctor about the possible treatment. Doing nothing is easy and it may be beneficial with regards to your quality of life for some time.

However, every treatment should focus on different aspects:

• Is there a chance to cure you completely or give you a chance for a longer life than without therapy?
• Is there a chance to improve your quality of life with the therapy?
• What kind and level of risk are you and your doctor willing to take (benefit risk)?
• What do you (and your family) want?

Doctors should recommend prehabilitation methods that have been shown to be associated with better outcomes after surgery.

These can be found in the European Code Against Cancer:

• Stop smoking
• Be active
• Try to be positive
• Eat well
• Don’t drink alcohol

Elective referral after surgery

Some procedures require post operative supervision on an ICU. This is an intensive care unit.

There is more personnel to take care of you. Some surgical procedures are so challenging and difficult, that you may need more intense therapy and care, A good example is the removal of more than 60 to 70% of the liver or the resection and replacement of an aortic aneurysm or the removal of the esophagus. In general a controlled wake up period, screening of your blood pressure and kidney and lung function are in the center of such a period.

ICUs can be very high tech with a lot of noise and alarms, hectic and full of machines you are not familiar with. That ́s why, for most patients, the time on ICU is associated with fear and insecurity and a lot of patients report that they felt helpless on ICU. Please, talk to your doctor about this before and let them tell you about the ICU stay.

Emergency referral to ICU

If you have surgery and complications occur, you may need to be admitted to the ICU because supervision and treatment options of critically ill patients are better there. Your doctors will guide you through this period.

Unexpected findings

There is always a chance that radiology does not show everything. Such findings sometimes require the change of the surgical strategy or they make it completely impossible to even do it.

Persisting problems

There is a chance that the surgery will not be successful and that you either have a recurring problem or that some problems remain. It is important that you talk to your doctor before the surgery about that and what it means for your quality of life. It is absolutely necessary that you understand the risks that come with such a procedure and that you can make a risk benefit decision for yourself.

Why do you need a list of medications

An up to date medication list is very important. Your GP can help you with that or even provide it. It can be a part of data provided by your insurance card.

Your list of medications is very important for every doctor who does not know you. It provides them with valuable information on your chronic diseases (like diabetes, high blood pressure or heart and lung problems).

Another important information for surgeons and anesthesiologists is whether you are taking blood thinners.

Blood thinners

These medicines reduce blood clotting in an artery, vein or the heart. Doctors prescribe these to help prevent heart attacks and strokes caused by blood clots.

Always take these drugs exactly as prescribed and make sure you always let your doctor, anesthesiologist or surgeon know exactly which blood thinners you are taking and why!

Antiplatelet medications

These drugs prevent blood cells called platelets from clumping together to form a clot. They are used in conditions such as after a myocardial infarction, after a stroke, in certain blood and heart vessel diseases. Most commonly used antiplatelet drug is Aspirin and should not be discontinued before surgery, expect in some cases, such as neurosurgery. When you are taking other antiplatelet drugs, such as clopidogrel, prasugrel or ticagrelor, you should never discontinue them unless specifically ordered to do so by your doctor.

Anticoagulants

They slow down your body’s process of making clots and are most often prescribed for conditions such as atrial fibrillation, venous thrombosis, some oncology diseases, after heart valve replacement and in the period after surgery. Most commonly used are warfarin, dabigatran, rivaroxaban, apixaban. If you are taking anticoagulants, you have to have your plan adjusted before having surgery, most often by your GP or internal medicine specialist.

This is a report describing your tumor on a molecular level. Maybe there was already a biopsy performed or you underwent a surgical procedure before where a mass was removed and investigated by a pathologist. Bring such reports to your appointment because it offers valuable information to your surgeon.

Surgeons need all the information available. You should bring imaging, like a CT, MRI, ERCP or endoscopy scans to the appointment!

It can be either imported through a CD or downloaded through an electronic health record.

It is very important to tell your surgeon and anesthesiologist about any allergies you have and what happens (you get dizzy, get a rash, start sneezing).

Share any information you have about your previous infections, specially with hepatitis B, C or HIV.

You should bring all medical records on previous surgeries, hospital stays (why were you in a hospital!), previous anesthesia and your updated list of medications.

It is good to bring the recent laboratory results from your GP or referring doctor.

Some values are very important. You may have a low hemoglobin level which indicates anemia. This can be due to bleeding or an inflammatory process in your body.

However, you will probably have your blood drawn during your appointment for more specific tests that show other organ systems functions. In any case, ask your doctor what the values mean.

It is important for the surgeons to have the name of your referring doctor and your GP. Your GP might be involved in your postoperative long-term treatment and has to be updated on your process of care. Good communication between you, the surgical department, and your GP/referring doctor is very important for an efficient flow of your care.

Most types of surgeries will require some form of anesthesia. Anesthesia is performed by anesthesiologists, who are doctors, specially trained in that area.

Drugs that are used in anesthesia work in three important ways: they keep your body from feeling pain, they keep you asleep and they make your muscles relaxed if that is needed for the surgery itself.

Most often anesthesia is either general or regional or a combination of both.

During your preoperative visit, the anesthesiologist will do an examination and ask questions about your general health, chronic diseases, smoking, and prior surgeries.

This doctor will most likely not be the one actually giving you anesthesia on the day of your surgery. Based on your age and health conditions, you will be asked to provide the doctor with specific test results.

You should bring lab and other results!

After the surgery you will spend some time in the recovery room, where a nurse will keep monitoring your vitals. When discharged by a doctor, you will return to your hospital room.

• Comfortable clothes and underwear for at least a week.
• Personal hygiene items such as tooth brush, hair brush and skin routine.
• All your previous medical records.
• Your false teeth, hearing aid, glasses.
• Your smartphone and charger.
• A small amount of money.
• All the important contact numbers.
• A book, a magazine and your favourite music.

• Pets and plants.
• Drugs, alcohol and cigarettes.
• Any medications that you don’t regularly take.
• Large amounts of money or expensive belongings like a watch and jewellery.

Wards usually have rooms with 2 beds, some hospitals still have 3 or 4 bed bedrooms.

Most rooms have showers and toilets included, however TV and Wi-Fi are optional and sometimes not included. If possible, try to eat at the table outside of your bed. Early mobilization really  helps with your recovery. On the day of surgery, have a shower, wear your most comfortable clothes, and have somebody accompany you.

• One of the biggest patient fears is to acquire a hospital infection or to die from sepsis.
• Hospital-acquired infections (HAIs)affect up to 10% of all patients hospitalized world-wide.
• HAI is an infection after more than 48h after referral to a hospital and up to 30 days after discharge from a hospital.
• HAIs are often associated with bacteria that develop resistance against antibiotics.
• HAIs lead to impaired immunity and  can cause sepsis.
• Post operative sepsis is mostly associated with complications.
• Sepsis requires fast intervention with application of fluid, antibiotics and removal of the source of sepsis (leakage, fluid collection, peritonitis).

When your doctors are happy with your progress, blood results and clinical outcomes, they will most likely discharge you home. It is better for you to go home to your everyday life as soon as you are medically fit to do so. The discharge process is different for every hospital, but usually you will have to wait for the discharge summary to be written and for doctors to do your medicine reconcilliation. You should be discharged with a list of medications and instructions on how to take them as well as general instructions for care at home, check-up appointments, and professional instructions for your primary care physician.

It is when your postoperative recovery does not go as expected. It means that you might need unplanned drugs, procedures, interventions or admission to the ICU.

Complications occur in 25% of all surgical procedures. One in four complications is considered major. Complications can be reduced by prehabilitation which is broadly presented in this app.

Prehabilitation

It consists of physical activity, optimal nutrition and psychological well-being on the one hand and optimizing patient factors, such as correcting anemia on the other hand.

ERAS

It means enhanced recovery after surgery. This app does not provide specific information on ERAS but you can access the following link:

https://erassociety.org/guidelines

• Longer hospital stay
• Failure to rescue – the more complications occur in a patient, the higher is the probability that it is  irreversible and results in major harm or even death
• Higher mortality rate
• Lower quality of life after your surgery
• Higher cost of care

You can always step back without having to state a reason.

Hospitals have to carefully plan their resources so it is appreciated to inform them about your cancellation at least three to five working days before your scheduled surgery.

That way they can allocate your slot to a patient who requires surgery just as urgently as you do.

It is important for you to name a person who will decide for you in case you are not able to. Think about who this person is, get her or his agreement and fill out a precautionary power of attorney form for medical and nursing decisions.

This guarantees a well structured process in case of unexpected events that make you temporarily unable to make decisions for yourself.

You can get a second opinion at whichever step you want. There are a lot of portals at large centers established that will review your case and speak directly to you.

The surgeon doing the surgery should get your informed consent. This is optimally done with a standardized form including checklists that can be filled out. Important remarks are written down.

It can be helpful for you if the doctor makes a sketch of the operation. For an elective procedure it is mandatory that you have sufficient time to think about your decision.

The doctor and you sign the document and write down the date. Ask for a copy of the document. Please note that informed consent must not be done by anybody else than a surgeon (like an anesthesiologist).

While nearly everyone potentially can benefit from a preoperative nutritional assessment and therapy, not everyone will benefit equally. You must be even more focused on proper nutrition before surgery if you are having esophageal, gastric, and some colorectal surgeries. Major orthopedic and neurological surgeries also pose a threat if your nutrition is not optimal before the surgery.

You should also get the best possible nutrition before surgery if you have lost weight prior to your surgery, have a low BMI, take steroids or immunosuppresants, or have cancer.

Malnutrition increases the risk of death after surgery, significantly raises the risk of postoperative complications, and is an important reason why patients are readmitted to the hospital.

Surgery poses a stress on the body, which triggers inflammation and depletes nutrients. This, in turn, can impair the immune response and increase the risk of postoperative complications, especially infections and the need for another surgical procedure.

Dehydration before operation is a common condition in surgery and may be associated with common postsurgical complications, like pneumnoia, myocardial infarction and respiratory failure or increased risk for needing a ventilator. Fasting before surgery results in a perioperative dehydration that may contribute to some physiologic effects, resulting in complaints of headache, nausea, vomiting, fatigue, lightheadedness, dizziness, and thirst.

It is always important to drink enough water, even more so before having surgery. The effects of water on daily performance and short and long-term health are quite clear. Water affects skin, brain, heart, kidney, liver, lung, gastrointestinal and musculoskeletal functions.

ERAS means enhanced recovery after surgery. It is a modern way of taking care of surgical patients. ERAS advocates for early sitting and walking after surgery, shorter time of urinary catheterization after surgery and early going to the toilet, earlier eating of solid foods, no nasogastric tube and early removal of all catheters. Some of the benefits of ERAS may be earlier return of bowel function, decreased time to mobilization for patients, fewer postoperative complications, ability to tolerate solid foods sooner, and lower readmission within 30 days postsurgery.

You can access the link to the ERAS guidelines here:

https://erassociety.org/guidelines

Smoking is a major cause of cancer, heart disease and chronic lung diseases.

If you smoke, your heart and lungs don’t work as well as they should. You may have breathing problems during or after surgery, and you are at greater risk of developing pneumonia. You are also much more likely to need a ventilator, a machine that breathes for you, after surgery. In addition, smoking reduces blood flow, which slows healing, so your surgical incision is more likely to become infected.

Quitting smoking even the day before your surgery can lower your risk of complications. This is because your body starts to heal and your heart  and lungs begin to work better as soon as you quit. The levels of  nicotine and carbon monoxide (the unhealthy chemicals you inhale in cigarette smoke) begin dropping immediately, improving blood flow, and reducing the likelihood of problems.

When to stop consuming what

• Stop eating 6 to 8h before surgery
• Stop drinking 2h before surgery
• Stop smoking 4h before or at all
• Stop chewing gum 2h before surgery

The stomach should be empty when you get general anesthesia. This will lead to complete relaxation and if there is anything in your stomach it may go back and directly into your lungs where it would cause pneumonia.

Carbohydrate loading

Not only runners can benefit from it. Research has shown that you can lose more carbohydrates stored in your muscles for energy, called glycogen, during surgery than during a long run or a bike race. Carb-loading can help reduce stress, anxiety and nausea before and after surgery and has been linked to better outcomes in non diabetics.

Drink a beverage containing 100 g of carbohydrates 12% the night before surgery (i.e. maltodextrin) (+ another 50g 2-3h before anesthesia.)

or 500ml of grape juice

Ensure Pre-Surgery Drink 296ml

Nutricia preOp Pre-Surgery Drink 200ml

Breakfast

Lunch

Dinner

Snacks

Grab a hand full of healthy snacks 1 to 2 times per day.

Once or twice per week sweets or chocolate are fine!

• Nuts
• Almonds
• Berries
• Veggie sticks
• Olives
• Cake
• Chocolate Ice Cream
• Fresh fruit

Zinc

Zinc is essential for the protein synthesis and reduced levels may impair recovery from surgery.

It is a so called antioxidant and helps to fight inflammatory reactions like a post surgical status; it is essential for protein synthesis and collagen formation. The recommended dose is 15-20 mg/day.

Vitamin D3

Vitamin D deficiency is very common worldwide and it has been proven to be associated with higher postoperative complications after certain procedures.

Vitamin D is a fat-soluble vitamin that promotes calcium absorption in the gut, promotes bone growth and has an important role in facilitating normal immune system function.

Most people can get a sufficient amount of Vitamin D by exposure to sunlight during spring and summer. Recommended dose for supplement is 400-800 IU or 10-20 micrograms per day.

Iron

Iron is essential for preparing your body for surgery and taking it will maximise it’s ability to build blood stores before surgery. Take 10-15 mg per day.

In general a hemoglobin level of <13g/dl indicates that you are anemic. Ask your doctors for Patient Blood Managament to optimize your hemoglobin before surgery.

Vitamin C

Vitamin C is an antioxidant that is necessary for tissue growth

and repair and has a primary role in formation of collagen. It can protect cells and and other molecules in our bodies from damage.

The daily recommended dose is 500-750 mg daily (in divided doses).

Folic acid

Folic acid (Vitamin B9) is involved in many processes in your body. It is essential for making your DNA, repairing it and building blood cells. When you are pregnant it is an important brick of building your baby’s brain.

Additional intake of 400mg per day is recommended in times of increased need.

Other B vitamins

B vitamins are water soluble group of vitamins that are necessary for multiple metabolic pathways. A defect affects almost every organ including the skin, blood and neural system. Side effects are known from supplemented B vitamins but not from natural sources.

The best way to take is a B-100 complex with B vitamins:

• Thiamine (B1)
• Riboflavin (B2)
• Niacin (B3)
• Pyridoxine (B6)
• Biotin
• Pantothenic acid
• Folic acic
• Cobalamin (B12)

Some supplements may have serious interactions with other drugs and cause damage to you. This may be a damage to organs like the liver or the kidneys. Interactions can potentiate the effects of drugs and thus increase the risk of their application.

Please stop the following supplements and tell your doctors about every drug and supplement that you use. It is important for you and the doctors!

Echinacea – It’s an immune system stimulant that can be damaging for liver in higher doses or combined with other drugs that may be used during your time in the hospital.

Melatonin – It can be used for treating jet lag or insomnia. Melatonin can potentiate CNS effects of barbiturates and other general anaesthetics.

Garlic, ginger and bilberry – There is some risk of prolonged clotting time, especially when combined with warfarin and other anticoagulants or antiplatelet activity drugs such as NSAIDs and aspirin.