Dr. Connie Pennington, MD

 

Entero-stomal Therapy

​

If your surgery involves the formation of a colostomy, ileostomy, or urostomy, you will be asked to see an Entero-stomal Therapist. An appointment with an entero-stomal therapy nurse is important for several reasons. During this appointment you will receive educational material, and questions will be addressed. You will also be marked for the stoma so that your stoma can be placed at a site that does not interfere with skin folds, belt lines, or scars that would impair proper sealing of stoma appliances. It is important to wear your favorite comfortable clothing so you can be marked accordingly.

​

Medication Management

​

​During the pre-operative period it is important to manage your medications in preparation for surgery. Be sure to communicate all medications and supplements. Some medications may need to be discontinued prior to surgery. Please review the following areas if they apply:  

 

The medication phenteramine must be stopped two weeks prior to any type of anesthesia.

​

If you are on any anticoagulants, including aspirin, they must be stopped a week prior to your procedure. Coumadin (warfarin) must be stopped four days prior to your procedure. You may be given clearance to stop Coumadin, or you may be given a prescription for Lovenox to use during this time. Here is a list of common anticoagulant Medications:

​

• Coumadin (warfarin)

 

• Plavix (clopidogrel)

 

• Aggrenox (dipyridamole + aspirin)

 

• Ticlid (ticlopidine)

 

• Pletal (cilostazole)

 

• Effient (prasugrel)

 

• Brilinta (ticagrelor)

 

• Pradaxa (dabigatran)

 

• Xarelto (rivaroxaban)

 

• Eliquis (apixaban)

 

 

Nonsteroidal Anti-Inflammatory Drugs (NSAIDS) can also cause bleeding during surgical procedures and must be stopped one week prior to your procedure. Here is a list of Nonsteroidal Anti-inflammatory Drugs (NSAID's) that can increase bleeding:

​

• Motrin/Advil (ibuprofen)

 

• Orudis KT, Oruvail, Actron (ketoprofen)

 

• Clinoril (sulindac)

 

• Aleve, Naprosyn, EC-Naprosyn, Naprelan, Anaprox, Anaprox-DS, Vimovo (naproxen)

 

• Lodine XL, Lodine (etodolac)

 

• Nalfon (fenoprofen)

 

• Arthrotec, Cataflam, Voltaren, Cambia, Voltaren-XR, Zipsor, Flector Patch, Voltaren Gel (diclofenac)

 

• Ansaid (flurbiprofen)

 

• Sprix, Toradol, Toradol IV/IM (ketorolac)

 

• Feldene (piroxicam)

 

• Indocin SR, Indocin (indomethacin)

 

• Ponstel (mefenamic acid)

 

• Mobic (meloxicam)

 

• nabumetone (Relafen)

 

• Daypro (oxaprozin)

 

• Actron, Orudis KT, Orudis, Oruvail (ketoprofen)

 

• Duexis (famotidine and Ibuprofen)

 

• Meclofen (meclofenamate)

 

• Tolectin (tolmetin)

 

• Disalcid (salsalate)

 

• Trilisate (choline magnesium trisalicylate)

 

• Dolobid (diflunisal)

 

• Celebrex (celecoxib)

​

Diabetes medications may be adjusted during the perioperative period. If you are diabetic you may need to check your sugar more frequently in the peri-operative period. If you need to drink juice do not hesitate to correct a low sugar. 

​

For patients with Type I diabetes, you will continue basal insulin without diminishing the dose. Do not take short acting insulin the morning of the procedure. If you are treated with an insulin pump, you may continue your usual infusion rate.

​

For patients with Type II diabetes do not take short-acting insulin the morning of the procedure. If you take glargine insulin (Lantus) at bedtime, take 1/2 your usual dose the night before the procedure. If you take glargine (Lantis) in the morning, take 1/2 your usual dose. For patients taking detemir insulin (Levemir) you may take your usual dose.

​

Oral medications like glucophage XR, and chlorpropamide (Diabenase) should not be taken the evening prior, or the morning of the procedure. Do not take Glipizide, Glyburide, Glimepride, Prandin, Starlix, Precose, Glyset, or Voglibose the morning of your procedure. Avandia or Actos should generally be held as well. Byetta, Symlin, Galvus, or Januvia should also be held the morning of your procedure. 

​

Vitamins and Supplements present an interesting challenge to physicians and surgeons. There are literally over 40,000 supplements and supplement combinations of varying doses on the market. The following supplements are known to possibly increase bleeding risks: Bilberry, Cayenne (Red Pepper), Dong Quai (angelica), Echinacea, Evening Primrose Oil, Feverfew, Fish Oil, Flaxseed Oil, Garlic, Ginger, Ginkgo Biloba, Ginseng, Hawthorne, Kava Kava, Licorice Root, Ma Huang, Melatonin, Red Clover, St. John's Wort, Valerian, Vitamin E, Yohimbe. Dr. Pennington recommends that you discontinue all vitamins and supplements a week prior to your procedure.

 

Bowel Preparation

 

You may or may not be required to do a bowel preparation.  If Dr. Pennington instructs you to do a bowel preparation prior to surgery, it will be a Moviprep as follows:

​

MoviPrep regimen: Around noon the day before surgery, take the first liter of MoviPrep solution over one hour (one eight ounce glass every 15 minutes), and then about two to three hours later, take the second liter of MoviPrep solution over one hour. In addition, take 1 L (approximately 32 ounces) of additional clear liquid during the evening before surgery. You should be finished with the prep by 6 pm. Do not eat or drink anything after midnight the day prior to your procedure. 

 

Antibiotics

 

You will also be given a prescription for two oral antibiotics to be taken the night before surgery:

​

1g of Neomycin to be taken at 2 pm, 3 pm, and 10 pm

and 1 g if Erythromycin base to be taken at 2 pm, 3 pm, and 10 pm

​

Alternately you may be given:

​

Amikacin (2 g) and Metronidazole (2g) to be taken at 6pm and 10 pm. 

​

It is very important to complete your bowel preparation if required and take the recommended antibiotics. This is the best defense against post operative wound infection.

​

In preparing for surgery, do not wear make up or hair spray. Removed hearing aids, contacts, and dental partials. Be prepared to remove glasses and dentures in the preoperative area. Remove all jewelery and body piercings and leave them at home.

 

The Day of Surgery

​

After arrival to the surgery center, you will be taken to the preoperative holding area to prepare for surgery. It is important that you know your past medical history, surgical history, and medications with daily doses. It may be helpful to write this information down carefully and bring it with you. An IV will be started and you will be given IV antibiotics. You may have hair clipped from the abdominal area. Your abdomen will be wiped down with an antiseptic cloth. You will be given a shot of anticoagulant to prevent blood clots.

​

Just before surgery Dr. Pennington will come and greet you and answer any last minute questions. She will also offer prayer. If you are feeling anxious or distressed the anesthesiologist will give you an IV medication to help relieve tension and promote rest. 

 

After Surgery

​

You will wake up in the recovery room where you will be carefully monitored and attended. You will be given pain medications as needed. We generally use Dilaudid. You may notice that another IV was started in surgery. You will have blow up booties on your legs to prevent blood clots. You will have a urinary catheter in your bladder. You will have a clean sterile dressing on your incision that will remain undisturbed for several days. The dressing is attached to a small suction device and ensures a clean undisturbed wound. When a room is ready for you upstairs you will be transported to a private room for the duration of your hospital stay. You will be allowed to have non-carbonated clear liquids the evening after your procedure, if you desire. You will go to your room with a on-demand pain pump or orders for liberal pain management utilizing dilaudid and or morphine. If you experience nausea, IV medication can be administered as needed. The day of surgery is a day of rest. On the day after surgery, you will be required to sit up in a chair, and may begin clear liquids, and even a full liquid diet if you are doing well. You should not need antibiotics post-operatively and you will be given probiotics to aid in repopulating the intestines with healthy bacteria. You will be given anticoagulant shots daily to prevent blood clots. The catheter in your bladder will be removed in first or second post operative day. You will be encouraged to walk no later than the second post-operative day. Physical Therapist are available to assist you. As soon as possible you will wean off of IV pain medications, in favor of oral pain medications. We generally use Percocet or Lortab. During the post-operative period the average return of bowel function is 4 days. Bowel function is encouraged by walking, eating or chewing gum, and decreasing pain medications. Most people are discharged home in 3-4 days. You will be provided with a prescription for pain medication, and if you are at high risk for a blood clot, you may be given a prescription for anticoagulant shots to be taken for up to one month.