Counselling is a highly important aspect of introducing enhanced recovery principles to the patient, managing expectation and defining expected milestones in recovery. The general principles of the discussion are well established but are adapted to the operation being proposed, the social circumstances of the patient and their age and co-morbidity. It is important that these messages are delivered by senior members of both medical and nursing staff and given in a consistent manner—ideally as a joint consultation with the consultant surgeon and the nurse specialist. Consultation should also take place with the family members or carers present. It should be reinforced with written information provided in an easily understandable format. For patients undergoing elective colorectal resection and who are without major co-morbidity, the conversation revolves around the anticipated recovery plan and it is stressed that the programme is aimed at improving the quality of recovery and reducing the complication rate rather than being aimed at early discharge per se. Discussion would include all of the following.

Information will be gained from the patient regarding the safety of the home environment and the levels of care and support available. Contact information for problems or concerns arising following discharge is also given to the patient.

For most patients they are informed that they will be able to drink free fluids on return to the ward following surgery. They will be offered a light evening meal on the day of surgery and a normal breakfast the following morning.

Patients are informed that it is anticipated that all lines and monitoring will be disconnected or removed on the morning following surgery—including intravenous access and urinary catheters. The exception to this is male patients undergoing low anterior resection who retain the urinary catheter for 48 h.

Patients are informed that discharge can occur as early as the first post-operative day as long as they fulfil the following criteria and that the average post operative hospital stay in our unit is 3 days.

Criteria for safe discharge to home

Our philosophy is that the earlier the patients can return home, the more mobile they will be, the better they will eat and the better they will sleep—all factors that contribute to high-quality recovery and rapid return to the anabolic state [12, 13]. It also removes the patient from a potentially dangerous environment with the risk of hospital-acquired infection. There is strong emphasis on being able to contact clinicians or return to the hospital in the event of failure to make progress or developing complications. Readmission to hospital is not considered a failure of treatment but is in any case a rare event. There are certain “red flag” symptoms that patients are told they must return to hospital emergency department immediately which include sudden onset of severe abdominal pain, symptoms of obstruction, fever or rigors.

Fortunately it is relatively unusual for patients with colorectal disease to be severely malnourished compared to patients with upper gastrointestinal diseases. The focus of nutrition is on the immediate preoperative phase to avoid preoperative starvation and provide carbohydrate (CHO) load preoperatively and attenuate the catabolic response to surgery. The mechanism of delivering CHO in the form of a drink also delivers a fluid load that ensures the patients come to surgery well hydrated. We provide 800 ml of CHO the evening before surgery and a further 400 ml 2 h before surgery using PRELOAD (Vitaflo, UK).

Mechanical bowel preparation is not routinely administered for patients undergoing colorectal resection. The bowel preparation protocol is determined by the planned surgery. Essentially, if a stapled anastomosis is to be fashioned trans-anally then a Phosphate enema is administered an hour prior to surgery to ensure the rectum and left colon are empty. It may also be self administered at home by the patient prior to admission. Full mechanical bowel preparation with stimulant and osmotic laxatives is reserved for patients having a rectal anastomosis with planned defunctioning loop ileostomy. For practical purposes this represents TME surgery for rectal cancer. This ensures that there is no bowel content between the stoma and the anastomosis. The Bowel preparation protocol is presented in Table 23.1.

All preoperative assessments including blood tests will have been carried out in a visit to the nurse led pre-assessment clinic. This will have included scrutiny of the patients’ drugs, blood tests and ECG. Protocolised referral for cardiopulmonary exercise testing (CPET) in an anaesthetist led clinic is arranged if the exercise capacity threshold is below 4 METS. This is determined by questioning or a Shuttle Walk test.

Preoperative anaemia will be treated according to the cardiopulmonary status of the patient and staging of their cancer. Anticoagulants such as Warfarin or Clopidogrel are stopped and appropriate anticoagulation commenced depending on the indication. ACE inhibitors are not given the day of surgery.

Admission is arranged for approximately 2 h prior to surgery unless there is a specific indication to admit earlier such as in-patient bowel preparation or planned blood transfusion.