Pancreatic Cancer and the Whipple Procedure A Medical

Pancreatic Cancer and the Whipple Procedure A Medical Surgical Case Study Lauren Walker 2015

This Presentation will address: • Intraductal Papillary Mucinous Neoplasm of the Pancreas • The Whipple Procedure

M. K 81 year old female admitted with Intraductal Papillary Mucinous Neoplasm of the Pancreas. 157 centimeters tall ~5 ft 2” 19 days hospitalized 12 days with MNT Admit Weight 59 kg Weight at Assessment 61. 7 kg Usual Body Weight 57 kg Ideal Body Weight 50 kg Body Mass Index 24

Past Medical History • • • Coronary artery disease Peripheral vascular disease Hyperlipidemia Hypertension Ongoing tobacco abuse Pancreatic mass in 2010

Social History • • Retired Widow Catholic Golfing Three adult children Four grandchildren Medicare and BCBS Insurance

Pancreas Roles and Functions • 1. Enzymes ▫ Digestive • 2. Hormones ▫ Regulate body fuels

Intraductal Papillary Mucinous Neoplasm of the Pancreas • Mucin producing neoplasms ▫ Grows on the main pancreatic ducts, side ducts, and head of the pancreas • Occur mainly in Men ▫ ~65 years • Malignant Potential • Surgery is best option

What is a Whipple? • Pancreaticoduodenectomy ▫ Targets tumors on the head of the pancreas ▫ 50 -70% pancreatic cancer pt’s have tumors in the head of the pancreas • Indications: ▫ Pancreatic Cancer ▫ Chronic Pancreatitis

Whipple Procedure Steps: • Clockwise Journey ▫ Resections: �Pancreatic head �Duodenum �Common bile duct �Gallbladder �Distal portion of stomach �Adjacent lymph nodes

Whipple Procedure Steps: • Counterclockwise ▫ ▫ ▫ 1. Creation of the jejunal feeding access 2. Pancreaticojejunal anastomoses 3. Choledochojejunal anastomoses 4. Enterojejunal anastomoses 5. Venous reconstruction

Mayo Foundation. Whipple Procedure. http: //www. mayoclinic. org/diseases-conditions/pancreatic-cancer/multimedia/whippleprocedure/img-20008531; 2015.

The Whipple Comparison Pylorus Preserving Classic Whipple • Preservation of stomach and proximal 2 -3 cm of duodenum. • Less radical of an operation ▫ Less surgical time ▫ Less Recovery time • In theory may prevent side effects commonly seen with classic Whipple. • Duodenal tumors • Bulky tumors of pancreatic head. • Dumping syndrome • Diarrhea • Weight loss

Complications of Whipple • Nutrients of concern: iron, calcium, zinc, copper, selenium, and the fat soluble vitamins, A, D, E, and K. • Pancreatobiliary secretions have to “catch up” to the chyme. • Dumping syndrome, Gastroparesis • Pancreatic insufficiency ▫ Diabetes Mellitus ▫ Pancreatic Enzymes

M. K’s Whipple • Attempted a pylorus preserving operation • Duodenum was “dusky” in appearance, so it was resected. • Classic Whipple was performed.

M. K’s Complications during hospitalization • • • Constipation Ileus Gastric ulcer Peripancreatic abscess Nausea Poor PO intake and early satiety.

M. K’s Additional Medical Tests and Procedures • Abdominal X-ray to identify ileus. • Drain placed for pancreatic abscess. • EGD showed marginal ulcer in stomach.

Lab Values Date Sodium Potassium Chloride Bicarbonate Blood Urea Creatinine Glucose Nitrogen (m. Eq/L) (mg/d. L) 20 -Feb 137 3. 6 100 25 19 0. 75 146 21 -Feb 139 3. 7 102 25 18 0. 8 121 22 -Feb 137 3. 4 97 28 11 0. 7 104 23 -Feb 136 3. 1 97 26 9 0. 57 84 24 -Feb 136 3. 9 99 25 26 0. 67 104 25 -Feb 138 3. 5 95 27 29 0. 69 114 27 -Feb 135 3 94 29 18 0. 73 131 28 -Feb 133 3. 7 96 27 30 0. 73 131 1 -Mar 135 3. 7 97 24 24 0. 7 112 3 -Mar 137 3. 3 98 29 20 0. 65 117 4 -Mar 132 4. 1 97 26 22 0. 56 119 5 -Mar 138 4. 3 102 25 21 0. 57 106 136 -145 3. 5 -5. 0 98 -106 22 -28 11 -20 0. 5 -1. 1 70 -105 Normal Levels

Medication Usage Medications Bisacodyl Stimulant laxative Nutritional Impact Abdominal cramping, diarrhea, distention, vomiting Hydrochlorothiazide Diuretic Hyponatremia, Hypomagnesia, Hypercalcinemia, Hyperglycemia Magnesium Hydroxide Laxative and Antacid Diarrhea, gastric discomfort Nifedipine Treats Hypertension May cause rapid weight gain. Ca+ interferes with absorption. Vancomycin Antibiotic Abdominal pain, Nausea, Vomiting

Dietary Recall Meal Breakfast Mid-Morning Snack Components Granola bar, 8 fl oz skim milk ½ cup of grapes, 8 fl oz coffee with 1 liquid creamer, 2 sugar packets Lunch 2 slices whole wheat bread, 2 tablespoons peanut butter, 1 clementine, 6 oz strawberry yogurt Dinner ¼ cup noodles, ¼ cup spaghetti sauce, 12 fl oz Pepsi, 1 cup iceberg lettuce, ¼ cup chopped cucumbers, ¼ cup tomatoes, 2 tablespoons ranch dressing 2 medium sized chocolate chip cookies Bed-time snack

Dietary Recall Analysis 90% Estimated daily caloric needs met. 80% Estimated daily protein needs met. Needs Amount Based on Caloric 1, 475 -1, 770 kcals 25 -30 kcal/kg Protein 59 -71 g protein 1 -1. 2 g/kg Fluid 1, 475 m. L 25 m. L/kg

Nutrition Timeline • • NPO for Whipple Procedure (2/20) Clear Liquids (2/21) Full Liquids (2/27) Clear Liquids (2/27) ▫ MNT Initial Assessment ▫ Calorie Count started • TPN initiated (3/2) ▫ Calorie Count canceled • Continue TPN, d/c lipids. Full Liquid. (3/4) • TPN wean with soft diet (3/5) ▫ Calorie Count restarted • Soft Diet (3/6 - discharge)

Nutrition Diagnosis 2/27/15 Nutrition Diagnosis: Etiology: Signs and Symptoms: Suboptimal Oral intake Dislikes clear liquid diet, early satiety, poor appetite, abdominal pain Pt on clear liquid/NPO x 7 days, Pt reports consuming around 25% of clear liquid diet trays.

MNT Intervention • Supplements: Ensure Clear, Unjury, Ensure, Mighty Shake, HP Shake. • 3 day Calorie Count Summary: MK meets 40% estimated daily caloric needs and 40% daily estimated protein needs. • Whipple Diet Education • Monitoring BM, Fiber education, Bowel regimen • Discussed feeding tube with pt and resident. Declined.

Post Whipple Diet Courtesy of the Academy of Nutrition and Dietetics Nutritional Guidelines post Whipple procedure provided by the Academy of Nutrition and Dietetics Eat small frequent feedings (5 to 6 meals per day). Limit fluids at 4 to 5 fl oz per meal. Eat slowly and chew foods thoroughly. Avoid simple sugars in foods and drinks. Include protein at each meal. Limit fat to less than 30%. Avoid sugar alcohols.

Post-Whipple Prognosis • Majority of patients rapidly lose weight after surgery and do not regain it. • Supplementation for iron, calcium, zinc, copper, selenium, and the fat soluble vitamins, A, D, E, and K. • Nutrition Support may be overlooked. • Ongoing diet counseling should be pursued.

M. K’s Prognosis • Mean survival is 10 years for Intraductal Papillary Mucinous Neoplasm of the Pancreas after pancreatic resection. • Depression • Recurrence rate 0 -20% • Strong support system with family • SAR

Goals for M. K • Sub-Acute Rehabilitation • Follow up regarding pancreas state • Improve PO intake • Follow a post Whipple diet to minimize GI side effects.

Bibliography • • • Stump SE. Nutrition and Diagnosis Related Care. 7 th ed. Baltimore Maryland: Lippincott Williams & Wilkins; 2012. Nelms A, Sucher KP, Lacey K, Roth SL. Nutrition Therapy and Pathophysiology. 2 nd ed. Belmont, CA: Cengage; 2011. Gattuso P, Reddy VB, David O, Spitz DJ, Haber MH. Differential Diagnosis in Surgical Pathology. 3 rd ed. Saunders: Elsevier; 2015. Cameron JL, Cameron AM. Current Surgical Therapy. 11 th ed. Elsevier; 2014. Parish et al. Post-Whipple: A Practical Approach to Nutrition Management. Nutrition Issues in Gastroenterology. Series #108. August 2012. Niederhuber JE, Armitage JO, Doroshow JH, Kastan MB, Tepper JE. Abeloff’s Clinical Oncology. 5 th ed. Churchill Livingstone: Elsevier; 2014. Gerritsen et al. Systematic Review of five feeding routes after pancreatoduodenectomy. British Journal of Sugery. Volume 100, Issue 5. 589 -598. January 2013. Sanford D et al. Severe Nutritional Risk Predicts Decreased Long Term Survival in Geriatric Patients Undergoing Pancreaticoduodenectomy for Benign Disease. Journal of American College of Surgeons. Volume 219, Issue 6. 1149 -1156. 2014. Marcason, W. What is the Whipple Procedure and What is the Appropriate Nutrition Therapy for It? Journal of Academy of Nutrition and Dietetics. Volume 115. Issue 1: 168. January 2015. Nolan JD, Johnston IM, Walters RF. Physiology of Malnutrition. Surgery. Volume 30, Issue 6. Elsevier. 268 -274. 2012. Carey S et al. Long term nutritional status and quality of life following major upper gastrointestinal surgery- A cross-sectional study. Clinical Nutrition. Volume 30, Issue 6. 774 -779. 2011.