Whipples Procedure Essay Example

cause damage or alteration to DNA in cells, resulting in incorrect replication of genetic information in subsequent generations of cells (1).

Normal cells are typically differentiated, meaning they have developed specific morphology and function. Errors in DNA replication can cause a decrease in differentiation, resulting in loss of original morphology or function. In cancer cells, proliferation often continues without the need for new cells, and as differentiation decreases, proliferation becomes their main function (1).

Early detection is crucial for effectively treating cancer, as the chances of survival greatly decrease if the cancer has spread. Research has demonstrated that, among patients with staged tumors, only those without any lymph node involvement, an indicator of no metastasis, were able to survive for 5 years (2).

If cancer is detected in its early stages, it can be eradicated or extracted when it is still confined (1). Thus, nutritional intervention focuses on the treatment approach and the site of the cancer (3). The conventional methods to treat cancer are radiation therapy, surgical excision, and chemotherapy. Each technique carries specific repercussions that may predispose patients to dietary complications depending on the tumor site and treatment modality used (3). A comprehensive inventory of potential nutritional consequences is provided in Appendix A, while Appendix B showcases dietary issues based on tumor location and treatment type.

Most patients with preampullary neoplasms are eligible for surgical removal of the tumor. This treatment is typically followed by a combination of radiation and chemotherapy, which has demonstrated to extend survival after curative Whipple resection (4).

Duodenal tumors can often be asymptomatic. However, they may cause blockage or bleeding, resulting in discomfort or cramping pain in the upper abdomen. Nausea and vomiting

may also occur and worsen as the tumor progresses. Tumors located before the ampulla of Vater can lead to painless jaundice, while weight loss is a common symptom (4).

The Whipples procedure is commonly performed for cancer of the head of the pancreas and three types of periampullary neoplasms: ampullary carcinoma, duodenal carcinoma, and distal common bile duct carcinoma. These conditions have similar risk factors such as smoking cigarettes, having diabetes mellitus, exposure to chemical irritants in certain industries, alcoholism, dietary factors, exposure to radiation, and specific ethnic/racial factors (3).

First described by Whipple in 1935, the Whipples procedure remains the standard method for removing a duodenal or preampulary carcinoma. This surgical procedure involves pancreaticoduodenectomy which includes removing the head of the pancreas along with parts of the common bile duct and stomach as well as the entire duodenum. To maintain gastrointestinal tract continuity after surgery, a section of the jejunum is brought up and stitched to connect to what remains of the stomach, common bile duct and pancreas (3).Appendix F provides a visual representation of comparing the appearance of the reconstructed intestinal tract to that of the resected specimen. The perioperative mortality rate for this procedure is less than 5%, indicating it has a low risk and is considered safe. Currently, the Whipple's procedure has an overall survival rate between 15% and 25% after five years. However, individuals with duodenum cancers that can be removed have a higher survival rate ranging from 40% to 60%. There is also an alternative option available during the procedure to preserve the pylorus of the stomach, which aims to alleviate specific gastrointestinal problems. Despite having similar rates of survivability, both

methods raise concerns regarding nutrition, digestion, and absorption. (4) (5).

Dumping syndrome, a common issue following Whipple's procedure, involves the premature emptying of stomach contents into the gastrointestinal tract. Symptoms include nausea, weakness, sweating, palpitation, and diarrhea (6). The pylorus preserving technique has been found to effectively prevent dumping and avoid enterogastric reflux while improving nutritional replenishment of body weight and serum albumin level at 6 months post-discharge compared to pylorus resection (8). Conversely, the pylorus resecting method does not typically cause significant dumping due to the absence of duodenal and pancreatic hormones affecting upper gastrointestinal motility. However, it does permit enterogastric reflux by eliminating the pylorus blocking action (7). This method reduces gastric volume by removing part of the stomach's lower region which can lead to feelings of fullness and early satiety. Inadequate food intake resulting from this can potentially trigger dumping if patients try consuming amounts similar to their preoperative habits (9). It is worth noting that pylorus resection alone may indirectly reduce side effects such as hypoglycemic rebound associated with late dumping syndrome.The excessive release of insulin due to rapid carbohydrate absorption in the small intestine can occur with gastric resection alone (6). This resection reduces insulinotropic hormones like gastrin and gastric inhibitory polypeptide, leading to a shorter reaction time for insulin release. As a result, excess insulin levels and hypoglycemic rebound may be prevented. Regardless of the presence of dumping syndrome, this hormonal change can slightly increase blood glucose levels to approximately 110-120 mg/dl (6.16-6.72 mmol/L) for about 1? to 2 hours (6). Moreover, long-term anemia may occur with the pylorus resecting method due to a potential lack of intrinsic factor required

for vitamin B12 absorption. The severity of this deficiency depends on the extent of gastric resection.

When the pancreas is taken out, there can be other nutritional issues because it has two functions: exocrine and endocrine. Both the secretion of enzymes needed for digestion (exocrine) and the secretion of insulin necessary for controlling blood glucose levels (endocrine) are affected. Studies have demonstrated that maldigestion with steatorrhea happens only when exocrine pancreatic secretion decreases by over 90% compared to normal secretion (11). Diabetes mellitus, which is caused by inadequate production of insulin, typically doesn't occur until more than 70% of the pancreas has been removed (3).

The patient's nutrition may be affected after the gallbladder is removed during postoperative care. This is because the removal reduces the presence of bile salts, which are essential for proper digestion and absorption of fats. Ultimately, this can result in steatorrhea (3).

To avoid dumping syndrome and ensure proper nutrition, it is advised that the patient consume frequent small and dry meals. Fluids should be taken at least 30 minutes before meals or an hour after. It's also essential to limit the intake of simple sugars, as they can speed up stomach emptying and lead to dumping syndrome. Initially, a low-fat diet may be necessary to prevent steatorrhea (3).

Malabsorption in a patient may indicate the need for enzyme replacement. The required amount of enzymes depends on the severity of the insufficiency, which can be determined through pancreatic functional tests such as the serum-PLT or PABA test or measurement of stool fat (11). According to Joanne Franko PDt at St. Pauls hospital, the standard practice is to administer 3 enzyme tablets with meals and

2 with snacks to ensure adequacy.

If the patient displays blood sugars over 11.1 mmol/l without any other contributing factors, they can be classified as diabetic and will need insulin. Meanwhile, glucose levels consistently exceeding the normal range of 5.5mmol/l may necessitate oral glycemic agents for managing blood sugar levels (12).

If the patient exhibits signs of anemia, administering a Shillings Test to test for B12 deficiency is advisable; if a deficiency is detected, the patient will require lifelong regular injections of B12 (6).

The procedure carries two main complications, sepsis and loss of anastomosis integrity. Sepsis is treated with specific antibiotics targeting the infecting agent (4). Healing of the anastomosis can be enhanced by using agents that inhibit pancreatic secretions, particularly proteases. In 1979, somatostatin hormone was first used to prevent exocrine excretion after a Whipples procedure, leading to reduced complications. Subsequently, the synthetic analog octreotite has been preferred due to its lower cost and longer half-life of 90 minutes compared to somatostatin's one minute half-life (13). The effectiveness of this treatment can be observed in Appendix C, which shows its impact on the 11 most common procedure complications. It is evident that octreotite decreases the occurrence of all 11 complications, making it an essential part of gastrointestinal therapy (14).- Whipple's Procedure to remove Ca was booked.
- Preadmission Lab Values from Medical Arts on 17/09/1996 were recorded:
- WBC: 6.0
- Hgb: 152
- Na: 139
- K: 4.3
- Cl: 105
- Urea: 5.3
- Creat: 80
- Random Glucose: 5.1
- The specimen removed included:
- 4cm portion of stomach
- duodenum
-

12cm of small bowel
- pancreas portion measuring 4.0 X 3.0 X 2.5cm
- gallbladder
- There was no evidence of metastasis to lymph nodes.
- A feeding jejunostomy tube was placed, along with two Jackson Pratt tubes to drain anastomoses, a nasogastric tube for gastric suction, and a foley catheter.
- Diet Hx showed that W. F. had a fairly regular intake of approximately 1600-2000 kcal per day, as well as a low daily intake of alcoholic beverages, which contributed to their caloric intake. However, the assessment of the alcoholic beverage intake could not be determined due to its variability. W. F. stated that they had experienced a loss of appetite one month prior to admission, which they attributed to nervousness about their upcoming operation and resulted in a weight loss of approximately 10 lbs.

According to the Metropolitan Life Tables, W. F. was in the appropriate weight range for his height and his diet history showed adequate food intake, which matched his weight. Therefore, there were no indications of nutritional deficiencies posing a risk.

Using the Harris Benidict equation W. Fs REE was assessed at 1700 kcal/day and using stress factors of 1.4 - 1.5 gave a range of approximately 2400 - 2550 kcal/day energy requirement. His protein requirements were assessed at 1.3 - 1.4g/kg of body Wt giving a range of 101 - 109g/day. There were no contraindications to using an intact tube feed formula that was isomolar and since the location of the tube feed presented no danger of aspiration, a noncolored formula would be appropriate. As a result, Osmolite HN was selected from St Pauls list of available products to use as the

entral feeding product. It was calculated that 95ml/hr of Osmolite HN would provide 2400 kcal/day with 100g Pro/day and 1938 ml fluid which would meet the patient's assessed needs. The recommendations for tube feed (T.F.) were set at 25ml/hr full strength for 24 hr then an increase to 50 ml/hr full strength for 8 hr then to 75ml/hr full strength for 8 hr then to the max rate of 95 ml/hr full strength.

1.Maintenance of weight is an indicator of whether the patient is receiving adequate nutritional support, therefore W. F. would have to be weighed throughout his hospital stay.

2. To determine if diabetic intervention is necessary, the blood sugar levels would be tested using chem strip testing to assess the adequacy of insulin production.

3. The presence of steatorrhea and accompanying weight loss can indicate the need for enzyme replacement therapy and assess the sufficiency of digestive enzymes in the exocrine system.

Once the patient has returned to an oral diet, the presence of symptoms can be used to assess dumping syndrome.

26/09: W. F. NPO prior to surgery. Surgical procedure has been completed.

27/09: W. F. is in ICU and in stable condition. NPO. Recommendations for tube feed placement from assessment have been documented in the patient's chart. Chem strips have been started and will be administered four times a day for 48 hours.

28/09: W. F. is sitting up and able to stand. No edema is present. Chem strips are discontinued. NPO.

29/09: W. F. has been transferred to the ward. NPO.

30/09: The doctor has ordered initiation of jejunal tube feed for the next day, with a reduction in

IV. As a result, the patient's temperature begins to increase.

W.F. had a fever on 01/10 and T.F. was withheld due to concerns of leakage. An x-ray was performed on 02/10 to check for leaks in W.F.'s anastomoses, but none were found. T.F. was started at a rate of 25ml/hr. On 03/10, W.F. remained disoriented and feverish, so the T.F. rate was increased to 60 ml/hr in the morning and then further increased to a maximum of 90 ml/hr in the evening.

W.F. continued to be very disoriented and febrile on 04/10, and on 05/10 he attempted to disconnect his I.V., resulting in restraints being applied for safety purposes while he remained in his disoriented state.

On 06/10, W.F. still showed signs of being disoriented and restrained, while experiencing diarrhea on 07/10 prompting x-rays to check for any dehiscing of the anastomoses; however, no dehiscence was observed.

Improvement was seen in W.F.'s condition with more stable temperature readings on 08/10, and by09 /10 he regained orientation regarding time and place while maintaining a stable condition.

When admitted on October-1st , W .F' s weight was recorded as being73 kg which marks a decrease by5kg from his initial admission weight.A request has been made to increase T .F.to100ml/hrin order that it may provide him with2520 Kcal/d &108 g pro/d.The feed has been adjusted accordingly .On October 15th, W.F.'s condition remains stable and the attending doctors or nurses inquire about his weight. On October 22nd, it is noted that there has been a further decrease in weight by 3 kg since October 10th. As a result, a request is made to increase T.F. to 110ml/hr in order to provide W.F. with 2772

Kcal/d and 118.8 g pro/d.

On October 23rd, the rate of T.F. is increased to 110ml/hr and W.F. is also started on clear fluids. His weight at this time is recorded as being 69kg.

On October 24th, W.F. is placed on a full fluids diet and the T.F. rate is reduced to75ml/hr.By supper time, the diet changes to DAT low fat with six small meals.

By October28th, W.F.'s weight increases to69.5kg and he has tolerated the diet well over the weekend.A calorie count begins and W.F.is educated on a low-fat diet with six small meals.A follow-up appointment is scheduled.

W.F.was discharged after an outpatient follow-up visit on November7th ,1996

Wt: 71kg (with clothes on). W. F. states that he has a good appetite and eats three meals and snacks every day but notices food lingering in his stomach. Despite this, his weight remains steady as he tries to follow a low-fat diet. W. F. receives guidance on improving the nutritional quality of his meals and is informed that he can seek further dietary support if needed when starting chemotherapy in January.

Most of W. F.'s laboratory values indicate no notable nutritional concerns. However, his white blood cell count indicates the severity of sepsis he endured and closely aligns with the dates of his elevated Glucose Serum Testing (GST) values. This correlation suggests that the sepsis, rather than pancreatic issues, is the cause of the elevated GST levels.

During W. F.'s hospital stay, he was prescribed multiple medications, but most of them do not affect nutrition. The only medication that directly affects the digestive process is octreotide, which is used to block exocrine excretion in order to promote wound healing.

In hindsight, it

would have been better to begin with the higher range of W.F.'s assessed nutritional requirements, as he continued to lose weight throughout his stay. The doctor only set the maximum rate at 90 ml/hr, which was less than the original calculation, exacerbating the impact of the initial under assessment.

However, the occurrence of sepsis in W.F. increased his requirements beyond what was initially calculated. This unexpected event could not have been predicted or planned for in advance and had to be addressed as it happened.

Osmolite HN was suitable for use as there were no contraindications to using a complete nutrient formula. Additionally, the patient's assessment did not indicate any specific need for a high protein intake that could not be fulfilled by Osmolite HN. As there were no unique requirements, the nutritional content of Osmolite HN adequately matched the patient's energy and protein needs. This enabled subsequent reassessed needs to be addressed by adjusting the flow rate without altering the formula.

After evaluating the lab values, it was found that there were no clear signs of insufficiency. Therefore, the rate of tube feed was increased only after measuring the patient's weight to check if the intake was inadequate. To determine if further adjustments were required, the patient's weight was continuously monitored and made when necessary.

During the patient's hospital stay, enzyme therapy was unnecessary since there were no indications of steatorrhea or pancreatitis.

The GSTs showed slightly elevated values, likely due to the severe sepsis experienced by the patient. Furthermore, a slight rise in blood sugar levels resulting from a delayed response to glucose caused by a deficiency of insulinotropic factors is expected (12). As a result, no

diabetic intervention was necessary.

The assigned meal plan and diet education provided to W. F. were suitable for a patient who had undergone a Whipples procedure. The subsequent follow-up appointment confirmed this as W. F.'s weight remained consistent during the weeks following his discharge.

The nutritional concerns for a patient undergoing a Whipples Procedure depend on the degree of resection of the digestive tract and associated systems. W.F. only experienced an infection, which may have temporarily increased his needs and caused discomfort. However, he did not develop any of the harmful nutritional complications that can occur with this procedure.

The recommendation for the upper end of the patients assessed requirements should have been made to ensure adequacy. However, as previously discussed, unforeseeable occurrences affected W.F.'s needs.

The long term prognosis for W. F. appears to be positive. There is no evidence of cancer spreading to the lymph nodes, and W. F. is adjusting well to his new diet and maintaining his weight. This suggests that there are likely no concerns about nutritional deficiencies at this time. However, potential problems may arise with the chemotherapy treatment scheduled for January.

17/09 6.01521394.31055.3805.1

26/0920.4H1481364.91064.394-

27/0915.3H130L1374.71104.9966.7H

28/0915.8H107L1383.81083.6L81-

29/0916.1H103L1413.71093.4L85-

01/1019.8H106L1354.01013.297-

04/1014.5H 86L1374.01022.6L75-

06/1013.9H 89L1394.11041.5L70-

? Inhibitors of digestive secretions:

- Octreotide, Famotidine, Ranitidine

- Cefuroxime, Ampicillin, Gentamycin, Cefotaxime,

? Antipsychotics & relaxants:

- Haloperidol, Halidol, Librium, Lorazepam,

Bibliography: