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

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

3. M.K
81 year old female admitted with Intraductal Papillary Mucinous Neoplasm of the Pancreas.
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

4. Past Medical History Coronary artery disease
Peripheral vascular disease
Hyperlipidemia
Hypertension
Ongoing tobacco abuse
Pancreatic mass in 2010
MK smoked 1 pack of cigarettes per day. Almost 1/3 of pancreatic cancer is attributed to tobacco abuse.

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

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

7. 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

8. What is a Whipple? Pancreaticoduodenectomy Indications:
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

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

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

12. Mayo Foundation. Whipple Procedure. http://www. mayoclinic

13. 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

14. 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

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

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

17. 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.

18. Lab Values Date Sodium Potassium Chloride Bicarbonate
Blood Urea Nitrogen
Creatinine
Glucose
(mEq/L)
(mg/dL)
20-Feb
137
3.6
100 25 19
0.75
146
21-Feb
139
3.7
102 18
0.8
121
22-Feb
3.4 97 28 11
0.7
104
23-Feb
136
3.1 26 9
0.57 84
24-Feb
3.9 99
0.67
25-Feb
138
3.5 95 27 29
0.69
114
27-Feb
135 3 94
0.73
131
28-Feb
133 96 30
1-Mar 24
112
3-Mar
3.3 98 20
0.65
117
4-Mar
132
4.1 22
0.56
119
5-Mar
4.3 21
106
Normal Levels
98-106
22-28
11-20
70-105

19. Medications Medication Usage Nutritional Impact Bisacodyl
Stimulant laxative
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

20. Dietary Recall Meal Components Breakfast
Granola bar, 8 fl oz skim milk
Mid-Morning Snack
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
Bed-time snack
2 medium sized chocolate chip cookies

21. 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
1-1.2g/kg
Fluid
1,475 mL
25 mL/kg

22. 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)

23. Nutrition Diagnosis 2/27/15 Nutrition Diagnosis:
Suboptimal Oral intake
Etiology:
Dislikes clear liquid diet, early satiety, poor appetite, abdominal pain
Signs and Symptoms:
Pt on clear liquid/NPO x7 days, Pt reports consuming around 25% of clear liquid diet trays.

24. 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.

25. 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.

26. 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.

27. 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

28. 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.

29. Bibliography
Stump SE. Nutrition and Diagnosis Related Care. 7th ed. Baltimore Maryland: Lippincott Williams & Wilkins; 2012.
Nelms A, Sucher KP, Lacey K, Roth SL. Nutrition Therapy and Pathophysiology. 2nd ed. Belmont, CA: Cengage; 2011.
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Cameron JL, Cameron AM. Current Surgical Therapy. 11th 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. 5th ed. Churchill Livingstone: Elsevier; 2014.
Gerritsen et al. Systematic Review of five feeding routes after pancreatoduodenectomy. British Journal of Sugery. Volume 100, Issue 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
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
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