Whipples Procedure Essay

This essay has a total of 3608 words and 23 pages.

Whipples Procedure



Whipple’s Procedure









Dietetic Intern
1996














Personal Data:

Name: W. F.
Date of Admission: Sept. 26 1996
Admitting Diagnosis: Ca of the Duodenum
Age: 48 yrs
Sex: M
Ht: 180 cm
Admission Wt: 77.9 kg
Attending Physician: Dr. G. Groot

Social Hx:

W. F. is divorced and lives alone in a private dwelling. He has worked as a city bus
driver for the past 10 yrs and plans to return to his job when he is able. W. F. also
works part time as a carpenter with a friend doing custom carpentry after his day job
ends.

W. F. received support by regular visits from his girlfriend and family located in the
city. Other family members live elsewhere but were in contact with him.

W. F. was a pack/day smoker for approximately 30 yrs and is currently trying to quit he
also usually has 2 beer or glasses of wine/day after work with supper.


Surgical Hx:

W.F. has had an appendectomy as well as nasal surgery 1991 to correct his snoring difficulties.

Hx of current illness:

In the summer of 1995 W. F. experienced heartburn & epigastric pain and was diagnosed (Dx)
with having an active duodenal ulcer and treated with Histamine H2 receptor blocking agent
Ranitidine to reduce gastric acidity and alleviate the ulcer. The symptoms eased but
persisted so in August 1996 the Dr. booked W.F. for a gastroscopy and a biopsy was taken
from the lesion. At this time a Dx of Adenocarcinoma, moderately differentiated, was made.


Etiology & Pathogenesis of Disease
The occurrence rate of cancer of the small intestine in Canada is approximately
17/100,000. Adenocarcinoma of the small intestine is said to form less than one percent of
all intestinal carcinomas but is the most common small intestinal malignancy (1).
Epidemiological studies have shown that there are many different possible causative agents
for the development of cancer. They include viruses, a wide variety of chemicals, both
ionizing and ultraviolet radiation, and even inherited forms of tumors such as
retinoblastoma (1).

The common element amongst all the causative factors is that they cause damage to or
alteration of the DNA in the cells leading to improper reproduction of the genetic
information in the next cell generation (1).

Most normal cells are differentiated, a term that indicates that they have developed
specific morphology and function. A series of errors in the reproduction of the DNA can
lead to a reduction in the degree of differentiation i.e. the loss of original morphology
or function. In a cancer cell, proliferation usually continues independent of a
requirement for new cells and as differentiation decreases the cells begin to adopt
proliferation as their primary function (1).

Early diagnosis is necessary for the successful treatment of cancer. If the cancer has
metastasized, the prognosis for survival in not good. It has been shown that in patients
with staged tumors the only patients who survived 5 years were those without lymph node
involvement, which is an indicator of a lack of metastasization (2).

If the cancer is caught early it can be destroyed or removed while it is still isolated
(1). Nutritional intervention therefore is concerned with the type of treatment and the
location of the cancer (3). The three traditional treatments for cancer are radiation,
surgical removal of the cancer and chemotherapy. Each has specific consequences which can
predispose the patient to nutritional problems based on the location of tumors and the
type of treatment used (3). A full list of possible nutritional consequences is given in
Appendix A as well nutritional problems based on location of tumor and type of treatment
are shown in Appendix B.

The majority of patients with preampullary neoplasms are candidates for operative
resection of the tumor. This treatment is usually followed by a combination of radiation
and chemotherapy which has show to prolong survival after curative Whipple resection (4).

Duodenal tumors are often asymptomatic but when symptoms do arise, they are usually
related to either obstructive phenomena or bleeding. Epigastric discomfort or cramping
pain associated with nausea and/or vomiting can increase with the severity of the lesion
while preampullary tumors may be associated with painless jaundice. Weight loss is also a
common symptom of these tumors (4).


Whipple’s Procedure
Cancer of the head of the pancreas and three periampullary neoplasms ( ampullary
carcinoma, duodenal carcinoma, and carcinoma of the distal common bile duct ) are the most
common reasons this procedure is done. All of these have been found to have similar risk
factors for their development. These include cigarette smoking, diabetes mellitus,
industrial exposure to chemical irritants, alcoholism, dietary factors, exposure to
radiation, and ethnic and racial factors (3)

The Whipple’s procedure is the standard for removal of a duodenal or preampulary
carcinoma. It involves a pancreaticoduodenectomy, first described by Whipple in 1935. The
procedure involves the resection of the head of the pancreas, the distal portion of the
common bile duct, the distal portion of the stomach, and the entire duodenum. A segment of
the jejunum is brought up and sewn to the remaining portion of the stomach, common bile
duct, and pancreas to maintain the integrity of the gastrointestinal tract (3). A diagram
of the reconstructed intestinal tract with the resected specimen can be found in Appendix
F. This procedure has a perioperative mortality of less than 5 percent as evidence of its
low risk and safety. At present the overall 5 year survival rate for recipients of the
Whipple’s procedure is 15 to 25 percent but the survival rate of individuals with
resectable cancers of the duodenum is 40 to 60 percent (4). There is currently an optional
method of performing the procedure which preserves the pylorus of the stomach in an
attempt to alleviate some of the gastrointestinal problems associated with the procedure
(4). While there is no difference in the survivability rates between these two modalities
there are some differences in the nutritional/digestion and absorption concerns created by
the procedure (5).

Nutritional Concerns
A common concern for post Whipple’s procedure patients is dumping syndrome which is the
early emptying of the stomach contents into the gastrointestinal tract leading to possible
symptoms of nausea, weakness, sweating, palpitation and often diarrhea (6). The pylorus
preserving method was theorized to prevent this and research has shown that patients with
this procedure do not show the tendency towards dumping (7). This version of the procedure
also helps to prevent enterogastric reflux (7) and has shown to improve the nutritional
repletion of both the body weight and the serum albumin level at 6 months after discharge
over that experienced by patients with pylorus resection (8).

The pylorus resecting method does not cause a large amount of dumping to occur due to the
loss of duodenal and pancreatic hormones that effect upper gastrointestinal motility but
it does however allow for enterogastric reflux by removing the blocking action of the
pylorus (7). There is also a reduction in gastric volume from the resection of the lower
portion of the stomach which leads to a feeling of fullness and early satiety. The early
satiety can lead to an insufficient intake of food and if the patient attempts to eat
preoperative amounts they can precipitate the dumping (9).

The pylorus resecting method may indirectly reduce the late dumping syndrome side effect
of a hypoglycemic rebound. This due to excess insulin released in response to the rapid
uptake of the carbohydrates dumped into the small intestine which can occur in gastric
resection alone (6). The resection causes a reduction in insulinotropic hormones such as
gastrin and gastric inhibitory polypeptide. This leads to a reduction in the reaction time
of insulin release and can reduce the excess insulin level thereby avoiding the
hypoglycemic rebound. Whether there is dumping syndrome or not the hormone alteration will
cause a slightly elevated blood glucose level (110 - 120 mg/dl ) = ( 6.16 - 6.72 mmol/L)
that will last approximatly 1 & 1/2 to 2 hours (10).

The pylorus resecting method may also lead to anemia over the long term as a possible
insufficiency of intrinsic factor necessary for vitamin B12 absorption can occur depending
on the degree of gastric resection (6).

Other nutritional concerns stem from the resection of the pancreas. This is due to the
fact that the pancreas is the source of both the exocrine secretion of many of enzymes
necessary for digestion and the endocrine secretion of insulin necessary for blood glucose
control. However research has shown that not until exocrine pancreatic secretion has been
reduced by more than 90% of the normal secretion does maldigestion with steatorrhea result
(11). Diabetes mellitus can be the result of insufficient insulin however it does not
usually develop until more than 70% of the pancreas is removed (3).

The removal of the gallbladder may also effect the nutrition of the patient post
operativly by restricting the amount of bile salts necessary for fat digestion and
absorption leading to steatorrhea (3).



Treatment of Nutritional Concerns
To reduce the risk of dumping syndrome and to ensure adequate nutritional intake the
patient is encouraged to eat small, frequent, dry meals with fluids taken at least half
and hour before and one hour after the meal. Limiting of simple sugars which can increase
the rate of gastric emptying will also aid in avoiding dumping from occurring. As well a
low fat diet may initially be required to avoid steatorrhea (3).

If there are signs of malabsorption the patient will require enzyme replacement. There are
many types available and the amount required will depend on the degree of insufficiency
which can be determined by pancreatic functional tests such as serum-PLT or PABA test or
measurement of stool fat (11). Joanne Franko PDt at St. Paul’s hospital stated that the
standard practice is to give 3 enzyme tablets with meals and 2 with snacks to ensure
adequacy.

If the patient shows signs of blood sugars over 11.1 mmol/l without any other contributing
factors, they can be considered diabetic and will require insulin. While values that are
consistently above the normal range of 5.5mmol/l may require oral glycemic agents to help
control the blood sugar levels (12).

If the patient shows signs of anemia a test for B12 deficiency such as the Shillings Test
should be performed and if a deficiency is discovered the patient will need regular
injections of B12 for the rest of their life (6).




Complications
The two most common complications of the procedure are sepsis and loss of the integrity of
the anastomoses created. The control of the sepsis is managed with antibiotics specific to
the infecting agent (4). The healing of the anastomoses can be aided through the use of
agents that block pancreatic secretions especially the proteases. The use of the hormone
somatostatin to block exocrine excretion following a Whipple’s procedure was first done in
1979 and resulted in a decrease in complications. Since then the synthetic somatostatin
analogue, octreotite, has been used for this purpose since it is cheaper and has a 1/2
life of 90 min. compared to somatostatin’s 1/2 life of 1 min. (13) The effectiveness of
this treatment can be seen in Appendix C which shows its effect on the 11 most common
complications of the procedure. It can clearly be seen that it reduces the occurrence of
all 11 and as such is an important part of the gastrointestinal therapy (14).


CASE
- W. F. was admitted Sept. 26 1996
- presented with Cancer of Duodenum
- Booked for Whipple’s Procedure to remove Ca
- Ht: 180cm Wt:77.9kg
- IBW: 71.4-77.3 kg UBW: 83 kg
- Preadmission Lab Values from Medical Arts 17/ 09 1996
WBC: 6.0, Hgb: 152, Na:139, K:4.3, Cl:105,
Urea:5.3, Creat:80, Random Glucose:5.1
Surgery Results
- Specimen removed includes 4cm portion of stomach, duodenum, 12cm of
small bowel, pancreas portion 4.0 X 3.0 X 2.5cm, gallbladder
- No evidence of metastasis to lymph nodes
- Placement of feeding jejunostomy tube, 2 Jackson Pratt tubes to drain
anastomoses, naso gastric tube for gastric suction, and foley catheter
for urine drainage.

Nutritional Management
Diet Hx showed W. F. had a fairly regular intake of approx. 1600-2000 kcal per day plus a
Continues for 12 more pages >>




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