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.
157centimeters 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
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Coronary artery disease
Peripheral vascular disease
Hyperlipidemia
Hypertension
Ongoing tobacco abuse
Pancreatic mass in 2010
Social History
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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:
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Pancreatic head
Duodenum
Common bile duct
Gallbladder
Distal portion of stomach
Adjacent lymph nodes
Whipple Procedure Steps:
• Counterclockwise
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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
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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
(mEq/L)
(mEq/L)
(mEq/L)
(mEq/L)
(mg/dL)
(mg/dL)
(mg/dL)
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
1-1.2g/kg
Fluid
1,475 mL
25 mL/kg
Nutrition Timeline
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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 x7 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 residentDeclined.
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
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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:
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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.
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Gerritsen et al. Systematic Review of five feeding routes after pancreatoduodenectomy. British Journal of
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