Pancreatic Cancer & the Whipple Procedure

1. Medical Management & Nutrition Therapy Guidelines Pancreatic Cancer & the Whipple Procedure Melissa Jakubowski

2. Why Pancreatic Cancer??? • It is estimated that 1 in 68 men and women born today will be diagnosed with cancer of the pancreas at some point during their lifetime • The average life expectancy after pancreatic cancer diagnosis is 3 to 9 months, and the five-year survival rate from point of diagnosis is less than 6%

3. Agenda • Pancreas Anatomy & Function • Pancreatic Cancer • Medical Nutrition Therapy • Presentation of the Patient • Critical Comments

4. The Organs of the Visceral Peritoneum

5. Regions of the Pancreas Gallbladder

6. The Biliary System

7. Pancreas Function Endocrine Exocrine Pancreatic acinarcells: synthesize and store inactive forms of digestive enzymes and alkaline fluid and secrete them into the duodenum via the pancreatic duct • The islets of Langerhans: specialized cells that synthesize and secrete various hormones into the bloodstream and are crisscrossed by a dense network of capillaries

8. Endocrine Cell Types

9. Endocrine Cell Function • The α (Alpha) Cells: secrete the hormone glucagon, which prevents hypoglycemia • The β (Beta) Cells: secrete the hormone insulin, which prevents hyperglycemia • Secrete amylin, which regulates blood glucose spikes postprandial

10. The Digestive System

11. Duodenum: Carbohydrate Digestion DextrinsPancreatic amylase Disaccharides Maltose Maltase Glucose + Glucose Lactose Lactase Glucose + Galactose Sucrose Sucrase Glucose + Fructose

12. Duodenum: Protein Digestion Polypeptide chains Trypsin & Chymotrypsin Shorter chains Carboxypeptidase & aminopeptidase split off one amino acid at a time, working from the ends of the polypeptides Dipeptidasehydrolyzes fragments of only two to three amino acids long

13. Duodenum: Fat Digestion • Bile salts from the liver & gallbladder: emulsify fat globules into smaller fat droplets • Fat droplets Pancreatic lipase Fatty acids & glycerol

14. Pancreatic Cancer: Prevalence • Accounts 44,000 newly diagnosed medical cases annually & 33,000 deaths annually • Significant increasing trend in pancreatic cancer • Fourth most common cause of death from cancer in men and the fifth in women

15. Tumor Site

16. Tumor Histology

17. Prognosis • The average life expectancy after diagnosis is 3 to 9 months

18. Etiology: Non-modifiable Risk Factors African American Male DNA Geriatrics Genetics

19. Etiology: Modifiable Risk Factors Obesity Cigarette Smoking Chemical exposure Alcohol abuse DNA Diet Long-standing Diabetes Chronic pancreatitis

20. Signs and SymptomsPancreatic Exocrine Tumors • Upper abdominal pain or back pain • GI disturbances • Poor appetite • Anorexia • Weight loss • Gallbladder enlargement • Jaundice • Blood clots or fatty tissue abnormalities • The Trousseau sign

21. The TNM staging system

22. Simplified Staging System

23. Diagnosis • By diagnosis, 90% of adenocarcinoma patients have locally advanced tumors that have retroperitoneal structures, spread to regional lymph nodes, or metastasized to the liver or lung • Once metastasized, a distinctive sign is severe upper abdominal pain with weight loss

24. Signs and Symptoms for DiagnosisAdenocarcinoma

25. Non-diagnostic Laboratory Tests

26. Other Blood Tests • Complete Metabolic Panel → to evaluate a patient's general state of health, such as liver, kidney, and bone marrow function • Fat-soluble vitamins: to determine if there is a deficiency associated with fat malabsorption

27. Biochemical Data: CA 19-9 • A tumor marker released into the blood by exocrine pancreatic cancer cells • Sometimes useful during treatment to determine if a treatment is working or after treatment to see if the cancer has recurred • Test is not recommended for routine screening of people without symptoms or a known diagnosis of cancer

28. Biochemical Data: CEA • Carcinoembryonicantigen (CEA), another tumor marker • Can help detect advanced pancreatic cancer in some people • Not sensitive enough to find the cancer early and is not recommended for screening

29. Diagnostic Procedures • Computed tomography (CT, CAT) scan • Magnetic resonance cholangiopancreatography(MRCP) • Endoscopic ultrasound (EUS) • Endoscopic Retrograde Cholangiopancreatography(ERCP)

30. Diagnostic Procedures

31. Treatment • Approximately $1.9 billion dollars are spent in the U.S. each year for pancreatic cancer treatment • Treatment may also be completed as part of palliative care • Standard treatment can involve: • Chemotherapy • Radiation therapy • Chemoradiation therapy • Targeted therapy • Surgery

32. PancreaticoduodenectomyWhipple Procedure • The removal of the: • Head of the pancreas • Duodenum • Lymph nodes near the pancreas • Gallbladder • Part of the common bile duct • Part of the stomach (sometimes)

33. The Whipple Procedure

34. Candidacy • Indication: resectable cancer in the head of the pancreas, duodenum, and/or distal bile duct • Contradiction: tumor is too large to be surgically removed • The surgery can sometimes be completed as part of palliative care

35. Potential Complications of the Whipple Procedure • Fistulas • Infection • Bleeding • Gastroparesis • Abscess inside the abdomen • Pancreatitis • Organ failure • Decreased appetite with consequent unintended weight loss • Decreased ability to digest fats sufficiently • Risk of dumping syndrome • 15-25% increased risk of becoming diabetic

36. Other Surgeries for Pancreatic Cancer Distal pancreatectomy Total pancreatectomy

37. Medications • Pain-killers • Antiemetics & antinauseants • Appetite stimulants • Stool softeners or stimulant laxatives • Soluble fiber supplements • Pancreatic enzymes • Proton pump inhibitors • Oral hypoglycemics or SQ insulin

38. The Role of the RD: Why? Pancreatic Cancer symptoms Treatment side effects Diarrhea Nausea Vomiting Dry mouth Stomatitis Tender gums Sore throat Trouble swallowing/chewing • GI disturbances • Pain • Poor appetite • Anorexia • Weight loss • Diabetes • Steatorrhea

39. The Role of the RD: Why? Whipple Complications • Diabetes • Weight loss • Dumping syndrome • Steatorrhea • Vitamin deficiency

40. Nutrition Care Process Assessment (A) Diagnosis (D) Intervention (I) Monitoring (M) Evaluation (E)

41. Assessment

42. Needs Assessment Based on the American Nutrition and Dietetics Evidence Library: Calorie Needs • 25-30 kcal/kg for maintenance • 30-35+ for repletion Protein Needs • 1.0-1.2 g/kg for maintenance • 1.2-2.0 g/kg for repletion

43. Nutrition Diagnosis • Malnutrition related to alteration in gastrointestinal tract structure/function • Secondary diagnoses: inadequate oral or energy intake, unintended weight loss, altered GI function, increased needs

44. Interventions & Monitoring/Evaluation: Pancreatic Cancer • Reduce and control nausea and vomiting • Prevent or correct weight loss and restore lean body mass • Control side effects of therapies and the disease • Monitor for depression and associated disordered or inadequate eating habits • Address identified micronutrient deficiencies

45. Intervention & Monitoring/Evaluation: Post-op Whipple • Dietary recommendations: • Small, frequent meals • Low fat diet (40-60 g/day) • No concentrated sweets if experiencing glucose intolerance and/or dumping syndrome • Low-fiber diet 1-2 weeks post-op • At least 64 fluid ounces of fluids per day • Avoid fluid consumption 1 hour pre- and post-prandial • Multi-vitamin supplementation

46. Post-op Whipple Addressing Vitamin Deficiencies • Fat-soluble vitamins • Vitamin B12 • Calcium • Selenium • Zinc • Iron

47. Nutrition Support: Route • Preferred method: J-tube • TPN only indicated when the GI tract is nonfunctioning • After a Whipple, GI functionality improves gradually… If the gut works, use it!

48. Nutrition Support: Formulas • Elemental formulas • Almost entirely amino acid-based, 2-3% calories from fat • Semi-elemental formulas • Peptide-based, MCT-based

49. Perioperative Nutrition Support • Surgery and trauma state can induce an arginine deficiency • Some evidence indicates that the use of immunomodulatingformulas (IMFs) in enteral feedings both before and after surgery can be beneficial

50. Presentation of the Patient • Initials: E.C. • Code Status: AND • 81 years old • Female • Caucasian