WHIPPLE PROCEDURE

CASE STUDY
P R E S E N T E D B Y: A N A S E S A T T Y , D I

HISTORY & PHYSICAL

VA is a 69 y.o. male, retired, Mexican American
PMH: GERD, hernia repair
Admitted to Methodist Specialty and Transplant
Hospital on July 17, 2015.
Signs & symptoms: abdominal pain, nausea, jaundice
Medical diagnosis: cholelithiasis pancreatitis with
pancreatic head mass

HISTORY & PHYSICAL

Pancreatic head mass

4 cm benign mass with atypical cells

Common bile duct obstruction
Common bile duct stent on July 20
Discharged July 22

Referred to Methodist Hospital for

Whipple procedure
Scheduled for September 1, 2015.

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PATHOPHYSIOLOGY
Cholelithiasis
Gallstones can be formed from:
Excess water or bile acid absorption
Excess cholesterol in bile
Cholesterol can precipitate

Pancreatitis
Gallstones block pancreatic duct

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Pancreas becomes inflammed

Cholelithiasis accounts for 45% of acute pancreatitis

PATHOPHYSIOLOGY
Pancreatic head mass
Acute or chronic pancreatitis
Activates pancreatic enzymes inside
the pancreas

Inflammatory cysts form

Cancerous or precancerous
Contain fluid
Commonly small but can be large
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MEDICAL DIAGNOSIS
Dx: Pancreatic head mass
Pancreatic head cancerous tumors

account for 60% of pancreatic cancers

Pancreatic head cystic tumors

account for 2% of pancreatic tumors

Different types of cysts

Can be located in the head, body, or tail of the pancreas

Malignant potential

If left untreated may evolve to a malignant tumor

DIAGNOSTIC TESTS
Endoscopic ultrasound
(EUS)
Thin, flexible tube with a
probe inserted through
mouth or anus
Detected the presence of
gallstones

Computerized tomography
(CT) scan
X-ray cross section images
Detected the presence of
pancreatic mass

Endoscopic retrograde
cholangiopancreatography
(ERCP)
Endoscope with camera
Placed common bile duct
stent

Biopsy
Cellular examination of
tissues
Pancreatic mass benign
with atypical cells

SIGNS & SYMPTOMS

Cholelithiasis
Pancreatitis

Abdominal pain
Fever
Jaundice
Nausea
Vomiting

Pancreatic Duct
Obstruction

Abdominal pain
Steatorrhea
Jaundice
Weight loss
Ascites

MEDICAL TREATMENT
Pancreaticoduodenectomy (PD)
Known as Whipple procedure
Common treatment for pancreatic cancer tumors and
pancreatic cysts that are:

Cancerous or precancerous
Obstructing biliary duct system
Causing jaundice
Causing dilation of the main pancreatic duct

Jejunal feeding tube placement

Robotic-assisted PD

PANCREATICODUODENECTOMY

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PROGNOSIS
Pancreatic cancer
Survival rates of <5 years even with tumor resection

Postoperative Whipple procedure

Mortality rates of <5% often less <2%
Complication rates of 30%-60%

Pancreatic fistulas
Surgical site infections
Hemorrhages
Intraabdominal abscess

Approximate hospital length of stay

6-9 days

NUTRITIONAL COMPLICATIONS
Delayed gastric
emptying
20%-25% of patients

Dumping syndrome
Weight loss
Hyperglycemia
(diabetes)
20%-50% of patients

Pancreatic
insufficiency
Maldigestion
Malabsorption
Lactose intolerance
Early satiety
Nutrient deficiencies

NUTRITION RECOMMENDATIONS
Pancreatic enzymes
Nutrient supplementation

Iron
Calcium
Folate
Zinc
Copper
Selenium
Fat soluble vitamins (A, D, E, K)
Vitamin B12
Fatty acids

Early nutrition intervention

Moving towards the

fast-track approach
Nasogastric tube removed
within 24 hrs post op
Clear liquid diet started
within 1-2 days post op
Advance to regular diet by
day 4-5.
Individualized diet
Tailored for individual symptom
management

NUTRITIONAL CONSIDERATIONS
Enteral nutrition
proven superior to
total parenteral
nutrition in
pancreatic cancer
patients post op
Whipple procedure

NUTRITIONAL CONSIDERATIONS
What is the optimal feeding
route?
European nutrition guidelines
Routine enteral feedings post
op

Fast track diet and GJT

shown to have shorter
lengths of hospital stay
Normal oral intake shown to
resume faster with fast
track diet alone
Average of 6 days

Keep in mind patient

variability
Individualize nutritional
needs and intervention

NUTRITION ASSESSMENT
Height: 5 ft 5 in Weight: 154#/70kg

BMI: 25.6

IBW: 136#/62kg IBW%: 113% (mildly overweight)

UBW: 168#/76kg

UBW%: 92% (mild deficit)

Diet Hx: Minimal PO intake in the last few weeks due to

early satiety and abdominal pain, reported 10# weight
loss in few weeks

Weight loss %: 8.3% (severe)

NUTRITION DIAGNOSIS
Problem:

Inadequate oral intake

Etiology:

Related to altered GI function

Signs & symptoms:

As evidenced by pt NPO and on JT feedings.

ESTIMATED NUTRIENT NEEDS

Calories: 1750 2100 kcal/day
25-30 kcal/kg CBW 70kg
Maintain healthy BW

Protein: 84-105 gm/day

1.2 1.5 gm/kg CBW 70kg
Promote wound healing
Preserve lean body mass

Fluid: 1750 2100 mL/day or

per MD
1.0 mL/kcal
Maintain hydration status
Pt received IV fluids

LABORATORY VALUES
Laboratory
Tests
Glucose
(mg/dL)

Referenc
eRanges

Post op
day 2

Post op
day 3

Post op
day 6

Post op
day 7

Post op
day 8

Laboratory Values
Interpretation

70 99

196

164

265

308

179

Surgery/trauma,
pancreatic insufficiency
Inflammatory response
from
surgery/pancreatitis

Albumin
(g/dL)

3.4 5.0

2.6

2.4

2.3

2.3

2.0

AST
(IU/mL)

5 40

85

51

Liver trauma from

surgery

ALT (IU/mL)

4 36

162

162

Liver trauma from

surgery

ALK PHOS,
TOTAL
(IU/L)

50 136

273

289

276

238

199

Cholestasis from biliary

obstruction

4.0 5.7

6.7

Indicative of diabetes

Hgb A1c

MEDICATIONS
Generic Name

Medical Uses

Nutritional Significance

Pepcid

H2 blocker that reduces stomach

acid secretion.

Treats GERD, stomach ulcers, and

common heartburn. VA has a history of
GERD.

Zofran

Antiemetic used to prevent and/or

treat nausea and vomiting.

VA experiencing nausea and severe

emesis on post op day 6.

Miralax

Laxative to stimulate bowel

movements.

Treats constipation or irregular bowel

movements.

Reglan

Stimulates GI muscle contractions to

increase gastric emptying

Treats hearburn and GERD. Stimulates

bowel movements.

Sliding scale insulin

(SSI)

Insulin regimen based on individual

blood glucose levels to control and
normalize blood glucose levels

Treats hyperglycemia and diabetes.

Controlling and normalizing VAs blood
glucose levels.

NUTRITION INTERVENTION
POST OP DAY 2
Current diet: Vivonex RTF @ 15 ml/hr
Goal:
Meet estimated nutrient needs this admit

Intervention:
Vivonex RTF goal of 75 ml/hr = 1800 kcals, 90 g pro (1.3 g/kg CBW),
and 1530 mLs of free H2O
Increase by 10 mL q 12 hrs to goal rate of 75 ml/hr

Monitoring:
TF tolerance
Diet advancement
Diet orders

Vivonex RTF: 1 kcal/L elemental formula

100% free AA and only 10% fat

NUTRITION INTERVENTION
POST OP DAY 3
Pt feeling well and tolerating tube feedings.
Current diet: Vivonex RTF @ 20 ml/hr
Meeting 27% of estimated nutrient needs
Goal rate of 75 ml/hr increasing by 10 ml q 12 hrs

Goal:
Meet estimated nutrient needs this admit

Intervention:

Increase Vivonex RTF by 10 mL q 12 hrs to goal rate of 75

ml/hr
H2O flushes per MD

Monitoring:

NUTRITION INTERVENTION
POST OP DAY 6

Pt with severe emesis did not tolerate clear liquids, NPO d/t
NGT placement for suction
Current diet: Vivonex RTF @ 55 ml/hr
Meeting 73% of estimated nutrient needs
Goal rate of 75 ml/hr increasing by 10 ml q 12 hrs

Goal:
Meet estimated nutrient needs this admit

Intervention:

Increase Vivonex RTF by 10 mL q 12 hrs to goal rate of 75 ml/hr

H2O flushes per MD
Discussed avoiding simple sugars and starting with sugar free foods
when diet advances

Monitoring:
TF tolerance, diet advancement, and diet orders

NUTRITION INTERVENTION
POST OP DAY 7
Pt feeling better no N/V remains NPO, elevated glucose
levels
Current diet: Vivonex RTF @ 70 ml/hr
Meeting 93% of estimated nutrient needs
Goal rate of 75 ml/hr
296 g CHO

Goal:
Meet estimated nutrient needs this admit

Intervention:

Glucerna 1.2 cal goal of 65 ml/hr = 1872 kcal, 94 g pro (1.3 g/kg
CBW), 178 g CHO, 1256 ml free H2O
H2O flushes per MD

Monitoring:

NUTRITION INTERVENTION
POST OP DAY 8

Pt tolerated sips of water and juice, talking to case manager

about home health for d/c in 1-2 days, pt placed on SSI
Current diet: Vivonex RTF @ 70 ml/hr + Clear liquids
Meeting 93% of estimated nutrient needs
Goal rate of 75 ml/hr

Goal:
Meet estimated nutrient needs this admit

Intervention:
Osmolite 1.2 cal goal rate of 65 ml/hr = 1872 kcal, 87 g pro (1.2 g/kg
CBW)
Initiate at 30 ml/hr and increase by 10 ml q 6 hrs
180 mls H2O flushes QID

Monitoring:
TF tolerance, diet advancement, and diet orders

NUTRITION INTERVENTION
POST OP DAY 9
Pt tolerated few pieces of fruit and will d/c tomorrow.
Current diet: Osmolite 1.2 @ 40 ml/hr + post gastrectomy
Meeting ~60% of estimated nutrient needs
Goal rate of 65 ml/hr increasing by 10 ml q 6 hrs

Goal:
Meet estimated nutrient needs this admit

Intervention:
Increase by 10 ml q 6 hrs to goal of 65 ml/hr
180 mls H2O flushes QID
Will provide post Whipple sx diet education before d/c

Monitoring:
TF tolerance, diet advancement, and diet orders

NUTRITION INTERVENTION
POST OP DAY 10
Post Whipple sx diet education consult
Current diet: Osmolite 1.2 @ 65 ml/hr + post gastrectomy
Meeting 100% of estimated nutrient needs

Goals:
Pt will consume 5-6 meals/snacks each day
Pt will drink liquids 30 mins before/after solid foods

Intervention:

Discussed and provided printed materials regarding:

Eating tips
Nutrition strategies for complications and symptoms
Lists of foods recommended and foods to avoid
Keeping food journal to identify foods that cause distress

Discussed and printed materials from the ADA Nutrition Care Manual
Whipple surgery nutrition therapy

CONCLUSION
VA discharged September 11, 2015
Osmolite 1.2 cal @ 65 ml/hr with 180 mLs H2O flushes
QID
Meeting 100% of estimated nutrient and fluid needs

Referred to outpatient clinic

Monitor tube feedings and surgical recovery

Good prognosis

REFERENCES
Academy of Nutrition and Dietetics. Whipple Surgery Medical Nutrition Therapy. Nutrition Care
Manual website.
https://www.nutritioncaremanual.org/vault/2440/web/files/Client-Ed/NCM/2014/WhippleSurgeryNutr
itionTherapy.pdf
. Accessed September 21, 2015.
Berry AJ. Pancreatic Surgery: Indications, Complications, and Implications for Nutrition
Intervention. Nutrition in Clinical Practice. 2013;28:330-357.
Chen S, Chen J, Zhan Q, et al. Robot-assisted laparoscopic versus open pancreaticoduodenectomy:
a prospective, matched, mid-term follow-up study. Surgical Endoscopy. 2015.
Gallstones (Cholelithiasis). University of California San Francisco Department of Surgery website.
http://www.surgery.ucsf.edu/conditions--procedures/gallstones-(cholelithiasis).aspx. Accessed
September 20,2015.
Gerritsen A, Besselink MGH, Gouma DJ, Steenhagen E, Borel Rinkes, I. H. M, Molenaar IQ.
Systematic review of five feeding routes after pancreatoduodenectomy. British Journal of Surgery.
2013;100:589-598.
Lee P, Stevens T. Pancreatic Neoplasms. Cleveland Clinic website.
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/gastroenterology/pancrea
tic-neoplasms/Default.htm
. Published February 2014. Accessed September 20, 2015.

REFERENCES
Liu C, Du Z, Lou C, et al. Enteral Nutrition Is Superior to Total Parenteral Nutrition for
Pancreatic Cancer Patients Who Underwent Pancreaticoduodenectomy. Asia Pacific
Journal of Clinical Nutrition. 2011;20:154-160.
Mahan LK, Escott-Stump S, Raymond JL, Krause MV.Krause's Food & the Nutrition
Care Process. 13th ed. St. Louis, Mo: Elsevier/Saunders; 2012.
Marcason W. What is the Whipple procedure and what is the appropriate nutrition
therapy for it? Journal of the Academy of Nutrition and Dietetics. 2015;115:168.
Munsell MA, Buscaglia JM. Acute pancreatitis. Journal of hospital medicine.
2010;5:241.
N. Decher, A. Berry. Post-Whipple: A practical approach to nutrition management
Practical Gastroenterol, 36 (8) (2012), pp. 3042.
http://www.medicine.virginia.edu/clinical/departments/medicine/divisions/digestive-h
ealth/nutrition-support-team/nutrition-articles/Decher_Berry_Aug_12.pdf
. Accessed September 21, 2014
Pancreatic Cysts and Pseudocysts. Cleveland Clinic website.
http://my.clevelandclinic.org/health/diseases_conditions/hic_Pancreatitis/hic-pancrea