FROM THE ACADEMY Question of the Month
What Is the Whipple Procedure and What Is the Appropriate Nutrition Therapy for It?
T
HE AMERICAN CANCER Society estimates that in 2014 there will be 46,420 new cases of and 39,590 deaths from pancreatic cancer.1 Pancreatic cancer accounts for about 3% of all cancers in the United States, and accounts for about 7% of cancer deaths.1 The treatment options for pancreatic cancer include surgery, chemotherapy, radiation, or a combination of these therapies. Pancreaticoduodenectomy (PD), popularized by A. O. Whipple, MD, in the late 1930s, is the standard surgical treatment for tumors of the pancreatic head, proximal bile duct, duodenum, and ampulla.2 This complex surgical procedure has undergone several technical modifications but is still generally referred to as the “Whipple procedure.” The classic PD procedure involves removing the head of the pancreas along with the distal bile duct, gallbladder, duodenum, first few centimeters of the jejunum, and the distal stomach (often about 50%) along with the pylorus.3 The nutritional complications that may develop from the Whipple procedure include delayed gastric emptying (gastroparesis), dumping syndrome, weight loss, diabetes mellitus, nutrient deficiencies, and malabsorption due to pancreatic exoc r i n e i n s u f fi c i e n c y. 4 I n a d d i t i o n , patients undergoing gastric surgeries are at a greater risk of developing malnutrition. Early identification and management of malnutrition risk improves and protects nutrition status and quality of life.5 More clinical research is needed to evaluate the appropriate nutrition support options—oral, enteral, or parenteral—when trying to correct nutritional status in these patients. The degree and types of complications that may develop depend on a
This article was written by Wendy Marcason, RDN, of the Academy of Nutrition and Dietetics’ Knowledge Center Team, Chicago, IL. Academy members can contact the Knowledge Center by sending an e-mail to [email protected]. http://dx.doi.org/10.1016/j.jand.2014.11.005
168
number of factors, including the extent of pancreatic disease, how the anatomy is altered during surgery, and the number of symptoms that may arise after surgery.3 The Academy of Nutrition and Dietetics’ Nutrition Care Manual6 lists some of the major issues that might arise:
Gasrtroparesis may occur in one-quarter to half of patients having surgery and usually resolves itself within a few months. Symptoms to be aware of are nausea, vomiting, bloating, early satiety, and abdominal pain. Dumping syndrome may occur 30 to 60 minutes after eating or may take 2 to 3 hours to develop. Pancreatic insufficiency and weight loss even with adequate intake may be noted. Pancreatic enzymes are prescribed in appropriate amounts to compensate for this. Diabetes resulting from decreased insulin production may develop in 20% to 50% of patients following surgery.3 Educating the patient about the classic symptoms of diabetes (excessive thirst and hunger, frequent urination, fatigue, and unintentional weight loss) is essential and appropriate nutritional education for the management of blood glucose. Nutrient deficiencies may result from the lack of food intake, malabsorption, or maldigestion after surgery. The most common nutrients of concern are iron; calcium; zinc; copper; selenium; and vitamins A, E, D, and K. Small bowel bacterial overgrowth may develop, with symptoms that include nausea, gas, bloating, diarrhea, vitamin B-12 deficiency, and elevated folate. Treatment usually requires antibiotics. Lactose intolerance may be an issue after surgery, causing gas,
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
bloating, or diarrhea after consumption of milk or milk products. General nutrition postgastrectomy4:
guidelines
eat small, frequent feedings (5 to 6 meals/day); limit fluids to 4 to 5 oz at a meal, drink other fluids 30 to 40 minutes after eating; eat slowly and chew foods thoroughly; avoid simple sugars in foods and drinks; include protein at each meal; limit fat to less than 30%; and avoid sugar alcohols.
Health professionals need to be more vigilant for symptoms after major gastrointestinal cancer surgeries, and the registered dietitian nutritionist is in a unique position to provide counseling to minimize gastrointestinal symptoms and improve nutritional status and quality of life.
References 1.
American Cancer Society. What are the key statistics about pancreatic cancer? http:// www.cancer.org/cancer/pancreaticcancer/ detailedguide/pancreatic-cancer-key-statistics. Accessed October 14, 2014.
2.
Pallisera A, Morales R, Ramia JM. Tricks and tips in pancreatoduodenectomy. World J Gastrointest Oncol. 2014;6(9):344-350.
3.
Decher N, Berry A. Post-Whipple: A practical approach to nutrition management. Practical Gastroenterol. 2012;36(8):30-42. http://www.medicine.virginia.edu/clinical/ departments/medicine/divisions/digestivehealth/nutrition-support-team/nutritionarticles/Decher_Berry_Aug_12.pdf. Accessed October 14, 2014.
4.
Matarese LE, Mullin GE, Raymond JL. The Health Professional’s Guide to Gastrointestinal Nutrition. Chicago, IL: Academy of Nutrition and Dietetics; 2015.
5.
Academy of Nutrition and Dietetics Evidence Analysis Library. Screening for Malnutrition Risk and Referral of Adult Oncology Patients 2013. http://www.andeal.org/template.cfm? template¼guide_summary&key¼4159& RESET¼TRUE. Accessed October 14, 2014.
6.
Academy of Nutrition and Dietetics. Nutrition Care Manual. Gastric Surgery. http:// www.nutritioncaremanual.org/topic.cfm? ncm_category_id¼1&lv1¼5522&lv2¼145 083&ncm_toc_id¼19309&ncm_heading¼ Nutrition%20Care. Accessed October 14, 2014.
ª 2015 by the Academy of Nutrition and Dietetics.
What Is the Whipple Procedure and What Is the Appropriate Nutrition Therapy for It?
T
HE AMERICAN CANCER Society estimates that in 2014 there will be 46,420 new cases of and 39,590 deaths from pancreatic cancer.1 Pancreatic cancer accounts for about 3% of all cancers in the United States, and accounts for about 7% of cancer deaths.1 The treatment options for pancreatic cancer include surgery, chemotherapy, radiation, or a combination of these therapies. Pancreaticoduodenectomy (PD), popularized by A. O. Whipple, MD, in the late 1930s, is the standard surgical treatment for tumors of the pancreatic head, proximal bile duct, duodenum, and ampulla.2 This complex surgical procedure has undergone several technical modifications but is still generally referred to as the “Whipple procedure.” The classic PD procedure involves removing the head of the pancreas along with the distal bile duct, gallbladder, duodenum, first few centimeters of the jejunum, and the distal stomach (often about 50%) along with the pylorus.3 The nutritional complications that may develop from the Whipple procedure include delayed gastric emptying (gastroparesis), dumping syndrome, weight loss, diabetes mellitus, nutrient deficiencies, and malabsorption due to pancreatic exoc r i n e i n s u f fi c i e n c y. 4 I n a d d i t i o n , patients undergoing gastric surgeries are at a greater risk of developing malnutrition. Early identification and management of malnutrition risk improves and protects nutrition status and quality of life.5 More clinical research is needed to evaluate the appropriate nutrition support options—oral, enteral, or parenteral—when trying to correct nutritional status in these patients. The degree and types of complications that may develop depend on a
This article was written by Wendy Marcason, RDN, of the Academy of Nutrition and Dietetics’ Knowledge Center Team, Chicago, IL. Academy members can contact the Knowledge Center by sending an e-mail to [email protected]. http://dx.doi.org/10.1016/j.jand.2014.11.005
168
number of factors, including the extent of pancreatic disease, how the anatomy is altered during surgery, and the number of symptoms that may arise after surgery.3 The Academy of Nutrition and Dietetics’ Nutrition Care Manual6 lists some of the major issues that might arise:
Gasrtroparesis may occur in one-quarter to half of patients having surgery and usually resolves itself within a few months. Symptoms to be aware of are nausea, vomiting, bloating, early satiety, and abdominal pain. Dumping syndrome may occur 30 to 60 minutes after eating or may take 2 to 3 hours to develop. Pancreatic insufficiency and weight loss even with adequate intake may be noted. Pancreatic enzymes are prescribed in appropriate amounts to compensate for this. Diabetes resulting from decreased insulin production may develop in 20% to 50% of patients following surgery.3 Educating the patient about the classic symptoms of diabetes (excessive thirst and hunger, frequent urination, fatigue, and unintentional weight loss) is essential and appropriate nutritional education for the management of blood glucose. Nutrient deficiencies may result from the lack of food intake, malabsorption, or maldigestion after surgery. The most common nutrients of concern are iron; calcium; zinc; copper; selenium; and vitamins A, E, D, and K. Small bowel bacterial overgrowth may develop, with symptoms that include nausea, gas, bloating, diarrhea, vitamin B-12 deficiency, and elevated folate. Treatment usually requires antibiotics. Lactose intolerance may be an issue after surgery, causing gas,
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
bloating, or diarrhea after consumption of milk or milk products. General nutrition postgastrectomy4:
guidelines
eat small, frequent feedings (5 to 6 meals/day); limit fluids to 4 to 5 oz at a meal, drink other fluids 30 to 40 minutes after eating; eat slowly and chew foods thoroughly; avoid simple sugars in foods and drinks; include protein at each meal; limit fat to less than 30%; and avoid sugar alcohols.
Health professionals need to be more vigilant for symptoms after major gastrointestinal cancer surgeries, and the registered dietitian nutritionist is in a unique position to provide counseling to minimize gastrointestinal symptoms and improve nutritional status and quality of life.
References 1.
American Cancer Society. What are the key statistics about pancreatic cancer? http:// www.cancer.org/cancer/pancreaticcancer/ detailedguide/pancreatic-cancer-key-statistics. Accessed October 14, 2014.
2.
Pallisera A, Morales R, Ramia JM. Tricks and tips in pancreatoduodenectomy. World J Gastrointest Oncol. 2014;6(9):344-350.
3.
Decher N, Berry A. Post-Whipple: A practical approach to nutrition management. Practical Gastroenterol. 2012;36(8):30-42. http://www.medicine.virginia.edu/clinical/ departments/medicine/divisions/digestivehealth/nutrition-support-team/nutritionarticles/Decher_Berry_Aug_12.pdf. Accessed October 14, 2014.
4.
Matarese LE, Mullin GE, Raymond JL. The Health Professional’s Guide to Gastrointestinal Nutrition. Chicago, IL: Academy of Nutrition and Dietetics; 2015.
5.
Academy of Nutrition and Dietetics Evidence Analysis Library. Screening for Malnutrition Risk and Referral of Adult Oncology Patients 2013. http://www.andeal.org/template.cfm? template¼guide_summary&key¼4159& RESET¼TRUE. Accessed October 14, 2014.
6.
Academy of Nutrition and Dietetics. Nutrition Care Manual. Gastric Surgery. http:// www.nutritioncaremanual.org/topic.cfm? ncm_category_id¼1&lv1¼5522&lv2¼145 083&ncm_toc_id¼19309&ncm_heading¼ Nutrition%20Care. Accessed October 14, 2014.
ª 2015 by the Academy of Nutrition and Dietetics.
