Care of the Care of the Hepato-Pancreato-Biliary (HPB) Hepato-Pancreato-Biliary (HPB)
PatientPatient
Lauri Bolo, MSN, RN, ACNP-CLauri Bolo, MSN, RN, ACNP-CNurse Practitioner HPB Program Nurse Practitioner HPB Program
St. John Providence Health SystemSt. John Providence Health SystemProvidence Hospital Providence Hospital
February 28, 2015February 28, 2015
Disclosures Disclosures
None None
Objectives Objectives
The role of the NP in the HPB program The role of the NP in the HPB program Provide an overview of Pancreas and Liver Provide an overview of Pancreas and Liver
Cancer Cancer Discuss the perioperative care of the HPB Discuss the perioperative care of the HPB
patients patients Discuss the common postoperative Discuss the common postoperative
complications of the HPB patient complications of the HPB patient
HPB Nurse Practitioner (NP)HPB Nurse Practitioner (NP)
Since 2007Since 2007 HPB Clinic & Inpatient HPB Clinic & Inpatient Navigate patients & families Navigate patients & families Act as a resource or point of contact Act as a resource or point of contact Manage patient/family telephone calls Manage patient/family telephone calls
re; symptom management & concerns; re; symptom management & concerns; Goal: Avoid ER Goal: Avoid ER
Educate and counsel patient and family regarding surgical treatment and recovery
Act as a resource or point of contact, available for questions or concerns
Initial VisitPreOp
HPB NP
Daily inpatient rounds and assessment
Evaluate labs, diagnostics tests, vitals, fluid status
Monitor and adjust medications as necessary
Manage post operative pain, nausea, wound care, & nutrition
Ensure patient progression along care pathway
Facilitate discharge from hospital • Collaborate with SW, PT/OT, case management • Assess patient readiness• Educate
SurgeryInitial Visit
PreOp
HPB NP
• Prepare prescriptions• Dictate d/c summary
Drive appropriate follow up care and consults
Post operative follow up care
Pain control
Provide education on lifestyle changes
Provide emotional support and resources to newly diagnosed cancer patients
Ensure continued surveillance of cancer patients
SurgeryInitial Visit
PreOpPost Op & Continued
Care
HPB NP
The PancreasThe Pancreas
Pancreatic CancerPancreatic Cancer
46,420 46,420 estimated new cases in 2014 estimated new cases in 2014
39,590 39,590 estimated deaths in 2014 estimated deaths in 2014
3%3% of all cancers in the U.S. are Pancreas Cancer of all cancers in the U.S. are Pancreas Cancer
4th 4th leading cause of cancer death in the United leading cause of cancer death in the United StatesStates
Cure is Cure is rarerare and only in and only in resected patientsresected patients
American Cancer Society. Cancer Facts and Figures 2014. Atlanta: American Cancer Society; 2014.
Pancreas Cancer: BackgroundPancreas Cancer: Background
Cure is rare and only in resected patients Cure is rare and only in resected patients In 100 patients with adenocarcinoma of the In 100 patients with adenocarcinoma of the
pancreaspancreas Only 15-20 will have resectable diseaseOnly 15-20 will have resectable disease
Most patients present with locally advanced (50%) or Most patients present with locally advanced (50%) or metastatic (35-40%) disease metastatic (35-40%) disease
Of these, 3-4 patients will have long term survivalOf these, 3-4 patients will have long term survival Outcomes:Outcomes:
Optimist view: 20% surgical cure rateOptimist view: 20% surgical cure rate Pessimist view: 3-4% overall cure ratePessimist view: 3-4% overall cure rate
Types of Pancreas NeoplasmsTypes of Pancreas Neoplasms CysticCystic
Serous CystadenomaSerous Cystadenoma Mucinous Cystic Mucinous Cystic
NeoplasmNeoplasm IPMNIPMN
SolidSolid AdenocarcinomaAdenocarcinoma PNETPNET MetastaticMetastatic Solid pseudopapillary Solid pseudopapillary
tumortumor
Symptoms on PresentationSymptoms on Presentation
Weight lossWeight loss 9292 JaundiceJaundice 8282 PainPain 7272 AnorexiaAnorexia 6464 Dark urineDark urine 6363 Light stoolsLight stools 6262 NauseaNausea 4545 VomitingVomiting 3737 WeaknessWeakness 3535 PruritusPruritus 2424 DiarrheaDiarrhea 1818 MelenaMelena 1212 ConstipationConstipation 1111 FeverFever 1111 HematemesisHematemesis 88
Weight lossWeight loss 110000 PainPain 8787 WeaknessWeakness 4343 NauseaNausea 4343 VomitingVomiting 3737 AnorexiaAnorexia 3333 ConstipationConstipation 2727 HematemesisHematemesis 1717 MelenaMelena 1717 JaundiceJaundice 77 FeverFever 77 DiarrheaDiarrhea 33
Head Body and Tail
TreatmentTreatment
SurgerySurgery is the only chance of cure is the only chance of cure
Treatment Treatment Surgical resectionSurgical resection
Tumors in the head/uncinate process
Tumors in the body & tail
Whipple Distal pancreatectomy ±splenectomy
Preoperative Workup Preoperative Workup
LabsLabs LFTs, CA19-9, CEA, CMP, CBC, Prealbumin, CoagsLFTs, CA19-9, CEA, CMP, CBC, Prealbumin, Coags
NutritionNutrition Imaging- U/S, CT Pancreas Protocol, Imaging- U/S, CT Pancreas Protocol,
MRI/MRCPMRI/MRCP Staging Staging
EUS/BiopsyEUS/Biopsy
Preoperative WorkupPreoperative Workup
Selective patients with severe jaundice Selective patients with severe jaundice require preoperative biliary require preoperative biliary drainage/decompressiondrainage/decompression ERCP (GI)ERCP (GI) Percutaneous biliary Percutaneous biliary drainage (IR)drainage (IR)
Whipple Procedure Whipple Procedure PancreaticoduodenectomyPancreaticoduodenectomy
Whipple Procedure Whipple Procedure PancreaticoduodenectomyPancreaticoduodenectomy
Removal of the pancreatic head, entire Removal of the pancreatic head, entire duodenum, gallbladder, and common bile duodenum, gallbladder, and common bile ductduct
Indications for the WhippleIndications for the Whipple Pancreatic head massPancreatic head mass
Cholangiocarcinoma of the Cholangiocarcinoma of the distal bile ductdistal bile duct
Ampullary tumorAmpullary tumor
Duodenal tumorDuodenal tumor
Chronic pancreatitisChronic pancreatitis
Most commonMost common
Least commonLeast common
Distal PancreatectomyDistal Pancreatectomy
Distal Pancreatectomy Distal Pancreatectomy
Tumors in the body & tail of the pancreas Tumors in the body & tail of the pancreas
Splenectomy vs spleen preserving Splenectomy vs spleen preserving
Vaccines Vaccines
LOSLOS
Total Pancreatectomy Total Pancreatectomy
Total Pancreatectomy Total Pancreatectomy
RareRare Benign & malignant diseaseBenign & malignant disease
Diffuse IPMNDiffuse IPMN Chronic PancreatitisChronic Pancreatitis Margin + panc cancer Margin + panc cancer
Unresectable Pancreatic CancerUnresectable Pancreatic Cancer
PALLIATIVE PALLIATIVE
Relief of obstructive jaundice Relief of obstructive jaundice
Prevention of duodenal obstruction Prevention of duodenal obstruction
Pain control Pain control
Palliation of Unresectable Palliation of Unresectable Pancreas Cancer Pancreas Cancer
Non Surgical Interventions Endoscopic biliary stent Endoscopic biliary stent
Percutaneous Transhepatic Percutaneous Transhepatic Cholangiogram drainage & Cholangiogram drainage & stent stent
Surgical CholedochojejunostomyCholedochojejunostomy
GastrojejunostomyGastrojejunostomy
Post-Op CarePost-Op Care
Pancreas Post-Op CarePancreas Post-Op Care AmbulationAmbulation
DietDiet NGT removal NGT removal
Urine output Urine output
LabsLabs CBC for bleeding risk CBC for bleeding risk Electrolytes Electrolytes BUN/Crt for fluid BUN/Crt for fluid
managementmanagement LFTs LFTs
MedicationsMedications Antibiotics- perioperative Antibiotics- perioperative DVT prophylaxis DVT prophylaxis Pain managementPain management
IV PCAIV PCA Epidural PCAEpidural PCA IV narcotics IV narcotics Toradol Toradol PO narcotics PO narcotics
Pancreas Post-Op Care Pancreas Post-Op Care
Drains Drains Anterior & Posterior to anastomosesAnterior & Posterior to anastomoses VolumeVolume Character of fluidCharacter of fluid Drain AmylaseDrain Amylase Removal Removal
Splenectomy Vaccines Splenectomy Vaccines Vaccine Route Revaccination pneumococcal vaccine (pneumovax 23) SQ 5-6 years haemophilus influenzae type B (hib TITER) SQ 5 years meningococcal vaccine IM none
* * Annual influenza vaccines are Annual influenza vaccines are recommended. recommended.
ComplicationsComplications
Early ComplicationsEarly Complications Wound infectionWound infection
Anastomotic leakAnastomotic leak Gastrojejunostomy Gastrojejunostomy (2-3%)(2-3%) Hepaticojejunostomy Hepaticojejunostomy (5%)(5%) Pancreatic (Pancreatic (10-25%)10-25%)
Delayed gastric emptying (DGE) Delayed gastric emptying (DGE) (~20%)(~20%)
HemorrhageHemorrhage
Pancreatic Fistula/LeakPancreatic Fistula/Leak Amylase rich fluid – 3x serum, POD #3 Amylase rich fluid – 3x serum, POD #3 Grade ABC Grade ABC Clinical signsClinical signs
Abdominal pain +/- distention Abdominal pain +/- distention Ileus Ileus DGEDGE Fever Fever TendernessTenderness Leukocytosis Leukocytosis
Pancreatic Fistula (PF)Pancreatic Fistula (PF)Management Management
Most pancreatic fistulae are of grade A and can be Most pancreatic fistulae are of grade A and can be managed non operatively with continued managed non operatively with continued peripancreatic drains placed intraoperatively peripancreatic drains placed intraoperatively
Few patients might require an CT guided drain Few patients might require an CT guided drain placement by Interventional Radiology to control the placement by Interventional Radiology to control the PF (Grade B)PF (Grade B)
Rarely patients require a surgical intervention Rarely patients require a surgical intervention (Grade C)(Grade C)
Delayed Gastric Emptying Delayed Gastric Emptying Postoperative inability to tolerate dietPostoperative inability to tolerate diet
Management Management
TreatmentTreatment NG for decompression NG for decompression Prokinetic agents Prokinetic agents Patience Patience
Nutrition Nutrition Enteral feeds via post pyloric NJ tube or surgical Enteral feeds via post pyloric NJ tube or surgical
J tube J tube TPNTPN
Discharge Discharge MedicationsMedications
LovenoxLovenox Metoclopropamide Metoclopropamide Proton pump inhibitor Proton pump inhibitor
(PPI)(PPI) Oral analgesics Oral analgesics Laxatives Laxatives CreonCreon
Drain teaching Drain teaching Home careHome care Activity & restrictions Activity & restrictions Diet Diet Insulin Insulin
Late ComplicationsLate Complications Pancreatic insufficiencyPancreatic insufficiency
DiabetesDiabetes
Marginal UlcersMarginal Ulcers
DumpingDumping
Strictures Strictures
Iron deficiency anemiaIron deficiency anemia
Cancer recurrence Cancer recurrence
Short Term & Long Term Follow Up Short Term & Long Term Follow Up
Surgery Surgery
OncologyOncology
Endocrine Endocrine
SurveillanceSurveillance Office visitsOffice visits Imaging Imaging Tumor markersTumor markers Liver function testingLiver function testing CMP CMP
The Liver The Liver FunctionsFunctions
Synthetic- albumin, Synthetic- albumin, transferrin, clotting transferrin, clotting factorsfactors
Synthesizes bile for fat Synthesizes bile for fat absorption absorption
Detoxifies drugs and Detoxifies drugs and toxins toxins
Hepatic Tumors Hepatic Tumors
Benign
HemangiomaHemangioma
Focal nodular Focal nodular hyperplasia (FNH)hyperplasia (FNH)
AdenomaAdenoma
Liver cysts Liver cysts
Malignant
Hepatocellular Hepatocellular carcinoma (HCC)carcinoma (HCC)
Colorectal cancer Colorectal cancer metastases (CRC)metastases (CRC)
Cholangiocarcinoma Cholangiocarcinoma
Hepatocellular Carcinoma (HCC)Hepatocellular Carcinoma (HCC)
Most common primary malignant tumor of Most common primary malignant tumor of the liver the liver
35,660 estimated new cases in 201535,660 estimated new cases in 2015 24,550 estimated deaths in 201524,550 estimated deaths in 2015 Risk Factors: hepatitis B, hepatitis C, cirrhosis, Risk Factors: hepatitis B, hepatitis C, cirrhosis,
alcohol, biliary cirrhosis, hemochromatosisalcohol, biliary cirrhosis, hemochromatosis
HCCHCC
SymptomsSymptomsNonspecific Abdominal painEarly satietyWeight lossjaundice
Physical findingsPhysical findingsAbdominal massAbdominal massSplenomegalySplenomegalyAscitesAscites
Colorectal Cancer MetastasesColorectal Cancer Metastases
22ndnd most common cause of cancer related most common cause of cancer related deaths in the US deaths in the US
~ 136,830 will be diagnosed CRC this year~ 136,830 will be diagnosed CRC this year ~50% of all patients with colorectal cancer ~50% of all patients with colorectal cancer
develop metastasesdevelop metastases Surgical resection offers best outcome Surgical resection offers best outcome
American Cancer Society. Cancer Facts and Figures 2014. Atlanta: American Cancer Society; 2014.
CholangiocarcinomaCholangiocarcinoma Malignancy of the extrahepatic or intrahepatic ducts Malignancy of the extrahepatic or intrahepatic ducts
Sx of biliary obstruction Sx of biliary obstruction Jaundice, pruritus, dark Jaundice, pruritus, dark urine, clay colored stools urine, clay colored stools
Preop Workup Preop Workup LabsLabs
LFTs, AFP, CMP, CBC, Prealbumin, CoagsLFTs, AFP, CMP, CBC, Prealbumin, Coags Imaging – U/S,CT, MRI Imaging – U/S,CT, MRI
StagingStaging If resectable If resectable no bx no bx
Degree of Cirrhosis Degree of Cirrhosis Childs Pugh Childs Pugh
Portal vein embolization (PVE)Portal vein embolization (PVE) Biliary drainage Biliary drainage
Child Pugh ClassificationChild Pugh ClassificationParameter
Points assigned
1 2 3
Ascites Absent Slight Moderate
Hepatic encephalopathy None Grade 1-2 Grade 3-4
Bilirubin <2 mg/dL 2-3 mg/dL > 3mg/dL
Albumin > 3.5 g/dL 2.8-3.5 g/dL <2.8 g/dL
Prothrombin time
Seconds over control < 4 4-6 >6
INR < 1.7 1.7-2.3 >2.3
Grade A = 5-6 points Grade A = 5-6 points well compensated disease well compensated disease *good operative risk *good operative risk
Grade B = 7-9 points Grade B = 7-9 points significant compromisesignificant compromise
Grade C = 10-15 pointsGrade C = 10-15 points decompensatedecompensated d
Portal Vein Embolization (PVE)Portal Vein Embolization (PVE) Selectively embolize the Selectively embolize the
portal vein of the portal vein of the pathologic lobe to allow pathologic lobe to allow hypertrophy of remnant hypertrophy of remnant liver to prevent post op liver to prevent post op liver failureliver failure
Surgical Resection of Hepatic Surgical Resection of Hepatic Tumors Tumors
Right hepatectomyRight hepatectomy
Left HepatectomyLeft Hepatectomy
TrisectionectomyTrisectionectomy
Biliary reconstruction Biliary reconstruction
Lap Vs Open Lap Vs Open
Post-Op Liver Post-Op Liver AmbulationAmbulation Diet Diet Drains Drains UOP UOP Medications Medications
Vitamin KVitamin K No toradolNo toradol
LabsLabs CBCCBC LFTsLFTs CoagsCoags BUN/CrtBUN/Crt Electrolytes – phos & Electrolytes – phos &
magmag AmmoniaAmmonia
Post-Op ComplicationsPost-Op Complications Liver failureLiver failure Bile leak Bile leak InfectionInfection BleedingBleeding Pleural effusionPleural effusion AscitesAscites PV ThrombosisPV Thrombosis
Liver failure Liver failure
Deterioration in the ability of the liver to maintain its Deterioration in the ability of the liver to maintain its synthetic, excretory, and detoxifying functions synthetic, excretory, and detoxifying functions increased INR increased INR hyperbilirubinemia hyperbilirubinemia
Early recognition and initiation of supportive care is Early recognition and initiation of supportive care is importantimportant
Bile leak Bile leak
Rare (5%)Rare (5%) ManagementManagement
Most are managed non operatively by following Most are managed non operatively by following drain outputdrain output
Few might require biliary drainage proceduresFew might require biliary drainage procedures PTCPTC ERCPERCP
Rarely patients require surgical interventionRarely patients require surgical intervention
Short Term & Long Term Follow Up Short Term & Long Term Follow Up
SurgeonSurgeon Oncologist Oncologist Hepatologist Hepatologist
Thank you!Thank you!
Questions?????Questions?????