Transcript Care of the Hepato-Pancreato-Biliary (HPB) Patient

Care of the
Hepato-Pancreato-Biliary (HPB)
Patient
Lauri Bolo, MSN, RN, ACNP-C
Nurse Practitioner HPB Program
St. John Providence Health System
Providence Hospital
February 28, 2015
Disclosures

None
Objectives




The role of the NP in the HPB program
Provide an overview of Pancreas and Liver
Cancer
Discuss the perioperative care of the HPB
patients
Discuss the common postoperative
complications of the HPB patient
HPB Nurse Practitioner (NP)





Since 2007
HPB Clinic & Inpatient
Navigate patients & families
Act as a resource or point of contact
Manage patient/family telephone calls
re; symptom management & concerns;
Goal: Avoid ER
HPB NP
Initial Visit
PreOp

Educate and counsel patient and family regarding
surgical treatment and recovery

Act as a resource or point of contact, available for
questions or concerns
HPB NP
Initial Visit
PreOp
Surgery

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
• Prepare prescriptions
• Educate
• Dictate d/c summary
HPB NP
Initial Visit
PreOp
Surgery
Post Op &
Continued
Care

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
The Pancreas
Pancreatic Cancer

46,420 estimated new cases in 2014

39,590 estimated deaths in 2014

3% of all cancers in the U.S.

4th leading cause of cancer death in the United
are Pancreas Cancer
States

Cure is rare and only in resected patients
American Cancer Society. Cancer Facts and Figures 2014. Atlanta: American Cancer Society; 2014.
Pancreas Cancer: Background


Cure is rare and only in resected patients
In 100 patients with adenocarcinoma of the
pancreas

Only 15-20 will have resectable disease

Most patients present with locally advanced (50%) or
metastatic (35-40%) disease
Of these, 3-4 patients will have long term survival
 Outcomes:

Optimist view: 20% surgical cure rate
 Pessimist view: 3-4% overall cure rate

Types of Pancreas Neoplasms

Cystic



Serous Cystadenoma
Mucinous Cystic
Neoplasm
IPMN

Solid




Adenocarcinoma
PNET
Metastatic
Solid pseudopapillary
tumor
Symptoms on Presentation
Body and Tail
Head















Weight loss
Jaundice
Pain
Anorexia
Dark urine
Light stools
Nausea
Vomiting
Weakness
Pruritus
Diarrhea
Melena
Constipation
Fever
Hematemesis
92
82
72
64
63
62
45
37
35
24
18
12
11
11
8












Weight loss
Pain
Weakness
Nausea
Vomiting
Anorexia
Constipation
Hematemesis
Melena
Jaundice
Fever
Diarrhea
100
87
43
43
37
33
27
17
17
7
7
3
Treatment
Surgery is the only chance of cure
Treatment
Surgical resection
Tumors in the
head/uncinate process
Tumors in the body &
tail
Whipple
Distal pancreatectomy
±splenectomy
Preoperative Workup

Labs



Nutrition
Imaging- U/S, CT Pancreas Protocol,
MRI/MRCP


LFTs, CA19-9, CEA, CMP, CBC, Prealbumin, Coags
Staging
EUS/Biopsy
Preoperative Workup

Selective patients with severe jaundice
require preoperative biliary
drainage/decompression
ERCP (GI)
 Percutaneous biliary
drainage (IR)

Whipple Procedure
Pancreaticoduodenectomy
Whipple Procedure
Pancreaticoduodenectomy

Removal of the pancreatic head, entire
duodenum, gallbladder, and common bile
duct
Indications for the Whipple

Pancreatic head mass

Cholangiocarcinoma of the
distal bile duct

Ampullary tumor

Duodenal tumor

Chronic pancreatitis
Most common
Least common
Distal Pancreatectomy
Distal Pancreatectomy

Tumors in the body & tail of the pancreas

Splenectomy vs spleen preserving

Vaccines

LOS
Total Pancreatectomy
Total Pancreatectomy


Rare
Benign & malignant disease
Diffuse IPMN
 Chronic Pancreatitis
 Margin + panc cancer

Unresectable Pancreatic Cancer
PALLIATIVE

Relief of obstructive jaundice

Prevention of duodenal obstruction

Pain control
Palliation of Unresectable
Pancreas Cancer
Non Surgical Interventions
Surgical

Endoscopic biliary stent

Choledochojejunostomy

Percutaneous Transhepatic
Cholangiogram drainage &
stent

Gastrojejunostomy
Post-Op Care
Pancreas Post-Op Care

Ambulation

Medications


Diet

NGT removal

Urine output

Labs




CBC for bleeding risk
Electrolytes
BUN/Crt for fluid
management
LFTs


Antibiotics- perioperative
DVT prophylaxis
Pain management
 IV PCA
 Epidural PCA
 IV narcotics
 Toradol
 PO narcotics
Pancreas Post-Op Care

Drains
Anterior & Posterior to anastomoses
 Volume
 Character of fluid
 Drain Amylase
 Removal

Splenectomy Vaccines
Vaccine
pneumococcal vaccine
(pneumovax 23)
haemophilus influenzae type B
(hib TITER)
meningococcal vaccine
Route
Revaccination
SQ
5-6 years
SQ
IM
5 years
none
* Annual influenza vaccines are recommended.
Complications
Early Complications

Wound infection

Anastomotic leak



Gastrojejunostomy (2-3%)
Hepaticojejunostomy (5%)
Pancreatic (10-25%)

Delayed gastric emptying (DGE) (~20%)

Hemorrhage
Pancreatic Fistula/Leak



Amylase rich fluid – 3x serum, POD #3
Grade ABC
Clinical signs






Abdominal pain +/- distention
Ileus
DGE
Fever
Tenderness
Leukocytosis
Pancreatic Fistula (PF)
Management



Most pancreatic fistulae are of grade A and can be
managed non operatively with continued
peripancreatic drains placed intraoperatively
Few patients might require an CT guided drain
placement by Interventional Radiology to control the
PF (Grade B)
Rarely patients require a surgical intervention
(Grade C)
Delayed Gastric Emptying

Postoperative inability to tolerate diet
Management

Treatment
NG for decompression
 Prokinetic agents
 Patience


Nutrition
Enteral feeds via post pyloric NJ tube or surgical
J tube
 TPN

Discharge

Medications






Lovenox
Metoclopropamide
Proton pump inhibitor
(PPI)
Oral analgesics
Laxatives
Creon





Drain teaching
Home care
Activity & restrictions
Diet
Insulin
Late Complications

Pancreatic insufficiency

Diabetes

Marginal Ulcers

Dumping

Strictures

Iron deficiency anemia

Cancer recurrence
Short Term & Long Term Follow Up

Surgery

Oncology

Endocrine

Surveillance





Office visits
Imaging
Tumor markers
Liver function testing
CMP
The Liver

Functions



Synthetic- albumin,
transferrin, clotting
factors
Synthesizes bile for fat
absorption
Detoxifies drugs and
toxins
Hepatic Tumors
Benign
Malignant

Hemangioma


Focal nodular
hyperplasia (FNH)
Hepatocellular
carcinoma (HCC)

Colorectal cancer
metastases (CRC)

Cholangiocarcinoma


Adenoma
Liver cysts
Hepatocellular Carcinoma (HCC)




Most common primary malignant tumor of
the liver
35,660 estimated new cases in 2015
24,550 estimated deaths in 2015
Risk Factors: hepatitis B, hepatitis C, cirrhosis,
alcohol, biliary cirrhosis, hemochromatosis
HCC





Symptoms
Nonspecific
Abdominal pain
Early satiety
Weight loss
jaundice
Physical findings
 Abdominal mass
 Splenomegaly
 Ascites
Colorectal Cancer Metastases




2nd most common cause of cancer related
deaths in the US
~ 136,830 will be diagnosed CRC this year
~50% of all patients with colorectal cancer
develop metastases
Surgical resection offers best outcome
American Cancer Society. Cancer Facts and Figures 2014. Atlanta: American Cancer Society; 2014.
Cholangiocarcinoma

Malignancy of the extrahepatic or intrahepatic ducts

Sx of biliary obstruction Jaundice, pruritus, dark
urine, clay colored stools
Preop Workup

Labs


LFTs, AFP, CMP, CBC, Prealbumin, Coags
Imaging – U/S,CT, MRI
Staging
 If resectable  no bx


Degree of Cirrhosis



Childs Pugh
Portal vein embolization (PVE)
Biliary drainage
Child Pugh Classification
Parameter
Points assigned
1
2
3
Absent
Slight
Moderate
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
<4
4-6
>6
< 1.7
1.7-2.3
>2.3
Ascites
Hepatic encephalopathy
Prothrombin time
Seconds over control
INR
Grade A = 5-6 points
Grade B = 7-9 points
well compensated disease
*good operative risk
significant compromise
Grade C = 10-15 points
decompensated
Portal Vein Embolization (PVE)

Selectively embolize the
portal vein of the
pathologic lobe to allow
hypertrophy of remnant
liver to prevent post op
liver failure
Surgical Resection of Hepatic
Tumors

Right hepatectomy

Left Hepatectomy

Trisectionectomy

Biliary reconstruction

Lap Vs Open
Post-Op Liver





Ambulation
Diet
Drains
UOP
Medications


Vitamin K
No toradol

Labs






CBC
LFTs
Coags
BUN/Crt
Electrolytes – phos &
mag
Ammonia
Post-Op Complications







Liver failure
Bile leak
Infection
Bleeding
Pleural effusion
Ascites
PV Thrombosis
Liver failure

Deterioration in the ability of the liver to maintain its
synthetic, excretory, and detoxifying functions



increased INR
hyperbilirubinemia
Early recognition and initiation of supportive care is
important
Bile leak


Rare (5%)
Management
Most are managed non operatively by following
drain output
 Few might require biliary drainage procedures

PTC
 ERCP


Rarely patients require surgical intervention
Short Term & Long Term Follow Up



Surgeon
Oncologist
Hepatologist
Thank you!
Questions?????