Erwin g.

dungog Bsn-111 Cancer of the liver:

causes

august 30,2010 madam cunanan

Hepatitis B can be caught from contaminated blood products or used needles or sexual contact but is frequent among Asian children from contamination at birth or even biting among children at play. The role of hepatitis B virus (HBV) infection in causing liver cancer is well established. Several lines of evidence point to this strong association. As noted earlier, the frequency of liver cancer relates to (correlates with) the frequency of chronic hepatitis B virus infection. In addition, the patients with hepatitis B virus who are at greatest risk for liver cancer are men with hepatitis B virus cirrhosis (scarring of the liver) and a family history of liver cancer. Perhaps the most convincing evidence, however, comes from a prospective (looking forward in time) study done in the 1970s in Taiwan involving male government employees over the age of 40. In this study, the investigators found that the risk of developing liver cancer was 200 times higher among employees who had chronic hepatitis B virus as compared to employees without chronic hepatitis B virus infection. Studies in animals also have provided evidence that hepatitis B virus can cause liver cancer. For example, we have learned that liver cancer develops in other mammals that are naturally infected with viruses related to the hepatitis B virus. Finally, by infecting transgenic mice with certain parts of the hepatitis B virus, scientists caused liver cancer to develop in mice that do not usually develop liver cancer. (Transgenic mice are mice that have been injected with new or foreign genetic material.) How does chronic hepatitis B virus cause liver cancer? In patients with both chronic hepatitis B virus and liver cancer, the genetic material of hepatitis B virus is frequently found to be part of the genetic material of the cancer cells. It is thought, therefore, that specific regions of the hepatitis B virus genome (genetic code) enter the genetic material of the liver cells. This hepatitis B virus genetic material may then disrupt the normal genetic material in the liver cells, thereby causing the liver cells to become cancerous. The vast majority of liver cancer that is associated with chronic hepatitis B virus occurs in individuals who have been infected most of their lives. In areas where hepatitis B virus is not always present (endemic) in the community (for example, the U.S.), liver cancer is relatively uncommon. The reason for this is that most of the people with chronic hepatitis B virus in these areas acquired the infection as adults, and very few develop an ongoing (chronic active) infection, which happens as often as 15% of the time in Asia.

Sign and symptoms The initial symptoms (the clinical presentations) of liver cancer are variable. It is becoming much more common for patients to be identified by screening people at high risk for the cancer and finding the cancer before there are any symptoms at all. In countries where liver cancer is very common, the cancer generally is discovered at a very advanced stage of disease for several reasons. For one thing, areas where there is a high frequency of liver cancer are generally developing countries where access to health care is limited. For another, screening examinations for patients at risk for developing liver cancer are not available in these areas. In addition, patients from these regions may actually have more aggressive liver cancer disease. In other words, the tumor usually reaches an advanced stage and causes symptoms more rapidly. In contrast, patients in areas of low liver cancer frequency tend to have liver cancer tumors that progress more slowly and, therefore, remain without symptoms longer. There are no specific symptoms of liver cancer, and in fact, the earliest signs are usually subtle and can be mistaken for simple worsening of cirrhosis and liver function. Abdominal pain is uncommon with liver cancer and usually signifies a very large tumor or widespread involvement of the liver. Additionally, unexplained weight loss or unexplained fevers are warning signs of liver cancer in patients with cirrhosis. These symptoms are less common in individuals with liver cancer in the U.S. because these patients are usually diagnosed at an earlier stage. However, whenever the overall health of a patient with cirrhosis deteriorates, every effort should be made to look for liver cancer.

Medical diagnosis Liver cancer is not diagnosed by routine blood tests, including a standard panel of liver tests. This is why the diagnosis of liver cancer depends so much on the vigilance of the physician screening with a tumor marker (alpha-fetoprotein) in the blood and radiological imaging studies. Since most patients with liver cancer have associated liver disease (cirrhosis), their liver blood tests may not be normal to begin with. If these blood tests become abnormal or worsen due to liver cancer, this usually signifies extensive cancerous involvement of the liver. At that time, any medical or surgical treatment may be too late. Sometimes, however, other abnormal blood tests can indicate the presence of liver cancer. Remember that each cell type in the body contains the full complement of genetic information. What differentiates one cell type from another is the particular set of genes that are turned on or off in that cell. When cells become cancerous, certain of the cell's genes that were turned off may become turned on. Thus, in liver cancer, the cancerous liver cells may take on the characteristics of other types of cells. For example, liver cancer cells sometimes can produce hormones that are ordinarily produced in other body systems. These hormones then can cause certain abnormal blood tests, such as a high red blood count (erythrocytosis), low blood sugar (hypoglycemia) and high blood calcium (hypercalcemia).

Another abnormal blood test, high serum cholesterol (hypercholesterolemia), is seen in up to 10% of patients from Africa with liver cancer. The high cholesterol occurs because the liver cancer cells are not able to turn off (inhibit) their production of cholesterol. (Normal cells are able to turn off their production of cholesterol.) There is no reliable or accurate screening blood test for liver cancer. The most widely used biochemical blood test is alpha-fetoprotein (AFP), which is a protein normally made by the immature liver cells in the fetus. At birth, infants have relatively high levels of AFP, which fall to normal adult levels by the first year of life. Also, pregnant women carrying babies with neural tube defects may have high levels of AFP. (A neural tube defect is an abnormal fetal brain or spinal cord that is caused by folic acid deficiency during pregnancy.) In adults, high blood levels (over 500 nanograms/milliliter) of AFP are seen in only three situations: Medical treatment

The treatment options are dictated by the stage of liver cancer and the overall condition of the patient. The only proven cure for liver cancer is liver transplantation for a solitary, small (<3cm) tumor. Now, many physicians may dispute this statement. They would argue that a small tumor can be surgically removed (partial hepatic resection) without the need for a liver transplantation. Moreover, they may claim that the one- and three-year survival rates for resection are perhaps comparable to those for liver transplantation. However, most patients with liver cancer also have cirrhosis of the liver and would not tolerate liver resection surgery. In fact, in the United States, only 8% of people with liver cancer are able to undergo surgery. But, they probably could tolerate the transplantation operation, which involves removal of the patient's entire diseased liver just prior to transplanting a donor liver. Furthermore, many patients who undergo hepatic resections will develop a recurrence of liver cancer elsewhere in the liver within several years. In fact, some experts believe that once a liver develops liver cancer, there is a tendency for that liver to develop other tumors at the same time (synchronous multicentric occurrence) or at a later time (metachronous multicentric occurrence). This makes sense, since whatever in the liver caused the cancer to develop in the first place is still there. Realistically, though, donor livers are a very limited resource, so many patients who need a transplantation will never receive one. The results of the various medical treatments available (see below; chemotherapy, chemoembolization, ablation, and proton beam therapy) remain disappointing. Moreover, for reasons noted earlier (primarily the variability in natural history), there have been no systematic study comparisons of the different treatments. As a result, individual patients will find that the various treatment options available to them depend largely on the local expertise. How do we know if a particular treatment worked for a particular patient? Well, hopefully, the patient will feel better. However, a clinical response to treatment is usually defined more objectively. Thus, a response is defined as a decrease in the size of the tumor on imaging studies

along with a reduction of the alpha-fetoprotein in the blood if the level was elevated prior to treatment. One thing to keep in mind is that in a relatively healthy patient there is never just one answer to this question. Usually, people go through multiple different treatments sequentially. Something is chosen as the best place to start, and then other treatments are tried once the previous one stops working. The idea is to make sure someone is healthy enough to be able to try another therapy if they still desire it. Nursing care

Your patient needs the following supportive care. * Administer analgesics as prescribed to prevent and relieve pain. * If your patient develops ascites, measure and document his abdominal girth and weight daily. Control edema by restricting sodium, fluids, and proteins, and document his fluid intake and output. To increase venous return and prevent peripheral edema, elevate his legs. * Assess for dyspnea or increased respirations, and watch for signs of hypoxia from intrapulmonary arteriovenous shunting or pleural effusions. * Relieve fever by giving your patient sponge baths and aspirin suppositories (unless he has signs of GI bleeding). However, avoid acetaminophen because his diseased liver can't metabolize it. If he develops a high fever from infection, administer antibiotics as prescribed. * Provide meticulous skin care. To prevent pressure ulcers, reposition your patient frequently. Keep his skin clean, apply lotion, and administer an antipruritic to relieve itching. Keep his finger nails short and clean, and apply mittens if necessary to prevent infection and excoriations from scratching. * Assess for encephalopathy: Monitor your patient's serum ammonia level, vital signs, and neurologic status. Control ammonia accumulation with prescribed treatments, such as sorbitol, neomycin, lactulose, and sodium polystyrene sulfonate. * If the patient has a transhepatic catheter to relieve obstructive jaundice, irrigate it frequently with the prescribed solution--for example, 0.9% sodium chloride or heparin, 5,000 units in 500 ml of D sub 5 W. Monitor for signs of bleeding or infection. * If he's receiving chemotherapy or radiation, monitor for nausea and vomiting, anemia, thrombocytopenia, neutropenia, and hair loss; provide appropriate treatment and support. * Encourage the patient and his family to voice their concerns. Discuss treatments and possible adverse effects. Explain the importance of eliminating alcohol and restricting salt, fluids, and protein. Teach the patient relaxation techniques to make him more comfortable and ease anxiety, and refer him and his family to support groups, outpatient-care services, or hospice care.

CHOLECYSTITIS AND CHOLELITHIASIS:

CHOLECYSTISIS-Acute cholecystitis is a sudden inflammation of the gallbladder
that causes severe abdominal pain. Call your health care provider if you think you have cholecystitis. If not treated properly complications will occur.

CAUSES
In about 90% cases, acute cholecystitis is caused by a gallstone obstructing a duct in the gallbladder. When a gallstone obstructs a duct in the gallbladder, bile becomes trapped in the gallbladder and causes infection. Other causes of cholecystitis are: alcohol abuse, severe illness, and tumors in the gallbladder. More information about gallstones.

SIGN AND SYPMTOMS

Unfortunately, symptoms may not appear for a number of years. When they do appear, the most common ones are: pain in the upper right portion of the abdomen (especially after a fatty mean) nausea fever loss of appetite jaundice Chills

COMPLICATIONS

If not treated properly or soon, complications may develop. Common complications of cholecystitis are: pus in the gallbladder inflammation of the lining of the abdomen

MEDICAL DIAGNOSIS

Your doctor will perform tests to determine if you have gallstones or inflammation. The most common tests are:

abdominal ultrasound blood tests (looking for elevated white blood cells) abdominal CT scan abdominal X-ray

MEDICAL TREATMENT
Sometimes cholecystitis will go away without treatment. However, most times treatment is needed. Treatments may include: surgery to remove the gallbladder or draining the gallbladder. Draining is used in very ill patients.

DRUG THERAPHY
Initial therapy of acute cholecystitis and cholangitis is directed towards general support of the patient, including fluid and electrolyte replacement, correction of metabolic imbalances and antibacterial therapy. Factors affecting the efficacy of antibacterial therapy include the activity of the agent against the common biliary tract pathogens and pharmacokinetic properties such as tissue distribution and the ratio of concentration in both bile and serum to the minimum inhibitory concentration for the expected micro-organism. Antimicrobial therapy is usually empirical. Initial therapy should cover the Enterobacteriaceae, in particular Escherichia coli. Activity against enterococci is not required since their pathogenicity in biliary tract infections remains unclear. Coverage of anaerobes, in particular Bacteroides spp., is warranted in patients with previous bile duct-bowel anastomosis, in the elderly and in patients in serious clinical condition. In patients with acute cholecystitis or cholangitis of moderate clinical severity, monotherapy with a ureidopenicillin--mezlocillin or piperacillin--is at least as effective as the combination of ampicillin plus aminoglycoside. In severely ill patients with septicaemia, an antibacterial combination is preferable. Therapy with aminoglycosides, mostly for Pseudomonas aeruginosa-related infections, should not exceed a few days because the risk of nephrotoxicity seems to be increased during cholestasis. Relief of biliary obstruction is mandatory, even if there is clinical improvement with conservative therapy, because cholangitis is most likely to recur with continued obstruction. Emergency invasive therapy is reserved for patients who fail to show a clinical response to antibacterial therapy within the first 36 to 48 hours or for those who deteriorate after an initial clinical improvement. Immediate surgery is indicated for gangrenous cholecystitis and perforation with peritonitis. Long-term administration of antibacterials is required for recurrent cholangitis, as seen in bile duct-bowel anastomosis. Oral cotrimoxazole (trimethoprim/sulfamethoxazole) is the preferred agent. Wound infection rates after biliary tract surgery can be significantly reduced by preoperative administration of prophylactic antibacterials. Newer generation beta-lactams have not proven to be of greater benefit than older agents such as cefuroxime or cefazolin. Antibacterial prophylaxis before endoscopic retrograde cholangiopancreatography (ERCP) should be reserved for patients with obstructive jaundice, since the risk of infectious complications seems to be strongly associated with this clinical condition. Failure to achieve full biliary drainage is the most important factor in

predicting septicaemia, and prophylaxis should be prolonged until the bile duct is unobstructed. Piperacillin, cefazolin, cefuroxime, cefotaxime and ciprofloxacin are effective for this indication.

CHOLELITHIASIS-Cholelithiasis is the fifth leading cause of hospitalization among adults. The disease may also be occur in persons who are obese, who have high cholesterol, or who are on cholesterol lowering drugs. In most cases, gallbladder and bile duct diseases occur during middle age. Between ages 20 and 50, they're six times more common in women, but incidence in men and women becomes equal after age 50. Incidence rises with each succeeding decade. Diseases of the gallbladder and biliary tract are common and painful conditions that may be life threatening and mostly require
surgery

. They are generally associated with deposition of calculi and inflammation. CAUSES

Cholelithiasis may be occur due to various causes such as:

Cholelithiasis may be occur due to changes in bile components Hormonal contraceptives Diabetes mellitus Celiac disease Pancreatitis Unexplained sepsis Right upper quadrant pain Fever Leukocytosis

This condition occurs when stones pass out of the gallbladder and lodge in the hepatic and common bile ducts, obstructing the flow of bile into the duodenum. Cholangitis, infection of the bile duct, is commonly associated with choledocholithiasis. Predisposing factors may include bacterial or metabolic alteration of bile acids. Cholecystitis, acute or chronic inflammation of the gallbladder is usually associated with a gallstone impacted in the cystic duct, that may cause painful distention of the gallbladder. Postcholecystectomy syndrome commonly results from residual gal1stones or stricture of the common bile duct. It may be occurs in 1 % to 5 % of all patients whose gallbladders have been surgical1y removed and may produce right upper quadrant abdominal pain, biliary colic, dyspepsia. and indigestion. SIGN AND SYMPTOMS

Cholelithiasis may be occur due to various causes such as:

Cholelithiasis may be occur due to changes in bile components

Hormonal contraceptives Diabetes mellitus Celiac disease Pancreatitis Unexplained sepsis Right upper quadrant pain Fever Leukocytosis

This condition occurs when stones pass out of the gallbladder and lodge in the hepatic and common bile ducts, obstructing the flow of bile into the duodenum. Cholangitis, infection of the bile duct, is commonly associated with choledocholithiasis. Predisposing factors may include bacterial or metabolic alteration of bile acids. Cholecystitis, acute or chronic inflammation of the gallbladder is usually associated with a gallstone impacted in the cystic duct, that may cause painful distention of the gallbladder. Postcholecystectomy syndrome commonly results from residual gal1stones or stricture of the common bile duct. It may be occurs in 1 % to 5 % of all patients whose gallbladders have been surgical1y removed and may produce right upper quadrant abdominal pain, biliary colic, dyspepsia. and indigestion. COMPLICATIONS

Complications and sequelae of Cholelithiasis from the Diseases Database include:

Abdominal pain Ileus Bile duct stricture Peritonitis Shoulder pain Nausea and vomiting Alkaline phosphatase liver isoenzyme levels raised (plasma or serum) Pancreatitis, acute Cholestasis, extrahepatic Abdominal mass

MEDICAL DIAGNOSIS

For a diagnosis of Cholelithiasis, the following list of conditions have been mentioned in sources as possible alternative diagnoses to consider during the diagnostic process for Cholelithiasis:

Acute cholecystitis Acute pancreatitis Peptic ulcer disease Appendicitis

Acute hepatitis (type of Hepatitis) Myocardial infarction Radicular pain

MEDICAL TREATMENT

The list of treatments mentioned in various sources for Cholelithiasis includes the following list. Always seek professional medical advice about any treatment or change in treatment plans.

Supportive measures Pain relief Fluids Surgery Call emergency service Intravenous access Intravenous analgesics Narcotic analgesics Meperidine Pethidine Bed rest Diclofenac Tenoxicam Ketorolac Antispasmodics Papverine Atropine Metoclopramide Prochlorperazine Cholecystectomy DRUG THERAPHY
Cholesterol cholelithiasis is one of the most common and costly digestive diseases. Although gallstones are usually asymptomatic and no treatment is generally required, it is imperative to treat symptomatic gallstones with or without complicated conditions. Laparoscopic cholecystectomy is first-line therapy for symptomatic gallstones. By contrast, a cautious study on the natural history of the disease and costs of therapy, indicates that non-surgical treatment of gallstones is currently restricted to a subgroup of patients with mild symptoms or with small radiolucent cholesterol gallstones in a functioning gallbladder. Appropriate selection of patients suitable for medical therapy is therefore of key importance. Oral litholysis with the hydrophilic bile acid ursodeoxycholic acid induces cholesterol desaturation of bile and may lead to gallstone dissolution in patients with small, radiolucent, cholesterol-enriched stones in a functioning gallbladder with a patent cystic duct. Recent studies from experimental animal models and

preliminary findings in humans also suggest that blocking intestinal absorption of cholesterol with the powerful, specific, and effective NPC1L1 inhibitor ezetimibe, may offer a novel and exciting strategy for the treatment of cholesterol gallstones. A similar possibility might arise from manipulation of specific nuclear receptors involved in cholesterol and bile acid homeostasis. Current views and perspectives on medicinal treatment of cholesterol gallstone disease are discussed here.

EXTRACORPOREAL SHOCK WAVE LITHOSTRIPSY

Extracorporeal shock wave lithotripsy (ESWL) uses shock waves to break a kidney stone into small pieces that can more easily travel through the urinary tract and pass from the body. See a picture of ESWL

You lie on a water-filled cushion, and the surgeon uses X-rays or ultrasound tests to precisely locate the stone. High-energy sound waves pass through your body without injuring it and break the stone into small pieces. These small pieces move through the urinary tract and out of the body more easily than a large stone. The process takes about an hour. You may receive sedatives or local anesthesia. Your surgeon may use a stent when your stones are larger than 2.5cm. A stent is a small, short tube of flexible plastic mesh that holds the ureter open. This helps the small stone pieces to pass without blocking the ureter. ENDOSCOPIC SPHINCTERETOMY Endoscopic sphincterotomy or endoscopic retrograde sphincterotomy (ERS) is a relatively new endoscopic technique developed to examine and treat abnormalities of the bile ducts, pancreas and gallbladder. The procedure was developed as an extension to the diagnostic examination, ERCP (endoscopic retrograde cholangiopancreatography); with the addition of "sphincterotomy," abnormalities found during the study could be treated at the same time without the need for invasive surgery.

The term ERS has three parts to its definition;

endoscopic refers to the use of an endoscope retrograde refers to the insertion of the endoscope up into the ducts in a direction opposite to or against the normal flow of bile down the ducts sphincterotomy, which means cutting of the sphincter or muscle that lies at the juncture of the intestine with both the bile and pancreatic ducts. CHOLECYSTECTOMY Cholecystectomy (pronounced /klsstktmi/, plural: cholecystectomies) is the surgical removal of the gallbladder. It is the most common method for treating

symptomatic gallstones. Surgical options include the standard procedure, called laparoscopic cholecystectomy, and an older more invasive procedure, called open cholecystectomy. NURSING CARE
Cholecystectomy is performed most frequently through laparoscopic incisions using laser. However, traditional open cholecystectomy is the treatment of choice for many patients with multiple/large gallstones either because of acute symptomatology or to prevent recurrence of stones.

CARE SETTING This procedure is usually done on a short-stay basis; however, in the presence of suspected complications, e.g., empyema, gangrene, or perforation, an inpatient stay on a surgical unit is indicated. RELATED CONCERNS Cholecystitis with cholelithiasis Pancreatitis Peritonitis Psychosocial aspects of care Surgical intervention Patient Assessment Database/Diagnostic Studies Refer to CP: Cholecystitis with Cholelithiasis. TEACHING/LEARNING Discharge plan DRG projected mean length of inpatient stay: 1 (laparoscopic)4.3 days May require assistance with wound care/supplies, homemaker tasks Refer to section at end of plan for postdischarge considerations. NURSING PRIORITIES 1. Promote respiratory function. 2. Prevent complications. 3. Provide information about disease, procedure(s), prognosis, and treatment needs. DISCHARGE GOALS

1. Ventilation/oxygenation adequate for individual needs. 2. Complications prevented/minimized. 3. Disease process, surgical procedure, prognosis, and therapeutic regimen understood. 4. Plan in place to meet needs after discharge.

Cancer of gallbladder:

Gallbladder cancer is a rare disease in which malignant (cancer) cells are found in the tissues of the gallbladder. The gallbladder is a pear-shaped organ that lies just under the liver in the upper abdomen. The gallbladder stores bile, a fluid made by the liver to digest fat. When food is being broken down in the stomach and intestines, bile is released from the gallbladder through a tube called the common bile duct, which connects the gallbladder and liver to the first part of the small intestine. The wall of the gallbladder has 3 main layers of tissue. Mucosal (innermost) layer. Muscularis (middle, muscle) layer. Serosal (outer) layer. Between these layers is supporting connective tissue. Primary gallbladder cancer starts in the innermost layer and spreads through the outer layers as it grows. CAUSES Risk factors for gallbladder cancer Gallbladder cancer is a rare cancer in the UK. It is more common in women than in men. About 7 out of every 10 cases of gallbladder cancer are diagnosed in women. It is more common in older people. Genetic factors and medical history The most common risk factor for gallbladder cancer is having gallstones and inflammation of the gallbladder (cholecystitis).Having a first-degree relative with gallbladder cancer increases your risk. Some rare abnormalities of the gallbladder that you are born and having non cancerous growths called gallbladder polyps can also increase risk. Lifestyle factors

There are some lifestyle risk factors such as being overweight, smoking or working in the metal or rubber industry. SIGN AND SYMPTOMS

These and other symptoms may be caused by gallbladder cancer. Other conditions may cause the same symptoms. A doctor should be consulted if any of the following problems occur: Jaundice (yellowing of the skin and whites of the eyes). Pain above the stomach. Fever. Nausea and vomiting. Bloating. Lumps in the abdomen. TREATMENT

Certain factors affect the prognosis (chance of recovery) and treatment options. The prognosis (chance of recovery) and treatment options depend on the following:

The stage of the cancer (whether the cancer has spread from the gallbladder to other places in the body). Whether the cancer can be completely removed by surgery. The type of gallbladder cancer (how the cancer cell looks under a microscope). Whether the cancer has just been diagnosed or has recurred (come back).

Treatment may also depend on the age and general health of the patient and whether the cancer is causing symptoms.Gallbladder cancer can be cured only if it is found before it has spread, when it can be removed by surgery. If the cancer has spread, palliative treatment can improve the patient's quality of life by controlling the symptoms and complications of this disease. NURSING CARE

These nutritional tips may help reduce symptoms:

Eliminate suspected food allergens, such as dairy (milk, cheese, and ice cream), wheat (gluten), soy, corn, preservatives and chemical food additives. Eggs, especially, may

irritate the gallbladder (as well as being high in cholesterol). Your health care provider may test you for food allergies. Eat foods high in B-vitamins and iron, such as whole grains (if no allergy), dark leafy greens (such as spinach and kale), and sea vegetables. Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes), and vegetables (such as squash and bell peppers). Avoid refined foods, such as white breads, pastas, and sugar. Eat fewer red meats and more lean meats, cold water fish, tofu (soy, if no allergy) or beans for protein. Eat more fiber. Consider fiber supplements, such as flaxmeal (1 tsp. 1 - 3 times per day). Combine 1 heaping tsp. of flaxmeal in 8 oz. of apple juice for a drink high in fiber and pectin. Use healthy cooking oils, such as olive oil or vegetable oil. Reduce or eliminate trans fatty acids, found in commercially baked goods such as cookies, crackers, cakes, French fries, onion rings, donuts, processed foods, and margarine. Avoid alcohol, and tobacco. Some evidence suggests that people who drink caffeinated coffee have a lower risk of gallstones, though study results are mixed. Talk to your doctor before increasing your caffeine intake, as caffeine can affect several conditions and interact with medications. If possible, exercise lightly 5 days a week.

You may address nutritional deficiencies with the following supplements:

A multivitamin daily, containing the antioxidant vitamins A, C, E, the B-complex vitamins, and trace minerals such as magnesium, calcium, zinc, and selenium. Vitamin C, 500 - 1,000 mg daily, as an antioxidant and for immune support. Phosphatidylcholine, 300 - 2,000 mg daily, may help dissolve gallstones. Alpha-lipoic acid, 25 - 50 mg twice daily, for antioxidant support. Magnesium, 400 - 600 mg daily, for nutrient support

Pancreatitis:
Pancreatitis is inflammation of the pancreas. The pancreas is a large gland behind the stomach and close to the duodenumthe first part of the small intestine. The pancreas secretes digestive juices, or enzymes, into the duodenum through a tube called the pancreatic duct. Pancreatic enzymes join with bilea liquid produced in the liver and stored in the gallbladderto digest food. The pancreas also releases the hormones insulin and glucagon into the bloodstream. These hormones help the body regulate the glucose it takes from food for energy. Normally, digestive enzymes secreted by the pancreas do not become active until they reach the small intestine. But when the pancreas is inflamed, the enzymes inside it attack and damage the tissues that produce them.Pancreatitis can be acute or chronic. Either form is serious and can lead to complications. In severe cases, bleeding, infection, and permanent tissue damage may occur.

CAUSES

Acute pancreatitis is usually caused by drinking too much alcohol or by gallstones. A gallstone can block the pancreatic duct, trapping digestive enzymes in the pancreas and causing pancreatitis. Chronic pancreatitis occurs when digestive enzymes attack and destroy the pancreas and nearby tissues. Chronic Pancreatitis is usually caused by many years of alcohol abuse, excess iron in the blood, and other unknown factors. However, it may also be triggered by only one acute attack, especially if the pancreatic ducts are damaged.

SIGN AND SYPTOMS

The symptoms of acute pancreatitis usually begins with severe pain the upper abdomen. The pain may last for a few days. Some of the other symptoms of pancreatitis are: swollen and tender abdomen, sweating, nausea, vomiting, fever, mild jaundice, and rapid pulse. COMPLICATIONS

Some of the complications from pancreatitis are: low blood pressure, heart failure, kidney failure, ARDS (adult respiratory distress syndrome), diabetes, ascites, accumulation of fluid in the abdomen, and cysts or abscesses in the pancreas. Acute pancreatitis can cause breathing problems. Many people develop hypoxia, which means that cells and tissues are not receiving enough oxygen. Doctors treat hypoxia by giving oxygen through a face mask. Despite receiving oxygen, some people still experience lung failure and require a ventilator. Sometimes a person cannot stop vomiting and needs to have a tube placed in the stomach to remove fluid and air. In mild cases, a person may not eat for 3 or 4 days and instead may receive fluids and pain relievers through an intravenous line. If an infection develops, the doctor may prescribe antibiotics. Surgery may be needed for extensive infections. Surgery may also be necessary to find the source of bleeding, to rule out problems that resemble pancreatitis, or to remove severely damaged pancreatic tissue. Acute pancreatitis can sometimes cause kidney failure. If your kidneys fail, you will need dialysis to help your kidneys remove wastes from your blood.

MEDICAL DIAGNOSIS

Besides asking about a person's medical history and doing a physical exam, a doctor will order a blood test to diagnose acute pancreatitis. During acute attacks, the blood contains at least three times more amylase and lipase than usual. Amylase and lipase are digestive enzymes formed in

the pancreas. Changes may also occur in blood levels of glucose, calcium, magnesium, sodium, potassium, and bicarbonate. After the pancreas improves, these levels usually return to normal. A doctor may also order an abdominal ultrasound to look for gallstones and a CAT (computerized axial tomography) scan to look for inflammation or destruction of the pancreas. CAT scans are also useful in locating pseudocysts. MEDICAL TREATMENT

Treatment depends on the severity of the attack. If no kidney or lung complications occur, acute pancreatitis usually improves on its own. Treatment, in general, is designed to support vital bodily functions and prevent complications. A hospital stay will be necessary so that fluids can be replaced intravenously. If pancreatic pseudocysts occur and are considered large enough to interfere with the pancreas's healing, your doctor may drain or surgically remove them. Unless the pancreatic duct or bile duct is blocked by gallstones, an acute attack usually lasts only a few days. In severe cases, a person may require intravenous feeding for 3 to 6 weeks while the pancreas slowly heals. This process is called total parenteral nutrition. However, for mild cases of the disease, total parenteral nutrition offers no benefit. Before leaving the hospital, a person will be advised not to drink alcohol and not to eat large meals. After all signs of acute pancreatitis are gone, the doctor will try to decide what caused it in order to prevent future attacks. In some people, the cause of the attack is clear, but in others, more tests are needed. DRUG THERAPHY

Antioxidant therapy in the management of acute, chronic and post-ERCP pancreatitis: a systematic review.

We systematically reviewed the clinical trials which recruited antioxidants in the therapy of pancreatitis and evaluated whether antioxidants improve the outcome of patients with pancreatitis. Electronic bibliographic databases were searched for any studies which investigated the use of antioxidants in the management of acute pancreatitis (AP) or chronic pancreatitis (CP) and in the prevention of post-endoscopic retrograde cholangio-pancreatography (post-ERCP) pancreatitis (PEP) up to February 2009. Twenty-two randomized, placebo-controlled, clinical trials met our criteria and were included in the review. Except for a cocktail of antioxidants which showed improvement in outcomes in three different clinical trials, the results of the administration of other antioxidants in both AP and CP clinical trials were incongruent and heterogeneous. Furthermore, antioxidant therapy including allopurinol and N-acetylcysteine failed to prevent the onset of PEP in almost all trials. In conclusion, the present data do not support a benefit of antioxidant therapy alone or in combination with conventional therapy in the

management of AP, CP or PEP. Further double blind, randomized, placebo-controlled clinical trials with large sample size need to be conducted. SURGICAL INTERVENTIONS BACKGROUND: This study evaluated the various surgical strategies for treatment of (suspected) infected necrotizing pancreatitis (INP) and patient referrals for this condition in the Netherlands. METHODS: This retrospective study included all 106 consecutive patients who had surgical treatment for INP in the period 2000-2003 in one of eight Dutch university medical centres including three teaching hospitals. Surgical approaches included an open abdomen strategy, laparotomy with continuous postoperative lavage, minimally invasive procedures or laparotomy with primary abdominal closure. The National Hospital Registration System was searched to identify patients with acute pancreatitis who were admitted to the 90 Dutch hospitals that did not participate in the present study. RESULTS: The overall mortality rate was 34.0 per cent, 70 per cent (16 of 23) for the open abdomen strategy, 25 per cent (13 of 53) for continuous peritoneal lavage, 11 per cent (two of 18) for minimally invasive procedures and 42 per cent (five of 12) for primary abdominal closure (P < 0.001). During the study interval, 44 (12.2 per cent) of 362 patients with acute pancreatitis who were likely to require surgical intervention had been referred to university medical centres. CONCLUSION: Laparotomy with continuous postoperative lavage is the surgical strategy most often used in the Netherlands. The results of the open abdomen strategy are poor whereas a minimally invasive approach seems promising.

CANCER OF THE PANCREAS:

CAUSES

While it can seldom be explained why one person gets pancreatic cancer and another doesn't, it is clear that the disease is not contagious. No one can "catch" cancer from another person. Although scientists do not know exactly what causes cancer of the pancreas, they are learning that some things increase a person's chance of getting this disease. Smoking is a major risk factor. Research shows that cigarette smokers develop cancer of the pancreas two to three times more often than nonsmokers. Quitting smoking reduces the risk of pancreatic cancer, lung cancer, and a number of other diseases. SIGN AND SYMPTOMSPancreatic cancer has been called a "silent" disease because early pancreatic cancer usually does not cause symptoms. If the tumor blocks the common bile duct and bile cannot pass into the digestive system, the skin and whites of the eyes may become yellow, and the urine may become darker. This condition is called jaundice.

As the cancer grows and spreads, pain often develops in the upper abdomen and sometimes spreads to the back. The pain may become worse after the person eats or lies down. Cancer of the pancreas can also cause nausea, loss of appetite, weight loss, and weakness. A rare type of pancreatic cancer, called islet cell cancer, begins in the cells of the pancreas that produce insulin and other hormones. Islet cells are also called the islets of Langerhans. Islet cell cancer can cause the pancreas to produce too much insulin or hormones. When this happens, the patient may feel weak or dizzy and may have chills, muscle spasms, or diarrhea. These symptoms may be caused by cancer or by other, less serious problems. If an individual is experiencing symptoms, a doctor should be consulted. MEDICAL DIANOSIS

To diagnose pancreatic cancer, the doctor does a complete physical exam and asks about the patient's personal and family medical history. In addition to checking general signs of health (temperature, pulse, blood pressure, and so on), the doctor usually orders blood, urine, and stool tests. The doctor may also ask for a "barium swallow," or "upper GI series." For this test, the patient drinks a barium solution before x-rays of the upper digestive system are taken. The barium shows an outline of the pancreas on the x-rays. Other tests may be ordered, such as:

An angiogram, a special x-ray of blood vessels. CT scans, x-rays that give detailed pictures of a cross- section of the pancreas. These pictures are created by a computer. Transabdominal ultrasound to view the pancreas. In this procedure, an instrument that sends out high-frequency sound waves, which cannot be heard, is passed over the abdomen. The sound waves echo off the pancreas. The echoes form a picture on a screen that looks like a television. ERCP (endoscopic retrograde cholangiopancreatogram), is a special x-ray of the common bile duct. For this test, a long, flexible tube (endoscope) is passed down the patient's throat through the stomach and into the small intestine. A dye is injected into the common bile duct, and x-rays are taken. The doctor can also look through the endoscope and take tissue samples. Endoscopic ultrasound is a relatively new procedure that can be used to diagnose pancreatic cancer. For the procedure, an endoscope is passed in the same way as for ERCP; however, on the end of the endoscope is an ultrasound probe which scans the pancreas for cancers. Because the ultrasound probe is closer to the pancreas than with transabdominal ultrasound, it is possible to identify small cancers within the pancreas. The cancers also can be biopsied through the endoscope.

A biopsy is the only sure way for the doctor to know whether cancer is present. In a biopsy, the doctor removes some tissue from the pancreas. It is examined under a microscope by a pathologist, who checks for cancer cells.

One way to remove tissue is with a long needle that is passed through the skin into the pancreas. This is called a needle biopsy. Doctors use x-rays or ultrasound to guide the placement of the needle. Another type of biopsy is a brush biopsy. This is done during the ERCP. The doctor inserts a very small brush through the endoscope into the bile duct to rub off cells to examine under a microscope. Sometimes an operation called a laparotomy may be needed. During this operation, the doctor can look at organs in the abdomen and can remove tissue. The laparotomy helps the doctor determine the stage, or extent, of the disease. Knowing the stage helps the doctor plan treatment. Tissue samples that are obtained with one kind of biopsy may not give a clear diagnosis, and the biopsy may need to be repeated using a different method. MEDICAL TREATMENT

Cancer of the pancreas is curable only when it is found in its earliest stages, before it has spread. Otherwise, it is very difficult to cure. However, it can be treated, symptoms can be relieved, and the quality of the patient's life can be improved. Pancreatic cancer is treated with surgery, radiation therapy, or chemotherapy. Researchers are also studying biological therapy to see whether it can be helpful in treating this disease. Sometimes several methods are used, and the patient is referred to doctors who specialize in different kinds of cancer treatment. Surgery may be done to remove all or part of the pancreas. Sometimes it is also necessary to remove a portion of the stomach, the duodenum, and other nearby tissues. This operation is called a Whipple procedure. In cases where the cancer in the pancreas cannot be removed, the surgeon may be able to create a bypass around the common bile duct or the duodenum if either is blocked. Radiation therapy (also called radiotherapy) uses high-powered rays to damage cancer cells and stop them from growing. Radiation is usually given 5 days a week for 5 to 6 weeks. This schedule helps to protect normal tissue by spreading out the total dose of radiation. The patient doesn't need to stay in the hospital for radiation therapy. Radiation is also being studied as a way to kill cancer cells that remain in the area after surgery. In addition, radiation therapy can help relieve pain or digestive problems when the common bile duct or duodenum is blocked. Chemotherapy uses drugs to kill cancer cells. The doctor may use just one drug or a combination. Chemotherapy may be given by mouth or by injection into a muscle or vein. The drugs enter the bloodstream and travel through the body. Chemotherapy is usually given in cycles; a treatment period followed by a recovery period, then another treatment period, and so on .

. SURGICAL TREATMENT

In this study the experiences with carcinomas of the pancreas, ampulla of Vater, terminal comma bile duct, and duodenum found in a series of 3,610 patients collected from 57 major Japanese institutions was compiled over a 26 year period. The results were analyzed as to the success of resectional and palliative surgery for the various lesions. The most common lesion was carcinoma of the head of the pancreas. Unifortunately, only 18.3% of these patients were resectable with a 25.3% mortality. Carcinoma of the body and the tail was the second most frequent lesion, and it also exhibited a low resection rate. Carcinomas of the ampulla and the terminal common bile duct and duodenal regions were the most favorable for resection; usually pancreatoduodenectomy with an overall mortality of 20.8%. As a result of the large number of pancreatectomies performed, there was also a large number of postoperative complications, the most frequent being leakage at an anastomotic line. Hemorrhage also occurred frequently. Distal pancreatectomies were reserved for carcinoma of the body and the tail of the pancreas, and the most common postoperative complication of this procedure was hemorrhage. There were only 45 total pancreatectomies among the 973 resections being performed most frequently in patients with carcinoma of the head of the pancreas. Again, the most frequent postoperative complication was hemorrhage, followed by anastomotic leakage. The long term survivals following resection for these lesions were each poor. The best mean survival time was 22.7 months for carcinoma of the ampulla of Vater. Patients having resections for carcinoma of the head of the pancreas had a mean survival time of 12.3 months. At 5 years there were few survivors and most of them were patients who had undergone resections for carcinoma of the ampulla of Vater. PANCREATIC JEJUNOSTOMY

Background: The surgical management of pancreatic pseudocysts can be established through a variety of techniques. Internal drainage has consistently proven to be the treatment of choice for both acute and chronic pancreatic pseudocysts. With the growing popularity of minimally invasive surgery and improvements in surgical technique, laparoscopic internal drainage procedures for pancreatic pseudocysts are being attempted. While most authors have focused on laparoscopic cyst-gastrostomies, few have written about laparoscopic cyst-jejunostomies. Methods: In this article, we report our experience with eight laparoscopic Roux-en-Y cystjejunostomies. Of the eight patients, six had alcoholic pancreatitis, and two had gallstone pancreatitis. There were five men and three women with a mean age of 48 (range 3571 years). Results: The mean operative time was 150 min, with a range of 100215 min. We report a mean EBL of 78 cc, a minor complication rate of 20%, and no major complications or mortalities. Conclusions: These data compare favorably with both open and laparoscopic internal drainage procedures. Laparoscopic cyst-jejunostomy offers a feasible alternative in the minimally invasive management of pancreatic pseudocyst. PANCREATICDUODENAL RESECTION(WHIPPLE PROCEDURE)

From an institutional review of 103 pancreaticoduodenal resections (PDRs) performed during the period 1968-1981, risk factors and selection criteria of this procedure were evaluated. A total of 43.7% of the patients were operated on for benign lesions, mainly right-sided chronic pancreatitis (35%); 56.3% of the interventions were performed for malignant disease, mainly

carcinoma of the periampullary region. Despite the absence of any selection, the hospital mortality in 103 consecutive PDRs only reached 10.6% for the whole group (11/103 patients) and 8.3% for the elective group (8/96 patients). Mortality was significantly influenced by age barrier over 65 years (p less than 0.0001) and by urgent degree of surgery (p less than 0.03). All three patients with renal insufficiency had a fatal outcome after PDR. A total of 19.4% of the patients (20/103 patients) developed a surgical complication. The most important complication was pancreatic fistula (15/103 patients, 14.5%) responsible for all digestive-related fatal outcomes (six patients). Surgical treatment of pancreatic fistula (10 patients) is compromised by a high morbidity and a high mortality rate (50%). Postoperative morbidity as well as the incidence of the pancreatic fistula were significantly influenced by the age of the patients over 65 years (p less than 0.01 and less than 0.001, respectively), and by the serum bilirubin level over 6 mg/dl (p less than 0.002). The poor quality of the pancreatic tissue (p less than 0.03) and the urgent degree of the intervention (p less than 0.03) also raised the incidence of pancreatic leakage. Morbidity rate was more important in the malignant disease group (p less than 0.05). Corrected 5-year actuarial survival after PDR is excellent for ampullary cancer, moderate for chronic pancreatitis, and extremely poor for pancreatic and bile duct carcinoma. The decision to perform PDR should be taken after evaluation of the aforementioned risk factors: the emergency, age, serum bilirubin, quality of pancreatic tissue and renal insufficiency, underlying disease, and psycho-social status of the patient.

POTENTIAL PROCEDURE OF THE WHIPPLE PROCEDURE

The Whipple operation was first described in the 1930s by Allan Whipple. In the 1960s and 1970s the mortality rate for the Whipple operation was very high. Up to 25% of patients died from the surgery. This experience of the 1970s is still remembered by some physicians who are reluctant to recommend the Whipple operation. Today the Whipple operation has become an extremely safe operation in the USA. At tertiary care centers where a large numbers of these procedures are performed by a selected few surgeons, the mortality rate from the operation is less than 4%. Studies have shown that for good outcomes from the Whipple surgery, the experience of the center and the surgeon is important. At USC, Dilip Parekh M.D. has performed more than 100 consecutive Whipple type of procedures over the past 9 years with good outcomes. What is a Whipple operation? In the Whipple operation the head of the pancreas, a portion of the bile duct, the gallbladder and the duodenum is removed. Occasionally a portion of the stomach may also be removed. After removal of these structures the remaining pancreas, bile duct and the intestine is sutured back into the intestine to direct the gastrointestinal secretions back into the gut.

Laparoscopic Whipple operation At USC, Dr Parekh is developing techniques for a laparoscopic Whipple operation. At present this procedure may be offered at USC to selected patients with chronic pancreatitis, cystic tumors and islet cell tumors of the pancreas and patients who have ampullary cancer. We do not offer the laparoscopic Whipple operation for pancreatic adenocarcinoma. The Whipple operation is performed laparoscopically utilizing a laparoscopic hand-access device. When is a Whipple operation required A Whipple operation is performed for

cancer of the head of the pancreas cancer of the duodenum cholangiocarcinoma (cancer of the the bottom end of the bile) cancer of the ampulla an area where the bile and pancreatic duct enter into the duodenum. whipple operation may also sometimes be performed for patients with benign (noncancerous) disorders such as chronic pancreatitis and benign tumors of the head of the pancreas.

What is the results of the Whipple surgery? Over the last 15 years major pancreatic centers in the United States have developed excellent results for the Whipple surgery. In almost all the major centers the death rate from this surgery is now less than 5%. Recent studies from Johns Hopkins and Memorial Sloan Kettering have shown that outcome from surgery for a Whipple operation is dependent on the experience of the hospital and the surgeon performing the surgical operation. In those that hospitals that perform high volume of these procedures the death rate from the Whipple operation is now less than 5%. In hospitals that infrequently perform the Whipple operation a much higher complication rate and the death rate from the surgery often greater than 15 to 20% has been reported in surgical literature. The American Cancer Society recommends that the Whipple operation should be performed in a center that is experienced and does high volume of these complex surgical procedures to ensure the best outcome. What is the experience of the Whipple operation at USC? At USC Dilip Parekh, MD has performed more than a hundred consecutive Whipple operations without any deaths from the surgical procedure. Will the Whipple operation improve my survival?

The overall survival after the whipple operation for pancreatic adenocarcinoma is about 20% at five years after surgery. Patients without spread of cancer into their lymph nodes may have up to a 40% survival. The actuarial survival is less than 5% at five years for patients patients with pancreatic adenocarcinoma who are treated with chemotherapy alone. The operation is usually curative in patients with benign or low grade cancers of the pancreas. Will I require any further treatment for my cancer after the Whipple operation? We recommend that all patients with pancreatic cancer should have chemotherapy and radiation therapy after the operation. Recent studies from Johns Hopkins University have shown that the survival rate can be increased by as much as 10% by adding chemotherapy and radiation therapy to the surgery for patients with pancreatic adenocarcinoma. We do not recommend any further treatment for patients who have benign tumors of the pancreas and in patients with neuroendocrine tumors of the pancreas. Will I become diabetic after a Whipple operation? During the Whipple operation part of the pancreas, the head of the pancreas, is removed. Pancreatic tissue produces insulin that is required for blood sugar control. When pancreatic tissue is removed the body releases less insulin and the risk of developing diabetes is present. Our experience has been that patients who are diabetic at the time of surgery or who have an abnormal blood sugar level that is controlled on a diet prior to surgery have a high chance for the severity of the diabetes becoming worse after the surgery. On the other hand patients who have completely normal blood sugar prior to surgery with no history of diabetes and do not have chronic pancreatitis have a low probability of developing diabetes after the Whipple operation. What can I eat after the surgery? There is no restriction of your diet after the operation. Some patients may not tolerate very sweet foods and may need to avoid this. Will my life be altered very much after the Whipple operation? Will I be able to do all the things that I can do now? There is acceptable alteration of lifestyle after the Whipple operation. Most patients are able to go back to their normal functional levels. Researchers at John Hopkins University mailed surveys to Whipple operation survivors who had been operated on at Hopkins between 1981 and 1997. The questionnaire was broken down into sections that looked at physical abilities, psychological issues and social issues; an additional section evaluated functional capabilities and disabilities. Scores were reported as a percentile, with 100 percent being the highest possible score. The same questionnaire was then sent to a group of healthy individuals and a group of patients who had laparoscopic gallbladder removal.

Responses from this study at Johns hopkins were tallied from 188 Whipple survivors, 37 laparoscopic gallbladder surgery patients and 31 healthy individuals. Whipple survivors on average rated their physical quality of life a 79, compared with an 83 among laparoscopic surgery patients and an 86 among healthy people. For psychological issues, Whipple survivors rated their quality of life to be a 79, compared with an 82 for laparoscopic surgery patients and an 83 among healthy people. Looking at social issues, Whipple survivors ranked their quality of life at an 81, compared with an 84 among laparoscopic surgery patients and an 83 among healthy individuals. There were no statistical difference amongst these groups. What are the complications that are likely to happen immediately after surgery for the Whipple operation? The Whipple operation is a complex operation with a high chance of developing complications if the surgeon performing the surgical procedure has limited experience in this operation. In the hands of surgeons who are experienced with this surgical operation the complication rate is usually very low. The problems and complications that may be seen after this operation include:

Pancreatic fistula: After the tumor is removed from the pancreas the cut end of the pancreas is sutured back into to the intestine so that pancreatic juices can go back into the intestine. The pancreas is a very soft organ and in some patients this suture line may not heal very well. If this happens then patients develop leakage of pancreatic juice. Usually the surgeon leaves behind a drainage catheter in the abdomen during the surgery. Any leakage of pancreatic juice after the surgery is usually removed from the body by this drainage catheter. In almost all patients who develop leakage of pancreatic juice after the surgery, the leakage heals on its own. It is uncommon for patients to be re-operated for this complication. At USC this complication has occurred in about 4% of all the surgeries that we have performed. Gastroparesis ( paralysis of the stomach): The first five to six days after the surgery, you will be provided with intravenous fluids until your bowel function returns. After your bowel function have return your surgeon will begin you on a diet of clear liquids and your diet will progress to a regular diet as you tolerate it. In up to 25% of patients, the stomach may remain paralyzed after the surgery and it may take up to 4 to 6 weeks for the stomach to adapt to the changes after the surgery to function normally. During this period you may not a tolerate a diet very well. If you fall in this category then you will be provided with nutrition through a small feeding tube that your surgeon has placed into the intestine at the time of surgery. In almost all patients the stomach function returns to normal after this 4 to 6 week period after the surgery

What are the long-term complications of the Whipple operation? Some of the long-term consequences of the Whipple operation include the following:

Mal-absorption: The pancreas produces enzymes required for digestion of food. In some patients removal of part of the pancreas during the Whipple operation can lead to a diminished production of these enzymes. Patients complain of bulky diarrhea type of stool that is very oily. Long-term treatment with oral pancreatic enzyme supplementation usually provides relief from this problem. Alteration in diet: After the Whipple operation we generally recommend that the patients ingest smaller meals and snack between meals to allow better absorption of the food and to minimize symptoms of feeling of being bloated or getting too full. Loss of weight: It is common for patients to lose up to 5 to 10% of their body weight compared to their weight prior to their illness. The weight loss usually stabilizes very rapidly and most patients after a small amount of initial weight loss are able to maintain their weight and do well.

What questions should I ask my surgeon about a Whipple operation? The Whipple operation is a very complex operation and staging of the patient and outcome of surgery is very dependant on the experience of the surgeon in treating the pancreatic cancer. Outcome research studies in Maryland, New York and elsewhere has suggested that best outcomes from the Whipple operation is dependant on the experience of the surgeon with this operation.An open and frank discussion with your physician may help you make appropriate choices regarding your therapy. The following are some of the question that may

How many pancreatic cancers are operated at your hospital on a yearly basis? How many Whipple operations have you done? How many Whipple operations do you do a year? What are the complications in your hands of a Whipple operations? What is the death rate of the Whipple operation at your institution and in your hands? How many pancreatic cancer patients do you treat per year? What is the average length of hospital stay of the patients that you have treated in the past?

NURSING CARE PLAN

The Whipple Procedure is a complex and delicate surgery that is most often done for chronic pancreatitis or cancer of the pancreas. The pancreas is an organ that has two functions. The first is to produce insulin that controls how much sugar is in your blood. The second is to produce digestive juices that neutralize the acid that is made by your stomach. Your doctor will discuss with you how the surgery affects you.

The Whipple is also called a pancreaticoduodenectomy. During the Whipple, part of the pancreas is removed, along with a portion of both the stomach and duodenum (small intestine). The common bile duct and the gallbladder may also be removed. The stomach and pancreas are

then attached to the small intestine to allow enzymes and gastric juices to pass into the digestive tract.

Day before Surgery: Bowel Prep

An important part of getting ready for surgery is cleaning your bowel. This is called a bowel prep. You need to buy 2 bottles of Magnesium Citrate (10 oz. each). You may buy this at any drugstore without a prescription. It is easier to drink chilled.

Eat a light breakfast and lunch. Drink only clear liquids after lunch until midnight (there is no limit on how much you may drink).

Clear liquids:

Water Broth or bouillon Juice without pulp (grape, apple, cranberry) Popsicles Hard candy Gatorade

Clear Jell-O, no fruit in it Carbonated drinks, clear sodas Weak coffee or tea, no milk or creamer. Sugar or substitute is okay No alcoholic beverages No dairy products Boost Breeze

At 2 pm, drink one bottle of Magnesium Citrate 10 oz. At 3 pm, drink the other bottle. You should keep drinking clear liquids only until midnight.

Remember: Nothing to eat or drink after midnight.

After Surgery

Care of the Incision

You will need to look at your incision daily. Call your doctor if you notice: Increased pain or tenderness at the incision Increased swelling or opening of the incision Any change in the color or amount of drainage Redness or warmth around the incision site Temperature (by mouth) above 100.4 F or 38 C

Your incision will be closed with staples or steri-strips (small tape strips).

If it is closed with steri-strips, keep them dry for 7 days. You may take a sponge bath or cover the incision with plastic wrap. After that time, you may shower and allow the strips to fall off slowly.If it is closed with staples, you may shower as soon as youd like. Do not rub the incision site. Just let the soapy water run over it. Do not use any lotions or creams. Keep it clean and dry.

Activities

For the first 3 weeks, avoid lifting things over 10 pounds. Keep walking and slowly resume your normal household activities. Be sure to stay within your lifting restrictions.

After 3 weeks, slowly increase your level of activity. Check with your doctor if you are not sure an activity is right for you. Listen to your body for cues. Let comfort be your guide. If it hurts, stop.

Check with your doctor about when you may:

Resume driving. DO NOT DRIVE if you are taking narcotic pain medicine. These include Percocet, Vicodin, or Tylenol #3. Return to work. Resume sexual activity.

Pain

It is normal to have some pain from the incision after you return home. Your doctor will order pain medicine for you to take home. Use these pills as you need them. They should not be taken more often than every 3 to 4 hours. A pain pill at bedtime can help you sleep well. Be sure to follow directions on the bottle. Do not drive when using narcotics. Pain medicine can cause some problems with constipation. You can promote good bowel habits by drinking plenty of fluids and adding fiber to your diet. If constipation is a problem for you, you can use a stool softener such as Colace or a mild laxative such as Milk of Magnesia. You should talk this over with your doctor first.

Diet

Eat what appeals to you when you get home. Try to eat a balanced diet with protein, fruits, bread, milk, and vegetables. Do not skip meals. You should eat small, frequent meals. Include an evening snack.

You may want to know what your blood sugar is when it is tested. This tells you that your pancreas is able to produce the insulin you need for normal living. Call your doctor if you have:

- increased thirst - fatigue

- frequent urination - lightheaded or dizziness

If you have questions, our dietician would be happy to go over a diet to fit your needs. Just ask your nurse to call the dietician.

You may also be given a medicine to replace the digestive enzymes that were produced by your pancreas. It is important that you take it as ordered so your body can break down the food you eat.

When to Call the Doctor Unusual pain in your right side Nausea Vomiting Severe fatigue that doesnt go away Unusual drainage at the incision Fever of 100.4 F or 38 C Any unusual or prolonged bleeding