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

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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

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Disclosures

• None

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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

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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

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• Educate and counsel patient and family regarding
  surgical treatment and recovery
• Act as a resource or point of contact, available
  for questions or concerns

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• 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

• Prepare prescriptions
• Dictate d/c summary

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• 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

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The Pancreas
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Pancreatic Cancer

• 46,420 estimated new cases in 2014
• 39,590 estimated deaths in 2014
• 3 of all cancers in the U.S. are Pancreas
  Cancer
• 4th leading cause of cancer death in the United
  States
• Cure is rare and only in resected patients

American Cancer Society. Cancer Facts and Figures
2014. Atlanta American Cancer Society 2014.
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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

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Types of Pancreas Neoplasms

• Cystic
• Serous Cystadenoma
• Mucinous Cystic Neoplasm
• IPMN

• Solid
• Adenocarcinoma
• PNET
• Metastatic
• Solid pseudopapillary tumor

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Symptoms on Presentation
Body and Tail
Head

• Weight loss 100
• Pain 87
• Weakness 43
• Nausea 43
• Vomiting 37
• Anorexia 33
• Constipation 27
• Hematemesis 17
• Melena 17
• Jaundice 7
• Fever 7
• Diarrhea 3

• Weight loss 92
• Jaundice 82
• Pain 72
• Anorexia 64
• Dark urine 63
• Light stools 62
• Nausea 45
• Vomiting 37
• Weakness 35
• Pruritus 24
• Diarrhea 18
• Melena 12
• Constipation 11
• Fever 11
• Hematemesis 8

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Treatment
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Surgery is the only chance of cure
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Treatment

• Surgical resection

Tumors in the head/uncinate process
Tumors in the body tail
Distal pancreatectomy splenectomy
Whipple
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Preoperative Workup

• Labs
• LFTs, CA19-9, CEA, CMP, CBC, Prealbumin, Coags
• Nutrition
• Imaging- U/S, CT Pancreas Protocol, MRI/MRCP
• Staging
• EUS/Biopsy

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Preoperative Workup

• Selective patients with severe jaundice require
  preoperative biliary drainage/decompression
• ERCP (GI)
• Percutaneous biliary
• drainage (IR)

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Whipple Procedure Pancreaticoduodenectomy
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Whipple Procedure Pancreaticoduodenectomy

• Removal of the pancreatic head, entire duodenum,
  gallbladder, and common bile duct

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Indications for the Whipple

• Pancreatic head mass
• Cholangiocarcinoma of the distal bile duct
• Ampullary tumor
• Duodenal tumor
• Chronic pancreatitis

Most common
Least common
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Distal Pancreatectomy
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Distal Pancreatectomy

• Tumors in the body tail of the pancreas
• Splenectomy vs spleen preserving
• Vaccines
• LOS

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Total Pancreatectomy
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Total Pancreatectomy

• Rare
• Benign malignant disease
• Diffuse IPMN
• Chronic Pancreatitis
• Margin panc cancer

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Unresectable Pancreatic Cancer

• PALLIATIVE
• Relief of obstructive jaundice
• Prevention of duodenal obstruction
• Pain control

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Palliation of Unresectable Pancreas Cancer

• Non Surgical Interventions

• Surgical

• Endoscopic biliary stent
• Percutaneous Transhepatic Cholangiogram drainage
  stent

• Choledochojejunostomy
• Gastrojejunostomy

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Post-Op Care
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Pancreas Post-Op Care

• Ambulation
• Diet
• NGT removal
• Urine output
• Labs
• CBC for bleeding risk
• Electrolytes
• BUN/Crt for fluid management
• LFTs

• Medications
• Antibiotics- perioperative
• DVT prophylaxis
• Pain management
• IV PCA
• Epidural PCA
• IV narcotics
• Toradol
• PO narcotics

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Pancreas Post-Op Care

• Drains
• Anterior Posterior to anastomoses
• Volume
• Character of fluid
• Drain Amylase
• Removal

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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 recommended.

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Complications
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Early Complications

• Wound infection
• Anastomotic leak
• Gastrojejunostomy (2-3)
• Hepaticojejunostomy (5)
• Pancreatic (10-25)
• Delayed gastric emptying (DGE) (20)
• Hemorrhage

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Pancreatic Fistula/Leak

• Amylase rich fluid 3x serum, POD 3
• Grade ABC
• Clinical signs
• Abdominal pain /- distention
• Ileus
• DGE
• Fever
• Tenderness
• Leukocytosis

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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)

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Delayed Gastric Emptying

• Postoperative inability to tolerate diet

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Management

• Treatment
• NG for decompression
• Prokinetic agents
• Patience
• Nutrition
• Enteral feeds via post pyloric NJ tube or
  surgical J tube
• TPN

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Discharge

• Medications
• Lovenox
• Metoclopropamide
• Proton pump inhibitor (PPI)
• Oral analgesics
• Laxatives
• Creon

• Drain teaching
• Home care
• Activity restrictions
• Diet
• Insulin

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Late Complications

• Pancreatic insufficiency
• Diabetes
• Marginal Ulcers
• Dumping
• Strictures
• Iron deficiency anemia
• Cancer recurrence

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Short Term Long Term Follow Up

• Surgery
• Oncology
• Endocrine

• Surveillance
• Office visits
• Imaging
• Tumor markers
• Liver function testing
• CMP

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The Liver

• Functions
• Synthetic- albumin, transferrin, clotting factors
• Synthesizes bile for fat absorption
• Detoxifies drugs and toxins

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Hepatic Tumors

• Benign
• Hemangioma
• Focal nodular hyperplasia (FNH)
• Adenoma
• Liver cysts

• Malignant
• Hepatocellular carcinoma (HCC)
• Colorectal cancer metastases (CRC)
• Cholangiocarcinoma

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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

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HCC

• Symptoms
• Nonspecific
• Abdominal pain
• Early satiety
• Weight loss
• jaundice

• Physical findings
• Abdominal mass
• Splenomegaly
• Ascites

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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.
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Cholangiocarcinoma

• Malignancy of the extrahepatic or intrahepatic
  ducts
• Sx of biliary obstruction ?Jaundice, pruritus,
  dark urine, clay colored stools

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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

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Child Pugh Classification
Parameter Points assigned Points assigned Points assigned
Parameter 1 2 3
Ascites Absent Slight Moderate
Hepatic encephalopathy None Grade 1-2 Grade 3-4
Bilirubin lt2 mg/dL 2-3 mg/dL gt 3mg/dL
Albumin gt 3.5 g/dL 2.8-3.5 g/dL lt2.8 g/dL
Prothrombin time      
Seconds over control lt 4 4-6 gt6
INR lt 1.7 1.7-2.3 gt2.3

• Grade A 5-6 points well compensated disease
  good operative risk
• Grade B 7-9 points significant compromise
• Grade C 10-15 points decompensated

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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

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Surgical Resection of Hepatic Tumors

• Right hepatectomy
• Left Hepatectomy
• Trisectionectomy
• Biliary reconstruction
• Lap Vs Open

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Post-Op Liver

• Ambulation
• Diet
• Drains
• UOP
• Medications
• Vitamin K
• No toradol

• Labs
• CBC
• LFTs
• Coags
• BUN/Crt
• Electrolytes phos mag
• Ammonia

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Post-Op Complications

• Liver failure
• Bile leak
• Infection
• Bleeding
• Pleural effusion
• Ascites
• PV Thrombosis

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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

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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

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Short Term Long Term Follow Up

• Surgeon
• Oncologist
• Hepatologist

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Thank you!

• Questions?????

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