Gemma Keating HPB Clinical Nurse Specialist Sarah Dann Clinical Lead HPB Dietitian Royal Free London NHS Foundation Trust
HPB CNS Role Key contact for patients Liaising with all MDT members Facilitate the care pathway for patients requiring treatment of HPB cancers (surgical or oncological) Symptom management, clinical expertise, education CNS-led follow up clinics Holistic Needs Assessment
Types of Pancreatic Surgery Whipple PPPD Total Pancreatectomy Distal Pancreatectomy & Splenectomy Bypass
Pain Management Paracetamol, Ibuprofen Tramadol/Co-codamol Oramorph Nerve Blocks Referral to Pain Team if necessary 1. Patient dependant 2. Disease dependant
Follow Up Telephone Clinic with HPB CNS MDT meeting Surgical Clinic Oncology Clinic Royal Free or locally Clinical Trials
Surveillance CT Chest/Abdomen/Pelvis with contrast 3 monthly for 2 years. 6 monthly for the following 3 years. Annually until 10 years post resection. Tumour Markers and routine blood tests.
After Surgery Appetite/weight loss Pain Nausea Steatorrhea Delayed gastric emptying Constipation Diet Diabetes PERT Bile/Pancreatic Leak Wound Care Thromboprophylaxis Mobility
Post Chemo Symptoms Nausea Dry skin/nails Vomiting Hair loss Diarrhoea Sore Mouth/Ulcers Fatigue Pain
Emotional Support for Patients and Carers CNS Counsellors MacMillan finance, benefits, children Charities, e.g. PCUK GP/District Nurses Patient Support Groups Carer/Bereavement Support Groups Hospice
Recurrence? CT CAP, tumour markers, referral to MDT MDT Outpatient clinic surgery or oncology? Counselling Palliative Care hospital and community
HPB Dietetic Service Pre-op Referred by a CNS or consultant we can offer telephone consultations for these patients Post op patients are referred if deemed high risk of malnutrition based on our screening tool However we aim to review all Whipples/total pancreatectomy patients Post discharge home We do not have an outpatient clinic however can offer telephone follow ups/see people in consultant clinics otherwise they are referred on to local community teams
Dietary problems after surgery Early problems Feeling full Weight loss Poor appetite Diarrhoea/steatorrhea Vomiting/ delayed gastric emptying Early/late dumping syndrome. Late problems Diabetes Malabsorption Vitamin/mineral deficiency: B12, Iron, fat soluble vitamins (A,E,D,K).
Dietary management advice Try eating little and often - aim for 5-6 small snack-size meals per day Do not skip meals. Try to eat something even if you are not hungry. Use food fortification ideas i.e. Adding additional butter, cream, cheese to meals, switching to full fat milk Eat a protein food with at least 2 main meals (e.g. lean meat, chicken, fish, eggs, lentils) Do not fill up on low calorie drinks e.g. tea, coffee, Bovril, thin soups, diet drinks which have little nutrition Keep fruit and vegetables to a minimum initially as they may fill you up If you suffering from nausea or vomiting keep away from cooking smells, which may make nausea worse. Reduce greasy foods as these pass slowly through the gut and can cause reflux or heartburn. Dry foods such as toast or plain biscuits can be easier to take
Dumping Syndrome Early dumping syndrome Normally, the stomach holds the food before it goes into the small bowel, but if the bottom portion of the stomach has been removed, dumping can happen. Food rushes quickly through the gut and dumps into the small bowel. It can happen 15-30 minutes after eating a meal. Symptoms include diarrhoea, fullness, stomach cramping and vomiting. You may also experience weakness after eating, redness of the face, dizziness and sweating. Late dumping syndrome This is related to blood sugar levels and can happen 2-3 hours after a meal. It happens because of a drop in blood sugar (hypoglycaemia). Symptoms include weakness, sweating, nausea (sickness), hunger and anxiety. How do I deal with the symptoms of dumping syndrome? Eat 6 + small meal per day, instead of 2-3 big meals Eat slowly, chew well and sit up straight when eating Avoid very sweet or sugary food and drink e.g. coke etc., juices, sweets, jellies, cakes, doughnuts, sweet biscuits, honey, jam - which can all rush through the gut Do not take large amounts of fluid during your meals (take sips only). Eat protein with each meal. Protein will move more slowly through the gut, e.g. eggs, meat, chicken, fish, milk, yoghurt, cheese
Pancreatic Exocrine Insufficiency Loose watery stool Undigested food in the stool Post-prandial abdominal pain Nausea / colicky abdominal pain Gastro-oesophageal reflux symptoms Bloating / flatulence Weight loss despite good oral intake Steatorrhoea (pale, floating, oily stool) Vitamin deficiencies (especially A,D,E,K,) Hypoglycaemia in patients with diabetes (Friess & Michalski, 2009)
Steatorrhoea Normal fat losses <7g/day Severe insufficiency >15g/day. Visible oil suggests losses 30-40g/day Up to 55g faecal fat losses may occur with no abdominal symptoms Low fat diets! Constipation
How much do we need? No two patients are the same! Mean Intradigestive Post Prandial Peak Lipase up to 1000u/min 3000 6000u/min Amylase 50 250u/min 500 1000u/min Proteases (Trypsin) 50 100u/min 200 1000u/min Enzymes release continues for approximately 2 hours post prandially (360,000-720,000u) Keller & Layer, 2005
Why are we all different? Variations in: Pancreatic function (atrophy / obstruction / resection / disease) PPI use Chewing patterns / temperature of meals Dietary intake / meal patterns / duration of meals Salivary / gastric / intestinal enzyme secretion Intestinal transit (opiates / SMA/SMV invasion) NOT JUST FAT...
Recommended dose STARTING DOSE... 44-50,000 units with meals 22-25,000 units with snacks 25-50,000 units with supplements Will probably need higher dose with larger meals Increase until symptom control
How should enzymes be taken? At the beginning of meal With a cold drink Split dose if slow eater If more than one capsule required take the second half way through the meal Patient choice on size of capsule vs. number of capsules. Consider storage below 25 / 15 o C (cars, windowsills, trouser pockets!!)
What if they don t work? Adequate dose? Correct timings? PPI? Compliance? Reduce fibre content of diet? Correct preparation? Are we missing something? Lankisch P.G, 1999; 60: 97-104 Bruno M.J, 2001; 1(suppl 1): 55-61
Other conditions to exclude: Bile acid malabsorption (caused by acidic environment causing bile salt precipitation) most common after cholecystectomy Bacterial overgrowth Infective diarrhoea Other GI disease Coeliac Disease! Lactase deficiency Lankisch P.G, 1999; 60: 97-104 Bruno M.J, 2001; 1(suppl 1): 55-61
Vitamin and mineral deficiencies Fat soluble vitamins: A, E, D, K. Higher risk of deficiencies if not absorbing fat efficiently. Bone disease can occur after this surgery due to a decreased intake, and sometimes, poor absorption, of calcium and vitamin D-rich foods (Adcal D). B12 - stomach makes a special protein (intrinsic factor) which helps the body absorb Vitamin B12. Iron deficiency can be common after surgery, this may be because of a reduced intake or poor absorption of iron in the gut
Diabetes Diabetes secondary to either an inflammation, tumour, trauma or surgery on your pancreas is known as Type 3c diabetes Can be more brittle diabetes and difficult to control More research is required as it is not a well understood condition Can be managed through diet and exercise, oral hypoglycaemics or insulin.
References Bruno MJ (2001) Maldigestion and exocrine pancreatic insufficiency after pancreatic resection for malignant disease. Pancreatology; Vol 1, issue 1 supp, 55-61 Friess H, Michalski CW (2009) Diagnosing exocrine pancreatic insufficiency after surgery: when and which patients to treat. The official Journal of international Hepato-Pancreato-Biliary Association; 11(Suppl 3): 7-10 Keller J and Layer P (2005) Human pancreatic exocrine response to nutrients in health and disease. Gut;54 (suppl VI):vi1-vi28 Lankisch PG (1999) What to do when a patient with pancreatic exocrine insufficiency does not respond to pancreatic enzyme substitution: a practical guide. 60: 97-104.
Any questions?