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

PatientPatient

Lauri Bolo, MSN, RN, ACNP-CLauri Bolo, MSN, RN, ACNP-CNurse Practitioner HPB Program Nurse Practitioner HPB Program

St. John Providence Health SystemSt. John Providence Health SystemProvidence Hospital Providence Hospital

February 28, 2015February 28, 2015

Disclosures Disclosures

None None

Objectives Objectives

The role of the NP in the HPB program The role of the NP in the HPB program Provide an overview of Pancreas and Liver Provide an overview of Pancreas and Liver

Cancer Cancer Discuss the perioperative care of the HPB Discuss the perioperative care of the HPB

patients patients Discuss the common postoperative Discuss the common postoperative

complications of the HPB patient complications of the HPB patient

HPB Nurse Practitioner (NP)HPB Nurse Practitioner (NP)

Since 2007Since 2007 HPB Clinic & Inpatient HPB Clinic & Inpatient Navigate patients & families Navigate patients & families Act as a resource or point of contact Act as a resource or point of contact Manage patient/family telephone calls Manage patient/family telephone calls

re; symptom management & concerns; re; symptom management & concerns; Goal: Avoid ER Goal: Avoid ER

Educate and counsel patient and family regarding surgical treatment and recovery

Act as a resource or point of contact, available for questions or concerns

Initial VisitPreOp

HPB NP

Daily inpatient rounds and assessment

Evaluate labs, diagnostics tests, vitals, fluid status

Monitor and adjust medications as necessary

Manage post operative pain, nausea, wound care, & nutrition

Ensure patient progression along care pathway

Facilitate discharge from hospital • Collaborate with SW, PT/OT, case management • Assess patient readiness• Educate

SurgeryInitial Visit

PreOp

HPB NP

• Prepare prescriptions• Dictate d/c summary

Drive appropriate follow up care and consults

Post operative follow up care

Pain control

Provide education on lifestyle changes

Provide emotional support and resources to newly diagnosed cancer patients

Ensure continued surveillance of cancer patients

SurgeryInitial Visit

PreOpPost Op & Continued

Care

HPB NP

The PancreasThe Pancreas

Pancreatic CancerPancreatic Cancer

46,420 46,420 estimated new cases in 2014 estimated new cases in 2014

39,590 39,590 estimated deaths in 2014 estimated deaths in 2014

3%3% of all cancers in the U.S. are Pancreas Cancer of all cancers in the U.S. are Pancreas Cancer

4th 4th leading cause of cancer death in the United leading cause of cancer death in the United StatesStates

Cure is Cure is rarerare and only in and only in resected patientsresected patients

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

Pancreas Cancer: BackgroundPancreas Cancer: Background

Cure is rare and only in resected patients Cure is rare and only in resected patients In 100 patients with adenocarcinoma of the In 100 patients with adenocarcinoma of the

pancreaspancreas Only 15-20 will have resectable diseaseOnly 15-20 will have resectable disease

Most patients present with locally advanced (50%) or Most patients present with locally advanced (50%) or metastatic (35-40%) disease metastatic (35-40%) disease

Of these, 3-4 patients will have long term survivalOf these, 3-4 patients will have long term survival Outcomes:Outcomes:

Optimist view: 20% surgical cure rateOptimist view: 20% surgical cure rate Pessimist view: 3-4% overall cure ratePessimist view: 3-4% overall cure rate

Types of Pancreas NeoplasmsTypes of Pancreas Neoplasms CysticCystic

Serous CystadenomaSerous Cystadenoma Mucinous Cystic Mucinous Cystic

NeoplasmNeoplasm IPMNIPMN

SolidSolid AdenocarcinomaAdenocarcinoma PNETPNET MetastaticMetastatic Solid pseudopapillary Solid pseudopapillary

tumortumor

Symptoms on PresentationSymptoms on Presentation

Weight lossWeight loss 9292 JaundiceJaundice 8282 PainPain 7272 AnorexiaAnorexia 6464 Dark urineDark urine 6363 Light stoolsLight stools 6262 NauseaNausea 4545 VomitingVomiting 3737 WeaknessWeakness 3535 PruritusPruritus 2424 DiarrheaDiarrhea 1818 MelenaMelena 1212 ConstipationConstipation 1111 FeverFever 1111 HematemesisHematemesis 88

Weight lossWeight loss 110000 PainPain 8787 WeaknessWeakness 4343 NauseaNausea 4343 VomitingVomiting 3737 AnorexiaAnorexia 3333 ConstipationConstipation 2727 HematemesisHematemesis 1717 MelenaMelena 1717 JaundiceJaundice 77 FeverFever 77 DiarrheaDiarrhea 33

Head Body and Tail

TreatmentTreatment

SurgerySurgery is the only chance of cure is the only chance of cure

Treatment Treatment Surgical resectionSurgical resection

Tumors in the head/uncinate process

Tumors in the body & tail

Whipple Distal pancreatectomy ±splenectomy

Preoperative Workup Preoperative Workup

LabsLabs LFTs, CA19-9, CEA, CMP, CBC, Prealbumin, CoagsLFTs, CA19-9, CEA, CMP, CBC, Prealbumin, Coags

NutritionNutrition Imaging- U/S, CT Pancreas Protocol, Imaging- U/S, CT Pancreas Protocol,

MRI/MRCPMRI/MRCP Staging Staging

EUS/BiopsyEUS/Biopsy

Preoperative WorkupPreoperative Workup

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

Whipple Procedure Whipple Procedure PancreaticoduodenectomyPancreaticoduodenectomy

Whipple Procedure Whipple Procedure PancreaticoduodenectomyPancreaticoduodenectomy

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

Indications for the WhippleIndications for the Whipple Pancreatic head massPancreatic head mass

Cholangiocarcinoma of the Cholangiocarcinoma of the distal bile ductdistal bile duct

Ampullary tumorAmpullary tumor

Duodenal tumorDuodenal tumor

Chronic pancreatitisChronic pancreatitis

Most commonMost common

Least commonLeast common

Distal PancreatectomyDistal Pancreatectomy

Distal Pancreatectomy Distal Pancreatectomy

Tumors in the body & tail of the pancreas Tumors in the body & tail of the pancreas

Splenectomy vs spleen preserving Splenectomy vs spleen preserving

Vaccines Vaccines

LOSLOS

Total Pancreatectomy Total Pancreatectomy

Total Pancreatectomy Total Pancreatectomy

RareRare Benign & malignant diseaseBenign & malignant disease

Diffuse IPMNDiffuse IPMN Chronic PancreatitisChronic Pancreatitis Margin + panc cancer Margin + panc cancer

Unresectable Pancreatic CancerUnresectable Pancreatic Cancer

PALLIATIVE PALLIATIVE

Relief of obstructive jaundice Relief of obstructive jaundice

Prevention of duodenal obstruction Prevention of duodenal obstruction

Pain control Pain control

Palliation of Unresectable Palliation of Unresectable Pancreas Cancer Pancreas Cancer

Non Surgical Interventions Endoscopic biliary stent Endoscopic biliary stent

Percutaneous Transhepatic Percutaneous Transhepatic Cholangiogram drainage & Cholangiogram drainage & stent stent

Surgical CholedochojejunostomyCholedochojejunostomy

GastrojejunostomyGastrojejunostomy

Post-Op CarePost-Op Care

Pancreas Post-Op CarePancreas Post-Op Care AmbulationAmbulation

DietDiet NGT removal NGT removal

Urine output Urine output

LabsLabs CBC for bleeding risk CBC for bleeding risk Electrolytes Electrolytes BUN/Crt for fluid BUN/Crt for fluid

managementmanagement LFTs LFTs

MedicationsMedications Antibiotics- perioperative Antibiotics- perioperative DVT prophylaxis DVT prophylaxis Pain managementPain management

IV PCAIV PCA Epidural PCAEpidural PCA IV narcotics IV narcotics Toradol Toradol PO narcotics PO narcotics

Pancreas Post-Op Care Pancreas Post-Op Care

Drains Drains Anterior & Posterior to anastomosesAnterior & Posterior to anastomoses VolumeVolume Character of fluidCharacter of fluid Drain AmylaseDrain Amylase Removal Removal

Splenectomy Vaccines Splenectomy Vaccines Vaccine Route Revaccination pneumococcal vaccine (pneumovax 23) SQ 5-6 years haemophilus influenzae type B (hib TITER) SQ 5 years meningococcal vaccine IM none

* * Annual influenza vaccines are Annual influenza vaccines are recommended. recommended.

ComplicationsComplications

Early ComplicationsEarly Complications Wound infectionWound infection

Anastomotic leakAnastomotic leak Gastrojejunostomy Gastrojejunostomy (2-3%)(2-3%) Hepaticojejunostomy Hepaticojejunostomy (5%)(5%) Pancreatic (Pancreatic (10-25%)10-25%)

Delayed gastric emptying (DGE) Delayed gastric emptying (DGE) (~20%)(~20%)

HemorrhageHemorrhage

Pancreatic Fistula/LeakPancreatic Fistula/Leak Amylase rich fluid – 3x serum, POD #3 Amylase rich fluid – 3x serum, POD #3 Grade ABC Grade ABC Clinical signsClinical signs

Abdominal pain +/- distention Abdominal pain +/- distention Ileus Ileus DGEDGE Fever Fever TendernessTenderness Leukocytosis Leukocytosis

Pancreatic Fistula (PF)Pancreatic Fistula (PF)Management Management

Most pancreatic fistulae are of grade A and can be Most pancreatic fistulae are of grade A and can be managed non operatively with continued managed non operatively with continued peripancreatic drains placed intraoperatively peripancreatic drains placed intraoperatively

Few patients might require an CT guided drain Few patients might require an CT guided drain placement by Interventional Radiology to control the placement by Interventional Radiology to control the PF (Grade B)PF (Grade B)

Rarely patients require a surgical intervention Rarely patients require a surgical intervention (Grade C)(Grade C)

Delayed Gastric Emptying Delayed Gastric Emptying Postoperative inability to tolerate dietPostoperative inability to tolerate diet

Management Management

TreatmentTreatment NG for decompression NG for decompression Prokinetic agents Prokinetic agents Patience Patience

Nutrition Nutrition Enteral feeds via post pyloric NJ tube or surgical Enteral feeds via post pyloric NJ tube or surgical

J tube J tube TPNTPN

Discharge Discharge MedicationsMedications

LovenoxLovenox Metoclopropamide Metoclopropamide Proton pump inhibitor Proton pump inhibitor

(PPI)(PPI) Oral analgesics Oral analgesics Laxatives Laxatives CreonCreon

Drain teaching Drain teaching Home careHome care Activity & restrictions Activity & restrictions Diet Diet Insulin Insulin

Late ComplicationsLate Complications Pancreatic insufficiencyPancreatic insufficiency

DiabetesDiabetes

Marginal UlcersMarginal Ulcers

DumpingDumping

Strictures Strictures

Iron deficiency anemiaIron deficiency anemia

Cancer recurrence Cancer recurrence

Short Term & Long Term Follow Up Short Term & Long Term Follow Up

Surgery Surgery

OncologyOncology

Endocrine Endocrine

SurveillanceSurveillance Office visitsOffice visits Imaging Imaging Tumor markersTumor markers Liver function testingLiver function testing CMP CMP

The Liver The Liver FunctionsFunctions

Synthetic- albumin, Synthetic- albumin, transferrin, clotting transferrin, clotting factorsfactors

Synthesizes bile for fat Synthesizes bile for fat absorption absorption

Detoxifies drugs and Detoxifies drugs and toxins toxins

Hepatic Tumors Hepatic Tumors

Benign

HemangiomaHemangioma

Focal nodular Focal nodular hyperplasia (FNH)hyperplasia (FNH)

AdenomaAdenoma

Liver cysts Liver cysts

Malignant

Hepatocellular Hepatocellular carcinoma (HCC)carcinoma (HCC)

Colorectal cancer Colorectal cancer metastases (CRC)metastases (CRC)

Cholangiocarcinoma Cholangiocarcinoma

Hepatocellular Carcinoma (HCC)Hepatocellular Carcinoma (HCC)

Most common primary malignant tumor of Most common primary malignant tumor of the liver the liver

35,660 estimated new cases in 201535,660 estimated new cases in 2015 24,550 estimated deaths in 201524,550 estimated deaths in 2015 Risk Factors: hepatitis B, hepatitis C, cirrhosis, Risk Factors: hepatitis B, hepatitis C, cirrhosis,

alcohol, biliary cirrhosis, hemochromatosisalcohol, biliary cirrhosis, hemochromatosis

HCCHCC

SymptomsSymptomsNonspecific Abdominal painEarly satietyWeight lossjaundice

Physical findingsPhysical findingsAbdominal massAbdominal massSplenomegalySplenomegalyAscitesAscites

Colorectal Cancer MetastasesColorectal Cancer Metastases

22ndnd most common cause of cancer related most common cause of cancer related deaths in the US deaths in the US

~ 136,830 will be diagnosed CRC this year~ 136,830 will be diagnosed CRC this year ~50% of all patients with colorectal cancer ~50% of all patients with colorectal cancer

develop metastasesdevelop metastases Surgical resection offers best outcome Surgical resection offers best outcome

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

CholangiocarcinomaCholangiocarcinoma Malignancy of the extrahepatic or intrahepatic ducts Malignancy of the extrahepatic or intrahepatic ducts

Sx of biliary obstruction Sx of biliary obstruction Jaundice, pruritus, dark Jaundice, pruritus, dark urine, clay colored stools urine, clay colored stools

Preop Workup Preop Workup LabsLabs

LFTs, AFP, CMP, CBC, Prealbumin, CoagsLFTs, AFP, CMP, CBC, Prealbumin, Coags Imaging – U/S,CT, MRI Imaging – U/S,CT, MRI

StagingStaging If resectable If resectable no bx no bx

Degree of Cirrhosis Degree of Cirrhosis Childs Pugh Childs Pugh

Portal vein embolization (PVE)Portal vein embolization (PVE) Biliary drainage Biliary drainage

Child Pugh ClassificationChild Pugh ClassificationParameter

Points assigned

1 2 3

Ascites Absent Slight Moderate

Hepatic encephalopathy None Grade 1-2 Grade 3-4

Bilirubin <2 mg/dL 2-3 mg/dL > 3mg/dL

Albumin > 3.5 g/dL 2.8-3.5 g/dL <2.8 g/dL

Prothrombin time      

Seconds over control < 4 4-6 >6

INR < 1.7 1.7-2.3 >2.3

Grade A = 5-6 points Grade A = 5-6 points well compensated disease well compensated disease *good operative risk *good operative risk

Grade B = 7-9 points Grade B = 7-9 points significant compromisesignificant compromise

Grade C = 10-15 pointsGrade C = 10-15 points decompensatedecompensated d

Portal Vein Embolization (PVE)Portal Vein Embolization (PVE) Selectively embolize the Selectively embolize the

portal vein of the portal vein of the pathologic lobe to allow pathologic lobe to allow hypertrophy of remnant hypertrophy of remnant liver to prevent post op liver to prevent post op liver failureliver failure

Surgical Resection of Hepatic Surgical Resection of Hepatic Tumors Tumors

Right hepatectomyRight hepatectomy

Left HepatectomyLeft Hepatectomy

TrisectionectomyTrisectionectomy

Biliary reconstruction Biliary reconstruction

Lap Vs Open Lap Vs Open

Post-Op Liver Post-Op Liver AmbulationAmbulation Diet Diet Drains Drains UOP UOP Medications Medications

Vitamin KVitamin K No toradolNo toradol

LabsLabs CBCCBC LFTsLFTs CoagsCoags BUN/CrtBUN/Crt Electrolytes – phos & Electrolytes – phos &

magmag AmmoniaAmmonia

Post-Op ComplicationsPost-Op Complications Liver failureLiver failure Bile leak Bile leak InfectionInfection BleedingBleeding Pleural effusionPleural effusion AscitesAscites PV ThrombosisPV Thrombosis

Liver failure Liver failure

Deterioration in the ability of the liver to maintain its Deterioration in the ability of the liver to maintain its synthetic, excretory, and detoxifying functions synthetic, excretory, and detoxifying functions increased INR increased INR hyperbilirubinemia hyperbilirubinemia

Early recognition and initiation of supportive care is Early recognition and initiation of supportive care is importantimportant

Bile leak Bile leak

Rare (5%)Rare (5%) ManagementManagement

Most are managed non operatively by following Most are managed non operatively by following drain outputdrain output

Few might require biliary drainage proceduresFew might require biliary drainage procedures PTCPTC ERCPERCP

Rarely patients require surgical interventionRarely patients require surgical intervention

Short Term & Long Term Follow Up Short Term & Long Term Follow Up

SurgeonSurgeon Oncologist Oncologist Hepatologist Hepatologist

Thank you!Thank you!

Questions?????Questions?????