Erwin g Dungog Ms Cunanan

7/29/2019 Erwin g Dungog Ms Cunanan

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Erwin g. dungog august 30,2010

Bsn-111 madam cunanan

Cancer of the liver:

causesHepatitis 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 bitingamong children at play. The role of hepatitis B virus (HBV) infection in causing livercancer 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 theliver) 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, theinvestigators 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 thatare 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 chronichepatitis 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 materialof 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 occursin 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 isrelatively uncommon. The reason for this is that most of the people with chronic hepatitisB 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.


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Sign and symptomsThe initial symptoms (the clinical presentations) of liver cancer are variable. It isbecoming 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 veryadvanced 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 livercancer 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 moreslowly 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 painis uncommon with liver cancer and usually signifies a very large tumor

or widespread involvement of the liver. Additionally, unexplainedweight lossorunexplained 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 livercancer.

Medical diagnosisLiver cancer is not diagnosed by routine blood tests, including a standard panel of livertests. This is why the diagnosis of liver cancer depends so much on the vigilance of thephysician 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), theirliver blood testsmay not be normal to begin with. If these blood testsbecome 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 genesthat 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, livercancer 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).
http://www.medicinenet.com/script/main/art.asp?articlekey=24627http://www.medicinenet.com/script/main/art.asp?articlekey=24627http://www.medicinenet.com/script/main/art.asp?articlekey=24749http://www.medicinenet.com/script/main/art.asp?articlekey=24749http://www.medicinenet.com/script/main/art.asp?articlekey=24749http://www.medicinenet.com/script/main/art.asp?articlekey=6274http://www.medicinenet.com/script/main/art.asp?articlekey=6274http://www.medicinenet.com/script/main/art.asp?articlekey=6274http://www.medicinenet.com/script/main/art.asp?articlekey=392http://www.medicinenet.com/script/main/art.asp?articlekey=392http://www.medicinenet.com/script/main/art.asp?articlekey=392http://www.medicinenet.com/script/main/art.asp?articlekey=98105http://www.medicinenet.com/script/main/art.asp?articlekey=98105http://www.medicinenet.com/script/main/art.asp?articlekey=98105http://www.medicinenet.com/script/main/art.asp?articlekey=98105http://www.medicinenet.com/script/main/art.asp?articlekey=392http://www.medicinenet.com/script/main/art.asp?articlekey=6274http://www.medicinenet.com/script/main/art.asp?articlekey=24749http://www.medicinenet.com/script/main/art.asp?articlekey=24627


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Another abnormal blood test, high serumcholesterol(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 widelyused biochemical blood test isalpha-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 womencarrying 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

duringpregnancy.)

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 (


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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 stopsworking. The idea is to make sure someone is healthy enough to be able to try another therapy if

they still desire it.

Nursing careYour 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 andoutput. To increase venous return and prevent peripheral edema, elevate his legs.

* Assess for dyspnea or increased respirations, and watch for signs of hypoxia fromintrapulmonary arteriovenous shunting or pleural effusions.

* Relieve fever by giving your patient sponge baths and aspirin suppositories (unless he hassigns 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 hisfinger nails short and clean, and apply mittens if necessary to prevent infection and excoriationsfrom scratching.

* Assess for encephalopathy: Monitor your patient's serum ammonia level, vital signs, andneurologic 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, andprotein. 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.


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CHOLECYSTITIS AND CHOLELITHIASIS:

CHOLECYSTISIS-Acute cholecystitis is a sudden inflammation of the gallbladderthat causes severe abdominal pain.

Call your health care provider if you think you have cholecystitis. If not treated properlycomplications will occur.

CAUSESIn about 90% cases, acute cholecystitis is caused by a gallstone obstructing a duct inthegallbladder. When a gallstone obstructs a duct in the gallbladder, bile becomestrapped in the gallbladder and causes infection.

Other causes of cholecystitis are: alcohol abuse, severe illness, and tumors in thegallbladder.

More information aboutgallstones.

SIGN AND SYPMTOMSUnfortunately, symptoms may not appear for a number of years. When they do appear, themost common ones are:

pain in the upper right portion of the abdomen (especially after a fatty mean)

nausea fever loss of appetite jaundice Chills

COMPLICATIONSIf not treated properly or soon, complications may develop. Common complications ofcholecystitis are:

pus in thegallbladder

inflammation of the lining of the abdomen

MEDICAL DIAGNOSISYour doctor will perform tests to determine if you havegallstonesor inflammation. Themost common tests are:
http://www.mamashealth.com/organs/gallbladder.asphttp://www.mamashealth.com/organs/gallbladder.asphttp://www.mamashealth.com/organs/gallbladder.asphttp://www.mamashealth.com/gstones.asphttp://www.mamashealth.com/gstones.asphttp://www.mamashealth.com/gstones.asphttp://www.mamashealth.com/fever.asphttp://www.mamashealth.com/fever.asphttp://www.mamashealth.com/liver/jaundice.asphttp://www.mamashealth.com/liver/jaundice.asphttp://www.mamashealth.com/organs/gallbladder.asphttp://www.mamashealth.com/organs/gallbladder.asphttp://www.mamashealth.com/organs/gallbladder.asphttp://www.mamashealth.com/stomach/cholecy.asphttp://www.mamashealth.com/stomach/cholecy.asphttp://www.mamashealth.com/stomach/cholecy.asphttp://www.mamashealth.com/stomach/cholecy.asphttp://www.mamashealth.com/organs/gallbladder.asphttp://www.mamashealth.com/liver/jaundice.asphttp://www.mamashealth.com/fever.asphttp://www.mamashealth.com/gstones.asphttp://www.mamashealth.com/organs/gallbladder.asp


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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:surgeryto remove the gallbladder ordraining the gallbladder. Draining is used in very ill patients.

DRUG THERAPHYInitial 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 suchas 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 Pseudomonasaeruginosa-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 prophylacticantibacterials. 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
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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 amongadults. The disease may also be occur in persons who are obese, who have high

cholesterol, or who are on cholesterol loweringdrugs. 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.

CAUSESCholelithiasis 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 quadrantpain 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 includebacterial 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 allpatients whose gallbladders have been surgical1y removed and may produce right upperquadrantabdominal 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
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Hormonal contraceptives Diabetes mellitus Celiac disease Pancreatitis Unexplained sepsis

Right upper quadrantpain 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 thegallbladder 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 upperquadrantabdominal pain, biliary colic, dyspepsia. and indigestion.

COMPLICATIONS

Complications andsequelaeof Cholelithiasis from theDiseases Databaseinclude:

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 ofCholelithiasis, the following list of conditions have been mentioned in sourcesas possiblealternative diagnosesto consider during the diagnostic process for Cholelithiasis:

Acute cholecystitis Acute pancreatitis Peptic ulcer disease Appendicitis
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Acute hepatitis (type ofHepatitis) Myocardial infarction Radicular pain

MEDICAL TREATMENT

The list of treatments mentioned in various sources forCholelithiasisincludes 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 studyon 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
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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 akidney stoneinto

small pieces that can more easily travel through theurinary tractand pass from the body.

See a picture ofESWL

You lie on a water-filled cushion, and the surgeon uses X-rays or ultrasound tests toprecisely 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 receivesedativesorlocal anesthesia. Your surgeon may use astentwhen your stones are larger than 2.5cm. A stent is a small,

short tube of flexible plastic mesh that holds theureteropen. This helps the small stonepieces to pass without blocking the ureter.

ENDOSCOPIC SPHINCTERETOMYEndoscopic sphincterotomy or endoscopic retrograde sphincterotomy (ERS) is arelatively new endoscopic technique developed to examine and treat abnormalities of thebile 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 junctureof the intestine with both the bile and pancreatic ducts.

CHOLECYSTECTOMYCholecystectomy (pronounced/klsstktmi/, plural: cholecystectomies) is the

surgical removal of thegallbladder. It is the most common method for treating
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symptomaticgallstones. Surgical options include the standard procedure, called

laparoscopiccholecystectomy, and an older more invasive procedure, calledopen

cholecystectomy.

NURSING CARECholecystectomy 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 asurgical unit is indicated.

RELATED CONCERNS

Cholecystitis with cholelithiasis

Pancreatitis

Peritonitis

Psychosocial aspects of care

Surgical intervention

Patient Assessment Database/Diagnostic StudiesRefer 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
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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 ofthe gallbladder. The gallbladder is a pear-shaped organ that lies just under the liver in the upperabdomen. 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.

CAUSESRisk 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 withgallbladder 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
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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 thesame 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. Theprognosis

(chance of recovery) and treatment options depend on the following:

The stage of the cancer (whether the cancer has spread from the gallbladder to otherplaces 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 hasrecurred(come back).

Treatment may also depend on the age and general health of the patient and whether the cancer iscausing 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 treatmentcan improve the

patient'squality of lifeby 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
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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 leafygreens (such as spinach and kale), and sea vegetables.

Eat antioxidant foods, including fruits (such as blueberries, cherries, and tomatoes), andvegetables (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 caffeinatedcoffee 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-complexvitamins, 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 stomachand 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 thesmall 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

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CAUSESAcute pancreatitis is usually caused by drinking too much alcohol or bygallstones. A gallstonecan 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 ofalcohol abuse, excessironin 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 SYPTOMSThe 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 tenderabdomen, sweating, nausea, vomiting,fever, mildjaundice, and rapid pulse.

COMPLICATIONSSome of the complications from pancreatitis are: lowblood pressure,heart failure,kidney

failure, ARDS (adult respiratory distress syndrome),diabetes, ascites, accumulation of fluid inthe abdomen, and cysts or abscesses in thepancreas. 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 toremove 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 DIAGNOSISBesides asking about a person's medical history and doing a physical exam, a doctor will order ablood 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
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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 TREATMENTTreatment 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 canbe replaced intravenously.

If pancreatic pseudocysts occur and are considered large enough to interfere with the pancreas'shealing, 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 itin order to prevent future attacks. In some people, the cause of the attack is clear, but in others,

more tests are needed.

DRUG THERAPHYAntioxidant 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
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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 surgicaltreatment 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 toidentify 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:

CAUSESWhile it can seldom be explained why one person gets pancreatic cancer and another doesn't, it isclear 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 learningthat some things increase a person's chance of getting this disease.Smokingis 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 earlypancreatic 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 calledjaundice.
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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 cellcancer 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, ordiarrhea.

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 stooltests. 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.

Transabdominalultrasoundto view the pancreas. In this procedure, an instrument that sendsout 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 bileduct. 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 pancreaticcancer. 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 apathologist, who checks for cancer cells.
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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 doctorinserts 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 thebiopsy may need to be repeated using a different method.

MEDICAL TREATMENTCancer 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, andthe quality of the patient's life can be improved.

Pancreatic cancer is treated with surgery,radiation therapy, orchemotherapy. Researchers are

also studyingbiological therapyto 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 isblocked.

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 patientdoesn'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 bileduct 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 soon

.
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. SURGICAL TREATMENTIn this study the experiences with carcinomas of the pancreas, ampulla of Vater, terminal commabile 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 wascarcinoma 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 theterminal 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. Distalpancreatectomies 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 complicationwas 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 amean 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 JEJUNOSTOMYBackground: The surgical management of pancreatic pseudocysts can be established through avariety 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 minimallyinvasive surgery and improvements in surgical technique, laparoscopic internal drainageprocedures 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 cyst-jejunostomies. 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


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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 forchronic 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 PROCEDUREThe Whipple operation was first described in the 1930s by Allan Whipple. In the 1960s and1970s 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 fewsurgeons, the mortality rate from the operation is less than 4%. Studies have shown that for goodoutcomes 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 backinto the intestine to direct the gastrointestinal secretions back into the gut.


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Laparoscopic Whipple operation

At USC, Dr Parekh is developing techniques for a laparoscopic Whipple operation. At presentthis procedure may be offered at USC to selected patients withchronic pancreatitis,cystic

tumorsandislet cell tumorsof the pancreas and patients who haveampullary cancer. We do not

offer the laparoscopic Whipple operation forpancreatic adenocarcinoma. The Whipple operationis performed laparoscopically utilizing alaparoscopic 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 ampullaan area where the bile and pancreatic duct enter into the

duodenum. whipple operation may also sometimes be performed for patients with benign (non-

cancerous) disorders such aschronic pancreatitisandbenign 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 outcomefrom 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 ofthese 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 ensurethe 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?
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The overall survival after the whipple operation forpancreatic adenocarcinomais 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 withpancreatic adenocarcinoma who are treated with chemotherapy alone.

The operation is usually curative in patients withbenignor 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 havechemotherapy and radiation

therapyafter the operation. Recent studies from Johns Hopkins University have shown that thesurvival 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 thepancreas 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 developingdiabetesis 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 theseverity 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 sweetfoods 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.
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Responses from this study at Johns hopkins were tallied from 188 Whipple survivors, 37laparoscopic 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 survivorsrated 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 healthyindividuals. 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 ifthe 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 isusually 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 issutured 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 beprovided 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 fol

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Erwin g Dungog Ms Cunanan