TUMORS OF THE HEAD OF THE PANCREAS
Sixty to eighty percent of pancreatic tumors occur in the head of the pancreas. Tumors in this region of the pancreas obstruct the common bile duct where the duct passes through the head of the pancreas to join the pancreatic duct and empty at the ampulla of Vater into the duodenum. The tumors producing the obstruction may arise from the pancreas, the common bile duct, or the am-pulla of Vater.
The obstructed flow of bile produces jaundice, clay-colored stools, and dark urine. Malabsorption of nutrients and fat-soluble vitamins may result from obstruction by the tumor to entry of bile in the gastrointestinal tract. Abdominal discomfort or painand pruritus may be noted, along with anorexia, weight loss, and malaise. If these signs and symptoms are present, cancer of the head of the pancreas is suspected.
The jaundice of this disease must be differentiated from that due to a biliary obstruction caused by a gallstone in the common duct, which is usually intermittent and appears typically in obese patients, most often women, who have had previous symptoms of gallbladder disease.
Diagnostic studies may include duodenography, angiography by hepatic or celiac artery catheterization, pancreatic scanning, per-cutaneous transhepatic cholangiography, ERCP, and percutaneous needle biopsy of the pancreas. Results of a biopsy of the pancreas may aid in the diagnosis.
Before extensive surgery can be performed, a fairly long period of preparation is often necessary because the patient’s nutritional and physical condition is often quite compromised. Various liver and pancreatic function studies are performed. A diet high in pro-tein along with pancreatic enzymes is often prescribed. Preoper-ative preparation includes adequate hydration, correction of prothrombin deficiency with vitamin K, and treatment of anemia to minimize postoperative complications. Parenteral nutrition and blood component therapy are frequently required.
A biliary-enteric shunt may be performed to relieve the jaun-dice and, perhaps, to provide time for a thorough diagnostic eval-uation. Total pancreatectomy (removal of the pancreas) may be performed if there is no evidence of direct extension of the tumor to adjacent tissues or regional lymph nodes. A pancreaticoduo-denectomy (Whipple’s procedure or resection) is used for poten-tially resectable cancer of the head of the pancreas (Fig. 40-7). This procedure involves removal of the gallbladder, distal portion of the stomach, duodenum, head of the pancreas, and common bile duct and anastomosis of the remaining pancreas and stomach to the je-junum (Stanford, 2001). The result is removal of the tumor, al-lowing flow of bile into the jejunum. When the tumor cannot be excised, the jaundice may be relieved by diverting the bile flow into the jejunum by anastomosing the jejunum to the gallbladder, a procedure known as cholecystojejunostomy.
The postoperative management of patients who have under-gone a pancreatectomy or a pancreaticoduodenectomy is simi-lar to the management of patients after extensive gastrointestinal and biliary surgery. The patient’s physical status is often less than optimal, increasing the risk for postoperative complications. Hemorrhage, vascular collapse, and hepatorenal failure remain the major complications of these extensive surgical procedures. The mortality rate after these procedures has improved because of advances in nutritional support and improved surgical tech-niques. A nasogastric tube and suction and parenteral nutrition allow the gastrointestinal tract to rest while promoting adequate nutrition.
Preoperatively and postoperatively, nursing care is directed to-ward promoting patient comfort, preventing complications, and assisting the patient to return to and maintain as normal and comfortable a life as possible. The nurse closely monitors the pa-tient in the intensive care unit after surgery; the patient will have multiple intravenous and arterial lines in place for fluid and blood replacement as well as for monitoring arterial pressures, and is on a mechanical ventilator in the immediate postoperative period. It is important to give careful attention to changes in vital signs, arterial blood gases and pressures, pulse oximetry, laboratory val-ues, and urine output. The nurse must also consider the patient’s compromised nutritional status and risk for bleeding. Depend-ing on the type of surgical procedure performed, malabsorption syndrome and diabetes mellitus are likely; the nurse must address these issues during acute and long-term patient care.
Although the patient’s physiologic status is the focus of the health care team in the immediate postoperative period, the pa-tient’s psychological and emotional state must be considered, along with that of the family. The patient has undergone major and risky surgery and is critically ill; thus, anxiety and depression may affect recovery. The immediate and long-term outcome of this extensive surgical resection is uncertain, and the patient and family require emotional support and understanding in the crit-ical and stressful preoperative and postoperative periods.
The patient who has undergone thisextensive surgery requires careful and thorough preparation for self-care at home. The nurse instructs the patient and family about the need for modifications in the diet because of malabsorption and hyperglycemia resulting from the surgery. It is important to instruct them about the continuing need for pancreatic enzyme replacement, a low-fat diet, and vitamin supplementation.
The nurse teaches the patient and family strategies to relieve pain and discomfort, along with strategies to manage drains, if present, and to care for the surgical incision. The patient and family members may require instruction about use of patient-controlled analgesia, parenteral nutrition, wound care, skin care, and management of drainage. It is important to describe, verbally and in writing, the signs and symptoms of complications, and to teach the patient and family about indicators of complications that should be reported promptly.
Discharge of the patient to a long-term care setting may be warranted after surgery as extensive as pancreatectomy or pan-creaticoduodenectomy, particularly if the patient’s preopera-tive status was not optimal. Efforts are made to communicate to the long-term care staff about the teaching that has been pro-vided so that instructions can be clarified and reinforced. Dur-ing the recovery or long-term phase of care, the patient and family receive further instructions about care that they will carry out at home.
A referral for home care may be indicated whenthe patient returns home. The home care nurse assesses the pa-tient’s physical and psychological status and the ability of the pa-tient and family to manage needed care. The home care nurse provides needed physical care and monitors the adequacy of pain management. In addition, it is important to assess the patient’s nutritional status and monitor the use of parenteral nutrition. The nurse discusses the use of hospice services with the patient and family and makes a referral if indicated.