The goal of this continuing education offering is to provide nurses current information on caring for patients with pancreatic cancer. After reading this article, you will be able to:
1. Discuss the often late onset of signs and symptoms of pancreatic cancer and explain the mechanism by which they develop.
2. Describe management strategies available for the patient with pancreatic cancer.
3. List five postoperative nursing interventions to prevent complications after pancreatic resection.
You can earn 1 contact hour of continuing education credit in three ways: 1) For im-mediate results and certificate, go to www.advanceweb.com/nurses. Grade and certificate are available immediately after taking the online test. 2) Send this answer sheet (or a photocopy) along with the $8 fee (check or credit card) to ADVANCE for Nurses, Learning Scope, 2900 Horizon Dr., King of Prussia, PA 19406. 3) Fax the answer sheet to 610-278-1426. If faxing or mailing, allow 30 days to receive certificate or notice of failure. A certificate of credit will be awarded to participants who achieve a passing grade of 70 percent or better.
Merion Publications Inc. is an approved provider of continuing nursing education by the Pennsylvania State Nurses Association (No. 008-0-07), an accredited approver by the American Nurses Credentialing Center's Commission on Accreditation. Merion Publications Inc. is also approved as a provider by the California Board of Registered Nursing (No. 13230) and by the Florida Board of Nursing (No. 3298).
Mr. H is a 67-year-old male who presented to his physician with a new onset of jaundice. He had been self-treating what he thought was "back strain" for several months with NSAIDs. His past medical history is significant for type 2 diabetes mellitus. Mr. H's evaluation included CT scan of the abdomen, which revealed pancreatic head enlargement with dilatation of the pancreatic duct.
During his diagnostic evaluation, Mr. H developed nausea and vomiting presumed secondary to duodenal obstruction from a tumor of the head of the pancreas, most likely an adenocarcinoma.
Mr. H is one of approximately 31,000 people in the U.S. diagnosed with pancreatic cancer each year. Cancer of the pancreas is the fourth leading cause of cancer in the U.S. The morbidity rate is high; more than 30,000 deaths in this country occur each year as a result of the disease.
These statistics are dismal because pancreatic cancer produces few symptoms until it has invaded nearby organs. Unlike some cancers, there is no reliable screening method for its early diagnosis.
The pancreas, a vascular organ located behind the stomach in the retroperitoneum, is responsible for many important functions, including the production and secretion of the endocrine hormones insulin and glucagon. The pancreas also is an exocrine gland producing the pancreatic enzymes amylase, lipase and trypsin, which aid in the digestion of carbohydrates, fats and proteins.
The risk factors for pancreatic adenocarcinoma include:
- age over 60;
- male gender;
- tobacco use;
- ethnicity (black);
- inherited susceptibility;
- type 2 diabetes mellitus; and
Possible risk factors include:
- physical inactivity;
- some pesticides; and
- high carbohydrate/sugar intake.
When pancreatic function goes awry with the onset of a cancerous or precancerous lesion, several signs and symptoms develop.
The invasion or obstruction of adjacent organs by a tumor also may result in some of the clinical sequelae associated with pancreatic cancer.
Making the Diagnosis
The clinical findings in patients with the disease depend highly upon the location of the lesion. Most patients report vague symptoms early in the course of the disease that they may ignore or self-treat. Most patients with head of the pancreas, ampullary or distal bile duct adenocarcinoma have the classic symptoms of jaundice, pruritus, acholic (pale, lacking bile pigment) stool and tea-colored urine. Vague upper abdominal pain radiating to the back is another common symptom. Fatigue, anorexia, malaise, weight loss, nausea and vomiting also have been reported.
Diagnostic interventions patients undergo once a suspicion of pancreatic cancer has surfaced include:
- right upper-quadrant ultrasound;
- magnetic resonance cholangiopancreato-graphy (MRCP);
- endoscopic retrograde cholangiopancreato-graphy (ERCP);
- percutaneous transhepatic cholangiography; and
- positron emission tomography (PET)(diagnostic use of this test has not yet been established).
Preoperative staging is integral to determining the prognosis and forming a management plan for patients. This staging is accomplished by performing a spiral CT scan and endoscopic ultrasound, which also can provide tissue diagnosis by fine-needle aspiration. Invasive imaging studies are not routinely performed. Tumors are staged according to their size, extent, lymph node involvement and the presence of metastases.
A large percentage (80-85 percent) of patients with adenocarcinoma of the pancreas have unresectable disease at the time a diagnosis is made. The management plan for these patients is to ease their symptoms and enhance their quality of life by alleviating pain, gastric outlet obstruction and obstructive jaundice. This objective is accomplished nonoperatively, either by percutaneous or endoscopic techniques; for example, the endoscopic placement of duodenal stents for duodenal obstruction. Biliary stents can be placed endoscopically or percutaneously to drain ducts obstructed by tumor.
Pain can be managed by the use of opioids and/or other analgesics. Another pain management technique is an ultrasound or CT-guided celiac plexus nerve block to more specifically target the neurologic pain caused by pancreatic cancer.
Procedures such as staging laparoscopy may be useful in directing the course of further interventions by accurately determining a tumor's surgical resectability. Appropriate patients can then undergo a planned surgical intervention. Patients with an unresectable tumor will avoid the higher complication rate of a laparotomy and choose an endoscopic or percutaneous technique.
Surgery is the only potentially curable intervention. However, only a small percentage of those with pancreatic cancer(10-20 percent) are candidates for surgical resection of the tumor.
Patients with a potentially resectable pancreatic or periampullary tumor will undergo a pancreaticoduodenectomy.
Two operative procedures accomplish this goal. One is the classic Whipple procedure, developed by surgeons Walther Kausch and Allan Whipple, and the other is the pylorus-preserving pancreaticoduodenectomy.
The classic Whipple procedure consists of the removal of the pancreatic head, duodenum, common bile duct, gallbladder, distal portion of the stomach and the adjacent lymph nodes.
The organ-preserving alternative to the classic Whipple procedure, the pylorus-preserving pancreaticoduodenectomy, includes the same resections but leaves a functional pylorus at the gastric outlet and anastomoses are made to the jejunum. The use of this procedure is an effort to reduce complications such as dumping syndrome, reflux of stomach contents and weight loss. More randomized controlled trials are needed to confirm these advantages.
Advances in surgical techniques and postoperative care of patients after pancreatic resection have improved outcomes and decreased the morbidity and mortality for patients with pancreatic cancer. High-volume centers that perform many of these procedures have gone to great lengths to improve care for patients and prevent complications, including pancreatic fistula formation, intra-abdominal fistula, sepsis and delayed gastric emptying.
Mr. H underwent a pylorus-preserving Whipple. He was admitted to the ICU for 2 days postoperatively. His nursing care was focused on recovery from general anesthesia and management of postoperative and cancer-related pain with opiates and nonpharmacologic measures, such as repositioning. In the immediate postop period, patient-controlled analgesia is the frequent choice for optimal pain management, converting to oral narcotics when the patient tolerates oral intake.
Aggressive pulmonary care was needed to prevent atelectasis, retained secretions and pneumonia. Pulmonary complications were thwarted by early and progressive ambulation. Ambulation, as well as sequential compression devices and anticoagulation, are important adjuncts in the prevention of venous thromboembolism in these high-risk patients.
In addition, nurses closely monitor for the onset of postoperative bleeding by assessing effluent from postoperative (frequently two Jackson Pratt) drains for blood, trending vital signs and watching hematocrit levels.
Anastomotic breakdown with leakage of biliary fluid is another complication that warrants aggressive assessment.
This dreaded complication is heralded by the onset of fever, abdominal pain and drainage of bile from postoperative drains.