Whipple Pathway

PYLORUS-PRESERVING PANCREATICODUODENECTOMY (WHIPPLE PROCEDURE)

Indications:

1. Benign periampullarly neoplasms not amenable to local resection with ampullectoomy

2. Duodenal neoplasms

3. Trauma (rare)

4. Pancreatic ductal adenocarcinoma

5. Pancreatic islet cell carcinoma

6. Malignant intraductal papillary-mucinous neoplasm (IPMN)

7. Ampullary carcinoma

8. Distal CBD carcinoma (cholangiocarcinoma)

9. Duodenal carcinoma

Approach:

1. Whipple Procedure

Pre-operative optimization:

1. Counselling per surgery (in regards to procedure), per PAU (in regards to anesthesia, including epidural)

2. Smoking cessation – Quit at first visit

3. ETOH abstinence – Quit at first visit

4. Immunonutrition (IMPACT) for 5-7 days prior to surgery

5. Nutrition counselling (surgery clinic)

6. Physical activity counselling (surgery clinic) – Exercise plan

7. Daily incentive spirometry (provided by PAU)

8. Pedometer (provided by PAU)

Morning of surgery:

1. PO water up until 2 hours before surgery

2. Boost Breeze 2-4 hours before surgery (except diabetics). Consider low glucose breeze for diabetics.

3. PO analgesic cocktail (Acetaminophen 1000 mg, Gabapentin 600 mg, oxycodone 10 mg)

4. Scopolamine patch

5. Epidural placement by anesthesia acute pain service (Standard Ropivacaine 0.1%, Morphine 2 mg, Fentanyl 2 mcg/ml; Bolus and start infusion after specimen is out)

6. Consider TAP (Transversus abdominis plane) catheter if unable to insert epidural

Intra-operative care:

1. Magnesium 30 mg/kg IV loading, 10 mg/kg IV q1h

2. Ketamine 0.3 mg/kg IV loading, 0.15 mg/kg IV q1h

3. Ibuprofen 10 mg/kg IV

4. Intravenous lidocaine infusion 1 mg/kg/hour for 24h in cases that do not get epidural or TAP (alert surgeon to hold local anesthetic infiltration of the surgical wound at the end of procedure)

5. Forced air warming to maintain normothermia

6. BIS monitoring

7. Avoid N2O

8. Avoid long acting opioids (hydromorphone)

9. Antimicrobial prophylaxis 30-60 minutes before skin incision

10. Dexamethasone 4 mg at induction

11. Ondansetron 4 mg at emergence

12. Nasogastric intubation

13. Maintain normoglycemia (< 180)

14. Flotrac monitoring for near-zero fluid balance (CI, SVV, SV)

15. Urine output monitoring for near-zero fluid balance (0.5 ml/kg/hour)

16. SCDs

17. Local anesthesia of the incisional wound by the surgeon if no epidural, unless patient is on lidocaine infusion

PACU:

1. Maintain Foley catheter

2. NPO

3. Acetaminophen if last dose > 6 hours

4. Fentanyl/hydromorphone per standard order set

5. Pain team to manage epidural and PCA orders

6. Goal normal blood pressure

7. Goal urine output 0.5 ml/kg/hour

8. Goal Flotrac normal CI, use SVV to direct fluid resuscitation

9. Incentive spirometry

10. HOB 45 degrees

Post-operative care:

1. Diet per surgeon’s orders on POD #1

2. Transition to PO analgesics

3. Erythromycin IV (GI motility) – Alternate with metoclopramide every 2 days

4. Reglan IV (GI motility) – Alternate with erythromycin every 2 days

5. GI ulcer prophylaxis

6. PO laxatives

7. Physical therapy assessment for early mobilization goal

8. Discontinue Foley catheter per surgeon’s orders (2-4 days)

9. Discontinue NGT per surgeon’s orders (goal < 150 ml/day, 2-4 days)

10. LMWH per surgeon’s orders POD # 1 (once daily due to epidural)

11. Incentive spirometry

12. Acute pain service follow up daily

General post-operative assessments:

1. Pain control

2. Adequate PO intake

3. Level of mobility

4. Patient satisfaction