Methodist Health System

Enhanced Recovery After Surgery (ERAS) for

Pancreatic Surgery

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Helpfulphonenumbers

§ MethodistDallasgeneraloperator 214-947-8181§ OutpatientServices(2ndfloorPav.II) 214947-3440§ Pre-SurgeryAssessment(1stfloorPav.II) 214-947-3888§ RadiologyScheduling 214-947-3441§ HospitalBilling 214-947-6300§ 4thfloorSchenkelTower 214-947-4099§ 8thfloorSchenkelTower 214-947-8099§ ICU(4thfloorSammonsTower) 214-947-3399§ Cancelling,priortosurgery contactyoursurgeon§ Cancelling,morningofsurgery 214-933-6308

Surgeon:____________________________________

Officenumber:_______________________________

Nursenavigator:______________________________

Scheduledsurgerydate:________________________

Pleasearriveatthehospitalby:__________________

PleasecheckinatOutpatientServicesonthe2ndfloorinPavilionII.

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Weareexcitedtojoinyourteam!YouhavebeenreferredtoMethodistDallasMedicalCenterforpancreaticsurgery.MethodistDallasisoneofthenation’shighestvolume,highestqualitytreatmentlocations,caringformorethan100pancreaticcancerpatientseachyearandperformingapproximately120pancreaticsurgeries,including60Whippleprocedures(pancreaticoduodenectomy).Studiesshowthatpancreaticsurgerypatientshavebetteroutcomesandfewercomplicationsifdoneatahospitalthatperformsthesespecializedsurgeriesmorefrequently.AtMethodistDallasMedicalCenter,youarebeingcaredforbyamultidisciplinaryteamthathasincreasedskillandexpertiseinthisspecialty.Thisteamincludes:surgeons,nurses,radiologists,internalmedicine,pathologists,cancerdoctors,andotherspecializedcaregivers.

OurGoalWewanttohelpyouthroughyourtreatmentfrombeginningtoendwithasfewcomplicationsaspossible.Thisguidebookwillhelpyoulearnaboutwhattoexpectbeforeandaftersurgery,soyouandyourfamilywillknowhowtoplayanactivepartinyourrecoveryandhealing.

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EnhancedRecoveryAfterSurgery(ERAS)Enhancedrecoveryaftersurgery(ERAS)isanevidence-basedrecoveryprogramdevelopedtominimizethestressofsurgeryandhelpyourecoverassoonaspossible.MethodistDallasisthefirsthospitalinDallastoinstituteanERASprogramforpancreaticsurgery.

UniqueareasoffocusforERASinclude:

• Preparationforsurgery• Preoperativediet• Surgicaltechniques• Painreliefandanesthesiaoptions• Nauseaprevention• Mobilityandrehabilitation

YourMultidisciplinaryTeamDuringyourhospitalstay,yourday-to-daysupportteamwillconsistofmanydifferentprofessionals,workingtogethertoprovidecoordinatedcare.• NurseNavigator

MethodistDallasprovidesadditionalcoordination,educationandsupportthroughitsoncologynursenavigator.Thisnavigatorwillreviewtheentireprocesswithyouandactasaresourcebefore,during,andafteryourstaywithus.

• Nurse YouwillmeetanumberofspeciallytrainednursesthroughoutyourvisitstoMethodist

Dallas,beginningwithPre-surgeryAssessmentandcontinuingonthedayofsurgerywithourPerioperativenursingstaff.Aftersurgery,yourfloornursewillcheckonyoumultipletimesadaytogiveyoumedications,monitoryourvitalsignsandincisions,assessyourconditioneveryfewhours,andreportchangestoyourdoctor.

• Surgeon Yoursurgeonwillformulateandcarryoutasurgicalplantogiveyouthebestchanceof

successindealingwithyourhealthproblem(s).Aftersurgerytheywillcheckonyouatleastonceperdayandguideyouthroughyoursurgicalprogressfromstarttofinish.

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• AnesthesiologistYourboard-certifiedanesthesiologistwillworkwithyoutodevelopastrategytominimizeyourriskduringandaftersurgery,whileprovidingoptimalpostoperativepainrelief.

• ResidentsandInterns ThesearedoctorswhohavefinishedmedicalschoolandarebeingtrainedatMethodist

DallasMedicalCenterbyyoursurgeon.Theywillbearoundfrequently,keepingaclosewatchonyourprogressandreportingtoyoursurgeon.Theyareinthehospital24hoursaday,soifanissuearises,theresidentsandinternsareeasilyavailable.

• DietitianAregistereddietitianwillseeyoubeforeandaftersurgerytohelpyoumanageyourdietathome.Thiswillhelpspeedhealingthroughimprovednutrition,andmaintainmusclemassdespitethechallengesposedbychemotherapy,whichmayberequiredbeforeoraftersurgery.Theywillgiveguidancetothesurgeonsinregardstowhichdietandsupplementsarebestforyou.

• CaseManagerAcasemanagerwillhelparrangehomehealthservices,supplies,physicaltherapy,and/orskillednursingafterdischarge,dependingontheneedsyoumayhave.

• PatientCareTechnician(PCT) YourPCTwillcheckonyoufrequentlyandhelpwithdailybathing,linenchanges,bathroom

assistance,vitalsigns,blooddrawing,andothernecessarytasks.• PhysicalTherapist

Aphysicaltherapistwillmeetwithyouonyourfirstdayaftersurgeryandconstructarehabilitationscheduletobestfityou.Theywillteachyouexercisesandotherskillstohelpgetyouupandwalkingtospeedtherecoveryprocessandpreventcomplications.

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BasicAnatomyandTypesofSurgeryThePancreasThepancreasisaglandthatsitsbehindthestomachandisattachedtothesmallintestine.Thepancreasisincontactwithveryimportantveinsandarteriesaswellasotherorgans.Allofthesehavetobeconsideredwhenoperatingonthepancreas.Whatdoesthepancreasdo?Ithastwojobs:

1.Itmakesenzymesthataresentintoyourintestinestohelpbreakdownfatsandotherfood.

2.Itproducesinsulin,whichcontrolsthelevelofsugarintheblood.Lackofinsulincausesdiabetes.

Whyispancreaticsurgerydone?Thissurgeryisusedtotreatmanydifferentdiagnosesincluding:•Intractablepainassociatedwithchronicpancreatitis

•Neuroendocrinetumors

•Precancerouslesions(ex.–IPMN)

•Invasivecancer

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TotalPancreatectomyAtotalpancreatectomyisanoperationtoremoveyourentirepancreas.Becauseofthelocationofthepancreas,otherportionsoforganswillberemovedaswell,includingasmallportionofthestomach,theduodenum(firstpartofthesmallintestine),theendofthecommonbileduct,thegallbladder,andthespleen.Thesurgeonwillreconnectyourstomachandtheremainingportionofyourcommonbileducttothejejunum.Thejejunumisthesecondpartofthesmallintestine.Thisensuresthatfoodandbileflowintoyoursmallintestines.Theareasinpurplewillberemoved.

Howwillmylifestylebeaffectedaftermyentirepancreasisremoved?• Thisoperationwillresultinmajorchangestoyourlife.Youwillbediabeticandwillneedto

manageyourbloodsugarswithinsulinafterwards.Youandacarepartnerwillslowlylearnhowtomanageyourdiabetes.Whenyougohome,youwillneedtohaveadoctortomanagethediabetes.Itcanbeyourinternistoranendocrinologist.Youcandiscussthiswithyoursurgeon.

• Youwillnolongerproducethepancreaticenzymesthathelpindigestion.Pancreatic

enzymesareneededtodigestfat.Aftertheoperation,youwillneedtotakepillswithyourmealsthatcontainenzymereplacements.Althoughyouwillneedtimetorecover,almostallpatientswhohavethissurgerygetbacktolivingtheirnormallives.Youshouldbeabletoeatanddrinknormallyandresumeyourusualactivities.

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PartialPancreatectomyWhippleProcedure(Pancreaticoduodenectomy)Thepancreashasthreeparts:head,body,andtail.TheWhippleProcedure(pancreaticoduodenectomy)–acommontreatmentforpancreaticcancer–involvestheremovaloftheheadofthepancreas,gallbladder,bileduct,partofthestomach,andsmallintestine.

DistalPancreatectomyandSplenectomyAdistalpancreatectomy,alsoknownasapancreatictailresection,isperformedprimarilyforbenign(non-cancerous),precancerous,orcancerousconditionsofthepancreas—usuallytoremoveatumor,acyst,orpartsofthepancreasdamagedbypancreatitis.Thetailandaportionofthebodyofthepancreasareremoved.Thespleenisalsoremovedbecauseitisattachedtothepancreas.

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Dependingonthereasonforsurgeryandexactlocationoftheproblem,thissurgerycanbeperformedeitherlaparoscopicallyorrobotically(withcamerasandseveralsmallpunctures)orasopensurgeryusingalargerincision.Yourdoctorwillletyouknowwhichtypeisplannedforyou.Howwillmylifestylebeaffectedwithaportionofmypancreasremoved?• Withbothoftheaboveproceduresthereisasmallriskofdevelopingdiabetesafter

removingapartofthepancreas.Inmostcases,ifyouarenotdiabeticbeforethesurgery,youwon’tbeafterwards.However,ifyouarediabeticbeforethesurgery,additionalinsulinormedicationmaybeneededafterwards.

• Theenzymesthatthepancreasmakestohelpwithdigestionoffoodmaybeaffectedafterthissurgery.Signsofenzymeinsufficiencycouldinclude:passingloose,greasy-lookingstoolsmorethanthreetimesaday,bloating,indigestion,andgas.Inthiscase,yourdoctorwillprescribeyouenzymesupplementstotakewithyourmealstohelpwithfooddigestionandtominimizesymptoms.Althoughyouwillneedtimetorecover,overtimeallpatientswhohavethissurgerygetbacktolivingtheirnormallife.Youshouldbeabletoeatanddrinknormallyandgetbacktoyourusualactivities.

BenefitsofsurgeryforcancerpatientsPotentiallycurativesurgeryisusedwhentestssuggestthatitlookslikeallthecancercanberemoved.Theaimofthissurgeryistoremoveallofthevisibletumororgrowth.Ingeneral,patientstreatedwithsurgerysurvivelonger.

SplenectomyThespleenisafist-sizedorganlocatedintheupperleftsideofyourabdomen.Thespleenhelpstofightinfections,getsridofoldordamagedredbloodcells,andstoresbloodforyourbody.Youcanlivewithoutaspleen,butyoumaybemoresusceptibletocertainbacterialinfections.Splenectomyisthenameoftheoperationthatwillbedonetoremoveyourspleen.Thespleenisattachedtothetailofthepancreassoitwillberemovedatthesametimeasyourpancreas,ifyouundergoadistalpancreatectomyoracompletepancreatectomy.Additionalpreparations,suchasvaccinations,mightberequiredifyoursurgeonrecommendsspleenremoval.

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VaccinesBeforeandAfterSurgeryYouwillneedtogotoyourprimarycarephysician,theDallasHealthDepartment,orPassportHealthtoobtainthesevaccinationstopreventinfection.Pneumococcalvaccinepolyvalent(Pneumovax®23)

Revaccinateevery6years

Age55andolder:Menigococcalpolysaccharidevaccine(Menomune®-A/C/Y/W-135)

Revaccinateevery3to5years

Ages16to55:Meningococcalpolysaccharidediphtheriatoxoidconjugatevaccine(Menactra®A/C/Y/W-135)

Mayneedrevaccinationevery3to5years

HaemophilusinfluenzatypeBconjugatevaccine

Norevaccinationneeded

Vaccinesneedtobedoneatleast14daysbeforesurgery,andrevaccinationshouldbedoneaccordingtothelistabove.Itisimportantthatyounotifyyourdoctorifyouhaveanyofthesesymptomsfollowingvaccination:•Fever•Chills•Abdominalpain•Skinrash

•Achyorweakfeeling•Cough•Vomiting•Diarrhea

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SurgicalExposureTerms• Laparotomy:Thisisanincisionmadethroughtheskinupanddownontheupperabdomentoprovideoptimalexposureofthesurgicalsite.Theskinwillbeclosedwithstaplesorsutureundertheskin.

• Minimallyinvasivesurgeryorlaparoscopy:Thistypeofsurgeryisdonethroughverysmallincisionsinyourabdomenthroughwhichacameraandothertoolsareplacedduringsurgery.Yourabdomenisfilledwithagascalledcarbondioxidetoprovidespacetoperformthesurgery.

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ThistypeofsurgerymaybedonewiththeuseofthedaVinciRobot®toprovideimprovedrecoveryandlessenpostoperativepain.Notallpatientsarecandidatesforroboticsurgery;yoursurgeonwilldiscussyourbestoptionswithyou.

HowtoprepareforyoursurgeryNutritionplaysakeyroleinhelpingyourbodyrecoveraftersurgery.Properpreoperativenutritionhasbeenshowntoimprovesurgicaloutcomeandshortenlengthofstayinthehospital.Itisimportantthatyoubegintoprepareyourbodyforsurgeryseveralweekspriortoyourscheduledsurgerydate.

• Weencourageyoutodrinktwoproteindrinksperday,inadditiontoyourregularmealsasprescribedbyyourphysicianandregistereddietitian.

o Werecommendstartingtwotofourweeksbeforeyoursurgery.Ifyoursurgerydateislessthantwoweeks,youcanstillmakeapositiveimpactonyouroutcomebydrinkingtwoproteinshakesperdayinadditiontoeatingabalanceddiet.Byincreasingyourproteinintake,youwillincreaseyourmusclestrengthandprepareyourbodytohandlethestressofsurgery.

• Ournutritionexpertsrecommendeatingfiveservingsoffruitorvegetablesperdaytomaximizeyournutrientstatuspriortosurgery.

• Ifyouarediabetic,pleaseensureyouobtainaproteindrinkappropriateforglucosecontrol.Youmayneedadditionalinsulinorrunthepossibilityofhigherglucoselevelsduringthistime.

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• Thetypeofdrinkbestsuitedforyouwillbechosenbyyoursurgeonandregistereddietitianbasedonanumberoffactorsincludinganyrecentweightloss,obesity,ordiseasestate.

Recommendedproteindrinks:

• Itisimportantthatyoutrytomakeyourselfasfitaspossible,beforesurgery,byexercisingdaily,orasmuchasyouareabletotolerate.Youcanstartwitha15-30minutewalkthreetimesaweekandincreasethelengthoftimeand/ornumberofdayswhenyoufeelyouareready.Pleasekeepyourroutinesimpleandsetrealisticgoals.

• Westronglyrecommendthatyoustopsmokingatleastonemonthbeforeyoursurgeryinordertodecreasetheriskofseriouscomplicationsduringandaftersurgery.

Possiblecomplicationsrelatedtosmokinginclude:

o Formationofbloodclotsinyourveinso Difficultybreathingduringandaftersurgeryo Increasedriskforinfectiono Increasedriskofstrokeorheartproblemso Significantdelayinsurgicalhealingandincreasedbreakdownofwounds

• Donotdrinkalcoholfor24hourspriortoyoursurgery.Theconsumptionofalcoholmayalsoleadtoseriouscomplicationssuchas:

o Increasedriskofbleedingo Increasedriskoftolerancetopainmedications,increasingthelikelihoodof

postoperativepainandcomplicationso Interactionwithcertainmedicationsinwayswhichcanbeverydangeroustoyour

healtho Dehydrationandincreasedkidneyproblems

• Vitaminsandherbalsupplementsshouldbestoppedtwoweeksbeforeyourprocedure.

General

•Ensure•Boost•Glucerna•Premier

Ptswith>10%weightlossin3mo

•Boost•EnsureComplete

Diabetics

•GlucernaComplete•GlucernaShake•BoostGlucoseControl

Obese

•IsopurePlus•BoostGlucoseControl•GlucernaShake

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• PleasestopallNSAIDs(Ibuprofen,Motrin®,Aleve®,orAspirin)1weekpriortosurgery.IfyouaretakingotheranticoagulantssuchasasCoumadin®(Warfarin),Eliquis®orArgatrobanyouwillneedtocontactyoursurgeon’sofficeforinstructionsregardingstoppingthesemedications.

• Ifyouaretakingmedicationsforchronicpainyoumaycontinuethoseuptosurgery.

• Prepareinadvance.Youmayneedadditionalhelpfromfamilyandfriendsforthefirst

fewdayswithmeals,chores,bathing,etc.,sopleasetrytomakearrangementswithyoursupportsystemathome.Ifyourbedroomisupstairsthentrytomoveessentialitemstoadownstairsareawhereyoumightsleepandrecoversafelyratherthanattemptstairsuntilyouarestronger.Stockyourhousewiththefoodsyouliketoeatintheeventthatyoumightnotfeeluptogoingshoppingforthefirstweekathome.

PreoperativeVisits• PleasevisitthePre-surgeryAssessmentCenter(PAC)forevaluationbyanesthesiaatleast

twoweeksbeforeyoursurgery;call214-947-3888toscheduleanappointment.Pleasebringyourmedicationbottlestothisappointment.Theanesthesiapersonnelwillreviewyourmedicationsandprovideadditionalinformationregardinganesthesiaandadvancedproceduresusedtocontrolsurgicalpainpostoperatively.

• Aboutaweekbeforesurgery,youwillbecalledtomakeapre-opappointmentatyoursurgeon’soffice.Duringthisappointment,yourmedicalhistorywillberecordedandyourbloodwillbedrawn.Bringyourmedicinebottleswithyoutotheappointment;thiswillgiveyoutheopportunitytoreviewyourmedicationswithyoursurgeonanddiscusshowtobestprepareforsurgery.

• Yoursurgeonmayorderavarietyoftests(forexample,labtests,x-raysand/oranEKG)inpreparationforyoursurgery.

• Youmaybereferredforevaluationtoaheartoralungspecialist.• YoumaybegivenaprescriptionforGabapentin(Neurontin®)tobestartedandincreased

overseveraldaysimmediatelypriortoyourscheduledsurgerydate.Thisdrugwillbecontinuedafteryoursurgerytohelpwithyourpain.

BeforeSurgery• Pleaseshowerwiththeantibacterialsoap(chlorhexidine)beforeyougotobedandagainin

themorningtosterilizeyourskinanddecreasetheriskforinfection.• Youcancontinuetoeatanormaldietuntil24hoursbeforeyoursurgery.Duringthe24

hoursbeforeyoursurgery,youmayonlyhaveclearliquids.Examplesinclude:chicken

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broth,Jell---O®,water,ClearFast®,Gatorade®,andapplejuice.Donotdrinkanythingredorpurple.

• Youmaybeinstructedtotakealaxativethedaybeforesurgery.• Thedaybeforesurgerypleasedrink1bottleoftheClearfastintheevening.

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• Youmaycontinuetodrinkadditionalclearliquidsonlythroughoutthenight.PleasedrinkthesecondbottleofClearfastthemorningofsurgeryupto2to4hoursbeforeyourscheduledproceduretime(forexample,5a.m.fora7a.m.scheduledsurgery.)

Ifyouarediabeticandtakinginsulin,pleasetestyoursugarlevelpriortoleavingforthehospital.Ifyourglucoselevelis>180,thentreatthisasyouwouldnormallytreatthebloodsugarlevelandreportyourinsulindosetothenurse.Ifyoutakepillsforyourdiabetespleaseremembertostopthismedicationthedaybeforesurgery

DayofSurgery• Arrive2½hoursbeforeyoursurgery.ThiswillgiveyoutimetoregisterintheOutpatient

Servicesonthe2ndfloorinPavilionIIandallowsthestaffenoughtimetocarryoutanyadditionaltasksandprovideanyneededmedicationpriortoyoursurgery.YoumayparkinPavilionIIorIIIgarageandfollowthesignstoPavilionIIOutpatientServices.OncecompletedinOutpatientServicesyouandyourfamilywillbeescortedtotheoperatingroom.

• BringyourCPAPifyouuseone.• Bringalistofyourmedications.• Donotchewgum,eathardcandy,orusechewingtobaccothemorningofsurgery.• BringacopyofyourAdvancedDirectiveform,ifyouhavecompletedone.• Bringabookorsomethingtoreadwhileyouarewaiting.• Bringachangeofclothesandtoiletriesfordischarge.

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• Bringarobetowearwhilewalkingthehallsandpajamabottoms.• Yoursurgeon,anesthesiaprovider,andoncologynursenavigatorwillseeyoupriorto

surgery.Thisisagoodtimetovoiceanyremainingquestionsyouoryourfamilymayhave.• Youranesthetistwilldiscusswhichtechniqueswillbeusedandyourmedicationoptions.• Bringchewinggumandhardcandytohaveaftersurgery.

AfterSurgeryImmediatelyaftersurgeryDependingonthetypeofsurgeryperformed,youwilleitherbetransferredtotherecoveryroomforaboutanhourortotheIntensiveCareUnit(ICU)forafewdays.Iftransferredtotherecoveryroomyourfamilywillbeupdatedbythesurgeononhowyoursurgerywent.IftransferredtotheICUyourfamilywillbeupdateddailyandallowedtovisit.

TubesanddrainsDependingonyourprocedure,youmighthaveonedrainagetubefollowingsurgery.Thistubewillbelocatedonyourabdomenandwillconnecttoalittlebulb.ThisiscalledaJackson-Prattdrain.Thistubewilldraintheextrafluidintheareawheresurgerywasdone.Thistubemaystayinafteryougohomeandwillberemovedinyourdoctor’sofficeatyourfirstfollow-upvisitaftersurgery.

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Dependingonthetypeofprocedure,youmayhaveaurinarycatheterorsomeothertypeofdraininplaceaftersurgery.Thiscatheterisusuallyinplacefortwotothreedaysandisdiscontinuedassoonasyouaregettinginandoutofbedfreely.

EatinganddrinkingThespleenandpancreasarejustbehindthestomach,soyourstomachmaytakeafewdaystobegintoworkagain.Ifyoursurgerywasdonelaparoscopicallyorrobotically,youwillbestartedonaclearliquiddietthedayaftersurgery.Ifitwasdonewithanopenincision,youwillnothaveanythingtoeatordrinkforthefirstday.

Fluidtokeepyouhydratedwillbedoneintravenously(throughyourarmintoyourveins).Duringthistime,youmayhaveicechips,sugar-freegum,andhardcandy.Chewinggumandhardcandyhavebeenshowntostimulateyourbowelsandgetthemworkingagain.Regardlessofwhetheryouhadanopen,laparoscopicorroboticsurgery,onceyouareawakefollowingsurgeryyouareencouragedtochewgumfor30minutesevery4hours.

Onceyoupassgas,youwilltrywaterandotherclearliquids.Ifyouareabletodrinkthesewithoutfeelingsicktoyourstomach,youwillbegivenheavierliquidsandthensoftfood.Thesestepswilltakeplaceoverseveraldays.Aregistereddietitianwillalsovisityouinthehospitalandworkwithyoursurgeontodevisethebestdietaryplanforyou.

Itmaybehardtoeatanddrinkatfirstbecauseoffeelingsicktoyourstomach.Thisisnotunusual.Pleaseletyournurseknowandheorshewillgiveyoumedicinetohelpwithyournausea.

After AfterSurgery:PainExpectationsandManagementWhatkindofpainshouldIexpectaftersurgery?Everyone’spainexperienceaftersurgeryisdifferentandunpredictableduetoopioid

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tolerance,previousexperience,comorbidities,age,gender,typeofsurgery,andtypeofanesthetic.WillIbepain-free?Thegoalofpainmanagementistorestorefunctionaftersurgery.Wewillworkwithyoutoestablishasafelevelofpainrelief.Yourdiscomfortlevelmaynotgodowntoa0outof10,butwewanttodoeverythingwecantomakeyouascomfortableaspossiblewithoutover-sedatingyou.Whyispainmanagementimportant?Withgoodpainmanagementyougetwellfaster.Youcanstartwalking,doyourbreathingexercises,andregainyourstrengthquicker.Goodpainmanagementhasbeenshowntospeedrecoveryandincreasegoodoutcomesbyallowingthepatienttomeaningfullyparticipateinpostsurgicalrecoveryactivities.HowcanIparticipateinmypainmanagement?Askaboutthescheduleofpainmedicines.Somemedicinesarescheduledandwillbeadministeredatasettime.Othermedicinesareadministeredtoyouonlywhenyourequestthem.Pleaseinformyournurseifyourpainisnotbeingwellcontrolled.CanIgetaddictedtopainmedicineaftersurgery?Aslongaspainmedicationistakenwhenthereisactualpainandnotforotherreasons,addictionshouldnotbeanissue.Addictiontopainmedicationcanhappenifthemedicationsareusedimproperly.Eachweekyourneedforpainmedicationwilldecreaseasyourincisionheals.Howwillmypainbemanaged?DuringsurgeryYouranesthesiologistandsurgeonwillworktogetheranddecidewhichpainmanagementoptionswouldbebestforyou,dependingonthetypeofsurgeryandyourphysicalanatomy.Youmayhaveapainmedicineinjectedintoyourbackimmediatelybeforesurgerywhileundersedation.Thisisknownasspinalmorphineandworkswellduringthefirstdayaftersurgerytoallowyoutoparticipateinyourrehabilitation.AnotheroptionyoursurgeonmaychooseisinsertinganOn-Q®painpumpintothesurgicalincision.Thissmallcatheterreleasesnumbingmedicinetothesurgicalsiteoverseveraldays.AfinaloptionwouldbetoperformaTAPblockwhileyouareasleep,usingalong-actingnumbingmedicinewhichmaylastuptothreedays.

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AftersurgeryIVnarcotics:Aftersurgery,intravenous(IV)painmedicationswillbeusedtotreatyourseverepain.Themostcommonaremorphineorhydromorphone(Dilaudid®).Oralnarcotics:Onceyouareabletoeatasoliddiet,oralpainmedicationswillbeusedtotreatpain.Commonoralmedicationsarehydrocodone(Norco®)andtramadol(Ultram®).Non-narcotics:Inadditiontonarcotics,yourphysicianwillorderothermedicationstoassistwithpainrelief.Acommonmythisthatmildmedicationslikeacetaminophen(Tylenol®)oribuprofen(Advil®)cannottreatpainbetterthanstrongnarcotics.Thetruthisthattheyworkverywellwhenusedtogetherandcangreatlyimprovepainreliefwhilereducingtheamountofnarcoticyouwillneed;narcoticscankeepyourintestinesfromworkingandprolongyourhospitalstay.UsingthelatestERASprotocols,wealsousegabapentin(Neurontin®)orpregabalin(Lyrica®),bothwhichhavebeenshowntobeeffectiveinimprovingyourpaincontrol.Whilethesedrugshavetraditionallybeenusedasanti-seizuremedications,theyalsoareusedbypainphysicianstotreatacuteandchronicpain.Whatalternativesaretheretomedications?

• Relaxation:Simpletechniquescanhelptoincreasecomfort

• Music:Musiccanproviderelaxationanddistraction

• Physicalagents:Heatorcoldtherapy,massage,rest,andgoodbodyalignmentmayhelpto

lessenpainWillIhavepainmanagementhelpaftergoinghome?Youwillgohomewithaprescriptionfororalpainmedicationifneededatthetimeofdischarge.

AfterCarePreventingProblems

Bloodclots:Aftersurgery,youwillbegivenadailyinjectionofabloodthinneruntilyougohome.Youwillalsohavebluewrapsonyourlegsthatpumpuptohelpyourbloodcirculate.Theriskofbloodclotsgoesupifthesewrapsarenotused.Pneumonia:Youwillbegivenabreathingexercisecalledanincentivespirometer.Youwillsuckonthislikeastraw,anditwillhelpyoutakedeepbreaths.Itmaymakeyoucoughaswell,whichisgoodforyourlungs.Youshouldtake10breathswiththeincentivespirometereveryhour(whileyouareawake)toreduceriskofgettingalunginfectionandtodecreasetheuseoftheoxygensupplement.SomepatientsfinditusefultouseeachcommercialtheyseeonTV

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asaremindertoperformtheirincentivespirometry.

Gettingoutofbedandwalking:Youcanbringarobefromhomeforwalkinginthehalls.AfteryouhaveyourFoleycatheterremoved,youcanwearyourownpantsorpajamabottoms.ActivityplanDay1:Spendatleasttwohoursoutofbedinthechair.Onewalkoutsideoftheroominthehallwaywithassistance.Day2:Spendfourhoursoutofbedinthechair.Thiscanbedoneonehourortwohoursatatimeifbreaksareneeded.Completetwowalksoutsideoftheroomwithassistance.Day3:Sixhoursoutofbed.Yourwalksshouldbegettinglonger.Day4:Takethreeormorewalksaroundthehallsfromthisdayforward.ALWAYSWAITFORSTAFFASSISTANCEBEFOREGETTINGOUTOFBED.Theaboveactivityplanisrecommendedtohelpwithrecovery.Incompleteparticipationinout-of-bedactivitiescanleadtoslowerrecoverytime,digestiondelay,andpossiblymoreseriousproblems.Formedicalreasons,yoursurgeonmaytemporarilyinstructyoutoslowdownorstopyourout-of-bedactivityforonetotwodays.

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DischargeHomeYouaregettingclosetodischargewhen:• YouareabletoeatsolidfoodanddrinkfluidsonyourownwithouttheneedforIVfluids• Yourpainiscontrolledwithpainpills• Youareabletowalkinthehallwithlittleornoassistance• Youareabletousethebathroomwithoutdifficulty• Youdonothavefeverorsignsofinfection

Distalpancreatectomy-mostpatientsgohomethreetofivedaysafterlaparoscopicsurgeryandfivetosevendaysafteropensurgery.Whippleprocedure-mostpatientsgohomefivetosevendaysafterlaparoscopicsurgeryandsevento10daysafteropensurgery.Totalpancreatectomy-mostpatientsgohomewithin10to14days.• Pleasemakearrangementsfortransportationhomepriortothedayofdischarge.• Weaskthatyougraduallyresumeyourexerciseprogramonceyouhavebeengiven

clearancebyyoursurgeon.• Priortodischargenursingstaffwillreviewyourmedicationswithyouandanswerany

questionsyouhaveregardingyourpostoperativecare;fillyourpainmedicationprescriptionassoonaspossible,andfollowthedirectionsonthebottle.

• Pleasescheduleyourfollow-upappointmentwithyoursurgeon’sofficepriortoleavingthehospital.

• Whenyougohome,wewillhelparrangeforyoutohaveresourcesclosetoyourhometohelpyouasyoucontinuetolearnhowtomanagebloodsugarcontrolandenzymereplacement.

FollowupAfollow-upappointmentwithyoursurgeonshouldbemadeforonetotwoweeksafteryourdischarge.Yourstaples,tubes,andabdominaldrainwillberemovedintheofficeatthattime.FurthertreatmentsIfyoursurgerywastoremoveatumororgrowth,asamplewassenttothelabtolookforcancercells.Ifcancercellswerefound,yoursurgeonwilltalkwithyouatyourfollow-upappointmentandwillassistwithmakinganappointmentwithanoncologist(acancerspecialist),whowilldiscusswithyouifchemotherapyisrecommended.

FurthertestingYouwillneedtovisityoursurgeon’sofficeeverythreemonthstomonitortherecoveryprogress.Ifcancerwasfound,itisimportantthatyoualsohaveaCTscaneverythreemonths.PleasebringtheCTscandiskwithyoutoyourfollow-upappointments.

Ifyouhaveanyotherquestions,pleasecontactyouroncologynursenavigatororyoursurgeon.

WhentocallyourdoctorwhenyouarehomeComplicationsaftersurgerycanoccur,andwhileweneverwantthistohappen,wedowantyoutoknowwhattolookfor.Ifatanytimeyouareworriedaboutoneormoreofthesymptomsbelow,pleasecontactyoursurgeon’sofficeimmediately.

BleedingIfyourincisionsuddenlybleeds,applypressureandseekemergencycare.FeverAnytemperaturehigherthan101degreesFahrenheitshouldbereportedtoyoursurgeonimmediately.Ifyounoticeyourselfsweating,havingchills,orfeelingwarm,checkyourtemperatureimmediately.

InfectionsLookatyourincisionsite(s)everydaytowatchforsignsofinfection:redness,swelling,oozingorliquidsleakingout,warmth,orfever.Thesecanstartfromtwodaystothreeweeksaftersurgery.Theinfectioncanspreaddeeperinthebodyifitisnottreated.Aninfectioncanalsocauseyourincisiontoreopen.LegpainorchestpainWalkinghelpspreventbloodclotsinyourlegscalleddeepveinthrombosis(DVT).However,ifatanytimeyounoticepainorswellinginthebackofyourlegsorifyoubecomeshortofbreathwithchestpains,youshouldcontactyourdoctororgototheemergencyroomrightaway.

PersistentnauseaorvomitingIfyoucannotkeepfoodandliquidsdown,youcangetdehydrated.Contactyoursurgeonifnauseaorvomitinghappensmultipletimes.SevereabdominalpainSevere,unbearablepainthatlastsforseveralhourscanmeansomethingseriousiswrong.Fluidcouldbeleakinginsideatthesurgerysite.Ifthishappens,youwilllikelyhaveafeverwiththepainandwillgenerallyfeelunwell.Pleasecontactthesurgeon’sofficeassoonaspossible.Itisnormaltohavemediumtostrongabdominalpainduringthefirstfewweeksaftersurgery.Thismayberelatedtoyourincisionorgascrampswitheating.

Pleasecall911ifyouthinkyouarehavinganyproblemsthatyouthinkareanemergency.

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