What to expect in a pancreaticoduodenectomy in the post operative period
Managing patients post Whipple can be like sailing in the sea - at times the going may be so smooth and you may run into rough weather at times. What should you expect in the post operative period, when you have undergone a Whipple's operation?
The time line for an uncomplicated course after a Whipple operation is 10 days. By 10th day, you will be on a normal diet, with all the tubes removed (except the feeding tube into the small intestine). The feeding tube will be removed at 3 - 4 weeks.
The post operative period begins in the ICU, where you will be staying for 3 days. During this time, you will have several tubes running out of your body. These tubes are for monitoring the vitalstatistics and also how the operated area is. The common tubes our patients have are the nasogastric tubes (conventionally referred as the Ryles tube, even though it is a Levine's tube), two drains on either side which will remove fluid from the operated area, a tube in the urinary bladder to drain and monitor the urine (called the Foley catheter), a feeding jejunostomy tube, which will be drained in the first 2 post operative days and an epidural catheter, which helps in reducing the pain.
On post operative day 1, we look for bleeding, either from the Ryle's tube or in the drains. These events have become uncommon in the early post operative period. We have learnt over the years, to meticulously operate to minimise this complication. In our unit, meticuluous ligation of the vessels from the portal vein and the SMA has prevented this complication. Bleeding from within the intestine is also a major issue. Again technical issues have sorted out these complications. Even though, utmost precautions have been taken, it is important for you to be aware of this complication and early detection is the most important. Early detection of bleeding will lead to a reoperation. The reoperation will identify the site of bleed and allow the surgeon to control it.
On day 1, you will be on IV fluids, antibiotics, pain killers and heparin. This will continue on post operative day 2 also. Technically, the only difference between day 1 and 2, is the mobilisation in the bed and rarely out of the bed. You will also receive good chest physiotherapy and will be asked to exercise with the triflow ball that you would have been provided before the surgery.
The key day in the post operative management of pancreatic resections is the post operative day 3. This is the day in which we assess when the place where we have joined the pancreas to the small intestine or stomach is completely healed. This assessment is done using fluid from the drains to assess amylase levels. If the drain fluid levels show elevated amylase levels, it indicates that there is impaired healing at the pancreatic small bowel anastomosis.
If the amylase levels are low, you will be started on tube feeds through the feeding jejunostomy. This is a better way to provide you with fluids and nutrition. If the amylase levels are elevated, we look for collections of fluid in the abdomen, the response of the body to abnormal fluid collections, which is medically known as systemic inflammatory response syndrome and start you on a medication called octreotide. We assess whether the amylase levels are coming down by serial assessments on alternate days. Our policy is to do a CT scan of the abdomen on POD 7, to assess adequacy of drainage and if inadequate, we insert radiologically guided tubes into the collection. We also do alternate day contrast instillation into the drain tube to look for inadequate drainage. This aggressive policy has allowed us to salvage some of the patients with pancreatic anastomotic leak.
From day 5, the amount of fluid infused into the jejunostomy tube would be 100 ml per hour. You will be free of IV fluids and we also allow a small quantity of liquids to be taken orally. The nasogastric tube and the epidural catheter would have been removed. The Foley catheter would have been removed, except when you need to be monitored for any serious infection.
By day 10, you would be on a soft solid diet. There are patients who are unable to tolerate oral feeds at this time as the stomach will not be functioning properly. This may indicate an underlying leak, but may also occur other wise. We may put you on prolonged tube feeds and allow time for the stomach to recover.
If your wounds have healed properly, you would be sent home on post operative day 12.
So to summarise, the key days in post Whipple management are day 1 when you expect bleeding, day 3 when you assess pancreatic leaks and day 10 when you assess gastric emptying.
So this is a short information regarding how your early post surgical treatment would be. Please use this information to clarify with your surgeon, whatever doubts that you may have. May you have a quick recovery from your surgery.
The time line for an uncomplicated course after a Whipple operation is 10 days. By 10th day, you will be on a normal diet, with all the tubes removed (except the feeding tube into the small intestine). The feeding tube will be removed at 3 - 4 weeks.
The post operative period begins in the ICU, where you will be staying for 3 days. During this time, you will have several tubes running out of your body. These tubes are for monitoring the vitalstatistics and also how the operated area is. The common tubes our patients have are the nasogastric tubes (conventionally referred as the Ryles tube, even though it is a Levine's tube), two drains on either side which will remove fluid from the operated area, a tube in the urinary bladder to drain and monitor the urine (called the Foley catheter), a feeding jejunostomy tube, which will be drained in the first 2 post operative days and an epidural catheter, which helps in reducing the pain.
On post operative day 1, we look for bleeding, either from the Ryle's tube or in the drains. These events have become uncommon in the early post operative period. We have learnt over the years, to meticulously operate to minimise this complication. In our unit, meticuluous ligation of the vessels from the portal vein and the SMA has prevented this complication. Bleeding from within the intestine is also a major issue. Again technical issues have sorted out these complications. Even though, utmost precautions have been taken, it is important for you to be aware of this complication and early detection is the most important. Early detection of bleeding will lead to a reoperation. The reoperation will identify the site of bleed and allow the surgeon to control it.
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| Bared portal vein after a Whipple's resection. If you notice the portal vein, you will note the small ties that are used to control the veins that drain into the portal vein. This meticulous ligation prevents the extraluminal bleeds in the immediate post operative period. |
The key day in the post operative management of pancreatic resections is the post operative day 3. This is the day in which we assess when the place where we have joined the pancreas to the small intestine or stomach is completely healed. This assessment is done using fluid from the drains to assess amylase levels. If the drain fluid levels show elevated amylase levels, it indicates that there is impaired healing at the pancreatic small bowel anastomosis.
If the amylase levels are low, you will be started on tube feeds through the feeding jejunostomy. This is a better way to provide you with fluids and nutrition. If the amylase levels are elevated, we look for collections of fluid in the abdomen, the response of the body to abnormal fluid collections, which is medically known as systemic inflammatory response syndrome and start you on a medication called octreotide. We assess whether the amylase levels are coming down by serial assessments on alternate days. Our policy is to do a CT scan of the abdomen on POD 7, to assess adequacy of drainage and if inadequate, we insert radiologically guided tubes into the collection. We also do alternate day contrast instillation into the drain tube to look for inadequate drainage. This aggressive policy has allowed us to salvage some of the patients with pancreatic anastomotic leak.
From day 5, the amount of fluid infused into the jejunostomy tube would be 100 ml per hour. You will be free of IV fluids and we also allow a small quantity of liquids to be taken orally. The nasogastric tube and the epidural catheter would have been removed. The Foley catheter would have been removed, except when you need to be monitored for any serious infection.
By day 10, you would be on a soft solid diet. There are patients who are unable to tolerate oral feeds at this time as the stomach will not be functioning properly. This may indicate an underlying leak, but may also occur other wise. We may put you on prolonged tube feeds and allow time for the stomach to recover.
If your wounds have healed properly, you would be sent home on post operative day 12.
So to summarise, the key days in post Whipple management are day 1 when you expect bleeding, day 3 when you assess pancreatic leaks and day 10 when you assess gastric emptying.
So this is a short information regarding how your early post surgical treatment would be. Please use this information to clarify with your surgeon, whatever doubts that you may have. May you have a quick recovery from your surgery.
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