Pancreas Surgery Typical Patient Journey
1. Referral to General Surgery for pancreatic cancer.
Patients who have been diagnosed with pancreatic cancer get a referral from their primary care provider or a gastrointestinal specialist to the department of General Surgery. This includes patients who have been diagnosed with benign and malignant tumors.
2. Patient has visit with surgeon.
In the General Surgery clinic, the patient meets with a surgeon who specialized in surgical oncology, or the surgical removal of cancer from the body. The patient and surgeon will discuss the surgery and the surgeon will do a physical exam on the patient.
3. Patient has exploratory surgery.
The patient is scheduled for laparoscopic exploratory surgery. Most of these procedures are scheduled to be performed within 3 days of the initial appointment in the General Surgery clinic. The patient gets general anesthesia, so the patient is asleep during the procedure. In addition, the exploratory surgery is same day surgery, so the patient does not stay overnight. The procedure is done with a few small incisions. The doctor puts a tiny tube that contains a camera into one of the cuts to view the pancreas and remove some of the cancer so that it can be tested. The exploratory surgery also helps the doctor see whether the patient is eligible for the Whipple procedure.
4. Patient is evaluated for Whipple procedure.
The Whipple procedure is the removal of the tail end and part of the body of the pancreas. The doctor assesses the pancreas to see where the cancer is located on the pancreas and whether it has spread to other parts of the body. That information helps the doctor assess whether the patient is eligible for the Whipple procedure.
Some pancreatic cancers are very extensive. The cancer may be close to other organs or involve many blood vessels. If the cancer is complex, the doctor presents the case at the weekly tumor board meeting. The doctor will also present the case if the cancer has spread, or metastasized, to other parts of the body. The tumor board is a group of doctors, nurses, and other medical professionals who specialize in the care of patients with cancer. They discuss the patient's case and make a recommendation for care.
- Patient can have Whipple procedure.
Patient is scheduled for surgery. If the patient is eligible to have the Whipple procedure, the medical secretaries in the General Surgery department schedule the patient for the procedure.
- Patient can not have Whipple procedure.
Some patients are not eligible for the procedure. If the cancer has metastasized, or spread, to other parts of the body, then the patient is not eligible for the Whipple procedure.
5. Patient has visit with medical oncology.
Regardless of whether the patient is eligible for the Whipple procedure, they meet with a medical oncologist. A medical oncologist is a doctor that specialized in the non-surgical care of patients with cancer. The Norris Cotton Cancer Center is the comprehensive cancer center at Dartmouth-Hitchcock Medical Center. Sometimes, the medical oncologist will see the patient before they have left the hospital after their exploratory surgery. A Clinical Resource Coordinator (CRC), a nurse who helps patients coordinate their care, will organize the visit for the patient to meet with the medical oncologist. The patient can also meet with the palliative care team that focuses on improving comfort and quality of life for patients and families experiencing a life-threatening illness.
Patients who are eligible for the Whipple procedure get 6 to 8 weeks of treatment with the medical oncologist before they have the surgery. Patients who are not eligible for the procedure see the medical oncologist to work out their treatment plan. Generally, doctors recommend that patients with pancreas cancer get chemotherapy and radiation treatment.
6. Patient meets with the nurse before surgery.
If the patient is eligible for the Whipple procedure, the patient comes to the General Surgery clinic before the surgery to meet with a nurse. The nurse explains how things will go on the day of surgery. During the nurse visit, the patient gets the bowel prep. Bowel prep is a liquid that the patient drinks to clean out the digestive tract before surgery.
7. Patient has Whipple procedure.
On the day of surgery, the patient comes in and is admitted through Same Day Surgery, located on Level 4. Once the patient is ready, they are moved to the Operating Room. The patient gets anesthesia and falls asleep so that they are not awake during surgery. Then the surgeon performs the surgery with the help of a team of specially trained surgical assistants. After surgery they wake up in the Post Anesthesia Care Unit (PACU) and are moved to 4 West, the inpatient floor where post-surgery patients are cared for. More detail is available about what happens on the day of surgery.
8. Post-surgery hospital care & discharge.
The patient stays at the hospital for 11 days, on average, after surgery. While the patient was under anesthesia, the doctor placed a special tube, called a "J-tube" into the patient's small intestine. The end comes out on the lower right side of the patient's abdomen. The J-tube is used to help feed the patient and ensure that they get enough calories and nutrition after surgery. The doctor will remove the J-tube about 6 weeks after surgery, when the doctor is assured that the patient is able to maintain proper nutrition without additional help. The doctor will leave the J-tube in whether or not it is being used by the patient.
Because the pancreas plays such a large role in making insulin and keeping sugar levels in the body controlled, the patient will need to learn new skills about how to care for themselves. If necessary, they will see an endocrinologist while they are still in the hospital, as well as in the outpatient clinic after they are discharged. The endocrinologist, or doctor who specializes in hormones, will teach the patient about replacing insulin in the body and measuring glucose (or blood sugar) levels.
The patient will also meet with a nutritionist while they are still in the hospital. The nutritionist will advise the patient on how to maintain proper nutrition once they leave the hospital.
The patient, with help from the nurses, is expected to be able to get up and walk around on the day after surgery. The nurses and doctors encourage the patient to tell them about any pain they are having. Then the nurses and doctors can help minimize any discomfort the patient is feeling.
The Clinical Resource Coordinator, a nurse who helps the patient coordinate care, helps the patient plan for discharge. The patient is discharged to either a rehabilitation facility or home. If the patient is discharged home, they may need or want additional care at home. If the patient qualifies, the Clinical Resource Coordinator sets up home visits from the Visiting Nurses Association (VNA).
The patient has to be able to eat solid food and take oral pain medications before they can be discharged.
9. Follow-up visit with General Surgery.
After surgery, the patient has a follow-up visit in the General Surgery clinic.