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Date issued: October 2022

Review date: October 2024

Ref: A-78/Oncology /CD/Whipple operation/Oncology v5

PDF:  Whipples Operation final October 2022 v5.pdf [pdf] 795KB

Introduction

You have been referred to University Hospitals Plymouth for the Whipple operation which involves specialist pancreatic surgery.

You may be surprised that you have been asked to receive treatment here, even if you do not live locally.

Studies have shown being treated at a specialist centre, such as University Hospitals Plymouth, results in better outcomes and reduces the chances of complications for patients. This is due to the increased skill and expertise of the multi-disciplinary team involved in all aspects of your care, and the increased number of patients being treated in one place.

In 2006, pancreatic surgery in Devon and Cornwall became centralised to University Hospitals Plymouth. Therefore, instead of small numbers of operations being done in several hospitals, all these operations are now done in University Hospitals Plymouth. We now perform one or two Whipple operations every week.

We appreciate that life may feel like an emotional roller coaster at the moment. You may have many questions and anxieties regarding the Whipple operation, your hospital stay, and financial concerns.

This booklet has been prepared to try to address many of these questions and more. It will hopefully supplement the information given to you by your doctors, surgeons, specialist nurses and ward nurses. It may not cover all your concerns so if you have any other questions or worries after reading this booklet, please don’t hesitate to contact one of the staff listed towards the end of the booklet.

Your relatives and close friends may also wish to read this booklet, to answer their questions and concerns, and to help them understand the treatment you will be undergoing.

The Whipple operation is usually performed for cancers in the head of the pancreas but is also used to treat cancers of the lower end of the bile duct, duodenum and ampulla (small opening of the end of the bile duct from the liver and pancreas at the point where they enter the duodenum).

The Whipple operation can also be performed for some pre-cancerous cysts in the head of the pancreas.

The aim of surgery when you have been given a cancer diagnosis is to remove all of the cancer. If you are having the Whipple operation for a pre-cancerous condition, the aim of surgery is to remove the obstruction or cyst before it potentially becomes cancerous.

The recommendation for you to have a Whipple operation has come from the full ‘multi-disciplinary team’, consisting of pancreatic surgeons, oncologists (cancer specialists), radiologists (X-ray doctors) and specialist nurses; it will not be the recommendation of a single surgeon.

Your wishes about treatment will be discussed with you and respected at all times by your surgical team. Other treatment options can be discussed with you and can be arranged within your local hospital as appropriate, if you decide to not undergo the Whipple operation.

Chapter 1

The Pancreas

Firstly, it is important that we mention the anatomy and function of the pancreas. This is because the Whipple operation greatly affects the pancreas and how the intestines function after the operation.

The pancreas is a solid gland/ organ measuring 20-25cm (8-10 inches) in length. It lies at the back of the upper abdomen, behind the stomach. The pancreas has a head, neck, body and tail.

The following two diagrams will demonstrate the location of the pancreas in the body and its proximity to blood vessels and other organs.

Anatomy of the Pancreas

Running behind the pancreas are many important blood vessels, which supply the liver, kidneys, spleen and the entire small bowel.

Functions of the Pancreas

The pancreas is part of the digestive system. The Whipple operation can affect the function of the pancreas and therefore extra medication to support pancreatic function may be required. This will be discussed later in the booklet.

1. It makes enzymes (pancreatic digestive juices) which are released into your intestines to enable you to break down and absorb nutrients from the food you eat.
2. It produces insulin to enable every part of the body to use glucose (sugar). Lack of insulin can cause diabetes.

The Whipple operation

This procedure is named after an American surgeon, Dr Allen Whipple, who developed the surgery during the 1930s. You may also hear the operation called the Kausch- Whipples Pancreatico-duodenectomy after a German surgeon, Warther Kausch. In 1912, he reported the first successful excision of the duodenum and a portion of the pancreas.

It is referred to as a  pancreato-duodenectomy in reference to the organs that are removed. During the Whipple operation, the head of the pancreas, most of the bile duct, the gallbladder, the duodenum and the bottom quarter of the stomach are removed.

After removal of these structures, the remaining pancreas is re-joined into the stomach through the back of the stomach. The bile duct and stomach are then re-joined to the small intestine. This allows pancreatic digestive juice, bile and food to flow back into the intestine, so that digestion can occur. The operation normally lasts five to seven hours.

Possible risks and complications associated with surgery

In the telephone and face to face clinic at University Hospitals Plymouth we shall explain the aims of the operation and the potential benefits and risks. On the day of surgery, the surgeon will go through these again and you will be asked to sign a consent form saying you give permission for the surgeon to perform the operation.

No treatment can be given to you without your consent and before you are asked to sign you should have been given full information regarding the benefits and risks of the proposed operation, plus possible alternatives. Please keep asking questions until you are satisfied that you have all the information you need.

As with all major operations, the surgery and the anaesthetic carry risks to your health. Some of the risks/ complications of this operation are serious and can be life-threatening. There is a 40-50% chance of some sort of complication as a result of this operation. They range from mild to severe and will be explained below. You will be under the care of a specialist team of doctors and nurses, who will monitor your condition to make sure that any complications that occur are treated as soon as possible.

Bleeding

With any operation there is a possibility of bleeding in the hours and days after the operation. If this occurs you will require further tests (endoscopy, CT scan) and may require radiological treatment or rarely surgery to stop the bleeding. You also may need a blood transfusion.

Pancreatic leak or bile leak

These are serious complications and occur in around 1 in 20 patients. Leaks are a result of pancreatic fluid or bile leaking from the joins made between the remaining pancreas, stomach, bile duct and the jejunum (small bowel). To minimise this risk we keep the stomach empty by using a draining tube from your nose to your stomach for a few days after the operation.

If a leak develops you are likely to be in hospital for two or three weeks or more. You will need more scans and tests and some of the plastic drain tubes coming out of your abdomen will be left in place to drain the fluid off until the leak has stopped.

The surgeons and nurses will check regularly for signs of a leak so it can be treated early on. In most instances a leak settles down on its own but on rare occasions another operation or procedure is needed to repair it.

Chest infection and problems with breathing

Due to the wound on your abdomen you may find it difficult to breathe deeply or cough, which may lead to a chest infection. The nurses will teach you deep breathing exercises to help prevent a chest infection (they are also detailed later in this booklet). It is important that you tell us if you have any pain as this will make it harder for you to do your exercises.

If you smoke you are more likely to develop a chest infection after your operation. It would benefit you greatly to stop smoking before your operation.

Wound infection

The surgical cut (wound or incision) on your abdomen can be quite large. Sometimes the wound can develop an infection. The nurses will check your wound for any signs of infection and keep the wound clean and dry. If an infection does develop you may be given antibiotics. If you are diabetic you are more at risk of infection. Ensuring your blood sugar is stable and below 10mmols can reduce this risk prior to surgery.

Delayed emptying of the stomach

After the surgery, some patients take longer to get back to normal eating and drinking because of slow recovery of the normal actions of the stomach. This is called delayed gastric emptying. During this time, if it happens to you, you will have a drip going into your vein to keep you hydrated with fluids. Symptoms are nausea and vomiting. To alleviate this we keep the stomach empty by using a draining tube from your nose to your stomach.

This can be unpleasant but not a life threatening complication. Rarely, if it continues for more than a week you will be fed with liquid food into a vein or a tube that passes through the stomach into the small intestine.

Chyle leak

Rarely, there may be a leak of milky liquid called chyle (lymph fluid) into your abdominal drain after surgery. This is treated by restricting certain things from the food you eat for a period of time. A chyle leak usually reduces and stops over one or two weeks.

General anaesthetic complications

A Whipple operation is a major operation and is done under general anaesthetic. This means that you will be unconscious and unaware of anything during the operation.

The majority of the risks relate to the operation itself. However, there are also risks to other organs, such as your heart and lungs. Major surgery such as this places a strain on the body’s resources; the risks for any individual patient are different and are assessed person by person. If we think the risks are much higher than average we will discuss with you whether or not surgery is the best option for you.

Blood clots (Deep Vein Thrombosis)

The risk of blood clots in the legs and/ or going to the lungs is increased post-surgery. Moving around as soon as possible after your operation can help to prevent this. You will also be given daily injections to help thin your blood to reduce the risk of blood clots. These injections are called Clexane and will need to continue for 28 days post-surgery. You and your relative can be show how to administer this prior to discharge home. If you feel this is not possible we can arrange a Practice/ District Nurse to administer.

Risk to life

The majority of people recover fairly well from the Whipple operation and are ready for discharge from hospital after 7-10 days. Most complications are relatively minor and just slow down your recovery a little, but some are much more serious and may mean you stay in hospital for much longer than you expected.

There is a very small risk that a combination of some of the complications described above may lead to an extended hospital stay and might ultimately lead to you dying as a result of the Whipple operation.

If you are in reasonably good general health then the risk to your life is about 3%; put the other way round, your chances of surviving the operation are 97%.

If you are elderly and/ or have other serious health problems then the risk to your life may be greater. This will be taken into account by the multi-disciplinary team and discussed with you in depth.

Chapter 2

Pre-habilitation- preparing for surgery

How can I prepare for the surgery?

Having major surgery such as a Whipple operation will put a lot of strain on your body, particularly on your heart and lungs. You will have a lot of tests to help assess whether you are able to have surgery, but there are some things that you can do to prepare yourself. The three important areas for you to work on are:

1. Stopping smoking and alcohol

2. Eating healthily

3. Exercising regularly

Stopping smoking

In addition to the general health risks associated with smoking, research has shown that smokers are more likely to suffer complications during and following surgery.

There is evidence to suggest the following benefits if you stop smoking before surgery:

1. Reduced risk of heart and lung post-operative complications

2. Faster wound-healing

3. Reduced length of stay in hospital

Even stopping smoking for three to four weeks before surgery will decrease your risk of getting complications. The longer before surgery you can stop the better.

Help is available through the NHS so please talk to your GP or Specialist Nurse.

Stopping alcohol

If you drink a lot of alcohol we recommend that you reduce the amount that you drink prior to your surgery. Alcohol can reduce the function of your heart and can affect your liver. It can also cause mild dehydration. However, reducing high alcohol intake suddenly when you come into hospital can also cause serious health problems, so it is better to cut down well in advance.

Help is available through the NHS so please talk to your GP or Specialist Nurse.

Nutrition

It is important that you are not malnourished when you have surgery. Good nutrition before an operation helps you recover and can reduce the risk of some complications after surgery. You will be assessed by our specialist dietitian to see whether you need help to increase the amount of food and drink you are able to eat before the operation. You may have lost weight because of a decreased appetite, jaundice, an inability to eat and/ or digestion problems resulting in pale loose stools. If this is the case, your dietitian will provide dietary advice on a high energy/protein diet, and you may be given high energy nutritional supplement drinks. You may also be started on pancreatic enzymes before your operation to help you absorb the fat/ protein/ carbohydrate in your diet. The dietitian will give your more information about this medication. You may also require referral for treatment if you are jaundiced as this can affect your appetite and energy levels.

Exercising regularly

Keeping fit and active as much as possible before the Whipple operation will help your recovery afterwards. For example walking 2-3 miles (on the flat/hill depending on your fitness level) every day will help keep your heart and lungs working well, and keep you in good condition ready for your operation. If this is not possible even walking up the stairs a couple of times a day and ‘getting out of breath’ can make a difference to your heart and lung function.

Respiratory (breathing) exercises

Respiratory exercises performed before and after surgery can help reduce the risk of lung problems by opening up your airways and moving phlegm. Respiratory exercises, coughing and walking after surgery can prevent post-operative chest infections and reduce your length of stay in hospital.

Practising respiratory exercises before your operation will make it easier to perform them afterwards. Here is a five -step guide to breathing exercises:

1. Sit upright in a supported chair.

2. Breathe in and out normally.

3. Take a slow deep breathe in so that your ribs expand sideways and your lungs fill up with air and then breathe out.

4. Take a slow deep breathe in and expand your lungs, hold that breathe for three seconds and then slowly breathe out.

5. Repeat three times.

If you feel dizzy or tired, return to breathing in and out normally.

Practice these respiratory exercises prior to surgery. After your operation you should do them every one to two hours.

Psychological wellbeing

We know that providing good quality personalised information for you and your relatives’ leads to reduced anxiety, improved patient experience and better surgical results. We aim to give you information and support during all stages of your surgical experience. Information is normally provided by your Surgeon, Specialist Nurses, ward nurses and the allied health professions.

It is important for us to consider how you are thinking, feeling and coping with your diagnosis and treatment at all times. Everyone in the team will be open to discussing these aspects with you at any time. Hopefully you will get a lot of reassurance from speaking openly and feeling understood by your healthcare professionals. There is added psychological and counselling support in your local Cancer Centres. Please see section on Cancer Support Centres.

Preparing your return home

Before your operation, it’s a good idea to start thinking about transport arrangements and how you will manage at home after surgery, especially in the first few days and weeks. We encourage patients to have a relative stay with them for the first week or so after returning home if possible.

If you live alone or require additional support, then please speak to the Surgeon/ Specialist Nurse and/ or ward nurses. The sooner we know this, the sooner we can start arranging something for you with the Ward Discharge Team. Talk to your close family, friends and GP to see what options you have.

Enhanced Recovery Programme

We have developed an Enhanced Recovery After Surgery (ERAS) programme for the Whipple operation. This process aims to ensure that you are discharged as early and as safely as possible with the best possible outcome.

You will be given leaflets before surgery about your role and recovery in hospital post-surgery. This will help you understand what to expect and when to expect it.

Hearts Together Hospital Hotel accommodation

For patients and relatives who have a long way to travel    there are a number of local hotels including ‘Hearts Together Hospital Hotel’ formerly ‘The Lodge’. Hearts Together provides accommodation for relatives, friends and carers of patients undergoing treatments in University Hospitals Plymouth. The accommodation is of a very high standard at affordable prices.

There are self-catering facilities and breakfast is provided. There is a small but excellent team who are both helpful and supportive. Hearts Together is within walking distance of Derriford Hospital (10 minutes) and a courtesy bus is provided for guests during the week at specified times. It is situated on the edge of a local nature reserve. Take a stroll through the gardens or relax on the balcony, taking in the beautiful views. Their telephone number is provided at the back of this booklet

Cancer Support Centre- The Mustard Tree

(Derriford Hospital)

If you are having the Whipple operation as a result of a cancer diagnosis and you or your family would like the opportunity to talk to someone about how you feel or just want a break from the usual routine we invite you to contact the Mustard Tree. The centre is available to anyone affected by cancer at any stage of the illness and offers a comfortable space where you can share your concerns, ask questions and receive support. It is staffed by professionals and trained volunteers many of whom have a personal experience of cancer.

The centre is open Mon–Fri 09.00–5.00 and is located on level 3 of University Hospitals Plymouth by the Royal Eye Infirmary entrance. Their telephone number is provided at the back of this booklet.

Other Cancer Support Centres in Devon and Cornwall if you are not local to Plymouth are as follows. Telephone numbers for these can be found via the Specialist Nurse or the Mustard Tree Cancer Support Centre-

Triangle Centres

 Kingsbridge Hospital (Tue 10.00-4.00)

 Liskeard Hospital       (Thur 10.00-4.00)

 Tavistock Clinic          (Fri 10.00-4.00)   

The Cove  Treliske Hospital, Truro.

The Force  Royal Devon and Exeter Hospital, Exeter.

The Lodge South Devon District Hospital, Torbay.

The Over and Above Fern Centre- North Devon  District Hospital.

Pre-assessment

Before your operation and anaesthetic we will need to know about your general health, any previous or current illnesses and your medication.

You will have an appointment at our pre-assessment clinic where several members of the team will assess your health and prepare you for the operation and anaesthetic.

Healthcare Assistant

A healthcare assistant will measure your height, weight, blood pressure and may carry out an ECG (electronic tracing of your heart). They will also take bloods to check your iron levels and the function of your kidneys and liver. You will also have swabs taken to screen for MRSA (Methicillin Resistant Staphylococcus Aureus).

Nurse

The nurse will ask you a number of questions to assess your fitness for a general anaesthetic and the Whipple operation.

The nurse will ask about the medicines you are taking, including herbal remedies and any supplements that you may be taking. Please bring a current list of your medications with you. Some medications (including Aspirin, Warfarin or Clopidogrel) make your blood thin and may result in you experiencing excessive bleeding during the operation. You may be asked to stop these medications a few days before the operation to allow their effects to wear off. You may be given an alternative treatment for those days.

The nurse will also give you verbal and written information about preparing you, your family and friends for your operation and stay in hospital. They will check you have information on the ‘ERAS’ pathway after surgery. The ‘Planned Surgery’ booklet will also be given, which explains some practical aspects of coming into University Hospitals Plymouth for an operation.

Anaesthetist

The anaesthetist will review the information gathered by the healthcare assistant and nurse and will discuss the anaesthetic and pain relief options with you.

You will be asked to do a Cardiopulmonary Exercise Test (CPET). This will involve a test on a static exercise bike; you will have been sent an information sheet explaining this. This is to see how well your heart and lungs are working. It gives the anaesthetist immediate information on your fitness and the anaesthetist will discuss the risks of surgery for you at this appointment. This discussion will determine the level of care you will need directly after the operation, for example a High Dependency Unit bed or a Level 1 bed on Stonehouse or Wolf wards.

If there are any concerns about the results of your test the surgeons may want to see you in clinic again before you proceed to surgery.

COVID Swab

You maybe be required to have a COVID swab 24-48hrs before the operation. If this is required, we will inform you. It can be done at your local hospital if you let us know in advance, otherwise this will be arranged at Derriford hospital.

Chapter 3

Day of Operation

You will be asked to come into University Hospitals Plymouth, the Planned Care Treatment Ward on the day of your surgery for 7am.

You will have received information about when to stop eating and drinking in your operation notification letter. If you are diabetic a special regimen of glucose and insulin will be given through a drip and your blood glucose level will be closely monitored.

Consent

Your surgeon will discuss your operation with you again including the expected benefits and the potential risks involved. It’s important that you understand the benefits and risks involved in the operation before you sign the consent form. If you have any questions or concerns, please ask the surgeon before the operation. It is never too late to have second thoughts, but the hope is that all of your questions will have already been answered either when you came to clinic or subsequently by your Specialist Nurse.

The Operation

You will be asked to put on a theatre gown. You will be taken to the anaesthetic room in the operating department by one of the nurses.

The operation usually takes between five to seven hours. After the operation, you will be taken to the recovery area adjacent to the operating theatre for about 2 hours while you fully wake up.

If the Consultant Surgeon has met your relative on the day of surgery and has a contact number there may be an opportunity for the Surgeon to let your relative know how the operation went and how you are progressing. This is only possible if you give your consent.

Before your operation you will have undergone certain tests or scans to check whether the Whipple operation can be performed. These tests are a good guide but they cannot always give us a completely clear picture and further problems may be discovered during the operation where the procedure is not possible. Your surgeon may perform a bypass operation to prevent a blockage of the bile duct or stomach occurring in the future. The post-operative information detailed later in this booklet still applies to a bypass operation.

All the tissue that is removed by the surgeon during your operation will be sent to the Histopathology Department to be analysed. This is where specialist doctors look at the tissue under the microscope to determine the exact nature of the problem. The results of this usually take at least 4-5 weeks and will be discussed with you at your follow up telephone or face to face clinic appointment.

Sometimes this may take longer if further work on the specimen is required.

Post operation- hospital stay

After your time in the recovery area, you will be transferred to the High Dependency Unit or the Level 1 facilities on Stonehouse Ward or Wolf Ward depending on your pre-operative level of fitness and how well you have been during the operation.

If you go to High Dependency Unit you will usually stay there for specialist care and monitoring for 12-48 hours. When the Surgeon and the High Dependency Unit Consultant are satisfied that you no longer need intensive nursing care you will go to the Level 1 facilities on Stonehouse or Wolf Ward.

There are a number of checks, which are normal and are part of the routine care for anyone having a Whipple operation. The ward nurses will regularly monitor the following:

Breathing and Oxygen Levels

Following your anaesthetic, you will require some extra oxygen to help you recover. This will either be given through a face mask or nasal prongs. Your oxygen levels will be monitored with a small probe that sits on your finger.

It is important to carry out your breathing exercises and cough, which will keep your lungs clear and prevent a chest infection developing. Your stomach may hurt, so please ask the nursing staff for pain relief if you are unable to breathe deeply or cough easily. You may be more comfortable to cough if you lean forward when sitting up and support your wound firmly with a pillow or a rolled up towel.

Blood pressure, pulse and temperature

Your blood pressure and pulse will be closely watched to check for any signs of complications after your operation. Your temperature will be monitored to check for any signs of infection. A sharp rise in your temperature may indicate that you have an infection although it is normal within the first 24 hours of surgery for your temperature to increase slightly as part of your body’s normal response to your surgery.

Tubes/ drains

When you wake up after your operation you will have some tubes attached to you. These will have been placed whilst you were asleep under anaesthetic. They may be uncomfortable at times but they are essential and we will remove them as soon as you recover.

You may have some or all of the following tubes:

1. A thin tube (drip) in the vein in your neck to give you fluid and certain medications (central venous catheter). 

2. A tube (drip) in your vein in your arm to give additional fluids and medication (peripheral venous catheter).

3. A tube that passes through your nose and into your stomach (nasogastric tube). This collects excess acid and bile from your stomach to prevent you feeling uncomfortable or sick. 

4. Near to the site of the operation (your wound), you may find one or two drainage tubes (abdominal drains) that go through the skin into the abdomen. They collect excess fluid from the operation site and fluid that has leaked from any of the tissues that are newly joined together.

5. A urinary catheter (fine tube) will have been placed into your bladder to collect urine into a bag.

The tubes and drains are usually removed by day four after the operation. Some patients will still have a tube coming out of their abdomen when they go home. If this is necessary for you, we will make sure that you understand why it is there and know how to look after it until we remove it in the post operation clinic appointment.

Pain control medication in hospital

Depending what you and your anaesthetist have discussed at your pre-assessment appointment will determine the type of pain control you will have during and after the Whipple operation.

The amount of pain you will experience is variable and individual, but we will work with you to ensure that pain is kept to a minimum. It is important you tell the nursing staff if you have pain, discomfort, or if there is any change in the amount of pain you feel. It is essential that you are comfortable after your operation to allow you to breathe properly and to help you move about as soon as possible.

Patient Controlled Analgesia (PCA)

This is a way of giving you pain relief after the operation that allows you to control the pain relief yourself. You will be connected to a pump containing a pain relieving medication, usually morphine. The pump is linked to a handset that has a button. When you press the button you will receive a small dose of morphine. This will stop when you no longer need it (able to eat and drink). You will be given pain relief tablets/ liquid instead. This change usually happens 2 to 4 days after the operation.

Pleural catheter

This is a small tube placed into the space around the lung whilst you are asleep which bathes the area in local anaesthetic. This has the effect of numbing the nerves which come from the area of the wound and will keep you more comfortable. This is used with a PCA.

Local Anaesthetic Infusions (LAI)

This is another tube coming out of the skin near your surgical wound and is a pain relieving infusion into the muscles surrounding the operation area. This is used with a PCA. A drip of paracetamol will also be given with a LAI and PCA.

Oral liquid morphine

This is usually given 2-4 hourly when you are able to drink and the PCA and LAI have been removed.

Personal Hygiene

Initially you will require help with your personal hygiene, but in a few days you will regain your independence. Once your drains have been removed and you are feeling well enough you will be able to have a shower.

Mobilisation

If possible you will be encouraged to get out of bed and sit in the chair on the day after your operation with support. Then short walks at frequent intervals will be encouraged daily with support. This will help prevent stiffness, bed sores, constipation, blood clots and help keep your chest clear.

Reducing the risk of blood clots

You will be given a daily injection of a blood thinning medicine (Clexane) which you will need to carry on having for 28 days after the operation. You or your relative will be shown how to give these injections but if this is a problem we shall arrange for a District or Practice Nurse to do this for you.

Wound

The cut on your abdomen will be covered with a dressing for 24 hours. The dressing can be removed after this time as long as the wound is dry. The wound can be closed with stitches that resemble ‘staples’ and are called clips. Glue is also used sometimes. Dressings around your drains may be renewed daily or often removed completely. It is important to report if there is any discharge from your wounds so that it may be treated appropriately. We sometimes use special “suction” dressings which can increase the speed of wound healing if the wound has opened up a little.

Diet and fluids

You will be encouraged to start drinking sips of water as soon as you feel able after your operation. Usually, from the second day after the operation you can drink normally and on the third day you will be able to start eating. Initially, you might prefer to eat little and often and a softer diet.

During your hospital stay and after, you may require high energy/protein nutritional supplement drinks (Ensure, Aymes) in addition to food to increase your daily calorie and protein intake.

When you start to eat your surgical team will prescribe you pancreatic enzymes to help you absorb your food. Your dietitian will advise you on how and when to take the enzymes.

Your ability to eat and drink may be affected by feelings of sickness. This is quite normal and nothing to be unduly concerned about. Please tell the nurse looking after you and they will provide you with medication for the sickness. More information on diet is available later in the booklet.

If you experience complications after surgery your digestive system/gut may struggle to work, and you may require parenteral nutrition (feeding directly into your blood stream). Parenteral nutrition carries a higher risk of infection than other types of feeding and is therefore only used if absolutely needed. Whilst you are receiving parenteral nutrition you will be seen by the nutrition support team. This team consists of specialist doctors, nurses, and dietitians.

Bowel function

You may experience altered bowel habits for a while as a result of your surgery, lack of mobility, change in diet and strong pain killers. This is normal post Whipple procedure. The first time, you may pass watery stools. As you begin to eat you may have loose and pale stools.

You will be given pancreatic enzyme tablets (Creon) to have with your food to help absorb the fats, proteins and carbohydrates you are losing in your stools as a consequence of the Whipple operation. Further information on Creon is available later in the booklet.

You may need to take a laxative temporarily to help you pass stools.

Planning your hospital discharge

You should expect a hospital stay of 7-10 days. Do not worry if you need to stay in hospital for longer than this. Recovery is very individual.

Transport

Please think about transport arrangements for discharge; if you have any problems with this the nurse on the ward can arrange transport, but there may be a charge. You may be transferred to the Discharge Lounge (level 3) on the day of your discharge where you can be collected by your family or arranged transport.

Wounds

You may be discharged home with wound clips. You should be sent home with a clip remover and wound dressings. Either the ward nurse will arrange, or you may be asked to arrange, a practice nurse or district nurse to remove the clips. These will need to be removed between 10-14 days after surgery.

Drains

If you are discharged with an abdominal drain in place, you will have a follow up clinic for assessment of the drain in 1-2 weeks. You will be taught how to empty the bag. When the bag is emptied please make a note of the amount drained so that the surgeons can make an assessment of whether to remove it at the post operation clinic appointment. Please ask for a replacement drainage bag. The ward nurse will arrange for a practice nurse or district nurse to check the skin around the drain and replace the bag if necessary.

Medication

We endeavour to arrange for your medication to be ready for you to take home in a timely manner. Unfortunately, there may be a 4-6 hour wait for this from pharmacy. Some of your usual medications may have been stopped and some new ones started in hospital, but a nurse will go through them with you before you leave.

You will be sent home on the pain medication that you are taking in hospital. You may feel you need to take this regularly to enable you to regain full mobility and be comfortable to resume normal activities. If you find that once at home you have increased discomfort because you are more mobile, please talk to your GP for advice. Some painkillers may cause constipation, in which case it may be helpful to take a gentle laxative.

Sick certificate

If required please ask the nursing staff to organise a sick certificate which will cover the time spent in hospital. Please ask your GP to organise a further sick certificate to cover post discharge from hospital.

Written discharge summary

You will be given a copy of your discharge summary. This includes information about your operation, scans and if you need follow up with the GP for further tests. Your GP will be sent a copy via the post or the ward nurse may ask you to deliver this to your GP if you are happy too.

Feeling unwell at home

If you feel unwell (symptoms of increased pain, temperature or vomiting) you should contact your Specialist Nurse, GP or out of hours service. In life threatening circumstances please visit your local Emergency Department. If you are admitted to a hospital other than University Hospitals Plymouth please ask them to inform us of your admission.

Chapter 4

Post-operation – at home

The following information has been designed to assist you after your hospital discharge. It covers the main questions commonly asked by patients.

After any major operation it takes time to get back to feeling yourself again. Once all the tubes and drains have been removed you will still tire easily and feel emotionally upset. This is normal and as time passes you will begin to feel more like yourself again. Try to be patient with yourself and allow yourself time to recover.

Rest, mobility and activity

You may feel tired and insecure when you first go home. You can also feel frustrated if you are not able to do all the things you could do prior to your hospital admission. This is normal, and so it is important to make a plan and slowly increase the things you do over the following weeks and months. It is important to be aware that it can take 3-6 months before you feel completely back to   normal.

Initially, you should avoid heavy tasks which involve    lifting, stretching and pulling, e.g., pushing a shopping    trolley or lifting and carrying children for at least 6 weeks.

It is often helpful to plan a rest period during the day at a time when you will not be disturbed. Depending on your home circumstances, you may need to accept some help from family, friends and neighbours until you have regained your strength.

While rest is a vital part of the recovery process, being active is also an important part of your progress at home. Being active will enable you to regain your     previous level of independence and will also help you to avoid the complications that can occur with reduced   activity after surgery.

Being inactive and immobile, in many instances, can be harmful and is associated with complications such as deep vein thrombosis. Therefore, we encourage you to walk daily as a good form of exercise to recover after surgery, increasing in distance over a period of weeks/ months.

Blood Clot - Deep Vein Thrombosis (DVT)

• To help prevent the postoperative complication of DVT:

• When resting, your legs should be raised, ideally above the level of your hip. The limbs should be supported along their entirety (pillows should not be placed solely under the knees or heels).

• Active movement of your feet whilst resting should be carried out for five minutes every hour.

• Avoid standing or sitting in one position for long periods. 

Alcohol

There should be no reason why you cannot drink alcohol but the effect may be felt faster than before, so be   careful.

Remember that certain medications can react with alcohol, always read the label.

Driving

Generally you should not resume driving until your levels of concentration, strength and mobility have improved enough for you to drive safely.

It is important to ensure you are able to perform an emergency stop and any other physical manoeuvre should be practised in a stationary car when you feel ready. It is advisable to check with your insurance company prior to driving, particularly if you are returning to a job that involves driving.

Sexual Activity

You may resume sexual intercourse once you feel confident and comfortable. Medication, hormones, chemotherapy and your general condition physically and mentally can alter your desire for and response to sex.

There is no correct time to return to sexual activity but if you experience problems or have questions, ask your Specialist Nurse or Doctor.

Wound Healing

• Healing of your wound will take place over a period of time as all wounds progress through stages of natural healing.

• Do not pull off scabs as these protect new tissue underneath.

• Look for signs of infection, for example areas of redness, swelling, discharge, odour, increased pain and increased body temperature.

• It is normal for the wound to tingle, itch or feel slightly numb.

• It is normal for the wound to feel slightly hard and lumpy.

• It is normal to experience a slight pulling around the wound. 

Please adhere to the rest, mobility and activity section discussed earlier as you have an increased risk of an incisional hernia. In time, if you feel this is the case, please see your GP.

Change in bowel habit

You may experience some changes in bowel habit. Diarrhoea, constipation and excess wind are common. These can be relieved with a review of your diet, medication to firm up stools (Lopermide) or increasing pancreatic enzymes (Creon). Both severe diarrhoea and constipation can be treated so be sure to tell your Specialist Nurse or GP.

Fatigue (Feeling exhausted most of the time), emotional impact

Everyone has good days and bad days, but fatigue is a very common experience post Whipple operation. This can last for several weeks or months after treatment is complete. There are many ways of combating fatigue and many strategies which can help you manage your everyday activities.

Similarly fear, anxiety, depression and changes in mood are all possible for patients undergoing this operation. Your life may feel like it has been turned upside down, and that all your future plans are on hold. Everyone needs support through difficult periods in their life. For advice and support please contact your Specialist nurse or GP.

Back to Work

How quickly you can return to work after the Whipple operation will depend on the type of work you do. It can take any time between three to six months. If you need to have chemotherapy after your surgery then you may find it difficult to return to work full-time until you have completed the course of treatment.

It’s normal to get tired very quickly in the first few months after surgery, and concentration and decision making may be difficult to start with. It’s best not to rush back to full-time work too soon as it may slow down your recovery. We advise you to ask if you can work part-time or on light duties for a few weeks initially. If you are self-employed you may be able to do short spells of work much sooner after surgery, but please do not over-do it.

Please visit your GP to continue your sick certificate from hospital. If you need advice regarding work and benefits, ask your Specialist Nurses who can arrange for you to see a Benefits Advisor in a Cancer Support Centre.   

When can I fly?

You will need to discuss this with your surgeon. It is not normally recommended until you are fully recovered from your surgery. Your insurance company will need to be informed of your plans for travel.

Dietary guidelines following the Whipple operation

After the Whipple operation it is very common to have a reduced appetite, altered taste sensation and to feel full after eating small amounts of food. This can take weeks or even months to resolve.

However, it is important to make sure that your diet is nourishing; this will help promote wound healing and also weight gain if you have lost some weight before and during your time in hospital.

If you have lost weight or have a reduced appetite, then you should:

1. Aim to eat high protein foods e.g., meat, fish, eggs, beans and pulses and nuts/seeds.

2. Try to have 5-6 small meals, snacks or nourishing drinks throughout the day rather than 3 meals.

3. Try to drink some full cream milk daily. Fortified milk with skimmed milk powder can be helpful. This can be used in drinks, cereals, sauces, puddings and to make up packet soups.

4. Add extra butter/cream/cheese to foods e.g., mashed potatoes, vegetables, stews, baked beans, scrambled eggs, and white savoury sauces.

5. Have snacks between meals e.g., cheese and biscuits, thick and creamy yoghurt, scone and butter, toasted tea cakes, milky drinks.

6. Extra sugar or glucose can be added to drinks, cereals and desserts if you do not have a problem with your blood sugar levels i.e., diabetes.

7. Increase nourishing drinks e.g., lattes, hot chocolate, Ovaltine, milkshakes, or smoothies  

Nutritional supplements drinks are also available in hospital or from your GP if you are losing weight and unable to get all the calories that you need from your dietary intake. These are free on prescription. Please contact your GP or Specialist Dietitian if you would like to discuss the range of products available and quantity recommended.

You may find it difficult to cope with a lot of fat. This can be a result of a lack of pancreatic enzymes. You will have been advised to take pancreatic enzymes to help digest your food you may need to adjust the amount you take depending on your diet, see next section.

Dietary guidelines for taking pancreatic enzymes

After pancreatic surgery, you will need to take a medication called ‘Pancreatic Enzyme Replacement Therapy’ to help break down and digest your food. Without this your body will not be able to obtain the nourishment it needs. You will need to take this medication for the rest of your life. An example of an enzyme drug is Creon.

Pancreatic enzymes are particularly important for the digestion of fat, proteins and carbohydrates after pancreatic surgery. Undigested fat especially can make your stools pale, bulky, loose (diarrhoea) and offensive (foul smelling). It is common for patients to experience bloating, excess flatulence and abdominal cramps. Contact your G.P, Specialist Nurse or Dietitian if you have these symptoms and are not taking an enzyme preparation.

• Take the enzymes prescribed at the start of each meal. If taking more than one capsule, you should space them out throughout your meals.

• Take the enzymes with a cold drink. Swallowing them with a hot drink may damage them and make them less effective.

• The amount of enzymes required varies enormously from patient to patient partly because of the different level of secretion by the remaining pancreas following the operation, and partly because there are still some enzymes secreted by the salivary glands, tongue, stomach and small intestine. The usual starting dose is 100,000 units with meals and 50,000 units with snacks. You may require a higher dose if you are still suffering from symptoms.

Also your requirement will be affected by:

• The amount of food you eat e.g., large meals containing fat, protein and carbohydrate will require more enzymes than small meals.

• A meal with a pudding/ dessert will require more enzymes.

• The type of food eaten e.g. meals which contain a lot of fat, for example fried fish and chips, will require more enzymes than a meal containing boiled potatoes and steamed fish.

• Remember some foods/ drinks do not require enzymes e.g. fresh or tinned fruit, vegetables eaten on their own, fruit jelly, fizzy drinks and squash, and salad without a fat dressing.

• Additional enzymes may be required if snacks are taken between meals, e.g. crisps, chocolate, cheese

• Milky drinks will require enzymes e.g., glass of milk, milky coffee, Horlicks®, hot chocolate, Ovaltine® and nutritional supplement drinks 

If you are taking enough enzymes your stools should return to a more normal appearance. A stable weight or weight gain is a good sign that you are taking enough.

It is a good idea to monitor your weight at home. Only weigh yourself once a week. When weighing yourself, use the same scales at the same time of day and with the same amount of clothing.

week

	Date	Weight
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6

Please contact your Dietitian, Specialist Nurse or GP if you are having any difficulty with your diet, if you are losing weight or if would like further information on nutritional supplements.

 Dumping syndrome

Although rare, Dumping syndrome describes a variety of symptoms that can occur after a Whipple operation.

The symptoms usually include a feeling of faintness or dizziness, which can occur immediately after eating or a couple of hours afterwards.  The faintness can be accompanied by sweating and sometimes palpitations, nausea, sickness and diarrhoea.

There are two types of dumping syndrome: early and late.  The information in this booklet should help to improve your symptoms.

Early Dumping syndrome

Occurs soon after eating causing symptoms like dizziness, faintness, nausea, sweating and abdominal bloating which can lead to an urgent bowel motion. This occurs due to food rapidly entering the bowel.  Early dumping syndrome usually resolves within 2-3 months after surgery.

What changes do I need to make to my diet?

• Try to eat slowly

• Aim to eat small, frequent dry meals (at least 6 small meals per day)

• Limit sugary foods e.g. sugar, chocolates, sweets, sweet biscuits, cake and fruit  

• Limit sugary drinks e.g. sugar in drinks, full sugar squashes, fruit juices.  Use low sugar drinks e.g. No added sugar squash      

• Be aware of alternative names for sugar  e.g. glucose, sucrose, fructose, dextrose and honey. 

• Use artificial sweeteners instead (if desired) e.g. Canderel, Hermesetas, Splenda, Sweetex, supermarket own brand

• Do not drink liquids with your meal and avoid soups.  Instead, drink liquids at least 30-60 minutes after food 

• Sitting or lying down after a meal for 15-30 minutes may also reduce the effects of early dumping syndrome (if lying down you may need to elevate your head upwards to avoid reflux). 

Late Dumping syndrome

This is more common and can occur a couple of hours after meals.  If large amounts of sugary or starchy foods are eaten, these are broken down by the body to glucose (sugar).  Glucose is quickly absorbed into the bloodstream causing the blood sugar level to rise rapidly. 

 

As a result, the body reacts to this by releasing large amounts of the hormone insulin. This insulin then causes your blood sugar to drop below normal levels.  When your blood sugar does become very low you can feel very faint and in very severe circumstances can pass out.

Other symptoms are cold sweats, palpitations, faintness or weakness and may lead to a bowel motion.

How to treat symptoms

Symptoms can be relieved by eating or drinking something sweet and/or containing carbohydrate. E.g. bread, crackers, biscuits, chocolate, cereal, milk or a sweet drink containing sugar. Glucose tablets (2-4 Lucozade tablets) may be helpful to take when symptoms first start.

How to prevent symptoms

Follow the same advice as for early dumping syndrome, small frequent meals, eat slowly, have food and fluids separately and reduce your intake of sugary foods and drinks.

Diabetes

The pancreas produces insulin which is required to control the amount of sugar in your blood (blood sugar level). As a portion of your pancreas is removed during the Whipple operation, there is a small risk that your remaining pancreas will not be sufficient to control your blood sugar levels. This is called diabetes.

Symptoms of diabetes include increased thirst, increased urination and/ or unexplained weight loss; if you develop any of these in the weeks/ months after your surgery, you should seek immediate advice from your GP (family doctor).

Fortunately, most people do not develop diabetes after a Whipple operation.

If you already have diabetes before your operation, your medication will be reviewed by the hospital diabetic team as changes may be necessary. After surgery, you may need to change from tablets to insulin injections which the diabetic team will help you manage before you leave the hospital. You may also be taught how to check your sugar levels at home with a finger-prick blood sugar meter.

A typical suggested range of blood sugar levels to aim for is 7-9 mmol/l before meals, but this can vary between patients. When your appetite returns and your food intake improves, you may find that your blood sugar levels begin to rise, particularly if your pancreatic enzyme supplement (Creon) medication has been adjusted. If your blood sugar level is regularly outside the range suggested to you or if you are concerned, you should seek advice from your GP.

Eating well and keeping well with diabetes

A good diet will help you to control your diabetes in combination with regular insulin injections.

Eat regular meals. Have breakfast, lunch, evening meal and supper. Depending on your regime you may also be advised to have a bedtime snack. Of course, if you are unable to eat large meals because of the Whipple operation then this will all require a lot of coordination; please contact your Diabetes Nurse Specialist for further advice if necessary.

Have starchy food such as bread, potatoes, rice, pasta or cereals at every meal. If possible, try to choose wholemeal or wholegrain varieties.

Include meat, chicken, fish, well-cooked eggs, milk, yogurt, cheese or pulses, such as lentils or baked beans, at least three times a day.

Avoid adding sugar and honey to foods and sugar coated cereals.

If you are feeling unwell or run down you must still try to eat and drink regularly. Nutritional supplement drinks can be useful if you do not feel able to cook. Keep a supply handy in the cupboard.

Never stop taking your insulin. Consult your GP or Diabetes Nurse Specialist if you are concerned about your blood sugar levels.

If your blood sugar level drops low or below a certain level (usually lower than 4 mmol/l) eat or drink something sweet (containing sugar). This should be followed by a meal or substantial snack containing a starchy food. You must ensure your take your enzymes with your meal/snack.

Clinical follow up

You will be offered an appointment for a telephone or face to face clinic at University Hospitals Plymouth, 4-6 weeks after discharge. At this appointment one of the surgical team will check that you are getting on as expected.

Everything that was removed at your operation will be looked at under the microscope by a histopathologist. At this post-operative clinic appointment the surgeon will go through the histopathologist’s report with you, and will discuss with you whether any further treatment is required. If further treatment is advised, the surgeons will refer you on for this in your local hospital.

Things to monitor long-term

It is worth asking your GP yearly for a blood test to check your blood sugars, iron and vitamin levels.

Blood sugars

Because part of your pancreas has been removed you are more at risk of developing diabetes in the future.

Vitamin absorption

The duodenum is where vitamins are absorbed. The duodenum is removed in the Whipple operation so there is a possibility that absorption of certain vitamins will be affected. It is generally recommended that you take a multi-vitamin and Calcium and Vitamin D supplement daily. Please speak to your specialist Dietitian regarding this.

Chapter 5

Who can I contact if I have any questions?