Nutrition Therapy following a Whipple Procedure

The National Cancer Institute estimates that pancreatic cancer will account for around 3 percent of all cancers in the US and approximately 8 percent of all cancer-related deaths in 2021. The treatment options for pancreatic cancer include surgery, chemotherapy, radiation, immune therapy, targeted drugs or a combination of these therapies. Pancreaticoduodenectomy, is the standard surgical treatment for tumors of the pancreatic head – more commonly known as the "Whipple procedure." In the traditional Whipple procedure, the duodenum, gallbladder, distal stomach and bile duct are also resected. However, another version of the Whipple procedure, known as the pylorus preserving pancreaticoduodenectomy (PPPD), may also be performed – sparing the resection of the distal stomach.

The degree and types of complications that may develop during treatment for pancreatic cancer depend on a number of factors, including the extent of pancreatic disease, how the anatomy is altered during surgery, and the symptoms that may arise after surgery. Nutritional complications that may develop from the Whipple procedure include delayed gastric emptying (gastroparesis), dumping syndrome, weight loss, diabetes mellitus, malabsorption due to pancreatic exocrine insufficiency, and nutrient deficiencies. Some research studies have indicated that PPPD may result in fewer post-operative symptoms than the standard Whipple procedure, including reduced occurrence of dumping syndrome and improved weight recovery. However, there was no significant advantage reported between the two surgeries in a recent Cochrane review.

In addition to nutrition-related risks, patients who are malnourished at the time of surgery are at an increased risk of both morbidity and mortality, with weight loss and malnutrition occurring in 50 to 90 percent of this population. Early identification of those at risk and management of their nutritional status can help improve overall quality of life.

A 2019 systematic review and meta-analysis looked at nutrition support following Whipple procedures and found that enteral nutrition was associated with a significantly shorter length of stay compared to patients on parenteral nutrition. There was insufficient research to evaluate how total oral nutrition compares to nutrition support when trying to correct nutritional status for these patients, however, many patients struggle to meet their needs with oral nutrition alone when initially recovering from these procedures.

For individuals who have undergone a Whipple procedure and are tolerating solid foods, general nutrition guidelines include:

• Small, frequent feedings (5 to 6 meals/day)
• Limit fluids to 4-5 ounces at a meal, drink other fluids 30 to 40 minutes after eating
• Eat slowly and chew foods thoroughly
• Avoid foods and drinks high in added sugars
• Include protein at each meal
• Limit high fat foods and total fat to less than 75 grams per day

Due to the myriad of possible symptoms resulting from pancreatic cancer, medical nutrition therapy will be tailored to the individual's specific needs. Registered dietitian nutritionist are in a unique position to provide counseling to minimize symptoms and improve nutritional status and quality of life for these patients as they recover from surgery and any other cancer treatments.

References:

• National Institute of Health: National Cancer Institute. Cancer Stat Facts: Pancreatic Cancer. Accessed July 7, 2021.
• Voss AC, Williams V. Oncology Nutrition for Clinical Practice, 2nd Ed. Chicago, IL: Academy of Nutrition and Dietetics; 2021.
• Matarese LE, Mullin GE, Raymond JL. Health Professional's Guide to Gastrointestinal Nutrition. Chicago, IL: Academy of Nutrition and Dietetics; 2015.
• Adiamah A, Ranat R, Gomez D. Enteral versus parenteral nutrition following pancreaticoduodenectomy: a systematic review and meta-analysis. International Hepato-Pancreato-Biliary Association. 2019, 21, 793-801.
• Academy of Nutrition and Dietetics. Nutrition Care Manual. Whipple Surgery Nutrition Therapy. Accessed July 16, 2021.