PATIENT EXPERIENCEThe hospital experience surrounding pancreatic surgery is made easier by having an understanding of what to expect. Reading the following information before and even during your hospital stay will help you and your family understand that experience and help with your recovery.
Pancreatic Surgery Day-by-Day
DAY PRIOR TO SURGERY
Fasting: You may eat normally up until midnight on the day prior to surgery. Oral medications may be taken on the day of surgery with a small sip of water. You will receive specific instructions relating to your personal medications by a member of the anesthesia team during a prescreening phone call. You can expect this call one or two days before your surgery.
Bowel preparation: While no formal bowel preparation is required, you may find that a mild laxative such as milk of magnesia or citrate of magnesia may be helpful on the day before surgery to make your recovery more comfortable.
DAY OF SURGERY
You and your family will be instructed to come to the hospital early in the morning. In the preoperative area you will meet the anesthesia team. The anesthesia team includes the pre-op nurse and CRNA or nurse anesthetist who will stay with you throughout your time in the operating room. The nursing staff will place one or more intravenous catheters (IV) to provide medications to help you relax and sleep during surgery. In some cases, a small catheter is placed in an artery in your wrist to constantly monitor blood pressure during surgery. Your anesthesiologist will discuss the anesthetic with you, including the possible use of an epidural catheter. Epidurals are small tubes inserted near the spine to provide pain relief on both the day of surgery and up to 4 days thereafter. If you choose to have an epidural, it will be inserted after you have received medication through an IV to make you sleepy, and you will also receive topical anesthesia to avoid discomfort during insertion.
You will find that many different members of the surgical team will review your medical history with you, and you will be asked the same questions over and over. This may seem a little frustrating to you, but all those participating in your care do it to insure your safety and help them gain a thorough understanding of your medical needs.
You may also be asked to consider participation in Dr. Jury’s ongoing research through the Beaumont Hospital BioBank. Dr. Jury’s current project includes analysis of genetic changes in pancreatic cancer cells in an effort to discover markers that may lead to earlier detection. If you choose to participate in this important research, a portion of tissue or fluid from the removed part of the pancreas may be saved for study. An extra blood sample may be drawn for other lab tests on the day of surgery, but should not affect your treatment or recovery in any way. Participation in any BioBank research project is purely optional. It will not affect any surgical decisions surrounding your treatment and will not cause any additional tissue to be removed.
Like most major academic medical centers, surgery at Beaumont Hospital includes the participation of surgical residents and medical students. It takes a large, skilled team to perform this major abdominal surgery. Along with the anesthesia team, a senior level surgical resident will assist Dr. Jury on all surgeries. As the leader of your surgical team, Dr. Jury will be present and directly responsible for every aspect of your surgery to insure the best outcomes for you.
IMMEDIATELY AFTER SURGERY
While you were asleep under the general anesthetic for this surgery, a tube was placed down your windpipe to allow for use of the breathing machine (respirator). Once you are awake after surgery, that tube will be removed. You will then be moved to the recovery room where specialized nurses will help you waken fully and comfortably. They will also treat any pain or nausea you may experience. Immediately after surgery, Dr. Jury will meet with your family to discuss your condition and any important details of the operation. Patients who undergo a Whipple procedure will spend at least one night in the intensive care unit for close observation and monitoring. Patients who undergo distal pancreatectomy will often go directly to a regular surgical floor following recovery. Whether you are in the ICU or on a regular surgical floor, family members will be able to see you and spend some time with you. It is rare that family members would need to spend the night at the hospital, but be assured that your family will have every opportunity to know that you're all right before leaving for home.
In some cases a nasogastric tube (NG) may be inserted to empty the stomach during surgery. This tube may remain in place after surgery, but can usually be removed on the morning after surgery. This tube usually makes you feel like you have a sore throat. This feeing will go away when the tube is removed. Nurses will give you ice chips and popsicles to help with any throat discomfort.
As uninviting as it sounds, we will make every effort to get you out of bed and into a chair as soon as possible. This kind of movement clearly speeds recovery and lessens complications of surgery. Our goal is to have you in a chair on the night of surgery, and on your feet by the next day. There is no better way to prevent blood clots or pneumonia after surgery than to be up and moving. At the same time, pain control and comfort will remain a priority. In addition, you will be provided with a small breathing device to encourage deep breathing and to exercise your lungs. Coughing after surgery is encouraged to keep airways clear. You will find that coughing will cause discomfort in the area of your incision, however, using a small blanket or pillow for support during a cough may help this.
DAY AFTER SURGERY
Move, move, move! Day One should bring removal of the NG tube if present, and the start of a clear liquid diet. All abdominal surgery slows down the function of the stomach and intestine, which is why we can't feed patients regular food right away. In addition, new connections to the stomach, bile duct and pancreas have been sewn during the Whipple procedure. We try to avoid undo stress on these new connections early in the recovery phase to allow healing to begin.
On Day One we will likely remove the arterial monitoring catheter, if placed. The bladder catheter (Foley) will be removed as well. If an epidural catheter has been placed for pain control, there is some risk that the bladder catheter may need to be reinserted, particularly in male patients. The benefit of early bladder catheter removal to avoid infection has been well proven, provided there is proper urinary function. Inflatable compression stockings are kept on to prevent blood clots while in bed. In addition, injections of heparin blood thinning agents will be used 2-3 times daily to further protect from blood clots. Once again, there is nothing better than walking to speed recovery of bowel function and protect from blood clots. You must walk, with assistance, at least 3 times per day beginning on the day after your operation.
Pain control is always a priority as you recover and can be provided in a number of ways. Patients usually require pain medication injections during the first 2-3 days. Often this will include a button that can be pushed to deliver a small and safe dose of medication before the pain becomes severe. This is called a PCA (patient-controlled analgesia) device and can be used with an epidural or directly as an IV treatment. Studies have shown this PCA allows patients to experience more even and sustained pain relief while using less narcotic overall.
Following most major pancreas operations, one or two soft drainage tubes are left in place to collect pancreatic juices that may leak from a new connection or from the point where the pancreas was divided. In most cases these drains will be removed at the bedside before you leave the hospital. We will observe the character and amount of fluid to help decide the appropriate timing of drain removal. In some cases, continued drainage of fluid may require that you are discharges with a drainage tube in place for later removal in the office.
POSTOPERATIVE DAYS 2-6
Over the next several days you are encouraged to increase your level of activity, make transitions to oral pain medications and begin to experience return of bowel function. You will find nurses and physicians constantly asking if you have passed gas or experienced a bowel movement, as this clearly indicates the return of normal function of the intestines. Decisions made regarding progression to a regular diet are based on the way you feel, the condition of your abdomen and your general progress. Surgical incisions are usually closed with dissolving stitches beneath the skin and do not require suture removal. Usually patients will be encouraged to shower on the second day after surgery and you may allow the incision to get wet without concern.
An important part of your recovery is to begin planning for the care you will need after discharge from the hospital. For older patients or those living alone, arrangements can be made for transfer directly from the hospital to a short-term nursing or rehabilitation facility. Our team of discharge planning specialists will meet with you and your family to discuss options that are generally covered by your insurance. It is never too soon to begin planning for care after your discharge. Ideally, family members would be available to assist in your transition to return home. While many patients or family members may feel more secure by having a longer hospital stay, patients who return home once adequate diet is tolerated and pain is controlled by oral medications, are found to recover faster and experience less hospital acquired infections.