The Role of Multidisciplinary Teams in Transplant Success

What is Hepatitis C?

Hepatitis C is a viral infection that affects the liver. We believe that 5 million Americans have been exposed the virus through blood transfusions before 1992, tattoos and sharing needles. There may be no symptoms of hepatitis C, and patient would not know they had it unless they were specifically checked for it.

Who should get tested for Hepatitis C?

The virus is spread through contact or contamination of blood. All persons born between 1945 and 1965 should get checked since they have the highest risk. Anyone who had a blood transfusion before 1992, received medical care in Mexico, has a tattoo or history of sharing needles should get checked. In some cases, we do not know how a person was infected.

How is Hepatitis C diagnosed?

Hepatitis C is first suspected if a patient has a positive hepatitis C antibody. This may be checked if liver tests are abnormal or if a patient has risk for HCV infection. The test is confirmed by measuring the amount of virus in the blood. This test is known as the HCV RNA. The next important test to know is the genotype of the virus, and there are 6 different strains of the virus. The most common genotype in the US is genotype 1a. An additional test known as “resistance testing” can be done to see how the new Hepatitis C medications will work best against the patient’s virus.

How can my doctor tell how much damage has been done to my liver?

A liver biopsy is the best test to determine the amount of damage to my liver. When examined under a microscope, the biopsy can be graded for the amount of scar tissue. Stage 1 and 2 indicates mild amounts of scar tissue. The highest amount of scar tissue is stage 4, which indicates cirrhosis of the liver. Cirrhosis is a very serious medical diagnosis. In some cases we can determine the stage of liver damage with a picture of the liver known as the fibroscan.

Can Hepatitis C be treated?

Yes, Hepatitis C is highly treatable! There are a number of FDA approved medications for hepatitis C and none of them require injections or interferon. New hepatitis C medications are all-oral and have low side effects with short durations of therapy. After taking these medications, more than 95% of people are cured for life.

Patients, who have recovered from pancreatitis due to gallstones, may need to have their gallbladder removed surgically. The procedure is called a cholecystectomy, and can be done with a camera and small incisions (laparoscopic) or through a larger cut (open). During the operation the cystic duct and artery have to be clipped and cut. The gallbladder will be separated from the liver, and removed.

Patients can usually leave the hospital the day after the operation after laparoscopic surgery. They able to eat a regular diet, and will be given medication for pain at their incision (cut).

Dialysis

About Dialysis

A treatment that removes excess water and toxins from the blood for those whose kidneys who have lost the ablity to do so on their own.

There are 2 options for Dialysis.

Hemodyalisis

Uses a machine and a filter to remove the waste and water from the blood using a solution. It is done outside the body then returned to you. To get the blood into the machine, the doctor needs to make an entry into the blood vessels. This is done by joining an artery to a vein under the skin to make a bigger blood vessel called a fistula. Or a soft plastic tube can join an artery and a vein under the skin, called a graft.

Peritoneal Dialysis

Uses a fluid (dialysate) that is placed into the abdominal cavity to remove the waste. The blood is cleaned inside your body. A catheter is placed into the abdomen to absorb the waste from the blood that passes in the abdominal cavity. The fluid is then drained away.

Pancreatic pseudocysts are fluid-filled masses in the pancreas. They form as a result of injury to the pancreas after acute pancreatitis.

Signs and Symptoms

Large pseudocysts can cause pain and difficulty eating. When pseudocysts get infected, patients present with fevers, chills and low blood pressure, and require immediate treatment.

Treatment

Most pancreatic pseudocysts cause no symptoms and require no treatment. If a cyst does not resolve without treatment, patients may require a cystgastrostomy*. Infected pseudocysts are treated with antibiotics and need to be drained like an abscess.

cystgastrostomy - A cystgastrostomy is a procedure or surgery, which allows the fluid from your pancreatic cyst to drain into the stomach. This can be done by your gastroenterologist during endoscopy or surgeon with laparoscopic surgery. A small hole will be made in your stomach right over the cyst, and the edge of the stomach and cyst will be sewn together. You will be able to eat and drink normally after your surgery.

When does Tumor Board meet?

What is hepatitis B?

Hepatitis B is a virus that can lead to liver damage, cancer and even death. Hepatitis B can be transmitted from birth or person-to-person, for example from sex or sharing needles.

How would I know if I have hepatitis B?

If you are concerned that you may have hepatitis B you may be referred to a hepatologist. The first sign might be flu-like or from yellowing of the skin and eyes (jaundice). In some cases no symptoms might be noted.   If the disease has been left untreated for many years, cirrhosis can develop.

Is there a test for hepatitis B?

Yes blood tests are recommended and your doctor may also recommend a liver biopsy. All patients with hepatitis B infection should be assessed for their risk of liver cancer.   Some may need an ultrasound of the liver every 6 months.

How can my doctor tell how much damage has been done to my liver?

A liver biopsy is the best test to determine the amount of damage to the liver.  When examined under a microscope, the biopsy can be graded for the amount of scar tissue.  Stage 1 and 2 indicates mild amounts of scar tissue.  The highest amount of scar tissue is stage 4, which indicates cirrhosis of the liver.  Cirrhosis is a very serious medical diagnosis. In some cases we can determine the stage of liver damage with a picture of the liver known as the fibroscan.

Can I be treated for hepatitis B?

Medicines for hepatitis B are available in pill form or shots.  Your doctor can discuss which are right for you.  Additionally, patients with hepatitis B should avoid alcohol and receive vaccinations for hepatitis A.  Sexual partners and other household members should receive the hepatitis B vaccine.

ABOUT SURGERY

Depending on the size and location of your tumor, you may need a “wedge resection” (or removal of a small part of your liver) or a “lobectomy” (or removal of a large part of your liver). In most patients, it is safe to remove up to 60-80% of the liver because the liver can regenerate! Liver surgery can be performed using an open incision or sometimes Laparoscopically.

How big will my incision be for open surgery?

In order to safely get to your liver, your surgeon typically makes incisions under the ribcage on the right side. Sometimes it is necessary to make a “Chevron” or “Mercedes-Benz” incision if your tumor is in a hard to reach spot!

How big will my incision be for laparoscopic or robotic surgery?

Since these surgeries are performed “minimally invasively,” your incisions are oftentimes smaller and located lower in your abdomen.   You may have one incision that is larger than the others because that is used to remove the tumor specimen from the body.

WHAT TO EXPECT DURING YOUR HOSPITAL STAY

After your operation, you will need to recover in the hospital anywhere between 2-7 days depending on the extent of your operation.  During this time we will repeatedly encourage and assist you with walking and deep breathing exercises.

Some patients will be transferred immediately to the Intensive Care Unit (ICU) for recovery.  Usually after 1-2 days they will be transferred to the inpatient floor to continue the recovery process.

Will I Have A Private Room?

All rooms at St Vincent are private and you will not share your room with another patient.

Can My Family Stay With Me?

Yes, we encourage family to visit and keep patients company during the day.  Family are not discouraged to stay overnight, however, so that patients can receive adequate sleep.

Am I Allowed to Eat Food From Home?

Yes, once approved by your care team it is allowed and encouraged to bring home-cooked meals.  However, if you are on a special restricted diet (for example, low sodium), we ask that family do not bring food from home.

Am I Allowed to Smoke/Vape While in the Hospital?

Unfortunately since smoking has been shown to inhibit wound healing, we prohibit smoking in our patients.  Additionally, because of the fire danger with smoking and oxygen cannulas (which most of our patients have!) any smoking is prohibited. We will prescribe you nicotine patches or gum when appropriate.

How Will You Control My Pain?

All patients will have their pain controlled after the operation.  This is typically achieved by using a combination of oral medications, epidural pumps, and patient controlled anesthesia (PCA) pumps. Be aware though:  narcotic medications can cause constipation and if your bowels are not moving after surgery, then sometimes it is necessary to decrease the amount of pain medications we give you.

How Will I know I am Ready for Discharge?

The goals for discharge include:

• Eating and drinking adequately with bowel function
• Able to walk and carry out basic functions independently
• Appropriate pain control and no longer needing IV medications
• No signs of untreated infection or bleeding

Sometimes patients will require the assistance of physical therapy at home or may even need to be discharged to a rehabilitation facility.  Our social workers will work with you to arrange this care.

Can I Stay Extra Days in the Hospital to Recover?

Once you are cleared to go home, the safest option for you is to leave the hospital.  Because the hospital is full of other sick patients, you have a greater chance of exposure the longer you stay.

• DISCHARGE AND FOLLOW-UP

On the day of discharge, a member of your care team will review your discharge paperwork, medications, and follow-up instructions with you and your family.  In the case of emergencies, please call (213) 484-5551.  If you feel the emergency is life-threatening, please call 911!

Common Reasons to Call your Care Team

• Fevers of Chills higher than 101°F (38.3 °C)
• Drainage of fluid from your incision (especially if foul smelling)
• Swelling, warmth, or increased redness around your incision
• Any sudden increase in abdominal pain
• Inability to eat and drink or persistent nausea or vomiting
• Your skin or eyes turn yellow, or your urine becomes dark
• Constipation or inability to pass gas for longer than 3 days

Do I need to remove stitches after surgery?  Is it painful?

Typically, stitches and medical “Super-Glue” will be used to close your incisions, and there is no need to take out the stitches afterward because they will dissolve.  If you have surgical staples, these will need to be removed by your doctor approximately 5-15 days after the surgery.  Taking out the staples is painless for most patients!

When Can I Shower after Surgery?

We prefer that you shower after surgery, and that can be done as soon as the first day after surgery!  We recommend against baths, jacuzzis, or submerged water.  You do not need to cover your incision when you shower.

When Can I Resume Exercise after Surgery?

It will be safe to resume full exercise by about six weeks postoperatively.  Between 1-6 weeks you are at high risk for a hernia developing in your incision, so please do not lift anything heavy (anything more than a milk jug!)  Please discuss with your doctor before resuming activity.

Can I Drive After Surgery?

Driving a car or operating heavy machinery is safe when you are no longer taking pain medications and are able to have appropriate reaction times.

Can I Drink Alcohol after Surgery?

Drinking alcohol after liver surgery is not advised, because your liver is still healing.

A cystgastrostomy is a procedure or surgery, which allows the fluid from your pancreatic cyst to drain into the stomach.

This can be done by your gastroenterologist during endoscopy or surgeon with laparoscopic surgery. A small hole will be made in your stomach right over the cyst, and the edge of the stomach and cyst will be sewn together. You will be able to eat and drink normally after your surgery.

Intensive Care Unit (ICU)

What can I expect if I am in the ICU after surgery?

Patients undergoing liver kidney, and pancreas surgery may require a short stay in our ICU on the 4th floor at St. Vincent Medical Center.  This is a common and expected part of your hospital course.

What to expect immediately after surgery in the ICU

In addition to the IV in your arm, the catheter in your bladder, tube that may be placed in your stomach and small tubes that may be placed into your abdomen during surgery that were previously described, the following are some other catheters that may need to be placed prior to or during your surgery and may be in place in the ICU.

Some patients after surgery may require their breathing tube to remain in place over night while in the ICU. If this occurs, you will receive continuous medications through your IV to alleviate anxiety and control pain until we are ready to remove the breathing tube.

Most patients will have a small catheter, the same size as the IV in your arm, placed into an artery in either of your wrists. This catheter will allow us to monitor your blood pressure every time your heart beats and also to draw blood samples from your arterial circulation as needed.

Some patients will require the placement of a larger intravenous catheter into a vein either on the side of your neck or just below your collarbone. This catheter will allow us to give medications that cannot be given in the IV in your arm and also allows us to monitor your heart during your procedure.

If your Anesthesiologist feels it would be beneficial, you may have a small catheter called an epidural placed into your back that will give you a continuous infusion of pain medication to alleviate the pain that accompanies surgery in your abdomen.

Each of these procedures is done in a sterile fashion, after you receive a local anesthetic and are done inside the operating room prior to starting your surgery. Each catheter will be removed once the ICU team and surgery team agree that it is time for them to be taken out.

As an alternate method of pain control, your anesthesiologist may start you on a patient controlled analgesia pump after surgery. This pump gives pain medication through your IV in your arm and allows you to control when you receive injections of pain medication, without having to request it from the Nurse.

After surgery some patients may have a tube that goes into bladder that allows it to drain during and after surgery. Your surgery team usually removes this tube once you are up and out of bed.

Every hour while you are awake you will be exercising your breathing using an incentive spirometer (pictured below), which is used to prevent pneumonia and is an essential part of your ICU care. Additionally your Nurse will be getting you out of bed on your first day after surgery, which is another essential component of preventing problems with your lungs after surgery.

When can my family visit?

Visiting hours in the ICU are from 8 AM to 7 PM and then from 8 PM to 7 AM. Patients are allowed to have two visitors at the bedside at any one time, with exceptions made on a case-by-case basis. We want our patients to have restful nights of sleep, so we encourage families to go home after 830pm each night but they are welcome to call the ICU for updates at any time. We do not allow fresh flowers in the ICU, but we do encourage families to bring in any assistive devices like glasses a patient may need to increase their comfort. We also encourage the use of eyeshades and earplugs for sleep or headphones with music as needed.

Who will manage my care in the ICU?

We have a team of trained Physicians, Physician Assistants and Nurse Practitioners that are in the ICU 24/7 who will manage the minute by minute care you receive while in the ICU, while remaining in contact with your Surgeon to discuss any changes and to give updates on your progress. Additionally, our hepatobiliary surgical team will see you each day to review findings of surgery, plans for each day and when you can expect to transfer out of the ICU.

Chemotherapy

Chemotherapy is a type of cancer treatment that uses one or more anti-cancer drugs as part of a standardized chemotherapy regimen. Chemotherapy may be given with curative intent, or it may aim to prolong life or to reduce symptoms.

Radiation Therapy

Radiation therapy or radiotherapy, often abbreviated RT, RTx, or XRT, is therapy using ionizing radiation, generally as part of cancer treatment to control or kill malignant cells and normally delivered by a linear accelerator.

Gallstones

Gallstones are stones that are Made in the gallbladder. They Can be very small and resemble Fine sand grains (also known as "Sludge" or as big as pebbles and rocks!

Patients, who have recovered from pancreatitis due to gallstones, may need to have their gallbladder removed surgically. The procedure is called a cholecystectomy, and can be done with a camera and small incisions (laparoscopic) or through a larger cut (open). During the operation the cystic duct and artery have to be clipped and cut. The gallbladder will be separated from the liver, and removed.

Patients can usually leave the hospital the day after the operation after laparoscopic surgery. They able to eat a regular diet, and will be given medication for pain at their incision (cut).

A Multidisciplinary Tumor Board is a team of doctors and nurses who discuss your individual case to recommend the best treatment options for you based on your specific information. The members of Tumor Board include:

• Surgeons
• Oncologists
• Radiologists
• Pathologists
• Gastroenterologists

When does Tumor Board meet?

Usually once a week

When will I be presented at Tumor Board?

The Tumor Board needs to have the latest imaging available to make accurate recommendations. Patients are typically presented after all of the appropriate tests are completed.

Am I allowed to participate in Tumor Board?

Because multiple patients are presented at a single Tumor Board, having patients attend is discouraged for privacy concerns. However, you will learn the recommendations of the Tumor Board at your next clinical appointment.

What is HCC?

When a cancer starts in the liver, it is most commonly a type of cancer known as hepatocellular carcinoma (HCC). Unfortunately, this is the 3rd most frequent cause of cancer in the United States. Liver cancer is a highly treatable form of cancer and can be controlled with different types of procedures performed by interventional radiologist and special medicines. In some patients with early cancer, it can be cured with a liver transplant.

Who gets liver cancer?

The reason patient get liver cancer is cirrhosis. As chronic damage happens in the liver that leads to cirrhosis, it also causes changes in the cells that lead to cancer. In the United States, the most common causes of cirrhosis that can lead to liver cancer are hepatitis C, hepatitis B and fatty liver.

How do I know I have liver cancer?

Unfortunately, liver cancer does not cause many symptoms until it is very advanced. In those cases, it may cause pain on the right side or yellowing of the eyes and skin or jaundice. Since liver cancer is highly treatable and there are no warning signs, it is recommended that patients with advanced liver disease or cirrhosis get a picture of the liver with ultrasound, MRI or CT every 6 months. Doctors know that finding a liver tumor early can save lives.

How is a liver cancer evaluated?

Once it is suspected that a patient has a liver tumor, a special MRI or CT scan is done to understand the quality, number and size of the tumors. There are also blood tests that can be done that sometimes detect liver cancer as well. The most common blood test used is the alpha-fetoprotein (AFP). All patients with cancer of the liver should be seen by a hepatologist and then referred to a special team of doctors that review the patient’s case together known as a tumor board. This expert panel of doctors includes liver doctors, liver surgeons, cancer doctors, and radiologists. The team will evaluate the patient’s case together and come up with an expert recommendation about the plan of care.

Can liver cancer be treated?

Yes, there are many treatment options for liver cancer. The best way to way to decide on a treatment plan is to review the patient’s case at tumor board. Most often, the first line treatment is to perform a locoregional therapy. A locoregional treatment is when a special kind of doctor known as an interventional radiologist delivers a treatment to the cancer either by bringing the chemotherapy right to it or burns it with microwave. The medicines that these doctors use include chemotherapy or radiation therapy, known as a TACE or Y90.

Some patients cannot get locoregional therapy and they are better candidates for medicines like sorafenib, regorafenib, or nivoluminab. Occassionally, there are limited options for a patient, and in those cases we offer clinical trials.

On the other hand, if the tumors are able to be controlled and are not too big the patient may be a candidate for liver transplantation, which is a cure for cancer.

What is the bottom line for liver cancer?

If you have liver cancer, we are equipped to quickly evaluate your case with state of the art technology in a multidisciplinary approach. Liver cancer is highly treatable and even curable. If you don’t have liver cancer but think you are at risk, then ask.

Cystgastrostomy

A cystgastrostomy is a procedure or surgery, which allows the fluid from your pancreatic cyst to drain into the stomach.

This can be done by your gastroenterologist during endoscopy or surgeon with laparoscopic surgery. A small hole will be made in your stomach right over the cyst, and the edge of the stomach and cyst will be sewn together. You will be able to eat and drink normally after your surgery.

If your tumor can be removed with surgery, your surgeon will recommend one of the following operations. The type of operation is dependent on the location of your tumor.

Radical Cholecystectomy

For very early-stage cancers a Surgery alone might be sufficient. Most patients with gallbladder cancer, that can be removed, will need a radical cholecystectomy. During surgery, the gallbladder, the adjacent liver, a portion of the bile duct (tube connecting the liver to intestines) and lymph nodes in the area will be removed. The goal of the surgery is to remove the entire tumor.

The bile duct needs to be reconnected to the intestine, so bile can reach the digestive tract. This is done with a hepaticojejunostomy, which means that the bile duct will be sewn to a piece of small intestine.

Resection and Reconstruction of the Bile duct

For bile duct cancer outside of the liver and pancreas (hilar cholangiocarcinoma), the bile duct, gallbladder and lymph nodes in the area will be removed. The bile duct needs to be reconnected to the intestine with a hepaticojejunostomy.

Patients with bile duct cancer in the liver (intrahepatic cholangiocarcinoma) will need a Surgery.

Patients with distal bile duct cancer (cholangiocarcinoma) will need a Surgery.

What is hepatitis B?

Hepatitis B is a virus that can lead to liver damage, cancer and even death. Hepatitis B can be transmitted from birth or person-to-person, for example from sex or sharing needles.

How would I know if I have hepatitis B?

If you are concerned that you may have hepatitis B you may be referred to a hepatologist. The first sign might be flu-like or from yellowing of the skin and eyes (jaundice). In some cases no symptoms might be noted.   If the disease has been left untreated for many years, cirrhosis can develop.

Is there a test for hepatitis B?

Yes blood tests are recommended and your doctor may also recommend a liver biopsy. All patients with hepatitis B infection should be assessed for their risk of liver cancer.   Some may need an ultrasound of the liver every 6 months.

How can my doctor tell how much damage has been done to my liver?

A liver biopsy is the best test to determine the amount of damage to the liver.  When examined under a microscope, the biopsy can be graded for the amount of scar tissue.  Stage 1 and 2 indicates mild amounts of scar tissue.  The highest amount of scar tissue is stage 4, which indicates cirrhosis of the liver.  Cirrhosis is a very serious medical diagnosis. In some cases we can determine the stage of liver damage with a picture of the liver known as the fibroscan.

Can I be treated for hepatitis B?

Medicines for hepatitis B are available in pill form or shots.  Your doctor can discuss which are right for you.  Additionally, patients with hepatitis B should avoid alcohol and receive vaccinations for hepatitis A.  Sexual partners and other household members should receive the hepatitis B vaccine.

What is Hepatitis C?

Hepatitis C is a viral infection that affects the liver. We believe that 5 million Americans have been exposed the virus through blood transfusions before 1992, tattoos and sharing needles. There may be no symptoms of hepatitis C, and patient would not know they had it unless they were specifically checked for it.

Who should get tested for Hepatitis C?

The virus is spread through contact or contamination of blood. All persons born between 1945 and 1965 should get checked since they have the highest risk. Anyone who had a blood transfusion before 1992, received medical care in Mexico, has a tattoo or history of sharing needles should get checked. In some cases, we do not know how a person was infected.

How is Hepatitis C diagnosed?

Hepatitis C is first suspected if a patient has a positive hepatitis C antibody. This may be checked if liver tests are abnormal or if a patient has risk for HCV infection. The test is confirmed by measuring the amount of virus in the blood. This test is known as the HCV RNA. The next important test to know is the genotype of the virus, and there are 6 different strains of the virus. The most common genotype in the US is genotype 1a. An additional test known as “resistance testing” can be done to see how the new Hepatitis C medications will work best against the patient’s virus.

How can my doctor tell how much damage has been done to my liver?

A liver biopsy is the best test to determine the amount of damage to my liver. When examined under a microscope, the biopsy can be graded for the amount of scar tissue. Stage 1 and 2 indicates mild amounts of scar tissue. The highest amount of scar tissue is stage 4, which indicates cirrhosis of the liver. Cirrhosis is a very serious medical diagnosis. In some cases we can determine the stage of liver damage with a picture of the liver known as the fibroscan.

Can Hepatitis C be treated?

Yes, Hepatitis C is highly treatable! There are a number of FDA approved medications for hepatitis C and none of them require injections or interferon. New hepatitis C medications are all-oral and have low side effects with short durations of therapy. After taking these medications, more than 95% of people are cured for life.

Hepatectomy

Hepatectomy is the surgical resection (removal of all or part) of the liver. While the term is often employed for the removal of the liver from a liver transplant donor, this article will focus on partial resections of hepatic tissue and hepatoportoenterostomy.

What is a Whipple Procedure?

The Whipple procedure, or pancreaticoduodenectomy, is the most common surgery to remove tumors in the pancreas. Surgery to remove a tumor offers the best chance for long-term control of all pancreatic cancer types. The Whipple removes and reconstructs a large part of the gastrointestinal tract and is a difficult and complex operation.

If surgery is part of your treatment plan, your doctor will likely suggest one of two surgical procedures:

Whipple Procedure
(also called Pancreaticoduodenectomy)

During surgery, the head of the pancreas, the gallbladder, the first part of the bowel called the duodenum, part of the stomach and bile duct are removed. New connections called “anastomoses” are made between the bile duct and the bowel, the pancreas and the bowel and the stomach and the bowel. These new connections are necessary for you to eat and digest your food.

Distal Pancreatectomy

The body or tail of the pancreas and the spleen are removed. No new connections or “anastomoses” are made. You will need vaccinations before surgery, because your spleen usually eliminates certain types of bacteria.

Vein resection and reconstruction

If your tumor grows into the portal vein, which is the main blood vessel to liver passing behind the pancreas, your surgeon might have to remove a small piece, when removing a tumor. The portal vein can be repaired.

Nonfunctioning Pancreatic Neuroendocrine Tumors

Pancreatic neuroendocrine tumors, which arise from islet cells, but do not make hormones are called nonfunctional. They represent the majority of pancreatic neuroendocrine tumors, and can be benign (not cancer) or malignant (cancer).

Signs and symptoms

Patients with nonfunctioning pancreatic neuroendocrine tumors can have vague symptoms such as diarrhea, indigestion abdominal and back pain, which worsen as the tumor grows in size. If the tumor is in the head of the pancreas, patients may become jaundiced.

Diagnosis

In addition to the standard workup for a pancreatic tumor, the patient’s blood will be checked for chromogranin A levels.

Treatment

Nonfunctioning pancreatic neuroendocrine tumors will be removed with surgery. Patients with a tumor in the head of the pancreas need a Pancreatic Adenocarcinoma and in the body or tail of the pancreas a Distal Pancreatectomy.

Distal Pancreatectomy is a surgery that removes a tumor from the body or tail of your pancreas.

Surgical removal of the tumor in the pancreas might also be recommended, if patients have metastases in other organs i.e. the liver.

This is a tumor of pancreatic island cells, which make insulin. Insulin controls the blood sugar. If there is too much insulin in the blood, the blood sugar will drop to a dangerously low level. Most insulinomas are benign (not cancer). Some are associated with a genetic disease called MEN 1. Those tumors have a higher chance of being a cancer (malignant).

Signs and symptoms

Patients with an insulinoma may feel light-headed, confused, weak, sweaty, always hungry and have blurry vision.

Diagnosis

In addition to the workup for any pancreatic tumor, there is a specific blood test for an insulinoma. The patient’s blood will be checked for blood sugar and insulin levels after fasting for at least 24 hours.

Treatment

Insulinomas will always be removed by surgery, even if they have spread beyond the pancreas. If the tumor is small, it can be enucleated.

Enucleation means that only the part of the pancreas containing the tumor will be removed. This is almost always done by laparoscopy, which involves a camera and surgical instruments being inserted into the abdomen through small cuts. The tumor can be taken out of the abdomen through one of these small incisions.

For larger tumors in the head or tail of the pancreas, that patient will need a Insulinoma or distal pancreatectomy.

A distal pancreatectomy is a surgery that removes a tumor from the body or tail of your pancreas.

This is a tumor of the islet cells that make gastrin. Gastrin stimulates the stomach to release acid, which helps with the digestion of food. Patients with too much gastrin and acid will have diarrhea and stomach ulcers. Gastrinomas are often malignant (cancer) and the most common pancreas tumors in patients with a genetic disease called MEN1.

Signs and symptoms

Patients with gastrinoma can have ulcers that cannot be treated with medication, acid reflux diarrhea and abdominal and back pain.

Diagnosis

In addition to the standard workup for pancreatic tumors, gastrin levels in the blood can be measured after fasting for at least 8 hours. A hormone named secretin can be given, and the amount of acid in the stomach can be measured, if the gastrin blood test is not conclusive. A special imaging test called an octreotide scan can be helpful, when a small tumor cannot be found on CT scan, MRI or Endoscopic Ultrasound.

Treatment

Gastrinomas will be removed with surgery. Patients with a tumor in the head of the pancreas need a surgery and in the body or tail of the pancreas a distal pancreatectomy.

A distal pancreatectomy is a surgery that removes a tumor from the body or tail of your pancreas.

This is a tumor of the islet cells that make Glucagon. Glucagon helps regulate the blood sugar by releasing sugar into the blood. Patients with excess glucagon will have a high blood sugar (hyperglycemia), which cannot be controlled with medication. Glucagonomas are often malignant (cancer).

Signs and symptoms

Patients with a glucagonoma can have a rash on their arms and legs, blood clots in their legs or lungs and experience all the effects of having a high blood sugar such as extreme thirst, dry mouth and skin, frequent urination, weakness and fatigue.

Diagnosis

In addition to the standard workup for a pancreatic tumor, glucagon levels can be measured in the blood after at least 8 hours of fasting.

Treatment

Glucagonomas will be removed with surgery. Patients with a tumor in the head of the pancreas need a surgery and in the body or tail of the pancreas a distal pancreatectomy.

A distal pancreatectomy is a surgery that removes a tumor from the body or tail of your pancreas.

This is a tumor of the islet cells that make somatostatin, which plays an important role in regulating blood sugar and other aspects of digestion. Somatostatinomas are often malignant.

Signs and symptoms

Patients with a somatostatinoma can experience all the effects of having a high blood sugar such as extreme thirst, dry mouth and skin, frequent urination, weakness and fatigue. They may have diarrhea, foul-smelling, fatty stools (steathorrhea) and gallstones.

Diagnosis

In addition to the standard workup for a pancreatic tumor, somatostatin levels can be measured in the blood after at least 8 hours of fasting. A special imaging test called an octreotide scan can be helpful, when a small tumor cannot be found on CT scan, MRI or Endoscopic Ultrasound.

Treatment

Somatostatinomas will be removed with surgery. Patients with a tumor in the head of the pancreas need a surgery and in the body or tail of the pancreas a distal pancreatectomy.

A distal pancreatectomy is a surgery that removes a tumor from the body or tail of your pancreas.

This is a tumor of the islet cells that make vasoactive intestinal peptide (VIP), which plays an important role in regulating other hormones and the body’s salt and water balance in digestions. VIPomas are often malignant.

Signs and symptoms

Patients with a Vipoma will have watery diarrhea and dehydration. The potassium levels in the blood will be low, and they may experience muscle weakness, cramps, tingling or numbness.

Diagnosis

In addition to the standard workup for a pancreatic tumor, VIP levels can be measured in the blood. While potassium will be low in the blood, potassium and sodium will be high in the stool.

Treatment

Somatostatinomnas will be removed with surgery. Patients with a tumor in the head of the pancreas need a surgery and in the body or tail of the pancreas a distal pancreatectomy.

A distal pancreatectomy is a surgery that removes a tumor from the body or tail of your pancreas.

Cystic neoplasms of the pancreas are different types of fluid-filled masses, which are benign (not cancer), but can become cancer over time. The type of cystic neoplasm is important for treatment.

These are the different types:

• Intraductal mucinous neoplasm (IPMN): This tumor s associated with the tubes (ducts) in the pancreas, which transport digestive juices to the intestine. The fluid is thick and called mucin. IPMN can become cancer.
• Mucinous cystic neoplasm (MCN): This tumor is in the pancreas, but not associated with ducts. It is filled with mucin. MCN can become cancer.
• Serous cystic neoplasm (SCN): This tumor is in the pancreas, but not associated with ducts. It is filled with thin (serous) fluid. SCN can become cancer.
• Solid pseudopapillary tumor: This tumor can occur anywhere in the pancreas, and is dense and not always fluid-filled. It occurs more common in young women. It is not cancer, but can become cancer.

Signs and Symptoms

Most cystic neoplasms do not cause any symptoms, and are discovered by chance, when patients get a CT scan, MRI or ultrasound for another reason. As they grow, these tumors can cause pain, yellowing of the skin and diabetes.

Treatment

The patient’s care team will recommend if the pancreatic cyst needs to be removed. Patients with a tumor in the head of the pancreas need a surgery and in the body or tail of the pancreas a distal pancreatectomy.

A distal pancreatectomy is a surgery that removes a tumor from the body or tail of your pancreas.

ABOUT LIVER ABLATION SURGERY

Liver ablation is an effective way of treating liver tumors. During an ablation, a needle is guided into the tumor at which point energy is applied to heat tumors to the point where the tumor is destroyed. After the tissue is destroyed, your body will reabsorb the cellular material. Ablations can be performed using an abdominal surgical incision (“open surgery”) or laparoscopic “keyhole” surgery.

How big will my incision be for an ablation?

Most ablations are performed laparoscopically (via “keyhole” surgery).

Sometimes, depending on the location of the tumor, the ablation will

need to be performed using an “open” incision.

Do I need to remove stitches after ablation?  Is it painful?

Typically, stitches and medical “Super-Glue” will be used to close your incisions, and there is no need to take out the stitches afterward because they will dissolve.  If you have surgical staples, these will need to be removed by your doctor approximately 5-15 days after the surgery.  Taking out the staples is painless for most patients!

When Can I Shower after Ablation?

We prefer that you shower after ablation, and that can be done as soon as the first day after ablation!  We recommend against baths, jacuzzis, or submerged water.  You do not need to cover your incision when you shower.

When Can I Resume Exercise after Ablation?

It will be safe to resume full exercise by about six weeks postoperatively.  Between 1-6 weeks you are at high risk for a hernia developing in your incision, so please do not lift anything heavy (anything more than a milk jug!)  Please discuss with your doctor before resuming activity.

WHAT TO EXPECT DURING YOUR HOSPITAL STAY

After your operation, you will need to recover in the hospital anywhere between 1-3 days depending on the extent of your ablation.  During this time, we will repeatedly encourage and assist you with walking and deep breathing exercises.

What Room Will I Be In?

Patients are typically send to the Med/Surg unit after the procedure to continue the recovery process.

Will I Have A Private Room?

All rooms at St Vincent are private and you will not share your room with another patient (???? Don’t know if this is correct)

Can My Family Stay With Me?

Yes, we encourage family to visit and keep patients company during the day.  Family are not discouraged to stay overnight, however, so that patients can receive adequate sleep.

Am I Allowed to Eat Food From Home?

Yes, once approved by your care team it is allowed and encouraged to bring home-cooked meals.  However, if you are on a special restricted diet (for example, low sodium), we ask that family do not bring food from home.

Am I Allowed to Smoke/Vape While in the Hospital?

Unfortunately since smoking has been shown to inhibit wound healing, we prohibit smoking in our patients.  Additionally, because of the fire danger with smoking and oxygen cannulas (which most of our patients have!) any smoking is prohibited. We will prescribe you nicotine patches or gum when appropriate.

How Will You Control My Pain?

All patients will have their pain controlled after the operation.  This is typically achieved by using a combination of oral medications, epidural pumps, and patient controlled anesthesia (PCA) pumps.   Be aware though:  narcotic medications can cause constipation and if your bowels are not moving after surgery, then sometimes it is necessary to decrease the amount of pain medications we give you.

How Will I know I am Ready for Discharge?

The goals for discharge include:

• Eating and drinking adequately with bowel function
• Able to walk and carry out basic functions independently
• Appropriate pain control and no longer needing IV medications
• No signs of untreated infection or bleeding

Sometimes patients will require the assistance of physical therapy at home or may even need to be discharged to a rehabilitation facility.  Our social workers will work with you to arrange this care.

Can I Stay Extra Days in the Hospital to Recover?

Once you are cleared to go home, the safest option for you is to leave the hospital.  Because the hospital is full of other sick patients, you have a greater chance of exposure the longer you stay.

DISCHARGE AND FOLLOW-UP

On the day of discharge, a member of your care team will review your discharge paperwork, medications, and follow-up instructions with you and your family.  In the case you Have questions or would like to Speak to a member of the team, Please call 213-484-5551.  If you feel the emergency is life-threatening, please call 911!

Common Reasons to Call your Care Team

• Fevers of Chills higher than 101°F (38.3 °C)
• Drainage of fluid from your incision (especially if foul smelling)
• Swelling, warmth, or increased redness around your incision
• Any sudden increase in abdominal pain
• Inability to eat and drink or persistent nausea or vomiting
• Your skin or eyes turn yellow, or your urine becomes dark
• Constipation or inability to pass gas for longer than 3 days

Can I Drive After Ablation?

Driving a car or operating heavy machinery is safe when you are no longer taking pain medications and are able to have appropriate reaction times.

Can I Drink Alcohol after Ablation?

Drinking alcohol after liver ablation is not advised, because your liver is still healing.

Pancreatic pseudocysts are fluid-filled masses in the pancreas. They form as a result of injury to the pancreas after acute pancreatitis.

Signs and Symptoms

Large pseudocysts can cause pain and difficulty eating. When pseudocysts get infected, patients present with fevers, chills and low blood pressure, and require immediate treatment.

Treatment

Most pancreatic pseudocysts cause no symptoms and require no treatment. If a cyst does not resolve without treatment, patients may require a cystgastrostomy*. Infected pseudocysts are treated with antibiotics and need to be drained like an abscess.

*cystgastrostomy - A cystgastrostomy is a procedure or surgery, which allows the fluid from your pancreatic cyst to drain into the stomach. This can be done by your gastroenterologist during endoscopy or surgeon with laparoscopic surgery. A small hole will be made in your stomach right over the cyst, and the edge of the stomach and cyst will be sewn together. You will be able to eat and drink normally after your surgery.