ORIGINAL CONTRIBUTION
En Bloc Pancreaticoduodenectomy and Right
Colectomy in the Treatment of Locally Advanced
Colon Cancer
Ji Zhang, M.D. Jia-hua Leng, M.D. Hong-gang Qian, M.D.
Hui Qiu, M.D. Jian-hui Wu, M.D. Bo-nan Liu, M.D.
Cheng-peng Li, M.D. Chun-yi Hao, M.D.
Key Laboratory of Carcinogenesis and Translational Research, Ministry of Education, Department of Hepato-Pancreatic
Biliary Surgery, Beijing Cancer Hospital, Peking University Cancer Hospital & Institute, Beijing, China
BACKGROUD: Carcinoma of the right colon invading
the pancreas or duodenum is rare. Evidence of the
indication, operative morbidity, and survival of en bloc
pancreaticoduodenectomy and right colectomy for right
colon cancer invading adjacent organs is limited.
OBJECTIVE: The goal of this study was to investigate the
feasibility, safety, indication, and long-term results of
en bloc pancreaticoduodenectomy and right colectomy
in the treatment of locally advanced right-sided colon
cancer.
DESIGN: This was a retrospective analysis of all inpatients
undergoing en bloc pancreaticoduodenectomy and right
colectomy. Detailed data of these patients were assessed
by a thorough review of medical charts.
SETTINGS: The study was conducted using a hospital
database.
PATIENTS: Fourteen patients who underwent en bloc
pancreaticoduodenectomy and right colectomy from
January 1989 through December 2011 were included in
the study.
MAIN OUTCOME MEASURES: In-hospital complications,
mortality, and survival were the primary outcomes
measured.
RESULTS: Major postoperative complications included
delayed gastric empting (n = 7), class B pancreatic
fistula (n = 3), and bile leakage (n = 1). Postoperative
Financial Disclosure: None reported.
Correspondence: Chun-yi Hao, M.D., No. 52 Fu-Cheng-Lu St, Beijing
100142, China. E-mail: drhaochunyi@163.com
Dis Colon Rectum 2013; 56: 874880
DOI: 10.1097/DCR.0b013e3182941704
The ASCRS 2013
874
death occurred in 2 patients. The median hospital stay
was 22.5 days (range, 17.057.0 days). Inflammatory
adhesion was confirmed by pathologic examination in
only 1 patient. Eight patients (57%) did not have lymph
node metastasis. The median follow-up time was 21
months (range, 4276 months). Ten patients were alive
at the time of their last scheduled follow-up. The overall
survival rates were 72% at 1 year and 60% at 2 years. No
patient was lost to follow-up. Three patients developed
tumor recurrence. The outcomes are no worse than those
of the stage-matched patients without adjacent organ
involvement and are much better than those of the stage-
matched patients who underwent bypass surgery and
chemotherapy.
LIMITATIONS: The number of patients in current studies
is limited.
CONCLUSIONS: En bloc pancreaticoduodenectomy
and right colectomy can be performed safely with an
acceptable morbidity and mortality rate in selected
patients with locally advanced right-side colon cancer.
The long-term results are promising.
KEY WORDS: En bloc resection;
Pancreaticoduodenectomy; Right-sided colon cancer.
L
ocally advanced colorectal tumors, that is, tumors
that infiltrate or adhere to adjacent organs without
distant metastases, represent 5.2% to 23.6% of all
colorectal cancers at the time of presentation.17 Extended
or multivisceral resection to achieve R0 resection is the
treatment of choice. Right colon cancer invading adjacent
organs is rare, and even fewer series have described
colon cancer with duodenal and/or pancreatic invasions.
Because preoperative diagnosis is difficult, the situation
is often identified for the first time at surgery when the
Diseases of the Colon & Rectum Volume 56: 7 (2013)
Diseases of the Colon & Rectum Volume 56: 7 (2013)
patient and surgeon might not be fully prepared for a
surgical resection of such complexity. It may require
complex and difficult surgical resolution that involves en
bloc pancreaticoduodenectomy (PD) plus right colectomy
(RC),814 which pose surgical challenges. This may explain
the scarce information about this issue in the literature.
Most reports of this condition are solitary cases that are
included in large analyses of extended colonic resections
at all sites.6,1519 Some studies enrolled patients who
underwent RC plus partial duodenectomy. As a result,
the evidence on the indication, operative morbidity, and
survival of en bloc PD for right colon cancer invading
adjacent organs is limited. The present retrospective
study reviewed 14 cases of en bloc PD and RC for locally
advanced right colon cancer.
MATERIALS AND METHODS
The study protocol was approved by the ethics committee
of the Beijing Cancer Hospital. We identified 531 patients
with primary right-sided colon cancer who underwent
radical RC with or without multivisceral resection at the
Beijing Cancer Hospital between January 1989 and De-
cember 2011 from a prospectively maintained operative
database and analyzed their records. Among them, 14 pa-
tients underwent en bloc PD and RC because of direct in-
volvement of the duodenum and/or pancreas wherein the
cases were not suitable for a lesser procedure.
Computed tomography (CT) to determine local tu-
mor infiltration was routinely performed. Preoperative
colonoscopy and histopathological confirmation of the
diagnosis were performed in all of the patients. The pre-
operative CEA levels were routinely tested in 12 patients.
Indications for surgery included primary lesions with
or without direct extension to adjacent organs including
the pancreas and/or duodenum, as determined by preop-
erative imaging assessment, which could be radically re-
sected. The absence of medical comorbidities precluded
the operation. PD combined with RC should only be con-
sidered when there is no other method to achieve com-
plete resection, and the surgical risk is acceptable. Patients
with distant metastasis, high operative risk, or secondary
involvement of the duodenum and/or pancreas rather
than direct spread were excluded. Patients with secondary
or recurrent tumors were not considered. Patients with lo-
cal duodenal involvement that could be radically resected
by partial duodenectomy were also excluded.
A CattellBraasch maneuver was initially performed.
An extended Kocher maneuver was then performed to fully
mobilize the duodenum with an effort to palpate a clear
plane between any tumor and the pulsation of the superior
mesenteric artery. The resectability of the tumor was eval-
uated after complete mobilization of the right colon and
duodenum by means of an extended Kocher maneuver.
875
Duodenal or pancreatic invasion was determined after lib-
eration of natural adherences to the colon. Once the resect-
ability was established, an RC was performed following the
standard technique. A stapled end-to-side ileocolic anas-
tomosis was routinely performed after the specimen was
removed. In all of the patients, PD was undertaken with
an antrectomy, and reconstruction was carried out with
an end-to-side pancreaticogastrostomy or pancreaticojeju-
nostomy. A pancreatic duct stent was usually used in the
pancreaticojejunostomy. If the portal vein and/or superior
mesenteric vein was involved, resection of the mesenteri-
coportal vein and an end-to-end anastomosis was carried
out, as reported previously.20 After completion of the re-
section and reconstruction, rubber drains were placed near
the biliary and pancreatic anastomosis. The drains were
removed progressively from postoperative day 7. Paren-
teral antibiotics and octreotide acetate were administered
to all of the patients prophylactically. When the drain fluid
turned cloudy with sediment before the abdominal drain
was removed, a low-speed intermittent irrigation was
added until the drain fluid returned clear. No attempt to
separate the involved structures from the tumor was made
during the operation. Finger fracture of the adhesions was
avoided. The staging process was based on the TNM clas-
sification proposed by the American Joint Committee of
Cancer (AJCC).21
A postoperative pancreatic fistula was defined accord-
ing to the International Study Group on Pancreatic Fistula
Definition.22 Hence, a postoperative pancreatic fistula was
drained via an operatively placed drain (or a subsequently
placed percutaneous drain) of any measurable volume of
drain fluid on or after postoperative day 3 with an amylase
content >3 times the upper normal serum value. Delayed
gastric emptying was defined according to the consensus
definition of delayed gastric emptying after pancreatic
surgery suggested by the International Study Group of
Pancreatic Surgery.23 Intraabdominal abscess was defined
as a pocket of infected fluid and pus located inside the ab-
dominal cavity.
All of the patients were examined during the first 2
postoperative years at 3-month intervals, during the third
to fifth years at 6-month intervals, and at least annually
thereafter. The patients were followed up according to a
standard protocol, including physical examination, CEA
measurement, chest radiography, and abdominal ultra-
sound or CT, and then the patients were followed-up via
annual colonoscopy exams at outpatient clinics.24
According to our search results, 47 stage-matched
patients with right-sided colon cancer without adjacent
organ involvement underwent radical surgery, whereas
7 stage-matched patients with right-sided colon cancer
underwent bypass surgery and chemotherapy during the
same period. Patient records were analyzed for outcome
comparison.
876
TABLE 1. Patient characteristics
Patient Age, y Sex Site of colon cancer
A 56 F HF
B 62 F HF
C 46 M HF
D 76 F HF
E 39 M HF
F 69 M HF
G 45 F HF
H 47 M ASC
I 46 M HF
J 48 M HF
K 54 M HF
L 48 F ASC
M 58 M HF
N 59 F ASC
ASC = ascending colon; F = female; HF: hepatic flexure; M = male; NA = not applicable.
RESULTS
Fourteen patients, including 6 women and 8 men, with
advanced right-sided colon cancer involving the pancreas
or duodenum underwent en bloc PD and RC at our hos-
pital between 1989 and 2011. The median age was 51 years
(range, 3976 years). Sites of the primary cancer were the
ascending colon (n = 3) and hepatic flexure (n = 11). The
demographics and tumor location are outlined in Table1.
Eight patients had anemia and 6 had abdominal pain
at presentation. Other prominent symptoms were abdom-
inal distension (n = 4), palpable fixed mass (n = 4), altera-
tion of bowel habits (n = 4), history of significant weight
loss (n = 4), and vomiting (n = 3). One patient (patient F)
underwent laparotomy and ileocolostomy followed by 1
cycle of chemotherapy (regimen unknown) at a local hos-
pital. The patient was recommended to our hospital for
further treatment. Another patient (patient G) received 6
cycles of modified folinic acid, fluorouracil, plus oxalipla-
tin (FOLFOX) treatment at a local hospital after the diag-
nosis had been established and was then transferred to our
hospital.
The median operative time was 360 minutes (range,
270600 minutes), and the median blood loss was 400mL
(range, 200800mL). One patient (patient N) had associ-
ated infiltration of the right kidney and had an en bloc ne-
phrectomy. Major postoperative complications occurred
in 9 patients (64%) with delayed gastric empting being
the most common complication (4 grade A and 3 grade
B). Eight patients developed pancreatic fistulas (5 grade A
and 3 grade B) according to the International Study Group
on Pancreatic Fistula Definition.22 Two patients devel-
oped intra-abdominal abscesses. Both of them underwent
pancreaticogastrostomy. Pancreatic fistula was the cause
of the abscesses. They were all successfully treated dur-
ing their primary hospital stay. Two patients (14%) died
postoperatively, 1 with pneumonia and septic shock and
another with delayed post-PD arterial bleeding after intra-
ZHANG ET AL: PANCREATICODUODENECTOMY FOR COLON CANCER
Comorbidity Preoperative CEA level, ng/mL
Hypertension 2.68
- 6.01
Hypertension 13.43
Chronic hepatitis 1.64
- 59.16
Anemia 4.60
- 7.65
- 5.04
- 4.64
Diabetes mellitus NA
- 3.71
- NA
- 5.21
- 188.91
abdominal abscess formation. No patient had an ileocolic,
gastrojejunal, or jejunojejunal anastomotic leak. The me-
dian hospital stay was 22.5 days (range, 17.057.0 days).
This was much longer than that reported by Western au-
thors because of the Chinese social insurance system. Nine
patients received adjuvant chemotherapy, 6 with modi-
fied FOLFOX 6; 1 with FOLFOX 4; 1 with folinic acid,
fluorouracil, plus irinotecan hydrochloride; and 1 with
capecitabine plus oxaliplatin treatment. The treatment,
perioperative course, and outcome are listed in Table2.
The median follow-up time was 21 months (range,
4276 months). During this period, 2 patients died from
recurrence. Ten patients were alive by their last scheduled
follow-up. No patient was lost to follow-up. Three patients
(21%) developed recurrence. Among them, 2 patients (pa-
tients B and D) died from a recurrence and 1 remained
alive. Three patients survived >5 years after surgery, in-
cluding 1 patient surviving >23 years. The overall survival
rates were 72% at 1 year and 60% at 2 years. During the
same period, 47 stage-matched (T4bNxM0) patients with
right-sided colon cancer without adjacent organ involve-
ment underwent radical surgery. The overall survival rates
were 76% at 1 year, 58% at 2 years, and 26% at 5 years.
Seven stage-matched patients with right-sided colon can-
cer underwent bypass surgery and chemotherapy. Only 1
patient was alive by the last scheduled follow-up. The me-
dium survival time was 5 months.
Direct invasion to the duodenum and/or pancreas
head was confirmed histologically in 13 patients. Among
them, 3 patients developed fistula formation between their
colon and duodenum. Only 1 patient had inflammatory
adhesions. Pathologic examination demonstrated poorly
differentiated adenocarcinoma (n = 5), moderately
differentiated adenocarcinoma (n = 7), well-differentiated
adenocarcinoma (n = 1), and mucinous adenocarcinoma
with signet-ring cell carcinoma (n = 1). All of the tumors
had clear resection margins (R0). According to the AJCC
cancer staging system,21 8 patients (57%) were staged
Diseases of the Colon & Rectum Volume 56: 7 (2013) 877

TABLE 2. Treatments and outcomes

Perioperative course
Blood
transfusion, Operative
Patient Operation EBL, mL units time, min LOS, d Complications Chemotherapy Survival, mo Status Cause of death
A PD+RC 300 2 390 30 PF(A), DGE - 63 Alive
B PD+RC 400 0 280 36 DGE, BF FOLFOX4 12 Dead Recurrence
C PD+RC 700 2 360 25 PF(A) FOLFOX6 60 Alive
D PD+RC 300 4 270 17 PF(A), DGE mFOLFOX6 10 Dead Recurrence
E PD+RC 500 0 360 23 PF(A) mFOLFOX6 48 Alive
F PD+RC 800 4 600 IAA - Dead PC
G PD+RC 300 1 325 18 - FOLFIRI 24 Alive
H PD+RC 400 0 410 PF(A), IAA - Dead PC
I PD+RC+PH 800 2 360 19 DGE mFOLFOX6 49 Alive
J PD+RC 500 4 315 22 PF(B), DGE, IAA mFOLFOX6 4 Alive
K PD+RC 200 6 420 22 PF(B), DGE mFOLFOX6 12 Alive
L PD+RC NA NA NA NA - NA 276 Alive
M PD+RC 400 6 500 24 DGE XELOX 18 Alive
N PD+RC+RN 300 0 420 21 - mFOLFOX6 13 Alive
BF = biliary fistula; DGE = delayed gastric emptying; EBL = estimated blood loss; FOLFIRI = folinic acid, fluorouracil, plus irinotecan hydrochloride; FOLFOX = folinic acid,
fluorouracil, plus oxaliplatin; IAA = intra-abdominal abscess; LOS = length of stay; m = modified; NA = not applicable; PC = postoperative complications; PD = pancreatico-
duodenectomy; PF = pancreatic fistula; PH = partial hepatectomy; RC = right colectomy; RN = right nephrectomy; XELOX = capecitabine plus oxaliplatin.

as N0, 2 as N1a, 1 as N1b, 2 as N2a, and 1 as N2b. The
pathologic characteristics are outlined in Table3.
DISCUSSION
Carcinoma of the right colon (CRC) invading the pan-
creas or duodenum is rare.2528 Only a few series have de-
scribed adjacent-organ resection.911,14,2531 In our study, 14
patients (2.6%) with advanced right-sided colon cancer
involving the pancreas and/or duodenum who underwent
en bloc PD and RC were recognized from the 531 patients
who underwent curative RC between 1989 and 2011. Pa-
tients who had metastatic or recurrent lesions affecting the
pancreas and/or duodenum were excluded. We also did
not include those patients with local duodenal infiltration
who underwent en bloc resection of the tumor and part
of the duodenal wall with a negative margin, because the
complexity, morbidity, and mortality are incomparable
between local resection of the duodenal wall and PD.
The feasibility of en bloc PD and RC in the treatment
of locally advanced CRC is controversial. CRC that
invades the adjacent pancreas and/or duodenum is often
considered to be unresectable. One of the reasons is that
such locally infiltrative tumors are generally believed to
be highly malignant. Actually, although all of the tumors
of this category are staged T4b, according to the AJCC
staging system, 21 The N staging of the cancer may not be
that advanced. According to the reports, 25% to 60% of
CRCs that invade the adjacent pancreas or duodenum do
not have lymph node metastasis.9,10,14,25,26 In our series, 8

TABLE 3. Pathologic findings

Staging Pathologic finding
Patient Site of adhesion T N M Tumor Margin Adhesion
A Du+Pa+Kid 4b 0 0 Moderately differentiated adenocarcinoma Negative Ca
B Du+Pa 4b 1a 0 Moderately differentiated adenocarcinoma with mucinous adenocarcinoma Negative Ca
C Du 4b 0 0 Moderately differentiated adenocarcinoma Negative Ca
D Du 4b 1b 0 Poorly differentiated neuroendocrine tumor Negative Ca
E Pa 4a 0 0 Mucinous adenocarcinoma with signet-ring carcinoma Negative In
F Pa 4b 2a 0 Moderately to poorly differentiated adenocarcinoma Negative Ca
G Du+Pa 4b 0 0 Moderately differentiated adenocarcinoma with mucinous adenocarcinoma Negative Ca
H Du+Pa 4b 0 0 Well-differentiated adenocarcinoma Negative Ca
I Pa+GB+Liv 4b 2a 0 Moderately differentiated adenocarcinoma Negative Ca
J Du+Liv 4b 0 0 Moderately differentiated adenocarcinoma Negative Ca
K Du+Pa 4b 0 0 Poorly differentiated adenocarcinoma Negative Ca
L Du 4b 0 0 Moderately differentiated adenocarcinoma Negative Ca
M Du 4b 1a 0 Moderately differentiated adenocarcinoma Negative Ca
N Du+Kid 4b 2b 0 Moderately differentiated adenocarcinoma with mucinous adenocarcinoma Negative Ca
Du = duodenum; Pa = pancreas; Kid = kidney; GB = gallbladder; Liv = liver; Ca = carcinomatous; In = inflammatory.
878
patients (57%) were staged as T4bN0M0 pathologically.
These patients should be staged as IIC. Radical resection
is possible for most of the patients at this stage. Another
reason is that en bloc PD plus RC poses a surgical
challenge because of its complexity and the significant
morbidity and mortality rates. Most surgeons believe
that the risks of such a radical resection may outweigh
the benefits. With the development of surgical skills
and perioperative care, postoperative mortality and
morbidity rates of PD have recently fallen to acceptable
levels.3237 Many reports have revealed that en bloc PD
plus RC could be performed safely and produce good
results.911,14,38,39 In our study, 8 patients developed
pancreatic fistulas (5 grade A and 3 grade B), according
to the International Study Group on Pancreatic Fistula
Definition,22 7 developed delayed gastric emptying, and
2 developed intraabdominal abscesses. Both of the 2
patients who developed abdominal abscesses underwent
pancreaticogastrostomy. Pancreatic fistula was the
cause of the abscesses. Most of the complications were
successfully treated. Two patients (14%) died in the 30-
day postoperative duration. When the PD volume in
our hospital reached 70 per year, no postoperative death
happened in patients who underwent PD and RC. We
believe that postoperative mortality and morbidity rates
of PD and RC are acceptable in an experienced team.
No preoperative examination is reliable in distin-
guishing between carcinomatous or inflammatory adhe-
sions. CT scan can only show the intimate relationship
between the tumor and adjacent structures. Barium en-
ema and duodenoscopy may identify some of the duo-
denocolic fistulas. However, negative findings cannot
rule out malignant adhesions. In our series, all of the pa-
tients accepted CT scans preoperatively. However, a CT
scan can only demonstrate the thickness of the colonic
wall and the close relationship between the tumor and
adjacent duodenum and/or pancreas head. Three pa-
tients developed duodenocolic fistulas. One fistula was
found by barium enema. The rest were revealed by post-
operative pathologic examination. Even during surgical
exploration, it is still difficult to distinguish malignant
adhesions from inflammatory adhesions.8,24,40 It is widely
accepted that all adhesions between the adenocarcinoma
and neighboring organs should be assumed to be ma-
lignant. When a right-sided colon cancer is staged T4b-
NxM0, as long as the patient is an appropriate candidate
for a radical operation, en bloc multivisceral resection
should be performed.
There are no widely accepted indications for en bloc
PD and RC in the treatment of locally advanced CRC. It
is generally accepted that en bloc multivisceral resection
is appropriate when it can be performed with minimal
added operative morbidity and mortality and with a re-
alistic chance of long-term survival. The indications that
ZHANG ET AL: PANCREATICODUODENECTOMY FOR COLON CANCER
we recommend for this procedure include the following:
1) no distant metastasis, 2) R0 resection being possible on
the basis of the preoperative examination, 3) the patients
condition being good enough to accept radical multivis-
ceral resection, and 4) the surgical team being experienced
enough to safely perform en bloc PD and RC. High-risk
patients (ie, elderly, malnourished patients or patients
with long-term anemia or severe comorbid disease) may
not be good candidates for this procedure. Preoperative
evaluations (performance status and functional test of the
vital organs) are highly recommended.
The mortality rate in our study was relatively higher
than in similar studies. The main reason is that we were
not as experienced in managing post-PD complications
when 20 PDs were performed every year. The mortality
rate dropped significantly in the past 5 years when 70 to
80 PDs were performed every year. Otherwise, most of
the correlating studies enrolled patients who underwent
partial resection of the duodenal wall rather than PD,
which makes it impossible to compare certain parameters
between different studies.9,10,14,26,27,29 The limitation of the
number of patients in current studies is another reason.
An extra postoperative death can alter the mortality rate.
Study on a larger scale is needed to provide more reliable
results.
According to previous reports, the prognosis of pa-
tients with CRC who accepted en bloc PD and RC is prom-
ising.10,14,25,30,41 In our series, 10 patients (71.4%) were still
alive by their last scheduled follow-up. The overall sur-
vival rates were 72% at 1 year and 60% at 2 years. The
outcomes are no worse than those of the stage-matched
patients without adjacent organ involvement. However, of
the 7 stage-matched patients with right-sided colon cancer
who underwent bypass surgery and chemotherapy, only
1 patient was alive by the last scheduled follow-up. The
medium survival was 5 months. Because the number of
patients is limited, definite conclusion on the basis of sta-
tistic analysis could not be drawn. Saiura et al25 reported
long-term survival in 12 patients with advanced colon
cancer after en bloc PD and RC. Palliative therapy could
not produce a comparable prognosis.10,39
Three (25%) of 12 patients, not including those who
died postoperatively, had recurrence. The recurrence rate
in our study was relatively low compared with that in
most of the previous studies.10,14,17,2528,30,40,41 We believe
that selection bias can significantly influence the final
results. Because the number of patients was limited in
all of the relevant studies, it is very difficult to make a
definite conclusion. It has been widely recognized that
staging, especially N staging, is a prominent prognostic
factor affecting survival.1,5,7,17,19 In our study, 8 patients
(57.1%) did not present any compromised lymph nodes
(N0). Meanwhile, nearly half of the stage T4 CRC patients
(49.1%; n = 255) in our series did not have lymph node
Diseases of the Colon & Rectum Volume 56: 7 (2013)
metastasis. Our findings are consistent with some previous
reports suggesting that some CRCs may behave in a
locally aggressive manner rather than causing lymphatic
or hematogenous spread.9,10,14,25,26 En bloc resection can
provide good results to patients with this condition.
Data collected from this special subgroup of patients
may not reflect the true situation. First, it is likely that only
successful cases are presented. The incident rate of CRC
infiltrating adjacent structures may not be representative,
because patients who were rejected from surgical treat-
ment at outpatient clinics were not entered into the stud-
ies. Second, only a few studies analyzed data from patients
who purely underwent en bloc PD and RC. In most cases,
data from patients who underwent en bloc PD and those
who underwent local resection of the duodenal wall were
mixed together. Third, different studies had different in-
dications for en bloc multivisceral resection. This may be
the reason why the reported percentage of carcinomatous
adhesions varied from 47.2% to 100.0%.2,5,7,911,14,1618,41,42
Some surgeons may not oppose en bloc PD and RC. How-
ever, when synchronous liver metastasis exists, although
it is resectable, the patient may not be recommended for
multivisceral resection. Finally, the incidence of CRC in-
vading the adjacent duodenum and/or pancreas is low. In
our study, in 22 years, only 14 en bloc PD and RC surgeries
were performed. Saiura et al25 collected data on 12 simi-
lar patients in 50 years. However, surgical skills and peri-
operative care improved during that time. Longer-term
study will have more of chance to gather inconsistent data,
which makes it difficult to compare certain parameters be-
tween studies.
CONCLUSION
Locally advanced right colon cancer that directly invades
the duodenum and/or pancreas can be safely resected with
acceptable morbidity and mortality by an experienced
team. All adhesions between the adenocarcinoma and
neighboring organs should be assumed to be malignant.
En bloc PD and RC surgeries are indicated when multi-
visceral resection can be performed with minimal added
operative morbidity and mortality. Bias exists in all of the
studies because of the limited number of enrolled patients.
Long-term and larger-scale studies may produce more re-
liable results.
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