ORIGINAL REPORTS
Combined Resection of the Duodenum and
Pancreas for Locally Advanced Colon Cancer
Rodrigo Oliva Perez, MD,* Roger Beltrati Coser, MD, Desidrio Roberto Kiss, MD,*
Renato Akira Iwashita, MS,* Jos Jukemura, MD, Jos Eduardo Monteiro Cunha, MD,
and Angelita Habr-Gama, MD*
*Colorectal Surgery Division, Department of Gastroenterology; General Surgery Division, Department of
Surgery; Pancreatobiliary Surgical Division, Department of Gastroenterology, School of Medicine, University
of So Paulo, So Paulo, Brazil
Colorectal cancer invading adjacent organs is a frequent event
occurring in 5.5% to 12% of all colorectal malignancies. Colon
cancer directly invading the duodenum and pancreas is rare and
may require combined resection of the colon, pancreas, and
duodenum, which represents a complex operation with signif-
icant morbidity and mortality rates.
In this article, a case of a 41-year-old patient with a right
colon cancer directly infiltrating the duodenum and head of the
pancreas is presented. The patient was treated by radical com-
bined resection of the colon, duodenum, and pancreas. Patho-
logical examination confirmed neoplastic invasion of the adja-
cent organs and absence of lymph node metastasis (T4N0). The
patient recovered uneventfully.
Patients with colorectal cancer infiltrating adjacent organs
such as the duodenum and the pancreas should be treated by
radical en bloc resection of the tumor. This procedure is the
preferred treatment strategy because it seems to be associated
with improved overall survival rates. (Curr Surg 62:613-617.
2005 by the Association of Program Directors in Surgery.)
KEY WORDS: colon cancer, pancreaticoduodenectomy, treat-
ment, en bloc resection
INTRODUCTION
Colorectal cancer remains one of the most common malignan-
cies in the Western world.1 Radical surgery is still the best
treatment option, and to obtain the best oncological results,
some basic principles should be observed such as adequate distal
and radial margins, high arterial ligations with regional lymph-
adenectomy, early venous ligature, and en bloc resection of
adjacent organs and structures.2
In approximately 10% of patients with colorectal cancer
the tumor is adherent to the adjacent organs,3-5 and this
Correspondence: Rodrigo Oliva Perez, MD, Rua Manoel da Nbrega 1564, 04005001, So
Paulo SP, Brazil; Fax: 55-11-3884-8845; e-mail address: rodrigo.operez@gmail.com
CURRENT SURGERY 2005 by the Association of Program Directors in Surgery
Published by Elsevier Inc.
adherence may represent true direct tumor infiltration in
45% to 70% of the cases.6-8 Intraoperatively, the surgeon is
confronted with the dilemma regarding the neoplastic or
inflammatory nature of such adherence. Under these cir-
cumstances, the preferred treatment strategy is complete en
bloc resection of the colon and the adjacent organs in direct
contact with the primary tumor.9 Depending on the nature
of other organs involvement by the primary colorectal tu-
mor, the surgeon may be forced to perform simple minor
associated resections such as oophorectomies or highly com-
plex operations such as duodenopancreatectomy with con-
siderable morbidity and mortality rates.6
In this article, we report a case of a right colon tumor locally
invasive to the head of the pancreas and duodenum, which is
treated by right hemicolectomy and cephalic duodenopancrea-
tectomy. The morbidity, mortality, and potential survival and
palliative benefits of this treatment strategy for such infrequent
situation are discussed.
CASE REPORT
A 41-year-old man, otherwise healthy, was admitted to the
hospital with a severe watery diarrhea for the last 3 months.
There was a 20% weight loss regarding the initial weight. Phys-
ical examination showed mild paleness and a palpable and mo-
bile mass in the right superior abdominal quadrant, with 5 cm
in diameter.
Blood testing confirmed anemia (Hb 10 g/dl, Ht
29%), low serum albumin (3.0 g/dl), and high carcinoem-
bryonic antigen levels (37.1 ng/ml). Colonoscopy revealed a
tumor in the hepatic flexure, with a large ulcer creating a
communication between the large and small bowel (Fig. 1).
Biopsy examination confirmed a moderately differentiated
colonic adenocarcinoma. Upper gastrointestinal endoscopy
demonstrated a duodenal ulcer at the second portion. Biop-
sies also confirmed duodenal invasion by a moderately
differentiated adenocarcinoma.
0149-7944/05/$30.00 613
doi:10.1016/j.cursur.2005.03.021
FIGURE 1. Colonoscopy reveals a tumor in colonic hepatic flexure, with
a large ulcer creating a communication with the small bowel.
An abdominal computed tomography (CT) scan showed a
large mass involving the duodenum, pancreas, and right colon
obliterating the pancreatoduodenal groove without evidences
of distant metastasis (Fig. 2).
At laparotomy, the liver appeared normal; there was no as-
cites or peritonial tumor seeding. The primary colonic tumor
was located at the hepatic flexure with firm adhesions to the
head of the pancreas and duodenum (Fig. 3).
A right hemicolectomy associated with pylorus-preserving
duodenopancreatectomy was performed, with en bloc resec-
tion, adequate free margins, and high arterial ligations (Figs. 4
and 5). After resection, reconstruction of the alimentary tract
was achieved by means of a primary ileocolic anastomosis, pan-
creatojejunostomy, hepaticojejunum anastomosis, and duode-
nojejunostomy as a modification of a previously described tech-
nique.10 The patient recovered uneventfully and was
FIGURE 2. Computed tomography scans show a large mass involving
the duodenum, pancreas, and right colon obliterating the pancreaticodu-
odenal groove.
614
FIGURE 3. Schematic representation of the primary colonic tumor lo-
cated at the hepatic flexure with firm adhesions to the head of the
pancreas and duodenum.
discharged from the hospital on the 13th postoperative day
with an excellent oral feeding acceptance.
Pathological report confirmed a moderately differentiated
adenocarcinoma, with a mucinous component, measuring 10
cm in greatest diameter infiltrating the pancreas and the duo-
denal wall (Figs. 6 and 7). Resection margins were free of tu-
mor, and there was no vascular or perineural invasion. There
was no neoplastic lymph node metastases in any of 31 resected
lymph nodes (17 were pericolic, 12 were peripancreatic, and 2
were mesenteric). Final staging classification was T4N0M0
consistent with stage II disease.
The patient is currently alive with no signs of disease recur-
rence after 24 months of follow-up. Carcinoembryonic antigen
level is 3.1 ng/ml (normal 4 ng/ml), a recent abdominal CT
scan was unremarkable, and a colonoscopy, performed at 18
months of follow-up, showed a ileo-colic anastomosis with no
signs of recurrent disease and a normal distal colon and rectum.
DISCUSSION
Despite recent advances in tumor markers, endoscopic imag-
ing, mass screening strategies, and public education, in many
patients, colorectal cancer is only diagnosed in advanced stages
of the disease.11 In this setting, direct adjacent organ invasion
may be a frequent event requiring aggressive surgical approach
for optimal oncological results.6
Locally advanced cancer is characterized by invasion or neo-
plastic adhesions to adjacent organs in the absence of distant
CURRENT SURGERY Volume 62/Number 6 November/December 2005
 FIGURE 4. Schematic representation of the organs resected.
FIGURE 5. Product of right hemicolectomy associated with pylorus-
preserving duodenopancreatectomy en bloc resection.
metastasis. At laparotomies for colorectal cancer resections, di-
rect adjacent organ invasion is found in approximately 5% to tended en bloc resection followed by thorough pathological
12% of the cases.3,4,6 examination.
Locally advanced tumors of the left colon may directly in- Preoperatively, locally advanced colon cancers may be sus-
volve the left kidney, spleen, abdominal wall, stomach, and pected according to physical examination and radiological stud-
distal pancreas. Sigmoid and rectal tumors may invade the blad- ies. The finding of a fixed palpable mass may indicate tumor
der, prostate, ovaries, and the uterus. Right-sided colon cancers invasion of surrounding structures. Computed tomography
may compromise the liver, pancreas, duodenum, and right kid-
ney. Adjacent organ invasion is most frequently observed in
sigmoid and rectal tumors, representing 66% to 89% of the
cases.4,9
Colorectal tumor adhesions may also be inflammatory, with-
out direct tumor invasion. It may be difficult for the surgeon to
distinguish between benign and malignant adhesions. At this
point, a decision should be made between an extended and a
standard resection. Combined extended resection should be
considered only for low-risk patients, sufficiently stable, and
with no signs of distant metastasis. In right-sided colon cancer,
40% of adherences to the head of the pancreas and duodenum
proved to be inflammatory after pathological examination of
the specimen.4,7 Biopsies and frozen-sections should not be
routinely performed because they are associated with high rates
of false-negative results and the risk of tumor exfoliation and
dissemination, which results in recurrence rates of 90% to
100%.11-13 Thus, once an adhesion of a colon cancer to another FIGURE 6. Moderately differentiated adenocarcinoma, with a mucinous
structure is observed, the preferred strategy is to perform ex- component and infiltrating the pancreas.

CURRENT SURGERY Volume 62/Number 6 November/December 2005 615


FIGURE 7. Moderately differentiated adenocarcinoma, with a mucinous
component and infiltrating the duodenal wall.
may reveal a hypodense mass involving the adjacent organs,
even though the differentiation between inflammatory and
neoplastic adherence may not be ascertained.14,15 Sometimes
there is no clinical or radiological hint of tumor local invasive-
ness, and the resection strategy may change during the opera-
tion after complete tumor mobilization. In this case, pancreatic
and duodenum invasion by the colonic tumor was determined
preoperatively.
Grey Turner16 in 1929 published the first duodenal resection
for locally advanced colon cancer, whereas Van Prohaska et al13
performed the first associated duodenopancreatectomy for di-
rect colon cancer invasion in 1953.17 Since then, direct invasion
of pancreatic head and duodenum by a colonic tumor remains
a major surgical challenge in the treatment of colorectal cancer.
The great complexity and the significant morbidity and mor-
tality rates associated with en bloc resection of the primary
tumor and the pancreaticoduodenum region have discouraged
surgeons from performing such a procedure for decades.
At laparotomy, the surgeon must confirm the absence of
distant metastatic disease before embarking in this extended
resection. Furthermore, a pylorus preserving procedure may be
performed, because regional pancreatic lymph node resection is
not needed in this situation.15
Data on morbidity and mortality rates for extended colorec-
tal resections associated with pancreaticoduodenectomy are
scant, because this situation is not frequently reported. Mortal-
ity rates seem to be higher in patients with combined resections
(12%) when compared with patients treated by exclusive colo-
rectal resections (6%).18 In contrast, survival rates indicate sig-
nificant benefits for patients treated by extended or combined
resections. Overall mean survival rates for locally advanced
colorectal cancer after bypass procedures, nonextended resec-
tions, and radical extended resections are 9, 11, and 40 months,
respectively.19
The survival benefit observed in patients treated with ex-
tended radical resections for locally advanced colorectal tumors
616 CURRENT SURGERY Volume 62/Number 6 November/December 2005
may be correlated to some pathological features such as lymph
node metastasis, tumor differentiation, and inflammatory local
response. Lymph node metastasis in T4 colorectal tumors
ranges from 18% to 48% of all cases. Because the nodal status is
a major survival determinant in colorectal cancer, this observa-
tion of frequent T4N0 lesions, as observed in the present case,
may influence the beneficial effect of extended radical resection
and may reflect a specific biological behavior of locally advanced
tumors.8,9,11,12,20,21
Furthermore, long-term survival rates are independent of the
primary tumor location, which supports the theory of a specific
tendency toward direct adjacent organ invasion rather than
lymphatic dissemination in T4 colorectal tumors.22,23 Also,
these tumors are frequently well differentiated and exhibit in-
tense inflammatory local response, which are features that may
also be responsible for the better overall results. Forty percent of
all tumor adherences may result from exclusive inflammatory
adhesions, which results in colorectal tumors confined to the
bowel wall. Moreover, the presence of lymphocitic infiltrate is a
favorable prognostic sign in colorectal cancer, which possibly
reflects a better overall immune response against the primary
tumor.14
Adjuvant chemotherapy has failed to bring unequivocal ben-
efits for patients with stage II colorectal cancer (absence of
lymph node metastasis), which leaves surgical radical resection
as the sole option with a proven positive impact on survival of
these patients.15 However, management of selected patients
with high-risk stage II colorectal cancer, including tumors
with adjacent organ invasion (pT4), remains controversial and
may benefit from adjuvant treatment as recommended by the
American Society of Clinical Oncology.24
The high overall survival rates associated with a better prog-
nosis for patients with locally advanced colorectal tumors may
encourage surgeons to perform complex combined resections,
such as duodenopancreatectomies, especially in centers where
morbidity and mortality rates for these procedures are low. This
treatment strategy may have a direct impact on patient survival
and provide better understanding of this specific subset of lo-
cally advanced colorectal tumors.
ACKNOWLEDGMENTS
The authors would like to thank Marcos Retzer for the
illustrations.
REFERENCES
1. Boring CC, Squires TS, Tong T, et al. Cancer statistics.
Cancer J Clin. 1994;44:7-26.
2. Nelson A, Petrelli N, Carlin A, et al. National Cancer
Institute Expert Panel. Guidelines 2000 for colon and
rectal cancer surgery. J Natl Cancer Inst. 2001;93:583-
596.
 3. Eldar S, Kemeny MM, Terz JJ. Extended resections for
carcinoma of the colon and rectum. Surg Gynecol Obstet.
1985;161:319-322.
4. Polk HC Jr. Extended resection for selected adenocarci-
noma of the large bowel. Ann Surg. 1972;175:892-899.
5. Sugarbaker ED. Coincident removal of additional struc-
tures in resections for carcinoma of the colon and rectum.
Ann Surg. 1946;123:1036-1046.
6. Bonfantti G, Bozzeti F, Doci R. Results of extended sur-
gery for cancer of large bowel of the rectum and sigmoid.
Br J Surg. 1982;69:305-307.
7. Davies GC, Ellis H. Radical surgery in locally advanced
cancer of the large bowel. Clin Oncol. 1975;1:21-26.
8. Orkin BA, Dozois RR, Beart RW Jr, et al. Extended re-
section for locally advanced primary adenocarcinoma of
the rectum. Dis Colon Rectum. 1989;32:286-292.
9. Curley SA, Carlson GW, Shumate CR, et al. Extended
resection for locally advanced colorectal carcinoma. Am J
Surg. 1992;163:553-559.
10. Machado MC, Da Cunha JE, Bacchella T, et al. New
technique of pancreaticojejunal anastomosis after par-
tial pancreaticoduodenectomy. Am J Surg. 1980;139:
451-453.
11. Mc Glone TP, Bernia WA, Elliotz DW. Survival follow-
ing extended operations for extracolonic invasion by colon
cancer. Arch Surg. 1982;177:595-599.
12. Hunter JA, Ryan JA, Schultz P. En bloc resection of colon
cancer adherent to other organs. Am J Surg. 1987;117:
595-599.
13. Van Prohaska J, Govostis MC, Wasick M. Multiple organ
resection for advanced carcinoma of the colon and rec-
tum. Surg Gynecol Obstet. 1953;97(2):177-82.
CURRENT SURGERY Volume 62/Number 6 November/December 2005
14. Charnsangavej C, Whitley NO. Metastases to the pan-
creas and peripancreatic lymph nodes from carcinoma of
right side of the colon: TC findings in 12 patients. AJR Am
Roentgenol. 1993;160:49-52.
15. Koea JB, Conlon K, Paty PB, et al. Pancreatic or duodenal
resection or both for advanced carcinoma of the right
colon: is it justified? Dis Colon Rectum. 2000;43:460-465.
16. Turner GG. Cancer of the colon. Lancet. 1929;1:1017-
1023.
17. Jass JR, Love SB, Northover JM. A new prognostic classi-
fication of rectal cancer. Lancet. 1987;1:1303-1306.
18. Gall FP, Tonak J, Altendrof A. Multivisceral resections in
colorectal cancer. Dis Colon Rectum. 1987;30:337-341.
19. Ellis H, Morgan HN, Wastell C. Curative surgery in car-
cinoma of the colon involving duodenum. Br J Surg.
1972;59:932-935.
20. Eienberg SB, Kraybill WG, Lopez MJ. Long-term results
of surgical resection of locally advanced colorectal carci-
noma. Surgery. 1990;108:779-786.
21. Fielding LP, Phillips RK, Frey JS, et al. Prediction of
outcome after curative resection for large bowel cancer.
Lancet. 1986;2:904-907.
22. Curley SA, Evans DB, Ames FC. Resection for cure of
carcinoma of the colon directly invading the duodenum or
pancreatic head. J Am Coll Surg. 1994;179:587-592.
23. Heslov SF, Frost DB. Extended resection for primary
colorectal carcinoma involving organs or structures. Can-
cer. 1988;62:1637-1640.
24. Benson AB 3rd, Schrag D, Somerfield MR, et al. Ameri-
can Society of Clinical Oncology recommendations on
adjuvant chemotherapy for stage II colon cancer. J Clin
Oncol. 2004;22:3408-3419.
617