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Brief Report Hepatobiliary & Pancreatic Diseases International

Combined right hemicolectomy and pancre-


aticoduodenectomy for locally advanced right
hemicolon cancer
Qin-Song Sheng, Wen-Bin Chen, Min-Jiang Li, Xiao-Bin Cheng, Wei-Bing Wang and Jian-Jiang Lin

Hangzhou, China

ABSTRACT: Extracolonic invasion of the duodenum and/or Introduction


pancreatic head rarely occurs in patients with right hemico-

L
lon cancer. However, when necessary, combined radical op- ocally advanced colorectal cancers, defined as the
eration is a challenge to the surgeon. We reported 7 patients invasion of neighboring organs and structures
with locally advanced right hemicolon cancer who underwent without distant metastases, account for 5.2%-23.6%
combined right hemicolectomy (RH) and pancreaticoduo- of all colorectal tumors at the presentation.[1] Extraco-
denectomy (PD) due to direct involvement of the duodenum lonic invasion usually appears in the rectum and sigmoid
or pancreatic head. This study included four males and three colon in which pelvic organs and tissues may be invaded,
females with a mean age of 66.95.9 years. Computed tomog-
but it rarely occurs in the right colon or proximal trans-
raphy (CT) scans revealed right hemicolon cancer with duo-
denal invasion (5 patients) and pancreatic invasion (2). The verse colon.[2, 3] Especially, right hemicolon cancer with
mean operation time was 41064 minutes and the estimated direct infiltration of the duodenum and/or pancreatic
blood loss was 514157 mL. After the operation, the mean head usually produces more morbidity, posing a surgical
postoperative hospital stay was 22.17.2 days. Five patients challenge.[3] Combined resection of multiple organs is
had postoperative complications. The mean follow-up time recognized as the best therapeutic strategy for patients
was 16.45.9 months. During this period, three patients died with locally advanced colon carcinoma without distant
from tumor recurrence, one from postoperative complications, metastasis. Combined right hemicolectomy (RH) and
one from pulmonary disease, and two survived until the last
scheduled follow-up. Five patients survived more than one
pancreaticoduodenectomy (PD) is the best radical choice
year. Combined RH and PD for locally advanced right hemi- to treat locally advanced right hemicolon cancer.[1, 3-5] Lo-
colon cancer can be performed safely, thus providing a long- cally advanced colorectal cancer seldom appears in the
term survival rate in selected patients in a high-volume center. right side of the colon and reports on the occurrence are
(Hepatobiliary Pancreat Dis Int 2015;14:320-324)
rare. The morbidity and long-term prognosis of patients
with right colon carcinoma who have undergone com-
KEY WORDS: combined resection; bined RH and PD are not clear.[6, 7]
pancreaticoduodenectomy; This report is to share our experience in seven pa-
colectomy;
colon cancer;
tients who successfully underwent combined RH and PD
direct invasion to treat locally infiltrative right hemicolon cancer invad-
ing the duodenum and/or pancreatic head directly.

Author Affiliations: Department of Colorectal and Anal Surgery, The First


Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou Methods
310003, China (Sheng QS, Chen WB, Cheng XB, Wang WB and Lin JJ);
Department of Colorectal and Anal Surgery, First Peoples Hospital of Patients
Wenlin, Wenlin 317500, China (Li MJ) A total of 2 772 patients with right hemicolon carcinoma
Corresponding Author: Wen-Bin Chen, MD, Department of Colorectal who had radical RH with or without multi-organ opera-
and Anal Surgery, The First Affiliated Hospital, Zhejiang University School tion were analyzed. These patients were treated at the
of Medicine, Hangzhou 310003, China (Tel: +86-571-87236882; Email:
cwbin@hotmail.com) First Affiliated Hospital, Zhejiang University School of
Medicine between January 2000 and December 2013.
2015, Hepatobiliary Pancreat Dis Int. All rights reserved.
doi: 10.1016/S1499-3872(15)60374-5 From the medical records, seven patients who had un-
Published online May 21, 2015. dergone combined RH and PD due to direct involvement

320 Hepatobiliary Pancreat Dis IntVol 14No 3 June 152015 www.hbpdint.com


Combined RH and PD for colon cancer

of the duodenum or pancreatic head were identified. mor-lymph node-metastasis (TNM) classification recom-
The seven patients had symptoms of abdominal dis- mended by the American Joint Committee of Cancer.[10]
tension, upper abdominal discomfort, melena, anemia, or Postoperative complications were categorized according
a change in bowel habits. One patient had jaundice and to the reported criteria including the presence of pancre-
three patients had a palpable abdominal mass, but digi- atic fistula (PF),[11] delayed gastric emptying (DGE)[12]
tal rectal examinations were negative. The preoperative and acute respiratory distress syndrome (ARDS).[13]
cancer antigen 19-9 and carcinoembryonic antigen (CEA)
levels were routinely tested in all patients. Preoperative Statistical analysis
computed tomography (CT) was routinely performed to Demographic variables, intraoperative parameters,
evaluate local tumor invasion. Preoperative upper endos- and postoperative data were recorded. In addition, all
copy, colonoscopy, and pathological affirmation of the patients were asked to visit our outpatient department
diagnosis were carried out in all patients. every month after discharge and the complications dur-
The indications for surgery included the following: 1) ing the follow-up period were also recorded. Numerical
patients with histologically confirmed colon carcinoma; data were presented as meanstandard deviation.
2) patients without severe comorbid disease and toler-
able to a radical multi-organ excision; 3) colon cancer
which could not be dissociated from the pancreatic head
or duodenum; 4) R0 resection feasible on account of
Results
preoperative evaluation and no distant metastasis; and Seven patients (4 males and 3 females) with locally ad-
5) the surgical team who have sufficient operating skills vanced carcinoma of the right hemicolon invading the
and clinical experience to perform such a delicate op- duodenum or pancreatic head had undergone combined
eration.[1, 3, 6, 7] Patients with high surgical risk, distant RH and PD. The mean age of the patients was 66.95.9
metastasis, or secondary invasion of the pancreatic head years. The tumor was located at right colic flexure (3
and/or the duodenum rather than direct infiltration patients) and the ascending colon (4). CT scans revealed
were excluded. And those who had local duodenal inva- duodenal invasion in five patients and pancreatic inva-
sion that could be excised radically by a partial duodenal sion in two. Preoperative upper endoscopies revealed
wall resection were also excluded.[1, 8] colon tumors without mucosal involvement. The patho-
logical results confirmed the diagnosis of right hemico-
Operations lon cancer in all of the patients, and their preoperative
After the right hemicolon was dissociated, a Kocher CEA values were 9.36.9 ng/mL. The CA19-9 levels were
maneuver was made to completely separate the duode- normal in all patients. None of the patients underwent
num to create a distinct plane between the tumor and preoperative chemotherapy. The demographic variables
the superior mesenteric artery. Then the terminal com- of the patients are listed in Table 1.
mon bile duct was separated and retracted for the liga- The operations in all patients were performed suc-
tion of the gastroduodenal artery. A tunnel was estab- cessfully. The average operation time was 41064 min-
lished in the plane anterior to the portal vein behind the utes, and the estimated blood loss was 514157 mL.
pancreatic neck. The plane was established at the inferior Blood was transfused intraoperatively in all patients
margin of the pancreas medial to the arranged course of with an average amount of 3.71.4 U. Pathological ex-
the superior mesenteric vein. The resectability of colon amination confirmed the involvement of the duodenum
cancer was evaluated after entire separation of the right (5 patients) and pancreas (2). In addition, moderately
hemicolon and duodenum. The involvement of the duo- differentiated adenocarcinoma (5 patients) and poorly
denum or pancreas was evaluated after liberation of the differentiated adenocarcinoma (2) were confirmed his-
original adhesions to the right hemicolon. If resection tologically. According to the TNM classification system,
was feasible, RH was done according to a standard pro- stage T4bN1bM0 (2 patients), stage T4bN0M0 (3), stage
cedure. A stapled ileocolic side-to-side anastomosis was T4bN2aM0 (1), and stage T4bN2bM0 (1) were defined. The
made. PD was performed with a standard procedure, and intraoperative parameters are listed in Table 2.
reconstruction was subsequently undertaken according After the operation, the postoperative hospital stay
to Child's reconstruction method.[9] After the resection was 22.17.2 days. None of the patients died during the
and reconstruction, suction drains were placed into the hospital stay. Five patients had postoperative complica-
pelvis and near the anastomotic stomas, and the abdomi- tions including DGE (1 patient), ileus (2), wound infec-
nal wall wounds were closed. tion (3), ARDS (2), and PF (1). The patients recovered
The tumor stage was assessed according to the tu- after conservative treatments. Among them, five patients

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Hepatobiliary & Pancreatic Diseases International

received adjuvant chemotherapy, including modified were alive. Five patients survived more than one year.
folfox 6 (3 patients) and capecitabine plus oxaliplatin The survival time of the four patients with lymph node
treatment (2). The median follow-up time was 16.45.9 metastasis was 13.84.5 months, whereas that of the
months. During this period of follow-up, three patients three patients without lymph node metastasis was 206.2
died from tumor recurrence, one from postoperative months. The postoperative data of the patients are listed
complications, one from pulmonary disease, but two in Table 3.

Table 1. Demographic variables of the patients


Preoperative CEA Preoperative
Patient no. Gender Age (yr) Site Invasion Comorbidity
(ng/mL) chemotherapy
1 M 69 Right colic flexure Duodenum Hypertension 7.5 No
Anemia
2 F 65 Ascending colon Duodenum Diabetes 1.9 No
Anemia
3 F 70 Right colic flexure Pancreas Hypertension 4.1 No
4 M 75 Ascending colon Duodenum Hypertension 20.3 No
Coronary heart disease
5 M 56 Ascending colon Pancreas Anemia 3.9 No
6 M 68 Ascending colon Duodenum Hypertension 11.4 No
Coronary heart disease
Pulmonary insufficiency
7 F 65 Right colic flexure Duodenum Hypertension 16.3 No
Anemia
CEA: carcinoembryonic antigen.

Table 2. Intraoperative parameters of the patients


Operative time Operative blood loss Intraoperative blood Intraoperative
Patient no. Pathological findings
(min) (mL) transfusion (U) complications
1 410 500 4 No Moderately differentiated (T4bN1bM0)
2 450 500 4 No Moderately differentiated (T4bN1bM0)
3 530 800 6 No Moderately differentiated (T4bN0M0)
4 400 600 4 No Poorly differentiated (T4bN2bM0)
5 340 300 2 No Moderately differentiated (T4bN0M0)
6 380 400 2 No Poorly differentiated (T4bN2aM0)
7 360 500 4 No Moderately differentiated (T4bN0M0)

Table 3. Postoperative data of the patients


Duration of hospital Postoperative Follow-up
Patient no. Postoperative complications Status Cause of death
stay (d) chemotherapy (mon)
1 18 Delayed gastric empting Xelox 19 Dead Recurrence
2 20 Ileus mFolfox 6 10 Dead Postoperative
Wound infection complications
3 25 ARDS No 25 Dead Pulmonary disease
Wound infection
4 35 Pancreatic fistula No 10 Dead Recurrence
Wound infection
5 12 No mFolfox 6 13 Alive -
6 20 Ileus Xelox 16 Dead Recurrence
ARDS
7 25 No mFolfox 6 22 Alive -
ARDS: acute respiratory distress syndrome.

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Combined RH and PD for colon cancer

Discussion patients.
Patients who have received margin negative multiple According to previous reports, 25%-60% of cases of
organ resection usually have a similar survival rate com- colon cancer that invades the neighboring duodenum
pared with those who have no neighboring structure in- and/or pancreas do not have lymphatic metastasis.[1]
vasion. However, local recurrence of a tumor is common These results indicate that neoplasms spread in a locally
(70%-100%) in patients without multiple organ resec- advanced manner rather than lead to hematogenous or
lymphatic metastasis, which is an important prognostic
tion. Therefore, many researchers[4, 6, 14] have suggested
factor for local recurrence, distant metastasis, and surviv-
a combined resection of the colorectal tumor with the
al in patients with colon carcinoma.[3] Therefore, patients
neighboring organs and structures. Since right hemico-
with locally aggressive colon cancer without lymphatic
lon cancer is suspected to infiltrate the duodenum and/
metastasis have a longer postoperative survival time than
or pancreatic head, combined RH and PD might be nec-
those with lymphatic metastasis.[4, 6] The present report
essary to radically resect the tumor.[1, 3] However, some
showed similar results.
researchers[1] think that combined RH and PD for locally
According to previous reports, the prognosis of pa-
advanced right hemicolon cancer is not the best choice
tients with colorectal cancer who have undergone a com-
of treatment. First, locally advanced cancers are largely
bined RH and PD is promising.[1, 4, 6] The long-term out-
considered to be highly malignant. Second, a combined
comes after the combined operation for right hemicolon
RH and PD procedure represents a surgical challenge to
cancer invading the pancreas resemble those after the op-
the surgeon due to its difficulty, complexity, and high
eration for colorectal carcinoma invading other organs
postoperative morbidity and mortality. In addition, the
or structures. It remains to be answered whether radical
surgeon's individual experience and financial restrictions
and combined operation of the neoplasm can improve
also need to be considered.[6]
the survival time of the patients. Especially, in patients
In the past, extracolonic invasion was usually first
with stage T4 right hemicolon cancer who accept com-
discovered at the time of laparotomy. The results of
bined resection with PD, the average disease-free survival
preoperative abdominal CT often indicated imprecise
may reach 54 months.[2] In the current study, the average
information about the degree of pancreatic or duodenal survival time was 16.45.9 months, whereas the overall
invasion due to right hemicolon cancer.[2, 3] With the one-year survival rate of patients was 5/7. Two patients
development of CT technology, however, a recent meta- in this series were alive after the scheduled follow-up.
analysis showed that CT precisely stage colonic tumors However, information from this particular subsec-
preoperatively and provide information about cancer tion of patients might not reflect the actual situation.
involvement exceeding the muscularis propria.[15] In First, the incidence of colorectal cancer invading neigh-
the current study, preoperative CT accurately revealed boring organs might not be representative because stage-
duodenal invasion in five and pancreatic invasion in two matched patients with right hemicolon cancer infiltrating
patients, which were consistent with the intraoperative the duodenum or pancreas who rejected surgical treat-
findings. However, a study[7] found that imaging often ment or only chose bypass surgery were not included in
cannot distinguish inflammatory adhesions from direct this study. Second, other researchers had different indi-
tumor infiltration. Even in surgical exploration, it is of- cations for the combined resection. Finally, many stud-
ten difficult to determine whether gross adhesions to the ies have suggested that these patients should be studied
carcinoma represent true malignant infiltration or an for a long-term period.[1, 4] Since perioperative care and
inflammatory reaction.[1] Moreover, a histological study surgical skills keep improving, a long-term study might
showed that 55%-70% of adhesions are tumor invasions increase the variety of the data, making comparison of
while the remainder are tumor-related inflammatory ad- some variables between studies difficult.
herence.[3] Therefore, the adherences between the tumor
and adjacent structures should be considered malignant. Contributors: SQS and CWB proposed the study. SQS performed
When a right hemicolon cancer is staged as T4bNxM0, the research and wrote the first draft. LMJ, CXB and WWB col-
combined multiple organ operation should be per- lected and analyzed the data. All authors contributed to the design
formed once the patient is suitable for a radical surgery.[1] and interpretation of the study and to further drafts. CWB is the
In the current study, all the patients were confirmed to guarantor.
Funding: None
have dense adherences between right hemicolon cancer
Ethical approval: Not needed.
and the duodenum or pancreas, and were candidates Competing interest: No benefits in any form have been received
for a combined radical resection. The final histological or will be received from a commercial party related directly or in-
results confirmed duodenal or pancreatic invasion in all directly to the subject of this article.

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Hepatobiliary & Pancreatic Diseases International

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