31(6):950-955,2006

Case Report

En Bloc Resection for Locally Advanced Right-sided Colon

Cancer with a Duodenocolic Fistula : Report of Two Cases

Koji ASAI, Jiro NAGAO, Manabu WATANABE,

Hidenori TANAKA, Akihiro OSAWA, Hiroshi MATSUKIYO,
Yoshihisa SAIDA, Shinya KUSACHI and Yoshinobu SUMIYAMA
Third Department of Surgery, Toho University School of Medicine
A 52-year-old man, who had right-sided colon cancer that had invaded the duodenum, pancreas, and liver,
had a curative resection that included a right hemicolectomy, a pancreatoduodenectomy (PD), and a right
hemihepatectomy. The pathological findings confirmed a well differentiated adenocarcinoma, which
directly invaded the pancreas, liver, and duodenum. Eighty-five months after the operation, the patient is
still alive and disease-free. A 73-year-old man, who had right-sided colon cancer that had invaded the
duodenum, gall bladder, and liver, underwent a curative resection that included a right hemicolectomy, PD,
and a partial hepatectomy. The pathological findings confirmed a moderately differentiated adenocar-
cinoma, which directly invaded the gall bladder, bile duct, liver, and duodenum. Six months after the
operation, the patient is still alive and disease-free. Invasion of the duodenum, pancreas, and liver by a right
-sided colon carcinoma does not mean that the patient has incurable disease . In fact, this condition can be
resected with en bloc PD, colectomy, and hepatectomy, which offers the patient a chance for survival.

Key Words : pancreatoduodenectomy, en bloc resection, colon cancer

lished. We report two patients, both of whom

Introduction
had a duodenocolic fistula, who were success-
Colorectal cancer invading adjacent organs is fully treated with en bloc right hemicolectomy,
not an infrequent event and occurs in 5.5%- PD, and hepatectomy for locally advanced right
16.7% of all colorectal malignancies ;1) true -sided colon cancer .
direct tumor infiltration may occur in 45% to
Case Reports
70% of the cases2`4) . Intraoperatively, the sur-

geon is confronted with a dilemma regarding Case 1

the neoplastic or inflammatoy nature of adhe- In April, 1999, an otherwise healthy 52-year
-old man was admitted to the hospital with
sions. Combined resections for locally

advanced right-sided colon cancer that include severe watery diarrhea. On physical examina-

pancreatoduodenectomy (PD) are not new, but tion, he was mildly pale, and there was a pal-

the role of combined surgery is not well estab- pable abdominal mass in the right upper quad-

rant with a diameter of 10 cm. Laboratory data

confirmed that he was anemic (red blood cells

Correspondence to : Koji Asai
Third Department of Surgery, Toho University School (RBCs), 339 ~ 104/mm3 ; hemoglobin (Hb), 10 g/

of Medicine, 2-17-6 Ohashi, Meguro-ku, Tokyo 153-8515, dl ; hematocrit (Ht), 29.5%) and had a low

Japan serum albumin (3.1 g/dl). The serum car-

950
 En Bloc Resection for Locally Advanced Right-sided Colon Cancer with a Duodenocolic Fistula : Report of Two Cases

cinoembryonic antigen (CEA) level was normal

(1.9 ng/ml ; normal <5 ng/ml). On colonos-
copy, a tumor in the hepatic flexure with a
large ulcer was found. On pathological finding
of the biopsy specimen, a well differentiated
adenocarcinoma was diagnosed. Upper gastro-
intestinal endoscopy demonstrated a duodenal
ulcer in the second part, that had created a
communication with the colon. On hypotonic
duodenography, a duodenocolic fistula was evi-
dent (Fig. 1A). Abdominal computed tomogra-
phy (CT) showed a large mass involving the
duodenum, liver, and right-sided colon without
evidence of distant metastasis (Fig. 1B). At
laparotomy, the liver appeared normal ; there
was no ascites or peritoneal tumor seeding.
The primary colonic tumor was located at the
hepatic flexure with firm adhesions to the head
of the pancreas, duodenum, and liver. A right
hemicolectomy associated with PD and a right
hemihepatectomy were performed, with en bloc
resection and adequate free margins. The
patient had a standard PD because the tumor
had dense adhesions to the first and second
parts of the duodenum. The intra-operative Fig. 1 A Hypotonic duodenography showed a
estimated blood loss was 1200 ml, and the duodenocolic fistula (arrow). B Abdominal

operation took 565 min. Pathological finding computed tomography showed a large mass
involving the duodenum, liver, and right-sided
confirmed a well differentiated adenocar-
colon (arrow).
cinoma, measuring 7 cm in its greatest diame-
ter, that infiltrated the pancreas, liver, and
duodenal wall (Fig. 2A) ; there was a giant alive with no signs of disease recurrence after
duodenocolic fistula (Fig. 2B). The resection 85 months of follow-up.
margins were free of tumor. There was no Case 2
neoplastic lymph node metastasis. The final In October 2005, a 73-year-old man was

staging classification was T4N0M0 consistent admitted to another hospital with abdominal
with stage II B disease (UICC TNM classifica- pain and vomiting. On colonoscopy, he had a
tion)5). tumor in the hepatic flexure with a large ulcer.
The patient recovered uneventfully and was Upper gastrointestinal endoscopy showed a
discharged from the hospital on the 32nd pos- duodenal ulcer in the second part of the duode-
toperative day and could tolerate oral feeding num that communicated with the colon. The
very well. The patient received adjuvant oral patient was diagnosed as having an intestinal
chemotherapy (tegafur/uracil) and is currently obstruction due to right-sided colon cancer that

951
 316

Fig. 3 A Upper gastrointestinal fluorography

revealed a duodenocolic fistula. A long tube was
inserted to the duodenocolic fistula (arrow). B
Abdominal computed tomography showed a large
mass involving the duodenum, liver, and right-
sided colon. A long tube was demonstrated in the
colon through the duodenocolic fistula (arrow).

had formed a duodenocolic fistula. At the

previous hospital, a long tube was inserted

through the duodenocolic fistula to deal with

the intestinal obstruction. Laboratory test

results showed an iron deficiency anemia (RBC,

458 ~ 104/mm3 ; Hb, 10.9 g/dl ; Hct, 35.2% ; iron,

17 g/dl; unsaturated iron-binding capacity

Fig. 2 A The resected specimen, consisting of 476 g/dl; and total iron-binding capacity, 493
the duodenum, pancreas, right-sided colon,
g/dl), and elevated serum levels of CEA (11.8

and liver. B A huge tumor causing a
ng/ml) and carbohydrate antigen (CA) 19-9
duodenocolic fistula was seen (arrow).
(110.2 U/ml ; normal <37 U/ml). Upper gastro-

intestinal fluorography revealed a duodenocolic

952
 En Bloc Resection for Locally Advanced Right-sided Colon Cancer with a Duodenocolic Fistula : Report of Two Cases

fistula. A long tube was inserted through the

duodenocolic fistula (Fig. 3A). An abdominal
CT showed a large mass involving the duode-
num, right-sided colon without evidence of
distant metastasis. A long tube was demon-
strated in the colon through the duodenocolic
fistula (Fig.3B). At laparotomy, the liver
appeared normal ; there was no ascites or per-
itoneal tumor seeding. The primary colonic
tumor was located at the hepatic flexure with
firm adhesions to the duodenum, gall bladder
and liver. A right hemicolectomy combined
with PD and a partial hepatectomy were perfor-
med, with en bloc resection and adequate free
margins. The patient had a standard PD due to
dense adhesions, as had the previous case. The
intra-operative estimated blood loss was 2412
ml, and the operation took 612 min. Pathologi-
cal finding confirmed a moderately differentiat-
ed adenocarcinoma, measuring 7 cm in its
greatest diameter, infiltrating the liver, gall
bladder, bile duct, and the duodenal wall. A
definite duodenocolic fistula was demonstrated
(Fig. 4A, B). The resection margins were free
of tumor, and there was no neoplastic lymph
node metastasis. The final staging classifica-
tion was T4N0M0, consistent with stage II B
disease (UICC TNM classification)5). The
patient developed a postoperative complication
and was referred for the treatment of anas-
tomotic leakage of the posterior bile duct to the
jejunum ; the patient gradually recovered with
conservative treatment. The patient received
adjuvant oral chemotherapy ( tegafur/uracil
and leucovorin). The patient was discharged
from hospital on the 90th postoperative day and
could tolerate oral feeding very well. The
patient is currently alive and has no signs of
Fig.4 A The resected specimen, which consisted
disease recurrence after 6 months of follow-up.
of the duodenum, pancreas, right-sided colon,
and liver. A huge tumor causing a duodenocolic Discussion
fistula was seen (arrow). B The direct invasion
to the gall bladder was demonstrated (arrow). Although right-sided colon cancer does not

953
 316

frequently involve the duodenum and pancreas, et al.6) reported that there were no operative

this condition presents a challenge for the sur- deaths and no complications related to the

geon because an extended radical resection multiple gastrointestinal anastomoses. A

may be needed6`9). A locally advanced right superficial wound infection and delayed gastric

-sided colon cancer that invades adjacent struc- emptying complicated the postoperative course

tures causes dilemma for the surgeon, because in 2 (28%) of 7 patients. In the 2 present cases,

he must decide during operation quickly and there was minor morbidity and no operative

properly whether or not to perform a combined deaths. Mortality rates seem to be higher in

PD. In right-sided colon cancer, 40% of adhe- patients with combined resections (12%) when

sions to the head of the pancreas and duodenum compared to patients treated by colorectal

have been shown to be inflammatory on patho- resections alone (6%)14). On the other hand,

logical examination3). Biopsies and frozen-sec- survival rates of patients treated by extended

tions should not be routinely done because they or combined resections have shown significant

are associated with a high rate of false-nega- improvements. Overall, the mean survival

tive results and the risk of tumor exfoliation rates for locally advanced colorectal cancer

and dissemination, which results in recurrence after bypass procedures, non-extended resec-

rates of 90% to 100%10`12). Five-year survival tions, and radical extended resections are 9,11,

seems different between patients who under- and 40 months, respectively17). The survival

went tumor dissection away from the adherent benefit observed in patients treated with

organs (0%-23%) and who underwent en bloc extended radical resections for locally

resections (40%-61%)11,13,14) Therefore, en bloc advanced colorectal tumors may be correlated

resection of the tumor with the adherent organs to other pathological features, such as lymph

is indicated. Thus, once adhesion of the colon node metastasis, tumor differentiation, and the

cancer to another structure is observed, the local inflammatory response. Since nodal sta-

preferred strategy is to perform extended en tus is a major survival determinant in color-

bloc resection followed by thorough pathologi- ectal cancer, the T4N0 lesions noted in both of

cal examination. Combined resections for the cases presented may have influenced the

locally advanced right-sided colon cancer in- benefit of extended radical resection and may

cluding PD are not new, but the role of com- reflect a specific biological behavior of locally

bined surgery has not yet been well established. advanced tumors4)10)11). In several articles, N0

In 1956, Van Prohaska et al.13) were the first to tumors represented from 45% to 75% of all

describe a PD in a patient with colon cancer. locally advanced colorectal cases were treated

Since then, different series have reported with extended resections13,16,18). Similar results

extended operations for right-sided colon can- have been observed in patients who had com-

cer that include en bloc PD with a right bined PD for locally advanced right-sided colon

colectomy13-16). In the 4 studies that have cancer6,8). There is no doubt that the complete

specifically analyzed the role of combined PD resection of the tumor can benefit a patient by

and colectomy for right-sided colon cancer improving survival time. Twenty patients with

with adhesions to adjacent organs, only 17 disease-free long-term survival times between

patients had an en bloc PD6`9). Data on morbid- 24 and 72 months after combined PD have been

ity and mortality rates for extended colorectal reported6`9,14,19,20). Curley et al.6) reported 4 of 7

resections associated with PD are scant. Curley patients who had en bloc PD living free of

954
 En Bloc Resection for Locally Advanced Right-sided
recurrence at a median follow-up of 42 months.
Another study reported 3 of 4 patients who had
a combined PD alive between 24 and 30 months
later without evidence of disease7).
patients of ours had their tumors resected with
clear margins, and they are alive, free of dis-
ease ; in fact, they are survivors (6 and
months).
In conclusion, in patients with a locally
advanced right-sided colon cancer and no evi-
dence of metastatic disease, en bloc resection is
justified when the operation can be performed
with low morbidity and mortality. Such an
approach provides the patient with a chance for
significant survival.
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