Right hemicolectomy combined with pancreatico-duodenectomy for the treatment of colon carcinoma invading the duodenum or pancreas

Locally advanced carcinoma in sigmoid colon and rectum often invades adjacent organs in the pelvis; whereas local invasion of the pancreas or duodenum is rare. Consequently combined hemicolectomy and pancreatico-duodenectomy in the treatment of locally advanced colorectal carcinoma is uncommon.1 To the best of our knowledge, there are currently only three such cases reported in the Chinese literature to date.2 This paper reports five cases of synchronous right hemicolectomy (RH) and pancreatico-duodenectomy (PD) for the treatment of locally advanced right colon carcinoma. METHODS Patients From January 1994 to December 2005, 2700 cases of colorectal carcinoma were treated in the First Affiliated Hospital of Sun Yat-sen University and the General Hospital of Guangzhou Military Command. Five patients (0.2%), three males and two females, with ages ranging from 39 to 68 years, underwent combined RH and PD. Four presented with symptoms of upper abdominal discomfort, melena and a change in their bowel habit. The fifth subject was transferred from another hospital after gastrointestinal bypass surgery. All patients had a palpable abdominal mass. Endoscopy confirmed that all carcinomas were located in the right hepatic flexure and gastroscopy was unremarkable in all patients. Preoperative computed tomography (CT) scan in four patiens revealed duodenal invasion in three patients. Operative exploration Only one patient had ascites at laparotomy. All tumors were located at the hepatic flexure and transverse colon and showed signs of both duodenal and proximal pancreatic invasion. The tumors could not be separated from the duodenum or the head of the pancreas. Tumor size varied from 8 to 14 cm. Adjacent lymph node metastasis was observed in three cases, and adhesion between tumor and superior mesenteric vein (SMV) in two cases. There was no sign of distant metastasis or peritoneal tumor seeding in all cases. Operation types Two patients had RH and pylorus-preserving pancreatico-duodenectomy (PPPD). Two patients underwent RH and standard pancreatico-duodenectomy (SPD) and the other one had RH and SPD with synchronous partial SMV resection and reconstruction. After resection, reconstruction of the alimentary tract was achieved by primary ileocolic anastomosis, pancreatico-jejunostomy, choledocho-jejunostomy and gastrojejunostomy according to Child's reconstruction method. Binding pancreatico-jejunostomy anastomosis was performed in 4 cases and a routine pancreatico-jejunostomy in the remaining subject. RESULTS Total intraoperative blood loss ranged from 600—1600 ml. Operation time varied from 6.5 to 10.5 hours. Three cases of moderately-differentiated and two of poorly-differentiated adenocarcinoma were confirmed pathologically. All tumors showed extensive duodenal invasion; two cases had pancreatic invasion, one showed invasion of the gastric pylorus and one the SMV. Two cases had adjacent lymph node metastasis. The patient who underwent routine pancreatico-jejunostomy developed pancreatico-jejunostomy anastomotic leakage and post-operative peritoneal infection. The 30-day peri-operative mortality is zero. Hospitalization duration ranged from 27 to 75 days. All patients were followed up. Three patients died of cancer recurrence and metastasis at the sixth month postoperatively, and two patients showed no sign of tumor recurrence after 82 and 108 months respectively. Of the two surviving patients carcinoembryonic antigen levels were normal, abdominal CT scan showed no evidence of tumor recurrence, and endoscopic examination showed all anastomosis free from recurrence. DISCUSSION The necessity of RH combined with PD Since locally advanced colorectal carcinoma rarely occurs in the right colon, reports are infrequent and as such there is few current literatures on either occurrence or mortality of patients undergoing combined RH with PD in colon carcinoma. Surgically, RH with PD is a challenging procedure. PD carries both a high mortality and morbidity. Indeed the risks of such a radical resection may outweigh the benefits. Moreover, the surgeon's individual experience, patient's co-morbidity and financial restrictions also need to be considered. Hence, because of these limitations many patients may have missed their best chance of a potential cure. In 1972, Ellis et al3 reported that even in advanced colorectal cancer with adjacent organ invasion, lymph nodes around the tumor may not be involved and following extended radical resection of the affected organs, patient survival may be prolonged. Nevertheless reported cases number is between 20—30, all with satisfactory results.1-12 Twelve cases survived from 24 to 72 months1,7-9,11 and one survived 116 months.1 Curley et al7 reported the average surviving time of four out of seven cases to be 42 months. Koea et al8 reported the average survival time of three out of four cases to be 24 to 30 months. Shang et al2 reported no recurrence at one-year follow-up in three cases. The 5-year survival rate of these patients without operation is 1.8%.12 Thus RH with PD is a feasible alternative. Patients without distant metastasis, even with invasion of either duodenum or pancreas may benefit from this extended resection. Indeed the 5-year survival rate of patients treated by chemotherapy and/or radiotherapy remains very low. Indications for RH combined with PD RH with PD is a radical operation with large amount of blood loss and long operation time. Complications and mortality are inevitably higher than more conservative measures. It is important to have clear indications for surgery, including: (1) age of patient < 75 years; (2) absence of severe co-morbid disease; (3) the tumor of colon can not be separated from the duodenum or head of the pancreas; (4) the tumor can be radically resected by RH with PD; and (5) without distant metastasis. Surgeons must have adequate clinical experience and knowledge to deal with such tedious surgery. Key points of the operation Previous reports of local tumor recurrence in patients without en bloc resection is 70% — 100% with a 5-year survival rate of 0—23%. Following en bloc resection, 5-year survival rate is 40%—61%.13 Sixty percent of adhesions between tumor and adjacent organs are due to direct tumor invasion, whilst only 40% are inflammatory in origin.1,13 The distinction between inflammatory and neoplastic adhesions is not possible with current techniques, although inflammatory adhesions are often more easily separated by sharp dissection. It would be very difficult to find definite border between tumor and normal tissue in carcinomatous infiltration. Hence trial dissection should not be performed. After careful examination, the surgeon should determine the field of resection and define the borders of tumor invasion so as to facilitate en bloc resection. Finally adequate clearance of lymph nodes must be carried out at the time of resection. Intra-operatively it is essential to confirm the connection between the tumor and large blood vessels and also the head of the pancreas must be separated from the portal vein, superiord mesenteric vein and celiac artery. Usually the transverse colon tumor prevents the examination. It is difficult to clarify the relationship between tumor and superior mesenteric vein. One patient in this report underwent partial resection of the superior mesenteric vein, without superior mesenteric vein clot and other complications postoperatively. Careful separation of blood vessels and a reliable haemostatic technique are the effective methods to prevent postoperative bleeding. The choice between PPPD or SPD operation depends on the extent of tumor invasion. Although PPPD can improve the quality of life, it must be based on en bloc tumor resection. Pancreatic leakage is the most frequent complication. According to Peng's experience, the method of binding pancreatico-jejunostomy is most effective to prevent pancreatic leakage14 consistent with our series. Four patients with this method did not have any pancretico-jejunostomy anastomotic leakage postoperatively, whilst one patient undergoing a routine pancreatico-jejunostomy anastomosis had pancreatic leakage postoperatively. Management post operation Though the mortality following PD is under 5%, complication rates are as high as 27% — 50%.8 Postoperative management is very important with careful monitoring of organ function, nutritional support in the early postoperative period (due to delayed gastrointestinal recovery), early hemostasis, control of pancreatic leakage and effective anti-infection treatment. Recurrence and metastasis remain the main problems which patients have to face. In our case series, three of the five patients died from tumor recurrence, in keeping with other reports.1,7,8 The pathologic data of the surviving patients showed that one patient (82 months postoperatively) had a moderately- differentiated adenocarcinoma, invading both the duodenum and pancreas, whilst the other (108 months postoperatively) had a poorly-differentiated adenocarcinoma, invading the duodenum only. Neither had adjacent lymph node metastasis and both received RH with PD. After RH with PD, colon carcinoma invading the duodenum and pancreas may have a better prognosis than pancreatic carcinoma invading the colon. Suzuki et al15 reported 12 cases of locally advanced pancreatic carcinoma invading the colon that underwent combined RH and PD. Survival time of all cases was less than 24 months. Analytic results suggested that patients with locally advanced colon carcinoma without lymph node metastasis survived for long time periods postoperatively than those with lymph node metastasis. The staging of tumor and en bloc resection are the main factors for the prognosis of the patient. Despite the morbidity of the operation, long term survival is possible in some cases and an attempt at more radical surgery may therefore be worthwhile.