Int J Colorectal Dis (2006) 21: 265268

DOI 10.1007/s00384-005-0756-z ORIGINA L ARTI CLE

Sorabh Kapoor
Biswabasu Das
En bloc resection of right-sided colonic
Sujoy Pal
Peush Sahni
adenocarcinoma with adjacent organ invasion
Tushar K. Chattopadhyay

Accepted: 9 February 2005

Published online: 7 June 2005
# Springer-Verlag 2005
S. Kapoor (*) . B. Das . S. Pal .
P. Sahni . T. K. Chattopadhyay
Department of Gastrointestinal Surgery,
All India Institute of Medical Sciences,
Room No 1007, 1st floor, PC block,
Ansari Nagar,
New Delhi, 110029, India
e-mail: sorabhkapoor@hotmail.com
Tel.: +91-11-26593461
Fax: +91-11-26588641
Abstract Background: Right-sided
colon cancers that invade the adjacent
organs are often missed on preopera-
tive imaging. These patients are often
considered unresectable at laparotomy
as the surgeon is not prepared for en
bloc resections. A few centers have
reported extended survival after en
bloc resection in such tumors. We
therefore decided to evaluate the out-
come of our patients after en bloc
right hemicolectomy. Patients and
methods: The records of all patients
who underwent en bloc resection of
adjacent organs for right colon can-
cers were analyzed. Results: Be-
tween 1992 and 2004, 11 patients had
an en bloc right hemicolectomy for
right-sided colon cancer. There were
ten males and one female with a mean
age of 44 years (3580 years). All
patients had anaemia at presentation
and most had weight loss and a fixed
palpable lump. Preoperative CT scan
was able to detect adjacent organ
infiltration in nine patients. Six pa-
tients had an en bloc pancreaticoduo-
denectomy, three patients had en bloc
local excision of duodenal wall, one
patient had en bloc resection of
segments 5 and 6 of the liver and one
patient had en bloc distal gastrectomy.
There was one operative mortality
after an en bloc pancreaticoduode-
nectomy. The median disease-free
survival was 54 months.
Conclusion: Right-sided colon can-
cers that invade adjacent organs in the
absence of distant spread may be a
subset of tumors that behave in a
locally aggressive manner without
causing hematogenous spread. En
bloc resection of these tumors is
possible, in select centers, with low
mortality and morbidity and extended
survival.
Keywords Hemicolectomy . Colon
cancer . Pancreaticoduodenectomy

Introduction Adjacent organ resection for right-sided colon cancers has

Colorectal cancers infiltrate adjacent organs in 5.516.7%
of cases [1]. Although extracolonic spread is common in
rectosigmoid tumors it is seen less often in right-sided
colon cancers [26]. Right-sided colon cancers which
invade the adjacent pancreas and duodenum pose a sur-
gical challenge, because complete removal of these tumors
involves resection of multiple infiltrated adjacent organs.
Such locally infiltrative tumors are often considered un-
resectable. In addition, adjacent organ infiltration is often
identified for the first time at surgery when the patient and
surgeon might not be fully prepared for a surgical resection
of such magnitude.
been done previously; the first description of a simultaneous
duodenal resection with a right hemicolectomy was by Grey
Turner in 1929 [7]. Van Prohaska et al., in 1956, described
the first en bloc pancreaticoduodenectomy for right colon
cancer [8]. In the past decade, more centers are doing
pancreaticoduodenectomy for periampullary and pancreatic
cancer with a low mortality [9]. However, only few case
series, involving small number of patients, have described
adjacent organ resection for right colon cancers [2, 4, 10, 11].
Most of these series have reported extended survival after
these complex procedures with a low operative mortality and
morbidity [1215]. Despite the large number of colon re-
sections performed all over the world, little information is
266
available about the mortality, morbidity, and outcome after
en bloc adjacent organ resection for right colon cancers.
We therefore evaluated our experience with such extended
resections.
Patients and methods
We reviewed the records of patients with colon cancer op-
erated in our department, who underwent right colonic
resections with en bloc resection of adjacent organs. Only
patients with primary colon cancers were included. Patients
who had undergone previous attempts at resection or bypass
were excluded.
The age, gender, symptoms and signs at presentation,
findings on computerized tomographic scan (CT), carcino
embryonic antigen level (CEA), histopathological findings
and follow up data of these patients was analyzed.
Results
Between 1992 and 2004, 11 patients had en bloc resection
of a right colon cancer with adjacent organs at the De-
partment of Gastrointestinal Surgery in the All India In-
stitute of Medical Sciences, New Delhi. There were ten
men and one woman with a mean age of 44 years (range
3580 years).
All patients had anemia at presentation and most had
a palpable fixed mass (n=10) and history of significant
weight loss (n=9). The other prominent symptoms were
abdominal pain (n=9), lower gastrointestinal bleeding
(n=7), and alteration of bowel habits (n=5).
Preoperative colonoscopy and histopathological confir-
mation of the diagnosis was done in all patients. All patients
had a positive test for stool occult blood at presentation and
had received 211 units of blood perioperatively (mean 3.8
units). The preoperative CEA levels were tested and normal
in ten patients. A preoperative CT scan was done in ten
patients (in one patient CT was not done) and detected
duodenal infiltration in eight of nine patients. CT scan was
unreliable for identifying pancreatic infiltration (two of five
patients; Table 1). An upper gastrointestinal endoscopy was
done in eight patients with suspicion of duodenal infiltration
on CT. It was able to identify duodenal infiltration in the form
of mucosal ulceration in three patients whereas in the other
five only extrinsic compression was reported.
At exploration, three tumors were invading a part of the
duodenum (one of these had a duodenocolilc fistula) and
were treated by en bloc resection of the tumor and part of the
duodenal wall. The duodenal defect was closed primarily in
one patient (as the excised portion of duodenal wall was less
than one third of the circumference) and in two patients, a
side-to-side duodenojejunostomy was done (involvement of
more than one third circumference of the duodenum). A
patient with extensive duodenal infiltration was treated with
Table 1 Adjacent organ infiltration in the patients studied
Organ CT scan At exploration Histopathology
Duodenum 8 9 9
Stomach 1 1 1
Liver 1 1 1
Pancreas 2 5 5
Kidney 1 1 1
Gall bladder 0 1 0
en bloc pancreaticoduodenectomy. Five patients had a tumor
adherent to the pancreas and were treated with an en bloc
pancreaticoduodenectomy. One of these patients had asso-
ciated infiltration of the right kidney and had a en bloc
nephrectomy done. Distal gastrectomy and cholecystectomy
was done in a patient with tumor adherent to the pylorus and
antrum of the stomach and the fundus of gall bladder. En bloc
resection of segments 5 and 6 of liver was done for a hepatic
flexure growth infiltrating the liver (Table 2).
Pathological examination of the specimens showed duo-
denal infiltration in nine patients; five of these also had
pancreatic infiltration and one had infiltration of the right
kidney. Infiltration into the pylorus was seen in one patient
(the adherent gall bladder in this patient was not infiltrated)
and hepatic infiltration in one patient (Table 1). Seven
patients had well differentiated tumors and four had mod-
erately differentiated tumors. Most of the patients were
pathological Stage II or III (TNM, AJCC 1997) (Table 3).
The mean operating time was 6.9 h (3.59 h) and the
mean intraoperative blood loss was 550 mL (3001400
mL). The median postoperative hospital stay was 10 days
(974 days). Major complications occurred in two patients.
One patient had an anastomotic leak from the ileo-colic
anastomosis after en bloc pancreaticoduodenectomy. This
patient was re-explored, an ileostomy and mucous fistu-
la were created and intestinal continuity restored after 6
weeks. Another patient had a pancreaticojejunostomy
leak and ileo-colic anastomotic leak. He was initially
managed with an ileostomy and peripancreatic drainage
but he subsequently developed massive upper gastroin-
testinal and intra abdominal bleeding and died 74 days
after the first operation. Minor complications in the form
of wound infection occurred in three patients.
Table 2 Adjunct operative procedures done
Operative procedure in addition to right hemi-colectomy Number
Pancreaticoduodenectomy 5
Pancreaticoduodenectomy and right nephrectomy 1
Partial resection of duodenal wall 3
Distal gastrectomy and cholecystectomy 1
Resection of segments 5 and 6 of liver 1

Table 3 Outcome in relation to the pathological stage
Tumor stage No Op Recurrence Survival
mortality >5 years
pT4 N0 M0 (Stage II) 5 0 0 2
pT4 N1 M0 (Stage IIIA) 5 1 1a 1 occurs in 70100% of the patients who are not treated by en
pT4 N2 M0 (Stage IIIB) 1 0 1b 0 bloc resection [2, 5]. Patients who undergo separation of
a adherent organs also have a lower 5-year survival (023%)
This patient developed distant metastasis after 68 months
b
This patient developed locoregional recurrence after 36 months
Seven patients received adjuvant chemotherapy; six had
lymph nodal involvement and the seventh had a moderately
differentiated tumor. Two patients, both with uninvolved
nodes and well-differentiated tumors, did not receive ad-
juvant chemotherapy. Another patient with node negative
disease but who had a duodeno-colic fistula is currently on
adjuvant chemotherapy. The median follow up of the pa-
tients was 54 months (mean 62 months). The median dis-
ease-free survival was 54 months (mean 52 months). One
patient developed local and lymph nodal recurrence after
36 months and died 48 months after surgery. Another pa-
tient developed hepatic and pulmonary metastasis after 68
months and died after 73 months. Eight patients are alive
and do not have a recurrence.
Discussion
Adjacent organ infiltration with right-sided colon cancers is
less common than for rectosigmoid tumors. However, most
large series of colon cancers have reported adjacent organ
infiltration into the duodenum, pancreas, stomach, and
liver in 5.516.7% of cases [1, 3, 16]. Adjacent organ in-
filtration is often discovered at laparotomy. Polk has
emphasized that right colon cancers which manifest as an
immobile mass often invade adjacent organs [10]. In our
series also, nine patients had a large immobile and palpable
mass on clinical evaluation. The results of preoperative
imaging are often unreliable in predicting adjacent organ
spread [17]. In our series, a large mass abutting the duo-
denum or gastric antrum was present in nine patients while
on pathological examination duodenal or gastric wall in-
filtration was found in ten patients. On the other hand CT
scan was unreliable in demonstrating pancreatic spread,
which was picked up in only two of five patients with
pancreatic infiltration on histopathology. Despite preoper-
ative imaging, extracolonic spread is often discovered for
the first time at laparotomy. Upper gastrointestinal endos-
copy may also fail to identify duodenal infiltration, because
tumor infiltration may be limited to the muscle layer without
invasion of the duodenal mucosa. Histological infiltration is
demonstrated in only 5570% of cases in which the tumor is
found to be adherent to the adjacent viscera [2, 4, 6, 16]
whereas the rest represent inflammatory adherence. In this
267
setting, curative surgery entails en bloc resection of the
adherent/infiltrated organ. Any attempt to separate the colon
from adherent organs may lead to spillage and dissemination
of tumor cells and risk leaving behind residual disease that
may result in early local recurrence. Early local recurrence
compared with patients treated by en bloc resections (40
61%) [2, 4, 5].
Patients found to have limited duodenal wall adherence
may be safely treated by a local resection and duodenal
repair whereas those with involvement of larger parts of the
duodenal wall or pancreas require a pancreaticoduode-
nectomy. Unlike the published reports of histological in-
filtration occurring in only 6070% cases with tumors
adherent to adjacent organs, we found histological infil-
tration in all patients where it was suspected intraopera-
tively [3, 10, 18].
Despite the presence of adjacent organ infiltration, seven
patients had well differentiated tumors and five patients had
no lymphatic spread. Similar findings of well differentiated
and node negative disease has been noted by other authors for
tumors with local infiltration [16]. This suggests that these
tumors behave in a locally aggressive manner rather than
causing lymphatic or hematogenous spread which are the
predominant prognostic factor affecting recurrence and
survival in colorectal cancer [19]. In our series two patient
developed disease recurrence. Both patients had multiple
involved pericolic lymph nodes.
Most series have reported minimal mortality rates with
such resections [1315], however it is possible there is a
publication bias, because only centers which have success-
fully performed these procedures may have reported them.
We had one hospital mortality after an en bloc pancreati-
coduodenectomy with right hemicolectomy which was be-
cause of a pancreaticojejunostomy leak and intra-abdominal
hemorrhage. Another patient with a pancreaticoduode-
nectomy developed an anastomotic leak from the ileo-
colic anastomosis but could be salvaged by re-exploration
and ileostomy with mucous fistula. The mean operating time
in our patients was similar to that reported by others [1215,
20]. The median disease free survival was 54 months. Two
patients developed recurrent disease after 36 and 68 months
and died 48 and 73 months postoperatively, respectively.
Eight patients are alive and disease-free with three patients
surviving beyond 5 years. Similar long-term recurrence-free
survival has been reported by others [1215, 20].
Conclusion
Adjacent organ infiltration by right-sided colon cancer does
not always render the tumor unresectable. In the absence of
distant metastasis many such tumors are amenable to en
bloc resection of the colon with the adjacent infiltrated
268
organs. Although these operations can be carried out with
low mortality and morbidity, they should be attempted in
centers and by surgeons experienced in doing such major
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