CASE REPORT OPEN ACCESS

International Journal of Surgery Case Reports 2 (2011) 206207

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Long term survival after right hemicolectomy and pancreatoduodenectomy for

locally advanced colonic cancer: Case report
Iraklis Perysinakis , Alexander Nixon, Aggeliki Katopodi, Emmanouil Tzirakis,
Despoina Georgiadou, Spyridon Avlonitis, Ilias Margaris
3rd Surgical Department, George Gennimatas General Hospital of Athens, Mesogeion Av. 154, 15669, Greece

a r t i c l e i n f o a b s t r a c t

Article history: Locally advanced colorectal tumors represent about 522% of all colorectal cancers at the time of pre-
Received 8 June 2011 sentation. Specically in the case of right colon cancer, the percentage of adjacent structure involvement
Accepted 22 June 2011 ranges between 11% and 28%. Organs that are most frequently invaded by right colonic tumors are the
Available online 29 June 2011
duodenum and the pancreatic head. We report the case of a 36-year old man with locally advanced right
colonic cancer, invading the head of the pancreas and the superior mesenteric vein, who was successfully
Keywords:
treated in our department with right hemicolectomy, pancreatoduodenectomy and short resection of the
Locally advanced colonic cancer
superior mesenteric vein with an end-to-end anastomosis, and remains alive and well, free of disease,
Right hemicolectomy
Pancreatoduodenectomy
nine years after the operation.
2011 Surgical Associates Ltd. Elsevier Ltd. All rights reserved.

1. Introduction taken during the colonoscopy revealed moderately differentiated

Locally advanced colorectal tumors represent about 522% of
all colorectal cancers at the time of presentation.1 Specically in
the case of right colon cancer, the percentage of adjacent struc-
ture involvement ranges between 11% and 28%, but only a few
series have reported adjacent organ resection.25 In these cases
there is a local treatment failure rate of 3653% following com-
plete resection.6 Invasion of the duodenum or the head of the
pancreas poses a rather challenging problem even to the skilled
surgeon.
We report the case of a 36-year old man with locally advanced
right colonic cancer, invading the head of the pancreas who was
successfully treated in our department with right hemicolectomy
and pancreatoduodenectomy and remains alive and well, free of
disease, nine years after the operation.
2. Presentation of the case
A 36-year old male patient was referred to our Department in
October 2002 with a history of gastrointestinal bleeding during the
past two weeks. The patient had no history of any systemic symp-
toms, such as fever, or any other signicant past medical or family
history. Colonoscopy revealed an ulcerative inltrating tumor in
the proximal transverse colon. Histological examination of biopsies
Corresponding author at: Kountouriotou 46, Holargos, 15562 Athens, Greece.
Tel.: +30 2117006178; mobile: +30 6973621867.
E-mail address: iraklisper@gmail.com (I. Perysinakis).
adenocarcinoma. Computed tomography (CT) scans of the chest
and abdomen failed to reveal either distant metastasis or local
invasion of adjacent structures and the patient was planned for
laparotomy and right hemicolectomy.
Despite the aforementioned CT ndings, intraoperatively, con-
tiguous invasion of the head of the pancreas was revealed. Taking
into account the patients young age and good physical status
as well as the absence of distant metastasis, it was decided that
a wide en bloc resection of the tumor was the treatment of
choice. In accordance with these considerations, right hemicolec-
tomy with pancreatoduodenectomy was performed. Furthermore,
a short resection of the superior mesenteric vein was undertaken
and the continuity of the vein was restored by an end-to-end anas-
tomosis. The postoperative course of the patient was uneventful
and he was discharged on the 12th postoperative day. Histology of
the specimen conrmed the diagnosis of moderately differentiated
tubule-papillary colonic adenocarcinoma, invading the pericolic
and peripancreatic adipose tissue and pancreatic head, as well as
the superior mesenteric vein. Out of the 48 lymph nodes included in
the resection specimen, only one was found to be inltrated. Surgi-
cal resection margins were clear (R0). The patient received adjuvant
chemotherapy with 5-Fluorouracil (5-FU) and leucovorin. Follow
up was performed at six month intervals and included physical
examination, full blood count, liver chemistry and carcinoembry-
onic antigen (CEA) at each review. Routine CT scanning of the chest
and abdomen was carried out annually for three years after primary
therapy, and colonoscopy was performed at three-year intervals.
At the 9-year follow up, the patient remains alive and well, free
of disease.

2210-2612/$ see front matter 2011 Surgical Associates Ltd. Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijscr.2011.06.008
 CASE REPORT OPEN ACCESS
I. Perysinakis et al. / International Journal of Surgery Case Reports 2 (2011) 206207
3. Discussion
Organs that are most frequently invaded by right colonic
tumors are the duodenum and the pancreatic head.7 In such
cases right hemicolectomy along with pancreatoduodenectomy
is indicated in order to achieve R0 resection. Patients who
undergo margin-negative resection display the same survival as
patients with no adjacent organ involvement on a stage-matched
basis.79
Clinical ndings and symptoms in patients presenting with
locally advanced right colon cancer include gastrointestinal bleed-
ing, anorexia, weight loss and diarrhea. Sometimes, diarrhea may
indicate a duodenocolic stula.
Computed tomography may sometimes reveal a hypodense
mass involving adjacent organs. Yet, CT scanning may be unable to
detect intra-abdominal metastases because of lesion size, paucity
of intra-abdominal fat, contiguity with the primary tumor, ascites,
implant location, and adequacy of bowel opacication. In such
cases, locoregional invasion is diagnosed during intraoperative
evaluation, as in our patient.2
Multivisceral resection must be restricted to patients with good
clinical condition and without distant metastasis. Following R0
multivisceral resection, 5-year survival rates up to 55% have been
reported. Saiura et al. reported a series of 12 patients, 5 of whom
survived for more than ten years without recurrence.10 Specically
in cases of T4 right colon cancer that undergo extended resection
with pancreatoduodenectomy, the median disease-free period may
reach 54 months. On the other hand, when patients undergo pal-
liative bypass, the mean length of survival is 9 months and, in cases
of incomplete resection (R12), the mean length of survival is 11
months.4
Based on this specic case as well as our whole experience, we
strongly encourage radical resection for locally advanced tumors. In
cases of unexpected ndings during the operation, it is our opinion
that the patient should be referred to a tertiary unit, with experi-
ence in multivisceral resections.
4. Conclusion
In summary, en bloc right hemicolectomy with pancreatoduo-
denectomy for locally advanced right colon cancer, invading the
duodenum or pancreatic head, may offer long-term survival in
selected cases, provided that free resection margins have been
achieved.
Conicts of interest statement
The authors have no commercial associations or sources of sup-
port that might pose a conict of interest.
Open Access
This article is published Open Access at sciencedirect.com. It is distributed under the IJSCR Supplemental terms and conditions, which
permits unrestricted non commercial use, distribution, and reproduction in any medium, provided the original authors and source are
credited.
207
Funding
None.
Ethical approval
Written informed consent was obtained from the patient for
publication of this case report. A copy of the written consent is avail-
able for review by the Editor-in-Chief of this journal on request.
Author contributions
All authors have made substantial contributions to all of the fol-
lowing: (1) the acquisition of data, or analysis and interpretation
of data, (2) drafting the article or revising it critically for impor-
tant intellectual content, and (3) nal approval of the version to be
submitted.
Open access
This article is published Open Access at sciencedirect.com. It is
distributed under the IJSCR Supplemental terms and conditions,
which permits unrestricted non commercial use, distribution, and
reproduction in any medium, provided the original authors and
source are credited.
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