J Huazhong Univ Sci Technol [Med Sci]

35(2):255-258,2015
DOI 10.1007/s11596-015-1420-7
J Huazhong Univ Sci TechnolMed Sci 35(2):2015 255

Right Hemicolectomy and Multivisceral Resection of Right Colon

Cancer: A Report of 21 Cases
Yu-zhou ZHAO ()1, 2, Guang-sen HAN ()2, Chao-min LU ()2, Ying-kun REN ()2, Jian LI ( )2,
Peng-fei MA ()2, Yan-hui GU ()2, Chen-yu LIU ()2, Jia-xiang WANG ()1#
1
Department of Surgery, the First Affiliated Hospital, Zhengzhou University, Zhengzhou 450052, China
2
Department of Surgery, the Affiliated Cancer Hospital, Zhengzhou University; Henan Cancer Hospital, Zhengzhou 450052, China

Huazhong University of Science and Technology and Springer-Verlag Berlin Heidelberg 2015

Summary: The long- and short-term outcomes in 21 patients with right colon cancer after right hemi-
colectomy and multivisceral resection surgery were investigated. Short-term therapeutic effects and
long-term survival rate were retrospectively analyzed in patients with right colon cancer. These indi-
viduals underwent right hemicolectomy in combination with multivisceral resections including pancre-
atic head, duodenum, kidney, liver, gallbladder, and abdominal wall at the Department of General Sur-
gery in the Henan Tumor Hospital between January 2003 and August 2014. The patients had an average
age of 58.9 years (range: 3978). Three patients had metastatic invasion only to the duodenum; mean-
while 18 patients had invasion to the duodenum and other adjacent organs. The median survival time
was 41 months (95% CI: 6.97275.028) with one death in the perioperative period. No patients lost
follow-up. One-, 3-, and 5-year survival rate was 75%, 56%, and 43%, respectively. It was concluded
that indications for surgery should be tightly controlled. Favorable clinical outcomes of right hemi-
colectomy and multivisceral resection surgery were demonstrated for patients with right colon cancer at
the T4 stage.
Key words: colonic neoplasms; neoplasm invasiveness; pancreaticoduodenectomy; survival rate

Radical surgery is the most important treatment op-
tion for colon cancer, and the five-year survival rates
may be as high as 70.5% to 83% after radical resection[1].
In addition to tumor stage and differentiation degree,
which are key factors affecting local colon cancer recur-
rence rate, both the negative surgical margin and the rule
of no touch for tumor operation also significantly im-
pact local recurrence rate. The median survival was only
9 months as noted by palliative short-circuit operation
reported by Fuks et al[2], and the survival in palliative
tumor resection was no better, with a median survival
rate of only 11 months. Both survivals were significantly
shorter than the median survival of 41 months in mul-
tivisceral resection. Studies reported that 5%12% of
colon cancers can invade adjacent organs, and 25% of
right colon cancers affect adjacent organs; 011% invade
the duodenum wall and pancreas, similar to our finding
of 1.2%. Therefore, adjacent organ invasion is not a con-
traindication for radical surgery. On the contrary, both
the postoperative survival rate and quality of life can be
improved effectively by proactive radical surgery with
multivisceral resection[3]. There were 1764 patients with
right colon cancer admitted into our department between
January 2003 and August 2014, including 21 patients
with adjacent organ invasion who underwent right
hemicolectomy combined with multivisceral resection.
Our experiences were shared below.
Yu-zhou ZHAO, E-mail: yuzhouzhao@126.com
# completed with a Roux-en-Y anastomosis in the se-
Corresponding author, E-mail: zzuwangjiaxiang@126.com
1 PATIENTS AND METHODS
1.1 Clinical Data
Clinical pathological examination results were re-
trieved from 21 patients who underwent right hemi-
colectomy and multivisceral resection in our department.
Our current study had 13 men and 8 women. Clinical
data were collected, including age, gender, tumor loca-
tion, maximal diameter, lymph mode, pathological type,
adjacent organ invasion, and postoperative survival time.
1.2 Surgical Procedures
After ligation of the corresponding marginal vessel
arch, the transverse colon and antrum were ligated by a
linear cutter. The mesentery of the transverse colon and
omentum were resected at the same time.
After cholecystectomy, the bile duct was removed.
The right gastric vessels and gastroduodenal artery were
transected, and the pancreatic neck was ligated.
The ileum was ligated with the mesentery. The
ileocolic vessels were isolated, separately ligated and
sectioned. The right colic vessels and middle colic ves-
sels were cut at their roots.
The space between the pancreatic uncinate process
and the superior mesenteric vessels (SMV) were sepa-
rated, and the uncinate process was ligated, with the gas-
trocolic vein transected from the SMV. Then the hori-
zontal part of the duodenum was ligated.
The retroperitoneal dissection was extended along
the surface of the perinephric fat. The operation was
256
quence of pancreaticojejunostomy, bilioenteric anasto-
mosis, and jejunojejunostomy, with a routine ileo-
colostomy.
1.3 Statistical Analysis
SPSS 13.0 software was utilized for statistical
analysis. The univariate Cox regression analysis was
used for comparison and P<0.05 was considered statisti-
cally significant.
2 RESULTS
En bloc resection of the right colon was performed
on 21 patients with right colon cancer at the T4b stage in
our department between January 2003 and August 2014.
The average age of patients was 58.9 years, with an age
range between 39 and 78 years. Primary colon tumors
were located in the ascending colon, hepatic flexure of
the colon, and transverse colon in 6, 10, and 5 patients,
respectively. No patients received preoperative chemo-
Fig. 1 Overall survival of 21 patients
Fig. 3 Overall survival in patients with or without abdominal
wall invasion
J Huazhong Univ Sci TechnolMed Sci 35(2):2015
therapy treatment, and 19 patients received postoperative
adjuvant chemotherapy, comprised of an oxaliplatin
scheme in combination with 5-fluorouracil (5-Fu) for 6
to 8 cycles. Pathological examination indicated that
low-differentiated adenocarcinoma and high-differen-
tiated adenocarcinoma were seen in 12 and 9 patients,
respectively. No patient lost follow-up. One-, three-, and
five-year survival rate was 75%, 56%, and 43%, respec-
tively (fig. 1). Nine out of 21 patients had a lymph node
metastasis (table 1). The association between tumor
characteristics and patient survival was shown in table 2.
Univariate Cox regression analysis suggested that the
patient survival time was associated with lymph node
metastasis (fig. 2) or invasion to adjacent organs includ-
ing the abdominal wall (fig. 3), liver, or gall bladder (fig.
4) (P<0.05). In comparison, the age, gender, tumor dia-
meter, and stomach or kidney invasion were not associ-
ated with the survival time (P0.05).
Fig. 2 Overall survival of patients with or without lymph node
metastasis
Fig. 4 Overall survival in patients with or without liver and gall
bladder invasion
J Huazhong Univ Sci TechnolMed Sci 35(2):2015 257
Table 1 Patients characteristics
Case Age Gender Tumor loca- Max. Lymph Pathological type Adjacent Postoperative
no. (years) tion diameter node me- organ inva- survival time
tastasis sion (months)
1 76 M Hepatic 6 No Low differentiation Du 134+
flexure
2 70 M Hepatic 7 Yes Low differentiation Du, Pa 39
flexure
3 43 M Hepatic 20 Yes High differentiation Du, Pa, Li, 11
flexure St, Ke
4 43 M Ascending 15 Yes High differentiation Du, Pa, Ab 10
colon
5 66 F Ascending 20 No Low differentiation Du, Ke 9
colon
6 39 F Hepatic 10 Yes High differentiation Du, Li 23
flexure
7 76 M Hepatic 20 No Low differentiation Du, Ke 76
flexure
8 47 M Hepatic 15 No High differentiation Du, St 97+
flexure
9 63 M Ascending 12 No Low to moderate Du, St, Ga 21
colon differentiation
10 57 M Ascending 10 No High differentiation Du 75+
colon
11 74 F Transverse 12 Yes Low differentiation Pa, St 41
colon
12 40 F Transverse 8 Yes Low differentiation Du, Li, Ab 7
colon
13 76 M Hepatic 20 No Low differentiation Du, Ke 76
flexure
14 48 M Hepatic 15 No High differentiation Du, St 49+
flexure
15 63 M Ascending 12 No Low to moderate Du, St, Ga 21
colon differentiation
16 57 M Ascending 10 No High differentiation Du 19+
colon
17 74 F Transverse 12 Yes Low differentiation Pa, St 17+
colon
18 52 F Transverse 8 Yes Low differentiation Du, Li, Ab, 12+
colon Pa
19 41 F Transverse 8 Yes Low differentiation Du, Li, Ab 1
colon
20 68 F Hepatic 9 No High differentiation Du, St 41+
flexure
21 55 M Hepatic 8 No High differentiation Du, Pa, Ga 5+
flexure
Du: duodenum; Pa: pancreas; Li: liver; St: stomach; Ab: abdominal wall; Ga: gall bladder
+: Survival during the entire follow-up period. The survival period was calculated until the end of follow-up.

Table 2 The association between pathological types and survival period

Item Group n P 95% CI
Age 60 years 11
0.821 0.3563.670
60 years 10
Gender Men 13
0.168 0.1191.449
Women 8
Maximal tumor diameter 10 cm 10
10 cm 11 0.639 0.2232.516
Lymph node metastasis Yes 9
0.016 0.0450.729
No 12
Pancreas invasion Yes 6
0.285 0.1351.801
No 15
Stomach invasion Yes 8
0.531 0.4374.976
No 13
Duodenum Yes 19
0.953 0.1197.435
No 2
Kidney invasion Yes 4
No 17 0.489 0.1852.238
Abdominal wall invasion Yes 4
0.010 0.0140.562
No 17
Pathological type Low to moderate differentiation 12
0.251 0.5798.083
High differentiation 9
Gall bladder or liver in- Yes 8
vasion No 13 0.009 0.0220.585
Univariate Cox regression analysis was used for comparisons, and P<0.05 was considered as significance.
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3 DISCUSSION
Previous studies reported right hemicolectomy and
multivisceral resection for right colon cancer had a
5-year survival rate ranging between 49% and 72%. In
comparison, the 5-year survival rate was only 0 to 23%
by palliative tumor resection[4, 5]. The current study
showed that the one-, three-, and five-year survival rate
was 75%, 56%, and 43%, respectively in the 21 patients
who underwent right hemicolectomy and multivisceral
resection.
Duodenal invasion of colon cancer is barely detect-
able preoperatively, and diagnosis is dependent mostly
on surgical exploration. Along with advances in imaging
technology, right colon cancer with adjacent organ inva-
sion can be easily diagnosed preoperatively by high-slice
spiral CT. Indications for right hemicolectomy and mul-
tivisceral resection in this study included discovery of
remote metastasis not found by abdominal surgical ex-
ploration (except for adjacent organs such as the duode-
num), ability to tolerate large-scale surgery, SMV which
were not affected by tumor, and presence of tumor and
invaded organ tissue that could be removed by en bloc
resection[6].
In this study, the patient survival time for those
without lymph node metastasis was longer than those
with lymph node metastasis. The one- and three-year
survival rate was 56% and 37%, respectively, in the 9
patients with lymph node metastasis. In comparison, the
one- and three-year survival rate was 91% and 71%, re-
spectively, in 12 patients without lymph node metastasis.
Our findings indicated that metastatic spread to the ab-
dominal wall and metastatic spread to the liver or gall
bladder were independent factors for patient survival rate
after a right hemicolectomy and multivisceral resection.
The one-year survival rate was only 25% in 4 patients
with abdominal wall metastases. One- and three-year
survival rate was 88% and 66% respectively in 17 pa-
tients without abdominal wall metastases. Similarly, the
one-year survival rate was 58% in 8 patients with liver or
gall bladder tumor invasion, and the one- or three-year
survival rate was as high as 85% in 13 patients without
liver or gall bladder tumor invasion. Kapoor et al re-
ported that the tumor differentiation degree was also as-
sociated with patient progress after pancreati-
coduodenectomy and right hemicolectomy[7], which was
not observed in this study. Meanwhile, tumor invasion to
the pancreas has been reported to be an independent fac-
tor for poor prognosis by Saiura et al[8]. However, our
findings suggested no significant difference between pa-
tients with and without tumor invasion into the pancreas.
One- and three-year survival was achieved for 4 patients
and 2 patients respectively with tumor invasion into the
pancreas.
Only 40% of patients showed tumor adhesion to
duodenum as revealed by surgical exploration. The ret-
rospective study confirmed tumor invasion to the duo-
denum by postoperative pathological examination[9].
However, palliative surgery may lead to 90% to 100%
tumor recurrence due to ambiguous surgical separation
of the tumor from adjacent adhesive organs. A five-year
survival rate may be decreased to 17% if the tumor was
J Huazhong Univ Sci TechnolMed Sci 35(2):2015
cut open or intraoperatively ruptured. which was far less
than the five-year survival rate of 49% seen by en bloc
resection[2]. Adjacent organ invasion instead of inflam-
matory adhesion was confirmed by postoperative patho-
logical examination in all patients in this study. This
might be the reason that the three-year survival rate was
lower in this study than that (66.7%) reported by Saiura
et al[8].
As for perioperative period complications, a post-
operative abdominal infection occurred in 4 patients who
recovered after drainage treatment. One patient had a
postoperative infection concurrent with abdominal and
gastrointestinal hemorrhage, which led to their deaths.
All of these postoperative complications occurred before
2010. Colon anastomosis contamination was considered
to be the reason for this outcome. Thus, the colonic an-
astomosis location was deliberately moved to the left
upper quadrant of the abdomen or at the descending co-
lon. This resulted in no postoperative abdominal infec-
tions found after 2010 in 8 patients.
In summary, multivisceral resection demonstrated
effectiveness as a surgical option for patients with ad-
vanced colon cancer and adjacent organ invasion without
remote metastasis.
Conflict of interest
The authors declare no conflict of interest.
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(Received Jan. 8, 2015; Revised Mar. 16, 2015)