En bloc pancreaticoduodenectomy for right colon cancer invading adjacent organs

Pancreaticoduodenectomies with Concurrent Colectomies: Indications, Technical Issues, Complications, and Oncological Outcomes

Multi-visceral resections for colon and pancreatic cancer (PDAC) are feasible, safe, and justified for early and late outcomes. However, the use of pancreaticoduodenectomy (PD) with concurrent colectomies is highly debatable in terms of morbidity and oncological benefits. Based on current literature data, this review assesses the early and long-term outcomes of PD with colectomies. The association represents a challenging but feasible option for a few patients with PDAC or locally advanced right colon cancer when negative resection margins are anticipated because long-term survival can be achieved. Concurrent colectomies during PD should be cautiously approached because they may significantly increase complication rates, including severe ones. Thus, patients should be fit enough to overcome potential severe complications. Patients with PD and colectomies can be classified as borderline resectable, considering the high risk of developing postoperative complications. Carefully selecting patients suitable for PD with concurrent colectomies is paramount to mitigate the potentially severe complications of the two surgical procedures and maximize the oncological benefits. These procedures should be performed at high-volume centers with extensive experience in pancreatectomies and colectomies, and each patient situation should be assessed using a multimodal approach, including high-quality imaging and neoadjuvant therapies, in a multidisciplinary team discussion.

Colo-pancreaticoduodenectomy for locally advanced colon carcinoma-feasibility in patients presenting with acute abdomen

BACKGROUND

En bloc right hemicolectomy plus pancreaticoduodenectomy (PD) is administered for locally advanced colon carcinoma that invades the duodenum and/or pancreatic head. This procedure may also be called colo-pancreaticoduodenectomy (cPD). Patients with such carcinomas may present with acute abdomen. Emergency PD often leads to high postoperative morbidity and mortality. Here, we aimed to evaluate the feasibility and outcomes of emergency cPD for patients with advanced colon carcinoma manifesting as acute abdomen.

METHODS

We retrospectively reviewed 4898 patients with colorectal cancer who underwent curative colectomy during the period from 1994 to 2018. Among them, 30 had locally advanced right colon cancer and had received cPD. Among them, surgery was performed in 11 patients in emergency conditions (bowel obstruction: 6, perforation: 3, tumor bleeding: 2). Selection criteria for emergency cPD were the following: (1) age ≤ 60 years, (2) body mass index < 35 kg/m², (3) no poorly controlled comorbidities, and (4) perforation time ≤ 6 h. Three patients did not meet the above criteria and received non-emergency cPD after a life-saving diverting ileostomy, followed by cPD performed 3 months later. We analyzed these patients in terms of their clinicopathological characteristics, the early and long-term postoperative outcomes, and compared findings between emergency cPD group (e-group, n = 11) and non-emergency cPD group (non-e-group, n = 19). After cPD, staged pancreaticojejunostomy was performed in all e-group patients, and on 15 of 19 patients in the non-e-group.

RESULTS

The non-e-group was older and had a higher incidence of associated comorbidities, while other clinicopathological characteristics were similar between the two groups. None of the patients in the two groups succumbed from cPD. The postoperative complication rate was 63.6% in the e-group and 42.1% in the non-e-group (p = 0.449). The 5-year overall survival rate were 15.9% in the e-group and 52.6% in the non-e-group (p = 0.192).

CONCLUSIONS

Emergency cPD is feasible in highly selected patients if performed by experienced surgeons. The early and long-term positive outcomes of emergency cPD are similar to those after non-emergency cPD in patients with acute abdominal conditions.

Pancreaticoduodenectomy outcomes for locally advanced right colon cancers: A systematic review

BACKGROUND

Pancreaticoduodenectomy (PD) with right hemicolectomy (RH) to treat locally advanced right colon cancer (LARCC) has been rarely reported in the literature. Herein, we characterize clinicopathologic factors and evaluate outcomes of en bloc PD and RH for LARCC.

METHODS

A systematic review of the literature was conducted on PubMed using MeSH terms ("pancreaticoduodenectomy" or "pancreas/surgery" or "duodenum/surgery" or "colectomy") and ("colonic neoplasms"). Data was extracted from patients who underwent en bloc PD and RH for LARCC. Factors investigated included patient demographics, surgical and pathologic parameters, postoperative complications, disease recurrence, and survival.

RESULTS

Our search yielded 27 articles (106 patients), including 1 case from our institution. Most patients were male (62.1%), median age 58 years (range 34-83). Surgical procedures performed included en bloc RH with PD (n = 91, 85.8%) and en bloc RH with pylorus-preserving PD (n = 15, 14.2%). Among reported, 95.5% of patients (n = 63), underwent R0 resection. One or more complications were reported in 33 patients (52.4%). Median survival was 168 months. Survival after resection was 75.9% at 2 years and 66.3% at 5 years. Overall survival was greater in patients with no lymph node involvement (IIC versus IIIC, hazard ratio 8.4, P = .003). Five-year survival for patients was 84.9% in patients with stage IIC versus 46.4% in patients with stage IIIC. There were 3 postoperative mortalities.

CONCLUSION

This data demonstrates that en bloc PD and RH is rarely performed yet can be a potentially safe treatment option in patients with LARCC. Lymph node involvement was the only independent prognostic factor.

Locally advanced colon cancer resulting in en bloc right hemicolectomy and pancreaticoduodenectomy: case report and review of literature

Locally advancement of right colon cancer to the surrounding organs requiring surgical intervention is an extensive procedure associated with numerous risks. There are not many cases of which this phenomenon may occur. En bloc pancreaticoduodenectomy and resection of involved viscera should be considered for patients who can appropriately undergo this exhaustive surgery. Our objective is to report the experience we had with this patient who underwent an en bloc pancreaticoduodenectomy and right hemicolectomy and review literature. Our method was a retrospective review of a patient with colon cancer

T4 Colon Cancer - Current Management

Colorectal cancer is the third most often encountered type of cancer and represents the third leading cause of cancer related deaths, on both sexes. One of the most important prognostic parameters is the tumor’s stage at the time of the diagnosis. T4 cancers represent advanced tumors associated with penetration of the visceral peritoneum (T4a) and/or direct invasion in adjacent structures (T4b). Preoperative diagnosis is influenced by the inability of the existent imaging modalities to accurately differentiate the true invasion from the simple, inflammatory adherence to the neighboring structures. As a consequence surgical treatment must follow the principle of en bloc resection; however the ability of achieving an R0 resection depends on the tumor location, invaded organ, and the type of the surgical procedure required. Neoadjuvant treatment for advanced colon cancer it may be very difficult to be applied. This review is focused on preoperative workup, therapeutic strategies and subsequent results in advanced T4 colon cancers.

En Bloc Pancreaticoduodenectomy for Locally Advanced Right Colon Cancers

Locally advanced right colon cancer may invade adjacent tissue and organs. Direct invasion of the duodenum and pancreas necessitates an en bloc resection. Previously, this challenging procedure was associated with high morbidity and mortality; however, today, this procedure can be done more safely in experienced centers. The aim of this study is to report our experience on en bloc right colectomy with pancreaticoduodenectomy for locally advanced right colon cancers. Between 2000 and 2012, 5 patients underwent en bloc multivisceral resection. No major morbidities or perioperative mortalities were observed. Median disease-free survival time was 24.5 months and median overall survival time was 42.1 (range: 4.5–70.4) months in our series. One patient lived 70 months after multivisceral resection and underwent cytoreductive surgery and total pelvic exenteration during the follow-up period. In locally advanced right colon tumors, all adhesions should be considered as malign invasion and separation should not be done. The reasonable option for this patient is to perform en bloc pancreaticoduodenectomy and right colectomy. This procedure may result in long-term survival with acceptable morbidity and mortality rates. Multidisciplinary teamwork and multimodality treatment alternatives may improve the results.

En bloc pancreaticoduodenectomy and right colectomy in the treatment of locally advanced colon cancer

BACKGROUND

Carcinoma of the right colon invading the pancreas or duodenum is rare. Evidence of the indication, operative morbidity, and survival of en bloc pancreaticoduodenectomy and right colectomy for right colon cancer invading adjacent organs is limited.

OBJECTIVE

: The goal of this study was to investigate the feasibility, safety, indication, and long-term results of en bloc pancreaticoduodenectomy and right colectomy in the treatment of locally advanced right-sided colon cancer.

DESIGN

: This was a retrospective analysis of all inpatients undergoing en bloc pancreaticoduodenectomy and right colectomy. Detailed data of these patients were assessed by a thorough review of medical charts.

SETTINGS

The study was conducted using a hospital database.

PATIENTS

Fourteen patients who underwent en bloc pancreaticoduodenectomy and right colectomy from January 1989 through December 2011 were included in the study.

MAIN OUTCOME MEASURES

In-hospital complications, mortality, and survival were the primary outcomes measured.

RESULTS

Major postoperative complications included delayed gastric empting (n = 7), class B pancreatic fistula (n = 3), and bile leakage (n = 1). Postoperative death occurred in 2 patients. The median hospital stay was 22.5 days (range, 17.0-57.0 days). Inflammatory adhesion was confirmed by pathologic examination in only 1 patient. Eight patients (57%) did not have lymph node metastasis. The median follow-up time was 21 months (range, 4-276 months). Ten patients were alive at the time of their last scheduled follow-up. The overall survival rates were 72% at 1 year and 60% at 2 years. No patient was lost to follow-up. Three patients developed tumor recurrence. The outcomes are no worse than those of the stage-matched patients without adjacent organ involvement and are much better than those of the stage-matched patients who underwent bypass surgery and chemotherapy.

LIMITATIONS

The number of patients in current studies is limited.

CONCLUSIONS

En bloc pancreaticoduodenectomy and right colectomy can be performed safely with an acceptable morbidity and mortality rate in selected patients with locally advanced right-side colon cancer. The long-term results are promising.

[Pancreatic metastases. Report of four cases and literature review]

The authors present the history of 4 patients with pancreatic metastases revealed by CT and MR during the last 2 years. In 2 patients pancreatic metastases developed more than 10 years after the primary renal neoplasm was diagnosed. In the other two patients (one with non small cell lung cancer and one with non-Hodgkin disease) pancreatic metastases developed shortly after the diagnosis of the primary malignancy. According to literature data metastases in the pancreas are rare. The authors conclude that the symptoms and imaging features of pancreatic metastases are variable and, therefore, non-invasive imaging diagnosis is difficult. To resolve this problem a thorough scrutiny of the medical history of the patients and functional imaging methods may be helpful.

Multivisceral resection for T4 or recurrent colorectal cancer

BACKGROUND

Approximately 10% of patients with colorectal cancer have locally advanced disease with peritoneal involvement (T4a) or invasion of adjacent organs (T4b) at the time of diagnosis. Of patients who undergo resection with curative intent, between 7 and 33% develop isolated locoregional recurrences. R0 surgical excision is potentially curative.

METHODS

We reviewed the literature relating to multivisceral resection for T4 or recurrent colorectal cancer.

RESULTS

Comprehensive staging to identify the local and systemic extent of disease is essential to determine resectability and patient suitability for a curative approach. PET scans and pelvic MRI (rectal) staging and a coordinated multispecialty input to neoadjuvant treatment, multivisceral surgical resection, reconstruction and adjuvant chemotherapy are essential. Intraoperative radiotherapy and hyperthermic intraperitoneal chemotherapy may have a role in selected patients. R0 resection can achieve 5-year local control rates for primary locally advanced and recurrent colorectal cancer of up to 89 and 38%, respectively, and overall 5-year survival up to 66 and 25%, respectively.

CONCLUSION

An aggressive surgical strategy as part of a multimodal strategy in the treatment of locally advanced or recurrent colorectal cancer in the absence of incurable metastatic disease affords the best prospect for long-term survival in selected patients.

Thirty-day outcomes in patients treated with en bloc colectomy and pancreatectomy for locally advanced carcinoma of the colon

OBJECTIVE

The aim of this was to define 30-day outcomes of patients treated with colectomy and en bloc pancreatectomy for invasive colon cancer.

METHODS

ACS NSQIP was used to identify patients who underwent colectomy and pancreatectomy concomitantly (n = 65) for colon carcinoma. Patients with en bloc pancreatectomy were compared to a propensity score-matched control group for 30-day outcomes.

RESULTS

Sixteen patients underwent a pancreaticoduodenectomy with colectomy and 49 patients underwent a distal pancreatectomy with colectomy. There were 195 matched control patients. En bloc pancreatectomy (Whipple vs. distal pancreatectomy vs. control) patients had longer OR times (390 vs. 265 vs.137 min) and length of postoperative stay (12 vs. 10 vs. 6 days). The frequency of pulmonary complications (31.3% vs. 36.7% vs. 3.6%), blood transfusions (2.9 vs. 1.7 vs. 0.3 U), wound dehiscence, (18.8% vs. 6.12% vs.0.5%) and surgical site infection (43.5% vs. 34.7% vs.14.9%) were substantially higher in the pancreatectomy group (p < 0.05). There were no statistically significant differences in 30-day mortality between the pancreatectomy group and the control group (6.3% vs. 0% vs. 1.5% p = 0.25)

CONCLUSIONS

Perioperative outcomes with en bloc pancreatectomy and colectomy include increased pulmonary complications, blood transfusions, wound complications, and length of stay compared to patients treated with colectomy alone for colon cancer.

Pyogenic liver abscess as initial presentation in locally advanced right colon cancer invading the liver, gallbladder, and duodenum

Locally advanced colorectal cancer complicated with adjacent organic invasion may remain confined to the local area with minimal metastasis. In the present paper, we report on a patient with advanced right colon cancer, including liver, gallbladder, and duodenal invasion behind the scene of liver abscess. En bloc resection was performed on the patient, with right-hemicolectomy, cholecystectomy, partial duodental resection, and hepatectomy. Postoperative management was administered, including nutritional support in the early postoperative period, effective anti-infection treatment, and adjuvant chemotherapy (FOLFOX4). The patient survived for 16 months after the operation. Common clinical manifestations of colorectal cancer were digestive symptoms and changes in defecation. However, the clinical manifestation of locally advanced colon cancer was extremely complicated. Extended or multivisceral resection may offer patients a chance to survive an acute crisis and allow for treatment with adjuvant therapy.

Right colon cancer presenting as hemorrhagic shock

A 67-year-old man visited our hospital with a history of continuous hematochezia leading to hemorrhagic shock. An abdominal computed tomography scan revealed a large mass in the ascending colon invading the duodenum and pancreatic head as well as extravasation of blood from the gastroduodenal artery (GDA) into the colon. Colonoscopy revealed an irregular ulcerative lesion and stenosis in the ascending colon. Therefore, right hemicolectomy combined with pylorus-preserving pancreaticoduodenectomy was performed. Histologically, the tumor was classified as a moderately differentiated adenocarcinoma. Moreover, cancer cells were mainly located in the colon but had also invaded the duodenum and pancreas and involved the GDA. Immunohistochemically, the tumor cells were positive for cytokeratin (CK)20 and carcinoembryonic antigen (CEA) but not for CK7 and carbohydrate antigen (CA)19-9. The patient died 23 d after the surgery because he had another episode of arterial bleeding from the anastomosis site. Although En bloc resection of the tumor with pancreaticoduodenectomy and colectomy performed for locally advanced colon cancer can ensure long-term survival, patients undergoing these procedures should be carefully monitored, particularly when the tumor involves the main artery.

Middle-preserving pancreatectomy for advanced transverse colon cancer invading the duodenun and non-functioning endocrine tumor in the pancreatic tail

A 73-year-old female was referred to our hospital with a diagnosis of advanced transverse colon cancer with severe anemia and body weight loss. Preoperative evaluations, including colonoscopy, gastroduodenoscopy, and computed tomography, revealed not only a transverse colon cancer massively invading the duodenum, but also a non-functioning endocrine tumor in the pancreatic tail. We performed middle-preserving pancreatectomy (MPP) with right hemicolectomy for these tumors with a curative intent. After the resection, about 6 cm of the body of the pancreas was preserved, and signs of diabetes mellitus have not appeared. The postoperative course was complicated by a grade B pancreatic fistula, but this was successfully treated with conservative management. After a 33-day hospital stay, the patient returned to daily life without signs of pancreatic exocrine insufficiency. Although the long-term follow-up of the patient is indispensable, in this case, MPP might be able to lead to the curative resection of transverse colon cancer massively invading the duodenum and non-functioning endocrine tumor in the pancreatic tail with preservation of pancreatic function.

En bloc right hemicolectomy and pancreaticoduodenectomy with superior mesenteric vein resection for advanced right-sided colon cancer

A 58-year-old female was referred to our hospital with a diagnosis of bowel obstruction due to advanced transverse colon cancer invading the duodenum. Two months after the emergency bypass operation for the bowel obstruction, we performed an en bloc right hemicolectomy with pancreaticoduodenectomy (RHCPD) with a curative intent. During the operation, we could not dissect the tumor from the superior mesenteric vein, so we performed a segmental cylindrical resection of the superior mesenteric vein and its reconstruction. The post-operative course was uneventful, and after a 34-day hospital stay the patient returned to daily life. A histologic examination also revealed a well-differentiated tubular adenocarcinoma invading the duodenum. All the surgical margins were negative and lymph node metastasis was not found. There were no signs of recurrence for 8 months after the operation. Complete resection clearly influences survival time of patients, and surgeons should not hesitate to perform RHCPD.

Surgical management of locally advanced and locally recurrent colon cancer

Locally advanced and locally recurrent colon cancers pose a surgical challenge with tumors extending into surrounding structures and organs. Anticipation of the need for an extended surgical resection, often with multivisceral en bloc organ removal, is critical for surgical planning. For both primary and recurrent tumors, postsurgical long-term survival is achievable but only after complete resection. The role of neoadjuvant and adjuvant therapy continues to be redefined in this era of biologic chemotherapeutics, and multimodality therapy holds promise in aiding resection and improving postsalvage survival.

En bloc pancreaticoduodenectomy and right hemicolectomy to treat locally advanced right colon cancer: report of three cases

ABSTRACT Although colorectal tumors are fairly common surgical conditions, 5 to 12% of these tumors are locally advanced (T4 tumors) upon diagnosis. In this particular situation, the efficacy of en bloc multivisceral resection has been proven. When right-colon cancer invades the proximal duodenum or even the pancreatic head, a challenging dilemma arises due to complexity of the curative surgical procedure. Therefore, en bloc pancreaticoduodenectomy with right hemicolectomy should be performed to obtain free margins. The present study reports three cases of locally advanced right-colon cancer invading the proximal duodenum. All of these cases underwent successful en bloc pancreaticoduodenectomy plus right hemicolectomy, with no death occurrence. Long-term survival was observed in two cases (30 and 50 months). In the third case, the patient did not present any recurrence twelve months after surgical treatment. Multivisceral resection with en bloc pancreaticoduodenectomy should be considered for patients who present acceptable risk for major surgery and no distant dissemination. This approach seems justified since the length of postoperative survival is longer in radically ressected groups (R0) than in palliativelly resected groups (R1-2).

Combined pancreaticoduodenectomy and extended right hemicolectomy: outcomes and indications

BACKGROUND

Pancreaticoduodenectomy (PD) combined with an en bloc extended right hemicolectomy is required to achieve complete oncological resection of various malignancies. Information regarding the indications and outcomes of this procedure is limited.

STUDY DESIGN

Patients requiring PD combined with extended right hemicolectomy for primary tumours from 2002 to 2008 were identified.

RESULTS

PD combined with an en bloc extended right hemicolectomy was required in 14 patients, constituting 8% of pancreaticoduodenal resections. Pancreatic adenocarcinoma (8), retroperitoneal sarcoma (2) and colon cancer (2) were the main primary tumours resected. The indication for an extended right hemicolectomy was extensive tumour involvement of the transverse mesentery in seven patients. Clear tumour margins were achieved in 11 individuals. The median operating time was 10 h with intra-operative transfusions required in three patients. One or more complications were noted in eight, with delayed gastric emptying and pancreatic fistula the most common. The median length of hospital stay was 8 days. The overall 2-year survival in this series was 37%, with a median survival of 20 months in pancreatic cancer patients.

CONCLUSIONS

This series suggests that PD combined with an en bloc extended right hemicolectomy is feasible and can achieve complete tumour clearance with acceptable morbidity.

En-bloc pancreatoduodenectomy and right hemicolectomy for treating locally advanced right colon cancer (T4): a series of five patients

A series of five cases of right-colon adenocarcinoma that invaded the proximal duodenum is presented. All patients underwent successful en-bloc pancreatoduodenectomy plus right hemicolectomy by General Surgery Service of the Teaching Hospital of the ABC Medical School, Santo André, SP, Brazil. The study was conducted between 2000 and 2007. There were two major complications but no mortality. Three patients did not present any recurrence over the course of 15 to 54 months of follow-up. Multivisceral resection with en-bloc pancreatoduodenectomy should be considered for patients who are fit for major surgery but do not present distant dissemination. Long-term survival may be attained.

Surgical Treatment for Right Colon Cancer Directly Invading the Duodenum

Right colon carcinoma with duodenal invasion is rare, and optimal management remains controversial. Twenty patients demonstrating right-colon carcinoma directly invading the duodenum presented at the Second Xiangya Hospital between 1990 and 2006. Different surgical management strategies were selected based on duodenal involvement, and patient outcomes were evaluated. There was no perioperative death in this series, but three major complications presented during the perioperative period: one case of duodenal stenosis and two duodenal leaks due to gastric or duodenal drainage. Eight of 13 patients treated by en bloc resection survived more than 3 years, including one 10-year survivor and four 5-year survivors. Of the seven patients treated with palliative resection, no patients survived more than 18 months. In conclusion, duodenal invasion by a right-sided colon carcinoma does not necessarily represent incurable disease. If carefully applied based on the extent of duodenal invasion, active surgical management is very useful for improving patient prognosis without increasing the risks associated with surgery.

Metastatic disease to the pancreas and spleen

Isolated metastases to the pancreas and spleen are a rare occurrence. When they are diagnosed, pancreatic metastases are most often from renal cell carcinoma, lung cancer, and breast cancer. The most common source of splenic metastases is gynecological in origin; the overwhelming majority is ovarian. If extensive staging studies reveal these metastases to be isolated, then curative resection may be warranted. This review will demonstrate that long-term survival may be achieved in patients with isolated metastases and a prolonged disease-free interval.

Management of patients with carcinoma of the right colon invading the duodenum or pancreatic head

BACKGROUND

Only few case series have been published about locally advanced carcinoma of the right colon invading the duodenum or pancreas (CRCDP). We report results of a retrospective study about this rare entity focusing on management and prognosis.

METHODS

We reviewed the complete data of patients operated for CRCDP between 1988 and 2005 in four French digestive-surgery departments.

RESULTS

Fifteen patients were managed [12 men, 3 women, mean age 63 years (43-86)]. These patients underwent attempted curative en bloc resection including right colectomy: 12 were treated by partial duodenectomy (tumours involving only a part of the duodenum); 3 were treated by pancreaticoduodenectomy. All tumours resected had clear resection margins (R0). About 53% of patients had hepatic metastases, duodenocolic fistula, carcinomatosis, abscess or perforation at presentation. Surgery was performed in emergency in 26% of cases. About 20% of patients had serious postoperative complications (heart failure, bile duct necrosis, septic shock), and three other patients had postoperative anastomotic leaks. No patient experienced duodenal fistula after partial duodenectomy. The mean median survival in resected patients was 22 months (0-122). Overall 1 and 3 years survival were 68% (n=7) and 56% (n=4). Despite clear resection margins in all patients, 26% of patients developed recurrence (duodenal wall resection n=3; pancreaticoduodenectomy n=1).

CONCLUSION

Morbidity and mortality after colectomy and en bloc partial duodenectomy or pancreaticoduodenectomy are high but in selected cases could offer prolonged survival. Aggressive surgery including major resection should be performed to obtain clear resection margins even in case of complicated forms.

Pancreatectomy for non-pancreatic malignancies results in improved survival after R0 resection

BACKGROUND

Pancreatectomy has a high morbidity but remains the only chance of cure for pancreatic cancer. Its efficacy for non-pancreatic malignancies is less clear. We reviewed our experience with pancreatectomy for non-pancreatic malignancies to determine outcomes and identify predictors of survival.

PATIENTS AND METHODS

The records of patients who underwent pancreatectomy for non-pancreatic malignancies between 1990 and 2005 were reviewed. Survival curves were constructed using the Kaplan-Meier method and compared using log-rank analysis. Cox proportional hazards was used to identify predictors of survival.

RESULTS

29 patients (18 M/11 F) with a mean age of 59.9 years (range 29-86) underwent pancreatectomy for non-pancreatic malignancies. 19 (66%) primary malignancies were GI in origin. Most operations were undertaken with curative intent (76%), whereas the remainder was for symptom palliation. Pancreatectomy was completed for metastatic disease in 7 patients (24%) or en bloc to achieve negative margins in 22 patients (76%). Complete (i.e., R0) resection was achieved in 17 (59%). Perioperative mortality was 3%. Median follow-up was 15 months (range 7-172). Median overall survival was 12 months with 1-year survival of 48%. Significant predictors of improved survival by univariate analysis were R0 resection, non-GI primary, and pancreatic metastasectomy (vs. en bloc resection). Only R0 resection was predictive of long-term survival by multivariate analysis (median 21 months vs. 6).

CONCLUSION

Pancreatic resection for non-pancreatic malignancies can be completed with minimal mortality. However, incomplete resection results in poor overall survival. Pancreatectomy for non-pancreatic malignancies should only be undertaken if complete resection is possible.

En Bloc Resection of the Duodenum for Locally Advanced Right Colon Adenocarcinoma

Direct invasion of colorectal adenocarcinoma into adjacent structures occurs frequently, but only rarely is the duodenum involved. This study was undertaken to assess the safety and efficacy of en bloc resection of locally advanced right colon carcinoma invading the duodenum. A retrospective review of 49 patients with locally advanced colon cancer, surgically managed between 2000 and 2005, was performed. Forty-six patients underwent en bloc resection of colon and adjacent organs not involving the duodenum. Three patients with duodenal invasion underwent en bloc partial duodenectomy. The mean operative blood loss, length of stay, postoperative morbidity, and mortality compare favorably between these two groups of patients. Of the 46 patients with en bloc resection of other organs, 27 are alive at 12 to 60 months follow up. Two patients with duodenal invasion are alive without recurrence at 15 and 20 months follow up. En bloc resection of colon cancer invading the duodenum can be performed safely because morbidity and mortality rates are comparable to those attending extended resections of other locally advanced colon carcinomas. Overall survival in patients who underwent surgery with curative intent justifies en bloc duodenal resection in selected patients.

Management of duodenal involvement in locally advanced colonic carcinoma

Removal of locally advanced right-sided colonic carcinoma involving the duodenum can be challenging. There are few data on the optimal surgical approach. Adjacent organ involvement is associated with a poor prognosis and may be classified as inoperable with patients having palliative bypass procedures rather than primary resection. Survival is however improved after en bloc resection of adjoining viscera compared with intestinal bypass. We present a variety of surgical options depending on the extent of local invasion and the debility of the patient.

Population-based assessment of the surgical management of locally advanced colorectal cancer

BACKGROUND

Evidence-based guidelines recommend multivisceral resection for patients with locally advanced adherent colorectal cancer because it reduces local recurrence and improves survival. However, this procedure can increase morbidity compared with standard resection and may not be practiced uniformly. We performed a population-based study to examine surgical practice and outcomes among patients with locally advanced adherent colorectal cancer in the United States.

METHODS

Patients who were 18 years or older and who had surgical resection for nonmetastatic, locally advanced adherent colorectal cancer from January 1, 1988, through December 31, 2002, were identified from the Surveillance, Epidemiology, and End Results (SEER) registry. Logistic regression was used to examine patient, tumor, and geographic factors associated with multivisceral resection. Cumulative early mortality (i.e., at 1 and 6 months after diagnosis) and 5-year survival were obtained from Kaplan-Meier estimates; adjusted risks of death were calculated using Cox proportional hazards models. All statistical tests were two-sided.

RESULTS

We identified 8380 patients who underwent surgical resection for locally advanced adherent colorectal cancer, of whom 33.3% were managed with multivisceral resection. Among colon cancer patients, younger age at diagnosis, female sex, SEER region, node negativity, and left-sided tumors were independently associated with having had a multivisceral resection. Among rectal cancer patients, younger age at diagnosis and female sex were positively and statistically significantly associated with multivisceral resection, whereas receipt of neoadjuvant radiation was inversely and statistically significantly associated with multivisceral resection. Compared with standard resection, multivisceral resection was associated with improved overall survival for patients with colon (hazard ratio [HR] = 0.89, 95% confidence interval [CI] = 0.83 to 0.96) and rectal (HR = 0.81, 95% CI = 0.70 to 0.94) cancer, with no associated increase in early mortality.

CONCLUSIONS

The majority of patients with locally advanced colorectal cancer did not receive a multivisceral resection. The geographic variation in the application of this procedure in patients with colon cancer suggests that local organizational structures and processes of care may play an important role in patient treatment and, therefore, prognosis.

En bloc resection of right-sided colonic adenocarcinoma with adjacent organ invasion

BACKGROUND

Right-sided colon cancers that invade the adjacent organs are often missed on preoperative 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 outcome 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 cancers were analyzed.

RESULTS

Between 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 (35-80 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 patients had an en bloc pancreaticoduodenectomy, 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 pancreaticoduodenectomy. The median disease-free survival was 54 months.

CONCLUSION

Right-sided colon cancers 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.

Resection of the colon simultaneously with pancreaticoduodenectomy for tumors of the pancreas and periampullary region: short-term and long-term results

Simultaneous resection of the colon with pancreaticoduodenectomy (PD) is occasionally inevitable to accomplish curative resection in instances when a periampullary tumor involves the mesentery of the colon. However, there is little information regarding short- and long-term outcomes of this aggressive surgery. Among 95 consecutive patients who underwent PD for periampullary malignant tumors, 12 had simultaneous resection of the right colon (group 1) and 83 underwent PD alone (group 2). Intraoperative variables, postoperative morbidity and mortality, and the length of the hospital stay were comparatively analyzed. Survival was also compared between the groups in a subset of 36 pancreatic adenocarcinoma patients. Group 1 included more patients with pancreatic cancer, and portal vein resection was more frequently performed, which seemed to be associated with a significantly longer operating time (640 vs. 510 minutes) and increased total blood loss (1965 vs. 1220 ml). However, morbidity and mortality rates did not differ between the groups (50,0% and 0%, respectively, in group 1; 44.6% and 1.2%, respectively, in group 2). The median hospital stays were 67 and 48 days in groups 1 and 2, respectively. In a subset of 36 pancreatic adenocarcinoma patients, the median progression-free survivals were 6 months in both groups 1 and 2; the median overall survivals were 14 months in group 1 and 12 months in group 2. There was no statistically significant difference in survival between the groups. Simultaneous right hemicolectomy with curative intent at the time of PD could thus be performed safely and may offer a survival benefit even for individuals who have advanced pancreatic cancers with involvement of the transverse mesocolon.