Case Report
the neoplastic or inflammatoy nature of adhe- In April, 1999, an otherwise healthy 52-year
-old man was admitted to the hospital with
sions. Combined resections for locally
advanced right-sided colon cancer that include severe watery diarrhea. On physical examina-
pancreatoduodenectomy (PD) are not new, but tion, he was mildly pale, and there was a pal-
the role of combined surgery is not well estab- pable abdominal mass in the right upper quad-
of Medicine, 2-17-6 Ohashi, Meguro-ku, Tokyo 153-8515, dl ; hematocrit (Ht), 29.5%) and had a low
950
En Bloc Resection for Locally Advanced Right-sided Colon Cancer with a Duodenocolic Fistula : Report of Two Cases
operation took 565 min. Pathological finding computed tomography showed a large mass
involving the duodenum, liver, and right-sided
confirmed a well differentiated adenocar-
colon (arrow).
cinoma, measuring 7 cm in its greatest diame-
ter, that infiltrated the pancreas, liver, and
duodenal wall (Fig. 2A) ; there was a giant alive with no signs of disease recurrence after
duodenocolic fistula (Fig. 2B). The resection 85 months of follow-up.
margins were free of tumor. There was no Case 2
neoplastic lymph node metastasis. The final In October 2005, a 73-year-old man was
staging classification was T4N0M0 consistent admitted to another hospital with abdominal
with stage II B disease (UICC TNM classifica- pain and vomiting. On colonoscopy, he had a
tion)5). tumor in the hepatic flexure with a large ulcer.
The patient recovered uneventfully and was Upper gastrointestinal endoscopy showed a
discharged from the hospital on the 32nd pos- duodenal ulcer in the second part of the duode-
toperative day and could tolerate oral feeding num that communicated with the colon. The
very well. The patient received adjuvant oral patient was diagnosed as having an intestinal
chemotherapy (tegafur/uracil) and is currently obstruction due to right-sided colon cancer that
951
316
Fig. 2 A The resected specimen, consisting of 476 g/dl; and total iron-binding capacity, 493
the duodenum, pancreas, right-sided colon,
g/dl), and elevated serum levels of CEA (11.8
and liver. B A huge tumor causing a
ng/ml) and carbohydrate antigen (CA) 19-9
duodenocolic fistula was seen (arrow).
(110.2 U/ml ; normal <37 U/ml). Upper gastro-
952
En Bloc Resection for Locally Advanced Right-sided Colon Cancer with a Duodenocolic Fistula : Report of Two Cases
953
316
frequently involve the duodenum and pancreas, et al.6) reported that there were no operative
this condition presents a challenge for the sur- deaths and no complications related to the
may be needed6`9). A locally advanced right superficial wound infection and delayed gastric
-sided colon cancer that invades adjacent struc- emptying complicated the postoperative course
tures causes dilemma for the surgeon, because in 2 (28%) of 7 patients. In the 2 present cases,
he must decide during operation quickly and there was minor morbidity and no operative
properly whether or not to perform a combined deaths. Mortality rates seem to be higher in
PD. In right-sided colon cancer, 40% of adhe- patients with combined resections (12%) when
sions to the head of the pancreas and duodenum compared to patients treated by colorectal
have been shown to be inflammatory on patho- resections alone (6%)14). On the other hand,
logical examination3). Biopsies and frozen-sec- survival rates of patients treated by extended
tions should not be routinely done because they or combined resections have shown significant
are associated with a high rate of false-nega- improvements. Overall, the mean survival
tive results and the risk of tumor exfoliation rates for locally advanced colorectal cancer
and dissemination, which results in recurrence after bypass procedures, non-extended resec-
rates of 90% to 100%10`12). Five-year survival tions, and radical extended resections are 9,11,
seems different between patients who under- and 40 months, respectively17). The survival
went tumor dissection away from the adherent benefit observed in patients treated with
organs (0%-23%) and who underwent en bloc extended radical resections for locally
resection of the tumor with the adherent organs to other pathological features, such as lymph
is indicated. Thus, once adhesion of the colon node metastasis, tumor differentiation, and the
cancer to another structure is observed, the local inflammatory response. Since nodal sta-
bloc resection followed by thorough pathologi- ectal cancer, the T4N0 lesions noted in both of
cal examination. Combined resections for the cases presented may have influenced the
locally advanced right-sided colon cancer in- benefit of extended radical resection and may
cluding PD are not new, but the role of com- reflect a specific biological behavior of locally
bined surgery has not yet been well established. advanced tumors4)10)11). In several articles, N0
In 1956, Van Prohaska et al.13) were the first to tumors represented from 45% to 75% of all
describe a PD in a patient with colon cancer. locally advanced colorectal cases were treated
Since then, different series have reported with extended resections13,16,18). Similar results
extended operations for right-sided colon can- have been observed in patients who had com-
cer that include en bloc PD with a right bined PD for locally advanced right-sided colon
colectomy13-16). In the 4 studies that have cancer6,8). There is no doubt that the complete
specifically analyzed the role of combined PD resection of the tumor can benefit a patient by
and colectomy for right-sided colon cancer improving survival time. Twenty patients with
with adhesions to adjacent organs, only 17 disease-free long-term survival times between
patients had an en bloc PD6`9). Data on morbid- 24 and 72 months after combined PD have been
ity and mortality rates for extended colorectal reported6`9,14,19,20). Curley et al.6) reported 4 of 7
resections associated with PD are scant. Curley patients who had en bloc PD living free of
954
En Bloc Resection for Locally Advanced Right-sided Colon Cancer with a Duodenocolic Fistula : Report of Two Cases
recurrence at a median follow-up of 42 months. surgery of colon cancers directly invading the
Another study reported 3 of 4 patients who had duodenum, pancreas and liver. Hepatogas-
troenterology 48 : 114-117, 2001
a combined PD alive between 24 and 30 months
9) Berrospi F, Celis J, Ruiz E, et al : En Bloc
later without evidence of disease7). Two Pancreaticoduodenectomy for Right Colon
patients of ours had their tumors resected with Cancer Invading Adjacent Organs. J Surg
clear margins, and they are alive, free of dis- Oncol 79 : 194-197, 2002
ease ; in fact, they are survivors (6 and 85 10) Mc Glone TP, Bernia WA, Elliotz DW : Sur-
vival following extended operations for
months).
extracolic invasion by colon cancer. Arch Surg
In conclusion, in patients with a locally 177 : 595-599, 1982
advanced right-sided colon cancer and no evi- 11) Hunter JA, Ryan JA, Schultz P : En bloc resec-
dence of metastatic disease, en bloc resection is tion of colon cancer adherent to other organs.
justified when the operation can be performed Am J Surg 117 : 595-599, 1987
12) Van Prohaska J, Govostis MC, Wasick M :
with low morbidity and mortality. Such an
Multiple organ resection for advanced car-
approach provides the patient with a chance for cinoma of the colon and rectum. Surg Gynecol
significant survival. Obstet 97 : 177-182, 1953
13) McGlone TP, Bemie WA, Elliot DW : Survival
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