Clin J Gastroenterol (2010) 3:259261
DOI 10.1007/s12328-010-0175-8
CASE REPORT
En bloc right hemicolectomy and pancreaticoduodenectomy
with superior mesenteric vein resection for advanced right-sided
colon cancer
Hiroshi Noda Takaharu Kato Hidenori Kamiyama
Nobuyuki Toyama Fumio Konishi
Received: 9 July 2010 / Accepted: 16 August 2010 / Published online: 16 September 2010
Springer 2010
Abstract A 58-year-old female was referred to our hos-
pital 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 opera-
tion. Complete resection clearly influences survival time of
patients, and surgeons should not hesitate to perform
RHCPD.
Keywords Pancreaticoduodenectomy
Colon cancer

Superior mesenteric vein
Introduction
Surgical resection with adequate margin (R0) is the only
potentially curative treatment for colorectal cancer
H. Noda (&)
T. Kato
H. Kamiyama
N. Toyama

F. Konishi
Department of Surgery, Saitama Medical Center,
Jichi Medical University, 1-847 Amanuma-cho,
Omiya-ku, Saitama 330-8503, Japan
e-mail: noda164@hotmail.co.jp
invading adjacent organs. In this situation, complete tumor
resection with the en bloc removal of adjacent organs is
associated with a mean survival time of 40 months and an
actuarial 5-year survival rate of 54% [1, 2]. In contrast,
median survival times of palliative bypass and incomplete
resection including organ separation were reported to be
9 and 11 months, respectively [1, 2].
Right-sided colon cancer can invade the duodenum
and/or pancreas, and in such a situation an en bloc right
hemicolectomy with pancreaticoduodenectomy (RHCPD)
is required for R0 resection. Pancreaticoduodenectomy
(PD) is a complex procedure, but has recently become
much safer in high-volume hospitals [35]. Several authors
have reported that PD for advanced colon cancer invading
the pancreas and/or duodenum now provides a favorable
long-term survival [2, 69]. Recently, we experienced a
successful case of a patient who underwent RHCPD with
superior mesenteric vein (SMV) resection and reconstruc-
tion for an en bloc R0 resection of a tumor. Our case is the
second report of RHCPD with SMV resection and recon-
struction in the world literature.
Case report
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. In our hospital, an
abdominal computed tomography (CT) scan revealed a
large irregular mass, about 10 cm in diameter, in and
around the duodenum and colon causing a bowel obstruc-
tion. The SMV was shown to run very close to the mass,
and tumor invasion to the SMV was suspected (Fig. 1).
We performed an emergency bypass operation for the
treatment of the bowel obstruction, and carried out a
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260 Clin J Gastroenterol (2010) 3:259261

Fig. 2 The tumor invaded the SMV about 4.0 cm (between arrows)

Fig. 1 CT scan demonstrates that the SMV runs very close to the
tumor for a long distance (between arrows)

side-to-side anastomosis of the ileum and transverse colon.

After her recovery, we performed further examinations. A
colonoscopy revealed a stenosis resulting from a circular
tumor, and a biopsy specimen of the tumor demonstrated a
well-differentiated adenocarcinoma. A gastroduodenos-
copy also revealed an irregular ulcerated mass in the sec-
ond part of the duodenum. Thus, we confirmed the
previous diagnosis, and recommended the patient to
undergo RHCPD with a curative intent; however she hes-
itated in having the operation, and one month after the
initial operation, the tumor caused a fecal fistula and severe
anemia. We gave her a blood transfusion several times for
the treatment of severe anemia caused by the bleeding from
the tumor and, because of this, we could not perform
chemotherapy. Therefore, the patient finally decided to
undergo RHCPD.
During the operation, we first evaluated the respect-
ability of the tumor after complete mobilization of the
right-sided colon and duodenum using Kochers maneuver.
The amount of duodenal and pancreatic involvement
should be estimated without dissecting the adherent organs
from the tumor. At this point we confirmed that RHCPD
could lead to R0 resection in this case. Second, after the
superior mesenteric vessels were identified by dissecting
the trunk of the ileocolic and middle colic vessels, we
confirmed that the tumor could not be dissected from the
SMV and the length of the invasion of the tumor to the
SMV was about 4.0 cm (Fig. 2). Therefore, we performed
a segmental cylindrical 4-cm long resection of the SMV
and reconstructed it with end-to-end anastomosis (Fig. 3).
Fig. 3 We performed RHCPD with resection of the SMV. The SMV
was reconstructed with end-to-end anastomosis (arrow)
Reconstruction of the bowel was performed by a functional
end-to-end ileotransversostomy and a modified Childs
reconstruction. The operative time was 538 min and the
operative blood loss was 2760 ml. The post-operative
course was uneventful, and after a 34-day hospital stay the
patient returned to daily life. The gross appearance of the
resected specimen revealed a tumor with a deep ulceration
in the colon measuring 10.0 cm in diameter invading
the duodenum. A histologic examination also revealed a
well-differentiated tubular adenocarcinoma invading the
duodenum; however, no tumor invasion to the SMV was
confirmed histologically. All the surgical margins were
negative, and lymph node metastasis was not found in
45 dissected lymph nodes. Thus, the tumor was stage II
(T4 N0 M0) according to TNM classification. To date,
the patient has been given capecitabine as adjuvant

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Clin J Gastroenterol (2010) 3:259261
chemotherapy and there were no signs of recurrence for
8 months after her operation.
Discussion
Several authors have reported that PD for advanced colon
cancer invading the duodenum and/or pancreas provides
favorable long-term survival [2, 69]. Saiura et al. [9]
reported that the overall survival rates of twelve patients
who underwent en bloc resection of colorectal cancer
invading the duodenum and/or pancreas were 75% at
1 year, 66% at 3 years, and 55% at 5 years. Furthermore,
they also reported that 5 of 12 patients survived for more
than 10 years [9]. Thus, a complete resection clearly
influences the survival time for patients, and surgeons
should not hesitate to perform RHCPD for R0 resections.
The patient in our report underwent RHCPD for advanced
right-sided colon cancer, and an R0 resection was suc-
cessfully carried out. A pathological examination of our
case showed a well-differentiated adenocarcinoma without
lymph node metastasis. It has been well documented that
patients with a node-negative status or a well-differentiated
adenocarcinoma who undergo RHCPD experience favor-
able survival outcomes [79]. Accordingly, a favorable
prognosis can be expected in our case also.
The complexity and the significant morbidity of PD
have discouraged surgeons from performing RHCPD for
many years; however, post-operative outcomes of PD in
high-volume hospitals have greatly improved and mortality
rates are reported to be 16%. Such good results allow a
wider indication for this complex procedure [35]. On the
other hand, concerning the mortality rates of RHCPD,
several authors have reported high post-operative mortality
rates ranging from 8.3 to 33.3% [79]. Our team annually
perform PD in about 30 cases, and our hospital is now
recognized as a high-volume hospital. It may be necessary
for RHCPD to be performed by a well-experienced surgical
team in a high-volume hospital to obtain a good post-
operative outcome.
In this case, PD with SMV resection and reconstruction
were required for an en bloc R0 resection of the tumor.
Yoshimi et al. first reported on cases with RHCPD and
cylindrical SMV resection and reconstruction in 1999 [10],
and our case is the second report of such a case in the world
literature; however, in our case, no tumor invasion to the
SMV was confirmed histopathologically. The discrepancy
between the intraoperative and histopathologic findings
about tumor invasion to the SMV was also reported by
261
Yoshimi et al. [10]. It is impossible to distinguish malig-
nant invasion from inflammatory adhesion at the time of
operation, because in approximately 40% of the cases,
fixation of the tumor to surrounding structures is caused by
inflammatory adhesions rather than direct tumor invasion.
[1113]. To date, our case has not developed any recur-
rence for 8 month after the operation. Long-term prognosis
is not clear, but the patient of Yoshimi et al. [10] lived for
37 months after their operation without recurrence. In spite
of technical difficulties, the case of Yoshimi et al. and our
case may encourage surgeons to perform RHCPD with
SMV resection and reconstruction for locally advanced
right-sided colon cancer.
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