Brief Report
Combined right hemicolectomy and pancre-
aticoduodenectomy for locally advanced right
hemicolon cancer
Qin-Song Sheng, Wen-Bin Chen, Min-Jiang Li, Xiao-Bin Cheng, Wei-Bing Wang and Jian-Jiang Lin
Hangzhou, China
ABSTRACT: Extracolonic invasion of the duodenum and/or
pancreatic head rarely occurs in patients with right hemico-
lon cancer. However, when necessary, combined radical op-
eration is a challenge to the surgeon. We reported 7 patients
with locally advanced right hemicolon cancer who underwent
combined right hemicolectomy (RH) and pancreaticoduo-
denectomy (PD) due to direct involvement of the duodenum
or pancreatic head. This study included four males and three
females with a mean age of 66.95.9 years. Computed tomog-
raphy (CT) scans revealed right hemicolon cancer with duo-
denal invasion (5 patients) and pancreatic invasion (2). The
mean operation time was 41064 minutes and the estimated
blood loss was 514157 mL. After the operation, the mean
postoperative hospital stay was 22.17.2 days. Five patients
had postoperative complications. The mean follow-up time
was 16.45.9 months. During this period, three patients died
from tumor recurrence, one from postoperative complications,
one from pulmonary disease, and two survived until the last
scheduled follow-up. Five patients survived more than one
year. Combined RH and PD for locally advanced right hemi-
colon cancer can be performed safely, thus providing a long-
term survival rate in selected patients in a high-volume center.
(Hepatobiliary Pancreat Dis Int 2015;14:320-324)
KEY WORDS: combined resection;
pancreaticoduodenectomy;
colectomy;
colon cancer;
direct invasion
Author Affiliations: Department of Colorectal and Anal Surgery, The First
Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou
310003, China (Sheng QS, Chen WB, Cheng XB, Wang WB and Lin JJ);
Department of Colorectal and Anal Surgery, First Peoples Hospital of
Wenlin, Wenlin 317500, China (Li MJ)
Corresponding Author: Wen-Bin Chen, MD, Department of Colorectal
and Anal Surgery, The First Affiliated Hospital, Zhejiang University School
of Medicine, Hangzhou 310003, China (Tel: +86-571-87236882; Email:
cwbin@hotmail.com)
2015, Hepatobiliary Pancreat Dis Int. All rights reserved.
doi: 10.1016/S1499-3872(15)60374-5
Published online May 21, 2015.
320 Hepatobiliary Pancreat Dis IntVol 14No 3 June 152015 www.hbpdint.com
Hepatobiliary & Pancreatic Diseases International
Introduction
L
ocally advanced colorectal cancers, defined as the
invasion of neighboring organs and structures
without distant metastases, account for 5.2%-23.6%
of all colorectal tumors at the presentation.[1] Extraco-
lonic invasion usually appears in the rectum and sigmoid
colon in which pelvic organs and tissues may be invaded,
but it rarely occurs in the right colon or proximal trans-
verse colon.[2, 3] Especially, right hemicolon cancer with
direct infiltration of the duodenum and/or pancreatic
head usually produces more morbidity, posing a surgical
challenge.[3] Combined resection of multiple organs is
recognized as the best therapeutic strategy for patients
with locally advanced colon carcinoma without distant
metastasis. Combined right hemicolectomy (RH) and
pancreaticoduodenectomy (PD) is the best radical choice
to treat locally advanced right hemicolon cancer.[1, 3-5] Lo-
cally advanced colorectal cancer seldom appears in the
right side of the colon and reports on the occurrence are
rare. The morbidity and long-term prognosis of patients
with right colon carcinoma who have undergone com-
bined RH and PD are not clear.[6, 7]
This report is to share our experience in seven pa-
tients who successfully underwent combined RH and PD
to treat locally infiltrative right hemicolon cancer invad-
ing the duodenum and/or pancreatic head directly.
Methods
Patients
A total of 2 772 patients with right hemicolon carcinoma
who had radical RH with or without multi-organ opera-
tion were analyzed. These patients were treated at the
First Affiliated Hospital, Zhejiang University School of
Medicine between January 2000 and December 2013.
From the medical records, seven patients who had un-
dergone combined RH and PD due to direct involvement
Combined RH and PD for colon cancer
of the duodenum or pancreatic head were identified.
The seven patients had symptoms of abdominal dis-
tension, upper abdominal discomfort, melena, anemia, or
a change in bowel habits. One patient had jaundice and
three patients had a palpable abdominal mass, but digi-
tal rectal examinations were negative. The preoperative
cancer antigen 19-9 and carcinoembryonic antigen (CEA)
levels were routinely tested in all patients. Preoperative
computed tomography (CT) was routinely performed to
evaluate local tumor invasion. Preoperative upper endos-
copy, colonoscopy, and pathological affirmation of the
diagnosis were carried out in all patients.
The indications for surgery included the following: 1)
patients with histologically confirmed colon carcinoma;
2) patients without severe comorbid disease and toler-
able to a radical multi-organ excision; 3) colon cancer
which could not be dissociated from the pancreatic head
or duodenum; 4) R0 resection feasible on account of
preoperative evaluation and no distant metastasis; and
5) the surgical team who have sufficient operating skills
and clinical experience to perform such a delicate op-
eration.[1, 3, 6, 7] Patients with high surgical risk, distant
metastasis, or secondary invasion of the pancreatic head
and/or the duodenum rather than direct infiltration
were excluded. And those who had local duodenal inva-
sion that could be excised radically by a partial duodenal
wall resection were also excluded.[1, 8]
Operations
After the right hemicolon was dissociated, a Kocher
maneuver was made to completely separate the duode-
num to create a distinct plane between the tumor and
the superior mesenteric artery. Then the terminal com-
mon bile duct was separated and retracted for the liga-
tion of the gastroduodenal artery. A tunnel was estab-
lished in the plane anterior to the portal vein behind the
pancreatic neck. The plane was established at the inferior
margin of the pancreas medial to the arranged course of
the superior mesenteric vein. The resectability of colon
cancer was evaluated after entire separation of the right
hemicolon and duodenum. The involvement of the duo-
denum or pancreas was evaluated after liberation of the
original adhesions to the right hemicolon. If resection
was feasible, RH was done according to a standard pro-
cedure. A stapled ileocolic side-to-side anastomosis was
made. PD was performed with a standard procedure, and
reconstruction was subsequently undertaken according
to Child's reconstruction method.[9] After the resection
and reconstruction, suction drains were placed into the
pelvis and near the anastomotic stomas, and the abdomi-
nal wall wounds were closed.
The tumor stage was assessed according to the tu-
Hepatobiliary Pancreat Dis IntVol 14No 3 June 152015 www.hbpdint.com 321
mor-lymph node-metastasis (TNM) classification recom-
mended by the American Joint Committee of Cancer.[10]
Postoperative complications were categorized according
to the reported criteria including the presence of pancre-
atic fistula (PF),[11] delayed gastric emptying (DGE)[12]
and acute respiratory distress syndrome (ARDS).[13]
Statistical analysis
Demographic variables, intraoperative parameters,
and postoperative data were recorded. In addition, all
patients were asked to visit our outpatient department
every month after discharge and the complications dur-
ing the follow-up period were also recorded. Numerical
data were presented as meanstandard deviation.
Results
Seven patients (4 males and 3 females) with locally ad-
vanced carcinoma of the right hemicolon invading the
duodenum or pancreatic head had undergone combined
RH and PD. The mean age of the patients was 66.95.9
years. The tumor was located at right colic flexure (3
patients) and the ascending colon (4). CT scans revealed
duodenal invasion in five patients and pancreatic inva-
sion in two. Preoperative upper endoscopies revealed
colon tumors without mucosal involvement. The patho-
logical results confirmed the diagnosis of right hemico-
lon cancer in all of the patients, and their preoperative
CEA values were 9.36.9 ng/mL. The CA19-9 levels were
normal in all patients. None of the patients underwent
preoperative chemotherapy. The demographic variables
of the patients are listed in Table 1.
The operations in all patients were performed suc-
cessfully. The average operation time was 41064 min-
utes, and the estimated blood loss was 514157 mL.
Blood was transfused intraoperatively in all patients
with an average amount of 3.71.4 U. Pathological ex-
amination confirmed the involvement of the duodenum
(5 patients) and pancreas (2). In addition, moderately
differentiated adenocarcinoma (5 patients) and poorly
differentiated adenocarcinoma (2) were confirmed his-
tologically. According to the TNM classification system,
stage T4bN1bM0 (2 patients), stage T4bN0M0 (3), stage
T4bN2aM0 (1), and stage T4bN2bM0 (1) were defined. The
intraoperative parameters are listed in Table 2.
After the operation, the postoperative hospital stay
was 22.17.2 days. None of the patients died during the
hospital stay. Five patients had postoperative complica-
tions including DGE (1 patient), ileus (2), wound infec-
tion (3), ARDS (2), and PF (1). The patients recovered
after conservative treatments. Among them, five patients
 Hepatobiliary & Pancreatic Diseases International

received adjuvant chemotherapy, including modified
folfox 6 (3 patients) and capecitabine plus oxaliplatin
treatment (2). The median follow-up time was 16.45.9
months. During this period of follow-up, three patients
died from tumor recurrence, one from postoperative
complications, one from pulmonary disease, but two
were alive. Five patients survived more than one year.
The survival time of the four patients with lymph node
metastasis was 13.84.5 months, whereas that of the
three patients without lymph node metastasis was 206.2
months. The postoperative data of the patients are listed
in Table 3.

Table 1. Demographic variables of the patients

Preoperative CEA Preoperative
Patient no. Gender Age (yr) Site Invasion Comorbidity
(ng/mL) chemotherapy
1 M 69 Right colic flexure Duodenum Hypertension 7.5 No
Anemia
2 F 65 Ascending colon Duodenum Diabetes 1.9 No
Anemia
3 F 70 Right colic flexure Pancreas Hypertension 4.1 No
4 M 75 Ascending colon Duodenum Hypertension 20.3 No
Coronary heart disease
5 M 56 Ascending colon Pancreas Anemia 3.9 No
6 M 68 Ascending colon Duodenum Hypertension 11.4 No
Coronary heart disease
Pulmonary insufficiency
7 F 65 Right colic flexure Duodenum Hypertension 16.3 No
Anemia
CEA: carcinoembryonic antigen.

Table 2. Intraoperative parameters of the patients

Operative time
Patient no.
(min)
1 410
2 450
3 530
4 400
5 340
6 380
7 360
Operative blood loss Intraoperative blood Intraoperative
Pathological findings
(mL) transfusion (U) complications
500 4 No Moderately differentiated (T4bN1bM0)
500 4 No Moderately differentiated (T4bN1bM0)
800 6 No Moderately differentiated (T4bN0M0)
600 4 No Poorly differentiated (T4bN2bM0)
300 2 No Moderately differentiated (T4bN0M0)
400 2 No Poorly differentiated (T4bN2aM0)
500 4 No Moderately differentiated (T4bN0M0)

Table 3. Postoperative data of the patients

Duration of hospital Postoperative Follow-up
Patient no. Postoperative complications Status Cause of death
stay (d) chemotherapy (mon)
1 18 Delayed gastric empting Xelox 19 Dead Recurrence
2 20 Ileus mFolfox 6 10 Dead Postoperative
Wound infection complications
3 25 ARDS No 25 Dead Pulmonary disease
Wound infection
4 35 Pancreatic fistula No 10 Dead Recurrence
Wound infection
5 12 No mFolfox 6 13 Alive -
6 20 Ileus Xelox 16 Dead Recurrence
ARDS
7 25 No mFolfox 6 22 Alive -
ARDS: acute respiratory distress syndrome.

322 Hepatobiliary Pancreat Dis IntVol 14No 3 June 152015 www.hbpdint.com

Combined RH and PD for colon cancer
Discussion
Patients who have received margin negative multiple
organ resection usually have a similar survival rate com-
pared with those who have no neighboring structure in-
vasion. However, local recurrence of a tumor is common
(70%-100%) in patients without multiple organ resec-
tion. Therefore, many researchers[4, 6, 14] have suggested
a combined resection of the colorectal tumor with the
neighboring organs and structures. Since right hemico-
lon cancer is suspected to infiltrate the duodenum and/
or pancreatic head, combined RH and PD might be nec-
essary to radically resect the tumor.[1, 3] However, some
researchers[1] think that combined RH and PD for locally
advanced right hemicolon cancer is not the best choice
of treatment. First, locally advanced cancers are largely
considered to be highly malignant. Second, a combined
RH and PD procedure represents a surgical challenge to
the surgeon due to its difficulty, complexity, and high
postoperative morbidity and mortality. In addition, the
surgeon's individual experience and financial restrictions
also need to be considered.[6]
In the past, extracolonic invasion was usually first
discovered at the time of laparotomy. The results of
preoperative abdominal CT often indicated imprecise
information about the degree of pancreatic or duodenal
invasion due to right hemicolon cancer.[2, 3] With the
development of CT technology, however, a recent meta-
analysis showed that CT precisely stage colonic tumors
preoperatively and provide information about cancer
involvement exceeding the muscularis propria.[15] In
the current study, preoperative CT accurately revealed
duodenal invasion in five and pancreatic invasion in two
patients, which were consistent with the intraoperative
findings. However, a study[7] found that imaging often
cannot distinguish inflammatory adhesions from direct
tumor infiltration. Even in surgical exploration, it is of-
ten difficult to determine whether gross adhesions to the
carcinoma represent true malignant infiltration or an
inflammatory reaction.[1] Moreover, a histological study
showed that 55%-70% of adhesions are tumor invasions
while the remainder are tumor-related inflammatory ad-
herence.[3] Therefore, the adherences between the tumor
and adjacent structures should be considered malignant.
When a right hemicolon cancer is staged as T4bNxM0,
combined multiple organ operation should be per-
formed once the patient is suitable for a radical surgery.[1]
In the current study, all the patients were confirmed to
have dense adherences between right hemicolon cancer
and the duodenum or pancreas, and were candidates
for a combined radical resection. The final histological
results confirmed duodenal or pancreatic invasion in all
Hepatobiliary Pancreat Dis IntVol 14No 3 June 152015 www.hbpdint.com 323
patients.
According to previous reports, 25%-60% of cases of
colon cancer that invades the neighboring duodenum
and/or pancreas do not have lymphatic metastasis.[1]
These results indicate that neoplasms spread in a locally
advanced manner rather than lead to hematogenous or
lymphatic metastasis, which is an important prognostic
factor for local recurrence, distant metastasis, and surviv-
al in patients with colon carcinoma.[3] Therefore, patients
with locally aggressive colon cancer without lymphatic
metastasis have a longer postoperative survival time than
those with lymphatic metastasis.[4, 6] The present report
showed similar results.
According to previous reports, the prognosis of pa-
tients with colorectal cancer who have undergone a com-
bined RH and PD is promising.[1, 4, 6] The long-term out-
comes after the combined operation for right hemicolon
cancer invading the pancreas resemble those after the op-
eration for colorectal carcinoma invading other organs
or structures. It remains to be answered whether radical
and combined operation of the neoplasm can improve
the survival time of the patients. Especially, in patients
with stage T4 right hemicolon cancer who accept com-
bined resection with PD, the average disease-free survival
may reach 54 months.[2] In the current study, the average
survival time was 16.45.9 months, whereas the overall
one-year survival rate of patients was 5/7. Two patients
in this series were alive after the scheduled follow-up.
However, information from this particular subsec-
tion of patients might not reflect the actual situation.
First, the incidence of colorectal cancer invading neigh-
boring organs might not be representative because stage-
matched patients with right hemicolon cancer infiltrating
the duodenum or pancreas who rejected surgical treat-
ment or only chose bypass surgery were not included in
this study. Second, other researchers had different indi-
cations for the combined resection. Finally, many stud-
ies have suggested that these patients should be studied
for a long-term period.[1, 4] Since perioperative care and
surgical skills keep improving, a long-term study might
increase the variety of the data, making comparison of
some variables between studies difficult.
Contributors: SQS and CWB proposed the study. SQS performed
the research and wrote the first draft. LMJ, CXB and WWB col-
lected and analyzed the data. All authors contributed to the design
and interpretation of the study and to further drafts. CWB is the
guarantor.
Funding: None
Ethical approval: Not needed.
Competing interest: No benefits in any form have been received
or will be received from a commercial party related directly or in-
directly to the subject of this article.

References
1 Zhang J, Leng JH, Qian HG, Qiu H, Wu JH, Liu BN, et al. En
bloc pancreaticoduodenectomy and right colectomy in the
treatment of locally advanced colon cancer. Dis Colon Rectum
2013;56:874-880.
2 Costa SR, Henriques AC, Horta SH, Waisberg J, Speranzini MB.
En-bloc pancreatoduodenectomy and right hemicolectomy for
treating locally advanced right colon cancer (T4): a series of
five patients. Arq Gastroenterol 2009;46:151-153.
3 Lee WS, Lee WY, Chun HK, Choi SH. En bloc resection for
right colon cancer directly invading duodenum or pancreatic
head. Yonsei Med J 2009;50:803-806.
4 Saiura A, Yamamoto J, Ueno M, Koga R, Seki M, Kokudo N.
Long-term survival in patients with locally advanced colon
cancer after en bloc pancreaticoduodenectomy and colectomy.
Dis Colon Rectum 2008;51:1548-1551.
5 Paquette IM, Swenson BR, Kwaan MR, Mellgren AF, Madoff
RD. Thirty-day outcomes in patients treated with en bloc col-
ectomy and pancreatectomy for locally advanced carcinoma of
the colon. J Gastrointest Surg 2012;16:581-586.
6 Song XM, Wang L, Zhan WH, Wang JP, He YL, Lian L, et al.
Right hemicolectomy combined with pancreatico- duodenec-
tomy for the treatment of colon carcinoma invading the duo-
denum or pancreas. Chin Med J (Engl) 2006;119:1740-1743.
7 Cirocchi R, Partelli S, Castellani E, Renzi C, Parisi A, Noya G,
et al. Right hemicolectomy plus pancreaticoduodenectomy vs
partial duodenectomy in treatment of locally advanced right
colon cancer invading pancreas and/or only duodenum. Surg
Oncol 2014;23:92-98.
8 Fuks D, Pessaux P, Tuech JJ, Mauvais F, Brhant O, Dumont F,
et al. Management of patients with carcinoma of the right co-
324 Hepatobiliary Pancreat Dis IntVol 14No 3 June 152015 www.hbpdint.com
Hepatobiliary & Pancreatic Diseases International
lon invading the duodenum or pancreatic head. Int J Colorec-
tal Dis 2008;23:477-481.
9 Yang YL, Xu XP, Wu GQ, Yue SQ, Dou KF. Prevention of pan-
creatic leakage after pancreaticoduodenectomy by modified
Child pancreaticojejunostomy. Hepatobiliary Pancreat Dis Int
2008;7:426-429.
10 Edge SB, Compton CC. The American Joint Committee on
Cancer: the 7th edition of the AJCC cancer staging manual
and the future of TNM. Ann Surg Oncol 2010;17:1471-1474.
11 Xu M, Wang M, Zhu F, Tian R, Shi CJ, Wang X, et al. A new
approach for Roux-en-Y reconstruction after pancreaticoduo-
denectomy. Hepatobiliary Pancreat Dis Int 2014;13:649-653.
12 Wente MN, Bassi C, Dervenis C, Fingerhut A, Gouma DJ, Iz-
bicki JR, et al. Delayed gastric emptying (DGE) after pancre-
atic surgery: a suggested definition by the International Study
Group of Pancreatic Surgery (ISGPS). Surgery 2007;142:761-
768.
13 Pitoyo CW. Acute respiratory distress syndrome. Acta Med In-
dones 2008;40:48-52.
14 Mora-Pinzon MC, Francescatti AB, Luu MB, Millikan KW,
Deziel DJ, Hayden DM, et al. En bloc right hemicolectomy/
pancreaticoduodenectomy for cancer: one institution's experi-
ence. Am Surg 2013;79:E238-239.
15 Dighe S, Purkayastha S, Swift I, Tekkis PP, Darzi A, A'Hern R,
et al. Diagnostic precision of CT in local staging of colon can-
cers: a meta-analysis. Clin Radiol 2010;65:708-719.
Received November 30, 2014
Accepted after revision February 11, 2015