Int J Colorectal Dis (2008) 23:477481
DOI 10.1007/s00384-007-0409-5
ORIGINAL ARTICLE
Management of patients with carcinoma of the right colon
invading the duodenum or pancreatic head
David Fuks & Patrick Pessaux & Jean-Jacques Tuech &
Franois Mauvais & Olivier Brhant &
Frdric Dumont & Denis Chatelain & Thierry Yzet &
Jean-Paul Joly & Benoit Lefebure & Sushil Deshpande &
Jean-Pierre Arnaud & Pierre Verhaeghe &
Jean-Marc Regimbeau
Accepted: 8 November 2007 / Published online: 24 January 2008
# Springer-Verlag 2007
Abstracts
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 (4386)]. 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
D. Fuks : O. Brhant : F. Dumont : D. Chatelain : T. Yzet :
J.-P. Joly : S. Deshpande : P. Verhaeghe : J.-M. Regimbeau
Digestive Medico-Surgical Department, CHU Nord,
Amiens, place Victor Pauchet,
80054 Amiens Cedex 01, France
P. Pessaux : J.-P. Arnaud
Department of Digestive Surgery, CHU Angers,
4 rue Larrey,
49933 Angers Cedex, France
J.-J. Tuech : B. Lefebure
Department of Digestive Surgery, CHU Charles Nicolle Rouen,
1 rue de Germont,
76031 Rouen Cedex, France
serious postoperative complications (heart failure, bile duct
necrosis, septic shock), and three other patients had postop-
erative anastomotic leaks. No patient experienced duodenal
fistula after partial duodenectomy. The mean median survival
in resected patients was 22 months (0122). 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.
Keywords Carcinoma right colon .
Adjacent organ involvement . En bloc resection .
Pancreaticoduodenectomy . Management
F. Mauvais
Department of Digestive Surgery, CH Beauvais,
40 avenue Lon Blum,
60000 Beauvais, France
J.-M. Regimbeau (*)
Department of Digestive Surgery, Hpital Nord Amiens,
Universit de Picardie,
place Victor Pauchet,
80054 Amiens CEDEX 01, France
e-mail: regimbeau.jean-marc@chu-amiens.fr
DO00409; No of Pages
478 Int J Colorectal Dis (2008) 23:477481

Introduction Society of Anesthesiologists (ASA) score], preoperative

Colorectal cancer remains one of the most common
malignancies in the Western World. Locally advanced
colorectal tumours represent about 522% of all colorectal
cancer at the time of presentation [1, 2] and are more
frequent in rectosigmoid (6689%) [35]. Carcinoma of the
right colon (CRC) invading adjacent viscera is rare (11
28%), and only few series have described adjacent-organ
resection [34, 67].
For the surgeon, the problem in the management of these
cancers is to determine if en bloc resection is justified and
which procedure should be performed according to the
patient who usually had bad health status.
We report a retrospective study about management of
patient with CRC invading the duodenum or pancreas to
determine the optimal management of these patients and
evaluate overall survival after curative surgery.
assessment [computed tomography (CT) scan)] and surgical
procedure. We focused on post-operative morbidity includ-
ing serious complications (additional surgery, transfer to
intensive care, death) [8]. Recurrence depending on type of
surgical procedure was noted. Recurrence was defined as
local when a tumour mass formation and/or lymph node
enlargement arose in the pancreatic bed or duodenal wall
alone by systematic colonoscopy or/and abdominal CT
scan. Otherwise, recurrence is classified into liver metastasis,
peritoneal carcinomatosis or pulmonary metastasis. Recur-
rence was not systematically confirmed by histology. We
analysed overall survival and disease-free survival. Follow-
up was not uniform in all surgical departments, but clinical
re-evaluation was performed 1 month after surgery, and
abdominal CT scan was regularly realised.
Results

Materials and methods Fifteen patients were included. There were 12 men and 3
women with a mean age of 63.2 years (range 4386).
Because of recent high number of patients managed in Most of the patients had bad health status: 13 (86%)
our Surgery Departments for CRC invading duodenum or patients had a significant weight loss (mean 8.87%).
pancreatic head, we decided to describe our own ex- Approximately 30% of patients were ASA III or IV.
perience. Firstly, we analysed retrospectively the data of Diagnosis of duodenal involvement was mainly sus-
patients operated for right colonic cancer in four French pected preoperatively by CT scan (93%). CT scan allowed
digestive-surgery departments (Amiens, Angers, Beauvais, discovering liver metastases (n=3), other adjacent organ
and Rouen) from database and local cancer registry. In infiltration (n=3) or neoplastic colonic abscess (n=2;
Angers hospital, 233 right colectomies were performed Table 1). No patient had preoperative radiotherapy or
between January 1988 and December 2005, 190 in Amiens radiochemotherapy.
Hospital, 160 in Beauvais hospital and 240 in Rouen
hospital. We identified 15 patients (2.4%) with CRC in-
vading duodenum or pancreatic head from January 1988 to Table 1 Details of patients resected for CRC invading duodenum or
December 2005. Patients with secondary tumours were not pancreas
considered. Patients initially undertaken for localised co-
Duodenal wall Duodenopancreatectomy
lonic cancer and who had duodenal or pancreatic invasion by
resection (n) (n)
recurrent disease were excluded, so with patients who
underwent palliative surgery. Unlike other reports, we Loss of weight 10 3
deliberately included patients with complicated forms at Preoperative 0 1
presentation: malignant duodenocolic fistula, hepatic metas- nutrition
tases, peritoneal carcinomatosis, perforated cancer, tumour Hepatic metastases 2 2
abscess. Duodenocolic 2 1
fistula
When attempted curative resection was decided, right
Peritoneal 1 1
colectomy was performed. Local resection of duodenal wall carcinomatosis
was realised when colonic tumour invaded less than one Perforated cancer 2 2
third of duodenal circumference. The duodenal defect was Tumour abscess 2 0
closed primarily without jejunal serosal patch. In case of Lymph node 7 2
larger involvement of duodenum or when pancreatic involvement
invasion was discovered at laparotomy, en bloc pancreati- Chemotherapy 9 2
Local recurrence 3 1
coduodenectomy was performed.
End points were demographic data (age, gender), preop- NED No evidence of disease, DOC dead of other causes, DOD died of
erative data [weight loss, preoperative mean American disease
Int J Colorectal Dis (2008) 23:477481
Fifteen patients had attempted curative surgery with re-
section of CRC. Twelve (80%) tumours involving duodenum
locally were treated by en bloc resection of a part of the duo-
denal wall. En bloc pancreaticoduodenectomy was performed
in three (20%) patients with malignant extension up to the
pancreas (Table 1). Pancreaticoduodenectomy with portal-
vein resection was performed for neoplastic invasion (n=1).
Among the three patients with synchronous liver
metastases, treatment consisted in preoperative radio-
frequency ablation (n=1), secondary left lobectomy (n=1)
and exclusive systemic chemotherapy (n=1).
Distal gastrectomy was done in two (13%) patients for
neoplastic adherence to the antrum of the stomach. Actually,
eight (53%) patients had initially complicated forms.
Surgery was performed in emergency for four (26%)
patients. For three of them, the reason was peritonitis by
perforation of colonic tumour. For the fourth patient,
percutaneous abscess drainage was not possible, and hence,
emergency surgery was performed.
The mean operating time for curative resection was 7.2 h
(4.79.5 h), and the mean intraoperative blood loss was
600 ml (3501,900 ml).
Serious postoperative complications occurred in three
(20%) patients. One of them had heart failure and died
2 days after partial duodenal resection. Another patient died
of septic shock 3 days after palliative surgery. For the last
one, operated by pancreaticoduodenectomy without anas-
tomosis because of a septic shock during preoperative
nutrition, intra-abdominal abscess occurred with bile duct
necrosis associated to wound infection. This patient died
86 days after primary operation. No patient experienced
duodenal fistula after partial duodenectomy.
Another patient operated by pancreaticoduodenectomy had
a pancreaticogastrostomy leak, but no additional surgery was
necessary. Two other patients had ileo-colic anastomotic leak;
only one needed additional surgery with ileo-colostomy. The
median postoperative length of stay was 16 days (786 days).
Pathological examination of the specimens showed
duodenal neoplastic infiltration in 100%. All tumours
resected were adenocarcinomas and had clear resection
margins (R0) whatever the surgery performed. No patient
had R1 or R2 resection margins. Three (30%) tumours were
well differentiated, four (40%) were moderately differenti-
ated, and three (30%) were poorly differentiated (missing
data n=5). Histopathologic examination showed lymph
nodal involvement in nine (60%) patients. Six (40%)
patients were stage II (pT4N0M0, TNM, AJCC 1997).
Nine (60%) patients were stage IIIA or B.
Follow-up recurrence
The median follow up of the 15 patients was 22 months
(0122). Six patients are currently followed, and no patient
479
was lost to follow-up. Overall survival rates at 1 and 3 years
were 68% (n=7) and 56% (n=4). Eleven (73%) patients
received adjuvant chemotherapy (5-fluorouracil mainly)
because of lymph node involvement (n=6) or T4 tumour.
Seven patients (46%) developed recurrence. Four patients
had local recurrence, two patients had distant recurrence
(liver, lung), and one patient had peritoneal carcinomatosis
alone. Treatment of patients with recurrence was surgery
(n = 3) and systemic chemotherapy alone (n = 4). All
recurrences resected were histologically confirmed and
occurred within 15 months after operation. Three (25%)
patients who had duodenal wall resection, and one of three
patients (33%) who underwent a concomitant pancreatico-
duodenectomy developed a local recurrence. Analysis of
risk factor of local recurrence does not find a significant
correlation between local recurrence and lymph node status,
differentiation of tumour or adjuvant chemotherapy.
Discussion
Only few small studies have specifically reported the
management of patients with CRC invading duodenum
and/or pancreas [3, 6, 7, 9]. Most reports of this condition
are solitary cases or large studies about multivisceral
resection of advanced colorectal cancer, where analysis of
resection for invasion of duodenum and pancreas is not
accurate. The incidence of this entity is 2.4% in our study.
Our work about 15 CRC invading duodenum and/or
pancreas operated mainly by duodenal wall resection (80%)
is one of the most important and gives some complemen-
tary information about management of these patients.
Originality of this work is to have included not only
selected patients but all the patients operated in four French
departments of digestive surgery. Complicated forms of
colon cancer affected 53% of patients, and surgery was
performed in emergency for 26% of patients. The mean
survival in resected patients was 22 months. Overall
survival rates at 1 and 3 years were 68% and 56%. After
partial duodenectomy, five (41%) patients had local re-
currence within 15 months after surgery.
Despite local aggressive behaviour in the way of invasion
of adjacent organs, CRC invading duodenum and/or pancreas
is not always associated with distant metastasis at presentation
[1]. Polk [5] emphasized that extended resection should not
be undertaken in patients with metastatic disease. In our
study, three patients had hepatic metastases at initial CT scan.
Liver metastasis treatment included preoperative radiofre-
quency ablation (n=1), secondary left lobectomy (n=1) and
exclusive chemotherapy (n=1). Among these patients, two
are alive after 3 and 8 months with adjuvant chemotherapy.
Liver metastases seem to be a poor prognostic factor for
these patients.
480 Int J Colorectal Dis (2008) 23:477481

Malignant duodenocolic fistula is reported in a hundred
cases in the English and Japanese literature [1012] and
seems to be another prognostic factor affecting survival.
Three duodenocolic fistulas were found in our study, and
two of them had hepatic metastases associated. Survival
of all the patients is lower than 1 year (mean survival
rate, 5.6 months). Izumi et al. [12] report only one patient
with 1 year survival treated by en bloc colectomy with
pancreatoduodenectomy for duodenocolic fistula.
Several authors emphasised that presence of lymph
node metastases is the most important pathologic deter-
minant of survival [1, 1316] even if several locally
invasive CRC were associated with negative lymph node
status [5, 17]. Several studies, interested in prognosis
factors of CRC, showed that 5-year survival in patients
with nodal metastasis was 0 to 11%, significantly lower
than the 37 to 76% survival rate in their patients without
nodal metastases [1, 1416]. Moreover, a high proportion
of well-differentiated lesions was noted in patients with
mean median survival [3, 4, 6] that is not found in our
study. Most of our patients (60%) had lymph node in-
volvement (Table 2).
Most series have reported minimal mortality rates and
high survival rate with en bloc resections [10, 1318];
however, it is possible there is a publication bias because
only centres which have successfully performed these
procedures may have reported them [3]. Several retrospec-
tive studies showed that in approximately 40% of the cases
[5, 19], fixation of the tumour to surrounding structures is
caused by inflammatory adhesions rather than direct tumour
invasion. Because this distinction is impossible to make
intra-operatively, the surgeon should make complete en
bloc resection with adequate margins [1, 2, 6, 2023].
Actually, separation of tissues is associated with higher
recurrence rates approaching 90 to 100% [67, 2021]. The
5-year survival rate was 17% after dissection or rupturing
of the tumour, compared with 49% after en bloc resection
[2223]. However, neoplastic histological infiltration was
confirmed in all cases in our study after en bloc resection as
in others [3, 5, 6, 9, 19, 24]. No inflammatory adherence
was noticed by histopathology. The performance of a
complete resection clearly influences survival time. The
complexity and the significant morbidity of pancreatico-
duodenectomy have discouraged surgeons from performing
such a procedure for decades [7]. However, improvement in
this surgery and a better management of morbidity allowed
planning this complex surgery in cancer invading adjacent
organs. Complete tumour resection with 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% [4,
6]. In contrast, palliative bypass is associated with a median
survival time of 9 months and incomplete resection
including organ separation, with a mean survival time of
11 months [4, 6]. The mean median survival (longer than
25 months) was obtained in six patients of our study. The
mean median survival in resected patients was 22 months
[2122] and 1 and 3 years overall survival rates were 68
and 56%. These rates are lower than others reports but can
be explained because we deliberately decided to include all
patients managed, including complicated colonic cancer at
presentation (53%). Moreover, the rate of stage IIIAIIIB
tumours (60%) and adjacent organ resection (33.3%) are
higher than in other series. Pathologic examination shows
that tumours of our patients had factor with detrimental
impact on prognosis [low differentiated tumour (30%),
lymph node involvement (60%)]. However, despite these
factors with detrimental impact on prognosis, some patients
had long overall survival (Table 2).

Table 2 Details of studies reporting more than five patients resected for CRC invading duodenum or pancreas

Period Total Tumour Adjacent Well- Lymph Complicated Surgery in DPC/ Local Serious
number stages organ differentiated node forms (%) emergency RDW recurrence postoperative
of IIIAIIIB resection tumour (%) invasion (%) (%) (%) complications
patients (%) (%) (%) (%)

Kapoor (3) 1992 9 54.5 27.2 63.6 9 0 66 18.1 18.1

2004
McGlone (18) 1972 24 16.6 87 16.6 0 8.3
1976
Curley (10) 1980 11 25 0 25 27 0 63 25 0
1993
Koea (6) 1986 8 37.5 12.5 0 62.5 0 0 100 25 0
2000
Present study 1988 15 60 33.3 30 60 53 26 20 46 17
2005

Serious complications: complication responsible of additional surgery, transfer to intensive care, death
Complicated forms: malignant duodenocolic fistula, hepatic metastases, peritoneal carcinomatosis, perforated cancer, tumour abscess
DPC Pancreaticoduodenectomy, RDW resection of duodenal wall
Int J Colorectal Dis (2008) 23:477481
Concerning preoperative management of patients with
severe weight loss, no data are found in literature. Preoper-
ative nutrition was decided in one patient, but major
complications (grade IVb, grade V) occurred. We think this
strategy runs the risk of development of complications with
urgent need for surgery and should be avoided.
Serious postoperative complications occurred in 17% in
our study. One patient had heart failure and died 2 days
after partial duodenal resection, and another one died of
septic shock 3 days after palliative surgery. For one patient
operated by pancreaticoduodenectomy, intra-abdominal
abscess and bile duct necrosis occurred, and he died 86 days
after primary operation.
Among the 15 patients resected, 7 (46%) developed
recurrence within 15 months after operation: local recurrence
(n=4), distant recurrence (n=2). Three (25%) patients who
had duodenal wall resection and one of three patients (33%)
who underwent a concomitant pancreaticoduodenectomy
developed a local recurrence. This rate of recurrence is
higher than in others studies [3, 6]. All of these patients had
T4 tumour, and the T stage is known to be an independent
risk factor of loco-regional recurrence [25]. In rectal cancer,
the rate of loco-regional recurrence was 4.7% in T4 tumour
in a recent Norwegian series. Even if no definitive
recommendation is possible because of the small number
of patients, our results about local recurrence (46%) should
make questionable the interest of pancreaticoduodenectomy
and the role of radiochemotherapy in this rare entity.
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. The high rate of local recurrence in spite of clear
resection margins makes questionable the role of preoper-
ative radiochemotherapy.
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