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

Locally advanced colon cancer resulting in en bloc right hemicolectomy and... Locally advancement of right colon cancer to the surrounding organs requiring surgical intervention is an extensive proced- ure associated with numerous risks. There are not many cases of which this phenomenon may occur. En bloc pancreatico- duodenectomy 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 pancreati- coduodenectomy and right hemicolectomy and review literature. Our method was a retrospective review of a patient with colon cancer INTRODUCTION endoscopies were found in her records. PMHx included COPD, Locally advanced colorectal cancer has beneficial treatment via osteoarthritis and DVT. Significant physical exam findings en bloc pancreaticoduodenectomy and right hemicolectomy. included mild, diffuse abdominal tenderness and RUQ palpable The morbidity and mortality rates are acceptable with an mass, and normal bowel sounds. Labs were significant for a experienced team. More often than not, excluding patients who hemoglobin of 5.7, hematocrit of 18.6% and CEA of 29.6. An are not surgical candidates due to various comorbidities, en abdominal/pelvis CT exhibited a 6 cm circumferential mass of bloc pancreaticoduodenectomy and right hemicolectomy the hepatic flexure (Figs 1–3). Two days later, a right hemico- should be performed for locally advanced colorectal cancers. lectomy with en bloc pancreaticoduodenectomy was performed. Bias does exist for numerous reasons but the most important Pathology showed adenocarcinoma stage IIIc (Figs 4–10). Post- being a lack of enrollment of patients. operatively, an abdominal/pelvis CT showed bilateral pulmonary emboli and a 14 cm pelvic abscess. Bilateral lower extremity ultrasound showed low probability for DVT. Exploratory laparot- CASE REPORT omy was performed where the pelvic abscess was seen and A 70-year-old female presented to the emergency department extensive lysis of adhesions, resection of ileocolonic anastomosis for contained leak and ileostomy performed. Approximately 4 with complaints of diarrhea, vague, dull abdominal pain, unin- tentional weight loss and poor appetite. No hematochezia or months after discharge, the patient passed away while in a long- term care facility. melaena stated. Fecal occult is strongly positive in the ED. No Received: March 28, 2018. Accepted: April 26, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy100/4999373 by Ed 'DeepDyve' Gillespie user on 21 June 2018 2 A. Loutfy and S. Vasani Figure 3: CT abdomen and pelvis (pre-operatively) – transverse view. Figure 1: CT abdomen and pelvis (pre-operatively) – axial view. Figure 4: Adenocarcinoma of the ascending colon. Figure 2: CT abdomen and pelvis (pre-operatively) – transverse view. DISCUSSION Locally advanced colon cancers to adjacent organs have been a rare phenomenon. However, recently, ~5.2–23.6% of all colorectal cancers, at the time of presentation, penetrate or adhere to adja- cent organs [1]. Even less have been discovered to invade the duodenum and/or pancreas [2]. In previous years, invasion of colorectal cancers were considered unresectable [2]. As research progresses, it has been proven that there has been a decrease in mortality rates with resection of the tumor and involved adja- cent organs [3]. Due to a lack of visualization, local metastatic colorectal cancers are often identified at the time of surgical Figure 5: Adenocarcinoma of the duodenum – high power. exploration, in which the surgeon may not be completely Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy100/4999373 by Ed 'DeepDyve' Gillespie user on 21 June 2018 Locally advanced colon cancer resulting in en bloc right hemicolectomy and pancreaticoduodenectomy 3 Figure 6: Adenocarcinoma of the duodenum – low power. Figure 9: Adenocarcinoma of the adjacent lymph node. Figure 7: Adenocarcinoma of the cystic duct lymph node. Figure 10: Adenocarcinoma of the head of the pancreas – high power pancreaticoduodenectomy are considerably lower than other methods of treatment. When it comes to surgical intervention, there are three main methods of management of locally invasive colorectal cancers. These include hemicolectomy along with either en bloc pancreaticoduodenectomy, partial duodenectomy with either a pedicled ileal flap repair or direct suture. A 1947 study presented by Calmenson e Black, included a series of eight patients whom had locally advanced colon cancer with duo- denal invasion. These patients agreed to a duodenal resection that resulted in a 0% survival rate after a year (three dying immediately in the post-operative period) [4]. The first case of right hemicolectomy with en bloc pancreaticoduodenectomy was described by Van Prohaska in 1953 [5]. Evidence shows that aggressive resection of adjacent organs along with a hemico- lectomy has acceptable morbidity and mortality rates [6]. In comparison, a partial duodenal wall resection was associated with a poor outcome [7]. Even though complete resection Figure 8: Adenocarcinoma of the gallbladder. remains controversial, microscopic examination of locally advanced colorectal cancers have shown to have a direct exten- sion through the serosa of adjacent organs in 53.4%, whereas prepared to resect such a complex spread of cancer. However, the remaining 46.6% showed a simple inflammatory adherence we believe that with an experienced team, post-operative mor- [8]. Since over 50% of locally advanced colorectal cancers tality and morbidity rates of right hemicolectomy with en bloc Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy100/4999373 by Ed 'DeepDyve' Gillespie user on 21 June 2018 4 A. Loutfy and S. Vasani resulted in a microscopic infiltration, a right hemicolectomy indications for en bloc multivisceral surgery that differ from plus pancreaticoduodenectomy is strongly recommend for the next. This is a possible explanation as to why reported per- tumors that invade or are suspected to invade the duodenum centages of carcinomatous adhesions ranged from 47.2 to 100% and/or the pancreas [3]. However, when limited to the duode- [3]. num, a local duodenal resection is sufficient [9]. When an R0 resection was possible (achievable in 93% of all colorectal can- CONFLICT OF INTEREST STATEMENT cers), a poor outcome was avoided. However, patients with R1 or R2 resection have a 0% 5-year survival rate, compared to the None declared. 80.7% in R0 resection patients [8]. The greatest factor in the sur- vivability of locally advanced colorectal cancer patients is when REFERENCES R0 resection is possible, as confirmed by Lehnert et al.[6]. Advanced age alone, apart from usually associated comorbid- 1. Eisenberg SB, Kraybill WG, Lopez MJ. Long-term results of ities, is not considered an absolute contraindication to multi- surgical resection of locally advanced colorectal carcinoma. visceral resection, considering the better overall results as Surgery 1990;108:779–86. opposed to more conservative approaches [1]. 2. Cirocchi R, Partelli S, Castellani E, Renzi C, Parisi A, Noya G, A 2013 study showed that patients who are appropriate for et al. Right hemicolectomy plus pancreaticoduodenectomy right hemicolectomy with en bloc pancreaticoduodenectomy vs partial duodenectomy in treatment of locally advanced have the following characteristics: ‘(i) no distant metastasis, (ii) right colon cancer invading pancreas and/or only duode- R0 resection being possible on the basis of the preoperative num. Surg Oncol 2014;23:92–8. doi:10.1016/j.suronc.2014.03. examination, (iii) the patient’s condition being good enough to 003. accept radical multivisceral resection and (iv) the surgical team 3. Berrospi F, Celis J, Ruiz E, Payet E. En bloc pancreaticoduo- being experienced enough to perform the procedure’ [10]. denectomy for right colon cancer invading adjacent organs. Preoperative evaluations are strongly recommended to ensure J Surg Oncol 2002;79:194–8. that patients qualify. Preoperative staging is also a key factor; 4. Compton CC. Colorectal carcinoma: diagnostic, prognostic, this is done through abdominal CT scans. CT scans have a sig- and molecular features. Mod Pathol 2003;16:376e88. nificant (99%) ability to detect liver metastases, moderate abil- 5. Varker KA, Muscarella P, Wall K, Ellison C, Bloomston M. ity to reveal cT4 stage (86%) cancers but are poor at detecting Pancreatectomy for non-pancreatic malignancies results in peritoneal carcinomatosis [10]. CTs are able to distinguish improved survival after R0 resection. World J Surg Oncol colonic tumor stages pre-operatively and can show invasion 2007;5:145. through the muscularis propria, indicating stage T3/T4 [10]. 6. Lehnert T, Methner M, Pollok A, Schaible A, Hinz U, Potential complications can occur post-operatively. A 2014 Herfarth C. Multivisceral resection for locally advanced pri- study showed, within a 30-day post-operative period, morbidity mary colon and rectal cancer: an analysis of prognostic fac- rates were 12.8% (5 out of 39 patients) with en bloc pancreatico- tors in 201 patients. Ann Surg 2002;235:217e25. duodenectomy and hemicolectomy, 12.5% (one out of eight 7. Linton RR. Two stage operation for carcinoma of transverse patients) with pedicled ileal flap repair, and 0% with duodenal colon producing duodenocolic fistula. Report of two cases. resection with direct suture. Pancreatico-jejunal anastomotic Arch Surg 1944;48:197e207. leak was frequently seen as a major complication after a pan- 8. Croner R, Merkel S, Papadopoulos T, Schellerer V, creaticoduodenectomy with en bloc right hemicolectomy (3 out Hohenberger W, Goehl J. Multivisceral resection for colon of 39 patients) [2]. A 1944 study by Linton described two cases carcinoma. Dis Colon Rectum 2009;52:1381e6. with duodeno-colic fistula complications post-operatively [7]. 9. Fuks D, Pessaux P, Tuech JJ, Mauvais F, Bréhant O, Dumont None of the series in the former 2014 study reported a 30-day F, et al. Management of patients with carcinoma of the right post-operative mortality rate. colon invading the duodenum or pancreatic head. Int J A study suggested that only successful cases were presented Colorectal Dis 2008;23:477–81. as well as rejection of patients from outpatient clinics. 10. Zhang J, Leng J, Qian H, Qiu H, Wu J, Liu B, et al. En bloc Secondly, few studies provided sufficient analysis of patients pancreaticoduodenectomy and right colectomy in the treat- who purely underwent en bloc pancreaticoduodenectomy and ment of locally advanced colon cancer. Dis Colon Rectum right hemicolectomy. Finally, each study had their own 2013;56:874–80. doi:10.1097/dcr.0b013e3182941704. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy100/4999373 by Ed 'DeepDyve' Gillespie user on 21 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Surgical Case Reports Oxford University Press

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

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Abstract

Locally advancement of right colon cancer to the surrounding organs requiring surgical intervention is an extensive proced- ure associated with numerous risks. There are not many cases of which this phenomenon may occur. En bloc pancreatico- duodenectomy 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 pancreati- coduodenectomy and right hemicolectomy and review literature. Our method was a retrospective review of a patient with colon cancer INTRODUCTION endoscopies were found in her records. PMHx included COPD, Locally advanced colorectal cancer has beneficial treatment via osteoarthritis and DVT. Significant physical exam findings en bloc pancreaticoduodenectomy and right hemicolectomy. included mild, diffuse abdominal tenderness and RUQ palpable The morbidity and mortality rates are acceptable with an mass, and normal bowel sounds. Labs were significant for a experienced team. More often than not, excluding patients who hemoglobin of 5.7, hematocrit of 18.6% and CEA of 29.6. An are not surgical candidates due to various comorbidities, en abdominal/pelvis CT exhibited a 6 cm circumferential mass of bloc pancreaticoduodenectomy and right hemicolectomy the hepatic flexure (Figs 1–3). Two days later, a right hemico- should be performed for locally advanced colorectal cancers. lectomy with en bloc pancreaticoduodenectomy was performed. Bias does exist for numerous reasons but the most important Pathology showed adenocarcinoma stage IIIc (Figs 4–10). Post- being a lack of enrollment of patients. operatively, an abdominal/pelvis CT showed bilateral pulmonary emboli and a 14 cm pelvic abscess. Bilateral lower extremity ultrasound showed low probability for DVT. Exploratory laparot- CASE REPORT omy was performed where the pelvic abscess was seen and A 70-year-old female presented to the emergency department extensive lysis of adhesions, resection of ileocolonic anastomosis for contained leak and ileostomy performed. Approximately 4 with complaints of diarrhea, vague, dull abdominal pain, unin- tentional weight loss and poor appetite. No hematochezia or months after discharge, the patient passed away while in a long- term care facility. melaena stated. Fecal occult is strongly positive in the ED. No Received: March 28, 2018. Accepted: April 26, 2018 Published by Oxford University Press and JSCR Publishing Ltd. All rights reserved. © The Author(s) 2018. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/ licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy100/4999373 by Ed 'DeepDyve' Gillespie user on 21 June 2018 2 A. Loutfy and S. Vasani Figure 3: CT abdomen and pelvis (pre-operatively) – transverse view. Figure 1: CT abdomen and pelvis (pre-operatively) – axial view. Figure 4: Adenocarcinoma of the ascending colon. Figure 2: CT abdomen and pelvis (pre-operatively) – transverse view. DISCUSSION Locally advanced colon cancers to adjacent organs have been a rare phenomenon. However, recently, ~5.2–23.6% of all colorectal cancers, at the time of presentation, penetrate or adhere to adja- cent organs [1]. Even less have been discovered to invade the duodenum and/or pancreas [2]. In previous years, invasion of colorectal cancers were considered unresectable [2]. As research progresses, it has been proven that there has been a decrease in mortality rates with resection of the tumor and involved adja- cent organs [3]. Due to a lack of visualization, local metastatic colorectal cancers are often identified at the time of surgical Figure 5: Adenocarcinoma of the duodenum – high power. exploration, in which the surgeon may not be completely Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy100/4999373 by Ed 'DeepDyve' Gillespie user on 21 June 2018 Locally advanced colon cancer resulting in en bloc right hemicolectomy and pancreaticoduodenectomy 3 Figure 6: Adenocarcinoma of the duodenum – low power. Figure 9: Adenocarcinoma of the adjacent lymph node. Figure 7: Adenocarcinoma of the cystic duct lymph node. Figure 10: Adenocarcinoma of the head of the pancreas – high power pancreaticoduodenectomy are considerably lower than other methods of treatment. When it comes to surgical intervention, there are three main methods of management of locally invasive colorectal cancers. These include hemicolectomy along with either en bloc pancreaticoduodenectomy, partial duodenectomy with either a pedicled ileal flap repair or direct suture. A 1947 study presented by Calmenson e Black, included a series of eight patients whom had locally advanced colon cancer with duo- denal invasion. These patients agreed to a duodenal resection that resulted in a 0% survival rate after a year (three dying immediately in the post-operative period) [4]. The first case of right hemicolectomy with en bloc pancreaticoduodenectomy was described by Van Prohaska in 1953 [5]. Evidence shows that aggressive resection of adjacent organs along with a hemico- lectomy has acceptable morbidity and mortality rates [6]. In comparison, a partial duodenal wall resection was associated with a poor outcome [7]. Even though complete resection Figure 8: Adenocarcinoma of the gallbladder. remains controversial, microscopic examination of locally advanced colorectal cancers have shown to have a direct exten- sion through the serosa of adjacent organs in 53.4%, whereas prepared to resect such a complex spread of cancer. However, the remaining 46.6% showed a simple inflammatory adherence we believe that with an experienced team, post-operative mor- [8]. Since over 50% of locally advanced colorectal cancers tality and morbidity rates of right hemicolectomy with en bloc Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy100/4999373 by Ed 'DeepDyve' Gillespie user on 21 June 2018 4 A. Loutfy and S. Vasani resulted in a microscopic infiltration, a right hemicolectomy indications for en bloc multivisceral surgery that differ from plus pancreaticoduodenectomy is strongly recommend for the next. This is a possible explanation as to why reported per- tumors that invade or are suspected to invade the duodenum centages of carcinomatous adhesions ranged from 47.2 to 100% and/or the pancreas [3]. However, when limited to the duode- [3]. num, a local duodenal resection is sufficient [9]. When an R0 resection was possible (achievable in 93% of all colorectal can- CONFLICT OF INTEREST STATEMENT cers), a poor outcome was avoided. However, patients with R1 or R2 resection have a 0% 5-year survival rate, compared to the None declared. 80.7% in R0 resection patients [8]. The greatest factor in the sur- vivability of locally advanced colorectal cancer patients is when REFERENCES R0 resection is possible, as confirmed by Lehnert et al.[6]. Advanced age alone, apart from usually associated comorbid- 1. Eisenberg SB, Kraybill WG, Lopez MJ. Long-term results of ities, is not considered an absolute contraindication to multi- surgical resection of locally advanced colorectal carcinoma. visceral resection, considering the better overall results as Surgery 1990;108:779–86. opposed to more conservative approaches [1]. 2. Cirocchi R, Partelli S, Castellani E, Renzi C, Parisi A, Noya G, A 2013 study showed that patients who are appropriate for et al. Right hemicolectomy plus pancreaticoduodenectomy right hemicolectomy with en bloc pancreaticoduodenectomy vs partial duodenectomy in treatment of locally advanced have the following characteristics: ‘(i) no distant metastasis, (ii) right colon cancer invading pancreas and/or only duode- R0 resection being possible on the basis of the preoperative num. Surg Oncol 2014;23:92–8. doi:10.1016/j.suronc.2014.03. examination, (iii) the patient’s condition being good enough to 003. accept radical multivisceral resection and (iv) the surgical team 3. Berrospi F, Celis J, Ruiz E, Payet E. En bloc pancreaticoduo- being experienced enough to perform the procedure’ [10]. denectomy for right colon cancer invading adjacent organs. Preoperative evaluations are strongly recommended to ensure J Surg Oncol 2002;79:194–8. that patients qualify. Preoperative staging is also a key factor; 4. Compton CC. Colorectal carcinoma: diagnostic, prognostic, this is done through abdominal CT scans. CT scans have a sig- and molecular features. Mod Pathol 2003;16:376e88. nificant (99%) ability to detect liver metastases, moderate abil- 5. Varker KA, Muscarella P, Wall K, Ellison C, Bloomston M. ity to reveal cT4 stage (86%) cancers but are poor at detecting Pancreatectomy for non-pancreatic malignancies results in peritoneal carcinomatosis [10]. CTs are able to distinguish improved survival after R0 resection. World J Surg Oncol colonic tumor stages pre-operatively and can show invasion 2007;5:145. through the muscularis propria, indicating stage T3/T4 [10]. 6. Lehnert T, Methner M, Pollok A, Schaible A, Hinz U, Potential complications can occur post-operatively. A 2014 Herfarth C. Multivisceral resection for locally advanced pri- study showed, within a 30-day post-operative period, morbidity mary colon and rectal cancer: an analysis of prognostic fac- rates were 12.8% (5 out of 39 patients) with en bloc pancreatico- tors in 201 patients. Ann Surg 2002;235:217e25. duodenectomy and hemicolectomy, 12.5% (one out of eight 7. Linton RR. Two stage operation for carcinoma of transverse patients) with pedicled ileal flap repair, and 0% with duodenal colon producing duodenocolic fistula. Report of two cases. resection with direct suture. Pancreatico-jejunal anastomotic Arch Surg 1944;48:197e207. leak was frequently seen as a major complication after a pan- 8. Croner R, Merkel S, Papadopoulos T, Schellerer V, creaticoduodenectomy with en bloc right hemicolectomy (3 out Hohenberger W, Goehl J. Multivisceral resection for colon of 39 patients) [2]. A 1944 study by Linton described two cases carcinoma. Dis Colon Rectum 2009;52:1381e6. with duodeno-colic fistula complications post-operatively [7]. 9. Fuks D, Pessaux P, Tuech JJ, Mauvais F, Bréhant O, Dumont None of the series in the former 2014 study reported a 30-day F, et al. Management of patients with carcinoma of the right post-operative mortality rate. colon invading the duodenum or pancreatic head. Int J A study suggested that only successful cases were presented Colorectal Dis 2008;23:477–81. as well as rejection of patients from outpatient clinics. 10. Zhang J, Leng J, Qian H, Qiu H, Wu J, Liu B, et al. En bloc Secondly, few studies provided sufficient analysis of patients pancreaticoduodenectomy and right colectomy in the treat- who purely underwent en bloc pancreaticoduodenectomy and ment of locally advanced colon cancer. Dis Colon Rectum right hemicolectomy. Finally, each study had their own 2013;56:874–80. doi:10.1097/dcr.0b013e3182941704. Downloaded from https://academic.oup.com/jscr/article-abstract/2018/5/rjy100/4999373 by Ed 'DeepDyve' Gillespie user on 21 June 2018

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Journal of Surgical Case ReportsOxford University Press

Published: May 18, 2018

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