Surgical Oncology xxx (2014) 1e7

Contents lists available at ScienceDirect

Surgical Oncology
journal homepage: www.elsevier.com/locate/suronc

Review

Right hemicolectomy plus pancreaticoduodenectomy vs partial

duodenectomy in treatment of locally advanced right colon cancer
invading pancreas and/or only duodenum
Roberto Cirocchi a, Stefano Partelli b, Elisa Castellani c, Claudio Renzi c, *, Amilcare Parisi a,
Giuseppe Noya c, Massimo Falconi b
a
Department of Digestive and Liver Surgery Unit, St Maria Hospital, Terni, Italy
b
Pancreatic Surgery Unit, Universit Politecnica delle Marche, Ancona, Italy
c
Department of General and Oncologic Surgery, University of Perugia, Perugia, Italy

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Pancreatic or duodenal invasion by locally advanced right colon cancer is an unusual event
Accepted 17 March 2014 whose management still represents a surgical challenge. This review aims to compare results of limited
vs. extended resection in case of primary right colon cancer invading pancreas and/or duodenum.
Keywords: Methods: A systematic search in Medline, Embase and Cochrane Central Register of Controlled Trials
Cancer (CENTRAL) was performed. All trials describing the surgical treatment of right colon cancer invading
Colon
pancreas and/or duodenum were considered. A data extraction sheet was developed, based on the
Duodenum
Cochrane Consumers and Communication Review Groups data extraction template.
Pancreas
Surgery
Results: 5-years overall survival was 52% after en bloc pancreaticoduodenectomy plus right hemi-
colectomy vs. 0 and 25% in case of duodenal resection with correction by direct suture or pedicled ileal
ap, respectively. 30-day postoperative morbidity rate was slightly higher after en block resections
(12.8%) with respect to duodenal local resection and direct suture or pedicled ileal ap repair (0 and
12.2%, respectively). After extended resection the rate of pancreatico-jejunal anastomotic leakage was
7.7%.
Conclusions: In patients with right colon cancer extended to the pancreas and/or duodenum surgical
multivisceral resection is suggested when complete tumour removal (R0) is achievable. Even though no
signicant differences in postoperative morbidity and mortality have been shown, 5 y OS has improved
in extended resections as compared to duodenal local resection with defect repair either by direct suture
or by a pedicled ileal ap.
2014 Elsevier Ltd. All rights reserved.

Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Study design and participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Systematic literature search . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Primary and secondary outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Data extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Data synthesis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

* Corresponding author. Department of General and Oncologic Surgery, Univer-

sity of Perugia, St. Maria Hospital, SantAndrea delle Fratte, Via Gambuli n.1, 06156
Terni, Italy. Tel.: 39 0755205468.
E-mail address: renzicla@virgilio.it (C. Renzi).

http://dx.doi.org/10.1016/j.suronc.2014.03.003
0960-7404/ 2014 Elsevier Ltd. All rights reserved.

Please cite this article in press as: Cirocchi R, et al., Right hemicolectomy plus pancreaticoduodenectomy vs partial duodenectomy in treatment
of locally advanced right colon cancer invading pancreas and/or only duodenum, Surgical Oncology (2014), http://dx.doi.org/10.1016/
j.suronc.2014.03.003
2 R. Cirocchi et al. / Surgical Oncology xxx (2014) 1e7

Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Description of included and excluded studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Quality assessment of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Primary and secondary outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Authorship statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Conflict of interest statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00

Introduction Systematic literature search

Locally advanced colon cancers (LACCs) are classied as a T4 A comprehensive systematic literature search in Medline,
lesion by the American Joint Committee on Cancer (AJCC) staging Embase and the Cochrane Central Register of Controlled Trials
system [1]. Adhesions between the colon and other organs may (CENTRAL) was performed.
suggest unresectability, but sometimes this may be simply due to The search strategy included MeSH terms and keywords, as
an inammatory reaction. The en-bloc resection of the colon follows:
together with the organs involved initially proposed by Bacon [2]
was subsequently challenged and treatment of these advanced - Multivisceral[All Fields] AND resection[All Fields] AND
cases remains still controversial. In fact, microscopic examination (colon[MeSH Terms] OR colon[All Fields]) AND (carcino-
conrmed the clinical suspicion of neoplastic inltration into ma[MeSH Terms] OR carcinoma[All Fields])
adjacent organs as a result of direct extension through the serosa in - En-bloc[Title] AND pancreatoduodenectomy[Title] AND right
53.4% of cases, while it showed simple inammatory adherence of [Title] AND hemicolectomy[Title]
the tumour to adjacent organs without microscopic inltration in - Resection[All Fields] AND AND (carcinoma[MeSH Terms] OR
the remaining 46.6% of cases [3]. carcinoma[All Fields]) AND (colon[MeSH Terms] OR colo-
LACC did not show a poor outcome when a R0 resection was n[All Fields]) AND invading[All Fields] AND (duode-
possible, condition usually achievable in 93% of all colorectal can- num[MeSH Terms] OR duodenum[All Fields])) OR
cers [4]. No patient with R1 or R2 resection survived at 5 years, ((pancreas[MeSH Terms] OR pancreas[All Fields] OR pan-
compared to 80.7% of patients who underwent R0 resection [3]. In a creatic[All Fields]) AND (head[MeSH Terms] OR head[All
series of 139 cases, of which complete R0 resection was possible in Fields])
91 (65.5%), Lehnert conrmed this factor as the greatest predictor of
survival [5]. The research has been performed in June 2012. Systematic
Pancreatic or duodenal invasion by right LACC is an unusual database investigation was implemented by manual search and
event whose management still represents a surgical challenge. further references were detected through the proceedings of
Intraoperative complexity and high postoperative risk of compli- various organizations of national reference (American Society of
cations for en-bloc right colectomy plus pancreaticoduodenectomy Colon and Rectal Surgeons, Association of Coloproctology of Great
(PD) often discourage surgeons from the procedure. Britain and Ireland, European Society of Coloproctologists, Societ
Aim of the present systematic review is to compare the peri- Italiana di Chirurgia Colo-Rettale and American College of Sur-
operative and long term results of limited vs. extended resection in geons annual meetings). The very early studies (1940s) did not
primary right colon cancer invading the pancreas and/or the seem to be relevant to current surgical practice, given the ad-
duodenum. vances in postoperative care, systemic therapy and surgical
management. Therefore studies from 1980 to June 2012 were
Materials and methods included.
Study selection: Records were obtained from each database, then
This systematic review was performed according to the moved to the bibliographic software package EndNote 8.02, and
Preferred Reporting Items for Systematic reviews and Meta- nally merged into a core database to remove duplicates. All
Analyses (PRISMA) statement [6]. Eligibility criteria provided pa- potentially relevant papers identied when analysing other sources
rameters of exclusion and inclusion. (reference lists of relevant trials, reviews, articles and textbooks)
were found and then collected by manually entering into EndNote.
Study design and participants Two authors (RC and EC) assessed independently and in duplicate
the titles and abstracts of all the reports of trials identied by the
Inclusion criteria: randomized clinical trials (RCTs) and non electronic search outlined above. Hard copies of the full text of
randomized clinical studies (non-RCSs) describing surgical treat- studies fullling the inclusion criteria were obtained. Agreement
ment of right LACC with pancreatic and/or duodenal invasion. No between the reviewers on assessment of each methodological item
language or publication status restrictions were imposed. was quantied with weighted kappa. Disagreements were resolved
Exclusion criteria: studies in which the outcomes of interest through discussion and involving a third author (CB).
were not reported or impossible to be extrapolated from the pub-
lished results. Primary and secondary outcomes
Type of participants: adult patients with right LACC with
pancreatic and/or only duodenal invasion irrespective of gender OS was considered as the primary outcome, 30-day post-
and comorbidities. operative mortality and overall rate of complications such as sec-
Type of treatment: multivisceral surgical resection. ondary outcomes.

Please cite this article in press as: Cirocchi R, et al., Right hemicolectomy plus pancreaticoduodenectomy vs partial duodenectomy in treatment
of locally advanced right colon cancer invading pancreas and/or only duodenum, Surgical Oncology (2014), http://dx.doi.org/10.1016/
j.suronc.2014.03.003
 R. Cirocchi et al. / Surgical Oncology xxx (2014) 1e7
Data extraction
A data extraction sheet was developed, based on the Cochrane
Consumers and Communication Review Groups data extraction
template [7].
Data synthesis
The assessment of methodological quality of the included
studies was carried out using the quality checklist for case series of
the National Institute for Health and Clinical Excellence (NICE) [8].
Two authors (RC and EC) independently extracted data for listed
outcomes and assessed the methodological quality of each study,
without masking the authors names.
Subgroup analysis of 30-day postoperative major morbidity and
OS was performed between the following groups: pancreatic and/
or duodenal resection with or without liver resection, SMV (Supe-
rior Mesenteric Vein) resection and nephrectomy.
Results
Description of included and excluded studies
We found 7.226 items concerning the topic by electronic search
and 12 additional through other sources (Fig. 1). Initial screening of
titles and abstracts resulted in exclusion of 7.175 studies, further 36
were excluded after detailed screening of the full articles [3,5,9e
42]. Fifteen published studies, which characteristics are listed in
Tables 1ae1c, were then included in the present systematic review
[43e57]. Only non-RCSs were included, since no RCTs were found.
The role of induction chemotherapy or chemoradiotherapy, which
might well be indicated in T4b colon carcinomas was not reported
in the selected trials. Furthermore, no selection criteria for opera-
bility nor data about comorbidities were described. Duration of
surgery was reported only in PD group, ranging from 225 min to
10 h [47,48,50,52,55]. At diagnosis none of the patients presented
with extra abdominal metastases. In the included studies three
different approaches for right LACC invading the duodenum and/or
pancreas were proposed: en bloc right colectomy plus PD, duodenal
resection with repair either through pedicled ileal ap or by direct
suture.
Figure 1. PRISMA ow chart of literature search.
Please cite this article in press as: Cirocchi R, et al., Right hemicolectomy plus pancreaticoduodenectomy vs partial duodenectomy in treatment
of locally advanced right colon cancer invading pancreas and/or only duodenum, Surgical Oncology (2014), http://dx.doi.org/10.1016/
j.suronc.2014.03.003
3
Quality assessment of included studies
The methodological quality assessment of the included studies,
described in Table 2, proved a fair quality of the selected items
evaluated with the NICE checklist [8]. Only the study by Koea et al.
[53] showed a good methodological quality.
Primary and secondary outcomes
Overall, 53 patients underwent R0 resection, of which 39 treated
with en bloc PD (Table 1a), 10 with partial duodenectomy and
pedicled ileal ap repair (Table 1b) and 4 with direct suture after
partial duodenectomy (Table 1c). 30-day postoperative morbidity
(according to the ClavieneDindo classication of surgical compli-
cations) [58] was 12.8% (5/39) in patients receiving en bloc PD and
right hemicolectomy, similar to 12.5% (1/8) after pedicled ileal ap
repair. No 30-day postoperative morbidity was found in patients
undergoing duodenal resection with direct suture. The most
frequently described major complication after PD and right hemi-
colectomy was a pancreatico-jejunal anastomotic leak (7.7%) (3/39).
None of the series reported 30-day postoperative mortality.
As regards survival, the reported 5-y OS was 52% for patients
who underwent R0 right colectomy with en bloc PD vs. 25 and 0%
for those submitted to partial duodenectomy and pedicled ileal ap
repair or direct suture, respectively.
Of the 29 patients who underwent PD plus RH 2 patients had a
negative CT for adjacent organ invasion. At histological examina-
tion of the operatory specimens 7 patients had only duodenal in-
vasion; 10 had only pancreas invaded; 9 had both pancreatic and
duodenal involvement, 3 did not presented invasion of the adjacent
structures [46]. In this group mean and median overall survival was
52 months and 30 months, respectively. Six out 10 patients who
underwent a PPPD plus RH had only duodenal involvement at
histology (1 CT negative) while the other 4 had both pancreas and
duodenum involved (two patients stage II, Dukes C). Their mean
and median OS after the intervention was 33 months and 24
months, respectively. Fourteen patients underwent partial
duodenal resection, with positive histological examination of the
specimens (7 stage III, Dukes C) with a mean and median survival
amounting to 32.6 months and 30 months, respectively.
In the group of patients who underwent en bloc right colectomy
plus PD, 9 received adjuvant therapy: 4 had 5-Fluorouracil and
Leucovorin (5FU/LV) [43,50,53]; 4 received 5FU and Levamisole [51]
and one had Capecitabine [47]. No chemotherapy was administered
to patients who underwent duodenal local resection. Statistical
analysis was impossible to perform because of the heterogeneity of
data.
Prognosis appears to be less favourable after duodenal resection,
but such statement is only based on a limited number of cases.
There was no signicant difference in 30-day postoperative major
morbidity and OS between the following subgroups: pancreatic
and/or duodenal local resection with or without liver resection,
SMV resection and nephrectomy.
Discussion
Locally advanced neoplasms invading adjacent organs are
frequently incurable. Colorectal cancer is an exception to this rule,
being LACC often completely resectable [59]. Extended surgical
resection has been a relatively common strategy for the treatment
of sigmoid cancer, rarer for that of the right colon. In 1926, Moy-
nihan described a case of LACC and suggested radical resection of
the tumour and involved organs or abdominal wall [60]. Among the
multivisceral resections for LACC, jejunal and ileal resections have
been performed with relative frequency, while duodenal resections
4 R. Cirocchi et al. / Surgical Oncology xxx (2014) 1e7

Table 1a
Characteristics of included studies: en bloc pancreaticoduodenectomy and right hemicolectomy.

Study Patients Grading of Tumour extension N status Multivisceral Survival

age-gender the tumour resection [years; months]

Perysinakis [43] 36 M Moderate Pancreas; SMV 1 PD; SMV (segment) DFS : 9 y

Costa [44] 63 M Moderate Duodenum; pancreas 0 PD DFS: 4 y
48 M Moderate Duodenum; pancreas; right kidney 0 PPPD; nephrectomy DFS: 2 y
OS: 30 m
51 M Moderate Duodenum 0 PPPD; liver resection DFS: 1 y
Henriques [45] 63 M Moderate Duodenum; pancreas 0 PD DFS : 4 y
Saiura [46] 59 F Mucinous Duodenum; pancreas 1 NR OS: 1 m
50 M Well Stomach; pancreas 0 NR OS: 3 y, 1 m
77 F Well Duodenum 0 NR OS: 14 y
51 F Well Duodenum 0 NR 18 y, alive
49 M Mucinous Duodenum; pancreas 1 NR OS:3 y, 3 m
55 M Well Duodenum 0 NR 10 y, alive
34 M Mucinous Stomach; duodenum 0 NR 11 y, 9 m, alive
68 M mucinous duodenum; pancreas 1 NR OS: 10 m
61 M Mucinous Duodenum 1 NR OS: > 12 y, 10 m
69 M Poorly Duodenum; liver 1 NR OS: 1 y, 3 m
62 M Well Pancreas 0 NR OS: >6 y, 6 m
62 F Well Stomach; duodenum 0 NR OS: >3 m
Meyer [47] 76 M Poorly Duodenum; pancreas 1 PD OS: >1 y, 6 m
Song [48] NR Poorly Duodenum NR NR DFS: 9 y
NR NR Duodenum; pylorus NR PD OS: 6 m
NR Moderate Duodenum; pancreas NR NR DFS: 82 m
NR NR Duodenum; pancreas NR NR OS: 6 m
NR NR duodenum; SMV NR PD; SMV OS: 6 m
Perez [49] 41M Moderate Duodenum; pancreas 0 PPPD OS: 2 y
Berrospi [50] 65F Moderate Duodenum; pancreas 0 PPPD OS: 9 y, 8 m
40M Poorly Duodenum; pancreas; liver 0 PPPD OS: 10 m
51M Moderate Duodenum; pancreas 0 PD; liver resection OS: 2 y, 6 m
Kama [51] NR NR Duodenum NR PPPD 3 patients DFS
NR NR Duodenum; liver NR PPPD; liver resection ranging 14e41 m
NR NR Duodenum NR PPPD
NR NR Duodenum; pancreas NR PPPD (8 m later)
Iwasaki [52] 57M Well Duodenum; pancreas; right kidney; liver 1 PD; nephrectomy; liver resection OS: >1 y
Koea [53] 46M Poorly Duodenum; pancreas 2 PD OS: 1y
65M Poorly Duodenum; pancreas 1 PD OS: >2 y
56F Poorly Duodenum; pancreas 1 PD OS: >2 y, 6 m
61M Poorly Duodenum; pancreas 0 PD OS: >2, 2 m
Praderi [54] NR NR Duodenum; pancreas NR PD OS: >10 y
NR NR Duodenum; pancreas NR PD OS: >11 y
Yoshimi [55] 66M Well Duodenum; SMV 1 PPPD; SMV (part) OS: 3 y, 1 m

SMV: superior mesenteric vein; PD: pancreaticoduodenectomy; PPPD: pylorus preserving pancreaticoduodenectomy; DFS: disease free survival; OS: overall survival; NR: not
reported.

Table 1b
Characteristics of included studies: pedicled ileal ap reconstruction for duodenal defect after right hemicolectomy.

Study Patients Histology/grading Tumour extension N status Multivisceral resection Survival

age-gender [years, months]

Lianwen [56] 58M Mucinous NR NR Partial duodenectomy OS: 2 y, 3 m

42F NR NR NR Partial duodenectomy OS: 2y
50M NR NR NR Partial duodenectomy OS: >3 y
40M NR NR NR Partial duodenectomy OS: >3 y
38M NR NR NR Partial duodenectomy OS: >3 y
33M Non-hodgkin NR NR Pylorus gastrectomy OS: >9 m
Lymphoma Partial duodenectomy
Richa [57] 53M NR Duodenum 0 Duodenectomy DFS: 2 y, 6 m
71M NR duodenum; Liver; gallbladder 0 Duodenectomy DFS: 6 m
Koea [53] 48M Poorly Duodenum 2 Duodenectomy OS: 2 y
75F Poorly Duodenum 0 Duodenectomy OS: >2 y, 2 m

NR: not reported; OS: overall survival; DFS: disease free survival.

Table 1c
Characteristics of included studies: duodenal resection and direct repair for duodenal defect after right hemicolectomy.

Study Patients Histology/grading Tumour extension N status Multivisceral resection Overall survival
age-gender [years, months]

Koea [53] 77M Poorly Duodenum 0 Duodenectomy >7 y

61M Poorly Duodenum 1 Duodenectomy 2 y, 6 m
Praderi [54] NR NR Duodenum; liver NR Duodenectomy; liver resection >3 y
NR NR Duodenum; liver NR Duodenectomy; liver resection 4 y, 4 m

NR: not reported.

Please cite this article in press as: Cirocchi R, et al., Right hemicolectomy plus pancreaticoduodenectomy vs partial duodenectomy in treatment
of locally advanced right colon cancer invading pancreas and/or only duodenum, Surgical Oncology (2014), http://dx.doi.org/10.1016/
j.suronc.2014.03.003
 R. Cirocchi et al. / Surgical Oncology xxx (2014) 1e7 5

Table 2
Evaluation of methodological quality of the included studies.

Items/authora 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57

Case series collected in more than one centre, i.e. multi-centre study 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Is the hypothesis/aim/ 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
objective of the study clearly described?
Are the inclusion and exclusion criteria (case denition) clearly reported? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Is there a clear denition of the outcomes reported? 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
Were data collected prospectively? 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0
Is there an explicit statement that patients were recruited consecutively? 0 0 0 1 0 1 0 1 1 0 1 0 1 1 0
Are the main ndings of the study clearly described? 1 1 1 1 1 0 1 1 0 1 1 1 1 1 1
Are outcomes stratied? (e.g., by disease stage, abnormal test results, 0 0 0 1 0 0 0 0 1 0 1 0 0 0 0
patient characteristics)
Total Score 4 4 4 6 4 4 4 5 5 4 7 5 5 5 4
Yes 1 No(not reported, not available) 0
Total score, 8; 3, poor quality; 4e6, fair quality; 7, good quality
a
Listed by references.

remained a much rare event. Peritoneum (35%), abdominal wall
(25%), small bowel (other than duodenum) (16%), omentum (16%),
urinary bladder (14%) and ovaries (12%) were the most frequently
invaded adjacent structures; invasion of the duodenum (3%), uterus
(4%), stomach (4%), retroperitoneum (4%) and Gerotas fascia (2%)
were rarely found [33].
Duodenal resection has never represented a technical contra-
indication. In fact, already in the 1930s the right colon carcinoma
with duodenal invasion was considered as potentially resectable,
although with a very poor prognosis due to possible complications
after resection and suture [65]. In 1944 Linton described two cases
of LACC complicated by malignant duodeno-colic stula [61]. In
1947 Calmenson e Black presented a series of 8 patients affected by
right LACC and duodenal invasion submitted to duodenal resection.
Three of them died almost immediately in the post-operative
period and no one was alive at year one [10]. In 1953 Van Pro-
haska described the rst case of right colectomy and en bloc PD for
right LACC invading duodenum and pancreas [11]. Two years later
Roux and Carcassonne focused on the treatment of advanced right
colon cancer with duodenal and/or pancreatic invasion, purposing
systematic right colectomy plus PD. Despite the radicality of such
procedure, prognosis still remained unfavourable [66].
Recently, even more case reports and case series described T4
right colon cancers requiring either pancreatic or duodenal re-
sections. Data from these studies provided evidence to support
aggressive resections of adjacent organs, including the pancreas,
with acceptable morbidity and mortality rates [4]. Partial duodenal
wall resection was only associated with poor outcomes when
compared to Whipple procedure, perhaps indicating the need for
radical resection of the secondarily involved organ to include the
lymphatic drainage. For patients with poor general conditions
some Authors suggest a partial duodenal resection plus RH, when
duodenum only is partially involved by the tumour, with the papilla
of Vater free of disease [56],. In case of non-metastatic right LACC,
multivisceral resection is actually increasingly advised [67]. Elderly
alone, taken apart comorbidities, should not be considered as an
absolute contraindication to multivisceral resection, since in
selected patients it may give better overall results than more con-
servative approaches [68].
Most important prognostic factor after primary cancer radical
resection, has been considered regional nodal status [59], but ac-
cording to recent investigations multivisceral resection may
improve survival, regardless of nodal status [32]. The majority of
patients whose prognosis was improved after extended resection,
suffered from mucinous adenocarcinomas, a neoplasm producing
signicant amounts of extracellular mucus, which constitutes more
than 50% of the tumour volume [69]. Mucinous adenocarcinomas
and/or adenocarcinomas with a mucinous component showed high
local proliferation rate but, as recently described by Lagner, those
neoplasms do not differ from conventional adenocarcinomas in
terms of prognosis and histological predictors of outcome [70]. In
this systematic review on right colon LACC invading pancreas and/
or duodenum, survival was improved for patients undergoing PD
plus hemicolectomy, but groups were not comparable as regards to
tumour size, blood loss, and demographics.
While in the past times the nding of a right LACC was often
intraoperative [15], currently the diagnosis is mainly preoperative,
with the exception of a small number of patients operated on in
emergency for obstruction or bleeding [21]. Preoperative staging of
LACCs is routinely performed through abdominal CT scanning,
whose ability to nd out liver metastases is excellent (99%), to
reveal cT4 stage good (86%), but still poor (33%) in detecting peri-
toneal carcinomatosis [62]. A recent meta-analysis shows that CT
accurately distinguished the colonic stage tumours preoperatively
and reported information on tumour invasion beyond the muscu-
laris propria (stage T3/T4) [63]. CT scan shows the highest accuracy
in detecting distant metastases [64], providing the best results as
regards those to the liver. The role of imaging should not just be
limited in the diagnostic of eventual duodenal and/or pancreatic
invasion, but guide the selection of patients eligible for a complete
cytoreduction, thus improving their prognosis. On the other hand
imaging cannot often distinguish between inammatory adhesions
and tumour direct inltration. Sometimes adhesions or inltration
of the adjacent organs can be detected for the rst time intra-
operatively and only histologic examination allows a certain diag-
nosis of the extent of the colonic cancer [kapoor 32]. However since
over 50% of the adherences of LACC to the surrounding organs
resulted in a histological inltration [berrospi 50], for larger tu-
mours invading or suspected to invade the duodenum and/or the
pancreas at the preoperative exams and/or at the surgical explo-
ration, a RH plus PD is advisable [koea 53]. In selected cases when
inltration or adhesions, detected during the surgical intervention,
are limited to the duodenum a local duodenal resection can be
performed.[ kama 51].
The possible surgical options described are very heterogeneous.
Some patients had PD plus hemicolectomy only, some patients had
nephrectomy, some patients had a liver resection.
In conclusion, in patients with right LACC, extensive multi-
visceral resection is suggested when complete tumour removal
(R0) is achievable. However evidence is not enough to establish
with certainty which one between PD and duodenal resection
provides superior long-term survival, being randomized trial about
the topic missing. Moreover no signicant differences in post-
operative morbidity and mortality emerged among the different
procedures associated to right hemicolectomy. Surgical treatment
of LACC invading pancreas and/or duodenum still represents an

Please cite this article in press as: Cirocchi R, et al., Right hemicolectomy plus pancreaticoduodenectomy vs partial duodenectomy in treatment
of locally advanced right colon cancer invading pancreas and/or only duodenum, Surgical Oncology (2014), http://dx.doi.org/10.1016/
j.suronc.2014.03.003
6 R. Cirocchi et al. / Surgical Oncology xxx (2014) 1e7
important topic. Data from a structured comparative group of pa-
tients were not available.
Conclusion
LACC with duodenal and/or pancreatic head invasion is still a
challenging surgical matter. The present systematic review was
impaired by the lack of primary data on this topic. With respect to
such uncommon condition, the results seem to show that the
challenge to improve survival can be achieved in those cases
receiving en bloc resection including both PD and colectomy.
Perhaps the other treatment options, such as pedicled ileal ap
repair and direct suture, should be considered depending on the
extent of the involvement and suggest differences in diseases
biology and patients general condition. These considerations
require some caution due to the very limited and highly hetero-
geneous data (case reports/small series), which can be subjected to
selection, confounding and publication bias. Since randomized
clinical trials on this important topic are not available and difcult
to plan also in the future, the present results might already drive
the surgical decision.
Conict of interest statement
All authors have no conicts of interest. No funding sources
supporting publication to be stated.
Authorship statement
Guarantor of the integrity of the study: Roberto Cirocchi, Mas-
simo Falconi, Giuseppe Noya
Study concepts: Roberto Cirocchi, Claudio Renzi, Amilcare Parisi,
Elisa Castellani
Study design: Roberto Cirocchi, Claudio Renzi, Amilcare Parisi,
Stefano Partelli
Denition of intellectual content: Roberto Cirocchi, Massimo
Falconi, Giuseppe Noya
Literature research: Claudio Renzi, Elisa Castellani, Stefano
Partelli
Data acquisition: Roberto Cirocchi, Claudio Renzi, Elisa Cas-
tellani, Stefano Partelli
Data analysis: Roberto Cirocchi, Claudio Renzi, Amilcare Parisi,
Elisa Castellani, Stefano Partelli, Massimo Falconi, Giuseppe Noya
Statistical analysis: Elisa Castellani, Claudio Renzi
Manuscript preparation: Roberto Cirocchi, Claudio Renzi, Elisa
Castellani, Stefano Partelli, Massimo Falconi
Manuscript editing: Claudio Renzi, Elisa Castellani, Stefano
Partelli
Acknowledgements
The authors report no conicts of interest. Besides they are the
only ones responsible for the content and writing of the paper.
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