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Colo-Pancreaticoduodenectomy for Locally Advanced Colon Carcinoma—Feasibility in Patients Presenting with Acute Abdomen

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Colo-Pancreaticoduodenectomy for Locally Advanced Colon Carcinoma—Feasibility in Patients Presenting with Acute Abdomen Chen et al. World Journal of Emergency Surgery (2021) 16:7 https://doi.org/10.1186/s13017-021-00351-6 RESEARCH ARTICLE Open Access Colo-pancreaticoduodenectomy for locally advanced colon carcinoma—feasibility in patients presenting with acute abdomen Joe-Bin Chen1,2, Shao-Ciao Luo1,3, Chou-Chen Chen1,2, Cheng-Chung Wu1,4,3,5,6*, Yun Yen5, Chuan-Hsun Chang6, Yun-An Chen7 and Fang-Ku P’eng1,4 Abstract Background: En bloc right hemicolectomy plus pancreaticoduodenectomy (PD) is administered for locally advanced colon carcinoma that invades the duodenum and/or pancreatic head. This procedure may also be called colo-pancreaticoduodenectomy (cPD). Patients with such carcinomas may present with acute abdomen. Emergency PD often leads to high postoperative morbidity and mortality. Here, we aimed to evaluate the feasibility and outcomes of emergency cPD for patients with advanced colon carcinoma manifesting as acute abdomen. Methods: We retrospectively reviewed 4898 patients with colorectal cancer who underwent curative colectomy during the period from 1994 to 2018. Among them, 30 had locally advanced right colon cancer and had received cPD. Among them, surgery was performed in 11 patients in emergency conditions (bowel obstruction: 6, perforation: 3, tumor bleeding: 2). Selection criteria for emergency cPD were the following: (1) age ≤ 60 years, (2) body mass index < 35 kg/m2, (3) no poorly controlled comorbidities, and (4) perforation time ≤ 6 h. Three patients did not meet the above criteria and received non-emergency cPD after a life-saving diverting ileostomy, followed by cPD performed 3 months later. We analyzed these patients in terms of their clinicopathological characteristics, the early and long-term postoperative outcomes, and compared findings between emergency cPD group (e-group, n = 11) and non-emergency cPD group (non-e-group, n = 19). After cPD, staged pancreaticojejunostomy was performed in all e-group patients, and on 15 of 19 patients in the non-e-group. Results: The non-e-group was older and had a higher incidence of associated comorbidities, while other clinicopathological characteristics were similar between the two groups. None of the patients in the two groups succumbed from cPD. The postoperative complication rate was 63.6% in the e-group and 42.1% in the non-e-group (p = 0.449). The 5-year overall survival rate were 15.9% in the e-group and 52.6% in the non-e-group (p = 0.192). Conclusions: Emergency cPD is feasible in highly selected patients if performed by experienced surgeons. The early and long-term positive outcomes of emergency cPD are similar to those after non-emergency cPD in patients with acute abdominal conditions. Keywords: Locally advanced colon carcinoma, Pancreaticoduodenectomy, Colectomy, Acute abdomen * Correspondence: [email protected] 1Department of Surgery, Taichung Veterans General Hospital, Taichung, Taiwan 4Department of Surgery, Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan Full list of author information is available at the end of the article © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Chen et al. World Journal of Emergency Surgery (2021) 16:7 Page 2 of 9 Background shown in Table 1. The causes of emergency cPD in this The prevalence of colorectal carcinoma is increasing group were as follows: 6 cases, acute bowel obstruction; worldwide [1]. In Taiwan, this cancer has ranked highest 2 cases, tumor perforation following colonoscopic among new malignant cases, especially over the last two biopsy; 1 case, spontaneous tumor perforation; and 2 decades [2]. The only promising cure at early stages is cases, tumor bleeding. radical colectomy, performed for R0 resection [3]. For During the same period, a total of 742 PDs were locally advanced colorectal carcinoma, en bloc resection performed in our hospital. Patients who received cPD is required for the involved adjacent organ [4]. Multior- not due to locally advanced colorectal carcinoma or for gan resection for colorectal carcinoma is often associated other diseases were excluded from our study. Patients with higher postoperative morbidity and mortality [3–5]. with locally advanced tumors extending to the duodenal When right colon cancer directly infiltrates the duode- wall with a well-preserved ampullary area but no need num near the ampulla of Vater or the pancreatic head, for cPD [9] were also excluded. The choice of classical radical resection consists of right hemicolectomy plus PD or pylorus-preserving PD [26] was made based on pancreaticoduodenectomy (PD) [5–25]. We have called the subjective evaluation of a gross negative margin this procedure colo-pancreaticoduodenectomy (cPD). present at the duodenal wall. PD techniques were demonstrated first by Kausch in A senior hepato-biliopancreatic surgeon (CCW) Germany and by Whipple in the USA in the early twen- performed or guided all 742 PDs during the study tieth century. This complex procedure has remained period. All perioperative assessments and operative pro- basically unchanged for nearly a century. The PD pro- cedures of cPD were performed by two senior surgeons cedure, also known as the “Kausch-Whipple procedure” (CCW and FKP), while colon cancer resection strategies [26], is the standard for treating neoplasms or complex were determined by another two colorectal surgeons injuries or diseases involving the duodenum and pancre- (JBC and CCC), and two oncologists (CHC and YY) atic head [26–34]. Recently, despite lowering of the op- designed chemotherapies and target therapies. erative mortality of PD to <5%, complication rates have Preoperative assessments for elective cPD, i.e., func- remained high (up to > 40%) [26–34]. The complexity of tional examinations of the lung, heart, liver, and kidney, cPD is greater than that of PD. In addition, cPD yields were performed on all 19 patients in the non-e-group. more operative morbidities and mortalities [5–25], and Their comorbidities were well controlled. The level of PD performed during emergency conditions poses fur- carcinoembryonic antigen was measured. Computed ther risks [20, 27–31, 33]. The operative mortality of tomography (CT) or magnetic resonance imaging was emergency PD exceeds 20 to 40% [20, 27–31, 33]. Patient also performed. preoperative conditions combined with the PD etiology are Selection criteria for emergency cPD patients with important contributors to surgical outcomes [29–31, 33]. obstruction and perforation were as follows: (1) age ≤ 60 Emergency resection of a bowel tumor is indicated for years, (2) body mass index < 35 kg/m2, (3) no poorly patients with acute abdomen caused by bowel obstruc- controlled comorbidities in perforation cases, with an tion, perforation or tumor bleeding [32]. estimated perforated duration of ≤ 6 h with no severe Our hospital is the only government-supported tertiary intra-abdominal contamination. For the other 19 referral medical center in central Taiwan. Patients often patients (non-e-group), after well-examined preoperative manifest life-threatening conditions related to colorectal studies, their cPD procedure was performed under an carcinoma. Few studies have yet reported on emergency elective regular schedule. cPD for patients with locally advanced colorectal carcin- The preoperative assessments of patients with locally oma presenting with serious acute abdominal conditions advanced colon cancer presenting with an acute abdo- [30–32]. To this end, we retrospectively reviewed pa- men were performed similarly for elective surgical treat- tients to evaluate the feasibility of emergency cPD for ments. These procedures were completed within 2 h patients with locally advanced colorectal carcinoma pre- following admission to the emergency department. senting with an acute abdomen. Emergency laparotomy was carried out to alleviate acute abdominal conditions after fluid resuscitation and Methods systemic antibiotic treatments. Diagnosis of the invasion Over a period of 25 years (from 1994 to 2018), we severity of the colon cancer was typically made after admitted 4898 patients for radical curative resection to exploratory laparotomy. treat their colorectal carcinoma. Of these patients, 30 Because the general conditions of the patients did not had locally advanced colon carcinoma infiltrating the meet the criteria outlined above, two patients with ini- duodenum and/or pancreatic head that needed cPD. Of tially diagnosed perforation cases and one patient with these 30 patients, 11 received cPD under emergency obstruction were treated via diverting
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