932

CASE AGE AND SEX

I. I. H. 45 M.

BRIT. J. SURG., 1972, Vol. 59, No. 12, DECEMBER

RESULT

Transverse I . Third part of duodenum Alive and well

OTHER VISCERA INVOLVED AND RESECTED SITE

colon 2. Anterior abdominal wall 6 yr. later 3. Loop of jejunum

‘CURATIVE’ SURGERY IN CARCINOMA OF THE COLON INVOLVING DUODENUM

2. H. A.

3. I. H.

A REPORT OF 6 CASES

BY HAROLD ELLIS, M. NAUNTON MORGAN, AND CHRISTOPHER WASTELL SURGICAL UNIT, WESTMINSTER HOSPITAL, LONDON

SUMMARY iliac fossa. Laparotomy revealed a carcinoma of the transverse colon with a pericolic abscess. A caecostomy was Performed- In November, 1966, a further 1aParotomY was carried out with drainage of an abdominal wall abscess. Biopsy showed an adenocarcinoma and the lesion was considered inoperable.

The patient was transferred to the Westminster Hospital for consideration of radiotherapy or cytotoxic therapy. On admission he was thin and anaemic (haemo-

INVASION of adjacent structures by a neoplasm is globin 12.7 g.). Faeces were discharging through the frequently s ~ o n Y m o u s with inoperability. The caecostomy and there was a palpable mass in the right common situation where this general rule meets with iliac fossa. This mass was adherent to the laparotomy its greatest exception is in cancer of the large bowel; scar, opening on to which were several purulent sinuses.

Six examples of duodenal involvement by ~ 0 1 0 ~ ~ cancer are reported. Two had a n associated duodenal fistula. Radical surgery was carried in all 6 cases, 3 of whom remain alive and free from recurrence u p to 6 years later.

66 M. Hepatic I . Second part of duodenum Died I yr. 4 mth. postoperatively (carcinomatosis)

flexure (fistula) 2. Permephric fat 3. Posterior abdominal wall

70 M. Ascending I . Second part of duodenum Alive and well 3 yr. colon 7 mth. later

Ascending colon

I . Second part of duodenum (fistula)

2. Posterior abdominal wall 3. Perinephric fat

(necessitating right nephrectomy)

A . C.M.

5 . J. McK.

6 . J . D.

74 F

45 M. Ascending I . Second part of duodenum Alive and well 2 yr.

44 M. Ascending I . Second part of duodenum Died I yr. 4 mth.

(carcinomatosis)

colon later

colon 2. Right kidney postoperatively

Died 10 mth. postoperatively (carcinomatosis)

here every experienced abdominal surgeon will have encountered examples where radical excision of the growth, together with adjacent adherent or invaded viscera, has been followed by relief of often intolerable symptoms and in a number of cases by long-term survival.

In this paper 6 examples of duodenal involvement by right-sided colonic carcinoma in which radical monobloc resection was possible are reported; in 2 cases there was a n established duodenocolic fistula. T w o tumours were also adherent to the right kidney, and another had invaded both the anterior abdominal wall and a loop of small intestine.

Brief reports of these 6 cases are as follows. The main features are summarized in Table I.

CASE REPORTS Case I.-Mr. I. H., aged 45 years, was admitted to

another hospital in October, 1966, with a mass in the right

It was decided first to defunction the tumour region and then, if possible, to carry out a resection.

The first operation was performed on 23 Dec., 1966 (H. E.). A long, oblique, left iliac fossa incision revealed a tumour of the transverse colon which was adherent to the abdominal wall, to a loop of small intestine about 1.5 m. from the duodenojejunal junction, and to the third part of the duodenum. The terminal ileum was divided, the splenic flexure was mobilized and divided, and their distal and proximal ends respectively were closed. An ileosplenic flexure end-to-end anastomosis was then per- formed (Fig. I). The large bowel was thus defunctioned, as a result of which the infection rapidly subsided and the patient’s general condition improved.

The second operation was performed on 10 Jan., 1967 (H. E.). As a preliminary the caecostomy was mobilized and closed. Wide excision of the anterior abdominal wall was performed to include the original scar and the discharging sinuses leading down to the tumour mass. The whole of the defunctioned large bowel was resected en bloc, together with the anterior abdominal wall, a portion

ELLIS ET AL.: CARCINOMA OF THE COLON 933

of the third part of the duodenum which was adherent to the tumour, the loop of involved jejunum, and the spleen. The duodenal defect was closed with two layers of catgut transversely and continuity of the small intestine was restored by end-to-end-anastomosis (Fig. 2).

Pathological examination revealed a moderately differ- entiated adenocarcinoma of the transverse colon infil- trating the pericolic fat and the anterior abdominal wall. It was involving the adherent duodenum and small intestine superficially but had not infiltrated into their muscle walls.

The patient made a satisfactory recovery and remains alive and well 6 years later (Fig. 3).

Tumour of Transverse Colon

Adherent , Duodenum

n FIG. I.-Case I . Findings at laparotomy and the short circuit of

the tumour of the transverse colon.

Case 2.-Mr. H. A., aged 66 years, was admitted in March, 1969, with a Iz-month history of diarrhoea and colicky abdominal pain. There was a palpable mass in the right hypochondrium and a barium-enema examination revealed a carcinoma of the hepatic flexure with a fistula between the colon and duodenum (Fig. 4).

Operation was carried out on I I March (H. E.). There was an extensive carcinoma of the hepatic flexure with a fistula into the second part of the duodenum. The adjacent posterior abdominal wall and perinephric fat were invaded. A right hemicolectomy was performed with excision of the involved duodenum, the resultant large defect being closed with two layers of catgut.

T u m o u r of An te r io r Transverse Colon Abdominal Wal l

of Duodenum

Caecostomy FIG. n.--Case I . Diagram of the resected specimen

FIG. 3 . 4 a s e I . Patient 5 years after resection of a carcinoma of the transverse colon invading the anterior abdominal wall, jejunum, and duodenum.

FIG. 4.--Case 2. Barium-enema film, showing a carcinomatous stricture of the ascending colon fistulating into the duodenum. Note the reflux of barium into the duodenum and upper jejunum.

934 BRIT. J. SURG., 1972, Vol. 59, No. 12, DECEMBER

Pathological examination of the specimen revealed a well-differentiated adenocarcinoma with fistulation into the adjacent duodenum. The lymph-nodes were not invaded.

The patient made an uneventful recovery but was admitted to Maidenhead Hospital in July, 1970, with carcinomatosis where he died I year and 4 months after the operation.

Case 3.-Sir I. H., aged 70 years, was admitted in March, 1969, complaining of diarrhoea, right-sided abdominal pain, loss of appetite, and anaemia over a 9- month period. Examination revealed a mass over the right upper quadrant of the abdomen. The haemoglobin was 7.1 g.

After a blood transfusion laparotomy was carried out on 18 April (C. W.). There was a large mobile carcinoma of the ascending colon which was invading the second part of the duodenum. Right hemicolectomy was performed with resection of a 3-cm. diameter circle of duodenum. The duodenal defect was closed transversely with inner catgut and outer interrupted thread.

Pathological examination revealed an adenocarcinoma invading the serosal surface of the duodenum. The lymph-nodes were not involved.

Recovery was uneventful and the patient is alive and well, at the time of this report, 3 years and 7 months later.

Case 4.-Mrs. C. M., aged 74 years, was admitted in November, 1969, with a +year history of anaemia and loss of weight. Examination revealed a mass in the right upper abdomen. The haemoglobin was 7.1 g.

Laparotomy was carried out on 2 Dec. (H. E.) after a preliminary blood transfusion. There was a carcinoma of the ascending colon which had infiltrated the posterior abdominal wall and the perinephric fat of the right kidney and also had fistulated into the second part of the duodenum. A monobloc excision taking the ascending colon, right kidney, and a segment 7 5 cm. long and 4 cm. wide on the anterior duodenal wall was performed. The duodenum was closed transversely with one layer of catgut. Recovery was uneventful.

Pathological examination revealed an annular carcinoma fistulating into the duodenum and invading extensively into the perinephric fat, although the kidney itself was not invaded. Adjacent lymph-nodes were not involved.

The patient developed recurrence of the tumour and died in Westminster Hospital on 12 Sept., 1970.

Case 5.-Mr. J. McK., aged 45 years, was admitted in September, 1970, with a I-year history of upper abdominal pain and diarrhoea. The haemoglobin was 10.4g. A barium-enema examination revealed a filling defect just proximal to the hepatic flexure.

An operation on 13 Oct. (M. N. M.) a large tumour of the ascending colon was resected together with the adjacent second part of the duodenum, which was closed transversely in two layers.

Pathological examination showed an annular carcinoma of the colon which was poorly differentiated. The wall of the duodenum was invaded, but the mucosa had not been breached. The lymph-nodes were not involved.

The, patient is alive and well over 2 years following operation.

Case 6.-Mr. J. D., aged 44 years, was admitted in April, 1971, with a 6-month history of right-sided abdo- minal pain and weight-loss. There was a tender mass in the right side of the abdomen and a barium-enema examination showed a filling defect in the ascending colon. Operation on 15 April (M. N. M.) revealed a carcinoma of the ascending colon which had invaded the second part of the duodenum and the right kidney. Right hemicolectomy, right nephrectomy, and excision of the segment of the anterior wall of the duodenum, measuring 2 3 cm. by 7.5 cm., was performed in one procedure. The duodenum was closed transversely in two layers and as there was some narrowing of the lumen an anterior gastro-enterostomy

was performed. There was postoperative delay in function of the gastro-enterostomy which was re-explored on 11 May. The stoma appeared widely open and no further procedure was necessary. Following this second laparo- tomy the patient made a satisfactory recovery. A sub- sequent barium-meal examination showed free flow of barium through the duodenum.

Pathological examination revealed a poorly differen- tiated adenocarcinoma of the ascending colon invading both the right kidney and the duodenum although it had not penetrated the rnuscularis of the duodenum. The lymph-nodes were free from tumour.

The patient died from recurrent disease 16 months after operation.

DISCUSSION T h e surgeon setting out to explore a patient with

a carcinoma of the colon hopes to find a localized tumour which is amenable to a standard resection procedure. When he encounters disseminated disease or adherence to adjacent structures, consider- able judgement is required i n order to decide on the correct treatment.

Deposits in the liver, provided that gross hepatic destruction has not taken place, should not deter him from resecting the primary growth and thus relieving or preventing intestinal obstruction, fistulation, etc. Our figures from Westminster Hospital show that one-third of patients submitted to such palliative resection will live for more than I year (Oxley and Ellis, 1969).

Adjacent structures which may be found adherent to the growth include the anterior or posterior abdominal wall, small intestine, the greater curvature of the stomach, spleen, duodenum, pancreas, kidney, ureter, bladder, uterus, and Fallopian tubes. This adherence may be entirely inflammatory (Cooke, 1956)~ but it is wise to assume that tumour invasion has occurred i n planning resection. A trial resection is often necessary to assess whether or not en bloc removal is a reasonable proposition, and here the patient’s general condition and the presence or absence of dissemination of tumour elsewhere should be taken into consideration. Distant peritoneal nodules, the presence of gross ascites, and heavy liver involvement contra-indicate radical surgery.

The results of radical surgery for advanced local disease are, under the circumstances, surprisingly good. Van Prohaska, Govostis, and Lasick (1953) reviewed 225 patients undergoing resection for carcinoma of the colon and rectum; 21 of these (9 per cent) required resection of adjacent structures, which included spleen, abdominal wall, bladder, etc. There was only I operative death and 14 of these patients (67 per cent) were alive 2-13 years later. Of particular interest in the present context were 2 patients who underwent right hemicolectomy together with pan- creaticoduodenectomy ; these survived operation but died 2; years and I I months after surgery respectively from metastatic disease. Jensen, Balslev, and Nielsen (1970) reported experience of 554 patients with carcinoma of the colon; 406 underwent resection and 60 of these cases required resection of the abdominal wall or other organs, Of these 60 patients, 23 were found to have only inflammatory adhesions and 13 of these were alive after 5 years. T h e remaining 37 cases had malignant invasion of adjacent structures and 5 of these were alive 5 years later. Again of particular relevence were 3 patients who had a

ELLIS ET AL.: CARCINOMA OF THE COLON 935

resection of adjacent duodenum; 2 of these proved to have malignant adherence but both died in the postoperative period. El-Domeiri and Whiteley (1970) noted 10 examples of invasion of the anterior abdominal wall in a series of 327 patients with carcinoma of the caecum undergoing resection; there was I postoperative death and 7 of the g survivors were still alive at the time of the review, 5 already having survived for 5 years.

FIG. 5.-Technique of repair of a duodenal defect adopted in this series of patients.

Very few reports deal specifically with the problem presented by adherence or fistulation of cancers in the region of the hepatic flexure and the duodenum. Juvara and Radulescu (1969) encountered 4 such cases in the course of 124 right hemicolectomies. Two of these had a coloduodenal fistula and 2 had malignant involvement of the duodenal wall without fistula formation. In our own experience in the Surgical Unit at the Westminster Hospital 6 cases of duodenal involvement, 2 with a fistula, have been encountered in the course of the past 5 years.

CLOSURE OF THE DUODENAL DEFECT Having carried out adequate excision of the affected

duodenum with a healthy cuff of adjacent bowel, there is the problem of adequate closure of the resultant duodenal defect. In our own cases this has been achieved without difficulty by simple one- or two-layer transverse closure (Fig. 5 ) and we have not encountered problems of either leakage or stenosis, although in I instance it was considered prudent to perform a gastrojejunostomy. Fortunately in none of these cases was the pancreatic duct involved since, under such circumstances, it would be necessary to consider a formal pancreaticoduodenectomy.

Juvara and Radulescu (1969) found in their cases that simple repair of the duodenal defect was not possible; they described an ingenious technique in which, following the right hemicolectomy, a loop of the intact terminal ileum just proximal to the ileocolic anastomosis was sutured as a patch over the duodenal defect, stitching the serous surface of the ileum around the edges of the duodenal defect by a series of interrupted seromuscular sutures (Fig. 6). This technique of closure of wounds of the duodenum by sewing the intact serosa of a jejunal loop over the defect was described in an experimental animal by Kobold and Thal (1963)~ and was used for closure of

experimentally produced grossly infected perforated duodenal stumps by Jones, Gregory, Smith, Saito, and Joergenson (1964). The technique has been used clinically to patch difficult intestinal perforations (McKittrick, 1965 ; Ballinger, McLaughlin, and Baranski, 1966; Jones and Steedman, 1969). In our own laboratory we have confirmed the efficacy of this

Jejunal Loop Repair ISerOsa to DuoOenal Defect1

.-Duodenal Intact , ’ Defect Jejunum

Transverse Section

FIG. 6.--Use of intact jejunal loop advocated for the repair of difficult duodenal defects and used in our experimental studies.

method in the closure of large duodenal defects in the dog. Subsequent histological studies showed that the duodenal mucous membrane grew from the cut edge of the defect over the serosal surface of the jejunal patch so that eventually the lumen of the duodenum became relined with mucous membrane. In I animal a fistula between the duodenum and the jejunum used for the patch developed. In view of this it is advisable to use as proximal a piece of bowel as possible. There is no doubt that in any case which we might encounter where duodenal closure is impossible by direct suture, whether such a defect resulted from surgical excision, trauma, or chronic perforation, we would not hesitate to employ this technique.

Acknowledgements.-We wish to thank Dr. Peter Hansel1 and the Department of Medical Illustration, Westminster Hospital, for the illustra- tions.

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