Abstract:Pancreatic cancer is one of the digestive malignancies with the worst prognosis and therefore, how to provide scientific and standard treatment for pancreatic cancer is a hot topic in the field of surgery. In this article, the authors discuss the similarities and differences in the treatment strategies between the “potentially curable pancreatic cancer” in the ASCO guideline and the “resectable and borderline resectable pancreatic cancer” in the NCCN guideline from five aspects: preliminary assessment, surgical indications, preoperative management, postoperative treatment and follow-up surveillance.

Abstract:Pancreatic cancer is difficult to diagnose at an early stage, with about 80% of patients having local invasion or distant metastasis at the initial consultation. At present, surgical resection remains the only hope for long-term survival in patients with pancreatic cancer. The level of comprehensive treatment of pancreatic cancer has somewhat improved over the past few years. In borderline resectable pancreatic cancer, the use of neoadjuvant therapy may achieve the goal of tumor downstaging, and screening and selecting potential patients for surgery. Proper selection of chemotherapy regimen and appropriate choice of surgery timing can further improve the resection rate of pancreatic cancer, and thereby prolong the survival time in this high-risk population.

Abstract:Clinical practice guidelines for pancreatic cancer 2016 issued by the Japan Pancreas Society (JPS) provide 76 recommendatory opinions with their levels of evidence and grades of recommendations based on GRADE criteria targeting toward 51 specific clinical questions from 8 main subjects that include the disease concepts, diagnosis, surgical therapy for resectable pancreatic cancer, adjuvant therapy of resectable pancreatic cancer, therapy of locally advanced unresectable pancreatic cancer, therapy of metastatic pancreatic cancer, stent therapy, and palliative medicine. The guidelines relatively fully summarize and synthesize the standard clinical practice management of pancreatic cancer nowadays in Japan, and reflect the current knowledge of pancreatic cancer and status of its diagnosis and treatment, and can be used as reference for learning and practicing.

Abstract:Objective: To identify the prognostic risk markers for pancreatic ductal adenocarcinoma (PDAC) through bioinformatics approaches. Methods: The clinical information and data of miRNA and gene expression profiles of PDAC patients were downloaded from TCGA website. Then, the miRNAs and genes significantly related to the prognostic risk of PDAC were screened successively by Elastic Net Cox’s proportional risk regression hazards model (EN-Cox), the receiver operating characteristic (ROC) curve and survival analyses. Finally, literature mining and function analyses were conducted on the significant prognostic risk genes and the potential target genes of the significant prognostic risk miRNAs. Results: After data preprocessing, the complete clinical records and data of expression profiles of total of 797 miRNAs and 19 969 genes in 137 PDAC patients were obtained. Based on the parameter λ (0.107), 59 potential prognostic risk factors that included 54 genes and 5 miRNAs were screened via EN-Cox analysis. After grouping of the patients according to the cutoff values derived from the ROC curves and then drawing of Kaplan-Meier curves, 17 significant prognostic risk markers were finally identified (all P<0.05), including 16 genes and 1 miRNA (miRNA-125a). Among the 16 prognostic risk genes, glutathione S-transferase mu 4 (GSTM4), inducible T-cell co-stimulator ligand (ICOSLG) and spermatogenesis associated 2 (SPATA2) were simultaneously the target genes of miRNA-125a; GATA binding protein 1 (GATA1) was the only one transcription factor encoding gene. Conclusion: The functions of these screened candidates in PDAC still need to be elucidated, and they may probably be used as prognostic risk indicators and even therapeutic targets of PDAC.

Abstract:Objective: To investigate the clinical efficacy of laparoscopic spleen-preserving distal pancreatectomy in treatment of tumors of the body and tail of the pancreas. Methods: By searching several English and Chinese databases, the eligible studies were selected through a screening process against defined inclusion and exclusion criteria. After data extraction and quality evaluation, Meta-analysis was performed by Manager 5.3 software. Results: Thirty studies were included involving 814 patients, of whom, 399 cases underwent laparoscopic distal pancreatectomy with spleen preservation and 415 cases underwent laparoscopic distal pancreatectomy with splenectomy. Results of the Meta-analysis showed that in patients undergoing laparoscopic spleen-preserving distal pancreatectomy compared with those undergoing laparoscopic distal pancreatectomy with splenectomy, the operative time (SMD=–0.79, 95% CI=–1.55––0.03, P=0.04), intraoperative blood loss (SMD=–1.00, 95% CI= –1.76––0.24, P=0.01) and length of hospital stay (SMD=–0.77, 95% CI=–1.34––0.21, P=0.008) were significantly reduced; no statistical differences were noted in the incidence of postoperative complications (OR=0.83, 95% CI=0.63–1.10, P=0.19) and reoperation rate (OR=1.54, 95% CI=0.52–4.59, P=0.44) between the two groups of patients. Conclusion: Laparoscopic spleen-preserving distal pancreatectomy has better clinical efficacy in treatment of tumors of the body and tail of the pancreas without increasing the incidence of postoperative complications.

Abstract:

Objective: To systematically evaluate the value of circulating miR-21 in diagnosis of pancreatic cancer through Meta-analysis. Methods: The studying data concerning using circulating miR-21 in diagnosis of pancreatic cancer published before May 2017 were collected through searching several national and international databases. After screening for inclusion criteria, data extraction and quality assessment, Meta-analysis was performed by using MetaDisc 1.4 and Stata 14.0 software. Results: A total of 8 studies were included with 261 pancreatic cancer patients and 242 control subjects. The results of Meta-analysis showed that the pooled sensitivity, specificity, positive likelihood ratio and negative likelihood ratio of circulating miR-21 for diagnosis of pancreatic cancer was 0.76 (95% CI=0.71–0.81), 0.76 (95% CI=0.70–0.81), 3.17 (95% CI=2.24–4.47) and 0.26 (95% CI=0.15–0.45), respectively. The diagnostic odds ratio value was 13.17 (95% CI=6.78–25.58), and the area under the summary receiver operator characteristic curve (AUC) was 0.8518. Subgroup analysis showed that the serum and plasma subgroups had a same AUC value of 0.8513, and the diagnostic accuracy of the healthy population control subgroup was better than that of the health population plus benign pancreatic disease patients control subgroup (AUC: 0.876 vs. 0.72, P<0.05). The Deek’s funnel plot for the diagnostic test showed that there was no publication bias, and the sensitivity analysis showed that the results of this analysis were not strongly dependent on any single study and that the conclusions were stable. Conclusion: Circulating miR-21 has certain value in diagnosis of pancreatic cancer.

Abstract:Objective: To investigate the short- and long-term effects of the combination of autologous dendritic cells-cytokine induced killer cells (DC-CIK) with conventional chemotherapy in treatment of metastatic pancreatic cancer. Methods: Ninety-six patients with metastatic pancreatic cancer were selected and randomly divided into control group and observation group, with 48 cases in each group. Patients in control group underwent the chemotherapy regimen of S-1 (tegafur/gimeracil/oteracil), while those in observation group received autologous DC-CIK transfusions based on S-1 chemotherapy. The short-term (two courses later) efficacy and long-term prognosis of the two groups of patients were compared. Results: In observation group compared with control group, the response rate showed no significant difference (39.58% vs. 27.08%, P>0.05), while the total disease-control rate was significantly increased ( 77.08% vs. 58.33%, P<0.05); there were no significant differences in T-lymphocyte subsets and levels of IFN-γ+, CD4+, between the two groups before treatment (all P>0.05), but the CD3+ and CD4+ cells, CD4+/CD8+ ratio and IFN-γ level were significantly higher, the CD8+ cells and IL-4 level was significantly lower than those in control group after treatment (all P<0.05). No significant differences were noted in the incidence of adverse reactions between the two groups of patients during treatment (all P>0.05). The average survival time as well as 1-, 2-, and 3-year survival rates in observation group were all significantly better in observation group than those in control group (15.0 months vs. 10.0 months; 66.67%, 29.17% and 8.33% vs. 43.75%, 10.42% and 0, all P<0.05). Conclusion: Autologous DC-CIK transfusions combined with conventional chemotherapy has improving effects on both short-term effect and long-term prognosis in patients with metastatic pancreatic cancer.

Abstract:Objective: To summarize the surgical experience in treatment of periampullary carcinoma by three-dimensional (3D) laparoscopic pancreaticoduodenectomy and its clinical efficacy. Methods: The clinical data of 101 patients with periampullary carcinoma undergoing 3D laparoscopic pancreaticoduodenectomy from January 2014 to March 2017 in Department of Hepatobiliary Surgery of Hunan Provincial People’s Hospital were retrospectively analyzed. Results: In the entire group, the average operative time was 325.7 (220–575) min and intraoperative blood loss was 175.9 (100–550) mL; postoperative complications included pancreatic fistula in 23 patients (22.8%) which were classified as biochemical fistula in 17 cases (16.8%), grade B pancreatic fistula in 5 cases (5.0%) and grade C pancreatic fistula in 1 case (1.0%), intra-abdominal bleeding in 7 patients (6.9%), bile leakage in 2 cases (2.0%), delayed gastric emptying in 4 cases (4.0%), intra-abdominal infection in 6 cases (5.9%), pulmonary infection in 3 cases (3.0%) and intestinal obstruction in 2 cases (2.0%); grade 3 complications according to Clavien classification were found in 9 patients (8.9%), of whom 3 cases required a repeated operation, and the 30-day in-hospital death occurred in one patient (1.0%). The average length of postoperative hospital stay was 14.8 (8–29) d. Postoperative pathological data showed that 27 patients (26.7%) had distal common bile duct cancer, 23 patients (22.8%) had ampullary carcinoma, 39 patients (38.6%) had duodenal papillary carcinoma, and 12 patients (11.9%) pancreatic ductal adenocarcinoma; the average tumor diameter was (2.3±1.3) cm, R0 resection rate was 95.0%, and the number of removed lymph nodes was 16.7±4.2, with the number of positive lymph nodes of 1.3±1.1. Conclusion: 3D laparoscopic pancreaticoduodenectomy is safe and effective in treatment of periampullary carcinoma, with a favourable short-term outcome.

Abstract:Objective: To construct lentiviral vector carrying siRNA targeting Jagged 2 (JAG2) gene and observe the effects of its transfection on biological characteristics in human pancreatic cancer cells. Methods: Several lentiviral expression vectors carrying different siRNA fragments targeting JAG2 gene were constructed using gene recombination technology, and were transfected into pancreatic cancer cells primarily isolated from the human pancreatic cancer tissue specimens through enzymolysis approach. Then, the siRNA fragment showing strongest inhibitory effect on JAG2 gene was selected for testing the influences of its transfection on proliferation, apoptosis, cell cycle and invasion and metastasis abilities in human pancreatic cancer cells by MTT assay, flow cytometry and transwell chamber assay, respectively. Results: All the lentiviral expression vectors carrying different siRNA fragments showed inhibitory effects, to different extents, on mRNA and protein expressions of JAG2. In pancreatic cancer cells after transfection with the JAG2 siRNA, the proliferation was decreased, apoptosis and S-phase arrest were enhanced, and invasion and metastasis abilities were reduced significantly (all P<0.05). Conclusion: lentiviral vector bearing JAG2 siRNA are successfully constructed and their transfection can effectively moderate the malignant biological characteristics of human pancreatic cancer cells.

Abstract:Objective: To investigate the miR-567 expression in pancreatic cancer cells and its function. Methods: The miR-567 expressions in normal pancreatic duct epithelial cell line HPDE6-C7 and pancreatic carcinoma cell line Panc-1, AsPC-1, HPAC and BxPC-3 were determined by qRT-PCR. The miR-567 overexpression lentivirus vectors were transfected into the Panc-1 cells, and then, the changes in proliferation, apoptosis and migration ability as well as expressions of KPN4 mRNA and protein and apoptosis-associated proteins were analyzed by CCK-8 assay, flow cytometry, scratch wound healing assay, qRT-PCR and Western blot, respectively. Results: The miR-567 expressions in all the pancreatic cancer cell lines were significantly lower than that in normal pancreatic duct epithelial HPDE6-C7 cells (all P<0.05). In Panc-1 cells after transfection with miR-567 overexpression lentivirus vectors, the proliferation was decreased, apoptosis rate was increased, scratch healing rate was reduced, and both KPNA4 mRNA and protein expressions were down-regulated, while the caspase-3 and Bax protein expressions were up-regulated significantly (all P<0.05). Conclusion: MiR-567 expression is decreased in pancreatic cancer cells, and up-regulating its expression can inhibit the growth and migration ability of pancreatic cancer cells, and the mechanism may possibly be associated with its decreasing KPNA4 expression and increasing the expressions of apoptosis-associated proteins.

Abstract:Objective: To investigate the expressions of the E3-ubiquitin ligase subunit Ring1B, lysine-specific histone demethylase 1 (LSD1) and cell cycle regulatory molecule P16 in pancreatic cancer and their relations with the prognosis of the patients. Methods: The distributions and expressions of Ring1B LSD1 and P16 proteins in the surgical specimens (cancer tissues and cancer-adjacent tissues) from 85 pancreatic cancer patients were determined by immunohistochemical staining, from which, 6 paired specimens were picked up for measurement of mRNA and protein expressions of Ring1B, LSD1 and P16 through qRT-PCR and Western blot, respectively. The correlations among their expressions in pancreatic cancer tissue, and relations of their expressions with the survival of the patients were analyzed. Results: The results of immunohistochemical staining showed that Ring1B and LSD1 were mainly expressed in the cytoplasm, while P16 protein was mainly found in the nucleus; the Ring1B and LSD1 expressions were significantly higher, while the P16 expression was significantly lower in pancreatic cancer tissue than those in cancer-adjacent tissue (all P<0.05); either the Ring1B or LSD1 expression had a negative correlation with P16 expression in pancreatic cancer (r=–476; r=–0.673, both P<0.05). The results of qRT-PCR showed that the average relative mRNA expression levels of Ring1B and LSD1 were significantly higher (8.908 vs. 1.947; 7.126 vs. 1.940, both P<0.05) and the average relative mRNA expression level of P16 in pancreatic cancer tissue was significantly lower (1.269 vs. 5.237, P<0.05) than those in cancer-adjacent tissue; the protein expression patterns of them were similar to their mRNA expressions as evidenced by Western blot analysis. The survival analysis showed that the survival rate in patients with high Ring1B or LSD1 expression was significantly lower than that in patients with low Ring1B or LSD1 expression (χ2=8.958, P=0.012; χ2=8.856, P=0.010), which in patients with high P16 expression was significantly higher than that in patients with low P16 expression (χ2=7.867, P=0.024). Conclusion: Ring1B and LSD1 expressions are increased and P16 expression is decreased in pancreatic cancer tissue. Ring1B and LSD1 may probably regulate P16 expression respectively through histone ubiquitination and demethylation, and thereby influence the prognosis of pancreatic cancer.

Abstract:Objective: To investigate the inhibitory effect of paclitaxel on hepatic fibrosis in rats and its mechanism. Methods: Thirty Wistar rats were equally randomized into normal control group, hepatic fibrosis model group and hepatic fibrosis model plus paclitaxel group. Hepatic fibrosis model was induced by intraperitoneal injection of dimethylnitrosamine daily for up to 7 d. After that, the rats in hepatic fibrosis model plus paclitaxel group underwent paclitaxel solution injection via the tail vein once every two days for a total of 3 times. At the end of the experiment, all rats were sacrificed, the pathological changes of liver and some serological variables were observed, and the expressions of the hepatic stellate cell marker α-SMA in the liver tissues were determined. The rat hepatic stellate cell line HSC-T6 was cultured with TGF-β1 or paclitaxel plus TGF-β1, with untreated HSC-T6 cells as control, and then, the expressions of fibronectin and type I and III collagen in each group of cells were determined. Results: No pathological alterations were noted in the liver tissues in normal control group, but histological changes of hepatic fibrosis were developed in hepatic fibrosis group, while only moderate degrees of liver necrosis without evident nodular lesions were observed in hepatic fibrosis model plus paclitaxel group; compared with normal control group, the levels of transaminases, total bilirubin (TBIL) and hyaluronic acid (HA) were increased, while the albumin (ALB) level was decreased significantly in either hepatic fibrosis model group or hepatic fibrosis model plus paclitaxel group (all P<0.05), but the conditions of TBIL, ALB and HA were significantly better in the latter than those in the former (all P<0.05); no obvious α-SMA expression was observed in the liver tissues in normal control group, which was found in the liver tissues in both hepatic fibrosis model group and hepatic fibrosis model plus paclitaxel group, but the number of α-SMA positive cells in the latter was significantly lower than that in the former (P<0.05). Compared with untreated HSC-T6 cells, both mRNA and protein the expressions of fibronectin and type I and III collagen were significantly up-regulated in HSC-T6 cells treated with TGF-β1 alone or treated with paclitaxel plus TGF-β1 (all P<0.05), but their up-regulating degrees was significantly milder in the latter than those in the former (all P<0.05). Conclusion: Paclitaxel can inhibit the occurrence and development of hepatic fibrosis in rats, and the mechanism may be associated with its suppressing TGF-β signaling pathway in hepatic stellate cells and thereby reducing the activation of hepatic stellate cells.

Abstract:Objective: To investigate the technical essentials of separation of the splenic vessels in performing Kimura’s procedure (laparoscopic resection of the body and tail of the pancreas with splenic vessel preservation). Methods: The clinical data of 18 patients undergoing resection of the pancreatic body and tail using Kimura’s procedure from January 2015 to December 2016 were retrospectively analyzed. Results: Kimura’s procedure was successfully completed in all the 18 patients. The operative time ranged from 136 to 220 min, with an average of 170 min, and the intraoperative blood loss ranged from 50 to 450 mL, with an average of 180 mL, and the length of hospital stay ranged from 6 to 21 d. with an average of 9.6 d. Postoperative pathology showed that all the lesions were benign or borderline tumors of the pancreas. Ten patints underwent splenic vein or artery repair for lacerations with a 5-0 Prolene suture during operation. Abdominal pancreatic fistula was the main complication, which occurred, including grade A pancreatic fistula in 8 patients (44.4%) and grade B pancreatic fistula in 2 patients(11.1%), and were all cured by conservative treatment. Conclusion: Kimura’s procedure for benign and borderline tumors in the body and tail of the pancreas is safe and feasible, and thorough preoperative preparation, sophisticated laparoscopic techniques and good cooperative abilities, especially the meticulous splenic vessel separating and suturing techniques are essential for completing the operation.

Abstract:Objective: To describe the experiences in treatment of infected pancreatic necrosis (IPN) by percutaneous catheter drainage (PCD) under positioning of the electrode plates and ultrasound guidance. Methods: The clinical data of 61 patients with IPN undergoing PCD under positioning of the electrode plates and ultrasound guidance between October 2010 and December 2016 were retrospectively analyzed. Results: PCD was successfully performed in the entire group of the 61 patients, of whom, 23 cases (37.7%) underwent PCD alone, 22 cases (36.1%) were converted to minimal access retroperitoneal pancreatic necrosectomy (MARPN) and 16 cases (26.2%) were converted to open pancreatic necrosectomy (OPN) after PCD. The mortality rate in the whole group was 24.6% (15/61), which included 6 cases undergoing PCD alone, 4 cases undergoing MARPN conversion and 5 cases undergoing OPN conversion. After PCD, complications occurred 36 times that included 12 times of bleeding, 15 times of pancreatic leakage and 9 times of intestinal leakage. Results of the drainage fluid cultures showed 19 cases (31.1%) had mono-bacterial infection and 42 cases (68.9%) had mixed bacterial infections, in which 38 cases (62.3%) were caused by multi-drug resistant organisms (MDRO). The factors associated with death of the patients included the severity score of acute pancreatitis (2012), reversal of sepsis after surgical intervention, bleeding after PCD and MDRO infection (all P<0.05). Conclusion: PCD under positioning of the electrode plates and ultrasound guidance is a simple and safe method of peripancreatic fluid drainage, based on which, the “step-up” approach is an effective strategy for dealing with IPN.

Abstract:Objective: To investigate the analgesic efficacy of ultrasound guided thoracic paravertebral block during open pancreaticoduodenectomy (PD). Methods: Forty three patients scheduled for an elective open PD were randomly designated to control group (21 cases) and observation group (22 cases). Patients in control group underwent general anesthesia alone, and those in observation group underwent ultrasound guided paravertrbral block through injection of 10 mL of 0.4% ropivacaine each at right T8–9 and T11–12 interspaces 20 min before general anesthesia induction. Patient controlled intravenous analgesia (PCIA) was used in all patients after operation. Several variables were recorded, including the mean artery pressure (MAP) and heart rate (HR) at the times of just after entering the operation room, before skin incision, 5 min after skin incision and shortly before the end of operation, the amount of intraoperative sulfentanil consumption, PCIA compress frequency within 48 h after operation, the visual analogue score (VAS) both during resting state and 90° body turning over at 2, 16, 24 and 48 h after operation, and the occurrence of adverse reactions. Results: There were no differences in baseline data between the two groups of patients (all P>0.05). In observation group compared with control group, the average MAP (83 mmHg vs. 95 mmHg) and HR (77 beats/min vs. 87 beats/min) at 5 min after skin incision were significantly decreased (both P<0.05), but showed no significant difference at the other 3 time points (all P>0.05), the average VAS scores at resting state and 90° body turning over were significantly reduced at 2, 16 and 24 h after operation (all P<0.05), but showed no significant differences at 48 h after operation (both P>0.05), and the average amount of intraoperative sulfentanil consumption (0.9 μg/kg vs. 1.5 μg/kg) and PCIA requirements (13.1 times vs. 27.6 times) were significantly decreased (both P<0.05). No significant differences were noted in the adverse reactions such as postoperative nausea, vomiting, sweating, dizziness, itching and delirium between the two groups (all P>0.05), and no respiratory depression occurred in either group. Conclusion: Ultrasound guided thoracic paravertebral block provides a remarkable pain relief effect for patients during and after open PD.

Abstract:Objective: To investigate the influence of short-term glucocorticoid therapy on liver function recovery in patients after hepatectomy for primary liver cancer and the associated adverse effects. Methods: The clinical data of 126 patients with primary liver cancer undergoing open hepatectomy during January 2014 to August 2015 were retrospectively analyzed. Of the patients, 63 cases received conventional postoperative management such as hepatoprotective treatment and albumin supplement (control group), the other 63 cases received the conventional postoperative management plus intravenous infusion of methylprednisolone, 80 mg/d, for the first three postoperative days and then 40 mg/d for the next two days (glucocorticoid therapy group). The pre- and postoperative liver function parameters, incidence of hepatic insufficiency, albumin usage and incidence of postoperative complications and length of hospital stay were compared between the two groups. Results: The preoperative and operative data were comparable between the two groups (all P>0.05). The serum levels of albumin and transaminases as well as postoperative albumin usage and length of postoperative hospital stay showed no significant difference between the two groups (all P>0.05), while, the total bilirubin level on postoperative day 2 and 3, incidence of hepatic insufficiency (19.0% vs. 34.9%) and overall incidence of postoperative complications (27.0% vs. 44.4%) in glucocorticoid treatment group were significantly lower than those in control group (all P<0.05). Conclusion: Short-term glucocorticoid treatment after hepatectomy for primary liver cancer is beneficial to liver function recovery and reducing complications of the patients, without increase of the glucocorticoid-related adverse effects.

Abstract:Objective: To compare the clinical effects of anterograde and retrograde invagination stripping for great saphenous varicose veins. Methods: The clinical data of 511 patients undergoing invagination stripping plus dot stripping for great saphenous varicose veins were retrospectively analyzed. Of the patients, 234 cases underwent stripping in an anterograde direction from the themedial malleolar region toward the saphenofemoral junction (anterograde stripping group) and 277 cases underwent stripping in a retrograde direction from the saphenofemoral junction toward the themedial malleolar region (retrograde stripping group). The main clinical variables between the two groups of patients were compared. Results: The preoperative data of the two groups of patients were comparable. There were no statistically significant differences in aspects of operative time, intraoperative blood loss, number of incisions, length of postoperative hospital stay, overall incidence of complications, postoperative leg acid bilges and ulcer healing time between the two groups (all P>0.05), but the incidence of saphenous nerve injury in the anterograde group recurrence rate of varicose veins in retrograde group in anterograde stripping group were significantly lower than those in retrograde stripping group (both P<0.05). Conclusion: For great saphenous varicose veins, anterograde stripping is superior to retrograde stripping in terms of reducing saphenous nerve injury and long-term efficacy.

Abstract:

Iodine-125 (125I) radioactive seed implantation brachytherapy is an emerging technique to treat pancreatic cancer, which, shown by clinical practice, offers benefits for pancreatic cancer patients in terms of pain relief, tumor progression control, quality of life improvement and survival time prolongation. Here, the authors present the current status and progress of 125I radioactive seed implantation brachytherapy in treatment of unresectable pancreatic cancer.

Abstract:Pancreatic ductal adenocarcinoma (PDAC) is a malignant tumor with aggressive biological behavior, difficult diagnosis at an early stage and dismal outcome. Recent investigations showed that the tumor microenvironment and immunomodulation are closely related to the occurrence of PDAC, and researches upon the biological environment may provide new strategies for the treatment of this lethal condition. The authors address the research progress in the field of PDAC microenvironment.

Abstract:Pancreaticoduodenectomy (PD) is one of the most complex procedures in the field of general surgery, which involves multiple anastomoses and has a high risk of complications such as pancreatic fistula, biliary fistula and abdominal infection, leading to a difficult perioperative management. The currently advocated and implemented surgical concepts of precision, minimal invasion and damage control have laid the foundation for the employment of enhanced recovery after surgery (ERAS). Although the international directive consensus and guidelines have been issued, there are still controversies concerning the use of ERAS program in perioperative management of PD in China. For carrying out the standardized ERAS protocols in perioperative management of PD, the authors discuss and classify several highly controversial subjects such as preoperative fasting time for food and water, timing for nasogastric tube and peritoneal drainage tube removal, and administration of postoperative somatostatin.