Pancreatic surgery has achieved substantial improvement in recent years,which was indicated by the continuous decrease of its mortality and morbidity.However,the over-all 5-year survival rate of pancreatic cancer patients has not been significantly improved,and puzzles together with controversies remain in the field of surgical treatment for this devastating disease.Clinical outcomes of pancreatic cancer patients remain poor,which we thought would largely explained by the extremely malignant biological behavior of pancreatic cancer.In this review,we also focused on the frequently discussed themes in the field of surgical treatment for pancreatic cancer.These themes include differential diagnosis for pancreatic head mass,preoperative biliary drainage for jaundice patients,value of R0/R1 resection for pancreatic cancer,pancreatic fistula and delayed gastric emptying after pancreaticoduodenectomy.

Pancreatic fistula is a common complication after pancreaticoduodenectomy(PD),and other complications occurred secondary to it such as hemorrhage and severe abdominal infection are also the main cause of death after PD.Proper selection of anastomotic methods is essential to the success of PD.The most common anastomotic methods can be divided into pancreaticojejunostomy and pancreatogastrostomy,but the effects of these methods have always been controversial consistently.In this paper,the effects of pancreaticojejunostomy and pancreatogastrostomy in the prevention of postoperative pancreatic fistula were synthetically analyzed based on recent research results.

Pancreaticoduodenal anastomotic dehiscence complicated with peritoneal hemorrhage following pancreaticoduodenectomy is a serious complication which threatens patients'life.Prevention and mangement of pancreaticoduodenal anastomotic dehiscence and peritoneal hemorrhage is the focus in the surgical treatment.Operation is the most reliable treatment for bleeding.While reoperation is difficult for most surgeons and the risk of fistula and rebleeding after reoperation exist.Some procedures will affect the endocrine and exocrine function of pancreas.We applied pancreaticojejunal bridge drainage for most patients with hemorrhage after pancreaticoduodenectomy.This procedure is easy,safe,and can protect the pancreatic function.

Post-operative pancreatic fistula(POPF)is the most common and severe complication after pancreaticoduodenectomy,which may have significant impacts on curative effects and prognosis.It has been shown that POPF is not only closely associated with texture of pancreatic parenchyma,diameter of pancreatic duct and tumor site,but also affected by surgeon's experience and surgical techniques.Double layer pancreaticojejunostomy and external pancreatic duct stent may be beneficial to decrease POPF.

Pancreaticojejunostomy is a difficult procedure in laparoscopic pancreaticoduodenectomy.How to improve the method of laparoscopic pancreaticojejunostomy and decrease the incidence of pancreatic leakage is a never-ending issue for clinicians.From November 2002 to March 2012,the digestive tract of 34 patients who received laparoscopic pancreaticoduodenectomy at the First Affiliated Hospital of Guangxi Medical University was constructed by wrapping pancreatic duct-jejunum anastomosis,and satisfactory outcomes were observed except for 2 patients with slight pancreatic leakage.The results of the study showed that wrapping pancreatic duct-jejunum anastomosis is a fast,safe and effective method for pancreaticojejunostomy.

Severe acute biliary pancreatitis can be treated by nonsurgical and surgical approaches,and choice of the surgical techniques as well as its timing are the keys points to the whole therapy.Early enteral nutrition via placing nasointestinal feeding tube plays an important role in the nutritional support for patients with severe acute pancreatitis.This paper intends to explore the experience in standardizing the therapy for all similar cases via reviewing and summarizing the treating process of a typical patient with severe acute biliary pancreatitis.

Postoperative pancreatic leakage remains a persistent problem after pancreaticoduodenectomy.For patients with a soft and nonfibrotic pancreas,double binding continuous hemstitch suture is an optimal method for anastomosis.From January 2011 to June 2012,92 cases of periampullary carcinoma with a soft pancreas underwent pancreaticoduodenectomy,and then a modified technique of pancreaticogastrostomy was performed with 2 continuous hemstitch sutures placed in the mucosal and seromuscular layers of the posterior gastric wall,respectively.The median time for pancreaticogastrostomy was 12 minutes,and only 15 patients had postoperative complications.Two patients developed pancreatic leakage(1 grade A and 1 grade B)postoperatively.Pancreaticogastrostomy with double binding continuous hemstitch sutures is a simple and safe reconstruction procedure for patients with a soft and fragile pancreas who received pancreaticoduodenectomy.

Objective To evaluate the pancreaticojejunostomy procedures selection strategy in pancreaticoduodenectomy.Methods The clinical data of 455 patients who received pancreaticoduodenectomy at the Xijing Hospital from June 2007 to June 2012 were retrospectively analyzed.For patients with pancreatic duct diameter≥4 mm,duct-to-mucosa pancreaticojejunostomy(DMPJ)was applied(DMPJ group,210 cases).For patients with pancreatic duct diameter ＜ 4 mm,modified Child pancreaticojejunostomy was applied to 140 patients(modified Child group)whose jejunal end was smaller than the pancreatic stump,and binding pancreaticojejunostomy was applied to 105 patients(binding group)whose jejunal end was bigger than or equal to the pancreatic stump.The clinical efficacy and incidence of postoperative complications were compared among the 3 groups.The count data and measurement data were analyzed by chi-square test and t test,respectively.Results The pancreatic duct diameter of the DMPJ group was(4.4 ± 0.7)mm,which was significantly bigger than(2.8 ± 0.6)mm of the modified Child group and(2.3 ± 0.7)mm of the binding group(t =2.25,2.48,P ＜ 0.05).The diameter of the pancreatic stump of the modified Child group was(36 ± 5)mm,which was significantly bigger than(21 ± 6)mm of the binding group(t =21.65,P ＜ 0.05).The overall incidence of pancreatic leakage was 8.4％(38/455).There were no significant differences in the incidences of pancreatic leakage,peritoneal bleeding,abdominal infection,digestive dysfunction rate and the mean duration of hospital stay among the 3 groups(x2 =0.53,0.88,1.63,5.34,F =2.53,P ＞ 0.05).Conclusion Pancreaticojejunostomy procedure selection strategy based on the diameters of pancreatic duct and pancreatic stump could obtain good clinical efficacy and is appropriate.

Objective To analyze postoperative complications of duct-to-mucosa pancreaticojejunostomy and side-to-end or end-to-end pancreaticojejunostomy following pancreaticoduodenectomy.Methods The clinical data of 342 patients who underwent pancreaticoduodenectomy at the West China Hospital of Sichuan University from June 2004 to May 2008 were retrospectively analyzed.All patients were divided into the duct-to-mucosa group (179 cases)and side-to-end or end-to-end group(163 cases)according to the styles of pancreaticojejunostomy.The relationship between the incidence and severity of postoperative complications of the 2 anastomotic styles were analyzed according to the Clavien grading system.The measurement data and the count data were analyzed using the t test or chi-square test.Results The overall complication rate was 48.8％(167/342),and the complication rate was 38.0％(68/179)in the side-to-end group and 60.7％(99/163)in the side-to-end or end-to-end group,with a significant difference between the 2 groups(x2=17.667,P ＜0.05).The incidences of grade Ⅱ and grade Ⅴ complications were 16.8％(30/179)and 1.1％(2/179)in the duct-to-mucosa group,which were significantly lower than 28.2％(46/163)and 5.5％(9/163)of the side-to-end or end-to-end group(x2=6.484,5.316,P ＜0.05).Conclusion Compared with side-to-end or end-to-end pancreaticojejunostomy,duct-to-mucosa pancreaticojejunostomy is a better style with a lower incidence of postoperative complication.

Translational medicine is a new concept in China.It sets up a bridge between basic research and clinical work,and aims to transfer the basic study results to clinical practice as soon as possible.It is necessary for a surgeon to master the research idea of translational medicine in order to be expert in science and technique.Many unsolved clinical problems could be found in routine work,which is an advantage for translational medicine research.How to raise questions in routine clinical work and get these questions resolved in laboratory,and then apply the results to clinical work is a demand for surgeons nowadays.In this article,the research idea of translational medicine is introduced based on an example of the research on the relationship between rapamycin and hepatocellular carcinoma.