About 20％-30％ of pancreatic neuroendocrine neoplasms (pNENs) are resectable after the initial diagnosis,and about 70％-80％ of pNENs are locally advanced or metastatic tumors.For resectable pNENs,primary and metastatic lesions are suggested to be resected,and for locally advanced or metastatic functional tumors,debulking surgery is encouraged for controlling the symptoms and alleviating the life quality; debulking surgery could not improve the overall survival of patients with non-functional neuroendocrine tumors,unless there are lifethreatening complications such as bleeding or obstruction.For type Ⅰ liver metastasis,simultaneous resection of primary and metastatic lesions is advised; while for type Ⅱ liver metastasis,systemic treatment combined with local treatment (radio-frequency ablation,transcatheter arterial chemoembolization and transartery embolization) is effective; for type Ⅲ liver metastasis,target therapy such as Sunitinib,Everolimus combined with long acting Sandostatin is effective.No adjuvant therapy is needed after radical resection of pNENs,while following therapy is suggested for patients after metastatic pNENs resection.

Neuroendocrine neoplasm (NENs) is a kind of rare tumor which occurs in multiple human organs.The prognosis of NENs is relatively good,but the diagnosis and treatment of NENs is complicated and involve different specialties.In major medical centers,comprehensive and standard diagnosis and treatment could improve the prognosis of NENs and reduce the waiting and treatment time via multidisciplinary team (MDT) model.The regional variation and differences in the techniques among hospitals are decreasing through communication and learning among the members of MDT.Recently,the excellent MDT is working in a spirit of cooperation and sharing to create the patients-centered model,with professional doctors and complete hardware facilities.The NENs clinical center needs to strengthen diagnosis,treatment,research and training.

The incidence and prevalence of pancreatic cancer have been steadily increasing globally and domestically. The common risk factors of pancreatic cancer include diabetes mellitus, chronic panereatitis, cigarette smoking, family history of pancreatic cancer, and alcoholism. There is no specific symptom and early diagnostic marker of pancreatic cancer. CA19-9 is the most commonly used serum marker for the detection and follow-up of pancreatic cancer. However, its sensitivity and specificity precluded its use in screening of the disease. Enhanced spiral CT scan is the routine radiological modality for the diagnosis and staging of pancreatic cancer. Newly developed diagnostic modality such as ultrasound contrast imaging, endoscopic ultrasound, PET/CT scan further improved the sensitivity and specificity of diagnosis. Preoperative fine needle aspiration (FNA) is not recommended for patients with resectable pancreatic cancer. Pathological confirmation by FNA is necessary for patients who will be treated by chemotherapy or chemoradiotherapy. Preoperative staging laparoscopy can rule out the patients with abdominal seeding, so that unnecessary open surgery is avoided. In order to achieve better survival, every effort should be made to achieve R_0 resection for patients with stage Ⅰ or Ⅱ disease.

Pancreatic neuroendocrine tumor (pNET) accounts for about 2％ of all malignant pancreatic tumors.According to presence or absence of specific hormone related symptoms,pNET is classified as functional and non-functional.About 75％ of pNET is non-functional.Surgery is the only potential treatment that cures pNET.Before operation,localization of primary tumor is very important.For localized lesions,pancreaticoduodenectomy,segmental pancreatectomy,distal pancreatectomy or enucleation could be chosen according to the site of primary tumor.For metastatic pNET,if the primary lesion and metastatic lesions could be resected simultaneously,aggressive approach is an optimal choice and better clinical outcome could be achieved.For those with big multiple metastatic lesions,especially in the liver,debulking operation should be considered when more than 90％ metastatic lesions could be resected,for debulking operation could improve the survival and quality of life of those patients.Liver transplantation should be reserved to patients with no extra-hepatic metastasis and tumor is stable with low grade,while R0 resection could be achieved for primary lesion.

The incidence of pancreatic neuroendocrine tumors is increasing in recent years. Scientific treatment strategy will improve the prognosis of patients. Surgical resection is the main treatment for pancreatic neuroendocrine tumors, especially for localized tumors. At present, there are still controversies about the treatment of pancreatic neuroendocrine tumors at home and abroad. Based on the literature and clinical practice, the author combs the related controversies and suggests that the age, physical condition, tumor location, staging, grading and functional status of the patients should be taken into consideration when making the surgical plan. The individualized treatment of pancreatic neuroendocrine tumor should be realized according to the specific situation of the patients and the evidence-based medicine.

Mounting evidences suggest that the ATRX (α-thalassaemia/mental retardation syndrome X-linked) and DAXX (death-domain associated protein) which encode 2 subunits of a chromatin remodelling complex required for H3.3 incorporation at pericentric heterochromatin and telomeres,and multiple endocrine neoplasia type 1 (MEN-1) genes are significantly mutated in most patients with pancreatic neuroendocrine tumors (pNETs),as are genes encoding key molecules of the mammalian target of rapamycin (mTOR) signaling pathway.These mutated genes promote deregulation of epigenetic processes such as chromatin remodeling,histone modification and activation of alternative lengthening of telomeres,and thus combined alteration of these genes may contribute to drive tumorigenesis and metastasis of pNETs which are characterized by complex patterns of phenotypes.These findings may have great significance in the diagnosis and treatment of pNETs and predicting the prognosis,as well as providing clinical implications for targeted cancer therapy.

Enhanced recovery after surgery (ERAS) includes preoperative education,intraoperative effective anaesthetization,analgesia,precision surgical techniques and postoperative early rehabilitation.Because of special location of the pancreas,difficulty of surgical techniques,longtime of learning and high incidence of postoperative complications,the application of ERAS in pancreatic surgery is restricted.While ERAS could reduce the stress after surgery and the incidence of complications,promote the recovery of patients,shorten the duration of hospital stay and reduce the expenses,which are confirmed by clinical practice.ERAS is the trend of the development of pancreatic surgery.How to balance the optimal prognosis and speed recovery is need to be resolved by pancreatic surgeons.

The incidence of pancreatic cancer has steadily risen in the past decades. Radical resection is still the best option for treatment of pancreatic cancer. Great progress has been achieved in pancreatic surgery;the mortality and morbidity have decreased dramatically, but long term survival after resection is still dismal. Standard pancreaticoduodenectomy is recommended now for pancreatic head cancer. Extended lymphadenectomy could not improve the prognosis of pancreatic cancer patients. Total pancreatectomy is suitable for some IPMNs patients, rather than a routine for pancreatic cancer patients. The current status and future of surgical treatment for pancreatic cancer will be summarized here.

Objective To investigate the diagnosis and treatment value of digital subtraction angiography (DSA) and transcatheter arterial embolization (TAE) for post pancreatectomy hemorrhage (PPH),and influencing factors of severity of PPH.Methods The retrospective case-control study was conducted.The clinicopathological data of 20 patients with PPH who were admitted to the Zhongshan Hospital of Fudan University from August 2009 to November 2016 were collected.Patients with PPH in the early stage underwent reoperations for hemostasis;patients with PPH in the later stage received conservative treatment,and then DSA and TAE were considered when patients had the stable vital signs.Observation indicators:(1) DSA situations:overall times,positive rate and bleeding sites;(2) TAE situations:successful rate of hemostasis,operating time and postoperative complications;(3) follow-up situations;(4) influencing factors analysis of severity of PPH.Follow-up using outpatient examination and telephone interview was performed to detect occurrence of complications after discharging from hospital up to April 2017.Measurement data with skewed distribution were described as M (range).Count data were evaluated by the ratio and proportion.The univariate analysis was done using the Fisher exact probability.Results (1) DSA situations:all the 20 patients underwent DSA,with overall times of 27.The direct sign was 18 times extravasation of the contrast medium,with a positive rate of 66.7％ (18/27).Of 18 times positive DSA,clear bleeding sites were located in 5 times gastroduodenal artery (3 times with pseudoaneurysm of gastroduodenal artery stump),in 4 times common hepatic artery (3 times with pseudoaneurysm of common hepatic artery),in 3 times superior mesenteric artery,in 2 times splenic artery,in 1 time left gastric artery,in 1 time right gastric artery,in 1 time left hepatic artery (pseudoaneurysm of left hepatic artery) and in 1 time inferior mesenteric artery.(2) TAE situations:of patients with 18 times positive DSA,patients with 15 times positive DSA received TAE,with a successful rate of hemostasis of 13/15,and patients with 5 times positive DSA received successful hemostasis by reoperation.A median operating time of TAE for patients with 15 times positive DSA was 30 minutes.There was no occurrence of adverse reaction,including fever,abdominal pain,melena,elevated aminotransferase and liver abscess.One patient complicated with splenic abscess after transcatheter splenic arterial embolization underwent puncture drainage and then had a good recovery.Of patients with 9 times negative DSA,patients with 8 times negative DSA were cured by conservative treatment and patient with 1 time negative DSA received successful hemostasis by operation.All the 20 patients were cured and then discharged from hospital.(3) Follow-up situations:20 patients were followed up for 4-92 months,with a median time of 24 months.During the follow-up,20 patients recovered well,without long-term complications.(4) Influencing factors analysis of severity of PPH:the results of univariate analysis showed that gender,age,preoperative blood sugar,preoperative combined jaundice,preoperative albumin (Alb),preoperative prothrombin time (PT) extended,preserving pylorus,pancreatic duct stent placement,pancreatic operation time,volume of intraoperative blood loss,intraoperative blood transfusion,property of tumor,postoperative pancreatic fistula and time of PPH were not factors affecting the severity of PPH (P＞0.05).Conclusion DSA is minimal-invasive in the diagnosis for PPH,and TAE is safe and effective for patients with positive DSA.

Objectives: To investigate the role of glutamine on splanchnic blood flow in SAP rats and underling mechanism. Methods: 32 rats were randomized divided into 2 groups:glutamine group(Gln group, n =16) and SAP group ( n =16).Jejunotomy was performed. Gln group received glutamine.SAP group received saline.All groups were subdivided into 2 groups.8 normal rats were used as the controls.At 12,24hours after the induction of SAP,8 rats in each group were sacrificed.Plasma glutamine concentrations were measured by HPLC.The regional pancreatic microvascular blood flow was measured by Dopplar ultrasound,the blood flow of portal vein,spleen artery and superior mesenteric artery was also measured. Results: Enterally administered Gln was well tolerated by the rats.There was an increase in plasma Gln levels after Gln supplementation on Gln group.The regional pancreatic microvascular blood flow decreased significantly in SAP group( P