How to make a surgeon? It's not an easy question to answer for some of the graduates with doctor degree (Ph.D.).Because the lack of systemic training and stringent qualification exams in the filed of surgery in our country,Ph.D.need to improve their clinical ability and also shift their roles when they are entering the world of surgery.In this article,the author would like to discuss the way to help Ph.D.in accelerating their changing process from a Ph.D.to a capable confident surgeon based on the author's personal experience.Ph.D.are suggested to improve themselves in the following ways:study like a humble student,learn how to improve oneself through observation,practice diligently on basic technique skills,be brave in surgical practicing,read and write as much as you can,and last but not least cultivate your professionalism.

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.

Pancreaticoduodenectomy (PD) is the procedure for treating adenocarcinoma in periampullary region.This involves resection of multiple organs and complex reconstructions.The modern surgery has witnessed the dramatic improvement in outcomes after PD.Mortality has dropped to less than 4％,however,the complication rate remains high,making this procedure still a big challenge for most surgeons. PD is so complicated that even small mistakes could jeopardize the whole procedure and outcomes.With experiences of over 1000 PDs,we discuss the challenges of this procedure and strategies to deal with them.

There was never a time in history that so many disciplines and specialists participate and try to lead the clinical management for acute pancreatitis. Chaos remains at bedside, and episodes of under-intervention and especially over-treatment frequently happened. Physicians are easily confused by questions and controversies in management for acute pancreatitis. We have reviewed the articles in acute pancreatitis and made our recommendations based on the latest evidences.

Pancreatic neuroendocrine neoplasms (pNENs) can be divided into functional and non-functional.Insulinomas,gastrinomas,glucagonomas and VIPomas are the common types of pNENs.Radical resection is the only way for curing pNENs or for a long-time survival of patients.The basic surgical procedures for pNENs are consist of local resection (tumor enucleation) or anatomical resection [pancreatoduodenectomy (standard or pylorus-preserving pancreatoduodenectomy),distal pancreatectomy (combined with splenectomy or spleen-preserving pancreatectomy) and middle segmental pancreatectomy].Liver is the most common site for metastases.Surgical resection is the method of choice for liver metastases.Radiofrequency ablation,transcatheter arterial chemoembolization and liver transplantation could be the adjunctive therapies.

Objective To study the clinical evaluation of calf blood as a combination of aspirin and aspirin for ischemic stroke and its effect on peripheral blood BCL-2,BAX and Caspase-3,IL-6 and pathogens.Methods 128 patients with ischemic stroke were enrolled in our hospital from September 2014 to October 2016.The patients were divided into observation group and control group by throwing coin method.The control group was treated with oral aspirin tablets and some conventional medical treatment,and the observation group on the basis of this increase in calf blood to the protein injection for treatment,the hemorheology,Barthel index,the national institutes of health stroke scale(NIHSS score)and peripheral blood BCL-2,BAX and Caspase-3 protein content of two groups were recorded before and after treatment.Results After treatment,the total effective rate in the observation group(96.9％)was significantly higher than that in the control group(71.9％),the NIHSS score and hemorheological index of the observation group were significantly lower than those of the control group,Bclhel index was significantly higher than that of the control group,the content of BCL-2 protein in the peripheral blood of the observation group was significantly higher than that of the control group,the levels of BAX and Caspase-3 protein in the peripheral blood of the observation group were significantly lower than those of the control group,the difference was statistically significant(P<0.05).Conclusion The clinical effect of calf blood protein injection combined with aspirin in the treatment of ischemic stroke can not only improve the daily life ability of patients,but also can improve the hemorheology and peripheral blood BCL-2; BAX,Caspase-3 protein content.

Radical resection is one of the important factors for improving the prognosis of patients with resectable carcinoma of head of the pancreas,carcinoma of the distal bile duct and periampullary carcinoma.In order to proceed with a R0 resection,there are many types of pancreaticoduodenectomy (PD) for pancreatic,biliary and periampullary carcinoma such as PD with lymphadenectomy.In this report,we described a PD with extended retroperitoneal lymphadenectomy (D2 +) for the adenocarcinoma of the distal bile duct.The case presented underscores the feasibility and safety of PD with D2 + lymphadenectomy.

Wheezing is the most common respiratory disease in children.In recent years,the incidence of childhood wheezing showed an upward trend,the hot topic in the current study is how to draw up a rational and effective treatment to reduce wheezing.This paper summarized the latest research progress of pathogenic factors,clinical classifi-cation,pathogenesis and prevention strategies in childhood wheezing.It aimed to provide a theoretical basis for early diagnosis and individual treatment for children with wheezing diseases.

Objective To observe the expression of MTA1 and ER in breast cancer,the correlation of the two factors and with the invasive capability of breast cancer.Methods The expression of MTA1 and ER in normal breast,precancerous lesions and breast cancer tissues was detected by using nucleic acid hybridization in situ(ISH) and immunocytochemistry(IHC) methods,and their correlation was analyzed by Spearman method.ResultsThe expression of MTA1 and ER was higher in ISH than in IHC.The mRNA expression of MTA1 in normal breast tissue,precancerous lesions and breast cancer tissne was 12.2%,33.3%,and 81.1% respectively,and the expression by IHC was 11.1%,31.1% and 72.2% respectively.The mRNA expression of ER in normal breast tissue,precancerous lesions and breast cancer tissue was 83.3%,61.1% and 37.8%,respectively,and the expression by IHC was70.9%,56.7% and 35.6% respectively.The positive expression of MTA1 was higher in ER-negative patients than that in ER-positive ones(86.2﹪vs.46.9﹪).ConclusionsCombined ISH and IHC detection can improve the detection rate of MTA1 and ER.With advancement of the disease and lowering of tumor differentiation,the expression of MTA1 gradually increases,while expression of ER decreases and even disappears.The expression of MTA1 is negative in relation to that of ER(the coefficient is-0.466).MTA1and ER could be important molecular markers for the prognosis and therapy of breast cancer.

Objective To investigate the expression of Toll-like receptor 4 (TLR4) and myeloid derived suppressor cells(MDSC) in bone marrow cells in children with acute myeloid leukemia (AML),and to detect its relationship with the clinical features,the effect of chemotherapy and prognosis.Methods Twenty-nine cases of children with AML were collected from June 2013 to March 2014 in People's Hospital of Wuhan University,in which 11 cases of low-risk group,10 cases of middle-risk group,8 cases of high-risk group;and 17 cases of non blood disease was as the control group.The expressions of TLR4 and MDSC were detected by using reverse transcription-polymerase chain reaction (RT-PCR),Western blot methods,immunohistochemical staining,and flow cytometry,respectively,in the bone marrow cells of 29 children with AML.Results The mRNA and protein expression of TLR4 in the initial treatment group was higher than those in the complete remission group(t =3.092,3.393,all P ＜ 0.05).The mRNA and protein expression of TLR4 in the relapse group was higher than those in the complete remission group(t =4.013,4.279,all P ＜ 0.05).The positive expression rates of MDSC in the above 3 groups were (29.77 ± 1.39) ％,(5.19 ± 0.65) ％,(38.62 ± 3.54) ％,respectively,compared with the control group [(1.32 ± 0.27) ％] and there was significant difference(all P ＜0.05).The positive expression rates of TLR4 and MDSC in the initial treatment group,relapse group and complete remission group were significantly higher than those in the control group,with significant differences (initial treatment group TLR4:t =3.559,P ＜ 0.05;MDSC:t =3.727,P ＜ 0.05;relapse group TLR4:t =4.043,P ＜ 0.05;MDSC:t =4.125,P ＜ 0.05;complete remission group TLR4:t =2.798,P ＜ 0.05;MDSC:t =3.469,P ＜ 0.05).Pearson rank correlation analysis showed that there was a positive correlation between the expression of TLR4 and MDSC (r =0.673,P ＜0.01).Conclusions The expressions of both TLR4 and MDSC play an important role in onset,progression,curative effect and prognosis in children with AML,and the two may play an importment role in synergistic effect.