Pancreatic carcinoma has the poorest prognosis in all the digestive cancers,and the management is still challenging.In recent years,the rapid development of surgical technique has led to the increase in the resection rate and the significant decrease in perioperative mortality and morbidity.However,the prognosis of pancreatic carcinoma has not been improved.Nowadays,the treatment strategy of pancreatic carcinoma has been changed from “surgery first” into the mode of multidisciplinary team.If “1 mm rule” was used as the standard protocol for assessment of resection margins,most of the pancreatic resection were therefore R1 resections.Neoadjuvant therapy is advocated for patients who meet specific characteristics.Under the guidance of the concept of precision medicine,surgical treatment of pancreatic carcinoma should be changed from the modes of morphology and surgery to the modes biology and oncology.

The need of pathological diagnosis of spaceoccupying lesions of the head of pancreas before pancreaticoduodenectomy is a hot issue in the pancreatic surgery.According to the present guidelines and consensus,pathological diagnosis is not required if the patient with clinically resectable space-occupying lesions of the head of pancreas.However,confirmation of tumor malignancy is mandatory for patients with borderline resectable disease to be treated by neoadjuvant therapy,for patients with unresectable tumors to be treated by chemoradiotherapy,and for patients with unresectable tumors to be treated with a palliative bypass procedure during the surgical exploration.When making a clinical decision,surgeons should fully communicate with the patients and their relatives,under the direction of a multidisciplinary team,and have a correct and dialectical knowledge of the guidelines and consensus.This would be helpful for the improvements of the diagnosis and treatment of space-occupying lesions of the head of pancreas.

Pancreatic carcinoma is still a challenging disease,although the resection rate and the operative safety have been improved,the prognosis of the patients is dismal.Now the therapy strategy is changed from surgery first into the mode of multidisciplinary team (MDT).Surgical resection is the only curable therapy for pancreatic carcinoma.Recently,the clinical role of extent of lymphadenectomy,combined vascular resection,and total mesopancreas excision was recognized more deeply.If 1 mm rule is applied to define the resection margin,most pancreatic cancer resections are R1 resections,which benefit the patients.There has been consensus on the definition of perioperative complications.Neoadjuvant therapy is advocated for patients with borderline resectable pancreatic carcinoma.

Pancreatic carcinoma is still a challenging disease.Although there is no randomized controlled trial (RCT) results,neoadjuvant therapy is encouraged to perform on patients with borderline resectable or resectable pancreatic cancers,which could probably increase the Ro resection rates.There has been some modifications about resection approach in recent years,for example,artery first,hanging maneuver,uncinate process first,etc,which seem as safe and effective options.Because of the modification of pathologic classification of R0 and R1 resection for pancreatic cancer,the clinical outcomes of R1 resection need to be reevaluated.The extent of lymphadenectomy in pancreaticoduodenectomy remains controversial.Based on several RCT reports,dissection of 2nd group of lymph nodes is recommended according to the Japan Pancreas Society classification.The discussion and clinical application about the concept of mesopancreas will help to improve the status of retroperitoneal margins via standardized surgical procedures.

The treatment concept for pancreatic cancer is being transferred from “surgery first”to MDT model.The postoperative adjuvant treatment of pancreatic cancer can significantly improve the prognosis of patients and has become the standardized diagnostic and treatment practice;the value and significance of neoadjuvant therapy remains unclear.Limited clinical studies of “borderline resectable”pancreatic cancer have shown that neoadjuvant therapy can improve the R0 resection rate and improve the prognosis of patients,and it is recommended for clinical application.But the significance of neoadjuvant therapy in “resectable”pancreatic cancer is still controversial.There is a lack of consensus on indications,cycles,and regimens.It is necessary to carry out a series of prospective control studies to objectively evaluate the value of neoadjuvant therapy in improving the prognosis of “resectable”pancreatic cancer.

As no fiber sheath covered,mesopancreas is considered to be different from mesocolon and mesorectum.Though amount of lymphatic,nervous,vascular and fat tissues are consisted in this structure,the margin and range are still controversial in the clinical practice.Only a few clinical reports show a higher R0 resection rate with the procedure of total mesopancreas excision (TMpE),but most of the studies are singlecentered and retrospective,from which we could not assess the outcome improvement for the patients undergoing TMpE.Moreover,the difference between the ranges of TMpE and ever-used extended excision or lymphectomy should be further evaluated.More anatomical and clinical studies are needed to standardize the operation range in order to benefit the patients.

The prognosis of pancreatic cancer is the worst in all kinds of digestive tract tumors. Fifty percent of pancreatic cancer patients have distant metastasis at the time of diagnosis, and liver is the most common site of metastasis. For pancreatic cancer patients, the presence of distant metastasis has been always considered as an absolute contraindication for surgical resection. However, with the establishment of multidisciplinary team, especially the researches of chemotherapy and targeted drugs and the application of new chemotherapy regimens in recent years, there are more and more evidences which show the survival benefit of surgical resection for some selected patients with liver oligometastasis after systemic chemotherapy. In this paper, the authors review current situation and progress in the treatment strategy for pancreatic cancer with hepatic oligometastasis, further investigate the indication of surgical treatment and evaluate its clinical outcomes.

The Hedgehog (Hh) signaling pathway plays a key role in the embryonic development, which is formed by the Hedgehog(Hh) , membrane-receptor complex Patched (Ptch) and Smoothened (Smo), multifunctional transcription factors Glioma-associated oncogene homolog (Gli) and other signal molecules. The Hh signaling pathway controls a variety of developing processes, however, no or less expression is observed in the normal pancreas tissues.The mutational activation of the Hh signaling pathway is associated with tumorigenesis and metastasis of the pancreatic cancer. The aim of this review is to present a brief overview of the Hedgehog signaling pathway in the mechanism of the tumorigenesis of the pancreatic cancer.

Humans ; Pancreatic Neoplasms ; surgery ; Pancreaticoduodenectomy