Preoperative 3D reconstruction and fluorescent indocyanine green for laparoscopic duodenum preserving pancreatic head resection:A case report

BACKGROUND Duodenum-preserving pancreatic head resection(DPPHR)is the choice of surgery for benign or low-grade malignant tumors of the pancreatic head.Laparoscopic DPPHR(LDPPHR)procedure can be improved by preoperative 3D model reconstruction and the use of intravenous indocyanine green fluorescent before surgery for real-time navigation with fluorescent display to guide the surgical dissection and prevention of from injury to vessels and biliary tract.CASE SUMMARY Here we report the successful short-and long-term outcomes after one year following LDPPHR for a 60-year lady who had an uneventful recovery and was discharged home one week after the surgery.CONCLUSION There was no bile leakage or pancreatic leakage or delayed gastric emptying.The histopathology report showed multiple cysts in the pancreatic head and localized pancreatic intraepithelial tumor lesions.The resected margin was free of tumor.

Dissimilar survival and clinicopathological characteristics of mucinous adenocarcinoma located in pancreatic head and body/tail

BACKGROUND Growing evidence shows that pancreatic tumors in different anatomical locations have different characteristics,which have a significant impact on prognosis.However,no study has reported the differences between pancreatic mucinous adenocarcinoma(PMAC)in the head vs the body/tail of the pancreas.AIM To investigate the differences in survival and clinicopathological characteristics between PMAC in the head and body/tail of pancreas.METHODS A total of 2058 PMAC patients from the Surveillance,Epidemiology,and End Results database diagnosed between 1992 and 2017 were retrospectively reviewed.We divided the patients who met the inclusion criteria into pancreatic head group(PHG)and pancreatic body/tail group(PBTG).The relationship between two groups and risk of invasive factors was identified using logistic regression analysis.Kaplan-Meier analysis and Cox regression analysis were conducted to compare the overall survival(OS)and cancer-specific survival(CSS)of two patient groups.RESULTS In total,271 PMAC patients were included in the study.The 1-year,3-year,and 5-year OS rates of these patients were 51.6%,23.5%,and 13.6%,respectively.The 1-year,3-year,and 5-year CSS rates were 53.2%,26.2%,and 17.4%,respectively.The median OS of PHG patients was longer than that of PBTG patients(18 vs 7.5 mo,P<0.001).Compared to PHG patients,PBTG patients had a greater risk of metastases[odds ratio(OR)=2.747,95%confidence interval(CI):1.628-4.636,P<0.001]and higher staging(OR=3.204,95%CI:1.895-5.415,P<0.001).Survival analysis revealed that age<65 years,male sex,low grade(G1-G2),low stage,systemic therapy,and PMAC located at the pancreatic head led to longer OS and CSS(all P<0.05).The location of PMAC was an independent prognostic factor for CSS[hazard ratio(HR)=0.7,95%CI:0.52-0.94,P=0.017].Further analysis demonstrated that OS and CSS of PHG were significantly better than PBTG in advanced stage(stage III-IV).CONCLUSION Compared to the pancreatic body/tail,PMAC located in the pancreatic head has better survival and favorable clinicopathological characteristics.

Pancreatic head carcinoma:clinical analysis of 189 cases

BACKGROUND: Pancreatic cancer is a lethal disease with an increasing incidence. We retrospectively reviewed the clinical data on diagnosis and treatment of pancreatic head carcinoma, and analyzed the factors affecting prognosis of the disease. METHODS: The data of 189 patients with pancreatic head carcinoma treated from September 1, 1995 to August 31, 2005 were reviewed retrospectively. Ninety-four patients treated from September 1, 2000 to August 31, 2005 were followed up in April 2008. The median survival time (MST) and 1- to 5-year cumulative survival rates of the patients were calculated by the life table method and the Kaplan-Meier method. Cox regression was used to screen out significant risk factors. RESULTS: 96.9% of the patients were more than 40 years old, and the male/female ratio was 1.63. The detection rate of transabdominal ultrasonography (US), computed tomography (CT), endoscopic ultrasonography (EUS), and serum tumor marker CA19-9 were 82.0%, 93.1%, 94.7% and 79.8%, respectively. The MST of patients with pancreatic head carcinoma was 360 +/- 60 days. The 1- to 5-year cumulative survival rates were 50.0%, 19.2%, 12.1%, 9.4% and 4.7%, respectively. However, patients with unresectable tumor survived for a shorter time (183 +/- 18 days). Their 1- to 2-year cumulative survival rates were 28.3% and 0.0%. Cox regression analysis showed that in pancreatic head carcinoma, the independent predictors for prognosis included tumor size, invasion of the superior mesenteric vessel, and radical resection. The MST of patients with pancreatic head carcinoma after radical resection was 510 days, significantly longer than that of patients undergoing non-specific treatment and palliative therapy (225 days). In addition, patients with slight jaundice survived for the longest time (533 +/- 51 days), compared with patients with severe jaundice (236 +/- 43 days) and without jaundice (392 +/- 109 days). CONCLUSIONS: Pancreatic head carcinoma is easily misdiagnosed, and is usually found to be advanced when tumor size is too large (above 4 cm in diameter) with local spread or metastatic disease. In these cases, surgical resection is usually not feasible, and its prognosis is usually very poor. Therefore, careful attention should be paid to these high-risk patients, especially, males, more than 40 years old, and presenting slight jaundice. Then imaging examination (US, CT and EUS) and serum tumor marker examination (CA19-9) are used to detect this disease earlier, and perform curative resection earlier. In this way, it is possible to cure the patients with a longer survival time and better quality of life.

Total mesopancreas excision for pancreatic head cancer: analysis of 120 cases

Objective： To evaluate the feasibility and safety of total mesopancreas excision （TMpE） in the treatment of pancreatic head cancer. Methods： The clinical and pathological data of 120 patients with pancreatic head cancer who had undergone TMpE in our center from May 2010 to January 2014 were retrospectively analyzed. Results： The mean operative time was （275.0±50.2） min and the average intra-operative blood loss was （390.0±160.5） mL. Post-operative complications were reported in 45 patients, while no peri-operative death was noted. The specimen margins were measured in three dimensions, and 86 patients （71.6%） achieved R0 resection. Conclusions： TMpE is safe and feasible for pancreatic head cancer and is particularly helpful to increase the R0 resection rate.

Pancreaticoduodenectomy for borderline resectable pancreatic head cancer with a modified artery-first approach technique

BACKGROUND： The treatment of borderline resectable pancreatic head cancer（BRPHC） is still controversial and challenging. The artery-first approaches are described to be the important options for the early determination. Whether these approaches can achieve an increase R0 rate, better bleeding control and increasing long-term survival for BRPHC are still controversial. We compared a previously reported technique, a modified artery-first approach（MAFA）, with conventional techniques for the surgical treatment of BRPHC.METHODS： A total of 117 patients with BRPHC undergone pancreaticoduodenectomy（PD） from January 2013 to June 2015 were included. They were divided into an MAFA group（n=78） and a conventional-technique group（n=39）. Background characteristics, operative data and complications were compared between the two groups.RESULTS： Mean operation time was significantly shorter in the MAFA group than that in the conventional-technique group（313 vs 384 min; P=0.014）; mean volume of intraoperative blood loss was significantly lower in the MAFA group than that in the conventional-technique group（534 vs 756 m L; P=0.043）; and mean rate of venous resection was significantly higher in the conventional-technique group than that in the MAFA group（61.5% vs 35.9%; P=0.014）. Pathologic data, early mortality and morbidity were not different significantly between the two groups.CONCLUSIONS： MAFA is safe, simple, less time-consuming, less intraoperative blood loss and less venous resection, and therefore, may become a standard surgical approach to PD for BRPHC with the superior mesenteric vein-portal vein involvement but without superior mesenteric artery invasion.

Pancreatic head cancer: Open or minimally invasive pancreaticoduodenectomy?

Pancreatic head cancer still represents an insurmountable barrier for patients and pancreatic surgeons.Pancreaticoduodenectomy(PD)continues to be the operative standard of care and potentially curative procedure for pancreatic head cancer.Despite the rapid development of minimally invasive techniques,whether the efficacy of minimally invasive pancreaticoduodenectomy(MIPD)is noninferior or superior to open pancreaticoduodenectomy(OPD)remains unclear.In this review,we summarized the history of OPD and MIPD and the latest staging and classification information for pancreatic head cancer as well as the proposed recommendations for MIPD indications for patients with pancreatic head cancer.By reviewing the MIPD-vs.OPD-related literature,we found that MIPD shows noninferiority or superiority to OPD in terms of safety,feasibility,enhanced recovery after surgery(ERAS)and several short-term and long-term outcomes.In addition,we analyzed and summarized the different MIPD outcomes in the USA,Europe and China.Certain debates over MIPD have continued,however,selection bias,the large number of low-volume centers,the steep MIPD learning curve,high conversion rate and administration of neoadjuvant therapy may limit the application of MIPD for pancreatic head cancer.

Laparoscopy and laparoscopic ultrasonography in judging the resectability of pancreatic head cancer

OBJECTIVE: To explore the clinical value of laparoscopy and laparoscopic ultrasonography (LUS) in judging the resectability of pancreatic head cancer. METHODS: LUS was employed as a prospective diagnosis of tumor staging before exploratory laparotomy in 22 patients diagnosed with pancreatic head cancer to identify whether the liver and peritoneum had small metastases or local invasion to the portal vein, superior mesenteric vessel, aorta, inferior vena cava. RESULTS: In the 22 patients receiving laparoscopy and LUS, we found peritoneal or surface liver metastases (3 patients), hepatic parenchyma metastases (1), and pancreatitis proved by biopsy under ultrasound guidance (1). Laparotomy was avoided in these 5 patients. Of the remaining 17 patients, 8 patients, including 2 patients with portal vein emboli due to tumor metastases had hypertrophic lymph nodes or tumor invasion of local vessels in the peritoneal cavity, retroperitoneum, and omentum and the other 9 patients had resectable tumors shown by LUS. The 17 patients were subjected to exploratory laparotomy, and pancreaticoduodenectomy was successful in 8 patients. CONCLUSIONS: Laparoscopy and LUS can be used to precisely estimate the possibility of resection of pancreatic head cancer, and prevent unnecessary exploratory laparotomy and its complications. It can be used as a routine examination before exploratory laparotomy.

“Total Arterial Devascularization First” Technique for Resection of Pancreatic Head Cancer during Pancreaticoduodenectomy

Summary： Integrated resection of the pancreatic head is the most difficult step in radical pancreati- coduodenectomy （RPD） in patients with the portal vein （PV） and superior mesenteric vein （SMV） inva- sion or oppression by the tumor. This study introduced a new idea and skill named the ＂total arterial devascularization first＂ （TADF） technique and its applications in RPD. Three arterial blood supplies of pancreatic head were obstructed before dissection of veins. The critical steps included exposure of the anterior surface of the abdominal aorta （AA） by completely transecting neural and connective tissue between superior mesenteric artery （SMA） and pancreatic mesounsinate, and transection of the mesounsinate from the origin of SMA to the root of the celiac trunk. From January 2012 through May 2013, a total of 58 patients with PV/SMV invasion or oppression underwent RPD using this technique. The median operative time was 5.1 h （ranging 4.5-8.1 h）. The median intraoperative blood loss was 450 mL （ranging 200-900 mL）. No intraoperative and postoperative bleeding of pancreatic head region oc- curred. Among the 58 patients, 21 were subjected to vessel lateral wall angiectomy or angiorrhaphy, and 10 to angiectomy and end-to-end anastomosis. The incidence of postoperative bleeding, postoperative pancreatic fistula and biliary fistula was 5.2%, 6.8%, and 1.7%, respectively. No patients died 3 months after operation. The TADF technique is a new method for intricate RPD and could improve the security of surgery and reduce intraoperative bleeding, which is expected to become standardized surgical ap- proach for RPD.

Xanthogranulomatous pancreatitis treated by duodenum-preserving pancreatic head resection

BACKGROUND:Xanthogranulomatosis is an idiopathic,rare process in which lipid-laden histiocytes are deposited at various locations in the body.We present two cases who were treated by duodenum-preserving pancreatic head resection and eventually diagnosed as having xanthogranulomatous pancreatitis. METHODS:A 30-year-old caucasian man was admitted to our clinic for vague abdominal pain and epigastric dullness. Magnetic resonance cholangiopancreatography and endoscopic retrograde pancreatography suggested the existence of chronic pancreatitis.Another 34-year-old caucasian woman was admitted to our clinic because of right upper quadrant pain. Magnetic resonance cholangiopancreatography demonstrated a dilatation and stone of the main pancreatic duct.Based on a diagnosis of chronic pancreatitis,pancreatic head resection was planned and a laparotomy was performed in both of cases. RESULTS:In both cases,duodenum-preserving pancreatic head resection was performed.Macroscopic and microscopic findings revealed xanthogranulomatous inflammation,which led to a diagnosis of xanthogranulomatous pancreatitis. CONCLUSION:Although this type of pancreatitis is extremely rare,it is important to keep it in mind for a differential diagnosis because it may simulate chronic pancreatitis or a malignant tumor on imaging.

Treatment strategy for pancreatic head cancer with celiac axis stenosis in pancreaticoduodenectomy:A case report and review of literature

BACKGROUND During pancreaticoduodenectomy in patients with celiac axis(CA)stenosis due to compression by the median arcuate ligament(MAL),the MAL has to be divided to maintain hepatic blood flow in many cases.However,MAL division often fails,and success can only be determined intraoperatively.To overcome this problem,we performed endovascular CA stenting preoperatively,and thereafter safely performed pancreaticoduodenectomy.We present this case as a new preoperative treatment strategy that was successful.CASE SUMMARY A 77-year-old man with a diagnosis of pancreatic head cancer presented to our department for surgery.Preoperative assessment revealed CA stenosis caused by MAL.We performed endovascular stenting in the CA preoperatively because we knew that going into the operation without a strategy could lead to ischemic complications.Double-antiplatelet therapy(DAPT)–which is needed when a stent is inserted–was then administered in parallel with neoadjuvant chemotherapy(NAC).This allowed us to administer DAPT for a sufficient period before the main pancreaticoduodenectomy procedure while obtaining therapeutic effects from NAC.Subtotal stomach-preserving pancreaticoduodenectomy was thenperformed.The operation did not require any unusual techniques and was performed safely.Postoperatively,the patient progressed well,without any ischemic complications.Histopathologically,curative resection was confirmed,and the patient had no recurrence or complications due to ischemia up to six months postoperatively.CONCLUSION Preoperative endovascular stenting,with NAC and DAPT,is effective and safe prior to pancreaticoduodenectomy in potentially resectable pancreatic cancer.

Safety and feasibility of irreversible electroporation for the pancreatic head in a porcine model

BACKGROUND Irreversible electroporation(IRE)is a local non-thermal ablative technique which has been suggested as a potential cancer therapy.However,the specific anatomic characteristics of the pancreatic head make it challenging to perform any local ablation in this region.Therefore,the safety and feasibility of IRE in the pancreatic head region should be further explored.AIM To evaluate the safety of IRE in pancreatic head region including its effects on pancreatic ducts,vessels,and adjacent gastrointestinal organs.METHODS Eight landrace miniature pigs underwent IRE of pancreatic head tissue successfully,with a total of 16 lesions created.Laboratory testing including white blood cell(WBC)count and serum amylase before IRE with follow-up laboratory analysis and pathological examination at 1,7,14,and 28 d postablation were performed.RESULTS All pigs tolerated the ablation procedure without serious perioperative complications.Transiently elevated WBC count and amylase were observed at 24 h post-IRE,suggesting an acute pancreatic tissue damage which was confirmed by pathological observations.Vascular endothelial cells and pancreatic duct epithelial cells in ablation zone were also positive in terminal deoxynucleotidyl transferase dUTP nick end labeling staining.There was extensive duodenum mucosa damage with local hemorrhage 24 h after ablation,while regeneration of new villous structures were observed at 7 and 28 d post-IRE.Masson’s trichromatic staining showed that the extracellular matrix was still intact in vessels and pancreatic ducts,and even in the duodenum.CONCLUSION IRE ablation to the pancreatic head may be safe and feasible without long-term damage to the surrounding vital structures.However,risks of stress injuries in acute phase should be taken into consideration to prevent severe perioperative complications.

Pancreatic head excavation for tissue diagnosis may reduce unnecessary pancreaticoduode- nectomies in the setting of chronic pancreatitis

BACKGROUND： The necessity to obtain a tissue diagnosis of cancer prior to pancreatic surgery still remains an open debate. In fact, a non-negligible percentage of patients under- going pancreaticoduodenectomy （PD） for suspected cancer has a benign lesion at final histology. We describe an approach for patients with diagnostic uncertainty between cancer and chronic pancreatitis, with the aim of minimizing the incidence of PD for suspicious malignancy finally diagnosed as benign disease. METHODS： Eighty-eight patients （85.4%） with a clinicoradio- logical picture highly suggestive for malignancy received for- mal PD （group 1）. Fifteen patients （14.6%） in whom preopera- tive diagnosis was uncertain between pancreatic cancer and chronic pancreatitis underwent pancreatic head excavation （PHEX） for intraoperative tissue diagnosis （group 2）： those diagnosed as having cancer received PD, whereas those with chronic pancreatitis received pancreaticojejunostomy （P]）. RESULTS： No patient received PD for benign disease. All pa- tients in group I had adenocarcinoma on final histology. Eight patients of group 2 （53.3%） received PD after intraoperative diagnosis of cancer, whereas 7 （46.7%） received PJ because no malignancy was found at introperative frozen sections. No signs of cancer were encountered in patients receiving PHEX and PJ after a median follow-up of 42 months. Overall survival did not differ between patients receiving PD for cancer in the group 1 and those receiving PD for cancer after PHEX in the group 2 （P=0.509）. CONCLUSION： Although the described technique has been used in a very selected group of patients, our results suggest that PHEX for tissue diagnosis may reduce rates of unnecessary PD, when the preoperative diagnosis is uncertain between cancer and chronic pancreatitis.

Total mesopancreas excision is the better staging tool of the mesopancreas in pancreatic head carcinoma

Preoperative imaging staging based on tumor,node,metastasis classification cannot be effective to avoid R1 resection because only further improvements in imaging technologies will allow the precise assessment of perineural and lymphatic invasion and the occurrence of microscopic tumour deposits in the mesopancreas.However,waiting for further improvements in imaging technologies,total mesopancreas excision remains the only tool able to precisely assess mesopancreatic resection margin status,maximize the guarantee of radicality in cases of negative(R0)mesopancreatic resection margins,and stage the mesopancreas.

Clinical value of extended lymphadenectomy in radical surgery for pancreatic head carcinoma at different T stages

BACKGROUND As the lymph-node metastasis rate and sites vary among pancreatic head carcinomas(PHCs)of different T stages,selective extended lymphadenectomy(ELD)performance may improve the prognosis of patients with PHC.AIM To investigate the effect of ELD on the long-term prognosis of patients with PHC of different T stages.METHODS We analyzed data from 216 patients with PHC who underwent surgery at our hospital between January 2011 and December 2021.The patients were divided into extended and standard lymphadenectomy(SLD)groups according to extent of lymphadenectomy and into T1,T2,and T3 groups according to the 8 th edition of the American Joint Committee on Cancer’s staging system.Perioperative data and prognoses were compared among groups.Risk factors associated with prognoses were identified through univariate and multivariate analyses.RESULTS The 1-,2-and 3-year overall survival(OS)rates in the extended and SLD groups were 69.0%,39.5%,and 26.8%and 55.1%,32.6%,and 22.1%,respectively(P=0.073).The 1-,2-and 3-year disease-free survival rates in the extended and SLD groups of patients with stage-T3 PHC were 50.3%,25.1%,and 15.1%and 22.1%,1.7%,and 0%,respectively(P=0.025);the corresponding OS rates were 65.3%,38.1%,and 21.8%and 36.1%,7.5%,and 0%,respectively(P=0.073).Multivariate analysis indicated that portal vein invasion and lymphadenectomy extent were risk factors for prognosis in patients with stage-T3 PHC.CONCLUSION ELD may improve the prognosis of patients with stage-T3 PHC and may be of benefit if performed selectively.

Application and progress of medical imaging in total mesopancreas excision for pancreatic head carcinoma

Pancreatic head carcinoma(PHC)is one of the common gastrointestinal malignancies with a high morbidity and poor prognosis.At present,radical surgery is still the curative treatment for PHC.However,in clinical practice,the actual R0 resection rate,the local recurrence rate,and the prognosis of PHC are unsatisfactory.Therefore,the concept of total mesopancreas excision(TMpE)is proposed to achieve R0 resection.Although there have various controversies and discussions on the definition,the range of excision,and clinical prognosis of TMpE,the concept of TMpE can effectively increase the R0 resection rate,reduce the local recurrence rate,and improve the prognosis of PHC.Imaging is of importance in preoperative examination for PHC;however,traditional imaging assessment of PHC does not focus on mesopancreas.This review discusses the application of medical imaging in TMpE for PHC,to provide more accurate preoperative evaluation,range of excision,and more valuable postoperative follow-up evaluation for TMpE through imaging.It is believed that with further extensive research and exploratory application of TMpE for PHC,large-sample and multicenter studies will be realized,thus providing reliable evidence for imaging evaluation.

A new three-step procedure for pancreatic head carcinoma with invasion of superior mesenteric artery

Pancreatic head carcinoma is characterized by high malignancy and a low survival rate and its mortality ranks fourth for malignant tumors with a 5-year survival rate of only 5%[1].Treatment of this cancer relies on surgical resection.However,the resection rate is only about 20%,because majority of the patients are classified as unresectable when diagnosed due to distant metastasis or

The optional extent of lymph node dissection for pancreatic head cancer

Objective The extent of lymph node dissection for pancreatic head cancer(PHC)is uncertain and controversial;therefore,this study evaluated whether PHC patients can benefit from different extents of lymph node dissection.Methods A total of 106 PHC patients underwent standard regional lymphadenectomy(SRLN;n=56,52.8%)and extended regional lymphadenectomy(ERLN;n=50,47.2%)between September 2015 and September 2019.None of the study participants had distant metastases.The median survival time and complications were compared between the two groups.Results The median survival time in the SRLN and ERLN groups was 27.01 months and 21.17 months,respectively(P=0.30).The postoperative major morbidity and mortality rates were 37.50%and 1.79%in the SRLN group,and 46.00%and 2.00%in the ERLN group,respectively.Moreover,the tumor differentiation,tumor diameter,lymph node involvement,perineural invasion,vascular invasion,and margin status all correlated with survival(P<0.05).Conclusion For PHC patients,ERLN cannot provide a significant survival benefit over SRLN.Moreover,ERLN increased morbidity and mortality,although without statistical significance.This indicates that ERLN should not be considered in PHC patients.

Impact of resection margins on long-term survival after pancreaticoduodenectomy for pancreatic head carcinoma

BACKGROUND The impact of resection margin status on long-term survival after pancreaticoduodenectomy(PD) for patients with pancreatic head carcinoma remains controversial and depends on the method used in the histopathological study of the resected specimens. This study aimed to examine the impact of resection margin status on the long-term overall survival of patients with pancreatic head carcinoma after PD using the tumor node metastasis standard.METHODS Consecutive patients with pancreatic head carcinoma who underwent PD at the Chinese People's Liberation Army General Hospital between May 2010 and May 2016 were included. The impact of resection margin status on long-term survival was retrospectively analyzed.RESULTS Among the 124 patients, R0 resection was achieved in 85 patients(68.5%), R1 resection in 38 patients(30.7%) and R2 resection in 1 patient(0.8%). The 1-and 3-year overall survival(OS) rates were significantly higher for the patients who underwent R0 resection than the rates for those who underwent R1 resection(1-year OS rates: 69.4% vs 53.0%;3-year OS rates: 26.9% vs 11.7%). Multivariate analysis showed that resection margin status and venous invasion were significant risk factors for OS.CONCLUSION Resection margin was an independent risk factor for OS for patients with pancreatic head carcinoma after PD. R0 resection was associated with significantly better OS after surgery.

A case of chronic pancreatitis treated by laparoscopic duodenum-preserving pancreatic head resection

Pancreaticoduodenectomy(PD) has long been used for chronic pancreatitis(CP), but greatly affects the postoperative quality of life. A new procedure called duodenum-preserving pancreatic head resection(DPPHR) has been introduced, and has little effect on the structure and function of the digestive system. With the development of minimally invasive surgical techniques, treatment of CP can be performed with laparoscopic DPPHR(LDPPHR). We present a case of CP that was successfully treated with LDPPHR. The postoperative pathological diagnosis was pancreatitis, demonstrating the feasibility of LDPPHR. We recommend this minimally invasive surgical method as preferred treatment for CP.

Surgical treatment of pancreatic head cancer: concept revolutions and arguments

As we have a deeper and more thorough understanding of the biological behavior of pancreatic head cancer, surgical treatment concepts of this lethal disease are changing all the time. Meanwhile, numerous arguments emerge. Thus, we will probe into the focuses and arguments in the surgical treatment of pancreatic head cancer in this article, including the scope of lymphadenectomy, total mesopancreas excision（TMp E）, vascular resection, minimally invasive pancreaticoduodenectomy（PD）, palliative resection, surgery for recurrent disease and surgery for primary pancreatic cancer and liver metastasis.