Overview of pancreatic cancer There are many treatment methods for malignant tumors, mainly surgery, radiotherapy and chemotherapy. Pancreatic cancer treatment is also mainly based on these methods. Pancreatic cancer is known as the “king of cancer” and there is still no better treatment for it, and most patients are already in advanced stage. Generally, surgery should be the first choice for patients who are eligible for surgery and have indications for surgery. This is the best way for patients to get the best results. However, surgery is limited to relatively early stage patients. Some patients whose condition itself is not eligible for surgical resection can also be addressed surgically because of acute complications such as jaundice obstruction and gastrointestinal obstruction. Palliative surgery is mainly used in the late stage to relieve biliary and intestinal obstruction and improve the quality of life. What is the current incidence and mortality rate of pancreatic cancer in China? In the 1960s, the incidence rate of pancreatic cancer was only 1 to 2 in 100,000. In the 21st century, the incidence rate of pancreatic cancer has increased exponentially. Especially in Shanghai, the high standard of living, westernized lifestyle and high stress have all contributed to the high incidence of the disease. Today, the incidence rate of pancreatic cancer in Shanghai is 17 out of 100,000 for men and close to 15 out of 100,000 for women. Pancreatic cancer is an aggressive disease that must be taken seriously. Among all malignant tumors, the new incidence and mortality rate of pancreatic cancer in Shanghai occupy the 6th and 4th place respectively. We often hear patients say that they have been suffering from back pain for several months, and they have tried Chinese medicine massage and acupuncture, but after half a year, early pancreatic cancer has become advanced; a patient with abdominal discomfort has had gastroscopy and colonoscopy, but they forgot to check the pancreas; what’s more, many patients have been transferred from hepatitis ward and mistaken the yellow eyes caused by pancreatic cancer as a symptom of liver disease. Besides early detection, what are the shortcomings of pancreatic cancer treatment? Oncology treatment has entered the era of standardization and individualization. However, the diagnosis and treatment of pancreatic cancer are far from standardized and precise. There are two problems among them. 1. The pathology acquisition rate of patients is low. Pathological diagnosis is the gold standard of oncology diagnosis, and molecular pathology is the “compass” of treatment. 2. The comprehensive treatment is seriously inadequate. Surgery is the fundamental method to cure pancreatic cancer, and after surgery, most patients need radiotherapy or simultaneous radiotherapy and chemotherapy. Most of them are willing to take Chinese medicine after surgery, and some of them are determined to do chemotherapy without surgery. What causes the low case acquisition rate? There are two ways to obtain pathology for pancreatic cancer. One is through ultrasound endoscopic puncture. The technical difficulties are: accurate puncture to find the mass, stable puncture to not puncture the pancreas, and sufficient puncture to remove enough volume for pathological analysis. Secondly, intraoperative pathology is taken. The pancreas is prone to leakage, and a slight error and leakage of pancreatic fluid can lead to complications such as fever and septicemia. Both of these methods are difficult to implement. High malignancy, poor differentiation, difficult to identify symptoms, difficult to obtain pathology, high surgical risk, and weak comprehensive treatment – these are the reasons why pancreatic cancer is called the “king of cancers”. How should pancreatic cancer be treated if the diagnosis is clear? Currently, about 15% of patients with pancreatic cancer are diagnosed at an early stage and surgical resection is performed. The five-year survival rate for patients with surgical resection is 20%. If the lymph nodes are negative, the five-year survival rate can even reach about 40%. For those who cannot be operated, long-term survival is almost impossible. Therefore, once diagnosed, the first step is to see if it can be operated, and then to do a comprehensive treatment. Why is it difficult to operate for pancreatic cancer? 1. The pancreas is the most secretive organ in the abdominal cavity, involving the most blood vessels and organs, and has the most complicated anatomical structure. 2. Pancreatic cancer surgery requires removal of multiple organs, including the pancreas with tumor, duodenum and part of the jejunum, and reconstruction of the connections between multiple organs, such as the channels between the bile duct, pancreas and digestive tract. 3. The surgery involves many important large blood vessels, including portal vein, hepatic artery, inferior vena cava, abdominal aorta, superior mesenteric vein, superior mesenteric artery, etc., while avoiding injury to the blood vessels. If these vessels are injured, hemorrhage may occur, while causing ischemia or bruising of the related organs, some of which are even fatal. 4. The incidence of postoperative complications of the pancreas is much higher than that of other general surgical procedures, and postoperative management is also difficult. Which patients are suitable for surgical treatment? 1. From the local lesion, the mass should not be too large and the disease should not be particularly advanced, mostly pancreatic cancer with clinical stage II or below. 2. The cancer is confined to the pancreas, without distant dissemination and metastasis, and without invasion of important blood vessels such as portal vein or superior mesenteric vein. 3.Depending on the age, the general condition is good. Patients who are too old have many systemic complications. If they have poor cardiopulmonary function or severe emphysema, they cannot safely undergo surgical anesthesia. Or with hematologic disorders and poor coagulation function, which can significantly increase the risk of surgery, should be extra cautious. 4, combined with the patient’s systemic condition, such as no serious diabetes, heart disease, or blood sugar, heart disease is effectively controlled, and there is no hypoproteinemia or intractable ascites. 5. Pre-operative prognosis of biological characteristics should be performed. Some patients have very small masses and very clean surgical cuts, but their cell biology is so poor that the cells will escape everywhere after surgery, causing distant metastases, and the patient does not benefit. In some patients, the mass is large and adherent to blood vessels, but it is an inert tumor and the patient can still survive long term after surgery. What is the meaning of “reconstruction” after resection? The term “perfect reconstruction” means that the pancreas and other tissues are “seamlessly” connected to minimize complications and allow the patient to safely survive the perioperative period. The pancreas is wrapped between the duodenum, jejunum, spleen and liver, and covered by the stomach and transverse colon in front. This not only makes the clinical symptoms of the pancreas insidious, but also makes surgical resection more difficult, as a portion of the stomach and jejunum, including the tumor, all of the duodenum, the gallbladder, and part of the common bile duct must be removed at the same time. After resection, it is necessary to completely reconstruct the connections of many organs of the digestive tract, including the pancreas and the intestine, the bile duct and the intestine, and the stomach and the intestine. One of the most critical reconstructions is the pancreatic duct-jejunum mucosal anastomosis, which can result in pancreatic fistula if not done carefully. This is the most common and fatal complication of pancreatic surgery. In recent decades, surgeons around the world have worked to address this problem. However, the incidence of pancreatic fistula remains at about 15%. What are the main postoperative complications of pancreatic cancer? In the recent past, the most common complication is pancreatic fistula, which is the leakage of pancreatic fluid out of the small pancreatic duct. A pancreatic fistula can accumulate in the patient’s abdominal cavity and cause infection. In particular, those with pancreatitis, diabetes, hypertension or poor health are more likely to become infected from a pancreatic fistula. The second common recent complication is bleeding, including abdominal bleeding, bleeding from the pancreatic-intestinal anastomosis, and gastrointestinal bleeding. Intra-abdominal bleeding is mainly due to incomplete intraoperative hemostasis, dislodged ligature wires, and dislodged electrocoagulation scabs. Severe preoperative jaundice and impaired coagulation mechanisms also contribute to bleeding. Abdominal bleeding may be fatal and should be given high priority. Gastrointestinal bleeding mostly occurs more than 3 days after surgery and may be related to stress ulcers. In terms of long-term complications, a proportion of patients develop diarrhea and gastroparesis of varying degrees. This may be related to the surgical removal of part of the vagus nerve and the retroperitoneal plexus, resulting in gastrointestinal dysfunction. Severe diarrhea can occur up to 20 times a day. Are there ways to avoid these complications? These complications are related to the surgery and are difficult to avoid. Take pancreatic fistula as an example. There is a main pancreatic duct inside the pancreatic tissue and many tiny capillary pancreatic ducts next to it. The surgery ensures that the main pancreatic duct is anastomosed with the intestine and that there is nothing inside the duct. However, when the needle is passed through the pancreatic tissue during suturing, it may pierce through one of the tiny branch pancreatic ducts and subsequently have to be pulled tight, and a small amount of pancreatic fluid may flow out. The incidence of small pancreatic fistulas like this one is in the range of 20-30% or even higher. How should postoperative complications be managed? The main management of pancreatic fistula is adequate drainage and nutritional support. We also grade patients according to their condition; grade A is the smallest pancreatic fistula, which can recover on its own in a few days with no sequelae. Some patients are discharged from the hospital for two months and still have a pancreatic fistula. At this time, we have to observe and prevent infection. To prevent abdominal bleeding, it is mainly to strengthen the correction of preoperative coagulation, to stop bleeding closely during surgery, and to check carefully before closing the abdomen. When the bleeding is small, the bleeding can be stopped first, and then depending on the situation, we can decide whether blood transfusion is needed, and closely observe the development of the disease. If the amount of bleeding is large, surgical hemostasis should be performed as soon as possible. To prevent and treat gastrointestinal bleeding, the main thing is to correct the patient’s nutritional status before surgery and minimize the adverse effects of surgery and anesthesia. Once it occurs, it can be treated by medication to stop bleeding, gastrointestinal decompression, embolization via gastroscopy or angiography to stop bleeding, or surgery in severe cases. After pancreatic cancer surgery, which patients are prone to recurrence? 1. Early metastasis and recurrence after surgery, mostly appearing 3 months and not more than 6 months after surgery. This kind of metastasis and recurrence may be related to the lack of clean resection and the malignancy of the tumor. It is not that the doctor does not try hard, but the enemy is too cunning. This comes back to a problem we mentioned before: we must analyze the biological characteristics of the tumor before surgery, so as to “educate” the cancer cells in advance and make them lower the stage. 2. It occurs about 1-2 years after surgery. This may be because the patient did not receive systematic and reasonable comprehensive treatment. Meanwhile, the efficiency of chemotherapy for pancreatic cancer is 30%-40%, which means half of the patients cannot escape from recurrence. To solve this problem, more and more effective chemotherapy drugs need to be developed, and multiple combinations of drugs and clinical trials need to be conducted. What is the maximum survival period after surgery for pancreatic cancer? Overall, the overall survival time for pancreatic cancer is six months to one year, and the five-year survival rate after surgery is 5% to 20%. The longest post-operative survival in our hospital was nearly 7 years. Is the length of postoperative survival related to the early or late detection of the disease? Once pancreatic cancer develops, it is highly malignant and progresses rapidly. The survival time after surgery depends mainly on the stage of the disease, the type and nature of the tumor, the patient’s general condition, the external environment where the tumor is located, and some factors that are not yet clear. For example, the disease is detected late and the opportunity of surgery is often lost. What should I pay attention to after pancreatic cancer surgery? 1. To listen to the doctor’s words. This includes cooperation with treatment during hospitalization and active follow-up after surgery. Baseline examination should be done 1 month after surgery, followed up every 3 months within 2 years and every 6 months after 2 years. The examination items include blood routine, liver and kidney function, blood test tumor markers, abdominal CT/B ultrasound, chest X-ray. 1 review every year after 5 years. It is better to do PET-CT once a year during chemotherapy to detect metastasis and recurrence as early as possible. 2. Light diet. Those who have had pancreatic surgery and successfully discharged from the hospital have no less quality of life than patients with stomach and intestinal cancer. This is because the risk of pancreatic surgery lies in the complications during the perioperative period. Once discharged from the hospital, there are no major problems. There is no need to be too careful in every aspect of life. Just in terms of diet, one should have less oil, no spicy and irritating food, and avoid smoking and alcohol. Other than surgery, what factors affect the long-term survival of patients? In terms of simple pancreatic cancer resection, there is not much difference in surgeons’ skills. What really affects the patient’s survival is the selection of a reasonable surgical scope and the implementation of a “perfect” reconstruction. The selection of the surgical scope is based on the knowledge of the characteristics and pathways of lymphatic metastasis of pancreatic cancer, and the reasonable clearance. The pancreas is a long and thin organ, divided into the head, neck, body and tail of the pancreas. It has been found that the location of tumor growth and the direction of lymphatic metastasis are related. Generally, lymph node groups 8, 12, 13, 14 and 16 have a high frequency of metastasis and are mandatory to be cleared.