Pancreatic cancer is one of the malignant tumors with the worst prognosis due to its high malignancy and low early diagnosis rate, and its five-year survival rate is less than 5%, and its annual incidence is close to the number of deaths.1-2 Scholars in surgery, gastroenterology, imaging and related basic disciplines have been actively studying the molecular mechanisms of its pathogenesis and exploring better treatments and methods, but its treatment outcome is still unsatisfactory. Radical surgical resection is still the most effective treatment for pancreatic cancer and is the most important factor to improve the prognosis and long-term survival of patients.2 In addition, several clinical RCT trials in recent years have confirmed that adjuvant radiotherapy and chemotherapy are also effective in the treatment of pancreatic cancer. Therefore, on the basis of standardized surgical resection with adjuvant therapy, it is expected that patients can obtain the best treatment effect and improve their survival rate. A. Standardized surgical resection is the key and foundation The anatomical location of the pancreas is deep, and the surrounding area is adjacent to important organs and large blood vessels, which makes surgery difficult and the complication rate is high. With the maturity of surgical techniques, pancreatic cancer surgery is gradually carried out in hospitals at all levels in China, but most of the patients are already in advanced stage when they are first diagnosed, and only 10-20% of them have the chance of surgical resection.3-4 Therefore, to pay attention to early diagnosis and improve the rate of surgical resection is the primary problem faced by surgeons, and clinically, we can strengthen scientific education, raise awareness, and collaborate with related departments such as radiology, gastroenterology, pathology, etc. In addition, we can improve the early diagnosis rate of pancreatic cancer through screening of high-risk groups and imaging examinations such as abdominal CT and ultrasound endoscopy, and make these patients undergo surgery as early as possible through the green channel to improve their prognosis5-7. Preoperative resectability assessment is the basis for standardized and rationalized treatment of pancreatic cancer patients, and through resectability assessment, unnecessary “dissection” can be reduced and medical costs can be saved. “NCCN guidelines, M.D. Anderson Cancer Center and China’s pancreatic cancer diagnosis and treatment guidelines have clear criteria, the core of which is to assess the extent of tumor invasion of surrounding large blood vessels, and abdominal CT + vascular 3D reconstruction can visually show the extent of vascular invasion, which can be used by surgeons as a preoperative treatment. Surgeons can use this as a routine preoperative examination and combine it with the general conditions of patients’ age, cardiopulmonary function, nutritional status and their own unit experience to make a comprehensive judgment.8 It should be emphasized that Borderline resectable is a special type of pancreatic cancer, which is between resectable and unresectable, and the M.D. Anderson Cancer Center has conducted systematic clinical studies on it. The M.D. Anderson Cancer Center has conducted a systematic clinical study and proposed CT anatomical criteria, including: no distant metastasis, involvement of the superior mesenteric artery less than 180°, small encapsulation of the common hepatic artery, no involvement of the abdominal trunk, small involvement of the SMV/PV but resectable reconstruction, etc.9 The determination of these patients also relies on multi-row spiral CT + vascular 3D reconstruction. There is no uniform treatment plan for these patients, but preoperative neoadjuvant radiotherapy can give these patients an opportunity for surgery and increase the chance of R0 resection.10 Standard pancreaticoduodenectomy is the classic procedure for pancreatic cancer surgery. However, there is still a gap in clinical practice whether the operation can be performed in a standardized manner, especially in less experienced units and physicians who only take successful completion of the operation as the standard or blindly pursue shortening the operation time while ignoring R0 resection, which cannot achieve the purpose of radical resection and is prone to local recurrence and metastasis after the operation This type of surgery cannot achieve radical resection and is prone to local recurrence and metastasis after surgery . In addition, because there is no uniform standard for pathological specimen processing and sampling of pancreaticoduodenectomy, surgeons neglect to mark the margins of each specimen during surgery, which makes it difficult to make accurate and standard judgment of each margin during pathological diagnosis, resulting in a wide variation of R1 resection rate reported in the literature, fluctuating from 10-85%.11-13 Many R0 resections that rely on the naked eye or subjective judgment of the surgeon are actually a large proportion of R0 resections. Many of the R0 resections that rely on the surgeon’s visual or subjective judgment are actually a large portion of R1 resections. This affects the objective evaluation of surgical resection on patient survival prognosis, resulting in similar prognosis between R1 and R0 resection as reported in some literature. Therefore, it is necessary to standardize and standardize the marking of surgical margins, especially the “superior mesenteric artery margins”. The surgeon can try to ensure the integrity of the specimen after surgical resection and mark each margin with ink. In Europe, the “1 mm rule” is mainly used, while in the United States and Canada, the presence or absence of tumor cells on the surface of the margins is the criterion.13-15 A multicenter prospective study can help to develop specific norms and standards suitable for China. Whether to expand lymph node dissection and combined vascular resection has been a hot topic of discussion and the most controversial area in the surgical treatment of pancreatic cancer. Surgeons, represented by Japanese scholars, advocate expanding lymph node dissection, skeletonizing the superior mesenteric and abdominal trunk arteries, and completely removing peripancreatic and retroperitoneal fatty soft tissue and nerve plexus, with the aim of minimizing micrometastases and avoiding postoperative recurrence.12 However, several prospective studies suggest16-18 that expanding lymph node dissection compared with standard lymph node dissection is not effective in prolonging patient survival and improving prognosis. Pawlik et al.19 developed a mathematical model to assess the efficacy of expanded radical treatment and showed that only 1 in 250 patients could benefit from expanded lymph node dissection treatment. Therefore, the implementation of expanded lymph node dissection is not currently advocated, but surgeons should still thoroughly remove peritumor lymph nodes according to the criteria to maximize the number of lymph node dissections and reduce the incidence of R1 resection. The maturity of the surgical technique has greatly improved the safety and effectiveness of whipple surgery combined with vascular resection, which aims at complete radical resection of the tumor, reducing residual lesions and ensuring negative retroperitoneal margins, and the perioperative mortality and complication rates are not significantly increased compared with those without vascular invasion, and the prognosis is not significantly different. For experienced physicians and centers, this procedure can be performed selectively20, but physicians who cannot guarantee negative margins even after PV/SMV resection and reconstruction or who have less surgical experience should choose this procedure with caution. In addition, there are various pancreatic-intestinal anastomoses, and the use of pancreaticogastric anastomosis has gradually increased in recent years and has shown some advantages. However, no matter what kind of anastomosis is used, it has its technical characteristics and shortcomings, and cannot be generalized. For tumors that can be resected by preoperative assessment but cannot be removed by surgical exploration, palliative resection is generally not advocated, and short-circuit surgery such as biliary-intestinal anastomosis and gastrointestinal anastomosis is feasible, but some studies suggest that the prognosis of pancreaticoduodenectomy with positive margins is still better than short-circuit surgery.21 This is mainly for R1 resection, because pancreaticoduodenectomy is traumatic, has a high rate of perioperative complications, and affects the quality of life of patients. Therefore, the pros and cons of this type of surgery should be weighed and carefully chosen when selecting this type of surgery. Since only less than 20% of pancreatic cancer patients have the chance of surgical resection, radiotherapy has become an important means of treating advanced pancreatic cancer, and gemcitabine alone is currently the first-line chemotherapy regimen for the treatment of advanced patients. The results of prospective studies such as CONKO 001, RTOG97-4 and ESPAC-124-26 have confirmed the importance of chemotherapy in the postoperative adjuvant treatment of pancreatic cancer, and R0 resection with postoperative adjuvant chemotherapy is considered to be the most critical factor in improving the prognosis of pancreatic cancer patients.27 In addition to chemotherapy, radiotherapy, especially 3D conformal radiotherapy, is gradually being used in the treatment of pancreatic cancer. In recent years, several phase III clinical trials, such as ESPAC-126 and EROTC28, showed that postoperative radiotherapy did not significantly benefit patients, but some scholars questioned the credibility of these trials and believed that radiotherapy combined with chemotherapy could still improve patients’ prognosis. Therefore, in clinical practice, physicians may choose to combine radiotherapy with chemotherapy at their discretion, taking into account the general condition and tolerability of patients. Preoperative radiotherapy (neoadjuvant) treatment is a major advancement in the comprehensive treatment of pancreatic cancer, through which the tumor size can be reduced and the surgical resection rate can be improved, in addition to assessing the patient’s sensitivity to chemotherapy and radiotherapy regimens, and then guiding the postoperative adjuvant treatment. In particular, preoperative neoadjuvant therapy is of great importance for “potentially resectable” pancreatic cancer. Patients who receive neoadjuvant radiotherapy generally have a reduction in tumor size, and even if the tumor does not shrink significantly, the gap between the tumor and the blood vessels becomes clearer than in the absence of treatment, which greatly increases the rate of surgical resection and also increases the chance of R0 resection. In a retrospective analysis of 160 cases of “potentially resectable” pancreatic cancer at the M.D. Anderson Cancer Center, it was found that with neoadjuvant therapy, 41% of patients eventually had the opportunity for surgical resection, with an R0 resection rate of 94% and a median survival of 40 months, which was significantly higher than that of the non-operated group (13 months)9. (13 months).9 There are no relevant research data in China yet, but the effect of neoadjuvant therapy on the treatment of pancreatic cancer, especially “potentially resectable” pancreatic cancer, is clear and can be actively carried out in units with the conditions. I125 ion implantation, radiofrequency, ultrasound focusing and argon helium knife are often used for patients with advanced inoperable disease, which can relieve symptoms and prolong survival to a certain extent, but they have certain complications and should be strictly controlled, in addition to the need to fully evaluate the degree of benefit to patients and avoid unnecessary waste of medical resources. In addition, it is necessary to fully evaluate the degree of benefit to patients to avoid unnecessary waste of medical resources. Immunotherapy, gene therapy, and molecular targeted therapy have emerged in recent years to provide a new idea and dawn for the treatment of pancreatic cancer.2,30 Although they are mostly in preclinical research, it is believed that through the gradual research on the pathogenesis of pancreatic cancer, interventional therapy targeting its key genes and regulatory targets can improve the early diagnosis and therapeutic effect of pancreatic cancer. III. Summary Improving the early diagnosis rate, standardizing surgical resection, increasing the R0 resection rate, and postoperative chemoradiotherapy based on gemcitabine are the core and key methods to improve the treatment outcome of pancreatic cancer at this stage. Multicenter prospective studies on current hot spots and controversial areas can provide evidence-based medical evidence for subsequent treatment. With the in-depth research on the molecular mechanism of pancreatic cancer development, we believe that through strengthening multidisciplinary collaboration, we will continue to make progress in conquering this stubborn stronghold of pancreatic cancer in order to improve the diagnosis and treatment, and improve the treatment outcome.