Microcirculation disturbance and ischemia of the pancreas are important pathophysiological changes in the onset of acute pancrea-titis,and organ hypoperfusion is a risk factor for poor prognosis.During the first 12 to 24 hours after admission,fluid resuscitation is the most important medical treatment for the early stage of acute pancreatitis,and timely and rational fluid infusion helps to improve prognosis. However,there lacks high -quality clinical evidence for type of fluid,infusion speed,and monitoring methods,and more randomized con-trolled trials are needed.

BACKGROUND:Three-dimensional visual model of cervical deep vein can be used to virtual simulation of puncture. The studies on elevating deep vein puncture in the clinic are stil in the stage of exploration.
OBJECTIVE:To find the application of three-dimensional virtual puncturation simulation to cervical deep vein puncturation.
METHODS:CT cross-sectional images were obtained from healthy volunteers. Mimics software was used to semi-automatical y cut and reconstruct of various tissue of the neck. Three-dimensional model revealed cervical deep veins and its surrounding anatomic structure. Cervical deep vein puncturation was simulated, including internal jugular vein, supraclavicular vein and subclavian vein.
RESULTS AND CONCLUSION:Three kinds of cervical deep vein puncturation were successful y simulated, showing three-dimensional adjacent relation of the virtual pin with surrounding anatomic structure. Safe angle, depth and optimal path of the pin were measured. A three-dimensional virtual puncturation simulation can provide visualized morphologic data for cervical deep vein puncturation.

ObjectiveTo evaluate the application of immunochemical fecal occult blood test for colorectal cancer screening in a gastroenterology clinic. MethodsTotal 512 outpatients received immunochemical fecal occult blood tests and colonoscopy for screening of colorectal cancer from January 2009 to October 2010 in Gastroenterology Clinic of Peking Union Hospital.The application of occult blood test was retrospectively evaluated using colonoscopy and pathological examination as the gold standard. Results Among 512 patients,203 were found positive for immunochemical fecal occult blood. According to the colonoscopy and histological study,115 patients had polyps,9 with high-grade dysplasia and 21 with colorectal cancer.The sensitivity,specificity,positive likelihood ratio and negative likelihood ratio of fecal occult blood to detect colorectal adenomatous polyps was 42.8％,60.9％,1.09 and 0.93,respectively.And those for detection of colorectal cancer and high-grade dysplasia were 76.6％,62.5％,2.05 and 0.37,respectively.ConclusionsImmunochemical fecal occult blood test was useful in the screening for colorectal tumors among gastroenterology clinic patients.More large-scale prospective studies are needed to establish a screening model for colorectal tumors.

Objective To determine the diagnostic accuracy of alarm features in predicting upper gastro intestinal malignancy in patients who received gastroscopy examination.Methods A retrospective analysis of patients who underwent gastroscopy from Oct 2014 to Oct 2015 was conducted.Biopsy or surgical pathological findings served as the golden standard.The main outcome measure was the diagnostic accuracy of alarm features.Results Among 921 gastrointestinal outpatients,39 patients (4.2％) with malignancy were detected,including 13 (33.3％) with esophageal cancer,24 (61.5％) with gastric cancer and 2(5.1％) with duodenal ampulla cancer.36 patients (92.3％) were found with advanced cancer.In 137patients who had alarm features,21 (15.3％) were found to have malignancy and all were advanced.The sensitivity,specificity,positive predictive value and negative predictive value of alarm features were 53.8％(21/39),86.8％ (766/882),15.3％ (21/137) and 97.7％ (766/784),respectively.Conclusions Alarm features have a definite but limited value in predicting upper gastrointestinal malignancy.Noninvasive screening methods for Chinese patients are still needed to reduce unnecessary endoscopy workload.

Objective To investigate the clinical features of cryptogenic multifocal ulcerous stenosing enteritis(CMUSE),and to improve the diagnosis of this rare disease.Methods From 2010 to 2015,clinical data of 10 patients with CMUSE were retrospectively analyzed,including clinical features,laboratory examination,imaging examination,appearance under endoscopy,pathologic characteristics,location of lesions,treatment and prognosis.Results Among the 10 patients with CMUSE (male six,female four),the mean age was (35.1±14.8) years.The predominant clinical manifestation was melena (eight cases),abdominal pain (eight cases) and anemia (nine cases).The results of laboratory examination showed normal in erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).Among seven patients,hypersensitive C reactive protein (hsCRP) of two patients increased.Imaging examination showed intestinal stricture and appearance under endoscopic examination was intestinal ulcers and stenosis.Pathologic finding was superficial ulcers at mucosal and submucosal layers.Lesions mostly involved small intestine,and one case involving ileocecal valves and rectum.Among the 10 patients,seven patients received combination of surgical resection and prednisone treatment,and three patients were only administrated with medications.After treatment,seven patients remainedremission and three patients relapsed after remission.Immunosuppressors and enteral nutrition was effective in two of them and glucocorticoid resistance happened in one patient.Conclusions The diagnosis of CMUSE should he considered in patients with unexplained recurrent bowel obstruction,melena,anemia and concomitant intestinal ulcer and stricture.Endoscopy plays an important role in the diagnosis.Glueocorticoid is effective but easy to relapse.Immunomodulators and enteral nutrition may be considered as second-line therapy.

Objective To evaluate the significance of detecting plasma methylated Septin9 (SEPT9) alone and combined with fecal immunochemical test (FIT) in screening colorectal cancer (CRC) and adenoma.Methods From October 2014 to April 2015,outpatients received CRC and adenoma screening were enrolled.Colonscopy examination and pathological diagnosis were taken as gold standard.The sensitivity and specificity of plasma methylated SEPT9 and FIT in CRC and adenoma were calculated.The diagnostic value of combined examination was evaluated.Receiver operating characteristic (ROC) curve of SEPT9 in CRC diagnosis was drawn.Results A total of 300 outpatients were enrolled.Among them,CRC was detected in 45 patients (15.0％) and adenoma was detected in 68(22.7％) patients,including 37(12.3％) cases of advanced adenomas.The sensitivity of SEPT9 and FIT for CRC diagnosis was 80.0％ and 88.9％,and the specificity was 95.3 ％ and 54.1％,respectively.The area under concentration curve (AUC) of methylated SEPT9 in CRC diagnosis was 0.923.The sensitivity of SEPT9 and FIT in advanced adenoma diagnosis were 10.8％ and 62.2％,and the specificity were 83.3％ and 49.0％,respectively.The sensitivity of combined examination in CRC diagnosis was 97.8％ and the specificity was 52.9％;the sensitivity in advanced adenoma diagnosis was 67.6％ and the specificity was 47.4％.Conclusions Plasma methylated SEPT9 is helpful in CRC screening,moreover,when combined with FIT,it can increase detection rate of colorectal adenoma.

Objective To evaluate the clinical value of the three-category classification of severe acute pancreatitis (SAP).Methods Clinical data of 337 traditional SAP patients,who were admitted to Peking Union Medical College Hospital (PUMCH)from January 2001 to December 2012,were retrospectively studied.These patients were classified into moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP) according to the latest 2013 Atlanta Classification.SAP patients were further categorized as critical acute pancreatitis (CAP) and non-CAP.Disease severity,therapy and prognosis among three groups were compared.Results Among the total 337 traditional SAP patients,253 were classified as MSAP and 84 as SAP.In the group of SAP,40 patients were categorized as CAP and 44 as non-CAP.Compared with non-CAP patients,CAP patients had significantly higher mortality rate which was 70％ (28/40).Other results were all significantly higher in CAP group rather than non-CAP group,including ICU admission rate 77.5％(31/40),length of ICU stay (15.5 ± 20.6) days,Ranson,APACHE Ⅱ,BISAP,MCTSI,modified Marshall scores 4.6 ± 1.4,16.8 ± 5.8,3.0 ± 1.0,8.6 ± 1.7,and 7.4 ± 2.9,respectively (P ＜ 0.01 in each endpoint).These parameters of SAP group were also significantly higher than those of MSAP group (P ＜0.01).Conclusions Using the new three-category classification to distinguish traditional severe acute pancreatitis,namely MSAP,SAP,and CAP,can better reflect the severity of disease,predict outcome and guide clinical management.

Acute respiratory distress syndrome (ARDS) is a common complication of severe acute pancreatitis (SAP) and a leading cause of early death in SAP patients, but its pathogenesis is still unclear. In recent years, the role of gut microbiota and its metabolites in regulating SAP-related ARDS has attracted more and more attention, and in-depth studies on the pathogenesis of “intestine-lung axis” may provide new ideas for the research and development of drugs for SAP-related ARDS. This article summarizes the recent research advances in gut microbiota and its metabolites in SAP-related ARDS.

Objective To investigate the complications and the risk factors of pancreatic fistula after pancreaticoduodenectomy.Methods The clinical data of 339 patients who underwent pancreaticoduodenectomy at the First Affiliated Hospital of Sun Yat-Sen University from January 2000 to Decembcr 2009 were retrospectively analyzed.The risk factors of pancreatic fistula were analyzed.The incidences of complications accured from 2000 to 2004 and from 2005 to 2009 were compared.All data were analyzed by the t test,chi-square test,Fisher exact probability or Logistic regression model.Results The incidence of complications of all patients was 33.0％ ( 112/339),and the incidence of pancreatic fistula was 8.6％ (29/339).Of the 29 patients complicated with pancreatic fistula,6 patients were in grade A,8 in grade B and 15 in grade C.Soft texture of remnant pancreas and the diameter of pancreatic duct smaller than 3 mm were the independent risk factors of pancreatic fistula( OR =1.75,3.75,P ＜ 0.05 ).The number of hospital death was 12,including 1 patient died during the first period (2000-2004) and 11 patients died during the second period (2005-2009).Three patients died of pancreatic fistula and abdominal hemorrhage,3 died of postoperative upper gastrointesitnal bleeding,2 died of cardiac insufficiency,1 died of respiratory failure,1 died of pancreatic fistula,abdominal infection and necrotic pancreatitis,1 died of abdominal hemorrhage and hepatic and renal failure,1 died of bililary fistula,abdominal infection and multiple organ dysfunction syndrome.Conclusions Soft texture of remnant pancreas and the diameter of the pancreatic duct smaller than 3 mm are important risk factors of postoperative pancreatic fistula.Pancreatic fistula is the main factor causing death after pancreaticoduodenectomy.

Objective To investigate the complications and the risk factors for pancreatic leakage after pancreaticoduodenectomy.Methods One hundred and sixty-nine patients who received pancreaticoduodenectomy in our hospital between January 2000 and December 2009 were reviewed.Chisquare and logistic statistic analysis were performed to determine the risk factors for pancreatic leakage.The difference in complication rates between different periods were analyzed.Results The mortality was 2.4％.The morbidity was 34.9％,and the pancreatic leakage rate was 7.7％.Logistic analysis revealed significant risk factors for pancreatic leakage included intraoperative bleeding of more than 400 ml(OR=2.87; 95％ confidence interval:1.17-8.19; P=0.048),soft texture of remnant pancreas(OR =1.95 ; 95 ％ confidence interval:0.87-6.19 ； P =0.032)and pancreatic duct diameter smaller than 3 mm(OR=3.78 ; 95 ％ confidence interval:1.01-10.63 ； P =0.019).There was no significant difference in mortality,morbidity,pancreatic leakage,and upper gastric bleeding between the periods 2000-2004 and 2005-2009.However,re-operation rate and postoperative hospital stay were significantly higher in the period of 2005-2009.Conclusions Intraoperative bleeding,soft texture of remnant pancreas and pancreatic duct diameter smaller than 3mm were significant risk factors for postoperative pancreatic leakage.A pancreaticojejunostomy anastomotic technique familiar to the surgeon might reduce postoperative pancreatic leakage.