The American College of Gastroenterology Guidelines:Management of Acute Pancreatitis(referred to as the"2024 guidelines"),released in March 2024,presents 11 recommendations and 23 key concepts for the management of acute pancreatitis(AP)based on different levels of evidence quality.The 2024 guidelines provide detailed explanations regarding the diagnostic criteria,etiology,initial assessment,severity stratification,initial management,endoscopic retrograde cholangiopancreatography,antibiotic use,nutritional support,and surgical interventions for AP.Compared to the 2023 edition of the American College of Gastroenterology Guidelines,the 2024 edition offers more detailed recommendations and comprehensive evidence-based medical data,which is of great significance in optimizing the diagnosis and treatment process for AP patients and improving patient outcomes.

Objective:To investigate the relationship between metabolic syndrome and 1-year poor outcome in elderly patients with acute cerebral infarction (ACI).Methods:The clinical data of elderly patients with ACI admitted to Renqiu Kangjixintu Hospital from January 2014 to November 2018 were selected and divided into metabolic syndrome group (931 cases) and non-metabolic syndrome group (1 851 cases). The clinical data of the two groups of elderly patients with ACI were compared, and the effect of metabolic syndrome on poor outcome (modified Rankin scale>2 scores) of elderly patients with ACI in 1 year was analyzed by multivariate Logistic regression.Results:The proportion of female, hypertension, diabetes, hyperlipidemia, coronary heart disease, smoking, excessive alcohol consumption and antiplatelet drug use in the metabolic syndrome group were higher than those in the non-metabolic syndrome group: 52.74%(491/931) vs. 32.58%(603/1 851), 79.16%(737/931) vs. 64.29% (1 190/1 851), 42.32% (394/931) vs. 6.43% (119/1 851), 17.19% (160/931) vs. 11.62% (215/1 851), 18.90% (176/931) vs. 14.10% (261/1 851), 62.73% (584/931) vs. 50.89% (942/1 851), 3.73% (69/931) vs. 1.61% (15/1 851), 19.23% (179/931) vs. 15.51% (287/1 851), the levels of body mass index, systolic blood pressure, diastolic blood pressure, fasting plasma glucose (FPG), fasting plasma glucose (TG), total cholesterol (TC), platelet (PLT), fibrinogen (FIB), fall score were higher than those in non-metabolic syndrome group: 26.67 (25.31, 28.60) kg/m 2 vs. 23.30 (21.48, 24.91) kg/m 2, (167.17 ± 22.96) mmHg (1 mmHg = 0.133 kPa) vs. (164.21 ± 24.90) mmHg, (87.06 ± 13.10) mmHg vs. (85.76 ± 12.99) mmHg, (7.33 ± 2.64) mmol/L vs. (5.35 ± 1.38) mmol/L, (2.12 ± 1.51) mmol/L vs. (1.13 ± 0.78) mmol/L, (4.97 ± 1.31) mmol/L vs. (4.65 ± 0.99) mmol/L, 213.00 (179.00, 256.00) × 10 9/L vs. 203.00 (172.00, 241.00) × 10 9/L, 3.07 (2.63, 3.52) g/L vs. 2.94 (2.55, 3.37) g/L, (6.12 ± 1.70) scores vs. (5.93±1.74) scores, the levels of age, high density lipoprotein cholesterol (HDL-C), homocysteine (Hcy) and pressure ulcer score were lower than those of non-metabolic syndrome group: (69.29 ± 6.96) years vs. (71.28 ± 7.66) years, (0.98 ± 0.34) mmol/L vs. (1.31 ± 0.88) mmol/L, (18.93 ± 13.07) mmol/L vs. (21.66 ± 16.39) mmol/L, (18.55 ± 2.42) vs. (19.02 ± 2.43), with statistical significance ( P<0.05). After 1-year follow-up, the proportion of poor outcomes in the metabolic syndrome group was higher than that in the non-metabolic syndrome group: 21.70%(202/931) vs. 18.69% (346/1 851), with statistical significance ( P<0.05). Multivariate Logistic regression analysis showed that age, stroke, national institutes of health stroke scale (NIHSS) score at admission, systolic blood pressure, Hcy, pressure ulcer score, fall score, metabolic syndrome were independent risk factors for poor outcome of ACI in 1 year ( OR = 1.056, 1.309, 1.138, 1.005, 1.006, 0.882, 1.076 and 1.285; 95% CI 1.040 to 1.072, 1.037 to 1.652, 1.097 to 1.180, 1.000 to 1.010, 1.000 to 1.013, 0.834 to 0.933, 1.004 to 1.152 and 1.001 to 1.657; P<0.05). Conclusions:Multiple risk factors for stroke are closely related to poor outcome of ACI in the elderly. And metabolic syndrome is an independent risk factor for poor outcome of ACI in the elderly in 1 year.

Objective:To explore the application value of artificial intelligence (AI) model based on deep learning in breast nodules classification of Breast Imaging Reporting and Data System of ultrasound (BI-RADS-US).Methods:The ultrasound images of 2 426 breast nodules from 1 558 female patients with breast diseases at Beijing Tongren Hospital, Capital Medical University between December 2006 and December 2019 were collected . The image data sets were divided into training (63%), verification (7%), and test (30%) subsets for the construction of AI model. The diagnostic efficiencies of AI model, doctors' arbitration results and doctors' diagnosis with or without AI model assistance were analyzed by using receiver operating characteristic (ROC) curve. The Cohen weighted Kappa statistic was used to compare the consistency of BI-RADS-US classification among 5 ultrasound doctors' diagnosis with or without AI model assistance. And the changes of BI-RADS-US classification were analyzed before and after each doctor adopted AI model assistance.Results:The differences in diagnostic efficiencies of AI model, doctors' arbitration results and doctors' diagnosis with or without AI model assistance were statistically significant (all P > 0.05). The consistency among 5 ultrasound doctors was improved due to AI model assistance and Kappa value was increased from 0.433 (category 3), 0.600 (category 4a), 0.614 (category 4b), 0.570 (category 4c) and 0.495 (category 5) to 0.812, 0.704, 0.823, 0.690 and 0.509 (all P < 0.05), respectively. The upgrade and downgrade of BI-RADS-US classification occurred in 5 doctors after the classification of AI model assistance. Downgrade from category 4 to 3 in benign nodules of 56.6% (47/76) and upgrade from category 4 to 5 in malignant nodules of 69.4% (34/49) were mostly observed. Conclusions:AI-assisted BI-RADS-US classification can effectively improve the consistency of classification among the doctors without reducing the diagnostic efficiency. AI model shows clinical values in reducing unnecessary biopsy of partial benign lesions and increasing diagnostic accuracy of partial malignant lesions through the adjustment of breast nodule classification.

Objective:To study the effiacious based on our experience of precise anatomical hemi-hepatectomy strictly guided by the middle hepatic vein (MHV) for regional to treat intrahepatic hepatolithiasis.Methods:A retrospective analysis was conducted on the data of 47 patients with regional hepatolithiasis treated with hemihepatectomy from July 2015 to July 2019 at the Department of Hepatobiliary and Pancreatic Surgery, The University of Hong Kong-Shenzhen Hospital. The study included 15 males and 32 females, aged (42±15) years. The exposure and preservation of the MHV was included in the precision surgery group ( n=26), and failure to fully expose the MHV or damage to the MHV was included in the control group ( n=21). The operation time, intraoperative blood loss and other surgical data and postoperative complications of the two groups were compared. Results:All patients successfully completed the operation. There was no patient who developed liver failure, and no patient died 90 days after the operations. The operation time (5.2±1.8) h and intraoperative blood loss (620.5±450.8) ml of the precision surgery group were not significantly different from those of the control group (4.9±2.3) h and intraoperative blood loss (760.5±540.2) ml ( P>0.05). A total of 19 patients (40.4%) (7 in the precision surgery group and 12 in the control group) developed 36 post operative complications of various types. The postoperative complication rate in the control group was higher than that in the precision surgery group [47.6%(10/21) vs 19.2% (5/26)], the difference was significant ( P<0.05). All 47 patients were followed-up for 6 to 30 months. For postoperative long-term complications: 5 patients in the control group had residual stones, biliary tract infection, liver abscess, and biliary-enteric anastomosis stenosis with recurrence of stones, and only 2 patients in the precision surgery group were found to have residual stones and biliary-enteric anastomotic stenosis. Stone recurrence, (the incidence of long-term complication) in the control group was significantly higher than that in the precision surgery group [23.8% (5/21) vs 7.7% (2/26)], ( P<0.05). Conclusions:Precise anatomical hemi-hepatectomy strictly guided by MHV for regional hepatolithiasis could more fully remove stones and lesions, and reduced the rate of stone recurrence. It was safe and feasible with favorable efficacy.

Objective:To compare the effects of the fracture line direction in the sagittal profile on the Gartland type Ⅲ supracondylar humerus fractures in children.Methods:A total of 153 cases of Gartland type Ⅲ supracondylar humerus fractures treated in the Department of Pediatric Orthopedics, Qilu Hospital of Shandong University (Qingdao) from January 2017 to April 2019 were retrospectively analyzed.They were categorized into the traditional oblique type (the fracture line went downward in the front and upward in the back), transverse type (the fracture line went horizontally) and reverse oblique type (the fracture line went upward in the front and downward in the back). Gender, age, injury side, cause of injury, ecchymosis before elbow, preoperative neurological symptoms, operation time, incision ratio, and Flynn scores of the elbow joint at the last follow-up were compared among the 3 groups.Results:Patients were followed up for (8.65±2.47) months (6-15 months). There were 60, 64 and 29 patients in the traditional oblique type, transverse type and reserve oblique type groups, respectively.There were no differences in the gender, injury side, and injury causes among the 3 groups (all P>0.05). The age of the traditional oblique type, transverse type and reverse oblique type group were (4.76±2.51) years, (4.71±2.09) years and (6.32±1.98) years, respectively, which was significant different among the 3 groups ( F=5.826, P<0.05). There were 10, 7 and 11 cases of preoperative elbow ecchymosis occurred in children of the traditional oblique type, transverse type and reverse oblique type groups, respectively, which was significant different ( χ2=9.902, P<0.05). No significant differences were found in preoperative neurological symptoms of the 3 groups ( P>0.05). The operative time for the traditional oblique type, transverse type and reverse oblique type group were (43.28±24.25) min, (40.95±27.41) min and (58.66±34.08) min, which was significant different ( F=4.337, P<0.05). The traditional oblique type and transverse type groups had 1 failure case of closed reduction, respectively, and the incision was performed during the operation.There were 4 cases in the reverse oblique type group who underwent the open reduction.The reduction rate was significantly different among 3 groups ( χ2=6.883, P<0.05). There was no significant difference in the excellent to good rate of traditional oblique type (96.67%, 58/60 cases), transverse type(95.31%, 61/64 cases)and reserve oblique type (93.10%, 27/29 cases) among 3 groups ( P>0.05). Conclusions:The reverse oblique Gartland type Ⅲ supracondylar humerus fractures are relatively rare in clinical practice, which involves more severe soft tissue damages and more obvious antecubital ecchymosis.The conventional reduction methods seem to be ineffectual for the reverse oblique supracondylar humerus fractures.

Objective: To investigate the incidence of postoperative pancreatic fistula (POPF) and its risk factors after radical gastrectomy. Methods: The prospective study was conducted. The clinicopathological data of 2 089 patients who underwent radical gastrectomy in 22 medical centers between December 2017 and November 2018 were collected, including 380 in the Zhongshan Hospital of Fudan University, 351 in the Renji Hospital of Shanghai Jiaotong University School of Medicine, 130 in the Ruijin Hospital of Shanghai Jiaotong University School of Medicine, 139 in the Peking University Cancer Hospital, 128 in the Fujian Provincial Cancer Hospital, 114 in the First Hospital Affiliated to Army Medical University, 104 in the First Affiliated Hospital of Nanchang University, 104 in the Affiliated Hospital of Qinghai University, 103 in the Weifang People′s Hospital, 102 in the Fujian Medical University Union Hospital, 99 in the First Affiliated Hospital of Air Force Medical University, 97 in the Sir Run Run Shaw Hospital Affiliated to Zhejiang University School of Medicine, 60 in the Hangzhou First People′s Hospital Affiliated to Zhejiang University School of Medicine, 48 in the Fudan University Shanghai Cancer Center, 29 in the First Affiliated Hospital of Xi′an Jiaotong University, 26 in the Lishui Municipal Central Hospital, 26 in the Guangdong Provincial People′s Hospital, 23 in the Jiangsu Province Hospital, 13 in the First Affiliated Hospital of Sun Yat-Sen University, 7 in the Second Hospital of Jilin University, 4 in the First Affiliated Hospital of Xinjiang Medical University, 2 in the Beijing Chao-Yang Hospital of Capital Medical University. Observation indicators: (1) the incidence of POPF after radical gastrectomy; (2) treatment of grade B POPF after radical gastrectomy; (3) analysis of clinicopathological data; (4) analysis of surgical data; (5) risk factors for grade B POPF after radical gastrectomy. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using ANOVA. Count data were described as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test. Univariate analysis was conducted using the t test or chi-square test based on data excluding missing data of clinico-pathological and surgical data. Multivariate analysis was conducted using the Logistic regression model based on factors with P<0.20 in univariate analysis. Results: There were 2 089 patients screened for eligibility, including 1 512 males, 576 females and 1 without sex information, aged (62±11)years. The body mass index (BMI) was (23±3)kg/m². (1) The incidence of POPF after radical gastrectomy: the total incidence rate of POPF in the 2 089 patients was 20.728%(433/2 089). The incidence rates of biochemical fistula, grade B pancreatic fistula, and grade C pancreatic fistula were 19.627%(410/2 089), 1.101%(23/2 089), 0, respectively. (2) Treatment of grade B POPF after radical gastrectomy: 2 of 23 patients with grade B POPF after radical gastrectomy had drainage tube placed for more than 21 days and received anti-infective therapy. Four of 23 patients with grade B POPF after radical gastrectomy had ascites detected by imaging examination, of which 2 received peritoneal drainage guided by ultrasound, 1 received failed puncture drainage, 1 received no puncture drainage, and they were given anti-infective therapy. Eleven of 23 patients with grade B POPF after radical gastrectomy had no ascites detected by imaging examinations, and they were given anti-infective therapy and inhibitors of pancreas secretion for clinical manifestation as fever or elevated white blood cells. Six patients with no typical clinical manifestations were given somatostatin to inhibite pancreas secretion and prolonged duration of abdominal drainage tube placement (with a median time of 7 days). All the 23 patients recovered well after treatment, without reoperation. (3) Analysis of clinicopathological data: for the 2 089 patients, BMI, cases with or without neoadjuvant therapy were (23±3)kg/m^2, 1 487, 160 of patients without pancreatic fistula, (23±3)kg/m^2, 386, 22 of patients with biochemical fistula, and (24±3)kg/m^2, 22, 1 of patents with grade B pancreatic fistula, showing significant differences between the three groups (F=5.787, χ²=8.269, P<0.05). (4) Analysis of surgical data: for the 2 089 patients, cases with open surgery, laparoscopic assisted surgery, totally laparoscopic surgery (surgical method), cases with D₁ lymph lode dissection, D₂ lymph lode dissection, and other lymph lode dissection (range of lymph lode dissection), cases with no omentectomy, partial omentectomy, and total omentectomy (range of omentectomy), cases with no usage of energy facility, usage of CUSA, LigaSure, LigaSure+ CUSA as energy facility, cases with or without biological glue, the number of lymph node dissection were 737, 624, 292, 24, 1 580, 51, 418, 834, 381, 63, 1 530, 23, 16, 1 431, 201, 33±14 of patients without pancreatic fistula, 146, 189, 74, 11, 389, 9, 110, 171, 128, 35, 359, 6, 9, 378, 31, 31±14 of patients with biochemical fistula, and 14, 5, 4, 0, 20, 3, 6, 13, 4, 2, 18, 1, 2, 22, 1, 37±16 of patients with grade B pancreatic fistula, showing significant differences between the three groups (χ²=15.578, 9.397, 15.023, 28.245, 8.359, F=4.945, P<0.05). (5) Risk factors for grade B POPF after radical gastrectomy: results of univariate analysis showed that usage of energy facility was a related factor for grade B POPF after radical gastrectomy (χ²=9.914, P<0.05). Results of multivariate analysis showed that laparoscopic assisted surgery, combined evisceration, application of LigaSure + CUSA, the number of lymph lode dissection were independent factors for for grade B POPF after radical gastrectomy (odds ratio=0.168, 3.922, 9.250, 1.030, 95% confidence interval: 0.036-0.789, 1.031-14.919, 1.036-82.602, 1.001-1.059, P<0.05). Conclusions The incidence of grade B POPF after radical gastrectomy is relatively low. Laparoscopic assisted surgery, combined evisceration, application of LigaSure + CUSA, and the number of lymph lode dissection are independent risk factors for grade B POPF. Trial Registration: This study was registrated at ClinicalTrial.gov in United States with the registration number of NCT03391687.

Objective:To investigate the effects of of anti tumor necrosis factor-α (TNF-α) in adjuvant treatment of strangulated intestinal obstruction combined with ischemic intestinal necrosis.Methods:From February 2011 to August 2016 in Huadu District People′s Hospital Affiliated with Southern Medical University, 122 patients with strangulated intestinal obstruction combined with ischemic intestinal necrosis were selected and were equally divided into the experimental group and control group with 61 cases in each group according to the random draw envelope principle. Conventional surgical resection and anastomosis was used in control group, the postoperative anti TNF-α therapy was given for 2 weeks based on the treatment in control group.Results:All patients completed surgery and there were no serious complications during operation.The postoperative anal exhaust time and symptom remission time in experimental group were significantly lower than those in control group: (2.14 ± 0.41) d vs. (6.24 ± 1.28) d and (3.54 ± 0.77) d vs. (6.99 ± 0.91) d ( P<0.05). The incidence of postoperative 14 d complications such as anastomotic leakage, wound infection, anastomotic stenosis and pulmonary infection in the experimental group was 4.9%(3/61), and that of the control group was 18%(11/61), and the incidence of postoperative complications in the experimental group was significantly lower than that in the control group ( P<0.05). The postoperative 1d and 7 d serum TNF-α content in the experimental group was significantly lower than that in the control group ( P<0.05). The postoperative 14 d anal function in the experimental group was significantly better than that in the control group ( P<0.05). MRASP and MSP of postoperative 14 d in experimental group were all significantly higher than those in the control group: (80.24 ± 11.39) mmHg (1 mmHg=0.133 kPa) vs. (76.24 ± 12.11) mmHg, (231.98 ± 45.29) mmHg vs. (226.39 ± 41.87) mmHg ( P<0.05). Conclusions:The anti TNF-α in adjuvant treatment of strangulated intestinal obstruction combined with ischemic intestinal necrosis can promote the recovery of clinical symptoms and inhibit the release of TNF-α. It also can reduce the incidence of postoperative complications and improve gastrointestinal motility of patients.

Objective:To evaluate the clinical effects of anterolateral thigh free flap with fascia lata in the repair of dura mater defect after resection of head squamous cell carcinoma.Methods:From June 2016 to June 2018, Xijing Hospital of Air Force Medical University applied the free transplantation of anterolateral thigh flap with fascia lata to repair the dura mater defect of 12 patients with head squamous cell carcinoma, including 9 males and 3 females, aged from 35 to 74 years. The size of scalp soft tissue defects in patients after carcinoma resection ranged from 12 cm×10 cm to 24 cm×21 cm, and the size of dura mater defect of patients ranged from 7 cm×6 cm to 16 cm×14 cm. The size of flap of patients ranged from 14 cm×12 cm to 27 cm×24 cm, and the size of fascia lata ranged from 8 cm×7 cm to 17 cm×15 cm. The superficial temporal artery and middle temporal vein were connected by end to end anastomosis with the first musculocutaneous perforating branch of the descending branch of lateral femoral artery and its accompanying vein. The flap donor area was transplanted with autologous split-thickness skin graft from trunk and fixed with packing. Postoperative survival of flaps and skin grafts was observed. The patients were followed up regularly. The cranial magnetic resonance imaging was performed to observe the recurrence of intracranial tumors and dural integrity, shape of the flap and whether the donor site region was left with significant dysfunction were observed.Results:All the flaps and skin grafts survived well in 12 patients after surgery. Ten patients had primary healing at the edge of the flap suture; 2 patients had local sinus tract formation at the suture site of flap, with a small amount of cerebrospinal fluid leakage, and were recovered after outpatient dressing change. The patients were followed up for 10 to 36 months, and 3 patients with tumors involving in the dura mater sagittal sinus region had postoperative intracranial tumor recurrence. The tumor was resected again. All the patients had good dural integrity. The flaps of all patients were in good shape, and no obvious dysfunction remained in the flap donor site.Conclusions:Free transplantation of anterolateral thigh flap with fascia lata is an effective and reliable method to repair the dura mater defect following head squamous cell carcinoma resection. It can repair the scalp and dura mater defects caused by the invasion of squamous cell carcinoma and provide possibilities for skull reconstruction.

Objective: To study the application of associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in hepatocellular carcinoma with mild-to-moderate liver cirrhosis. Methods: There are 14 patients with hepatocellular carcinoma underwent ALPPS at the Department of Hepatobiliary and Pancreatic Surgery, Hong Kong University-Shenzhen Hospital from April 2014 to December 2017. The clinical data was retrospectively studied. The studying objects consisted of 9 males and 5 females, aged from 26 to 71 years old with the average age of 51, all cases were of Child-Pugh grade A. The degree of liver cirrhosis, operation and postoperative complications were analyzed. Results: All 14 patients completed the ALPPS, 1 patient died post stage 2 operation with liver failure. Comparing the groups with no liver cirrhosis (n=4) with the groups of mild liver cirrhosis (n=5) and moderate liver cirrhosis (n=5), the future liver remnant liver volume growth rates were 58%, 46% and 45.6%, respectively. The average operation intervals were 9.0, 11.2 and 12.8 days, respectively. Postoperative complications occurred in 4 patients: 2 patients with liver failure, 1 patient with intestinal obstruction, and 1 patient with hepatic ascites. Conclusion ALPPS for Child-Pugh grade A, hepatocellular carcinoma with mild-to-moderate liver cirrhosis treatment is safe and feasible.

Objective: To explore the application value of the convolutional neural network (CNN)-based artificial intelligence-assisted diagnosis model in the ultrasound differentiation diagnosis of benign and malignant breast nodules. Methods: A total of 7 334 ultrasound images from 1 351 patients with breast nodules including 807 benign cases and 544 malignant cases were retrieved by using the CNN-based artificial intelligence-assisted diagnosis model from Beijing Tongren Hospital of Capital Medical University ultrasound images database between December 2006 and July 2017. The study included training subset (6 162 images), verification subset (555 images), and test subset (617 images), which were performed in the artificial intelligence-assisted diagnosis model. The outcome results of test subset in diagnosis model were compared with the pathological results. The sensitivity, specificity and accuracy of the artificial intelligence-assisted diagnosis model were calculated. Results: After the test of 617 images, the model diagnostic results could be automatically output with a rectangular frame indicating the nodule position, benign and malignant diagnosis, benign and malignant probability values. The diagnosis time was approximately 4 seconds for each nodule. The sensitivity, specificity and accuracy of the diagnostic model in differentiating benign and malignant breast nodules were 84.1%, 95.0% and 91.2% , respectively. Conclusion The CNN-based artificial intelligence-assisted diagnosis model has satisfactory results in the differentiation diagnosis of the benign breast nodules and the malignant ones, which indicating the promising application prospect.