【Background】Causes of hepatic encephalopathy are mainly due to decreased metabolic capacity associated with hepatic parenchymal dysfunction and portosystemic shunt associated with portal hypertension. The basis of treatment is the removal of toxic substances, mainly ammonia, and the correction of metabolism of amino acids. In recent years, rifaximin, poorly absorbed antibiotics became available. This time, we decided to investigate the use of rifaximin and its therapeutic effects.

【Methods】The subjects were 60 cirrhosis patients who received rifaximin for hepatic encephalopathy in our hospital from September 2016 to November 2019. We investigated the efficacy and safety of patients with hepatic encephalopathy.

【Results】Concomitant drugs were branched chain amino acid preparation（88%），lactulose（75%），levocarnitine preparation（42%），and zinc preparation（6.7%）．Good results were also obtained in patients switching from kanamycin sulfate. Serum ammonia concentration was approximately halved one month after rifaximin administration, and good control was obtained thereafter. Relapse of hepatic encephalopathy was concentrated within 100 days from the start of rifaximin administration. Overt encephalopathy relapse was more common in the elderly, patients with high Child-Pugh scores, and patients with portosystemic shunt.

【Conclusion】The current state of rifaximin administration in our department, the efficacy and safety for hepatic encephalopathy were confirmed.

We herein report an experience of neuroendocrine carcinoma of the breast. A 73-year-old woman visited our hospital because of a tumor of the left breast. The tumor was diagnosed as category 3 by mammography. Ultrasonography diagnosed as 16mm size in diameter with relative clear margin in D area in the left breast. Imaging of MRI showed the tumor had early enhancement following gradual decreasing. PET displayed a slight accumulation of FDG on the tumor. Biopsy of the tumor was diagnosed as invasive carcinoma histologically. We performed partial mastectomy of left breast and sentinel lymph node biopsy. Tumor cells were demonstrated having formation of　Rosset and pseudo-Rosset in perivascular lesion histopathologically. Tumor cells were displayed as positive of Chromogranin A stain, positive of NSE stain, slight positive of CD56 stain, and positive of Synaptophysin stain immune-pathologically. The tumor was made a definite diagnosis as poorly differentiated neuroendocrine carcinoma having many mitotic figures and strong cellular atypia. After surgery the patient received radiation therapy and has been under follow-up observations with medication of aromatase inhibitor. Generally atypical carcinoid is said to be high grade of malignancy, so this case should be under careful observation in a long-term.

We experienced a case of intractable pancreatic fistula after pancreatoduodenectomy, successfully cured by fistulo-jejunostomy directly under the abdominal wall. A 56-year-old woman underwent pancreatoduodenectomy for carcinoma of pancreatic head. After removal of the drainage tube of anastomosis of pancreato-jejunostomy, pancreatic juice started to discharge from the median wound. Conservative therapy such as fasting, TPN, and administration of somatostatin analogue failed to achieve complete healing of pancreatic fistula. The patient underwent surgical treatment 64 days after pancreatoduodenectomy. At laparotomy, fistulo-jejunostomy was performed directly under the abdominal wall. A splint tube was inserted into the anastomosed site and the jejunum and abdominal wall were sutured for fixation, and drainage was made externally via the splint tube. Postoperative course was uneventful and she had no recurrence of pancreatic fistula until now. This surgical procedure is easily and safety and make a certain fixation of jejunum to fistula, so it might be a useful treatment of intractable pancreatic fistula after pancreatoduodenectomy. Because long-term results of its procedure is unknown, further consideration should be needed after collecting cases.

We here report a case of retroperitoneal and posterior mediastinal schwannoma resected via a thoracoscopic approach.

A man in his 40s was referred to our hospital because a well-circumscribed 51×47 mm diameter mass had been identified in the retroperitoneal area between the abdominal aorta and left kidney by computed tomography（CT）．The mass also extended into the posterior mediastinum. The suspected diagnosis being neurogenic tumor, surgery was performed for diagnostic and therapeutic purposes. Surgery was initiated via a thoracoscopic approach because the tumor head was located in the posterior mediastinum. The tumor appeared to have originated in the sympathetic trunk and was removed completely via the thoracoscopic approach. The pathological diagnosis was retroperitoneal benign schwannoma. The postoperative course was uneventful and the patient was discharged 7 days post-surgery. Thus, schwannoma located in retroperitoneum and posterior mediastinum could be successfully resected via a thoracoscopic approach.

We provided long-term intensive care to a patient with fibrodysplasia ossificans progressiva（FOP）who had acute respiratory failure due to influenza pneumonia. The patient was a 36-year-old woman diagnosed with FOP at 7 years of age. When she was 33 years old, she experienced sepsis-induced pneumonia due to candidiasis, which was completely cured with artificial ventilation. Presently, she was admitted to our hospital for fever and vomiting caused by influenza A virus infection, which led to pneumonia. Artificial ventilation was started, and she was moved to the intensive care unit because of acute respiratory failure on the 18th day from the onset of disease. Administration of noradrenaline maintained the blood pressure, and she underwent tracheostomy on the same day. Therefore, she could not be weaned from artificial ventilation support；however, the chest x-ray findings improved. Her P/F ratio stabilized to more than 400 after antibiotic administration, and she was moved to a long-term care hospital. Long-term management by artificial ventilation may be required for the treatment of acute respiratory failure in FOP, and invasive procedures, such as tracheostomy and/or intrathoracic drainage, are important for the management.