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In the framework of Phase I of the MYRRHA project implementation, the superconducting linear accelerator with proton beam parameters 100 MeV, 4 mA is going to be built. To stop the beam, a beam dump based on Al-6061 alloy is designed. The evaluation of radiological impact of an accidental radioactivity release requires the reliable estimates of primary radiation source terms with associated uncertainties. The article addresses the propagation of nuclear data uncertainties through beam dump activation calculations. The Total Monte Carlo approach was used to generate large number of random excitation functions for residual products of proton interactions with materials of Al-6061 alloy. The residual products do not impose any feedback on proton and neutron spectra in the beam dump, moreover the calculation of the production rates is sufficient to obtain uncertainties on final activities. This significantly accelerates the uncertainty quantification allowing to study the convergence of mean and higher moments (variance, variance of variance) for individual nuclides.

Treatment of biliary leaks is challenging and complex. Even if endoscopic sphincterotomy with biliary stenting is usually resolutive in restoring the original bile flow, common bile duct (CBD) diameter is crucial in defining the size and features of the stent. Additional factors, such as uncommon anatomical reconstructions due to a previous abdominal surgery, could make the endoscopic approach more difficult, therefore increasing the risk of failure. Many articles deal with uncommon technique adopted to allow an optimal healing of biliary leaks but, thus far, only two reports of biliary stent using an esophageal through-the-scope (TTS), partially-covered, self-expandable metal stent (SEMS) exist in the current literature. This article describes the deployment of an esophageal SEMS into the CBD for a refractory type A Strasberg fistula in a Billroth-II reconstruction. To our knowledge, this is the first report concerning the use of an esophageal stent for CBD drainage in a Billroth-II reconstruction.

Background: The best operative approach to large hiatal hernias still remains controversial between suture cruroplasty and prosthetic hiatal herniorrhaphy. This study aims at analysing results from a single institution in Italy in terms of subjective and objective outcomes., Methods: Retrospectively collected data of all patients that underwent laparoscopic hiatal hernia repair since 2011 were considered. Sixty-five patients were included overall; 17 of them fit the criteria of large hiatal hernia. Follow-up (FU) was assessed by visit, questionnaires and X-ray imaging., Results: No major complications occurred in the post-operative course. No patient was lost during the FU period. Out of all the patients included, 13 agreed to have an X-ray with water-soluble contrast. The questionnaires showed a 76.5% rate of satisfaction (13 patients), and the recurrence rate demonstrated by radiology was 29.4% (five patients). There were no major mesh-related complications., Conclusion: The best operative approach for large hiatal hernias remains far from standardised: There is a lack of evidence on the use of a mesh for this kind of surgery as well as substantial controversy over the definition of what a giant hiatal hernia is. Nevertheless, the results from this study and the main studies in the literature seem to be encouraging in improving giant hiatal hernia repair outcomes., Competing Interests: None

Introduction: The technical complexity of D2 lymphadenectomy and esophago-jejunal anastomosis are the main factors that limit the application of laparoscopic surgery in the treatment of gastric cancer. Robotic assisted gastric surgery provides potential technical advantages over conventional laparoscopy but an improvement in clinical outcomes after robotic surgery has not been demonstrated yet., Evidence Acquisition: Data from 128 consecutive patients who had undergone robotic gastrectomy for gastric cancer at our center institution from April 2017 to June 2020 where retrospectively reviewed from a prospectively updated database. A narrative review was then carried out on PubMed, Embase and Scopus using the following keywords: "gastric cancer," "robotic surgery," "robotic gastrectomy" and "robotic gastric surgery"., Evidence Synthesis: Ninety-eight patients underwent robotic distal gastrectomy and 30 underwent robotic total gastrectomy. The mean value of estimated blood loss was 99.5 ml. No patients required conversion to laparoscopy or open surgery. The median number of retrieved lymph nodes was 42. No tumor involvement of the proximal or distal margin was found in any patient. The median time to first flatus and first oral feeding was on postoperative day 3 and 5, respectively. We registered 6 leakages (4.6%), namely, 1 duodenal stump leakage and 5 anastomotic leakages. No 30-day surgical related mortality was recorded. The median length of hospital stay was 10.5 days (range 4-37)., Conclusions: Published data and our experience suggest that the robotic approach for gastric cancer is safe and feasible with potential advantages over conventional laparoscopy.

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Background: The aim of our retrospective study is to compare the efficacy and indications of transanal endoscopic microsurgery (TEM), endoscopic submucosal dissection (ESD), and endoscopic full-thickness resection device (FTRD) with Over-The-Scope Clip (OTSC ® ) System for en-bloc resection of rectal lesions., Methods: This study collected 76 cases of rectal neoplasms from a single hospital institution. Primary endpoints were complete en-bloc resection, intraprocedural adverse events, R0 en-bloc resection and an early discharge of the patient. Secondary endpoints included procedure-related adverse events., Results: Mean tumor sizes were statistically significant smaller among patients treated with FTRD rather than TEM and ESD. TEO and FTRD treated patients experienced a higher en-bloc resection rate, with a shorter procedure time and hospital stay. No significant difference concerning the R0 resection was found. TEO and FTRD recorded lower perforation rates as compared to ESD, whereas no difference emerged concerning the bleeding rate and the post-polypectomy syndrome rate., Conclusions: Our study showed that each technique has specific features, so that each one offers advantages and disadvantages. Nevertheless, all of them ensure high en-bloc resection rates, whereas no difference exists for R0 resection rate. TEO provides the possibility to remove low rectal large lesions as compared to ESD and FTRD.

Background: In recent decades, transanal surgery for rectal lesions has become a valid alternative treatment for the treatment of small lesions of the rectum. Significant benefits in terms of morbidity and mortality are confirmed. There are multiple platforms for transanal surgery but the TEO system® is one of the best known., Methods: Between November 2017 and July 2019, 25 patients with rectal lesions suitable to transanal treatment came to our observation. In all reported cases, full-thickness rectum resections were performed. Demographic, histopathological, surgical morbidity/mortality and clinical outcome in all patients who underwent TEO were retrospectively evaluated from a prospectively collected database., Results: For a period of less than 2 years, 25 rectal lesions were excised by TEO. Sixteen lesions (64%) were low (<4 cm), 7 (28%) were mid-rectal (4-8 cm) and 2 (8%) were in the proximal rectum (>8 cm). Postoperative complications included: 3 (12%) bleedings, and 8 (32%) post-polipectomy syndrome., Conclusions: Our initial experience suggests TEO is safe and feasible. Full-thickness resection guarantees adequate deep margins. Moreover, the limited number of cases requires the development of adequate reference centers.

Introduction: Sinistroposition of the gallbladder, or true left-sided gallbladder (LSG) without situs viscerum inversus, is a rare congenital anatomical variant where the gallbladder is located to the left of round/falciform ligament. It can be associated with anomalies of the biliary tree, portal system and hepatic vascularization. The surgical management of a LSG could be challenging even for an experienced operator, being usually an incidental intraoperative finding., Case Report: A 72 years old woman was admitted to our emergency department because of acute cholecystitis. There were no pre-operative indications of sinistroposition of the gallbladder and its aberrant position was discovered during the explorative laparoscopy; because of the unusual anatomy and chronic flogosis, the laparoscopic approach was converted to open surgery. The patient underwent a successful intervention and was discharged after 4 days without complications. Her family history revealed a daughter with biliary atresia., Discussion: LSG could remain undetected at preoperative imaging, but today, with advances in diagnostic imaging, the report of this condition has increased. Several hypothesis suggest the presence of an underlying embriologic mechanism for LSG and its associated anomalies, but its etiology is still unknown. The association with the daughter's biliary atresia makes reasonable a possible genetic correlation with this condition., Conclusions: In case of LSG, laparoscopic cholecystectomy could be feasible and safe, but with an increased risk of injury to the major biliary structures, mostly in case of severe and chronic inflammation of the gallbladder. Surgeons have to know this variant because of its associated hepatic anomalies., Key Words: Cholecystectomy, Emergency Surgery, Left-Sided-Gallbladder.

Introduction: Aim of our observational and retrospective study is to compare efficacy and indications of endoscopic full-thickness resection device (FTRD) with the over-the-scope (OVESCO) clip closure for en bloc resection of colorectal lesions (including adenomas, early carcinomas, inflammatory polyps and neuroendocrine tumors)., Material and Methods: This article collected 36 cases of colorectal neoplasms from a single Italian referral center per colorectal disease treatment. Primary endpoints included en bloc resection, R0 resection and an early discharge of the patient. Secondary endpoints included procedure-related adverse events., Results: Mean procedure time± standard deviation (SD) was 19.6±22.1 minutes and mean hospital stay (± SD) was 2.2±1.1 days. Overall, an en bloc resection was achieved in 34 cases (94.4%), with an R0 resection rate of 91.6%. Among the three not R0 patients, further additional treatments were needed., Discussion: Along the same line of other already published articles, the main current indications of EFTR by FTRD-OVESCO are limited to superficial or low-risk malignancy lesions (eg, adenomas, early cancers or subepithelial tumors), not suitable to conventional endoscopic resection or in patients with a severe surgical risk. Both en bloc resection rate and complication rate are aligned with other authors' data., Conclusions: EFTR by FTRD system represents an effective and safe options whenever a recurrent lesion in a challenging environment occurres (eg, recent scar, low rectum or beyond a large colonic bend). Procedure-related adverse events are potentially severe, so that this novel technique should be performed by "expert hands"., Key Words: Difficult polypectomies, Early carcinomas, Endoscopic Full-Thickness Resection (EFTR), Full-Thickness Resection Device (FTRD) by Over-The-Scope (OVESCO) clip closure, Literature overview, Single center experience.

Since gastroduodenal FTRD system is commercially available, several data have been reported in Literature concerning duodenal full-thickness resections, whereas few cases of gastric full-thickness resections has been described. In this case series We report three patients treated with this innovative tool for resecting lesions of the gastric wall. The indications ranged notably: a neuroendocrine tumor in a difficult to treat environment in the first case, a recurrent adenocarcinoma in a poorly surgical candidate patient in the second case and a pre-pyloric lesion for the third patient. In the third patient, a complete pyloric stenosis due to the clip deployment occurred. Clinical success rate was 100%. Even if current Literature is still poor of articles dealing with gastric full-thickness resection device based on over-the-scope-clip system. Our case series show how this novel tool might be take into consideration for whenever both surgery and standard endoscopic resection techniques are poorly feasible.

Aim: The purpose of this study is to analyze a rare and under-reported complication of abdominal liposuction and the role of laparoscopy., Clinical Case: We report a case of bowel perforation after 7 days of abdominal liposuction and bilateral mastopexy. The patient presented clinical and radiological findings of bowel obstructive syndrome and bilateral peripheral pulmonary embolism. An emergency diagnostic laparoscopy was performed and confirmed the diagnosis of bowel perforation., Discussion: Bowel perforation is a known but under-reported comSOD Romaplication of abdominal liposuction, and it is characterized by a difficult diagnosis. The clinical presentation is characterized by a difficult diagnosis and severe complications. Bowel obstructive syndrome was constant, as our case and also peritonitis was never frank. This is an important point because it is one of the reasons for diagnostic delay. The development of laparoscopic surgery has changed the way to manage such conditions, where the diagnosis was doubt. In particular, when an acute abdomen occurs, laparoscopy may have three different roles: to confirm or not the diagnosis, to facilitate and guide a subsequent laparotomy or, finally, to entirely treat the disease., Conclusion: The bowel perforation is a dramatic and underestimated complication of abdominal liposuction. Diagnosis is complex. A clinical and radiological investigation should be quickly performed. In doubtful cases, an emergency laparoscopy can confirm the diagnosis and guide a possible subsequent laparotomy.

Hiatal hernias (HHs) are usually divided into two main groups: sliding and para-esophageal (torsional) ones. Sometimes patients presenting HHs experience progressive anemia, whereas rarely an acute anemia with melena or hematemesis can occur. In such cases a Cameron ulcer should be suspected and a careful esophago-gastro-duodenoscopy (EGDS) with a meticulous inspection of the mucosal folds along the neck of the hernia is the best examination in order to find out the ulcer itself. In front of massive hemorrhage due to a Cameron erosion, the first aim should be the control of the bleeding itself, in order to ree1Romastablish hemodynamic stability. The Authors report the case of a 72-year-old man presenting a severe bleeding secondary to a large Cameron ulcer in a para-esophageal hiatal hernia. Firstly, a combined medical-endoscopic therapy was tried; the patient underwent transfusions of pooled red blood cells and endovenous anti-acid therapy combined with an operative endoscopic treatment; unfortunately this initial approach failed, therefore the patient was referred to surgery. The surgeons realized a minimally invasive atypical gastric resection associated with the HH repair; the post-operative course was uneventful and no other rebleeding episodes occurred. The urgency treatment of a life-threatening bleeding for Cameron ulcers remains a very challenging problem as no univocal and standardized recommendation has been described in literature since now. In this case-report the Authors make an overview of the current literature on the treatment of Cameron ulcers, describing a novel surgical technique for massive upper gastro-intestinal bleeding secondary to these lesions.

Background and Aim: Chemoradiotherapy (CRT) is the gold standard treatment for anal cancer, which permits the maintenance of the anal function. However, about 30-40% of patients develop local disease progression, for which surgery represents a good salvage therapy. The aim of this study is to evaluate survival and morbidity rate in patients who undergo salvage surgery in our single institution, with an overview of the literature., Methods: A retrospective study was carried out on patients who underwent surgical treatment of anal canal cancer after failure of CRT. We evaluated overall survival at 1, 3, and 5 years and postoperative morbidity rate., Results: Twenty patients who underwent radical surgery with abdominoperineal resection were included in the study. The survival rates at 1, 3, and 5 years were 75, 60, and 37.4%; with a disease-free survival of 67, 53, and 35%, respectively. There was no postoperative mortality. The morbidity rate was 35%., Conclusion: Surgery represents the recommended therapy for persistent or recurrent anal canal cancer after CRT, with a good survival rate and an acceptable morbidity., (© 2017 S. Karger AG, Basel.)

Hepatocellular carcinoma with osteoclast-like giant cells is extremely rare, and only six cases have been previously reported. Its histogenesis is at the moment controversial. The authors report a case of hepatocellular carcinoma with osteoclast-like giant cells found in a 74-year-old woman. The patient came with a dull pain in the right upper abdominal quadrants due to a liver neoplasm described at CT scan. A wedge resection of the fifth hepatic segment with appendectomy, omentectomy, and debulking of the major peritoneal implants was performed. Histologically, the diagnosis of hepatocellular carcinoma with high grade differentiation associated with giant osteoclast-like cells was done without any evidence of hepatitis or cirrhosis in the surrounding hepatic parenchyma. Immunohistochemistry was positive for CD10 and CD68 and in situ hybridization revealed the expression of receptor activator of nuclear factor-kappa B (RANK) in the giant cells and receptor activator of nuclear factor-kappa B ligand (RANKL) in the tumor cells.

Introduction: Squamous-cell carcinoma (SCC) of the middle rectum is a rare disease with an estimated incidence of 0.1-0.25/1000 colorectal neoplasms. Literature is represented essentially by case report and short series, and only seventy-six cases of colorectal squamous carcinoma have been documented in literature., Presentation of Case: We report the case of a SCC of the middle rectum, associated to an ureteral inverted papilloma, occurred in a patient with a past history of prostate cancer treated with prostatectomy and radiotherapy., Discussion: Colorectal squamous-cell carcinoma is a rare disease. This localization is more frequent than the right colon, but no more epidemiological informations are actually available apart from a slight predominance of the female sex. Risk factors for SCC of the rectum are unknown and many hypotheses have been evocated. Because of its rarity, the interpretation of available information is clouded by a lack of uniformity in diagnosis and treatment., Conclusion: Treatment of SCC remains very challenging, and the acquisition of more consistent data is needed., (Copyright © 2014 The Authors. Published by Elsevier Ltd.. All rights reserved.)