[Learning curve for inflatable penile prosthesis]. / Courbe d'apprentissage d'implantation de prothèse pénienne.

INTRODUCTION: Inflatable penile prosthesis surgery is relatively rare in France, and around ten surgeons perform most of this surgery. The objective of this study was to define the learning curve concerning this surgery. METHODS: This study is a retrospective monocentric cohort of first time implantation of inflatable penile prosthesis between 2008 and 2016 in a university hospital. 68 consecutive patients underwent this procedure performed by a single surgeon. These patients were dispatched into two groups: a group of the first 20 patients and a group of the 48 last patients. For each patient, multiple parameters were measured including: duration of surgery, per operative complications, post operative morbidity according to Clavien classification, length of stay, and functional satisfaction. Parameters were compared using Fisher or Wilcoxon tests. RESULTS: Patients were on average 58.2 year old and average operating time was 87.7minutes. The average complication rate was 16.2%. Five patients from the first group and 3 patients from the second group presented a grade 3 post operative complication according to Clavien classification. The complications included 5 infections, one erosion, one irreductible paraphimosis and a prosthesis dysfunction. This difference was statistically significative (P=0.043). The average duration of hospitalization was significantly shorter in the second group (P=0.004). There was no significative difference concerning the satisfaction using the EDITS score (P=0.52) or a Likert scale (P=0.72). CONCLUSION: In this monocentric and retrospective study, the learning curve for first time implantation of inflatable penile prosthesis is acquired after 20 surgeries. Specific training could lower this number, but needs further evaluation. LEVEL OF EVIDENCE: 3.

Stillbirth in dairy calves is influenced independently by dystocia and body shape.

The objectives of this study were to determine (1) if stillborn calves born following dystocia present with specific injuries/pathological changes compared to stillborns delivered without difficulty, and (2) whether such stillborns differ in conformation from dystocic calves that survive. Post-mortem examinations were carried out on 20 stillborns that were either unassisted (N) or were 'farm-staff'-assisted/normally presented (FN) at birth. Evidence of greater trauma and bruising was observed in the FN calves and parameters such as body length, birth-weight and thyroid:body weight were similar. In a second part of the study birth-weight, body length and height, girth length, body mass (BMI), and ponderal (PI) indices were assessed in 490 calves. Regardless of the severity of dystocia, stillborns had greater body lengths and lower BMIs and PIs than calves born alive (P<0.05), suggesting prenatal factors contribute to their post-natal survival. FN calves were heavier than N calves (P<0.05), and both FN and farm-staff-assisted/malpresented calves had lower PIs than N calves (P<0.05). The study found that criteria such as grossly visible carcass haemorrhage, bruising, and brain congestion were not reliable in terms of identifying calves that had experienced dystocia. Half of the stillborns had breathed indicating they were alive and possibly had experienced pain/distress at time of delivery. Body conformation was related to stillbirth independently of dystocia, a finding likely reflecting inadequate prenatal development.

The impact of dystocia on dairy calf health, welfare, performance and survival.

Up to one-third of dairy calves are born after dystocia and this is a major cause of calf mortality. This study investigated the neonatal physiology, survival, health and subsequent growth of dairy calves following dystocia and is the first longitudinal study to analyse multiple effects and to look beyond the perinatal period. A total of 455 live born Holstein calves (N: No assistance, n=360; FN: Farmer assistance but normally presented calf, n=82; FM: Farmer assistance of malpresented calf, n=13) were followed from birth to first service (heifers) or until leaving the farm (bulls). Compared to N calves, FN and FM animals had higher salivary cortisol concentrations at day 1 (P<0.001) and FN calves had lower passive immune transfer (P=0.03). Dystocia had no biologically significant impact on rectal temperature throughout the first 4 days (P>0.05). During the first 60 days, FM calves had a higher proportion of days with non-routine health treatments (P<0.05) and, by the time of weaning, mortality in FN and FM heifers was higher than in N calves (2.8×; P<0.01). However, in surviving calves, growth to first service was not affected by dystocia category (P>0.05). Calves which survive dystocia experience lower passive immunity transfer, higher mortality and higher indicators of physiological stress. Such calves have poorer welfare in the neonatal period and possibly beyond. Strategies need to be implemented to improve the subsequent health and welfare of such calves and to lower the incidence of dystocia.

Short communication: survival, growth to weaning, and subsequent fertility of live-born dairy heifers after a difficult birth.

The experience of a difficult birth (dystocia) is traumatic and has adverse effects on the newborn in various species. Despite affecting up to 1 in 3 births in dairy cattle, studies on calves have been mostly limited to the first day of life. The objective of this study was to investigate the effects of dystocia on the survival to calving, growth to weaning, and subsequent fertility as nulliparous animals. Historical data from live-born Holstein heifer calves born from cows with various birth difficulty scores (no assistance; moderate; high difficulty) were obtained from 2 herds (Edinburgh herd: n=1,237; Crichton Royal Farm herd: n=721). Each herd was analyzed separately for birth weights, weaning weights, growth rate to weaning, number of services to conception, and age at first calving using REML and generalized linear mixed model analyses. Survival analysis (Cox proportional hazards model) was used in the Edinburgh herd to analyze the subsequent survival of live-born heifers, whereas descriptive data are presented for the Crichton Royal Farm herd. A higher mortality risk to weaning and to first service was observed in the live-born heifers that experienced moderate difficulty at birth compared with heifers born naturally. Surviving dystocial heifers had similar growth-to-weaning and fertility performance as heifers born naturally in both herds. It could be that the performance of dystocial heifers that survived to weaning was not affected or that it was compensated for by farm management. This study highlights long-term effects of the early experience of a difficult birth and thereby stresses the importance of preventing dystocia not just from the point of view of the adult cow, but also from the perspective of the calf. This would also improve farm efficiency and calf welfare.

Effect of a difficult calving on the vigour of the calf, the onset of maternal behaviour, and some behavioural indicators of pain in the dam.

The neonate's development and survival is dependent upon being vigorous at birth and receiving appropriate maternal care. However, difficulty at delivery can result in less vigorous offspring and maternal care can be altered, probably as a consequence of exhaustion, pain and human intervention. The first 3h after expulsion of the calf were observed continuously from videos following twelve natural calvings and sixteen calvings assisted by farm staff (including four malpresentations) from Holstein cows. Calvings were balanced within groups for parity of the dam, genetic group, sex and birth weight of the calf, calving pen and calving season. Assisted calves were less vigorous with higher latencies to attempt to stand, achieve standing, walk and reach the udder than unassisted calves (P<0.05). Furthermore, assisted calves also tended to be less likely to stand and walk within the first 3h after birth (P<0.1), spent more time lying on their flank (P=0.019) and had more frequent bouts of this behaviour (P=0.033). Assisted dams did not take longer to lick the calf and performed as much licking as unassisted dams (P>0.05), indicating no delayed onset or impaired expression of maternal behaviour in dams given assistance at delivery. Study of potential pain-related behaviours revealed that assisted dams spent less time self-grooming (P=0.033) than dams delivering naturally, which could suggest greater pain. However, there were no significant differences in any of the other pain-related behaviours. Our results suggest that, although maternal behaviour was unaffected by a difficult delivery, dairy calves born following difficult calvings have lower vigour in the first 3h after birth than unassisted calves. This might have longer-term effects on the health and survival of the calves.

Calving difficulty in dairy cows has a longer effect on saleable milk yield than on estimated milk production.

A difficult calving affects the welfare of the cow and has economic implications for the farm. The degree of calving difficulty can vary from no assistance needed through a slight pull required to surgery being needed. With respect to milk production, it is not clear at which degree of calving difficulty adverse effects occur or for how long they last. Studies usually only consider the milk produced by animals who completed full lactations but the saleable milk production of the whole herd, regardless of each cow having achieved a full lactation, might be a better indicator of the productivity of the cows and the underlying stresses they experience, as well as being more representative of the real losses that producers incur. The objective of this study was to investigate how various degrees of calving difficulty would alter both the cow's milk production and their production of saleable milk over different stages of their subsequent lactation. The calving difficulty scores and the subsequent milk production were retrieved from an experimental dairy farm (in the United Kingdom) for 2 herds that contained 2,430 and 1,413 lactations. To account for milk saleable by the farmer, individual cumulative saleable milk yields, referred to as saleable milk yields (SMY), were calculated at 30, 60, 90, and 300 d in milk unconditional on the animal having achieved the lactation stage of interest. Lactation SMY were obtained based on the real lactation length achieved by the animal. Mean daily milk yields were also calculated for the same lactation stages as an estimate of the cow's milk production (CMP). Calving difficulty impaired milk production of dairy cows in terms of CMP and SMY in both herds, highlighting impaired income for dairy producers as well as detrimental effects to the productivity of the cows and potentially impaired health and survival. The management of the herd affected the presence of an effect of each degree of difficulty on SMY and CMP as well as its magnitude and duration. The analysis of SMY, independently of each animal having achieved a full lactation, could be a more sensitive indicator of the subsequent long-lasting biological stresses than CMP alone.

[Jaw osteonecrosis induced by oral biphosphonates: 12 cases]. / Ostéonécroses des mâchoires induites par les biphosphonates oraux: 12 cas.

INTRODUCTION: The incidence of jaw osteonecrosis induced by oral or intravenous biphosphonates (BP) has been increasing. Two hundred cases of jaw osteonecrosis induced by oral BP (JONOBP) were reported, with an incidence of 4 % and a prevalence of 1/952. We report 12 cases of JONOBP observed from January 2007 to January 2009. MATERIAL AND METHODS: A pluridisciplinary committee including odontologists, stomatologists, and maxillofacial surgeons from two Paris hospitals was asked to manage patients treated by BP. Twelve patients presenting with JONOBP were included from January 2007 to January 2009. For each of these patients, age, sex, associated co-morbidities, any triggering factor, previous or current combination treatments, the type of BP used, its initial indication, dosage, delay before onset of JONOBP, and delay between first clinical signs and diagnosis were studied. JONOBP localization, stage (American Association of Oral and Maxillofacial Surgeons [AAOMS] classification), clinical and radiological signs, anatomopathological and bacteriological examinations (when performed) were documented. The treatment and evolution were described. RESULTS: Ten women and two men, mean age 65 years (36 to 82 years), were included. BP were taken orally once a week or daily. The mean duration of BP exposure was 39.6±2,4 months (19 to 58 months). The indication for BP was prevention or treatment of osteoporosis in 11 cases and breast with bone metastases in one case. Tooth extraction was the triggering factor in nine cases. The premolar and molar mandibular area was the most often affected. Corticosteroid therapy was combined to BP in half of the cases. There were no clinical, radiological, and histological specific signs. BP treatment was stopped in all patients. Nine patients underwent surgery. Evolution was favorable for nine patients. Six patients were cured, on average 3.8 months after beginning management (one to nine months). Three male patients improved. Three female patients were lost to follow-up. Alendronate was the most frequently implicated (six cases) and risedronate (five cases). Five patients presented with diagnosed or suspected auto-immune conditions. DISCUSSION: The duration of exposure to BP was superior to three years in most cases. The triggering factor was tooth extraction. The mean diagnostic delay was five months. There were more stage 2 and 3 patients, according to the AAOMS classification. They were the most frequent, probably because of the higher number of co-morbidities, especially corticosteroid intake. Patient management complied to Afssaps and AAOMS recommendations. The evolution was favorable for all managed patients.

Medium-term effects of repeated exposure to stray voltage on activity, stress physiology, and milk production and composition in dairy cows.

The medium-term effects of permanent or random exposure to stray voltage applied to the water trough were evaluated on milk production and stress physiology in lactating dairy cows. Seventy-four Holstein cows were assigned during two 8-wk experimental periods to 1 of 3 treatments. The treatments were permanent exposure to voltage (PERM, 1.8 V, n=23) applied to the water trough, random exposure to voltage (RAND, 1.8 V, 36 h/wk, n=25), and no exposure to voltage (control, n=26). On the first day of voltage exposure, PERM cows had higher activity levels than control cows (9.8+/-2.70 vs. -2.3+/-2.74 14-s periods of movement/h). During the eighth week of exposure, RAND cows had higher activity levels than control cows (4.2+/-3.64 vs. -7.7+/-3.54 14-s periods of movement/h) and higher milk cortisol concentration than PERM cows (0.21+/-0.024 vs. 0.14+/-0.020 ng/mL). No differences were observed between treatments for cortisol response after an ACTH challenge during the seventh week of exposure. No effects of voltage exposure were observed on production traits and daily water intake. There was a transient decrease in milk yield on the second day of exposure in PERM cows (-1.4+/-0.74 kg) and on the third day of exposure in RAND cows (-3.5+/-1.03 kg) compared with control cows. In dairy cows, permanent or random exposure to stray voltage (1.8 V; 3.6 mA) could induce a transient stress response. Moreover, unpredictable voltage exposure could be considered a mild stressor, with slight modifications in stress physiology and activity but no impairment in production in the medium term.

[Surgical site infections in orthognathic surgery and risk factors associated]. / Les infections du site opératoire en chirurgie orthognathique et leurs facteurs de risque.

INTRODUCTION: Surgical site infections (SSI) in orthognathic surgery are considered infrequent and without any important consequence for the final operative result. A procedure of epidemiological surveillance was implemented to determine the frequency of SSI in orthognathic surgery and to better document their risk factors. MATERIAL AND METHOD: This prospective study included all interventions in our orthognathic surgery department between September 1(st) 2006 and August 31(st) 2007. SSI and their risk factors were documented for up to one year of follow-up. Risk factors were correlated to SSI using monovariate and multivariate analyses. RESULTS: Ten (7%) out of 143 consecutive interventions in orthognathic surgery were complicated by a SSI. All the SSI were secondary to a mandibular ramus sagittal split osteotomy. The two significantly correlated risk factors with the SSI in multivariate analysis were the length of surgery and the type of antibiotic prophylaxis. DISCUSSION: This rate of SSI correlates to published data. To decrease this rate, it would be necessary, in association with the usual precautionary measures, to limit the operating time and to recommend an antibioprophylaxis combining amoxicillin plus clavulanic acid (Augmentin).

[Pancreaticoduodenectomy for cancer of the head of the pancreas]. / Duodénopancréatectomie céphalique pour cancer.

Many modifications of the original technique have been proposed to try to improve the results of the pancreaticoduodenectomy described by Whipple. To evaluate these modifications, we have reviewed randomized controlled trials, meta-analyses, and well-conducted retrospective series. Neither total pancreatectomy nor extended lymph node dissections have shown an improve of survival in retrospective studies. Preoperative evidence of mesenteric or portal vein involvement does not contraindicate pancreatic resection and survival rates are similar to those of patients with no venous involvement. Prospective trials and one meta-analysis have shown neither advantage nor disadvantage of pylorus-preserving pancreaticoduodenectomy or of pancreatico-gastric anastomosis. Three trials and one meta-analysis of pancreatico-gastric anastomosis have failed to demonstrate a decrease in the risk of pancreatic fistula. Two trials suggest that the risk of fistula formation is decreased by implantation of the pancreatic remnant into the jejunum or by trans-jejunal stenting of the pancreatico-jejunal anastomosis with external drainage; but these findings are not supported by a third trial. The results of the antisecretory use of somatostatin are contradictory. Leak and fistula formation were decreased when the criteria for leakage was based on laboratory findings; but in 4 out of 5 trials, somatostatin did not decrease the incidence of clinical fistula. The use of fibrin glue to occlude the pancreatic duct or seal the cut surface of the pancreas did not decrease the rate of intra-abdominal complications. In conclusion, the pancreaticoduodenal resection described by Whipple may still be considered the gold standard for resection of pancreatic cancer. The technical experience of surgeons and their institutional support staff resulted in lower perioperative morbidity and mortality and in higher survival rates.

[Inguinal hernia repair: time interval between surgical repair and recurrence]. / Hernies inguinales: délais d'apparition des récidives.

This study seeks to evaluate the time interval between initial inguinal hernia repair and the appearance of recurrent hernia in patients undergoing re-operation. Recurrent hernia was identified in 94 (6.4%) of 1,474 patients having undergone initial hernia repair at our institution. Recurrence appeared within two years in 40 patients (42%). Recurrences were noted beyond five years in 32 patients (34%), and after 20 years in 18 patients (19%). 75% of recurrences had occurred within 15 years. We conclude that almost two-thirds of recurrences occur later than five years after the initial intervention and a quarter occur at an interval of more than fifteen years. Most studies underestimate hernia recurrence due to an insufficient period of post-operative observation.

Prognosis of stage II colon cancer by non-neoplastic mucosa gene expression profiling.

We have assessed the possibility to build a prognosis predictor (PP), based on non-neoplastic mucosa microarray gene expression measures, for stage II colon cancer patients. Non-neoplastic colonic mucosa mRNA samples from 24 patients (10 with a metachronous metastasis, 14 with no recurrence) were profiled using the Affymetrix HGU133A GeneChip. Patients were repeatedly and randomly divided into 1000 training sets (TSs) of size 16 and validation sets (VS) of size 8. For each TS/VS split, a 70-gene PP, identified on the TS by selecting the 70 most differentially expressed genes and applying diagonal linear discriminant analysis, was used to predict the prognoses of VS patients. Mean prognosis prediction performances of the 70-gene PP were 81.8% for accuracy, 73.0% for sensitivity and 87.1% for specificity. Informative genes suggested branching signal-transduction pathways with possible extensive networks between individual pathways. They also included genes coding for proteins involved in immune surveillance. In conclusion, our study suggests that one can build an accurate PP for stage II colon cancer patients, based on non-neoplastic mucosa microarray gene expression measures.

[Self-expandable metallic stent for palliative treatment of colorectal malignant obstructions: risk of perforation]. / Prothèse métallique expansive dans le traitement palliatif des occlusions colorectales malignes : risque de perforation.

OBJECTIVE: The self-expandable metallic stents are a good alternative to surgery for the palliative treatment of malignant colonic obstructions. The aim of this paper was to emphasize the causes which could increase the risk of perforation. PATIENTS AND METHODS: From November 2000 to November 2001, 6 patients with malignant colonic obstruction, to whom surgery was denied due to tumor extension and/or poor general condition, have had a palliative treatment (N = 5) or an attempt (N = 1) with self-expandable metallic stents placed by endoscopy. RESULTS: Only one patient did not developed any complication and died 5 months later of cancer. Five out of the 6 patients (83%) developed a colonic perforation following stenting (N = 4) or the attempt to place the stent (N = 1), two into the first 24 h after the procedure, and three 3, 5, and 10 months later. Subsequent colostomy was done in 2 patients while the 3 others have had an external drainage of the perforation and died postoperatively. CONCLUSION: The self-expandable metallic stents seems to be a less aggressive alternative therapy to surgery for malignant colonic obstructions. Nevertheless, the high rate of colonic perforations, suggests reconsidering the indications in the definitive palliation of malignant colonic obstructions.

[Surgical treatment of gastroesophageal reflux disease in adults]. / Le traitement chirurgical du reflux gastro-oesophagien chez l'adulte.

Pathological gastroesophageal reflux is common. The aim of this review was to compare the results of different surgical techniques. Papers were selected on Medline from 1990 to April 2001. A critical analysis was performed, concerning definitions of included patients, surgical techniques, and criteria of evaluation. For comparison, the results of 23 randomized studies were mainly selected. Their heterogeneity has not allowed a meta-analysis. A few techniques had poorer results than others: simple closure of His angle, Hill operation, Belsey Mark IV technique, and Angelchik prosthesis. In most studies, results of partial fundoplication on reflux were as good as those of total Nissen fundoplication and fewer patients had postoperative dysphagia. In a double blind trial, immediate advantages of laparoscopic approach were less important than those observed in non comparative studies. Another trial was interrupted after inclusion of 103 patients because of the higher rate of side-effects in the laparoscopic group. These results may help the surgeon in the choice of a technique. Patients have to be informed of potential adverse effects of the different techniques chosen by their surgeon.

Randomized trial of 5-fluorouracil, leucovorin and cisplatin in advanced pancreatic cancer.

BACKGROUND/AIMS: Phase II trials of combined 5 fluorouracil, leucovorin and cisplatin have demonstrated an 18-28% response rate in advanced pancreatic carcinomas. We investigated the effect of this chemotherapy regime on patients' survival. METHODOLOGY: Patients included gave informed consent. They had an advanced and proven pancreatic adenocarcinoma. The trial was multicentric, prospective and randomized. It compared a 5-day course of leucovorin (200 mg/m2/day), 5-fluorouracil (375 mg/m2/day) and cisplatin (15 mg/m2/day) repeated every 21 days (23 patients) with a control group (22 patients). The main end points were survival time (Kaplan-Meier and log-rank methods) a[not readable: see text]side effects of chemotherapy. RESULTS: Association of leucovorin, 5-fluorouracil and cisplatin failed to demonstrate any advantage of this regimen compared with supported care alone. Median survival times were 8.6 months (SD +/- 1.8) and 7.0 months (SD +/- 0.6), respectively. The modulation of 5-fluorouracil by leucovorin and cisplatin was well tolerated with moderate toxic effects. CONCLUSIONS: This multicentric trial failed to demonstrate any advantage of the evaluated chemotherapy regime in the palliative treatment of cancer of the exocrine pancreas. Other trials including gemcitabine and/or radiotherapy are needed in advanced pancreatic adenocarcinoma.

[Direct and reservoir colonic-anal anastomoses. Short and long term results]. / Anastomoses colo-anales directes et avec réservoir. Résultats à court et à long-terme.

STUDY AIM: This retrospective study was designed to assess the operative, oncologic and functional results of total proctectomy with coloanal anastomosis (CAA). PATIENTS AND METHOD: Between 1990 and 1994, 81 patients (44 males/37 females: mean age: 59 years) were operated for a cancer (n = 67) or a benign lesion (n = 14) of the rectum. Sixty-four patients had a straight CAA and 17 patients had a colonic J-pouch. RESULTS: There was no operative mortality. Two patients were reoperated for colonic necrosis and underwent abdominoperineal resection. An anastomotic leak was observed in 11 patients and its severity was decreased by a diverting stoma. An anastomotic stricture was observed in 10 patients. Of the 67 patients with cancer, 19 (28%) developed metastases and 11 (16%) developed local recurrence. The 5-year survival rate was 69%. Twelve months after the operation, continence was similar with the two types of CAA, but the mean daily stool frequency was lower in patients with a reservoir. With a long follow-up (mean = 9 years), functional results were good with regard to continence and stool frequency, almost similar with the two types of CAA; functional disorders (noctumal stools, fragmentation, urgency) were reported by 25 to 40% of patients. CONCLUSION: Total proctectomy with coloanal anastomosis yields good oncologic results. With regard to functional results, the superiority of the colonic J-pouch, which is observed in the first postoperative year, was lost beyond this period; long-term results are good for continence and stool frequency, but some disorders persist in a significant proportion of patients.

Local recurrence of cancer of the rectum.

BACKGROUND: [corrected] Although radiotherapy or total mesorectal excision decreases the risk of local recurrence of rectal cancer, this risk remains around 10%. METHODS: Of 80 patients having a local recurrence, 38 (48%) underwent a re-resection combined in 10 cases with resection of mestastases. RESULTS: The incidence of asymptomatic detected recurrence was higher after anterior resection (39%) than after abdominoperineal resection (18%). Re-resection was performed more often (P <0.01) in the past 2 decades after anterior or Hartman first procedure than after abdominoperineal resection (67% versus 21%), and more often in asymptomatic patients than in symptomatic patients (71% versus 38%). The actuarial 5-year survival rate after re-resection was 20%. CONCLUSIONS: Early detection of local recurrence, with PET scan using (18)F-fluorodeoxyglucose (8 cases in the present series), leads to an improved re-resection rate. In patients who did not undergo radiotherapy (all patients but 1) re-resection can be achieved safely (no postoperative mortality). The place for radiation in the treatment of rectal cancer has to be revaluated and compared with total mesorectal excision and results of re-resection for local recurrence.

Irradiation therapy for gallbladder carcinoma: recent advances.

PURPOSE: Gallbladder carcinomas were usually considered to be radioresistant. So far, the role of radiotherapy has not been adequately evaluated. The aim of this report is to assess the value of radiotherapy in carcinoma of the gallbladder. METHODS: We reviewed publications concerning the role of radiation therapy in gallbladder carcinoma from 1974 to 2000. External radiation therapy, intraoperative radiation therapy, and brachytherapy were evaluated in two different groups: one group of patients underwent surgery, with apparently complete resection of the tumor; and another group underwent palliative treatment. RESULTS: Local control of the tumor and reduction of tumor size were reported in several publications. Collected data suggested a slight improvement in survival after adjuvant or palliative radiotherapy. The best benefit was obtained in tumors resected with only microscopic residual tissue. If possible an intraoperative "boost" (15 Gy) is recommended on the gross lesion, residual lesion, or tumor bed. Additional postoperative external radiotherapy (45-50 Gy) must be delivered. CONCLUSION: Radiotherapy appears to be a safe procedure that slightly improves the survival time of patients treated for gallbladder carcinoma. Further trials are needed to assess the role of combined radiotherapy and chemotherapy.