[Male neurogenic stress urinary incontinence treated by artificial urinary sphincter AMS 800™ (Boston Scientific, Boston, USA): Very long-term results (>25 years)]. / Traitement de l'incontinence urinaire masculine neurologique par le sphincter urinaire artificiel AMS 800™ (Boston Scientific, Boston, États-Unis) : résultats à très long terme (>25 ans).

OBJECTIVE: The aim of the study was to report the very long-term functional outcomes of artificial urinary sphincter (AUS) in male neurological patients. MATERIAL AND METHODS: Male neurological patients diagnosed with stress urinary incontinence due to sphincter deficiency and undergoing AUS (AMS 800®) implantation between 1985 and 1992 were enrolled. Continence, defined by no pad/condom usage, explantation and revision rates were reported. RESULTS: Fourteen patients with a median age of 27.3 years (IQR: 27.3-40.8) were included: four had a spinal cord injury and ten a spina bifida. Prior continence surgery was reported by 6 patients (42.9 %). Artificial urinary sphincter was implanted in a peribulbar (n=4) or periprostatic position (n=10). Median follow-up was 18.3 years (IQR: 10.1-20.3). At last follow-up, all patients were alive. Three native devices were still in place, eight were revised (four of them were secondarily explanted) and three were explanted due to erosion or infection. The 5-, 10-, 15-, 20-year explantation-free survival rates were respectively 85.7, 62.3, 52.0, 39.0 %. The 5-, 10-, 15-, 20-year revision-free survival rates were respectively 78.6, 42.9, 28.6, 7.1 %. At last follow-up, 50 % patients were continent. CONCLUSION: In the very long run, AUS provided a 50 % continence rate in male neurological patients but the revision rates were important. LEVEL OF EVIDENCE: 4.

Patterning of perovskite-polymer films by wrinkling instabilities.

Organic-inorganic perovskites are semiconductors used for applications in optoelectronics and photovoltaics. Micron and submicron perovskite patterns have been explored in semitransparent photovoltaic and lasing applications. In this work, we show that a polymeric medium can be used to create a patterned perovskite, by using a novel and inexpensive approach.

[Placement of tension-free vaginal tape in women with stress urinary incontinence: Long-term functional outcomes in a prospective series]. / Résultats fonctionnels à long terme de la bandelette sous-urétrale rétropubienne TVT (tension-free vaginal tape) pour le traitement de l'incontinence urinaire d'effort féminine : étude monocentrique prospective.

PURPOSE: To evaluate the long-term functional outcomes after retropubic tension-free vaginal tape (TVT) placement to treat female stress urinary incontinence (SUI). METHODS: From September 1998 to September 2000, we prospectively enrolled all consecutive women in our center suffering SUI caused by urethral hypermobility. All women had a retropubic TVT inserted by the same surgeon. Patients were evaluated at 1, 3, 6 and 12 months postoperatively, and annually thereafter. Postoperative assessment included a measurement of post-voiding residual volume, urinalysis, a 1-hour pad test, a urinary symptom questionnaire, and an assessment of quality-of-life. Objective continence (defined as no urine leakage at clinical examination) and subjective continence (defined as no urine leakage, whatever the mechanism, reported by the patient) were reported. RESULTS: Overall, 58 consecutive women (median age 59; IQR 49-67; min 21-max 78) were evaluated. Median follow-up was 10.2years (IQR 1.4-16.0; min 1-max 13.2). At the last follow-up, objective and subjective continence rates were 93% and 78%, respectively and remained stable in the long run. Pad tests, urinary symptom questionnaire scores and quality-of-life were significantly improved. Self-intermittent catheterisation was required by three women. A section of one TVT and removal of another tape was undertaken in two women with chronic pelvic pain. One patient had a chronic urinary infection. Rate of de novo urgency was 10%. CONCLUSIONS: TVT implantation offered good and stable functional long-term outcomes. This procedure enhanced quality-of-life and had low morbidity. LEVEL OF EVIDENCE: 3.

Spontaneous assembly of carbon-based chains in polymer matrixes through surface charge templates.

Stable chains of carbon-based nanoparticles were formed directly in polymer matrixes through an electrode-free approach. Spontaneous surface charges were generated pyroelectrically onto functionalized ferroelectric crystals, enabling the formation of electric field gradients that triggered the dipole-dipole interactions responsible for the alignment of the particles, while embedded in the polymer solution. The phenomenon is similar to the dielectrophoretic alignment of carbon nanotubes reported in the literature. However, here the electric fields are generated spontaneously by a simple heat treatment that, simultaneously, aligns the particles and provides the energy necessary for curing the host polymer. The result is a polymer sheet reinforced with well-aligned chains of carbon-based particles, avoiding the invasive implementation of appropriate electrodes and circuits. Because polymers with anisotropic features are of great interest for enhancing the thermal and/or the electrical conductivity, the electrode-free nature of this technique would improve the scaling down and the versatility of those interconnections that find applications in many fields, such as electronics, sensors, and biomedicine. Theoretical simulations of the interactions between the particles and the charge templates were implemented and appear in good agreement with the experimental results. The chain formation was characterized by controlling different parameters, including surface charge configuration, particle concentration, and polymer viscosity, thus demonstrating the reliability of the technique. Moreover, micro-Raman spectroscopy and scanning electron microscopy were used for a thorough inspection of the assembled chains.

Recovery of body composition improves long-term outcomes after lung volume reduction surgery for emphysema.

Nutritional status deteriorates along with progression of emphysema, with the decline of body composition correlating with risk of disease-related events. Lung volume reduction surgery (LVRS), by improving respiratory function and recovering body composition, may influence long-term disease-related morbidity and mortality when compared to respiratory rehabilitation (RR). In this non-randomised study, 44 male patients with moderate-to-severe emphysema underwent LVRS, while 35 received RR. Respiratory parameters, body composition, number and time-to-occurrence of disease-related events were evaluated for 5 yrs. After LVRS, respiratory and nutritional parameters had significantly greater and longer lasting improvements than after RR. Disease-related events occurred later and less frequently after surgery than after rehabilitation, with better morbidity and mortality survival curves (p<0.01 and p<0.03, respectively). Body mass index (BMI) > or =23kg x m(-2), BODE (BMI, airflow obstruction, dyspnoea, exercise capacity) index < or =2 and fat-free mass index (FFMI) > or =16kg x m(-2) at 1 yr were the best positive predictors of post-operative outcomes (p<0.03, p<0.04 and p<0.005, respectively). Reduction in residual volume at 36 months after surgery was significantly correlated with the increase of BMI (rho = -0.56, p = 0.009) and FFMI (rho = -0.64, p = 0.001). LVRS significantly and durably improved respiratory function and body composition over RR. Relationships among residual volume, BMI, FFMI and disease-related events suggest that recovery in respiratory dynamics improves nutritional status, thus significantly reducing long-term disease-related morbidity and mortality.

Chitosan composite microparticles: A promising gastroadhesive system for taxifolin.

Taxifolin possesses gastroprotective property but is characterized by low water solubility, is instabile in alkaline medium, and is degraded by the intestinal bacteria flora. The purpose of the work was therefore to produce a gastroadhesive formulation to prolong taxifolin residence time and release in the stomach. We first demonstrated that taxifolin is stable in simulated gastric fluid with or without pepsin and mucus, and is able to cross pig gastric mucus layer and stomach mucosa. Next, gastromucoadhesive microparticles composed of Syloid® AL-1 mesoporous silica, chitosan and HPMC were produced using spray-drying. Microparticles were characterized by a spherical shape and a mean volume-equivalent diameter around 12 µm. The optimized microparticles were able to release taxifolin and to adhere to pig stomach mucosa for 5 h.

Transthoracic repair of Morgagni's hernia: a 20-year experience from open to video-assisted approach.

BACKGROUND: Foramen of Morgagni's hernia is an uncommon congenital diaphragmatic hernia. Repair is mostly performed through laparotomy. We prefer the transthoracic approach, which allows better and safer control during thoracic dissection, although it is considered more painful and related to greater morbidity. In recent years we introduced the transxiphoid hand-assisted videothoracoscopic approach, which combines the advantages of the thoracic route with a mini-invasive procedure facilitated by one hand inside the chest. METHODS: A retrospective review was performed over a 20-year period (1985-2005). Twenty-two patients who had a foramen of Morgagni's hernia repaired were identified and relevant data were collected. Average age was 57 +/- 10 years and one half of the patients were asymptomatic. Chest roentgenograms, chest computerized tomography, and barium enema were used as diagnostic utilities. Posterolateral thoracotomy was performed in 17 (15 right-sided) patients, whereas in 5 (all right-sided) the defect was repaired by transxiphoid hand-assisted videothoracoscopy. Operative time, pain scored by visual analog scale, hospital stay, and cosmetic results by acceptance score were reviewed for every patient. RESULTS: Hernial sac was present in all cases and contained only omentum (n = 13), omentum plus transverse colon (n = 7), omentum plus transverse colon and small bowel (n = 2). In 6 patients (2 videothoracoscopy) we repaired the large defects with polypropylene mesh. Videothoracoscopy achieved significant good results compared to thoracotomy in operative time (85 +/- 7.9 versus 110 +/- 11.3 min, p < 0.01), 24-h visual analog scale (3.5 +/- 1.1 versus 6.7 +/- 3.9, p < 0.01), hospital stay (2.6 +/- 0.5 versus 6.4 +/- 1.2 days, p < 0.01), and acceptance score (4.3 +/- 0.5 versus 3.1 +/- 0.8, p < 0.05). Postoperative course was always uneventful. Patients were followed for an average period of 58.6 +/- 14.7 and 109.7 +/- 43.5 months, respectively: no recurrences were found in any group. CONCLUSIONS: We believe that the transthoracic approach is a safe and effective method for repairing Morgagni's hernia. The videothoracoscopic approach is a promising alternative and it may be facilitated by introducing a hand inside the chest.

Improvement of dissolution rate of piroxicam by inclusion into MCM-41 mesoporous silicate.

The aim of the present paper was the use of mesoporous silicate MCM-41 to increase the dissolution rate of piroxicam, a non-steroidal anti-inflammatory drug-class II of the Biopharmaceutic Classification System. The inclusion/adsorption compound of piroxicam in MCM-41 was obtained with a drug loading of about 14%. X-ray powder diffraction and differential scanning calorimetry (DSC) revealed the presence of piroxicam not arranged in crystalline form and FT-IR spectroscopy showed the presence of light interactions (hydrogen bonds) between the silicate silanols and the drug. The decrease of Brunauer, Emmett and Teller (B.E.T.) specific surface area and pore volume between free MCM-41 and the inclusion/adsorption compound was a prove of the presence of piroxicam inside the mesopores. The inclusion compound was submitted to in vitro dissolution tests and a remarkable dissolution rate improvement was observed in comparison to the crystalline drug in all tested conditions. The dissolution profile at pH 1.2 was comparable to that of the marketed product Brexin, a formulation with rapid analgesic effect onset. The improvement of dissolution rate is due to both the lack of drug in the crystalline form and to the extremely large surface area of the siliceous support. Physical stability tests of the free drug and the inclusion/adsorption complex were conducted as well over one month storage at 40 degrees C at different relative humidity.

Transmission of metallo-ß-lactamase-producing Pseudomonas aeruginosa in a nephrology-transplant intensive care unit with potential link to the environment.

Pseudomonas aeruginosa has been recovered in hospitals from many different sources including sinks and taps. Because P. aeruginosa is one of the main agents of nosocomial infections and increasingly resistant to antibiotics, environmental reservoirs in hospital settings are of great concern. We report here on a cluster of five cases of infection by P. aeruginosa expressing VIM carbapenemases (VIM-PA) in a nephrology intensive care unit. Our investigation pointed to transmission of VIM-PA via hands related to a contaminated tap. VIM-PA may be cross-transmitted to other patients if an environmental reservoir exists. Sinks and taps should be well designed and thoroughly cleaned and disinfected, and use of alcohol hand rub should be promoted.

Intercalation of the radical scavenger ferulic acid in hydrotalcite-like anionic clays.

Hydrotalcite is a biocompatible lamellar anionic clay formed by double hydroxide layers with a metal cation coordinating four OH groups. The different layers are held together by anionic hosts that can be replaced by a simple ion-exchange process. The synthetic Mg-Al-hydrotalcite was used to intercalate ferulic acid, a compound that shows antioxidant properties due to its free radical scavenger capacity. Analysis of the intercalated compound showed a good intercalation percentage (35.53%) accompanied by an increase of the interlayer space from 7.8A (chloride form) to 17.1A due to the presence of the ferulate. The intercalation product was stable in water, did not show any significant degradation after UV-irradiation, had a higher capacity of UV absorption in comparison to both the pure ferulic acid and ferulic acid-hydrotalcite chloride physical mixture. The intercalated compound was formulated in a siliconic cream and the ferulate in vitro release profiles determined.

Care-related pain in hospitalized patients: severity and patient perception of management.

BACKGROUND: Hospitalized patients commonly undergo painful procedures, but little is known about care-related pain (CRP) in the overall population of inpatients. We conducted a cross-sectional 1-day survey to assess the prevalence and characteristics of CRP and its management in all units of a university hospital in Paris and determined the factors linked to severe CRP. METHODS: All patients who were able to communicate and were hospitalized for at least 24 h but not in a day-care or neonatal unit were included. RESULTS: From 938 patients who completed the questionnaire, 554 patients reported pain within the previous 24 h, for a 59% prevalence of pain, and 540 (58%) had experienced CRP in the previous 15 days (51% males; mean [SD] age 54 [18] years). Of 907 procedures, 330 (37%) resulted in severe pain. The most-often reported painful procedures were vascular punctures and patient mobilization. Severe CRP was associated with long hospitalization; non-vascular invasive punctures, catheterization, mobilization or radiological examination; or pain during the previous 24 h due to surgery or treatment. Only half of the patients declared that they had received information regarding the painful procedure. Treatment for pain was proposed and delivered in less than one quarter of cases. CONCLUSIONS: Our results of a survey of pain management in hospitalized patients relate to a wide variety of medical conditions and procedures. Health-care workers should be more systematic in managing CRP, and attention should be paid to patients at greatest risk of severe CRP.

Effect of cellulose structure and morphology on the properties of poly(butylene succinate-co-butylene adipate) biocomposites.

Composites based on poly(butylene succinate-co-butylene adipate) (PBSA) containing amorphized and crystalline cellulose reinforcements have been prepared and characterized. In order to improve the polymer/filler interfacial adhesion, an efficient compatibilizing agent has been synthesized by chemical modification of PBSA and characterized by FT-IR, FT-NIR and (1)H NMR spectroscopy. Uncompatibilized and compatibilized composites have been tested through morphological, mechanical, calorimetric and thermogravimetric analysis. Moreover, water vapor permeability and biodegradation kinetics of composites have been investigated. The addition to PBSA of cellulose fillers differing from each other by crystallinity degree and morphology, and the use of a compatibilizing agent have allowed modulating tensile and thermal properties, water vapor transmission rate and biodegradation kinetic of the composites.

Studies on the antibacterial and antifungal properties of 1, 4-naphthoquinones.

1. New halogenated 1,4-naphthoquinones were synthesized and together with other known 1,4-naphthoquinones, were screened for antibacterial activity by a turbidimetric method, and for antifungal activity by the diffusion method on agar plates.2. The half-wave potentials and the influence on the oxidative phosphorylation of some of these compounds were determined.3. 2-chloro-3,2'-chloro-ethyl-1,4-naphthoquinone (half-wave potential=-187 mV) was the most active compound, completely inhibiting cell respiration.4. While the natural active naphthoquinones, vitamin K and ubiquinones, possess, as substituent, the electron repelling methyl group, the microbiologically active 1,4-naphthoquinones are substituted, in the quinone moiety, with electron attracting groups such as OH or Cl.5. The half-wave potentials can give only an initial indication of the activity of the compounds studied; a good correlation, on the contrary, can be found between the ultraviolet spectra of such compounds and their activity which seems to depend on the ability of active compounds to exist in an extensively conjugated structure and to form hydrogen bonds.

The diaphragmatic flap: A multiuse material in thoracic surgery.

BACKGROUND: The use of diaphragmatic pedicle flaps for reconstructive procedures in thoracic surgery is not very popular. Nevertheless, it provides considerable advantages. METHODS: Our experience covers 10 years (1987-1997) with a total of 25 patients in whom the diaphragmatic flap was used for different purposes. In 6 patients we used the diaphragmatic flap to protect the bronchopleural fistula at its early onset, which was not beyond 12 hours from the clinical diagnosis. We performed prophylactic suture protection after neoadjuvant therapy in 9 high-risk patients who underwent pneumonectomy and in 2 who underwent sleeve lobectomy. Postpneumonectomy pericardial defect repair was performed in 4 patients. In another 4 patients the diaphragmatic flap was used after spontaneous (n = 2) and iatrogenic (n = 2) lesions of the esophagus after 24 to 72 hours. RESULTS: No perioperative mortality was recorded. Complications were mainly related to the severe preoperative conditions of the patients: arrhythmia, respiratory insufficiency, and empyema. We report only 2 cases of minimal persistent bleeding from the chest tube, which spontaneously ceased. For those patients who survived for more than 1 year (n = 11), no diaphragmatic hernias were recorded. Bronchopleural fistulas and pericardial defects healed in all instances. The diaphragmatic flap was also effective in bronchopleural fistula. A late fistula caused by cancer relapse at the bronchial stump developed in only one patient. Excellent repair was achieved in all patients with esophageal lesions. CONCLUSIONS: We conclude that the diaphragmatic flap can be considered a practical, safe, and redundant material particularly indicated for defect or fistula closure and for suture line protection in the thoracic cavity.

The value of the Nd:YAG laser for the surgery of lung metastases in a randomized trial.

OBJECTIVE: A prospective randomized trial was established in our department to compare the usefulness of the neodymium:yttrium-aluminum-garnet (Nd:YAG) laser in resection of lung metastases. We report the results of the first 45 patients after a minimum of 2 years of follow-up. DESIGN: Randomized prospective trial from March 1987 to March 1995. SETTING: University teaching hospital. PATIENTS: Forty-five patients underwent resection for pulmonary metastases with two different techniques chosen at random: 23 patients were treated with an Nd:YAG laser (group A) and 22 patients with a traditional diathermic device (group B). INTERVENTIONS: A total of 71 pulmonary lesions were resected by minimal excision, 41 by laser and 30 by diathermy. Sixty-three lesions were diagnosed as active metastases from various sites. RESULTS: No deaths occurred during surgery. Eight patients (6 in group B) developed minor complications. In two patients from group B, lesions recurred at the resection site. The use of Nd:YAG laser was not associated with a significantly longer survival (log rank test, p=0.49). Laser resection allowed more tissue sparing (mean ratio lesion diameter/volume resected, 0.94 vs 1.11, p<0.008). Univariate and multivariate analyses revealed the importance of laser use in reducing the number of days of postoperative air leakage (3.91 vs 5.00 days) and hospital stay (7.50 vs 9.90 days). CONCLUSIONS: Laser use significantly reduced tissue loss, postoperative air leakage, and hospital stay. Influence on long-term survival was not statistically proven.

En bloc minimal laser resection for T3-chest wall lung cancer in patients with poor pulmonary function.

OBJECTIVE: To analyze the value of en bloc minimal laser resection in patients with marginal function with non-small cell lung cancer invading the chest wall. DESIGN: Retrospective study from March 1987 to December 1993. SETTING: University teaching hospital. PATIENTS: Study group consists of 10 patients with impaired pulmonary function (FEV1 < or = 1.3 L and forced expiratory flow between 25% and 75% < or = 0.8 L/s) operated on for lung cancer invading the chest wall. There were 7 men and 3 women; ages ranged between 51 and 77 years (mean, 66.2 years). None of the patients had tumors greater than 3 cm or involving the first 2 ribs as well as clinical N2 or T4 disease. INTERVENTIONS: All patients underwent en bloc chest wall combined with minimal resection. Parenchyma dissection was accomplished by Nd:YAG laser encompassing the lesion at distance of 2.0 cm. The median number of ribs resected was 1.6 and no patients required chest wall reconstruction. Local postoperative radiation therapy beginning within 1 month after resection was always performed. RESULTS: Tumor resection was considered complete in every case. Four patients had adenocarcinoma, three had squamous cell carcinoma, and three had large cell carcinoma. Currently, 7 patients had NO, 2 had N1, and 1 had N2 disease. There was no perioperative mortality. Postoperative complications were prolonged air leak (n = 2) and atelectasis (n = 1). At the present moment, 6 patients are alive, 5 of whom are free from tumor, 2 with a follow-up longer than 5 years. Three patients died: 2 from disseminated disease, after 47 months and 32 months, respectively, and the third at 27 months from another cause. One patient was unavailable for follow-up. Only 1 patient had a local recurrence, 15 months later, and he underwent a new, successful, limited resection. CONCLUSIONS: These findings suggest that en bloc minimal laser resection can offer an acceptable risk/benefit ratio in the case of patients who cannot tolerate a lobectomy.

Prognostic impact of VEGF, CD31, CD34, and CD105 expression and tumour vessel invasion after radical surgery for IB-IIA non-small cell lung cancer.

AIMS: To evaluate the prognostic impact of tumour angiogenesis assessed by vascular endothelial growth factor (VEGF), microvessel density (MVD), and tumour vessel invasion in patients who had undergone radical resection for stage IB-IIA non-small cell lung cancer (NSCLC). METHODS: Fifty one patients (42 men, nine women; mean age, 62.3 years; SD, 6.9) undergoing complete surgical resection (35 lobectomy, 16 pneumonectomy) of pathological stage IB (n = 43) and IIA (n = 8) NSCLC were evaluated retrospectively. No patient underwent postoperative chemotherapy or neoadjuvant treatment. Tumour specimens were stained for VEGF and specific MVD markers: CD31, CD34, and CD105. RESULTS: VEGF expression significantly correlated with high CD105 expression (p < 0.0001) and tumour vessel invasion (p = 0.04). Univariate analysis showed that those patients with VEGF overexpression (p = 0.0029), high MVD by CD34 (p = 0.0081), high MVD by CD105 (p = 0.0261), and tumour vessel invasion (p = 0.0245) have a shorter overall survival. Furthermore, multivariate Cox regression analysis showed that MVD by CD34 (p = 0.007), tumour vessel invasion (p = 0.024), and VEGF expression (p = 0.042) were significant predictive factors for overall survival. Finally, the presence of both risk factors, tumour vessel invasion and MVD by CD34, was highly predictive of poor outcome (odds ratio, 3.4; 95% confidence interval, 1.7 to 6.5; p = 0.0002). CONCLUSIONS: High MVD by CD34 and tumour vessel invasion are more closely related to poor survival than the other neoangiogenetic factors in stage IB-IIA NSCLC. This may be because these factors are more closely related to the metastatic process.

Analysis of cell cycle regulator proteins in non-small cell lung cancer.

BACKGROUND/AIMS: Abnormalities of the proteins involved in cell cycle checkpoints are extremely common among almost all neoplasms. This study aimed to investigate the expression of four components of the cell cycle machinery-p21, p16, p53, and proliferating cell nuclear antigen (PCNA)-in non-small cell lung cancer (NSCLC). METHODS: The expression of p21, p16, p53, and PCNA was examined in 68 well characterised NSCLC specimens using immunohistochemistry. The coregulation of these proteins and their influence on survival were analysed using both univariate and multivariate analyses. RESULTS: By univariate analysis, the expression of all the proteins examined, except for PCNA, was significantly correlated with survival. In multivariate analysis, the only immunohistochemical parameter able to influence overall survival was p16, confirming the hypothesis that the RB-p16 tumour suppressor pathway is inactivated in most lung cancer samples. Finally, the group of patients with NSCLC who were negative for both p21 and p16 had a significantly shorter overall survival. CONCLUSIONS: These results suggest that loss of control of cell cycle checkpoints is a common occurrence in lung cancers, and support the idea that functional cooperation between different cell cycle inhibitor proteins constitutes another level of regulation in cell growth control and tumour suppression.

Transxiphoid bilateral palpation in video-assisted thoracoscopic lung metastasectomy.

OBJECTIVE: To evaluate indications, limits, and merits of transxiphoid bilateral palpation during video-assisted thoracoscopy (VAT) lung metastasectomy. DESIGN: Survey retrospective study with a minimum follow-up of 1 year. SETTING: University hospital. PATIENTS: From December 1995 to September 1999, 29 of 45 patients operated on for pulmonary metastasectomy were approached through a transxiphoid VAT. Primary sites were colon-rectum (n = 13), kidney (n = 4), limb osteosarcoma (n = 3), uterus (n = 2), larynx (n = 2), breast (n = 1), skin melanoma (n = 1), prostate gland (n = 1), back fibrosarcoma (n = 1), and ovary (n = 1). Bilateral palpation was performed in 23 patients, although only 10 had radiological evidence of bilateral disease. RESULTS: No perioperative or 30-days postoperative mortality was recorded. Acute and chronic pain was similar to that of other VATs and significantly less than sternotomy. Mean +/- SD chest-drain time and hospital stay were 2.8 +/- 1.19 days and 4.3 +/- 1.78 days, respectively. Sixty-nine lesions, 60 of them metastatic, were resected by laser (n = 29) or stapler (n = 40). Bilateral exploration permitted the discovery of 15 radiologically undetected lesions, 11 of which were found to be malignant. Contralateral metastases were found in 5 patients predicted to have unilateral disease. Mean +/- SD follow-up was 22.89 +/- 10.87 months (range, 9-60 months). Six patients developed new pulmonary metastases after a mean interval of 13.6 months; 3 of these patients relapsed in the unexplored hemithorax after 6, 9, and 12 months, respectively. CONCLUSIONS: The use of the transxiphoid VAT approach was safe, applicable in many instances, and effective in detecting occult metastases by manual bilateral palpation. The advantages of a VAT procedure can be coupled with those provided by a radical operation.