Surgical Opinion Research Articles

FSSA statement on individual surgeons’ outcomes data

The Federation of Surgical Specialty Associations (FSSA) comprises the presidents of all the surgical specialties recognised by the General Medical Council. Together with the presidents of the four royal colleges, the FSSA constitutes the Surgical Forum of GB and Ireland. The FSSA is therefore representative of surgical opinion in the UK and Ireland, irrespective of specialty, College affiliation or place of work. As the corporate body of the Surgical Specialty Associations, the primary aim of the FSSA is to represent and coordinate the views, aims and policies of surgeons from across the UK and Ireland. The FSSA is committed to advancing, promoting and protecting the highest standards in the practice of surgery in the best interests of patients. The FSSA supports the publication of surgical outcomes. This transparency informs patients and provides assurance that care is safe. Importantly, it also allows surgeons to benchmark their outcomes against their peers and this leads to improvement in the quality of patient care. However, the FSSA has misgivings about the publication of individual surgeons’ crude outcomes data.

Autogenous Capsular Interpositional Arthroplasty Surgery for Painful Hallux Rigidus: Assessing Changes in Range of Motion and Postoperative Foot Health

The autogenous capsular interpositional arthroplasty procedure can be a motion-sparing alternative to arthrodesis for the treatment of recalcitrant hallux rigidus deformity. Previous studies have reported positive results; however, many had small samples or lacked comparable preoperative measures. The present study used a prospective cohort study to assess the benefit of this technique for increasing range of motion, and comparative data to assess the reduction of pain and improvements in perceived foot health status for a consecutively drawn sample of patients. Thirty-four patients (44 feet) reviewed using a long-arm goniometer at a mean of 3.75 years after surgery experienced a significant increase in dorsiflexion (preoperative mean 11.09° ± 10.13°; postoperative mean 26.64° ± 10.07°; p < .001); plantar flexion remained unchanged. Additionally, 15 of 17 patients for whom the hallux abductus angle was initially greater than the normal range was within the normal range postoperatively. The postoperative patient perceptions of foot pain were significantly better than those from a comparable sample of patients presenting for a surgical opinion (t[69] = 6.80), just as were the perceptions of foot function, foot health, and footwear comfort (p < .001 for all). The postoperative perceptions of foot pain were comparable with the postoperative results from a range of previously published studies. These results have shown, with improvements in range of motion and reduction in pain, that autogenous capsular interpositional arthroplasty is a useful, motion-sparing technique in the treatment of painful hallux rigidus and should be considered for classification as a clinical practice guideline.

Characteristic Radiological findings in Preterm Infants with Missed Intestinal Perforation

BACKGROUND: Pneumoperitoneum on radiological imaging is typical in intestinal perforation in necrotizing enterocolitis [NEC]. However, it is not seen in all cases and intestinal perforation is missed on occasions. We present a series of preterm infants with characteristic x-ray findings that on exploration revealed missed intestinal perforation.METHODS: Retrospective review of neonates with intra-operative diagnosis of intestinal perforation which was missed on x-ray abdomen over a period of 6 months is being presented here.RESULTS: Three neonates born at 24 (24-30) weeks of gestation were identified. PDA was noted in all 3 patients and they required ventilator and inotropic support. Feeds were commenced at 5 (2-7) days of life. All three patients were treated for NEC. Surgical opinion was sought in view of localized gas shadow in a fixed position seen on repeated x-rays in all three patients. All three patients had laparotomy and small bowel resection with ileostomy formation at a mean age of 26 (24-46) days. Intra-operatively, small bowel perforation and adjacent pseudocysts filled with air and intestinal contents were noted in all 3 patients. Post-operatively full feeds were established in all patients.CONCLUSION: In premature infants with NEC, intestinal perforation can be missed on occasions. Our patients interestingly, developed characteristic abdominal x-ray findings that in our experience should prompt for surgical intervention.

Characteristic Radiological findings in Preterm Infants with Missed Intestinal Perforation.

Pneumoperitoneum on radiological imaging is typical in intestinal perforation in necrotizing enterocolitis [NEC]. However, it is not seen in all cases and intestinal perforation is missed on occasions. We present a series of preterm infants with characteristic x-ray findings that on exploration revealed missed intestinal perforation. Retrospective review of neonates with intra-operative diagnosis of intestinal perforation which was missed on x-ray abdomen over a period of 6 months is being presented here. Three neonates born at 24 (24-30) weeks of gestation were identified. PDA was noted in all 3 patients and they required ventilator and inotropic support. Feeds were commenced at 5 (2-7) days of life. All three patients were treated for NEC. Surgical opinion was sought in view of localized gas shadow in a fixed position seen on repeated x-rays in all three patients. All three patients had laparotomy and small bowel resection with ileostomy formation at a mean age of 26 (24-46) days. Intra-operatively, small bowel perforation and adjacent pseudocysts filled with air and intestinal contents were noted in all 3 patients. Post-operatively full feeds were established in all patients. In premature infants with NEC, intestinal perforation can be missed on occasions. Our patients interestingly, developed characteristic abdominal x-ray findings that in our experience should prompt for surgical intervention.

Breast pathology review: does it make a difference?

Breast pathology is a challenging field, and previous work has shown discrepancies in diagnoses, even among experts. We set out to determine whether mandatory pathology review changes the diagnosis or surgical management of breast disease. Cases were referred for pathology review after patients presented for surgical opinion to the Dubin Breast Center at Mount Sinai Medical Center over the course of 2years. Surgical pathologists with expertise in breast disease reviewed slides submitted from the primary institution and rendered a second opinion diagnosis. Comparison of these reports was performed for evaluation of major changes in diagnosis and definitive surgical management. A total of 306 patients with 430 biopsy specimens were reviewed. Change in diagnosis was documented in 72 (17%) of 430 cases and change in surgical management in 41 (10%). A change in diagnosis was more likely to occur in patients originally diagnosed with benign rather than malignant disease (31 vs. 7%, p<0.001). Twelve (7%) of 169 specimens initially diagnosed as benign were reclassified as malignant. A malignant diagnosis was changed to benign in 4 (2%) of 261 cases. Change in diagnosis was less common in specimens originating from commercial laboratories than community hospitals or university hospitals (8, 19, 21%, p=0.023). Change in management was not dependent on initial institution. Type of biopsy specimen (surgical or core) did not influence diagnostic or management changes. We recommend considering breast pathology review based on the individual clinical scenario, regardless of initial pathologic diagnosis or originating institution.

Invited Commentary

This paper by Nakanishi and coworkers [1Nakanishi R. Fujino Y. Yamashita T. Shinohara S. Oyama T. Thoracoscopic anatomic pulmonary resection for locally advanced non-small cell lung cancer.Ann Thorac Surg. 2014; 97: 980-986Google Scholar] represents the continuing evolution of thoracoscopic anatomic resection. There are several laudable aspects of the article. The first is a formal grading of the complications using the National Cancer Institute's common terminology criteria for adverse event reporting system. Such rigorous objective reporting should serve as a model for other clinical papers. The second is the low conversion rate of 2.6%. That depicts the expertise of the surgical team and their motivation to complete the resection thoracoscopically—both are required elements of maturing a team's thoracoscopic experience. The third is a reasonably low mortality and morbidity. A 2.6% mortality rate for this group of patients is very respectable. Of note, the researchers report a 1.3% incidence of pneumonia, a remarkably low rate. One wonders if this is a result of good patient selection or aggressive pulmonary rehabilitation. Indications of increasing experience include decreasing operating time and blood loss, and a decreasing pneumonectomy rate coupled with increasing bronchoplasty rate. The experience at our institution is quite similar to that of Nakanishi and colleagues [1Nakanishi R. Fujino Y. Yamashita T. Shinohara S. Oyama T. Thoracoscopic anatomic pulmonary resection for locally advanced non-small cell lung cancer.Ann Thorac Surg. 2014; 97: 980-986Google Scholar] in the feasibility of performing resections for locally advanced lung cancers. Although we have a higher incidence of conversion to open thoracotomy, a thoracoscopic approach is attempted for almost every patient. However, some differences do exist in our approach. The major difference is our increasing reliance on transcervical extended mediastinal lymphadenectomy for lymph node clearance. Also, unlike Nakanishi and colleagues [1Nakanishi R. Fujino Y. Yamashita T. Shinohara S. Oyama T. Thoracoscopic anatomic pulmonary resection for locally advanced non-small cell lung cancer.Ann Thorac Surg. 2014; 97: 980-986Google Scholar], we continue to use interrupted sutures for bronchial anastomoses. Another small difference in our experience is that we have never needed to break up a specimen in the bag to extract it. An important aspect of thoracoscopic resection of locally advanced lung cancer is the reliance of the surgeon on haptic sensation as well as visualization during dissection. With increasing adoption of robotic surgery, it remains to be seen if such resections can be safely performed in the absence of haptic feedback. Overall, this superb report highlights the ability of video-assisted thoracoscopic surgery to resect locally advanced lung cancer with acceptable oncologic results. Although a randomized controlled trial would be ideal to prove oncologic equivalence to open surgical resection, it is unlikely that it will ever be done. Therefore, retrospective evidence of the kind presented here will help shape surgical opinion. Thoracoscopic Anatomic Pulmonary Resection for Locally Advanced Non-Small Cell Lung CancerThe Annals of Thoracic SurgeryVol. 97Issue 3PreviewThe safety and feasibility of thoracoscopic lobectomy for locally advanced lung cancer remain controversial. Full-Text PDF

The effectiveness and cost of corticosteroid injection and physiotherapy in the treatment of frozen shoulder—a single-centre service evaluation

Frozen shoulder is a common condition resulting in pain, stiffness and functional impairment. Symptoms can persist for months or even years if left untreated. Various treatments are available, but a standard care package does not exist and the most cost-effective treatment has not been established. The objective of this study was to conduct a service evaluation of current practice to establish the effectiveness of corticosteroid injection and physiotherapy intervention and the costs associated. A review of all patients with a diagnosis of frozen shoulder who had received a corticosteroid injection and physiotherapy was undertaken for a 12-month period at a single NHS hospital in the UK. Patient-reported outcome measures were analysed and the costs for treatment calculated. Out of the 55 patients, 43 were happy to be discharged following treatment. Ten were referred for a surgical opinion and two were lost to follow-up. The median pain rating significantly reduced from 8 (interquartile range (IQR) 7, 9) to 2 (IQR 0, 3.75) (p < 0.001). Of the patients, 62% reported a greater than 60% improvement. On average, patients attended for an initial consultation and four follow-up sessions at a total cost to the NHS of £135. Based on this small service evaluation study, corticosteroid injection administered by an experienced physiotherapist with follow-up physiotherapy appears to be an effective treatment for frozen shoulder.

Musculocutaneous Nerve Entrapment after Biceps Long Head Tendon Rupture

Biceps long head tendon rupture is relatively common and requires approximately four weeks of splintage as a general treatment. Musculocutaneous nerve entrapment is commonly caused by excessive exercise or direct external force. Musculocutaneous nerve syndrome has barely been reported; however, association of biceps long head tendon rupture and musculocutaneous nerve entrapment syndrome has never been reported. The authors experienced a 70-year-old male patient, who suffered a traffic accident and was hospitalized due to shoulder joint pain caused by direct external force, delayed forearm lateral aspect hypoesthesia and elbow flexion weakness. For identification of the cause, magnetic resonance imaging, electromyography, and surgical opinion were synthesized, resulting in diagnosis of delayed musculocutaneous nerve entrapment syndrome occurring after biceps long head tendon rupture. With surgical treatment, pain, sense, and elbow flexion weakness were recovered, a showing successful treatment result.

Cystic Biliary Atresia : Why Is It Important to Distinguish This from Congenital Choledochal Cyst ?

We present a 2-month-old jaundiced infant with a rare type of biliary atresia who appeared to have a choledochal cyst on magnetic resonance cholangiopancreatography (MRCP) and ultrasound. Intra-operative findings were the only proof of biliary atresia. Following portoenterostomy, the liver function tests (LFTs) and bilirubin levels were returned within normal range and his jaundice was resolved. Any neonate presenting to a pediatric clinic with prolonged jaundice lasting more than two weeks, especially in cases of direct hyperbilirubinemia, must be thoroughly assessed and referred as early as possible for a pediatric surgical opinion to rule out the possibility of biliary atresia.

An overview of history, pathogenesis and treatment of perforated peptic ulcer disease with evaluation of prognostic scoring in adults

Peptic ulcer disease including both gastric and duodenal ulcer form a substantial part of patients seeking surgical opinion world-wide. The concept of acid in peptic ulcer disease, which was the basis of treatment of peptic ulcer was revolutionized by the discovery of H2-receptor antagonists, that led to the principle of acid suppression therapy for duodenal ulcer which followed decades of preference for surgical interventions in the form of gastric resections, vagotomy etc., After the discovery of Helicobacter pylori organism as the causative factor a triple drug regime was identified to treat peptic disease which was further modified to sequential therapy to avoid antibiotic resistance. This recognition has not concluded the chapter on peptic ulcers. The management of ulcer disease and its complications remain a surgical challenge. All the materials for this review have been accessed from various internet search engines. The references have been narrowed down to 34 by excluding cross references, duplicated citations, pediatric studies, case reports, iatrogenic and malignant perforations and including microbiological, immunohistochemistry references and studies with more than a sample size of ten. Case control, cohort studies, prospective/retrospective, metaanalytical studies were preferred in that order. This article attempts to take an overview of all aspects of the management of peptic ulcer.

The Benefits of Hernioscopy for Type 3 and 4 Amyand's Hernia.

Dear Sir, We have read, with interest, the case report entitled “Amyand’s hernia: a case of an unusual inguinal herniace” by Mishra et al. [1] in the Indian Journal of Surgery. The authors presented a case of Amyand’s hernia, a rare condition, reported with all treatment aspects. The symptoms and signs of acute appendicitis are marked, especially by the incarcerated inguinal hernia, preventing preoperative diagnosis of this rare situation. The operative approach is shaped according to the localization of the condition of the appendix within the hernial sac and the presence of additional pathologies. Additional pathologies which could be found include appendicular ischemia, necrosis and perforation causing peritonitis, abscess formation, or bowel obstruction. In a surgical opinion, if an appendectomy cannot be performed easily (due to anatomy, immobile cecum, or infection) or laparotomy is required (with relation to additional pathologies), hernioscopy is an alternative method to laparoscopy as an initial procedure, previous to laparotomy. In the hernioscopy, the trocar is placed from the dissected hernial sac through the abdominal cavity [2]. With the help of this, one is able to explore the peritoneal cavity without the need for laparotomy, especially for type 3 and 4 Amyand’s hernia, as classified by Losannoff and Basson [3]. If it is needed, a laparoscopic appendectomy (or any kind of laparoscopic procedure) can be done by inserting the other trocars. This simple method helps prevent unnecessary laparotomies, especially for a complex and unusual inguinal herniace.

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Introduction: Case report: Case of 43 years old male, non alcoholic was admitted with pain abdomen, jaundice and fever. Diagnosed as amoebic liver abscess based upon detection of space occupying lesions in USG and CT abdomen and positive serologic test for antibodies to Entamoeba histolytica antigens. Intravenous metronidazole 0.75gm three times a day was started. Patient developed new onset of atrial fibrillation. Patient deteriorated during his hospital course and developed septic shock and multiorgan failure. Repeat imaging was suggestive of ruptured abscess to the pleural and peritoneal cavity. Surgical opinion was taken and abscess drained. Patient improved with above treatment. Patient was discharged with another two weeks of oral metronidazole as USG abdomen showed persistence of abscess cavity in liver after initial three weeks of intravenous metronidazole. Patient was admitted after one week of discharge with complaints of slurring of speech and ataxia without focal motor and sensory deficit. Neurological examination was positive for cerebellar signs. Clinical diagnosis was made of embolic stroke in view of history of atrial fibrillation. MRI brain revealed symmetric areas of hyperintensity in dentate nuclei of cerebellum and dorsal pons on FLAIR, T2W images. Review of literature suggests these findings are consistent with metronidazole toxicity. Metronidazole was stopped on same day. Total metronidazole intake was 63 grams over four weeks. Patient improved significantly over next four weeks. Follow up MRI brain showed complete resolution of that lesion. Patient had intermittent atrial fibrillation so ischemic stroke was suspected etiology in our patient. Subsequently on reviewing radiological images & temporal association suggest the diagnosis of metronidazole toxicity. Spontaneous resolution of sign and symptoms and reversal of changes in MRI imaging after stopping the drug confirm the diagnosis. Neurotoxicity should be suspected in patients with new onset cerebellar symptoms in presence of prolong treatment with metronidazole in high doses. To our knowledge, this is the 40th case report of radiological proven metronidazole induced CNS toxicity worldwide.

AUGIS trainee prize winner: Antimicrobial prophylaxis prior to pancreatico-duodenectomy

AUGIS trainee prize winner: Antimicrobial prophylaxis prior to pancreatico-duodenectomy

The impact of a hand therapy screening and management clinic for patients referred for surgical opinion in an Australian public hospital

Study designRetrospective cohort study. PurposeTo measure the impact of initial treatment by a hand therapist of people referred to a hand surgeon for common hand conditions. MethodsThis retrospective cohort study included 224 patients with Carpal Tunnel Syndrome, Trigger Finger/Thumb, de Quervain's tenosynovitis, and trapeziometacarpal osteoarthrosis. All were invited to attend for assessment and non-operative treatment and were followed up for at least one year. Between groups comparisons for who attended (N = 164) and those who did not (N = 60) were conducted. Results40.8% of the non-operative treatment group and 65% of the no treatment group underwent surgery, which was statistically significant (p = 0.02). Univariate analysis found that the variable “attending non-operative treatment” was able to predict those who did not have surgery (p = 0.02). Multivariate analysis using logistic regression also showed that this was the only significant predictor of not progressing to surgery (p = 0.001). ConclusionsAssessment and treatment by a non-operative provider were associated with a decrease in the rate of operative treatment. Prospective, randomized studies could help determine if this observed difference is related to the treatment approach. Level of evidence2C

What Do Clinicians Think about Hip Precautions following Total Hip Replacement?

Introduction: Hip precautions are routinely recommended by occupational therapists to reduce the risk of dislocation following total hip replacement. The purpose of this study was to report the views and experiences of clinicians on the use of hip precautions with this client group. Method: Data were gathered from six National Health Service trusts, through 16 semi-structured telephone interviews. Participants included occupational therapists, physiotherapists, surgeons and nurses and data were analysed thematically. Results: Themes identified were: the rationale for, and disadvantages of, routine hip precautions and issues in the consistency of their application; the barriers and facilitators to relaxing hip precautions and the process and impact of changing practice; the contextual factors of service change and support for further research. Conclusion: There is variation in the views of clinicians regarding hip precautions due to differences in surgical opinion and lack of evidence as to whether precautions affect the risk of dislocation. Relaxing the routine provision of hip precautions is perceived to have an impact on patient recovery and satisfaction, the role and skill mix of therapy services, length of hospital stay and resource use. Trials are urgently required to investigate the effect of hip precautions on patient and surgical outcomes.

A survey of expert follow-up practices after successful endoscopic eradication therapy for Barrett's esophagus with high-grade dysplasia and intramucosal adenocarcinoma

Despite the increasing number of patients undergoing endoscopic therapy for Barrett's esophagus (BE) with high-grade dysplasia (HGD) or intramucosal cancer (IMC), there are few data to guide clinical decision making and research initiatives in the area of posttreatment follow-up. We aimed to define expert practice patterns regarding follow-up after endoscopic treatment of BE with HGD and IMC. Electronic survey. Forty-eight endoscopists in the United States with expertise in BE endotherapy based on high-impact publications and national reputation. A 21-item Web-based survey inquiring about post-BE endotherapy follow-up practices. Of 48 expert endoscopists, 42 completed the survey. After successful treatment of BE with HGD or IMC, all experts perform surveillance upper endoscopy, most commonly at 3-month intervals in the first posttreatment year, every 6 months during the second year, and annually thereafter. None of the experts perform surveillance EUS after treatment of HGD, and only 19% perform EUS after treatment of IMC. After cancer eradication, only 36% of experts refer patients for CT, and 24% refer patients for positron emission tomography. Thirty-eight percent of experts refer patients for a surgical opinion when IMC extends into the muscularis mucosa; 100% refer when IMC extends into submucosa. Not a consensus document; only U.S. experts included. This study reports the follow-up practices of expert endoscopists after successful endotherapy for BE with HGD and IMC. Additional research is necessary to establish optimal surveillance intervals, the role of follow-up EUS, CT, and positron emission tomography, as well as the surgical implications of low-risk IMC extending into the muscularis mucosa.

PF.49 Term Admissions to the Neonatal Unit; Are They Avoidable?

IntroductionApproximately 10% of all babies born require admission to the neonatal unit and term infant represent a significant percentage of NICU admission and are major contributors to workload.AimTo identify potentially...

PM.73 Case Report: Abdominal Cutaneous Nerve Entrapment Syndrome in the Pregnant Patient

Case ReportA 25 yr para 1 (NVD) at 30 + 2 weeks gestation presented with severe right sided abdominal pain. Vital signs were stable. Tenderness was elicited in the right...

Use of antibiotic prophylaxis in elective inguinal hernia repair in adults in London and south-east England: a cross-sectional survey

PurposeEvidence regarding whether or not antibiotic prophylaxis is beneficial in preventing post-operative surgical site infection in adult inguinal hernia repair is conflicting. A recent Cochrane review based on 17 randomised trials did not reach a conclusion on this subject. This study aimed to describe the current practice and determine whether clinical equipoise is prevalent.MethodsSurgeons in training were recruited to administer the Survey of Hernia Antibiotic Prophylaxis usE survey to consultant-level general surgeons in London and the south-east of England on their practices and beliefs regarding antibiotic prophylaxis in adult elective inguinal hernia repair. Local prophylaxis guidelines for the participating hospital sites were also determined.ResultsThe study was conducted at 34 different sites and received completed surveys from 229 out of a possible 245 surgeons, a 93 % response rate. Overall, a large majority of hospital guidelines (22/28) and surgeons’ personal beliefs (192/229, 84 %) supported the use of single-dose pre-operative intravenous antibiotic prophylaxis in inguinal hernia repair, although there was considerable variation in the regimens in use. The most widely used regimen was intravenous co-amoxiclav (1.2 g). Less than half of surgeons were adherent to their own hospital antibiotic guidelines for this procedure, although many incorrectly believed that they were following these.ConclusionIn the south-east of England, there is a strong majority of surgical opinion in favour of the use of antibiotic prophylaxis in this procedure. It is therefore likely to be extremely difficult to conduct further randomised studies in the UK to support or refute the effectiveness of prophylaxis in this commonly performed procedure.

Editorial Comment: Lung-sparing total pleurectomy: the surgical option of choice in malignant pleural mesothelioma?

The incidence of malignant pleural mesothelioma (MPM) in Western Europe is increasing significantly [1]. Increased patient awareness of potential therapy and results from North American centres have stimulated specialist European surgical centres to expand their programs. There has been a shift in specialist surgical opinion away from extrapleural pneumonectomy (EPP) towards lung-sparing surgery in MPM. This may be attributed to an increasing age at presentation with consequent increasing comorbidity, particularly COPD. There is also an increasing appreciation that lung-sparing surgery can prolong survival from MPM. This finding is confirmed by Bolukbas et al .[ 2] in this issue, who report 28% 5-year survival in 42 patients with IMIG Stage III MPM. In their series, survival was even greater (median survival 38 months) in those who underwent a complete resection. Unfortunately, macroscopic complete resection was not achieved in 16 of the 42 patients and one wonders whether EPP may have been preferable in these cases. These authors highlight other important prognostic factors, particularly tumour infiltration of previous diagnostic biopsy sites. While also noted by the Boston group [3], this finding may in itself be a surrogate marker for increased tumour volume, thus leading to incomplete R2 resection, or for unfavourable tumour biology. The clinical implication of this is that core biopsy of suspicious biopsy sites should be performed prior to radical surgery. Positive results could then prompt induction chemotherapy to exclude those who may progress inexorably despite therapy. The time interval between diagnosis and major surgery is not clear in the Wiesbaden experience, but this should be kept as short as possible. Apart from involvement of previous incisions and completeness of excision, Bolukbas did not identify nodal status or cell type as significant prognostic factors. These findings do not correlate with the largest series of survival data for mesothelioma surgery reported by the IASLC staging group [4] and probably reflect the small sample. It is imperative that radical surgery should only be considered in patients whose prognosis would be better than with non-surgical treatment. Comparable data are limited but a Nordic study has reported survival from chemotherapy alone in early-stage disease of 22 months [5]. In the IASLC database, postoperative survival was inferior to this in Stages III and IV disease and in non-epithelioid cell types. The inference is that surgery with life prolongation as its aim should be limited to those patients with epithelioid MPM without nodal metastases, particularly in the upper mediastinum. This area is proposed to represent a later stage of MPM based on a ‘gravitational hypothesis’ in which the disease is suggested to progress from the base to the apex of the hemithorax. The poorer prognosis of paratracheal nodal disease suggested from several series [3, 6] promotes the use of mediastinoscopy in patient selection for radical surgery. As alluded to above, there is increasing enthusiasm for lungsparing radical surgery over EPP. The reduced risk of pneumonectomy avoidance may be as high as 40% [7] together with the potential for preserved respiratory function. The recent under