Response to comment on: ‘Hybrid operating room: the leading edge of thoracic surgery’

We sincerely appreciate the interest and comments for our article entitled “Preoperative Dye Localization for Thoracoscopic Lung Surgery: Hybrid Versus Computed Tomography Room” (1). The authors have comprehensively analyzed and discussed several of the important issues described in our manuscript.

First, we appreciate the comment on an important issue: radiation dose. As mentioned in the article, the balance between image quality and lower radiation dose is still controversial (2). Although a higher cone bean computed tomography (CT) radiation dose is needed to achieve soft tissue image quality to equivalent to that available on conventional CT, we agreed that “excellent’ image quality may be not necessary for preoperative nodule localization. Although the learning curve is a possible factor influencing the result, modifying the procedure for every individual patient may be a more important key factor for improvement (3). We believe it is an important issue to focus on in future practice, by applying preoperative planning and low-dose screening sequences for the initial evaluation in the localization procedure. To reduce the radiation dose in the hybrid room group, a new flowchart should be designed for cooperation between the radiologist and thoracic surgeon as per the authors’ suggestion.

Moreover, the comment showed the concern regarding the time difference of the epidural procedure. Currently, thoracic epidural analgesia is considered as the intraoperative and postoperative gold standard mainly for thoracotomy. However, it still poses a high risk of hypotension due to the reduced cardiac output. Therefore, the intercostal nerve blockade, rather than epidural analgesia, was the routine procedure in the postoperative pain control in our institute (4). The matter in Figure 1B in the paper should be corrected as a steel wire, which placed a surface localization guide (1). Mostly, the intercostal nerve block would be performed after wound incision. Therefore, the procedure time for the intercostal nerve block would be included in the surgery time for both groups. We suggest that the waiting time in the general ward and the transport time between the ward, CT room, and operating room may be the key factors for the large gap in global time between the hybrid room group and CT room group.

The authors also indicate the difference in the malignancy rate. During our matching, propensity score matching was performed to compare the hybrid and CT room group considering the operation method and lesion number, depth, and size. As a result, the malignancy rate was not the factor we set for the matching and showed the difference between both groups. However, the pathology of the nodule does not influence the difficulty of the localization or the operation. According to our previous experience of CT guide localization, the malignancy rate is near 85%, similar to the mean of the two groups.

Retrospectively collected data limited the verity of our study (1). Although use of the hybrid room in thoracic surgery has been shown to be a novel procedure with potential benefits, further studies and experiences from additional medical centers are necessary to produce more robust evidences in the future. For this reason, we believe a prospective study is necessary to clarify this dilemma in the future.

Acknowledgments

Funding: This study is funded by the National Taiwan University Hospital (NTUH 108-N004298) for the English editing of this manuscript.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Video-Assisted Thoracic Surgery. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/vats.2019.10.02). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Chen PH, Hsu HH, Yang SM, et al. Preoperative Dye Localization for Thoracoscopic Lung Surgery: Hybrid Versus Computed Tomography Room. Ann Thorac Surg 2018;106:1661-7. [Crossref] [PubMed]
2. Ujiie H, Gregor A, Yasufuku K. Hybrid operating room: the leading edge of thoracic surgery. Video-assist Thorac Surg 2019;4:7. [Crossref]
3. Hsieh MJ, Wen CT, Fang HY, et al. Learning curve of image-guided video-assisted thoracoscopic surgery for small pulmonary nodules: A prospective analysis of 30 initial patients. J Thorac Cardiovasc Surg 2018;155:1825-1832.e1. [Crossref] [PubMed]
4. Lin MW, Tseng YH, Lee YF, et al. Computed tomography-guided patent blue vital dye localization of pulmonary nodules in uniportal thoracoscopy. J Thorac Cardiovasc Surg 2016;152:535-544.e2. [Crossref] [PubMed]