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Eur J Cardiothorac Surg 2004;26:234-235
© 2004 Elsevier Science NL

Letter to the Editor

Reply to Carcoforo et al.

Department of Thoracic Surgery, Scientific Institute H San Raffaele, Vita-Salute University, Via Olgettina 60, 20132 Milan, Italy

Received 9 April 2004; accepted 13 April 2004.

^* Corresponding author. Tel.: +39-02-26437138
e-mail: ciriaco.paola{at}hsr.it

Key Words: Pulmonary nodule • Video-assisted thoracoscopy • Hookwire

We appreciate the comments of Carcoforo et al. regarding our paper on ‘Video-assisted thoracoscopic surgery for pulmonary nodules: rationale for preoperative computed tomography-guided hookwire localization’. They highlight several points of discussion: first, they comment on the complications correlated with the positioning of hookwires. Most of the complications reported in the literature are minor and do not require treatment [1,2], and major events such as pulmonary venous air embolism are rarely reported [3]. In our experience the complication rate was 7.5% and none of the patients experienced severe symptoms or required invasive treatment that could modify the outcome of the surgical procedure. The outcome was not influenced either by the peri-nodular inflammation that might have occurred at the site of hookwire positioning since we always provided at least 1.5 cm of free margins on each side of the specimen, which was always confirmed by frozen section [1].

Among the various techniques to localize pulmonary nodules present in literature, hookwire positioning is reported as having a percentage of success close to 95% in contrast with a failure rate of around 13% of other techniques like injection of methylene blue or colored collagen [1,2]. Despite its high sensitivity, specificity and lack of complications, intraoperative ultrasound may present limitations due to the presence of trapped air in the lung as in patients with obstructive lung disease and difficulties in localizing inflammatory nodules [4]. Moreover, only scant series are reported in the literature.

CT hookwire positioning allows pulmonary nodules that otherwise could not be detectable to be resected via a VATS procedure, thus reducing operative time, postoperative pain and hospital stay. Preparation of the patient in the Radiology Unit further avoids wasting the operative room time.

The ‘hookwire and suture system’ reported by Dendo et al. [5] may be a viable solution to prevent hookwire dislodgment and to alleviate patient discomfort. We tried to minimize the chance of hookwire dislodgment by positioning the patient in a thoracotomy position on the CT table, and transferring the patient to the operative room in the same position. At the same time, we left an adequate length of the hookwire outside the chest, to enable the wire to follow the deflated lung during single-lung ventilation.

In conclusion we think that preoperative hookwire marking is a safe and effective procedure in experienced hands provided that there is close cooperation between surgeons and radiologists.

References

1. Ciriaco P., Negri G., Puglisi A., Nicoletti R., Del Maschio A., Zannini P. Video-assisted thoracoscopic surgery for pulmonary nodules: rationale for preoperative computed tomography-guided hookwire localization. Eur J Cardiothorac Surg 2004;25:429-433.[Abstract/Free Full Text]
2. Thaete F.L., Peterson M.S., Plunkett M.B., Ferson P.F., Keenan R.J., Landrenau R.J. Computed tomography guided wire localization of pulmonary lesions before thoracoscopic resection: results in 101 cases. J Thorac Imaging 1999;14:90-98.[Medline]
3. Horan T.A., Pinheiro P.M., Araujo L.M., Santiago F.F., Rodrigues M.R. Massive gas embolism during pulmonary nodule hook wire localization. Ann Thorac Surg 2002;73:1647-1649.[Abstract/Free Full Text]
4. Kerviler E. Limitations of intraoperative sonography for the localization of pulmonary nodules during thoracoscopy. Am J Roentgenol 1998;170:214-215.[Medline]
5. Dendo S., Kanazawa S., Ando A., Hyodo T., Kouno Y., Yasui K., Mimura H., Akaki S., Kuroda M., Shimizu N., Hiraki Y. Preoperative localization of small pulmonary lesions with a short hook wire and suture system: experience with 168 procedures. Radiology 2002;225:511-518.[Abstract/Free Full Text]

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