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Kuang-Ming Liao Chung-Han Ho 1Department of Internal Medicine, Chi Mei Medical Center, Chiali, Tainan City, Taiwan; 2Department of Medical Research, Chi Mei Medical Center, Chiali, Tainan City, Taiwan Dear editor We thank the authors for their comments. In our Table 3, the odds ratio of adverse clinical outcomes for laparoscopic cholecystectomy patients with and without COPD was adjusted by all variables listed in Table 1, including age at surgery, gender, income, hospital level, and comorbidities. We agreed that time period was long in our observation study and the management strategy, especially for COPD patients, has evolved and changed a lot. It is an inherent limitation in the long observational study. Secondly, the information on intraoperative and postoperative respiratory management cannot be obtained from the database. The preoperative optimization strategy for risk reduction and postoperative patients care were relevant to individual physician performance. This is not only the characteristics of the national database but also real-world conditions. In Taiwan, if hospitals are capable of performing laparoscopy, most of them also provide services of hemodialysis, mechanical ventilation, and intensive care unit. We agreed that proper patient selection is crucial and is associated with outcome and prognosis.

<p>Poor outcome of laparoscopic cholecystectomy in patients with COPD: how determinant it is? [Response to Letter]</p>