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Uniportal video assisted thoracoscopic surgery right upper sleeve lobectomy- The first experience in Hospital Kuala Lumpur

Diong NC, Dharmaraj B, Sathiamurthy N

Med J Malaysia, 2020 07;75(4):445-446.
PMID: 32724014

Sleeve lobectomy is a lung sparing surgery and is the preferred alternative to pneumonectomy for centrally located tumours, which has less postoperative morbidity and mortality. Surgical approach for the technically demanding sleeve lobectomy evolved over the decades from conventional thoracotomy to video assisted thoracoscopic surgery (VATS) to uniportal VATS (uVATS) which allows for quicker recovery and less pain postoperatively. We report our very first successful uVATS sleeve right upper lobectomy performed in the Hospital Kuala Lumpur, Malaysia.
Surgical subspecialty training outside Malaysia during COVID-19 Pandemic: Perspectives and experiences of Trainees

Tan YL, Ng EHB, Diong NC

Med J Malaysia, 2021 11;76(6):906-908.
PMID: 34806681

Subspecialty surgical training is an integral part of continuous professional development. It represents a unique opportunity for surgeons to enhance and develop specific advanced skills in their sub-disciplines. Hence, hands-on training in an international training centre abroad allows one to bring home new technical and management skills in the expansion of Malaysian surgical services to raise to be on par with the international standards. The unexpected onset of the COVID-19 pandemic brought in previously unknown hindrances to the training both locally and abroad but our success in engagement with international centres despite the pandemic restrictions serves as a valuable experience towards maintaining international networking for future collaborations.
Non-intubated vs. intubated video-assisted thoracoscopic bullectomy - a retrospective cohort study

Palaniappa MP, Diong NC, Benedict D, Amiruddin NMK, Narasimman S

Med J Malaysia, 2023 Sep;78(5):570-573.
PMID: 37775481

INTRODUCTION: Thoracic surgery procedures evolved enormously over time from open surgery to video assisted thoracoscopic surgery (VATS) and now non-intubated uniportal VATS. At our centre, the initial approach for bullectomy was by uniportal intubated VATS (iVATS) for most cases. Only in mid-2020, in the midst of COVID-19 pandemic, uniportal non-intubated VATS (NiVATS) took precedence. We compared the outcome of bullectomy via iVATS versus NiVATS for a period of 5 years.
MATERIALS AND METHODS: We reviewed the medical records of all patients that underwent bullectomy from 1st June 2017 to 31st May 2022. Mann Whitney U-test was completed for all variables. Primary objective was to compare operating time (OT), global operating time (GOT), post-operative length of stay (LOS) and complication rate.
RESULTS: A total of 90 bullectomies performed in which 36 were approached via iVATS and 54 NiVATS. It was found that the post-operative LOS, GOT, and OT were significantly shorter in the NiVATS as compared to iVATS. Complication rate between both groups showed no significant difference.
CONCLUSION: NiVATS bullectomy demonstrated a safe and reliable alternative surgical approach with superior surgical outcome than iVATS bullectomy.
Fulltext Growing teratoma syndrome of mediastinal nonseminomatous germ cell tumor

Diong NC, Dharmaraj B, Joseph CT, Sathiamurthy N

Ann Thorac Med, 2020 01 02;15(1):38-40.
PMID: 32002046 DOI: 10.4103/atm.ATM_296_19

Mediastinal nonseminomatous germ cell tumor (NSGCT) is rare. NSGCT shows excellent response to cisplatin-based chemotherapy. However, some tumors continue to enlarge despite normal tumor markers after chemotherapy, a rare condition called growing teratoma syndrome (GTS). Recognition of this condition is imperative for prompt surgical resection to prevent further cardiopulmonary compression and to improve survival. Multidisciplinary team meeting is important for perioperative preparation and care to improve the outcome of this high-risk surgery. Here, we report two cases of mediastinal GTS and underwent surgical resection, of which one died of pericardial decompression syndrome and the other is well.
Fulltext Is there a role for lung surgery in initially unresectable non-small cell lung cancer after tyrosine kinase inhibitor treatment?

Diong NC, Liu CC, Shih CS, Wu MC, Huang CJ, Hung CF

World J Surg Oncol, 2022 Nov 26;20(1):370.
PMID: 36434641 DOI: 10.1186/s12957-022-02833-6

BACKGROUND: The role of lung surgery in initially unresectable non-small cell lung cancer (NSCLC) after tyrosine kinase inhibitor (TKI) treatment remains unclear. We aimed to assess the survival benefits of patients who underwent surgery for regressed or regrown tumors after receiving TKI treatment.
METHODS: The details of patients diagnosed with unresectable NSCLC treated with TKI followed by lung resection from 2010 to 2020 were retrieved from our database. The primary endpoint was 3-year overall survival (OS), whereas the secondary endpoints were a 2-year progression-free survival (PFS), feasibility, and the safety of pulmonary resection. The statistical tests used were Fisher's exact test, Kruskal Wallis test, Kaplan-Meier method, Cox proportional hazards model, and Firth correction.
RESULTS: Nineteen out of thirty-two patients were selected for the study. The patients underwent lung surgery after confirmed tumor regression (17 [89.5%]) and regrowth (two [10.5%]). All surgeries were performed via video-assisted thoracoscopic surgery: 14 (73.7%) lobectomies and five (26.3%) sublobar resections after a median duration of 5 months of TKI. Two (10.5%) postoperative complications and no 30-day postoperative mortality were observed. The median postoperative follow-up was 22 months. The 2-year PFS and 3-year OS rates were 43.9% and 61.5%, respectively. Patients who underwent surgery for regressed disease showed a significantly better OS than for regrowth disease (HR=0.086, 95% CI 0.008-0.957, p=0.046). TKI-adjuvant demonstrated a better PFS than non-TKI adjuvant (HR=0.146, 95% CI 0.027-0.782, p=0.025).
CONCLUSION: Lung surgery after TKI treatment is feasible and safe and prolongs survival via local control and directed consequential therapy. Lung surgery should be adopted in multimodality therapy for initially unresectable NSCLC.
Chest wall resection and reconstruction: a case series of 20 patients in Hospital Kuala Lumpur, Malaysia

Dharmaraj B, Diong NC, Shamugam N, Sathiamurthy N, Mohd Zainal H, Chai SC, et al.

Indian J Thorac Cardiovasc Surg, 2021 Jan;37(1):82-88.
PMID: 33442211 DOI: 10.1007/s12055-020-00972-7

Chest wall resection is defined as partial or full-thickness removal of the chest wall. Significant morbidity has been recorded, with documented respiratory failure as high as 27%. Medical records of all patients who had undergone chest wall resection and reconstruction were reviewed. Patients' demographics, length of surgery, reconstruction method, size of tumor and chest wall defect, histopathological result, complications, duration of post-operative antibiotics, and hospital stay were assessed. From 1 April 2017 to 30 April 2019, a total of 20 patients underwent chest wall reconstructive surgery. The median age was 57 years, with 12 females and 8 males. Fourteen patients (70%) had malignant disease and 6 patients (30%) had benign disease. Nine patients underwent rigid reconstruction (titanium mesh for sternum and titanium plates for ribs), 6 patients had non-rigid reconstruction (with polypropylene or composite mesh), and 5 patients had primary closure. Nine patients (45%) required closure with myocutaneous flap. Complications were noted in 70% of patients. Patients who underwent primary closure had minor complications. In total, 66.7% of patients who had closure with either fasciocutaneous or myocutaneous flaps had threatened flap necrosis. Two patients developed pneumonia and 3 patients (15%) had respiratory failure requiring tracheostomy and prolonged ventilation. There was 1 mortality (5%) in this series. In conclusion, chest wall resections involving large defects require prudent clinical judgment and multidisciplinary assessments in determining the choice of chest wall reconstruction to improve outcomes.