Trans-fissural extension in post-tubercular lung parenchymal sequelae: A predictor of difficult surgery and poor outcomes

Patients with post-tubercular sequelae often present with aspergilloma, bronchiectasis, or dense fibrosis, despite adequate medical therapy, making it the most challenging subset for thoracic surgery. In our experience of 632 post-tubercular lung parenchymal sequelae cases, 17% demonstrated trans-fissural extension. Among various predictors of poor surgical outcomes, trans-fissural extension in post-tubercular sequelae was the critical determinant, showcasing the chronicity and aggressiveness of parenchymal involvement. It necessitated extended lobar resections, leading to longer operative time, more intra-operative blood loss, higher incidence of residual space, prolonged air leak, post-operative infected collections, and requirement of re-surgery (i.e. window thoracostomy or completion pneumonectomy) compared to patients with lobe limited disease. In this complex cohort, recognizing the trans-fissural extension preoperatively is necessary for risk stratification, operative planning, and adopting the preventive strategies to optimize the surgical outcomes.