Endobronchial Watanabe Spigot for Acute Empyema With Bronchopleural Fistula: A Case Series

Authors: Kento Yokota, Takayuki Niitsu, Satoshi Tanaka, Daiki Nagira, Saki Nishibeppu, Naoya Takada, Satoshi Tobita, Moto Yaga, Kiyonobu Ueno, Yasunobu Funakoshi

Abstract

Empyema with bronchopleural fistula (BPF), defined by persistent air leak with pleural infection, undermines negative‐pressure drainage and often leads to highly invasive procedures such as fenestration. While endobronchial Watanabe spigots (EWSs) have mainly been used for postoperative or chronic fistulas, their role as an early intervention in acute infectious empyema with BPF remains uncertain. We report three consecutive frail patients with acute empyema and persistent air leak due to BPF treated using a prospectively predefined early EWS approach. After adequate drainage and antibiotics failed to seal the fistula, endobronchial occlusion was performed at the earliest bronchoscopic opportunity before considering fenestration. In all cases, EWS placement achieved complete cessation of air leak, allowed chest tube removal within 6–26 days and obviated fenestration. Diverse microbiology, including polymicrobial infection and nontuberculous mycobacteria, was controlled without observed device‐related infection or migration. Early EWS may offer a minimally invasive, fenestration‐sparing option in selected patients.

Introduction

Empyema with bronchopleural fistula (BPF), characterised by a persistent air leak with concomitant pleural infection, poses a significant therapeutic challenge [1].

Contemporary care pathways for pleural infection favour antibiotics plus drainage as initial management, consider intrapleural tPA–DNase when drainage is inadequate or loculations persist, escalate to video‐assisted thoracoscopic surgery debridement if needed and reserve fenestration for refractory cases [2].

In acute empyema complicated by a BPF, durable healing generally requires functional arrest of the fistula. However, continuous airflow into the pleural space undermines negative‐pressure drainage. Conventional surgical approaches, including lobectomy, direct fistula closure or fenestration, can achieve closure but are highly invasive and often necessitate prolonged hospitalisation with muscle flaps or even thoracoplasty [3].

Over the past decades, endobronchial occlusion with the endobronchial Watanabe spigot (EWS) has emerged as a less invasive option to abolish air leakage and facilitate infection control [4]. Prior publications have described EWS across heterogeneous contexts, most commonly postoperative fistulas, intractable pneumothorax [5] or chronic/tuberculous empyema [6], with limited disease‐specific data for acute infectious empyema detailing microbiology and short‐term outcomes.

To address this gap and the physiologic barrier above, we define and apply an early EWS strategy, targeting endobronchial occlusion at the earliest bronchoscopic opportunity after confirming acute empyema with BPF and before considering fenestration, with the a priori aim of restoring a favourable pressure gradient, collapsing the cavity and enabling non‐surgical cure.

Here, we report a consecutive three‐patient series of acute infectious empyema with BPF managed under this early EWS strategy, providing microbiology‐anchored descriptions and short‐term outcomes across varied patient backgrounds to illustrate its proactive, fenestration‐sparing role in selected cases.

Cases Series

Case 1

A 72‐year‐old woman with a history of total laryngectomy and permanent tracheostomy for tongue and supraglottic cancer underwent maintenance immunotherapy with pembrolizumab. Following coronavirus disease 2019 pneumonia complicated by a lung abscess, chest imaging revealed a large cavity with fibrotic interstitial lung disease (Figure 1A,B). The patient was cachectic (body mass index [BMI] 16 kg/m^2^) and functionally impaired, with a Barthel Index score of 25/100. She was admitted because of a cough, purulent sputum and dyspnea. Left‐sided empyema with BPF was diagnosed (Figure 1C,D), and an intercostal chest tube was subsequently inserted. Empirical therapy with ampicillin/sulbactam (ABPC/SBT) plus clindamycin was initiated. Sputum and pleural fluid cultures revealed Staphylococcus aureus and Mycobacterium kansasii , prompting the addition of rifampicin, ethambutol and clarithromycin to the treatment regimen. Given the extensive underlying lung disease and the potential morbidity of surgical closure, endobronchial occlusion using EWS was selected early to abolish the air leak and maintain effective drainage.

On day 16, EWSs were placed in three segmental bronchi (B8a, B8b and B9a using 6‐, 6‐ and 5‐mm spigots, respectively). Additional spigots were placed (B1 + 2 and B3 using 6‐mm and 5‐mm, respectively) on day 23 to eliminate residual air leaks (Figure 1E–G). After discontinuing levofloxacin on day 24, the air leak ceased, allowing chest tube removal on day 29 (13 days after the first EWS placement) (Figure 1H,I). The patient was discharged on day 70 and subsequently transferred to a convalescent hospital after infection control, where bronchoscopic access was limited, making elective removal of the spigots difficult. During 6 months of follow‐up, no EWS‐related complications were observed.

Case 2

A 74‐year‐old obese woman (BMI 33.0 kg/m^2^) with a history of impaired glucose tolerance was referred from another hospital due to right‐sided empyema (Figure 2A). Empirical treatment with meropenem plus vancomycin was initiated and was subsequently changed to ABPC/SBT on day 6. Pleural fluid cultures identified Streptococcus anginosus group and Fusobacterium nucleatum . Surgical debridement of the pleural cavity was attempted on day 10. However, due to extensive intrathoracic adhesions, only partial debridement (~80%) was achieved.

On day 17, an air leak developed, and a BPF originating from the right lower lobe was suspected, leading to a diagnosis of empyema with BPF (Figure 2B). Considering the extent of adhesions and the potential morbidity of reoperation, endobronchial occlusion using EWS was chosen early to close the fistula.

On day 28, a 6‐mm EWS was inserted into the B6b. Subsequently, a Neoveil sheet was implanted into the same bronchus due to a minor residual leak (Figure 2C,D). The chest drain was successfully removed on day 54 (26 days after initial EWS placement) (Figure 2E). On day 57, antimicrobial therapy was switched to amoxicillin/clavulanic acid. Antibiotic treatment was completed on day 72. The patient was discharged on day 59, and the EWSs have been retained without complications during 6 months of follow‐up. Elective removal is planned at a forthcoming bronchoscopy.

Case 3

A 78‐year‐old woman with a history of Alzheimer disease (FAST score, 5) presented to our emergency department with a productive cough, pleuritic chest pain and dyspnea. She was emaciated (BMI 16 kg/m^2^) and was diagnosed with right‐sided empyema with BPF upon admission (Figure 3A). On the same day, two chest drains were inserted into the posterior apical and posterior basal regions of the right thoracic cavity (Figure 3B). Empirical antimicrobial therapy using piperacillin/tazobactam and linezolid was initiated. Sputum and pleural fluid cultures were positive for Streptococcus anginosus group, prompting de‐escalation to ABPC/SBT on day 5. Considering the patient's comorbidities and the potential morbidity of surgical closure, endobronchial occlusion using EWS was selected to abolish the leak and expedite medical cure.

On day 8, a 6‐mm EWS was placed in the B4 bronchus (Figure 3C). The posterior apical chest drain was removed on day 14, six days after EWS placement. The posterior basal drain was removed on day 19, eleven days after placement (Figure 3D). Antimicrobial therapy was discontinued on day 26. The EWS has been retained without complications during 3 months of follow‐up. The patient developed advanced oropharyngeal cancer and subsequently died. Therefore, removal was not undertaken.

Procedural Note (Common to All Cases)

Air‐leak localization relied on thin‐section axial and multidetector CT with MPR to depict the fistulous tract and plan access, supplemented by virtual bronchoscopy navigation and an in‐house CT image‐analysis method [7] to preselect candidate bronchi.

During bronchoscopy, brief scope wedging at these candidate sites suggested the targets, as evidenced by the maximal and immediate reduction or cessation of water‐seal bubbling under suction without balloon occlusion. Endobronchial valves were not used because they are approved for use only in emphysema in Japan. Regarding EWS insertion, all procedures employed the curette technique [8]. The bronchoscope equipped with an EWS attached to the tip of the curette was inserted into the target bronchus by adjusting the angle and direction of the spigot. Once the EWS fully occluded the target bronchus, the curette was withdrawn while gently pressing the spigot with the bronchoscope to ensure secure placement. Sutures on EWS were attached to permit easy retrieval if malposition occurs and provide a rescue handle in the event of distal migration.

Discussion

This case series highlights the successful application of EWS placement as an early minimally invasive strategy in three patients with acute empyema with BPF of diverse etiologies. Each patient presented with a persistent air leak secondary to BPF, yet durable closure was achieved without resorting to invasive surgical procedures. EWS occlusion resulted in the complete resolution of air leaks and allowed chest tube removal within 6 to 26 days after placement, leading to clinical recovery. Importantly, the effectiveness of EWS was demonstrated across varied patient backgrounds and infectious pathogens, underscoring its versatility and potential role in the management of acute empyema with BPF (Table 1).

The EWS, a silicone bronchial filler developed by Watanabe et al. in 2001 [9], was initially applied to intractable pneumothorax, postoperative air leaks [6], tuberculous empyema [10] and its indications have since expanded to include empyema with BPF.

Previous series have reported air leak cessation in approximately 82% of patients with BPF [11] and chest tube removal within an average of 18 days, [12] with some achieving removal within 7 days [10], underscoring its ability to provide timely fistula closure and facilitate recovery.

However, in acute empyema with BPF, disease‐specific reports, including detailed microbiology, remain insufficient. More importantly, the role of early EWS as a strategy to avoid surgical procedures remains undefined in current treatment algorithms. In acute empyema with BPF, direct surgical closure may reopen and fenestration is associated with loss of lung expansion, functional decline, prolonged hospitalisation and quality of life requiring complex reconstruction [13, 14, 15]. Reports describe heavy procedural burden, delayed closure, increased mortality when open‐window cavities remain unclosed and marked quality‐of‐life impairment [3].

Against this background, early bronchoscopic defunctionalisation of the fistula with EWS can maintain negative‐pressure drainage and enable non‐surgical cure with antibiotics, potentially obviating fenestration and downstream reconstructive procedures. Our series documents successful early EWS use across heterogeneous acute infectious causes, including S. aureus with nontuberculous mycobacteria, anaerobes with Fusobacterium and S. anginosus , suggesting broader applicability in carefully selected cases.

Nevertheless, questions remain regarding standardised algorithmic approaches.

The optimal number, size and positioning of spigots remain largely empirical; complications such as recurrent air leak, migration or expectoration can occur.

Additionally, although short‐term success has been well documented [4], long‐term outcomes such as reinfection risk and pulmonary function remain poorly characterised.

Existing evidence, however, suggests that prolonged EWS retention can be safe when clinically justified [16], and our observations were consistent with these reports.

Heimlich valves may also carry a risk of pleural‐space infection [17].

In Japan, endobronchial valves are not approved for air leak and were therefore not available as a treatment option. Consequently, EWS represented the only feasible bronchoscopic occlusion strategy in routine clinical practice for these patients.

Future work should focus on (i) consensus protocols for spigot selection and placement informed by computed tomography/bronchoscopic mapping; (ii) comparative studies versus one‐way endobronchial valves or ambulatory drainage strategies; (iii) development of biodegradable occluders that do not require retrieval [18]; and (iv) prospective multicentre studies to define generalizability and evidence‐based selection criteria in older, frail or immunocompromised populations.

In conclusion, by documenting consecutive cases of acute empyema with BPF of heterogeneous background managed successfully with early EWS, this series adds disease‐specific evidence that EWS may serve as an early, minimally invasive option to abolish air leak and avoid highly invasive procedures such as fenestration in selected patients. Given its minimally invasive nature, EWS could be considered for a broader range of patients with empyema complicated by BPF.

Author Contributions

K.Y. and T.N. drafted the manuscript. T.N., S.T., M.Y. and Y.F. revised the manuscript accordingly. K.Y., T.N., S.T., D.N., S.N., N.T., S.T., M.Y. and Y.F. managed patients. All authors have reviewed and revised the manuscript for intellectual content. All the authors approved the final version of the manuscript.

Funding

The authors have nothing to report.

Consent

The authors declare that written informed consent was obtained from all the patients for the publication of this manuscript and accompanying images using the consent form provided by the Journal.

Conflicts of Interest

The authors declare no conflicts of interest.