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

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.