Uniportal thoracoscopic suture fixation of an endobronchial spigot for postoperative bronchial fistula.

BACKGROUND: Postoperative bronchial fistula is a serious complication after lung resection, and when empyema develops, bronchoscopic placement of an Endobronchial Watanabe Spigot (EWS) is often attempted. However, in large postoperative fistulas, the EWS cannot be securely fixed and frequently migrates, rendering it ineffective. No established method exists to stabilize the EWS in such cases. CASE REPORT: A man in his 70s developed a persistent bronchial fistula after left lower lobectomy and lingular resection for metastatic lung cancer. An L-size EWS was placed bronchoscopically, but he developed empyema. Although the infection was controlled with antibiotics, the device repeatedly migrated into the pleural cavity, and the air leak persisted. TREATMENT: Using a single-port thoracoscopic approach, the fistula and the dislodged EWS were directly visualized. Because the bronchial wall was fragile, suturing the bronchial wall alone carried a risk of rupture. The EWS was fixed to the stump by passing sutures through the bronchial wall, the spigot, and the opposite bronchial wall. After a leak test, no residual air leak was detected. RESULTS: The chest drain was removed on postoperative day 3. Bronchoscopy at 6 months confirmed complete closure of the fistula. The patient later died from recurrent colorectal cancer without recurrence of empyema or air leakage. CONCLUSION: Thoracoscopic suture fixation of an EWS is a minimally invasive and effective option for stabilizing the device in large postoperative bronchial fistulas where bronchoscopic placement alone is insufficient. This technique may be useful when direct stump closure is difficult due to tissue fragility.