Application of 3D printing imaging technology in the treatment of bronchopleural fistula with individual customized bronchial occluder.

Surgical approaches to lung cancer resection are rapidly evolving, particularly for early-stage lung cancer. Advances in chest CT technology and increasing use of CT in patient care have led to detection of smaller nodules, many with ground-glass attenuation that do not require lobectomy for resection. Lung-sparing and minimally invasive techniques have been shown to result in improved patient outcomes compared with those of traditional open thoracotomy and are noninferior in terms of cancer recurrence. As more patients undergo these surgeries, it is important for radiologists to be aware of useful information for surgeons before the operation. It is helpful for radiologists to understand the indications for lung-sparing surgery and have a basic understanding of the techniques involved in video-assisted and robotic thoracic operations. Identification of the location and morphology of the tumor, as well as the pulmonary vasculature that feeds and drains the segment of lung containing the tumor is important. Also, the presence of emphysema, pulmonary fibrosis, and incomplete fissures is useful information. In addition, chest imaging is also progressing, with improvements in multiplanar reformations and three-dimensional imaging allowing for more detailed and accurate image-based localization of tumors and visualization of anatomy. Nodule localization for surgery plays an even larger role given the limited ability to palpate nodules during surgery with minimally invasive surgery approaches. Methods can involve imaging and in vivo localization, with transthoracic and bronchoscopic methods used to label a nodule. Finally, radiologists should be aware of postoperative complications and their imaging characteristics, such as suture line granulomas and bronchopleural fistulas. Supplemental material is available for this article. ©RSNA, 2025.

Background: Post-pneumonectomy bronchopleural fistula (PPBPF), although infrequent, represents one of the most devastating complications after pneumonectomy, carrying high morbidity and mortality. Accurate risk stratification is essential for timely management. Systemic inflammation-based hematologic indices-such as neutrophil-to-lymphocyte ratio (NLR), C-reactive protein/albumin ratio (CAR), systemic inflammation response index (SIRI), systemic immune-inflammation index (SIII), prognostic immune-inflammation index (PIII), and platelet-to-lymphocyte ratio (PLR)-serve as accessible, low-cost biomarkers reflecting host immune status and inflammatory burden. This study aimed to evaluate their association with mortality risk in patients with PPBPF. Methods: A multicenter retrospective cohort of 33 PPBPF patients (2014-2023) was analyzed. Demographic, clinical, and laboratory data at diagnosis were retrieved. Inflammatory indices were calculated from hematologic parameters. Associations with mortality were assessed using receiver operating characteristic (ROC) curves and univariate logistic regression. Post hoc power analyses were performed for key biomarkers. Results: Nine patients (27.3%) died during follow-up. Non-survivors had significantly higher levels of all biomarkers (p < 0.05). ROC analysis identified NLR as the most powerful discriminatory marker (AUC: 0.862), while SIII, SIRI, and CAR also demonstrated high accuracy (AUC > 0.83). Optimal thresholds of NLR ≥ 12 and CAR ≥ 10 yielded 88.9% sensitivity, >80% specificity, and excellent negative predictive values (NLR: 94.4%; CAR: 94.7%). Post hoc power analysis demonstrated robust statistical power for SIRI (94.9%), CAR (87.2%), and SIII (84.5%). Conclusions: Systemic inflammation-based biomarkers, particularly NLR and CAR, show strong associations with mortality in PPBPF. Incorporating these indices into clinical practice may help identify patients at increased risk and facilitate tailored surveillance and management strategies.

Tension-type pneumothorax in particular is a life-threatening emergency that requires prompt diagnosis and treatment. Although imaging modalities—a chest CT scan being the gold standard—are frequently employed for confirmation, clinical diagnosis is essential in cases when imaging delays could be lethal. A bronchopleural fistula (BPF) complicated spontaneous pneumothorax in an obese patient with a body mass index of 43.6 kg/m². Before the chest tube was inserted, the diagnosis was verified by a straightforward and repeatable bedside diagnostic technique: loss of syringe plunger recoil following pleural entrance with a 16G trocar cannula. The patient experienced a persistent air leak that was consistent with BPF after tube thoracostomy, and this was meticulously watched. After three weeks of conservative treatment, the air leak eventually closed on its own, negating the need for surgery. This case demonstrates how the syringe plunger recoil test can be used as a simple and trustworthy bedside tool to support imaging in the quick diagnosis of pneumothorax, enabling prompt treatment to start. It also implies that a cautious conservative approach may allow for the spontaneous closure of a bronchopleural fistula with careful monitoring and the right safeguards, saving some patients from the hazards associated with major surgery.

Robotic-assisted thoracic surgery (RATS) is increasingly acknowledged for its efficacy in managing early-stage non-small cell lung cancer (NSCLC), owing to its distinct technical advantages. Nevertheless, individuals with pronounced incomplete interlobar fissures often face higher rates of conversion to alternative procedures and an increased likelihood of postoperative complications. This retrospective study introduces a novel robotic surgical technique tailored to the challenges posed by incomplete fissures, evaluating both its safety and therapeutic outcomes.A retrospective analysis was performed on the clinical data of individuals who received robotic-assisted lobectomy for NSCLC at our center from March 2021 to September 2024. Altogether, 554 cases were incorporated and divided into two cohorts-those with fully developed fissures and those with partially developed fissures-based on the anatomical features of their lung fissures.Among the 554 patients analyzed, 302 were categorized as having complete fissures, while 252 were identified with incomplete fissures. Comparative evaluation revealed no statistically significant differences between these groups in terms of operative duration (p = 0.411), intraoperative blood loss (p = 0.822), chest tube retention time (p = 0.733), rate of prolonged air leakage (PAL, p = 0.805), or postoperative hospital stay (p = 0.962). Importantly, neither group exhibited cases of bronchopleural fistula, pneumonia, or perioperative death.Incomplete fissures do not increase the procedural difficulty of lobectomy when employing this robotic surgical approach. This newly developed, robot-specific technique ensures both safety and efficacy for patients with incomplete fissures.

Background: Medical Thoracoscopy (MT) is a minimally invasive endoscopic procedure that allows almost complete visualization of pleural cavity, collection of appropriate amount of samples and to do necessary work for the treatment of pathologies. MT is gaining popularity world-wide and few centers in Dhaka practicing it. Here, this study observed the utility of MT in a single centre in a single calendar year. Methods: It was a retrospective study done at respiratory medicine center of a tertiary care hospital, Dhaka reviewing records of all cases of medical thoracoscopy (MT) done as a diagnostic and/or therapeutic procedures over one year. After collecting data, we analyzed them to see the indications, pre- and post-procedural status, outcomes and safety of this procedure. Results: Total 16 patients with unexplained pleural effusion were undergone medical thoracoscopy (MT) last year in Square Hospital. All 16 had diagnostic MT and 7 had therapeutic MT as well. Among all 16 patient, 3 patients were from Oncology, 2 from intensive care unit, 1 from gastroenterology unit and 1 from nephrology unit, others were from our inpatients. MT revealed malignancy in 7 cases (43.75%), tuberculosis in 4 (25%), complicated multiloculated empyema in 3 cases (18.75%), hepatic and renal hydrothorax in 1 case respectively. Among malignant cases, bronchial carcinoma predominates, followed by breast cancer (1 patient) and uterus (1 patient). Pleural adhesionolysis and deseptation was done in 5 cases and pleurodesis by talc slurry or poudrage in 4 cases. There was no major adverse effect seen at or after the procedure. Pain due to chest tube was the main adverse-effect which was managed with simple analgesics. One patient had mild reperfusion pulmonary edema which was easily managed with perenteral steroid for 3 days. One patient had bronchopleural fistula which was managed with repeated tetracycline pleurodesis. All patients were managed effectively with only 2 patients shown to have minimal residual effect like pleural thickening. Conclusion: Medical thoracoscopy or pleuroscopy is a safe and very effective procedure for the diagnosis of the primary etiologies of unexplained pleural effusion and their management. J Bangladesh Coll Phys Surg 2025; 43: 277-293

While meso/dextrocardia, a cardiac axis abnormality, is associated with various complications and a poor prognosis, few studies have been reported. We aimed to identify and review patients at our hospital who had been diagnosed with fetal meso/dextrocardia. The medical records of 29 patients diagnosed with fetal meso/dextrocardia between April 1, 2014 and March 31, 2024 were reviewed. We identified eight cases of mesocardia and 21 cases of dextrocardia (17 dextropositions and four dextroversions). Right lung hypoplasia (including 3q trisomy, esophageal bronchopleural fistula, and left pulmonary artery sling) was identified in three cases. Five cases of persistent left superior vena cava (PLSVC) were identified [isolated PLSVC (n = 2), VACTERL association (n = 1), trisomy 13 (n = 2)]. Dextroposition was linked to congenital pulmonary airway malformation (eight cases), left pulmonary sequestration (one case), congenital diaphragmatic hernia (six cases), right lung hypoplasia (one case), and VACTERL association with right lung aplasia and esophageal atresia (one case). Dextroversion was associated with asplenia syndrome (two cases), single-ventricle (one case), and Temple syndrome with PLSVC and bilateral hypoplastic pulmonary arteries (one case). Among 29 newborns, six (20.7%) died during the early neonatal period and seven (24.1%) required postnatal multidisciplinary treatment, highlighting a poor prognosis in many cases. While some patients, such as those with isolated PLSVC, had favorable outcomes, several cases involved severe complications requiring intensive perinatal management. When fetal meso/dextrocardia is detected, it is critical to evaluate fetal anomalies comprehensively and not limit assessment to the heart and lungs.

To explore the feasibility and safety of using 3D-printed models to assist in the treatment of refractory peripheral bronchopleural fistulas with Amplatzer II-type occluders or coils. This was a retrospective analysis of 13 patients-10 males (76.9%) and 3 females (23.1%)-with an average age of 65.62 ± 12.30years (34-83years), who were treated at our center between April 2023 and August 2024 for peripheral bronchopleural fistulas. Primary diseases included lung cancer, esophageal cancer, severe pneumonia, and pulmonary hydatid disease. The fistulas were located in the right lung in 6 patients (46.2%) and in the left lung in 7 patients (53.8%), with a total of 19 fistulas in 13 patients. All the patients were diagnosed, with their fistula locations identified using 3D-printed models combined with tracheoscopic thoracic drainage tube injection of methylene blue, and were treated with Amplatzer II-type occluders or coils. All 19 fistulas were successfully occluded in a single attempt, with a technical success rate of 100%; coils were used in 4 patients (21.1%) and Amplatzer II-type occluders in 15 patients (78.9%). In 12 patients (12/13, 92.3%), the empyema cavities closed or were successfully drained without fluid, allowing for the removal of chest drainage tubes. In one patient (1/13, 7.7%), despite the occluder being well placed, there was no significant improvement in subcutaneous or mediastinal air accumulation, resulting in a clinical success rate of 92.3%. One month post-operation, significant differences in body temperature, white blood cell count, and performance status (PS) score were noted compared with preoperation values. 3D printing aids in the diagnosis and localization of peripheral bronchopleural fistulas. The use of vascular plugs or coils for occlusion treatment is safe and effective and is worthy of clinical promotion.

BackgroundLung abscess is typically managed by performing abscess drainage. While pulmonary resection effectively controls infection, its role in eliminating necrotic tissue remains debatable due to risks such as bleeding, desaturation, systemic inflammation, persistent air leakage, and bronchopleural fistula. In this study, we evaluated the outcomes of pulmonary resection for lung abscess refractory to medical therapy.MethodsWe retrospectively analyzed 70 patients who underwent salvage thoracoscopic surgery for lung abscess, along with 60 days’ follow-up, at a tertiary referral hospital between January 2016 and August 2022. Thirty-two patients underwent lobectomy, while 38 did not. The patients’ demographics, comorbidities, disease progression, 30-day and 60-day mortality, and operative morbidity were compared between the lobectomy and non-lobectomy groups.ResultsNecrotizing pneumonia was the leading cause of lung abscess (n = 53, 75.7%), with empyema being the most common sign of disease progression (n = 36, 51.4%). The lobectomy group had a lower mortality rate compared with the non-lobectomy group (15.6% vs. 36.8%, p = 0.047). Multivariate analysis identified a higher Charlson Comorbidity Index (CCI) as a risk factor for 30-day mortality (HR = 1.286, 95% CI = 1.059–1.561; p = 0.011), while lobectomy mitigated the 30-day mortality risk (HR = 0.255, 95% CI = 0.068–0.959; p = 0.043). Similarly, a higher CCI augmented the 60-day mortality risk (HR = 1.317, 95% CI = 1.105–1.571; p = 0.002), whereas lobectomy lowered it (HR = 0.319, 95% CI = 0.110–0.921; p = 0.035).ConclusionLobectomy significantly improves the 30- and 60-day mortality outcomes compared to non-lobectomy surgery, making it a viable option for pharmacotherapy-refractory lung abscess.

Bronchopleural fistula (BPF) is a serious postoperative complication following pneumonectomy for non-small cell lung cancer (NSCLC), significantly impacting morbidity and mortality. This study aimed to compare the clinical outcomes of carinal sleeve resection and primary suturing techniques in the surgical management of BPF, with a focus on complication rates, early mortality, and long-term survival. This retrospective study analyzed 33 patients who developed BPF after pneumonectomy for NSCLC between 2019 and 2024 at our institution. Patients were divided into two groups according to the surgical intervention employed: Group A (carinal sleeve resection) and Group B (primary suturing). Postoperative morbidity, 30-day mortality, re-fistulization rates, and long-term survival were assessed. The median length of hospital stay was significantly shorter in Group A (p = 0.016), and 30-day mortality was also lower in this group (p = 0.035). Group B exhibited a higher rate of re-fistulization (p = 0.024). No significant difference was observed between the two groups in terms of 5-year overall survival (p = 0.606). Carinal sleeve resection may offer a favorable alternative in selected patients with BPF, with reduced early mortality and shorter hospitalization. While long-term survival was comparable between techniques, individualized surgical planning based on patient-specific factors remains essential.

The purpose of this paper was to define the specturm of management for Parapneumonial Pleural Effusion/Pleural Empyema (PE/PPE) in children in Italy. We conducted an online survey, distributed by the SIVI committee to 54 Italian pediatric surgery centers. A total of 23/54 (43%) Italian pediatric surgery centers responded. All responders (100%) required an anteroposterior chest radiograph (CXR) as the first imaging approach to suspect PPE, and chest Ultrasound (US) was routinely used in 96% of centers. A preoperative CT scan was routinely performed in 70% of centers. An etiological diagnosis was obtained in more than 80% of patients in 13% of centers, between 40% and 80% of cases in 61% of centers and in less than 40% of patients in 26% of centers. Empirical antimicrobial therapy with 2 antibiotics is the most commonly used therapeutic scheme (78% of centers) and targeted antibiotic therapy was used in 82% of enrolled centers. The majority of centers (57%) approached advanced stage pleural empyema with pleural drain placement and fibrinolysis (PDF); 26% of centers preferred to execute upfront Video-Assisted Thoracoscopic Debridement (VATD), and in 13% of centers, both fibrinolysis and VATD were used. In all cases (100%), urokinase was the fibrinolytic agent of choice. Broncho-Pleural Fistula (BPF) was treated conservatively with prolonged Pleural Drainage (PD) and antibiotics in 82% of centers, while the remaining 18% proposed early surgical treatment. 82% of centers proposed prolonged antimicrobial therapy for the treatment of Lung Abscess (LA), while 18% of centers preferred to execute upfront ultrasound-guided or thoracoscopic positioning of a pig-tail drain. As expected, we observed a lack of homogeneity in the treatment between the different centers: most of these have a preference for fibrinolysis over the use of primary VATD, with urokinase being the only fibrinolytic agent used in all centers. It would be desirable to involve as many centers as possible for the drafting of shared national guidelines in the treatment of PPE in children in Italy.

The management of residual or new ground-glass nodule (GGN)-like lung cancer after video-assisted thoracoscopic surgery (VATS) is challenging for patients who are not suitable for reoperation. This retrospective, large-sample, multicenter study aimed to evaluate the feasibility, safety, and preliminary efficacy of microwave ablation (MWA) for residual GGN-like lung cancer after VATS in early-stage lung cancer. A total of 216 patients with 216 residual GGN-like lung cancers who underwent 235 procedures of CT-guided percutaneous MWA after VATS (R0) of stage I-IIA lung adenocarcinoma from July 2016 to December 2023 were included in the study. The primary endpoints were technical success, complications, and pulmonary function test (PFT) variations after the MWA procedure. The secondary endpoints were local progression-free survival (LPFS) and overall survival (OS). The rate of technical success was 100%. The major complications after MWA included pneumothorax (12.3%, 29/235), pleural effusion (5.5%, 13/235), pulmonary infection (2.6%, 6/235), hydropneumothorax (1.3%, 3/235), intrathoracic hemorrhage (0.4%, 1/235), and bronchopleural fistula (0.4%, 1/235). No MWA procedure-related death was observed. The PFT at 1-3 months after MWA was not significantly different from the baseline. The median follow-up duration was 58.5 months, and the 1-, 3- and 5-year OS rates were 100%, 99.1% and 96.3%, respectively. The median follow-up period after MWA was 33.8 months, and the 1-, 2- and 3-year LPFS rates were 100%, 97.7% and 96.3%, respectively. CT-guided percutaneous MWA is a safe, effective, and potentially curative approach for patients with residual GGN-like lung cancer after VATS.

ABSTRACTIn the treatment of bronchopleural fistulas, it is necessary to consider bronchoscopic intervention and surgery depending on the patient's condition and fistula size. Submucosal injection and spreading of fibrin glue under bronchoscopy may be useful methods for the closure of small, pinhole‐like fistulas that are several millimeters in size.

Respiratory fistulas remain clinically challenging in endoscopic treatment due to the absence of convenient non-compressive sealing materials. Here, we developed an in situ self-fused powder adhesive (PP powder) to address this limitation. This material integrates the adaptive conformability of hydrogel microparticles with the pressure-resistant sealing capability of bulk hydrogels via water-triggered self-assembly. The PP powder exploits electrostatic attraction and topological effects between cationic microspheres (PL-TCEP) and polyacrylic acid (PAAc). This design yields strong tissue adhesion (29.7 kPa), robust sealing (24.7 kPa), and inherent antibacterial properties. Additionally, it promotes efficient coagulation by synergistically aggregating blood cells and autoactivating the coagulation cascade. Furthermore, we have rigorously validated those hemostatic, sealing, healing capabilities and translational potential through liver injury models, bronchopleural fistula models, infected wound models and rabbit tracheal fistula models. This multifunctional platform advances emergency fistula management while providing a paradigm for designing biomaterials addressing complex clinical scenarios requiring simultaneous hemostasis, sealing, and antimicrobial action. STATEMENT OF SIGNIFICANCE: This study introduces a rapidly self-assembled poly(amino acid)-based microgel, formed through dynamic ionic crosslinking between cationic poly(amino acids) and poly(acrylic acid) (PAAc). This microgel exhibits exceptional deliverability through narrow channels and hygroscopic self-assembly capabilities, making it an ideal candidate for endoscopic surgical applications, particularly in sealing respiratory tract fistulas. The engineered microgel demonstrates robust mechanical properties, far exceeding the physiological pressures of human airways. Leveraging the spatial architecture of cationic poly(amino acid) microspheres, the microgel not only exhibits inherent antimicrobial activity but also significantly enhances blood cell aggregation, thereby accelerating clot formation more effectively than commercial hemostatic powders. Furthermore, owing to its outstanding biocompatibility, the microgel shows great promise in visceral hemostasis and tissue regeneration, highlighting its potential for advanced biomedical applications.

PurposeTo compare the clinical outcomes of single operative port thoracoscopic anatomical lesion resection (TALR) with multi-portal video-assisted thoracic surgery (M-VATS) in the treatment of congenital lung malformations (CLMs) located in pulmonary segments S9-10, and to evaluate its safety and feasibility in routine practice.MethodsWe retrospectively analysed 46 paediatric CLMs cases treated thoracoscopically at our institution from January 2023 to January 2025. Patients were grouped by surgical approach: 13 underwent single operative port TALR, and 33 underwent M-VATS. Clinical parameters were compared between groups.ResultsCompared to M-VATS, the single operative port TALR showed significantly reduced blood loss (P = 0.01), chest tube time (P = 0.04), hospital stays (P = 0.04), and incision length (P < 0.01). No bronchopleural fistulas, conversions to open surgery, no recurrence or residual lesions occurred in either group.Conclusionsingle operative port TALR is safe, feasible, minimally invasive, and offers excellent cosmetic outcomes, representing a promising surgical technique for treating CLMs involving segments S9-10.

Streptococcus anginosus group (SAG) consists of oral facultative anaerobic bacteria that are increasingly identified as causative organisms of empyema, yet they are not often considered to be a cause of community-acquired pneumonia. The objective of this study was to determine the pathogenesis of empyema caused by SAG bacteria in pure culture (ie, no other organisms grown in culture or seen on Gram stain of the exudate) and in mixed cultures. This retrospective cohort study was conducted in 3 hospitals in an urban region of Southern California. The sample included adult patients with empyema and pleural fluid cultures positive for 1 or more SAG microorganisms. We excluded patients with bronchopleural fistulas or lung abscess because SAG bacteria are known to be a cause of those infections and can breach the physical barrier of the visceral pleura. Thirty-seven patients with SAG empyema were identified: 14 had had polymicrobial cultures including 1 or more species of SAG bacteria (pSAG) and 23 had pure cultures of SAG bacteria. The patients were mostly middle-aged men with comorbidities, some of which predispose to aspiration or the inability to clear aspirated secretions. The patients with pSAG empyema were more likely to have cancer and/or prior surgical disruption of the esophagus with resulting mediastinitis. Patients with SAG empyema were more likely to use substances such as alcohol, sedatives, and narcotics. All computed tomography (CT) scans were initially interpreted as atelectasis abutting the empyema, but 13 patients with SAG empyema had contrast-enhanced CT scans that were suitable for measuring Hounsfield units (HUs) in the areas of consolidation adjacent to the SAG empyema; these scans revealed that they all had pneumonia as the source of their empyema. The most common species isolated from the SAG cases was Streptococcus intermedius. Community-acquired SAG empyema is a complication of unrecognized SAG pneumonia. S intermedius was the most common species to cause SAG empyema and pneumonia in this small series. The pneumonias were subacute and misdiagnosed as "adjacent atelectasis." Some cases of pSAG empyema were a complication of mediastinitis in patients with malignancies. Measurement of HUs in consolidations adjacent to empyema is useful for establishing the diagnosis of pneumonia in patients who present with what appears to be primary SAG empyema. In terms of limitations, this is a retrospective analysis, and not all patients with SAG empyema had contrast-enhanced CT scans. Furthermore, none of the pSAG cases were reanalyzed to measure HUs in the consolidated lungs. We also did not use molecular methods to speciate SAG isolates or detect fastidious anaerobes in the empyema fluids, although all the exudates were cultured anaerobically on multiple media for at least 5 days.

Efficacy and safety of endobronchial spigot for the management of postoperative fistula, refractory pneumothorax, and hemoptysis: A single-center retrospective study.

Pleural empyema is a recognized complication of pneumonia and causes significant morbidity in children. Insertion of a small-bore chest drain shortens hospital admission but can be associated with pneumothorax. This is usually assumed to be caused by a bronchopleural fistula or a displaced drain and therefore under pressure, requiring surgical intervention. We describe two children who developed a pneumothorax after a large empyema was drained. Both children were clinically stable and the pneumothorax was not under pressure. They were managed conservatively with complete resolution after 3-6 months. By highlighting these cases, we hope to stop other children undergoing unnecessary surgery.

An innovative bronchial occluder for postresectional bronchopleural fistula: A comparative clinical study

Abstract Background Bronchopleural fistula (BPF) is a rare but serious complication following lung surgery and is associated with significant morbidity and mortality, particularly in the first 2 weeks after surgery. BPFs are more common after right-sided resections, particularly pneumonectomy, than left-sided resections due to anatomical and physiological factors. Traditional management of postoperative pyothorax includes open-window thoracostomy (OWT) or thoracoplasty to control infection and promote pleural healing. In March 2023, the first Japanese guideline for the management of pyothorax was published, which recommended OWT or closure for BPF; this recommendation was based on level 2D evidence. In the case reported here, left-sided BPF was managed without direct bronchial stump closure or subsequent pyothorax cavity obliteration procedures, thereby emphasizing the importance of early diagnosis, effective drainage, and personalized management. Case presentation A 70-year-old man with clinical stage IB (T2aN0M0) squamous cell carcinoma of the left upper lobe had undergone thoracoscopic lobectomy. Fourteen days postoperatively, he presented with a fever of 37.4°C and an oxygen saturation of 94%. Laboratory tests revealed leukocytosis (13.9 × 103/μL) and elevated C-reactive protein level (22.6 mg/dL), indicating an inflammatory response. Computed tomography (CT) revealed left anterior pleural effusion, which was later diagnosed as empyema, while initial bronchoscopy revealed no obvious fistula. However, contrast injection after pigtail drainage confirmed a BPF. The empyema caused by the BPF was controlled with catheter drainage and antibiotics. Persistent air leak and difficulty in direct bronchial stump closure led to OWT on postoperative day 21. The patient recovered uneventfully within 35 days. After discharge, oral antibiotics were continued for 1 month. Follow-up imaging revealed no recurrence or residual infection, highlighting the effectiveness of early imaging-based diagnosis and management, which avoided surgical closure of BPF. Conclusions The present case demonstrates the effectiveness of innovative approaches that avoid bronchial stump closure for managing complex thoracic conditions, such as BPFs. The successful outcome suggests the potential for broader application of similar techniques, offering a viable alternative to more invasive procedures.