Emergency thoracoscopic management of early ablation-tract bronchopleural fistula after low-power lung microwave ablation: a case report

Background Microwave ablation (MWA) is an established local therapy for selected pulmonary nodules in patients who are poor candidates for surgery. Bronchopleural fistula (BPF) is a rare but serious complication after lung ablation. Case presentation A 74-year-old woman with prior bilateral thoracic interventions and impaired pulmonary reserve underwent CT-guided percutaneous MWA (30 W for 4 min) for a right upper lobe ground-glass nodule on post-ablation day (PAD) 0. On PAD2, chest radiography showed a large right pneumothorax with more than 50% right lung compression, and right chest tube drainage was promptly performed with symptomatic improvement. On PAD5, she developed worsening chest tightness and rapidly increasing fever; in the context of recurrent pneumothorax and poor lung re-expansion despite chest drainage, urgent CT showed findings highly suggestive of BPF with pleural infection/empyema, including an air-fluid cavity along the ablation tract. Emergency VATS was performed on the same day. Intraoperatively, a thick-walled purulent necrotic cavity was identified along the ablation tract and communicated with a distal branch of the anterior segmental bronchus. Thoracoscopic adhesiolysis, decortication, debridement, partial pulmonary resection of the fistula-bearing lung tissue, pleural irrigation, and chest tube drainage were performed. The pneumothorax resolved, lung re-expansion was satisfactory, and the patient recovered and was discharged. At 3 months, no clinical evidence of recurrent fistula or need for reintervention was observed, and 1-month CT showed no definite radiologic evidence of recurrent BPF, empyema, or local progression. Conclusions This case highlights that BPF may occur early even after low-power lung MWA. In a post-MWA pneumothorax patient, new fever, poor lung re-expansion despite chest drainage, and a CT air-fluid cavity along the ablation tract should raise suspicion for MWA-tract-related BPF. In selected severe cases with pleural infection/empyema and a non-expanding lung, prompt thoracoscopic source control may be considered, but a single case cannot define a universal management algorithm.