EBUS Offers Lifesaving Alternative for Loculated Pleural Collection After Lung Surgery: Case Report

The report, authored by Güntuğ Batıhan and İhsan Topaloğlu from the Department of Thoracic Surgery at Kafkas University, Turkey, describes how EBUS-guided aspiration provided a safe and minimally invasive alternative when conventional transthoracic approaches were deemed too risky.

Loculated pleural collections that develop after major lung surgery often resemble empyema and can be difficult to evaluate using standard methods. In this case, the surgical changes following right superior bilobectomy made access challenging, prompting clinicians to opt for a nontraditional approach. The patient, a 67-year-old man who had undergone surgery six months earlier for central squamous cell lung carcinoma, returned with clinical indicators of infection, including elevated inflammatory markers and leukocytosis.

Postoperative recovery for this patient had been complicated by a prolonged air leak and incomplete re-expansion of the remaining right lower lobe. Earlier imaging had shown a sterile, loculated collection in the upper right hemithorax. On his current presentation, CT scans revealed that this pocket had developed air–fluid levels suggestive of infection. However, due to mediastinal shift, obstruction by the scapula, and the close proximity of major vessels and ribs, conventional ultrasound-guided thoracentesis was considered unsafe.

Given the anatomical constraints, the team selected EBUS as a feasible alternative. After explaining potential risks such as bleeding and infection, they obtained informed consent and proceeded with the procedure under general anesthesia using a laryngeal mask airway. Through a right paratracheal route, the EBUS probe successfully identified the loculated pleural pocket. A 22-gauge EBUS-TBNA needle was then used to aspirate approximately 15 cc of pleural fluid, which appeared echogenic with visible debris.

While blood, urine, sputum cultures, and pneumococcal antigen testing showed no evidence of infection, microbiological analysis of the pleural fluid confirmed the presence of Streptococcus pneumoniae. The patient was treated initially with intravenous ceftriaxone for two weeks, followed by oral amoxicillin–clavulanate for an additional 14 days. He showed progressive clinical improvement, inflammatory markers normalized, and he was discharged in stable condition. At a nine-month follow-up, he remained symptom-free.

The authors emphasized that postoperative thoracic anatomy can significantly alter the feasibility of traditional diagnostic pathways. In this scenario, EBUS provided a practical and safe alternative for accessing pleural collections that otherwise could not be reached. They note that while EBUS is typically used for mediastinal lymph node evaluation, its application is expanding as clinicians recognize its potential in complex thoracic conditions.

The case highlights how interventional bronchoscopy techniques are evolving to meet diagnostic challenges in patients with surgically altered anatomy. As demonstrated here, EBUS-guided aspiration may offer a valuable option in selected cases where conventional approaches are limited or unsafe.

Reference:

Batıhan, G., Topaloğlu, İ. Transbronchial EBUS-guided aspiration of a loculated pleural collection following right superior bilobectomy: a case report. BMC Surg 25, 562 (2025). https://doi.org/10.1186/s12893-025-03317-6