# A Case of Negative Pressure Wound Therapy Following Open Window Thoracostomy With Muscle Flap Filling for Chronic Empyema With Bronchopleural Fistula

## TL;DR

A 90-year-old woman with chronic tuberculous empyema and a fistula was successfully treated using open window thoracostomy with muscle flap and NPWT, significantly reducing cavity size.

## Contribution

A novel therapeutic strategy combining primary fistula closure and NPWT for chronic empyema with bronchopleural fistulas is presented.

## Key findings

- The empyema cavity decreased by 88.8% after treatment with NPWT and muscle flap coverage.
- Primary fistula closure during thoracostomy enabled early NPWT implementation and improved outcomes.
- The patient was transferred on day 65 following successful cavity reduction and wound care.

## Abstract

Negative pressure wound therapy (NPWT) after open window thoracostomy effectively reduces empyema cavity volume, but fistula control remains challenging in cases of bronchopleural/alveolopleural fistula. We report the successful treatment of chronic tuberculous empyema with bronchopleural and/or alveolopleural fistulas through primary closure during thoracostomy, combined with simultaneous NPWT. A woman in her 90s, with a history of left upper lobectomy (60 years prior), developed chronic tuberculous empyema with a cutaneous fistula. Chest computed tomography (CT) showed an air-containing empyema cavity with surrounding pneumonia. Despite spontaneous cutaneous fistula closure, thoracic drainage confirmed an air leak, and Mycobacterium
tuberculosis was isolated. Open window thoracostomy was performed with fourth-ninth rib resection (20 cm incision), alveolopleural fistula coverage using a pedicled serratus anterior flap, and cavity volume reduction with latissimus dorsi and serratus anterior flaps. NPWT commenced on postoperative day 3, continuing for six weeks after negative foam cultures. The empyema cavity decreased by 88.8%, from 118.2 cm³ to 13.2 cm³, facilitating gauze-based wound care and enabling patient transfer on day 65. Primary fistula closure during open window thoracostomy enables early implementation of NPWT, facilitating marked cavity reduction in chronic tuberculous empyema with fistula and representing a novel therapeutic strategy.