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+A 61-year-old male patient had a history of chronic obstructive pulmonary disease under regular bronchodilator treatment.
+In 2014, he suffered from severe productive cough with mucus sputum for several months and unintentional body weight loss 6 kg within 6 months.
+After sputum analysis and chest imaging examinations in May 2014, he was diagnosed of squamous cell carcinoma in right upper lobe lung (cT3N2M0, stage IIIa).
+Then he received neoadjuvant chemoradiotherapy (etoposide 70 mg [45 mg/m2] + cisplatin 79 mg [50 mg/m2]; 4500 cGY in 25 fractions) from June to July 2014.
+In October 2014, surgical intervention was arranged.
+Because the tumor was located at right hilum and invaded main bronchus and major vessels, video-assisted thoracoscopic surgery with right side intrapericardial pneumonectomy was performed.
+Postoperatively, pathological exams revealed squamous cell carcinoma, T3N0M0, stage IIB.
+The postoperative course was smooth but he suffered from severe cough and right chest pain one month later.
+Laboratory exams revealed leukocytosis (white blood cells = 21,860 μL) and elevated C-reactive protein to 23.94 mg/dL.
+Chest X-ray showed cavitary lesion and computed tomography showed pleural effusion and fluid collection with mottled gas appearance in the dependent portion of right hemithorax (Fig.1A).
+According to the patient's history, results of laboratory exams, and imaging findings, postpneumonectomy empyema was diagnosed and bronchopleural fistula was highly suspected.
+After admission, chest tube drainage was inserted and bronchoscopic tissue glue sealing was performed.
+However, persistent air leakage was presented and we decided to repair the bronchial stump with flap coverage.
+Because the patient just received neoadjuvant chemoradiotherapy a few months ago, the flaps harvested from chest area were not appropriate because the pedicle arteries might have been injured by irradiation.
+After discussing with the plastic surgeon, we decided to repair the bronchial stump by a TRAM flap.
+Intraoperatively, the patient was placed in supine.
+Right side exploratory thoracotomy was performed and the bronchial stump was located.
+The superior epigastric vascular artery and right rectus abdominis muscle was identified and the location of the TRAM flap was marked on the skin (Fig.2A).
+Then the TRAM flap was harvested from right rectus abdominis (Fig.2B) and was deepithelialized (Fig.2C).
+Through a subcutaneous tunnel, the TRAM flap was moved toward the right thoracic space with no tension or kinking on the pedicle (Fig.2D).
+Then the TRAM flap was fixed to posterior chest wall to cover the bronchial stump (Fig.2E) and the tissue glue was also applied to the bronchial stump under bronchoscope.
+The donor site of flap was closed with mesh repair.
+The postoperative course was smooth and the air leak was diminished gradually.
+Then the patient was discharge under stable condition and was free from air leak after following for 12 months (Fig.1B).
+The patient provided written informed consent for publication of this report and all accompanying images.