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.