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Paper text:
a 69-year - old man was referred due to newly developed hemoptysis and was diagnosed as operable adenocarcinoma of the right upper lobe of the lung . because the tumor was invading the right main bronchus and azygos vein ,
however , from the 6th postoperative day , he developed tachypnea , desaturation ( sao2 85% to 90% under room air ) , and atrial fibrillation with rapid ventricle response around 150 beat per minute . despite increased oxygen supply , desaturation gradually progressed , and the patient was intubated for mechanical ventilation . after initiating positive mechanical ventilation , severe subcutaneous emphysema developed .
bronchoscopic examination revealed a bronchopleural fistula ( bpf ) on the right main bronchus stump ( fig .
exudates in the right pleural cavity were evacuated by closed thoracostomy , and microrganisms such as streptococcus pneumonia and pseudomonas aeruginosa were isolated from the pleural fluid .
after 5 days of conservative treatment with antibiotics and pleural cavity drainage , surgery was decided to obliterate bpf because the onset of empyema was relatively acute and stump fistula was too large to expect spontaneous closure .
after redo thoracotomy through previous incision , primary closure of bpf was performed by multiple interrupted sutures along with transposition of omental flap to the bronchial stump ( fig .
after thorough debridement and irrigation of pleural cavity , the right pleural cavity was packed with sterilized gauze and pericostal sutures were applied to approximate the intercostal space .
vacuum - assisted closure ( vac ) sponge ( curavac ; daewoong , seoul , korea ) was applied just above the rib leaving the pleural cavity communicated through intercostal space .
a 12 french chest tube was placed into the vac sponge to apply negative pressure .
the skin above the vac sponge was widely covered using adhesive drape and negative pressure of 120 mmhg was applied for exudates evacuation .
three additional vac dressing changes were performed under general anesthesia on every 3 days after bpf closure . after confirming that no more organisms from the right pleural cavity were isolated by follow - up microbial culture ,
clagett operation was performed on 9th postoperative days from bpf closure and thoracotomy wound could be closed without additional vac apply .
the patient remains asymptomatic without any evidence of infection or wound problem for 7 months follow - up .
postpneumonectomy empyema ( ppe ) is a life - threatening complication , and is often related with a bpf .
treatment of ppe should be targeted on closure of bpf , effective drainage of pleura cavity , and obliteration of the dead space .
one of the most popular approaches to treat ppe with bpf is the closure of bronchial stump followed by irrigation of the pleural space through open window thoracotomy .
delayed closure is performed with dead space filled by antibiotics solution ( so - called clagett operation ) .
although this approach has been shown to be highly successful , it forces the patient long hospitalization during the sterilization and stressful daily irrigation with dressing change .
, novel technique using vac has been widely used for various wound infections , such as deep sternal wound infection and open orthopedic fractures .
vac device promotes wound healing by generating negative pressure which leads to granulation tissue formation , removal of exudates , and reduction of edema with increased tissue perfusion by arteriolar dilatation .
we borrowed this advantage of vac for the sterilization of pneumonectomy space instead of daily irrigation with dressing change through open thoracotomy . in this patient ,
peribronchial tissue was fresh enough for early surgical repair because the detection of ppe with bpf was relatively earlier .
therefore we thought early sterilization with vac was possible , if we could obliterate the bpf with omental flap transposition . before we decided to conduct this procedure , one of our main concerns was complication induced by negative suction pressure , such as bleeding , disruption of repaired fistula , or mediastinal shifting .
in this case , we packed sterilized gauze into pleural cavity to avoid direct contact of negative pressure to mediastinum ( fig .
exudates were evacuated by the vac system through communication along the intercostal space . by these methods stated above , we could control the ppe effectively for relatively short period , less cost and trouble for patient .
although vac dressing in ppe with bpf is not widely used method , it could be an effective alternative method for the open window sterilization with shorter treatment period in selected patients .
postpneumonectomy empyema is a life - threatening complication , which is often related with a bronchopleural fistula . 
 after surgical repair of fistula , sterilization of infected pleural cavity is important and usually carried out by long - term cyclic irrigation . 
 we report a case in which vacuum - assisted closure device was successfully applied to sterilize the pleural cavity and obliterate bronchopleural fistula .