Several guidelines on the management of tuberculosis exist. They are considered a very good starting point for treatment, but not the only option, especially in cases of lung complications. Surgical treatment of these complications still may be challenging. We report the surgical strategy adopted to avoid thoracoplasty in a 38-year-old Bangladesh patient with bilateral cavitary pulmonary tuberculosis, complicated by a right empyema with bronchopleural fistula (BPF). After 6 months of proper medical treatment and surgical drainage of the right pleural cavity to achieve lung re-expansion, pleural decortication was attempted. Due to the persistence of chronic BPF and to the incomplete expansion of the lower and middle lobe, we decided to perform an open-window thoracostomy (OWT) instead of major surgery on the chest wall. This approach was preferred to a major lung resection, because of the increased surgical risks caused by inflammatory process around pulmonary vessels and the persistent pleural cavity infection. We achieved the intrathoracic infection resolution but not the BPF repair. Thus, the final step of the treatment consisted in closing both the BPF and the OWT with a myocutaneous pedicled flap of the rectus abdominis muscle. This decision was made to avoid disabling surgery of the chest. This case suggests that intrathoracic muscle transposition (IMT) may be an effective option to control BPF and residual thoracic cavity in chronic tuberculous empyema avoiding permanent open-window thoracostomy and thoracoplasty. The patient recovered well having an uncomplicated postoperative course.

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