BACKGROUND: Recurrent thoracic empyema in the presence of residual lung tissue can be treated with an open window thoracostomy (OWT). Vacuum-assisted closure (VAC) of these large thoracic defects is a novel option. METHODS: Nineteen patients with residual lung tissue received an OWT for treatment of recurrent thoracic empyema. In this retrospective case series, 8 patients (aged 58 +/- 20 years, all male) were treated conventionally, and 11 patients (aged 53 +/- 17 years, 8 male) were treated with VAC. RESULTS: The application of the VAC system resulted in rapid debridement of the thoracic cavity and reexpansion of the residual lung tissue. The duration of OWT and VAC therapy was 39 +/- 17 and 31 +/- 19 days, respectively. All 11 patients were amenable for subsequent closure using pedicled muscular flaps. In 2 patients, VAC therapy alone resulted in complete closure of the OWT. The average duration of follow-up was 46 +/- 19 months. All patients, except 1, have recovered well. One patient died of nonpulmonary causes. In the non-VAC group (n = 8), the OWT was managed conventionally by application of saline-soaked gauzes. In 2 patients, the OWT was eventually closed using pedicled muscular flaps (after 75 and 440 days, respectively). Four patients died of OWT-related complications (1 bleeding, 3 recurrent infections) during follow-up; 1 patient died of a cause unrelated to OWT. The average duration of OWT was 933 +/- 1,422 days. CONCLUSIONS: When compared with conventional management of OWT, VAC therapy accelerates wound healing and improves reexpansion of residual lung tissue in patients with OWT after empyema, allowing rapid surgical closure.