From the Guidelines
The primary treatment for a transphrenic fistula typically involves surgical repair, with a lift operation being a potential approach depending on the specific anatomical considerations. The surgical intervention aims to close the abnormal connection between the pleural space and the abdominal cavity. Before surgery, patients usually require stabilization with chest tube drainage to manage any pneumothorax or effusion, along with appropriate antibiotic therapy if infection is present.
Key Considerations
- The surgical repair may involve a thoracotomy or thoracoscopic approach to access the diaphragm, with direct closure of the fistula using sutures, possibly reinforced with a muscle flap or synthetic mesh for larger defects.
- Optimization of the patient's nutritional status is crucial before surgery, as malnutrition with BMI <20 kg/m2 appears as an independent risk factor for complications, as demonstrated in studies 1.
- Early nutritional support, independently of the route of administration, decreases the occurrence and severity of fistulas, and a multidisciplinary team including a gastroenterologist, surgeon, and dietitian should be involved in the treatment plan 1.
Postoperative Care
- Postoperatively, patients require continued chest drainage until the lung has fully expanded and any air leak has resolved, typically for 3-7 days.
- Pain management is essential and may include intercostal nerve blocks, epidural analgesia, or systemic analgesics.
- The prognosis is generally good following successful repair, though outcomes depend on the underlying cause of the fistula and any associated conditions, and recurrence is possible, particularly in cases where the fistula developed due to chronic inflammation or malignancy, necessitating close follow-up after the procedure.
From the Research
Transphrenic Fistula Treatment
The primary treatment for a patient with a transphrenic fistula is not explicitly mentioned in the provided studies. However, we can look at the treatment options for similar conditions, such as anal fistulas, to gain some insight.
Treatment Options for Anal Fistulas
- Total fistulectomy with simple closure of the internal opening has been used for the management of complex anal fistulas, with a success rate of 74% 2.
- Total fistulectomy with sphincteroplasty and closure of the residual cavity has been shown to be effective for trans-sphincteric perianal fistulas, with a success rate of 97.7% 3.
- Fistulotomy with end-to-end primary sphincteroplasty has been used for complex anal fistulas, with a success rate of 95.8% 4.
- Ligation of the intersphincteric fistula tract (LIFT) is a sphincter-sparing technique that provides complete resolution of the transsphincteric fistula, with a primary success rate of 84% 5.
Lift Operation
- The LIFT procedure has been shown to be a feasible treatment option for primary and recurrent fistulas, with excellent success rates 5.
- The success rate of the LIFT procedure is influenced by fistula characteristics rather than the chosen technique 5.
Transphrenic Fistula
- There is limited information available on the treatment of transphrenic fistulas, and it is not clear if the lift operation is a suitable treatment option for this condition.
- Further research is needed to determine the most effective treatment for transphrenic fistulas.