Open surgical excision vs. endoscopic radiofrequency ablation in managing congenital pyriform sinus fistula-a comprehensive analysis of 166 cases

Abstract

Background: Congenital pyriform sinus fistula (CPSF) is uncommon congenital abnormality, and the optimal definitive treatment has not yet been established. The aim of the present study was to comparatively evaluate patients with CPSF regarding the indications and outcomes of treatment with open surgical excision (OSE) vs. endoscopic Radiofrequency Ablation (RA), and the advantages of both therapeutic procedures were also analyzed.

Methods: An observational, longitudinal, retrospective, analytical and comparative study was conducted on 166 consecutive pediatric patients with CPSF treated at Shanghai Children's Hospital between December 2018 and September 2023.

Results: In this study, there were 79 males and 87 females. The median age at operation was 4.8 years (8 days to 15 years). OSE and Endoscopic RA were respectively performed in 48 and 118 children. The gastric tube retention time after RA was longer (3 days vs. 14 days) than after OSE. Patients with a history of incision and drainage (I&D) tended to choose OSE (75.0% vs. 39.0%, P < 0.01). There were no significant differences in postoperative complications and recurrence rates between these two groups (P > 0.05), but the hospitalization duration was shorter for RA group compared to OSE group [2 (2-3) vs. 4 (3-5), P < 0.01].

Conclusions: Both OSE and RA are recognized as first-line treatment options for CPSF, which show no significant differences in prognosis, except hospitalization duration and the gastric tube retention time. Nevertheless, the indications for OSE and RA differ, which are influenced by factors such as the inflammatory stage, specific typing, previous treatments, and the surgeon's expertise. The selection of surgical approach should be carefully determined based on individual circumstances.

Keywords: children; congenital pyriform sinus fistula; endoscopic radiofrequency ablation; neck abscess; open surgical excision.

Figure 1

Intraoperative images of endoscopic RA. (A) The internal opening of the fistulous tract; (B): low-temperature plasma electrode in the sinus tract during R; (C): view after RA. White arrow: the internal opening of CPSF; Black arrow: plasma electrode (D): I&D of neck abscess in combination with RA in AIS. CPSF: congenital pyriform sinus fistula; RA: radiofrequency ablation; AIS: acute infection stage.

Figure 2

Intraoperative images of open surgical excision. (A) Neck fusiform incision; (B): methylene blue as an indicator; (C): the methylene-blue- dyed fistula under thyroid cartilage. (D) High ligation and resection of the fistulous tract. White circle: the internal opening; White arrow: fistula; Black arrow: laminae of thyroid cartilage.

Figure 3

Giant piriform fossa cyst of newborn. (A) CT images; (B) clinical photograph. White arrow: giant piriform fossa cyst.

Figure 4

Ultrasound of neck. Tubular hypoechoic fistula into the posterior part of the right lobe of the thyroid gland. White arrow: fistula; Black arrow: thyroid gland.

Figure 5

CT scan of neck. (A) Axial view; (B) coronal view. Black arrow and black circle: irregular low-density mass in the left lobe of the thyroid, consistent with a deep cervical abscess near the left thyroid; white arrow: point-like gas density shadow.