Anatomical Study Of Congenital Pyriform Fistula And Clinical Application Of Modified Fistulectomy In The Treatment Of Congenital Pyriform Sinus Fistula

ObjectiveTo investigate the actual tract.?segamental and its adjacent anatomy of CPSF(Congenital Pyriform Sinus Fistula).According to the actual anatomic characteristics of CPSF,the operative methods and procedures were improved and compared with the traditional ones,and the clinical application and significance of the modified operation were discussed.MethodsThe complete data of 90 patients with CPSF undergoing open surgery(seen during operation)were analyzed retrospectively.The course and adjacent anatomy of fistula were summarized and analyzed.The anatomic characteristics of CPSF were summarized and the fistula was classified according to its local anatomic characteristics.The clinical data of 84 patients with CPSF treated by modified Pyriform sinus fistulectomy and 40 patients treated by traditional operation were analyzed retrospectively.The Key evaluation indicators include operation time,intraoperative blood loss,postoperative complications(temporary vocal cord paralysis,permanent vocal cord paralysis,cough,wound bleeding,wound infection,pharyngeal fistula)and curative ratio were compared between the two methods.ResultsAll 90 patients successfully exposed the fistula,38 cases(42.22%)entered the piriform fossa from the medial of inferior cornu of the thyroid cartilage through the inferior constrictor of pharynx,and 9 cases(10.0%)passed through the inferior cornu of the thyroid cartilage into the piriform fossa,fistula was perforated the inferior constrictor of pharynx and descending from the lateral of inferior cornu of thyroid cartilage in 43 cases(47.78%).the fistula entered the thyroid gland in 73 cases(81.11%)and did not enter the thyroid gland in 16 cases(17.78%).in all 90 patients,the fistula entered the pyriform fossa superiorly to the recurrent laryngeal nerve entering the larynx,the tract of all the fistulas actually walked far different from that of theoretical ones,according to the course and adjacent anatomy of cpsf,we divided the whole fistula into 4 segments,that is:the posterior inner segment of thyroid cartilage,the inferior cornu of thyroid cartilage segment,the inner segment of thyroid gland,the lateral inferior segment of thyroid gland.The posterior inner segment of the thyroid cartilage is initial part of the fistula.It originated from the apex of pyriform sinus,then piercing out of the inferior constrictor of pharynx inferiorly near the Inferior Cornu of the Thyroid Cartilage(ICTC),and descending between the lateral branch of the superior laryngeal nerve and the recurrent laryngeal nerve.the ICTC segment is the second part of the fistula,piercing out of the inferior constrictor of pharynx and/or cricothyroid muscle,then entering into the upper pole of thyroid.The relationship between fistula and ICTC can be divided into three types:type A(medial inferior to ICTC)42.2%(38/90);type B(penetrate ICTC)3.3%(3/90);type C(lateral inferior to ICTC)54.5%(49/90).the internal segment of thyroid gland is the third part of fistula walking into the thyroid gland terminated in its upper pole(92.2%,83/90)or deep cervical fascia near the upper pole of thyroid(7.8%,7/90).the lateral inferior segment of thyroid gland is the last part of the fistula starting from the lateral margin of thyroid gland,most of which are iatrogenic pseudo fistula.The meticulous anatomy of fistula was carried out by anterograde anatomy of fistula in"modified Pyriform fossa fistula resection".The operative procedure can be summarized into four parts.That is,retrograde anatomy of recurrent laryngeal nerve,anatomy of external branch of superior laryngeal nerve,anterograde anatomy of fistula and partial thyroidectomy.All 124 patients successfully completed the operation and discharged from the hospital,the operation time,intraoperative blood loss and average hospital stay of the modified operation were less than those of the traditional operation(P<0.05).There were 1 case of postoperative infection,1 case of temporary vocal cord paralysis,no bleeding,no pharyngeal fistula,no dysphagia,no permanent vocal cord paralysis and no cough,the incidence of complications was 2.3%(2/84).There were 3 cases of wound infection and 2 cases of bleeding after traditional operation.There were 3 cases of temporary vocal cord paralysis and 2 cases of pharyngeal fistula,the incidence of complications was 25.0%(10?40).The incidence of complications in the modified operation was significantly lower than that in the traditional operation.There was significant difference between the two methods(P<0.05).There were no complications such as permanent recurrent laryngeal nerve paralysis or hypothyroidism.Three cases of recurrence treated by.traditional operation recurred at 3,8 and 12 months after operation,all of them showed cervical swelling and pain,among them,1 case was treated by endoscopic cauterization and 1 case was cured by reopening surgical resection,1 case lost follow-up.All patients in the modified group were followed up for 14?60 months and no recurrence was found.ConclusionCPSF fistula have a complicated pathway,each segment is closely related to the main tissues and organs?nerves and vessels.Familiar with the actual tract and subsection and its adjacent anatomy will facilitate precise positioning and accurate resection in open surgery.On the basis of well understanding of fistula anatomy,meticulous anatomy and accurate resection of fistula by procedure optimized"modified Pyriform fossa fistula resection"can greatly reduce the complexity of the operation,eliminate recurrence and significantly reduce complications.