Pediatric Ovarian Torsion

Rate of oophorectomy in pediatric ovarian torsion: risk factors and change over time

PURPOSE

The management of ovarian torsion in pediatric patients has evolved over time. Ovarian salvage is currently recommended given concerns for fertility preservation and the low likelihood of malignancy. Studies have shown that the incidence of oophorectomy is higher amongst pediatric surgeons in comparison to gynecologists. Using a national database, this study examined how the surgical management of ovarian torsion has evolved.

METHODS

Children with a discharge diagnosis of ovarian torsion (ICD-9 code 620.5, ICD-10 code N835X) and procedure codes for oophorectomy (CCS code 119) were identified within the KID database from 2003, 2006, 2009, 2012, 2016, and 2019. Diagnosis of ovarian pathology was based upon ICD-9 and ICD-10 codes at the time of discharge.

RESULTS

A total of 7008 patients, ages 1-20, had a discharge diagnosis of ovarian torsion. Of those patients, 2,597 (37.1%) were diagnosed with an ovarian cyst, 1560 (22.2%) were diagnosed with a benign ovarian neoplasm, and 30 (0.4%) were diagnosed with a malignant neoplasm. There was a decreased risk of oophorectomy in urban-teaching versus rural hospitals (OR: 0.64, p < 0.001). The rate of oophorectomy has decreased overtime. However, patients with benign or malignant neoplasms were more likely to undergo oophorectomy than those without a diagnosis (OR: 2.03, p < 0.001; 4.82, p < 0.001).

CONCLUSION

The rate of oophorectomy amongst children with ovarian torsion has decreased over time. Yet, despite improvements, oophorectomy is common amongst patients with benign ovarian neoplasms and those treated at rural hospitals. Continued education is needed to optimize patient care in all clinical scenarios.

LEVEL OF EVIDENCE

IV.

Unusual imaging findings associated with abdominal pediatric germ cell tumors

Germ cell tumors of childhood are tumors arising from germline cells in gonadal or extragonadal locations. Extragonadal germ cell tumors are characteristically located in the midline, arising intracranially or in the mediastinum, retroperitoneum, or pelvis. These tumors are generally easily diagnosed due to typical sites of origin, characteristic imaging findings, and laboratory markers. However, germ cell tumors can be associated with unusual clinical syndromes or imaging features that can perplex the radiologist. This review will illustrate atypical imaging/clinical manifestations and complications of abdominal germ cell tumors in childhood. These features include unusual primary tumors such as multifocal primaries; local complications such as ovarian torsion or ruptured dermoid; atypical presentations of metastatic disease associated with burned-out primary tumor, growing teratoma syndrome, and gliomatosis peritonei; endocrine manifestations such as precocious puberty and hyperthyroidism; and antibody mediated paraneoplastic syndrome such as anti-N-methyl-D-aspartate-receptor antibody-mediated encephalitis. This review aims to illustrate unusual imaging features associated with the primary tumor, metastatic disease, or distant complications of abdominal germ cell tumors of childhood.

Improving Turnaround Time of Transabdominal Pelvic Ultrasounds with Ovarian Doppler in a Pediatric Emergency Department

Introduction

Adnexal torsion is an emergent surgical condition. Transabdominal pelvic ultrasound (US) with ovarian Doppler is used to diagnose adnexal torsion and requires a sufficient bladder volume. Reduce the turnaround time for US by 25% in girls 8-18 years of age who present to the emergency department (ED) for 24 months.

Methods

Our baseline period was from January 2020 to June 2021, and the intervention period was from July 2021 to June 2023. Patients 8-18 years old who required an US in the ED were included. There are two key drivers: early identification of US readiness and expeditious bladder filling. Interventions were (1) bladder volume screening; (2) utilization of bladder volume nomogram to identify US readiness; (3) epic order panels; and (4) rapid intravenous fluid method. The primary outcome was US turnaround time. Secondary outcomes were percentage of patients requiring invasive interventions to fill the bladder and patients with an US study duration of ≤45 minutes. The percent of patients screened by bladder scan was used as a process measure. Balancing measures used episodes of fluid overload and ED length of stay.

Results

Turnaround time for USs improved from 112.4 to 101.6 minutes. The percentage of patients who had successful USs without invasive bladder filling improved from 32.1% to 42.6%. Bladder volume screening using a bladder scan increased from 40.3% to 82.9%. The successful first-pass US completion rate improved from 77% to 90% consistently.

Conclusions

Through quality improvement methodology, we have identified pelvic US readiness earlier, eliminated some invasive bladder-filling measures, and implemented a rapid fluid protocol. We have sustained these successful results for 2 years. This study can be generalized to any ED with similar patients.

Ovarian Salvage With Prompt Surgical Intervention for Adnexal Torsion: Does Timing Matter?

BACKGROUND

Adnexal torsion requires treatment to limit ischemic injury and tissue loss. Optimal time to surgical intervention has not been established. We compared outcomes of ovarian loss amongst pediatric patients.

METHODS

We conducted a retrospective review of 88 patients with adnexal torsion from March 2014 through April 2021. Rates of ovarian loss were compared for patients who underwent surgery within and beyond 60 minutes from diagnosis.

RESULTS

Most patients underwent surgery more than 60 minutes from the time of diagnosis (83%; median time 116 minutes). Comparing patients with and without ovarian loss, there was no statistically significant difference in time to surgery from time of diagnosis (P = .618). Patients with ovarian loss had a longer duration of symptoms (24 vs 96 hours; P = .017).

CONCLUSIONS

While surgical repair of adnexal torsion may be urgent, this study suggests that duration of symptoms should be considered when assessing a patient's likelihood of ovarian loss.

Clinicopathological features and surgical procedures of adnexal masses with abdominal pain in pediatric and adolescent patients

PURPOSE

This study investigated the clinicopathological features and surgical procedures of adnexal masses with abdominal pain in pediatric and adolescent patients. Our objective was to better define the clinical presentation of adnexal torsion and to distinguish characteristics of those with torsion and those with an alternate diagnosis.

METHODS

Retrospective cohort study of 212 pediatric and adolescent patients was performed who admitted for abdominal pain and presenting with an adnexal mass between March 2012 to December 2019.Medical records were reviewed for age at operation, including presentation of symptoms and signs; the levels of tumor markers; imaging examinations; pathologic findings; the size of masses; treatment; and outcome. Data management and descriptive analyses were performed using SPSS 26.0.

RESULTS

The median age of the patients was 14.5 ± 3.6 years at the operation. 126 (59.4%, 126/212) patients presented with an abrupt onset of abdominal pain. A total of 82.1% (174/212) of the participants underwent adnexal conservative surgery. 179 (84.5%, 179/212) patients underwent laparoscopic surgery with an average tumor size of 7.7 ± 3.4 cm, while 33 patients ( 15.6%, 33/212) underwent laparotomy. Rupture of mass and ectopic pregnancy accounted for 7.5% (16/212) and 0.9%(2/212), respectively. Torsion was responsible for 36.8% (78/212) of all patients. Among the patients with torsion, the symptom of nausea and vomiting was more common among girls without torsion (P < 0.0001). 88.5% of the girls with torsion had acute onset of abdominal pain, while 92.3% had persistent pain that could not be relieved or occurred repeatedly, which significantly higher than that in the patients without torsion (P < 0.001). 69.2% of patients with torsion had fixed pain sites, compared with 42.2% in patients without torsion (P < 0.001). 88.5% of girls with torsion had an ovarian cyst/mass ≥ 5 cm, compared with 75.0% in girls without torsion (P = 0.038). 66.7% of girls underwent ovary-preserving surgery, compared with 92.2% in patients without torsion. The most common pathologic types were mature teratoma and simple cyst, accounting for 29.4% and 25.6%, respectively. The multivariate analyses confirmed that mass size greater than 5 cm (OR 4.134, 95% CI: 1.349-12.669,P = 0.013), acute onset pain (OR 24.150,95%CI: 8.398-69.444,P = 0.000), persistent or recurrent pain (OR 15.911,95%CI: 6.164-41.075,P = 0.000) were significantly associated with increased risk of torsion.

CONCLUSIONS

Torsion which is a relatively rare event in the pediatric population was not an uncommon condition and responsible for more than one third of all pediatric and adolescent patients presented with adnexal masses and abdominal pain. Pain assessment in children and adolescents is important to distinguish characteristics of those with torsion and those with an alternate diagnosis.Thus, pediatric and adolescent patients particularly with a pelvic mass size greater than 5 cm, acute onset pain, persistent or recurrent pain have a benign cause and not missing the devastating condition that needs emergent attention. Thus, a strategy of earlier and liberal use of Diagnostic Laparoscopy (DL) may improve ovarian salvage.

A rare case of isolated fallopian tubal torsion in adolescent girls: A case report and system review of literature

Isolated torsion of a fallopian tube in adolescent girls is a very rare acute abdomen. How to early diagnose and treatment isolated torsion of a fallopian tube has always been one of key points. We reported a rare case of isolated torsion of a fallopian tube in a 14-year-old girl and conducted a systematic review of the literature over the past 21 years. We collected data on clinical characteristics, diagnosis and treatment, prognosis and follow-up outcomes. According to our research strategies, 43 reported cases were included. The results (Mean ± SD) showed that the onset age was 14.09 ± 2.49, the cycle torsion was 2.79 ± 1.18, and the cyst size was 6.43 ± 2.25. The main clinical symptoms (percentage) are 100% lower abdominal pain, 67.44% nausea, 51.16% vomiting, and 50.00% right side lesions. And the accurate rate of preoperative diagnosis was only 27.91%, in which laparoscopic exploration, tubal necrosis, and tubal preservation accounted for 79.07%, 41.86%, and 32.56%, respectively. Extremely difficult diagnosis of isolated torsion of a fallopian tube, because of non-specific clinical manifestations, led to the adverse clinical outcome of salpingectomy. However, the accuracy of preoperative diagnosis can be improved by improving acknowledge of ultrasound diagnosis and the awareness of clinical gynecologists. However, the accuracy of preoperative diagnosis can be improved by improving knowledge of ultrasound diagnosis and awareness of clinical gynecologists. The laparoscopic exploration is sole gold standard for diagnosis and treatment. The operation of preserving the fallopian tube may be the first choice, especially in the early stage of isolated torsion of a fallopian tube.

Enhancing Pediatric Adnexal Torsion Diagnosis: Prediction Method Utilizing Machine Learning Techniques

This study systematically examines pediatric adnexal torsion, proposing a diagnostic approach using machine learning techniques to distinguish it from acute appendicitis. Our retrospective analysis involved 41 female pediatric patients divided into two groups: 21 with adnexal torsion (group 1) and 20 with acute appendicitis (group 2). In group 1, the average age was 10 ± 2.6 years, while in group 2, it was 9.8 ± 21.9 years. Our analysis found no statistically significant age distinctions between these two groups. Despite acute lower abdominal pain being a common factor, group 1 displayed shorter pain duration (28.9 h vs. 46.8 h, p < 0.05), less vomiting (28% vs. 50%, p < 0.05), lower fever incidence (4.7% vs. 50%, p < 0.05), reduced leukocytosis (57% vs. 75%, p < 0.05), and CRP elevation (30% vs. 80%, p < 0.05) compared to group 2. Machine learning techniques, specifically support vector classifiers, were employed using clinical presentation, pain duration, white blood cell counts, and ultrasound findings as features. The classifier consistently demonstrated an average predictive accuracy of 87% to 97% in distinguishing adnexal torsion from appendicitis, as confirmed across various SVM models employing different kernels. Our findings emphasize the capacity of support vector machines (SVMs) and machine learning as a whole to augment diagnostic accuracy when distinguishing between adnexal torsion and acute appendicitis. Nevertheless, it is imperative to validate these results through more extensive investigations and explore alternative machine learning models for a comprehensive understanding of their diagnostic capabilities.

Synchronous ovarian epidermoid cyst torsion with appendicitis in a 2.5-year-old girl: Case report

Introduction and importance

Acute appendicitis associated with ovarian epidermoid cyst torsion is extremely rare. To our knowledge, there are about 7 cases that have been reported in English literature, and there was no epidermoid cyst in any of them.

Case presentation

Herein, we present the case of a 2.5-year-old girl with a history of vomiting, fever, and abdominal pain. She was prepared for the operation following the clinical and radiological assessment. At laparotomy, appendicitis and left ovarian lesion torsion were found. An appendectomy and salpingo-oophorectomy were performed with no complications occurring during surgery or the follow-up period. The results of the histology analysis showed that the appendix was inflamed and that there was an epidermoid cyst with a wide infarction.

Clinical discussion

Epidermoid cysts of the ovary are uncommon and often discovered by accident, and histological investigation is required for a definitive diagnosis. In our case, the signs and symptoms before surgery suggested appendicitis. Acute appendicitis in young children is also uncommon. Ovarian lesion torsion associated with acute appendicitis is extremely rare. The treatment is surgery and often requires appendectomy and salpingo-oopherectomy as in our case.

Conclusion

Such cases should be considered in the differential diagnosis of abdominal pain at any age, and early diagnosis and surgery are always required.

•

Ovarian epidermoid cyst torsion and acute appendicitis rarely occur together.

•

A 2.5-year-old girl was presented with an acute abdomen.

•

A torsion of an ovarian cyst and an inflamed appendix were found by laparotomy.

•

A histological examination is required for a definitive diagnosis of an epidermoid cyst.

Pediatric and Adolescent Gynecologic Emergencies

Diagnosis of gynecologic emergencies in the pediatric and adolescent population requires a high index of suspicion to avoid delayed or incorrect diagnoses. This article aims to dispel common misunderstandings and aid with diagnosis and management of 3 common pediatric and adolescent gynecologic emergencies: adnexal torsion, vulvovaginal lacerations, and nonsexually acquired genital ulcers.

Ovarian torsion in the pediatric population: predictive factors for ovarian-sparing surgery-an international retrospective multicenter study and a systematic review

STUDY OBJECTIVE

Ovarian torsion (OT) in pediatric age is a challenging condition to diagnose and treat. To date, there is still no clear consensus about its management. Our aim was to assess some possible associated factors that can help surgeons in decision-making.

DESIGN

We conducted a retrospective multicentric study of pediatric OT surgically treated between 2010 and 2020 in six Italian and German institutions, comparing our findings with a literature review of the last 10 years (2010-2020).

PARTICIPANTS

Patients aged 0-18 years with a diagnosis of OT intraoperatively confirmed and surgically treated at the involved institutions.

RESULTS

Ninety-seven patients with a mean age at diagnosis of 8.37 years were enrolled in the study. Severe abdominal pain was present in 82 patients (84.5%). Eighty children (82.5%) presented an enlarged ovary with an US diameter > 5 cm and only 32 (40%) of them underwent conservative surgery. A laparoscopic approach was performed in 60 cases (61.9%) although in 15 (15.5%) conversion to open surgery was deemed necessary. A functional cyst was present in 49 patients (50.5%) while 11 children (11.3%) suffered from OT on a normal ovary.

CONCLUSIONS

Our results showed that a post-menarchal age (p = .001), a pre-operative US ovarian size < 5 cm, (p = .001), the presence of severe abdominal pain (p = .002), a laparoscopic approach (p < .001), and the presence of a functional cyst (p = .002) were significantly associated with conservative surgery.

The protective effects of trimetazidine against ovary ischemia-reperfusion injury via the TLR4/Nf-kB signal pathway

Late diagnosis and treatment of ovarian ischemia can lead to worsening of ischemia, irreversible damage to ovarian functions and infertility. In this process, there is no approved medical treatment that can reduce the negative effects of ischemia and contribute positively to ovarian functions during reperfusion after detorsion. Rats were randomly assigned into one of six groups of eight animals each. The groups were designed as follows: The control group, The ischemia(I) group, The Ischemia + Trimetazidine (I + TMZ) (20 mg/kg) group, and The ischemia-reperfusion group (I/R). The Ischemia-Reperfusion + Trimetazidine (I/R + TMZ) (20 mg/kg) group, and The Sham + Trimetazidine (Sham + TMZ) (20 mg/kg) group. In this study performed thiobarbituric acid reactive substances (TBARS), total thiol (-SH), interleukin 1 beta (IL-1β), interleukin 6 (IL-6), toll-like receptor 4 (TLR4), and nuclear factor-kappa B(NF-κβ). Increased oxidative stress and inflammation were as a result of ovarian I and I/R application. Trimetazidine (TMZ), was sufficient to reduce the oxidative stress and inflammation. TLR4 and NF-κβ, which were upregulated by oxidative stress and inflammation, were regressed by TMZ. TMZ should be considered as a potential therapeutic agent in addition to surgery in the clinical treatment of ovarian torsion.

Ovarian Torsion in Adolescents with and without ovarian mass: A Cross-sectional Study

STUDY OBJECTIVE

The aim of this study was to compare the characteristics of adolescents with and without adnexal mass who were diagnosed with ovarian torsion (OT).

DESIGN

Retrospective cross-sectional study.

SETTING

Gynecology Department at Tepecik Education and Reseach Hospital, Izmir, Turkey.

PARTICIPANTS

Adolescent girls who received surgery for OT between March 2012 and October 2020 in our institution.

INTERVENTIONS AND MAIN OUTCOME MEASURES

The patients were divided into 2 groups according to the presence or absence of an ovarian mass and compared. Demographic and clinical characteristics, imaging findings, surgery, and pathology reports of the patients were obtained. Differences in initial symptoms, ultrasound findings, the diagnostic process, and the degree of torsion in patients with and without ovarian mass.

RESULTS

Seventy-six patients were diagnosed with OT. Of the 76 patients, 41/76 (53.9%) had an ovarian mass (OTwM), and 35/76 (46.1%) had no pathology (OTnP). The admission to surgery interval was longer in the OTnP group (P = .03). Ultrasound findings of ovarian edema and the appearance of free fluid were significant in the OTnP group (P = .001). The largest dimension of the nontorsion ovary in the OTnP group was greater than in the OTwM group (P = .03). In addition, it was found that torsion more than 360° was more common in the OTnP group than in the OTwM group (24/35, 68.5% vs 41/18, 43.9%; P = .03).

CONCLUSION

In symptomatic adolescents without an ovarian mass, the presence of follicle peripheralization suggesting ovarian edema on ultrasound and the presence of free fluid in the abdomen are important in terms of suspicion of torsion for clinicians. In addition, the degree of torsion was increased in these patients.

Isolated torsion of a fallopian tube: an uncommon cause of abdominal pain in an 11-year-old

This report describes a rare case of isolated fallopian tube torsion (IFTT) in a premenarchal 11-year-old girl. The patient presented with subacute abdominal pain, associated with nausea and vomiting. Sonographic findings revealed left tube enlargement with free intraperitoneal fluid. Doppler mapping was not unequivocal. During exploratory laparoscopy, a large pelvic necrotic mass was found to be a twisted left fallopian tube. After detorsion, salpingectomy was performed and the patient recovered promptly, showing no complications 3 months post operation. IFTT should be considered as a differential diagnosis of lower abdominal pain in adolescent girls with normal-appearing ovaries on ultrasound. Conservative management for fertility preservation is the ideal approach. Therefore, avoiding delay in laparoscopy is crucial.

Contralateral recurrence of fallopian tube torsion: A case report

Unilateral lower quadrant pain is a common presenting complaint in the emergency room with a wide differential. It is important to consider fallopian tube torsion in the differential, especially in premenopausal women, as fertility-sparing detorsion, especially in a woman with a previous salpingectomy or other fertility-affecting surgery, is essential. This case report is of a 25-year-old woman with worsening left lower quadrant abdominal pain over 24 h found to have an extraovarian cystic mass. When taking into consideration the patient with a history of contralateral fallopian tube torsion secondary to a paraovarian cyst, now presenting with left lower quadrant abdominal pain and a cystic extraovarian mass, immediate laparoscopic evaluation was warranted. Immediate intervention revealed an isolated fallopian tube torsion and resulted in surgical preservation of fertility.

•

Recurrent paratubal cyst resulting in isolated fallopian tube torsion

•

Immediate fallopian tube detorsion as fertility sparing procedure

•

Gross necrotic appearance of adnexa does not require salpingectomy/oopherectomy.

Is color Doppler ultrasonography reliable in diagnosing adnexal torsion? A large cohort analysis

INTRODUCTION

Color Doppler ultrasonography (CDU) is widely used to diagnose adnexal torsion (AT). However, its validity remains questionable due to its low sensitivity. Our study aimed to evaluate the accuracy of CDU for the preoperative diagnosis of AT.

MATERIAL AND METHODS

The electronic medical records of patients who were taken to the operating room with the diagnosis of suspected AT were reviewed. Patients having surgically/pathologically-proven AT were compared with patients who were found to have a different pathology at the time of surgery. CDU validity was assessed using a 2 × 2 table and compared with a diagnostic model that consists of the Doppler findings, patient's age, and previous surgical history.

RESULTS

AT was diagnosed correctly in 74.6% of cases. Absent Doppler flow was seen in only 18.6% of cases. Although its specificity and positive predictive value were high, CDU had very low sensitivity and negative predictive value. The combined diagnostic model exceeded CDU alone in terms of diagnostic accuracy.

CONCLUSIONS

The use of CDU alone is not a reliable modality to exclude AT. Absent Doppler flow is a sign of ovarian necrosis. Clinical correlation between CDU findings and the patient's symptoms makes the diagnosis of AT more timely and accurate.

Adnexal torsion with paraovarian cysts in pediatric and adolescent populations: A retrospective study

BACKGROUND

Determination of the clinical characteristics associated with adnexal torsion involving paraovarian cysts in pediatric and adolescent populations.

METHODS

Retrospective review of all cases of paraovarian cysts operated on in our department between 2007 and 2019. Demographic characteristics, clinical and sonographic findings were reviewed.

RESULTS

The cohort was composed of 39 pediatric and adolescent patients with an operative diagnosis of adnexal masses located in the paraovarian area. The patients were classified into two groups: 19 girls (48.7%) with a confirmed operative diagnosis of adnexal torsion and 20 girls (51.3%) without torsion. The preoperative diagnosis of adnexal torsion was correct in ≈70% of the cases. The mean BMI were similar in both groups. The preoperative sonographic detection rate of paraovarian cysts was also similar (11/19 [57.9%] vs. 14/20 [70.0%]; P = 0.514). The mean cyst diameter did not differ between groups, nor did the classification into cyst size groups (≤50 mm, 51-99 mm and ≥100 mm).

CONCLUSION

Adnexal torsion is a common complication diagnosed in girls undergoing surgery for paraovarian cysts, and is not associated with sonographic appearance or cyst diameter. In order to prevent torsion, surgical removal of paraovarian cysts should thus be considered in young girls undergoing surgery for paraovarian cysts.

TYPE OF STUDY

Retrospective case series.

LEVEL OF EVIDENCE

IV.

Variations in the management of adolescent adnexal torsion at a single institution and the creation of a unified care pathway

PURPOSE

Adnexal torsion is a gynecologic emergency, requiring intervention for tissue preservation. At our institution, torsion is managed by pediatric surgeons or gynecologists. We evaluated differences between specialties to streamline evaluation for children with gynecological emergencies, develop a clinical pathway, and prevent care delays.

METHODS

A retrospective review of adolescents undergoing intervention for adnexal torsion from 2004-2018 was performed. Differences in time to intervention, operation duration, the procedure performed, and length of stay (LOS) between the specialties were analyzed.

RESULTS

Eighty-six patients underwent 94 operations for presumed adnexal torsion with 87 positive cases. Pediatric surgeons performed 60 operations and 34 cases were performed by gynecologists. Preservation of fertility was the goal in both cohorts and the rate of oophoropexy, cystectomy, and oophorectomy were similar between the cohorts (p = 0.14, p = 1.0, p = 0.39, respectively). There was no difference in intra-operative time (p = 0.69). LOS was shorter in the gynecology cohort (median 1 day [1-2] vs. 2 days [2-3], p > 0.001).

CONCLUSIONS

Adnexal torsion is a time-sensitive diagnosis requiring prompt intervention for ovarian or fallopian tube preservation. A multidisciplinary institutional care pathway should be developed and implemented.

Ovarian volume ratio is a reliable predictor of ovarian torsion in girls without an adnexal mass

PURPOSE

The aims of this study were to identify ultrasound-based predictors of ovarian torsion in girls without an adnexal mass and establish a set of normal values for ovarian volume ratio (OVR).

METHODS

A retrospective review was performed of all premenarchal patients ≥3 years of age with a normal pelvic ultrasound between January 2016 and January 2019. A comparison group of premenarchal girls presenting between 2011 and 2019 with torsion in the absence of an adnexal mass was utilized.

RESULTS

Five-hundred and four premenarchal girls underwent pelvic ultrasound evaluation with a normal examination. The mean OVR was 1.6 ± 0.7 (range 1.0-6.5). OVR did not vary with age (r = -0.06) as compared to ovarian width which increased steadily with age (r = 0.53, p < 0.001). OVR was increased in girls with torsion (7.6 vs 1.4, p < 0.0001), and by receiver operating characteristic (ROC) analysis a cutoff value of >2.5 demonstrated the best diagnostic accuracy of any predictive variable (sensitivity 100%, specificity 94%, AUC 0.991, p < 0.001).

CONCLUSIONS

OVR is an excellent predictor of ovarian torsion in premenarchal girls without an adnexal mass. Unlike ovarian width, OVR does not increase with age, and a cutoff OVR > 2.5 demonstrates high sensitivity and specificity for identifying ovarian torsion in this population.

TYPE OF STUDY

Study of diagnostic test.

LEVEL OF EVIDENCE

Level III.

An ovarian torsion in a 2-year-old girl: a case report

Background

Abdominal pain is one of the most common complaints by patients in the emergency department. Diarrhea, constipation, and urinary tract infection are the commonest etiologies among these patients, but there are surgical emergencies, such as appendicitis and volvulus of the intestine, which are less common. Torsion of the ovary is rarer than all of the above conditions. Ovarian torsion occurs following the twisting of the ovary on its ligamentous attachment, possibly with a cyst, leading to the impediment of blood flow. Prompt diagnosis with a high clinical suspicion is essential to salvage the ovaries and to prevent complications, including death.

Case presentation

Here, we present a case of ovarian torsion in a 2-year-old Sri Lankan girl who presented with nonspecific abdominal symptoms after being symptomatically treated twice by her general practitioners for 3 days. Following biochemical and radiological investigations, she was diagnosed with a twisted necrotic ovarian torsion and underwent laparoscopic right-sided oophorectomy.

Conclusions

Finding the etiology of a child with abdominal pain is challenging, especially because of the limited history, examination findings, the difficulty in carrying out radiological investigations, and the poor specificity of the results compared with adults. This is a case presentation and a brief discussion about the dilemmas and difficulties in the diagnosis and treatment of ovarian torsion in young children.

Isolated fallopian tube torsion associated with hydrosalpinx in a 12-year-old girl: a case report

Background

Isolated fallopian tube torsion associated with hydrosalpinx is a rare condition in the pediatric population. We present this unusual clinical case study in a sexually inactive girl.

Case presentation

a12-year-old Caucasian girl presented symptoms of acute abdominal pain. Pelvic ultrasound revealed a normal looking uterus and ovaries and next to left ovary a imaging compatible with hydrosalpinx. She was discharged 48 hours later after clinical monitoring with oral analgesia and normal blood workup. At 3 weeks, she was readmitted for acute abdominal pain. Leukocytosis with left shift and raised C-reactive protein were observed. Her clinical condition worsened, and complication of the preexisting hydrosalpinx was suspected. Exploratory laparoscopy confirmed torsion of the fallopian tube. Left salpingectomy was performed. Histopathologic study confirmed a fallopian tube with hemorrhagic infarct.

Conclusion

Torsion of the fallopian tube must be considered in the event of acute abdominal pain. Early diagnosis and trying conservative management with a view to preserving fertility in this group of patients are essential.

Imaging of Acute Abdominal Pain in the Pediatric Population

Acute abdominal pain is a common complaint in pediatrics. Although age and location of pain can help focus differential diagnosis, imaging plays an essential role in clinical evaluation. In this review, we discuss the optimal imaging approach to pediatric patients with acute abdominal pain and important imaging findings in the most common causes of abdominal pain in the pediatric population. [Pediatr Ann. 2020;49(9):e380-e388.].

Isolated fallopian tube torsion in pediatric age: An Italian multicenter retrospective study

PURPOSE

The purpose of this study was to quantify the experience of five Italian centers on the diagnosis and management of isolated fallopian tube torsion (IFTT) in children.

METHODS

We retrospectively reviewed the data of 20 patients aged 1-16 years of age with surgically diagnosed IFTT between 1991 and 2017 from five Italian centers of pediatric surgery. We analyzed common presenting signs, symptoms, and radiographic findings, as well as surgical interventions to describe management offering further insight into the diagnosis and treatment of this rare entity.

RESULTS

Twenty cases of IFTT were collected. Median age was 13.1 years. Menarche was present in 14 cases. A clinical history of abdominal pain was present in 13 patients, whereas in 7 patients the clinical picture was an acute abdomen. Ultrasonography was the first diagnostic examination in 16 cases. Surgical approach was by laparoscopy in 16 cases and laparotomy in 4 cases. In 11 patients IFTT was associated with another pathologic condition. In 7 of the remaining 9 IFTT without pathologic association, the girls played sports. Salpingectomy was performed in 13 patients and de-torsion in 7.

CONCLUSIONS

IFTT is a rare condition that seems to occur in younger adolescents. Vague clinical presentation contributes to low preoperative suspicion. IFTT should be considered in girls with abdominal pain who practice sports with sudden body movements. Preoperative suspicion may be increased based on radiographic findings of an enlarged tubular/cystic structure with adjacent normal ovary. Conservative management is controversial but could be preferred in order to provide the best option for future fertility of these girls.

TYPE OF STUDY

Treatment Study (Retrospective Study) - Level IV.

Premenarchal patients present differently: A twist on the typical patient presenting with ovarian torsion

BACKGROUND/PURPOSE

The aim of this study was to characterize differences between pre- and postmenarchal females with ovarian torsion.

METHODS

A single-center review was conducted of all nonneonatal pediatric patients with ovarian torsion from 2011 to 2018. Clinical data were compared between pre- and postmenarchal patients.

RESULTS

One hundred and twenty-seven patients were identified, and 25% were premenarchal. Premenarchal patients were more likely to have a delay in diagnosis (38% vs 20%, p = 0.042), develop ovarian necrosis (34% vs 17%, p = 0.036), and present without an associated adnexal mass (44% vs 0%, p < 0.001). All patients without a mass (n = 14) were premenarchal and presented with ovarian asymmetry. Patients without an associated mass underwent oophoropexy in the majority of cases. There were no differences in postoperative complication or recurrence rates between groups.

CONCLUSION

Premenarchal females with ovarian torsion can present differently than females postmenarche and often have a delay in diagnosis. Premenarchal females are more likely to undergo torsion without an associated adnexal mass and are at higher risk for ovarian necrosis. Oophoropexy is an appropriate treatment in the absence of an adnexal mass. A high-index of suspicion for ovarian torsion should be maintained for premenarchal females presenting with abdominal pain and an otherwise negative workup.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

Level III.

Analysis of the risk of ovarian torsion in 49 consecutive pediatric patients treated at a single institution

Purpose

An early diagnosis of ovarian torsion is sometimes difficult due to variable clinical symptoms and non-specific imaging findings. We retrospectively reviewed patients with pediatric ovarian masses manifesting torsion.

Methods

Fifty-eight ovarian masses (55 episodes) in 49 non-neonatal patients treated from April 1984 to March 2017 were retrospectively analyzed. The Mann-Whitney U test and Fisher’s exact test were used for the statistical analysis.

Results

The median age of these 55 episodes was 10.5 years old (range 1.0–23.0). Thirty-three patients presented with abdominal pain. Forty-five tumors and 13 cystic masses were resected and diagnosed pathologically (50 benign and 8 malignant). Torsion was identified in 15 cases (25.9%) at operation. The torsion masses were all benign, and 8 ovaries (53.3%) were successfully preserved. Comparing the torsion cases with the non-torsion cases, only the white cell count was significantly higher in the torsion cases (p=0.0133) and in the patients presented with abdominal pain (p=0.0068). The duration of abdominal pain was significantly shorter in ovary preserved cases than in oophorectomy cases.

Conclusion

The white blood cell may be a helpful indicator of the presence of torsion as well as the need for surgery.

Ovarian Torsion in Premenarchal Girls

STUDY OBJECTIVE

To investigate characteristics that differentiate premenarchal girls with ovarian torsion (OT) from those without OT at the time of surgery.

DESIGN

Retrospective chart review of 36 premenarchal girls who underwent 42 surgeries for either OT (n = 33) or a nontorsed ovarian mass (n = 9) from 2006 to 2017.

SETTING

Large, tertiary care academic institution.

PARTICIPANTS

We included patients aged 0-12 years with International Classification of Diseases, Ninth Revision codes for torsion of the ovary, adnexa, ovarian pedicle, or fallopian tube. Controls had International Classification of Diseases, Ninth Revision codes for ovarian mass or cyst, who also underwent surgery and did not have OT.

INTERVENTIONS

Records were reviewed for patient characteristics including laboratory and imaging studies, surgical intervention, and pathologic diagnosis. Fischer exact test and the nonparametric Mann-Whitney U test were used for statistical analysis.

MAIN OUTCOME MEASURES

Characteristics predictive of OT in premenarchal girls.

RESULTS

Twenty-nine premenarchal patients were diagnosed with 33 episodes of OT. Nine patients underwent surgery for ovarian masses but did not have OT. All patients with OT reported abdominal pain (compared with 55.6% without OT; P < .001) and most had nausea and/or emesis (81.8% vs 33.3%; P < .009). Ultrasound findings of ovarian enlargement and decreased Doppler flow were significant in the OT group (P < .083, P < .009). There were 2 cases of malignancy in each group.

CONCLUSION

Patients with OT had significantly more nausea, emesis, and abdominal pain compared with those without OT. Additionally, 2 of 4 malignancies were found in patients with OT, indicating that malignancy should still be considered with large, complex masses.

Does ischemia reperfusion affect fecundability in a rat model?

BACKGROUND

Adnexal torsion constitutes 2.7% of all gynecological emergencies. Because normal follicular growth has been demonstrated after examination of surgical specimens retrieved from oophorectomies, organ-sparing strategy has gained more popularity irrespective of the appearance of the ovary. However, the functionality of the remaining follicles has not been known. The aim of the study was to evaluate the effect of ischemia-reperfusion on fecundability in a rat model with adnexal torsion.

METHODS

A total of 30 female adult Wistar albino rats were assessed. In the first laparotomy, right ovaries were twisted for 8 (Group I, n = 10) or 24 (Group II, n = 10) hours. Second laparotomy was performed to untwist the torsion side and oophorectomy to the other side. In the control group (Group III, n = 10), left ovaries were removed and right ovaries were kept without any intervention. After 30 days from the last operation, female rats were mated for 10 days and euthanized 4 days later. Fecundability was calculated using beta-human chorionic gonadotropin (hCG) levels for detection of pregnancy rates.

RESULTS

The mean beta-hCG values in control, 8-hour, and 24-hour groups between pregnant rats were 19.8 ± 26.02, 11.7 ± 0.17, and 22.97 ± 11.87 mIU/mL, respectively. Whereas two out of 10 rats (20%) conceived in the 8-hour group, three out of 10 rats (30%) got pregnant in the 24-hour group. In total, whereas five out of the 20 rats got pregnant in the experimental groups, in the control group, seven out of 10 subjects conceived (25% vs 70 %, p = 0.018).

CONCLUSION

Although there was a statistical difference between experimental and control groups, statistical significance was not reached among 8-hour and 24-hour torsion subgroups. In this context, patients with torsion but treated with detorsion should be further investigated for their fecundability potency and be informed accordingly.

Ischemia modified albumin in experimental ovarian torsion with and without controlled reperfusion

Purpose: Ovarian torsion, being a gynecological emergency, requires to be rapidly diagnosed and treated with minimal consequences on ovarian function after the removal of torsion. As ischemia modified albumin (IMA) is considered a good biomarker in diverse ischemic diseases, the aim of our study was to determine the effect of different ovarian torsion/detorsion models on serum and ovarian homogenates levels of IMA in an experimental study.

Methods: IMA was measured in the serum and ovarian homogenates of 7 groups of female rats (10 animals in each group): 1 - control (no intervention); 2 - sham (only laparotomy); 3 - ischemia group: 3 hours ovarian torsion (OT); 4 - 3 hours OT (ischemia), 1 hour simple reperfusion; 5 - 3 hours ischemia, 1 hour controlled reperfusion that was assured during the first two minutes by opening and closing the clips on the ovarian pedicles in 10 seconds intervals, followed by simple reperfusion; 6 - 3 hours ischemia, 24 hours simple reperfusion; 7 - 3 hours OT, 24 hours controlled reperfusion. The results were analyzed by Welch’s ANOVA and Spearman correlation.

Results: Ischemia increases the IMA in both serum and ovarian homogenates compared to control and sham groups. The controlled reperfusion groups had a statistically significant lower IMA in serum compared to simple reperfusion groups. IMA was found to be higher in the ovarian homogenates of simple reperfusion compared to controlled reperfusion groups.

Conclusion: Our results suggest that controlled reperfusion prevent the processes that increase the IMA in ovarian torsion.

Adnexal Torsion in Children and Adolescents: A Retrospective Review of 245 Cases at a Single Institution

STUDY OBJECTIVE

Adnexal torsion (AT) requires urgent surgical intervention to preserve ovarian function. Historically, treatment for AT was oophorectomy because of concerns related to leaving a nonviable ischemic ovary. No published studies support these theoretical concerns and current literature supports conservative management. The aim of this study was to review the institutional outcomes for AT cases, including salvage rates and complications. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: This study was approved by the institutional review board at Baylor College of Medicine. A retrospective chart review on cases of AT from 2007 to 2016 at a single Children's hospital was performed on the basis of International Classification of Diseases, 10th revision and Current Procedural Terminology codes. A standardized chart review form was used in data extraction. Statistical analysis was performed using SAS version 9.4 (SAS Institute).

RESULTS

Chart review identified 245 torsion cases in 237 patients. The mean age was 12.4 ± 3.29 years. Of the participants, 230 (94%) underwent minimally invasive laparoscopy with ovarian preservation in 233 (95%) of the cases. There were no complications due to detorsion of the affected adnexa. Intraoperatively, the right adnexa was affected in 134 (55%) cases and a lesion was noted in 193 (79%) cases, most commonly paratubal cysts and mature teratomas. The malignancy rate was low, noted only in 4/245 patients at (1.2%). Pediatric gynecology performed most of the cases (n = 214; 87%).

CONCLUSION

The findings of our study continue to support the conservative management of patients with AT.

Adnexal Torsion

Adnexal torsion is an uncommon gynecologic disorder caused by the partial or complete rotation of the ovary and/or the fallopian tube on its vascular support. Delay in treatment can impact fertility adversely. The objective of this report is to provide clinical recommendations based on the latest evidence. Specifically we discuss epidemiology, clinical presentation, diagnostic approach and management of adnexal torsion in adolescents.

How can the risk of ovarian retorsion be reduced?

BACKGROUND

In the current treatment of idiopathic ovarian torsion, the use of oophorectomy has declined in favor of preserving the ovary. This approach brings with it the question of how to reduce the possibility of retorsion of the detorsioned ovary. The aim of this study was to analyze how retorsion can be prevented.

METHODS

Five patients (a 30-day-old Caucasian girl, a 55-day-old Caucasian girl, an 8-year-old Caucasian girl, a 10-year-old Caucasian girl, and a 16-year-old Caucasian girl) who underwent surgery due to non-neoplastic ovarian torsion were retrospectively analyzed for diagnosis and treatment in terms of reducing the possibility of retorsion.

RESULTS

In all patients, a precise diagnosis of idiopathic unilateral ovarian torsion was made during laparotomy, and the patients underwent different procedures. The ovary was found to be autoamputated in one patient, and two patients underwent salpingo-oophorectomies due to adnexal necrosis. The ovaries were detorsioned in the remaining two patients. During the operations, patients were evaluated regarding the prevention of retorsion of the ipsilateral and/or contralateral ovary; cyst drainage, cystectomy, ligament fixation, and/or oophoropexy were performed. The median follow-up period of the patients was 2 years (range 1.5-6 years), and they continue to be followed uneventfully.

CONCLUSIONS

To date, there is no standard approach to protect the ovary from retorsion in patients who undergo surgery due to torsion. The surgical procedure should be tailored on a case-by-case basis.

Clinical and sonographic predictors of adnexal torsion in pediatric and adolescent patients

OBJECTIVE

To investigate the accuracy of torsion diagnosis in the pediatric and adolescent population.

METHODS

This retrospective study included 87 patients <18years who presented with acute pelvic pain and were operated for suspected adnexal torsion from January 2009 to September 2016.

RESULTS

Adnexal torsion was found in 53 of 87 (60.9%) cases operated for suspected torsion. The rate of accurate torsion diagnosis was significantly higher among pre-menarchal (21/21, 100%) compared with post-menarchal girls (32/66, 48.5%) (p<0.001). Patients with torsion were more likely to report nausea or vomiting (73.6% compared with 32.3%, p<0.001) and had higher rates of peritoneal irritation signs on exam (15.1% compared with 0.0%, p=0.02). On the pre-operative ultrasound, patients with torsion were characterized by higher rates of enlarged ovary showing signs of edema (49.1% compared with 8.8%, p<0.001) and free pelvic fluid (45.3% compared with 17.6%, p<0.001). In post-menarchal girls without adnexal torsion, the leading diagnosis was hemorrhagic corpus luteum cyst (found in 18/33, 78.3%) cases.

CONCLUSIONS

Various clinical and ultrasound findings may point to the correct diagnosis of torsion in the pediatric and adolescent population. However, none of the clinical and ultrasound characteristics are sufficient to confirm or disprove the pre-operative diagnosis, and young patients with the clinical suspicion of adnexal torsion should undergo laparoscopy.

LEVEL OF EVIDENCE

Level II.

TYPE OF STUDY

Clinical retrospective study.

Conservative laparoscopic management of adnexal torsion based on a 17-year follow-up experience

Laparoscopic unwinding of adnexal torsion has been proposed for decades. However, this technique is still controversial regarding the concern of thromboembolic events. We present two cases of conservative laparoscopic management of adnexal torsion. In the first case, a 16-year-old adolescent with serous cystadenoma was successfully managed by untwisting and cystectomy. We followed up this patient for 17 years with regular re-examinations in our hospital. To the best of our knowledge, this is the longest follow-up reported of this condition. In the second case, a 32-year-old infertile woman who received oocyte retrieval 3 days before being admitted to hospital was referred to hospital with right ovarian torsion. We treated her successfully based on our long-term follow-up experience, and she is now asymptomatic and in her 7th month of pregnancy.

Isolated fallopian tube torsion with hydrosalpinx: Review of a debated management in a pediatric population

PURPOSE

To quantify our experience with and assess the literature on diagnosis and management of isolated fallopian tube torsion (IFTT) with hydrosalpinx (HSX) in children.

METHODS

A PubMed search was performed on pediatric cases of IFTT with HSX to provide a comprehensive review analyzing details and management of this association, focusing on the problem of fertility preservation.

RESULTS

In addition to our 3 cases, 17 patients of pediatric IFTT associated with HSX were identified, for a total of 21 cases (median age 12.2 years). Menarchal status was present in 10/13 (76.9%); blood tests were reported in 9/20 (42%) showing leucocytosis in 7/9 (75%). Ultrasonography was performed in all cases except one. Laparoscopy was the surgical approach in 84.6% of the reported cases. The torsion was to the right in 36.8%, and to the left in 63.2% of the cases. In one case the torsion was bilateral and asynchronous. Performed procedures were salpingectomy (52.4%) and partial salpingectomy (14.3%); conservative management was reported in 33.3% of the cases.

CONCLUSIONS

The literature describes different management techniques. Salpingectomy is the most frequently performed procedure but recently conservative management seems to be increasingly applied. A long-term study is necessary to define the most effective treatment for the preservation of future fertility in pediatric patients.

TYPE OF STUDY

Treatment study (Retrospective Study): LEVEL IV.