Ovarian Salvage (Torsion & Benign Tumor): Practice Gap discussion at Update...

This is a 13-year-old female presents with severe lower abdominal pain, vague lower abdominal tenderness. She has an ultrasound that shows an enlarged right ovary with vascular flow and a 7 centimeter cystic mass. What's the most appropriate next step? In her management. A would be observation, B, a transvaginal ultrasound. See a CT. D, intravenous antibiotics or E, laparoscopy. Just to reiterate, you see by ultra she's got, she's in severe pain, and by ultrasound, you see a mass, but there is vascular flow to that mass. To that ovary. I'll just say that a pediatric radiologist a few years ago who was actually president of the Pediatric Radiy Society at the time always made the point that an ultrasound is a horrible test for torsion. Just don't use ultrasound for torsion. I'll just make that comment. That's the radiologist, I think. I think it's good at identifying it, but it should never give you comfort in saying that there is not torsion. It's good at identifying the mass, yes, the mass ovary, but regardless of the presence or absence of flow in the ovary, that's right. Saying that we see good flow to the ovary should not give you any comfort that the patient's not torse. So the correct answer here? Laparoscopy and I don't think this is a surprise to anyone in the audience, but I think in terms of emphasizing what Mac has already started out with the fact is ultrasound is not very sensitive. It's a coin flip in terms of whether you see vascular. Flow or not, so please don't rely on that to keep you out of the operating room. Um, now the other issue with this particular case is, uh, when you reduce that, uh, uh, torsion, then what do you do with that ovary? Leave it. If it's black, it's dead. We've been trained up. We've been hit, hit by the rolled up newspaper and us, then we know what to say now. I think, I think what this does is, is, uh, what if it's got a cystic mass in it? I'll leave it in. Well, we haven't talked about what we're doing about the cyst. We're leaving the ovary in. Yeah, no, that's actually we're gonna walk through one by one. So the first thing is, the first thing is how you make the, whether you go ahead right away with the diagnosis and, and ultrasound. So that's the first, the first the first tweet is. Don't ever trust ultrasound for ovarian torture, right? So go ahead, OK. Number 2, that dead ovary. What do you do with that dead ovary? And uh what we've heard from the, from the group already at the podium is, is absolutely right. You leave it in place. That is, you can't let it, whatever it does. Well, OK, so this is what I wanted to hit on here. If there's a, what do you do about the cyst then? OK, we're going to come to that. So let's, so, so, so two comments. One is about the ultrasound needing laparoscopy. That is absolutely the correct answer. Now we're doing a study to try to improve that. We, we think that it's. We believe, we think that that it is crazy in 2018 that we cannot get a better diagnostic test for torsion. Right now we don't have it. We haven't identified it, but there has got to be a way to decrease the number of negative laparoscopies just like we did with appendicitis. I think we can decrease our number of negative laparoscopies by improving our accuracy of preoperative imaging. Uh, that's the number 1 point. The second point is, but right now at this point in time, we don't have it. Uh, the, the, the second, and so we're creating a scoring system. The second thing is, I have a question for you because knowing that you were gonna present this case, um, uh, since I trained in DC, uh, 12 years, 12 years ago, um, I've always been taught to keep the black ovaries in the belly. And I We almost never have ever taken out an ovary except 2 weeks ago. And this was my question for you and I was going to show a picture and ask everyone here if this was still a wrong move. It sounds like it might have been. So the two things about this case that made me do a salpingo oophorectomy, which I don't think I've ever done for a twisted ovary, um, was that it was liquid. It had been, it was 3 weeks that it was a neurologically impaired patient. It had inflamed to everything in the belly. It was stuck, and when I took the bowel off of it and separated off, it was a soup. Well, that's a little different if it's a neurologically impaired patient. Why? I mean, you're, this is a ser, but my point is the neurological impairment part was that it took her that long to get to us. And the second question I had was the fallopian tube was black. And so it felt risky to me to leave a scarred fallopian tube because of the potential for a tubal pregnancy. So what, what, when is there a time that it is appropriate to take out the ovary? That was my question. Well, when there's a malignancy associated with it, so we're going to come back to the mass and the malignancy sort of, but, but that's the question. I think it's a legitimate question in terms of dead ovary, and I think the message that it's screaming from this is that we leave the ovary. Now it's a little reminiscent though when you say that. Is what do you, when do you take out, do a pancreatectomy for acute pancreatitis? Well, when it's, when it's liquefied and you, you, you kind of drain it out, if it's a neurologically impaired patient, you're not worried. I mean, my idea of concept of a neurologically impaired patient, you're not worried about fertility. So I think it's in that instance, I think it was reasonable to take it out given all these other factors that didn't play into mind. It was for me, it was that it was, I was thinking I was leaving her at risk by leaving it, and that's the question is was I, was I not? And I wanted to ask the panel here, and I will say that maybe I did, maybe I was too aggressive in this case, but I wondered what everyone here thought. You can always come back, you know, if you don't feel comfortable, quote, comfortable managing it. You can always leave it there and come back soon thereafter, get more studies, get an ultrasound, confirm everything, and then you could go back with a GYN. He's already had a complication. He had a liquefied ovary, which is causing inflammation of all the surrounding organs that are contracting. No, I think in his scenario, I think it was OK. Yeah, I think it's, but I think it's mainly the literature would say that just think, you know, this is going to be like, you know, one. 2% of all of the ovaries, right? If you have some questions of liquefied ovaries, liquefied ovaries, which, you know, I mean it, you know, it's a black leave liquefied, yeah, I mean an ovary is liquefaction is a part of the ovary and you still have ovarian, I know viable ovarian cortex somewhere and it's, it's, it's kind of fertility, but it's also that if you take that ovary out and there's a contralateral torsion, hormonal function, yeah, then you're, then you're, then you're down. You know, then, then you're done. So the the and the literature would say that clinical assessment at the time of the operation is unreliable in determining the presence of viable ovarian cortical tissue. In that lump, so I don't think what we're trying to do, we're not trying to mandate any one thing or another, but I think the message is loud and clear that these dead over, you can't tell. And in fact, my experience, my own experience underscores that is ones that I was absolutely sure were dead, and you get all. Ultrasounds in follow serial ultrasounds and you see follicle. They can tell this is there's ovarian tissue there that's functional. I think that the issue really is that you've got a cyst. I mean, if, if you have a torsion, let's take a torsion that doesn't have a cyst, OK, just a regular torsion. You know, we, we, if it's black, you leave it. The issue is for a lot of surgeons is that you now have a mass in the, in the ovary. It's a 7 centimeter mass. It, you know, so, so, you know, if it's, if a lot of people say a greater than 8 centimeter, but let's say, you know, the, the risk of malignancy is on their minds and they're trying to make a decision whether to leave this, this. This ovary that's torsed and has a mass and is it a malignancy and that becomes becomes almost a well I'm almost better off taking this out and putting it in the bucket, OK and and and the issue is how, how do you make that decision? How do you decide no, this is probably a benign mass and in fact I'm going to detorse it and leave this mass in situ and and. Come back to fight another day for this mass because that's what, at least that's what I would do if I had a dermoid cyst that was on a torsed ovary and it was all swollen, it was all black, whatever, I would detorse it. Not only would I have done this a number of times. I would detorse it. I'd put it back in. I'd walk out to the parents and say, I'm going to follow this with ultrasound, see if it survives, and if it survives, you get an ultrasound there as a baseline. When's your? Well, I usually have had one, right? I mean, because before you, before you untwist it, you know, I hardly see them when they have an ultrasound. But, but I get ultrasounds then to follow to see over the next 6 weeks or so whether or not the ovary survives, and if the ovary survives with that cyst there or that mass there, I go back in and take it out. And how do you make the decision whether it's a malignancy or not? And I pull out, you know, I've been. It's kind of cool that that the Midwest Pediatric Surgeon Consortium is hitting on these, on these same things. So Kate Dean's has funding from the Thrasher Foundation through the Midwest Pedic Surgeon Consortium to study an algorithm which involves looking at tumor markers, looking at size, looking at tumor markers, looking at radiologic confirmation, and therefore coming down to say this is benign. And you can be pretty, you know, you're not going to be 100%, but this is benign and therefore you can leave it in place and be confident. And in fact what we've had is a couple of instances in our hospital where surgeons were about to take out the. And uh we're gonna try to continue on with the event in a much more casual environment. Uh, thanks for bearing with us and uh uh Craig, we're gonna finish off with the last few uh topics, right? Indeed, uh, congratulations, Todd. I think one of the most important qualities of a surgeon is flexibility and you've certainly demonstrated that for us, us today. The um. Ron, I think we're we're, we're in, when we lost power, might have been that comment, so you left the audience in suspense about, uh, your colleague. So fill us in. Well, the colleague was about to, uh, remove the ovary and, and, uh, he said, uh, uh, do you think I should, should remove it? And I, I said, well, let's go look at the algorithm and in fact, the algorithm suggested that the chance of malignancy was exceedingly low and therefore we left the, um, the cyst in the left ovary, left the cyst in place, and, uh, and salvaged the ovary, went back actually and took out the dermoid cyst, what turned out to be a dermoid cyst, uh, six weeks later. And I think that experience uh sort of underscores one of the learning points from, from this particular question, and that's to say number one is that that masses themselves in association with ovarian torsion are relatively common, that is on the order of 20%, but the risk of malignancy is very, very low. So in fact, the strategy of detorsing that ovary and then if you can deal with the. The mass at that time, you, it's OK to take that out if you're ovarian sparing, you can perform ovarian ovarian surgery, but if there's any uncertainty or the conditions aren't, aren't favorable for that, then close, come back, monitor by ultrasound. You can do your, uh, your blood work for tumor markers and come back and deal with that at another setting. Yeah. Let me just make one more comment, and that is not only that. But there's really no urgency. You can get your, you can get your tumor markers. You can take it to tumor board. You can get other people's input, and you can decide then that yes, this has a reasonable risk of malignancy, and I'm going to go back right away and take it out. But you don't have to make that decision immediately right then. Well, it's just if you, whether you're coming, whether you're at the first operation or you're coming back for the second operation. To take it out, um, and you wanna resect the mass and leave the ovary and you wanna do that laparoscopically, I just pointed out that there are some technical challenges to that operation, much easier to do a fan and still and pull it up and out where you can touch it and feel it and, and, and work through it. So I didn't know if people wanted to comment about, uh, technical aspects of a laparoscopic mass resection with ovarian sparing surgery. Do I have any takers? I think the important thing that we're trying to emphasize here in ovarian torsion is deal with the, uh, detorsion first, and then the mass is a separate issue. But with that mass, since most of those are going to be benign, the key is ovarian sparing surgery. And if you're able to accomplish that laparoscopically, wonderful. If you, if you. Can't you really want to remove that whole mass. So the notion is if you need to make a fan and steel incision, deliver that out, that that's certainly much preferable. So although an oophorectomy is a perhaps an easier technical operation or or a quicker operation, if you will, that's a, that's the thing that we want to avoid short of a malignant situation. So in terms of uh teaching points that we want to, uh, what's the tweet what's the tweet? Well, the tweet is a couple of things. Number one is to emphasize that ultrasound is unreliable. So if you suspect torsion right now until Todd's group gives us another modality. To make that decision, the, the strategy right now is proceed to laparoscopy, make the diagnosis, detour it at that time, and then the mass, you can always deal with in a delayed fashion, but, uh, you're gonna want to do that ovarian sparing surgery. Is that too many tweets? No, that's a great tweet. OK, I think with that, we'll move on to the next.