Update Course Rewind: Ovarian Torsion Management 2023

Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hello, pediatric surgery family. I'm M. Goldie, a research fellow from Cincinnati Children's Hospital Medical Center. Our 11th annual update course in pediatric surgery was held past August. In this video series, we'll recap the sessions and share the main highlights with you. Today we'll talk about ovarian torsion management with a sample case. Joining the discussion is are Dr. Leslie Breach, a pediatric gynecologist, and Dr. Aaron Rawl and Dan von Allman are both pediatric surgeons. Let's hear our case from Dr. Breach. So I just want to talk a little bit about a patient that you all might see more frequently than you might see from fertility preservation. Five-year-old female, acute onset of pelvic pain and vomiting. Comes to the emergency department, gets an ultrasound, large cystic mass, no blood flow to the right ovary, and you decide to take this patient's operating room. You find right ovarian torsion, and you can see this sort of dark purple ovary. You're in the OR and deciding. What are you going to do now? So this patient, you see a cystic area on ultrasound, but often when you get there, that's actually edema of the fallopian tube. So what I really wanted to show you on this case is that oftentimes there isn't something to drain. You have a highly edematous ovary or edematous fallopian tube. So if there is a cyst, I see people have an appetite and want to go for it and aspirate things. So the important point though, and I think that this has been made several times over the last several years is that you should not do an oophorectomy. And there are still colleagues who are saying they would do an oophorectomy. Anyway, I just think we need to drive home that point. My first thought of the day. All right, great. That's what happens when you work in the integrated gynecology team. Correct. We should be never doing an oophorectomy. And there isn't good data that would show us the timeline and the appearance that would say the ovary is not going to live. In this situation, you would always de-torse the ovary and leave it. In a recent review on a quality improvement project, there were some institutions where as many as 25% of the time, surgeons were taking out the ovary in similar cases. So Dr. Breach has recommended to avoid that. Now there's more question about the fallopian tube, how to manage a blue black fallopian tube. Take a look at the tube. If the tube is black, it's edematous, you've de-torsed it, you've given it plenty of time, then I would say a consideration about what to do about that tube. If it's a prepubertal girl, you have it plenty of time to figure it out. But if the patient is an adolescent and it is edematous, there is some concern about the future. So the future function of the tube needs to be able to do this. You cannot have like a, you know, a leg pipe tube that's going to work well. And you have to have open fimbria. So scarring of the tube is a concern for the future and risk for ectopics. There isn't anything causing the torsion. I know it's possible. Then I have a contingency plan which is drain the cyst or cystectomy if there is something that clearly caused it and then hope for the best. If there's not, those are the couple of instances that I've tried to attack pexy. Oh, really? The ones? Yeah, really, cuz otherwise I think I haven't done anything differently that won't prevent it from recurring two hours from now. Love this. We'll start with saying a good percentage of the patients will have nothing wrong with the ovary. And so particularly in prepubertal patients will just de-torse. It's a big chunky edematous ovary. You're like, oh I don't want to do with this. They're going to de-torse again in 48 hours. You kind of tuck it down. Some people have talked about trying to reduce some of that edema by incising the cortex, having some release of that edema so that the swelling will come down. So understand that hesitation. However, with all that edema, it's hard to tell if there is something in that ovary that needs to be removed. So we would say most gynecologists untwist, leave things be, and do come back for some imaging to show you what's in that ovary that might have caused it. If you have a big paratubal cyst, that increase the risk of torsion. So if someone has a paratubal or paraovarian cyst, yes, I agree with you. I want you to remove that, baby. Don't aspirate that baby because we're coming back later to get that when the next torsion happens. And the highest risk of torsion in an edematous ovary is in a prepubertal girl. In a pubertal female, you have a posterior cul-de-sac that has plenty of room to house a 4 to 5 centimeter ovary, quite frankly, has a cyst and ovulation that happens monthly. And we tolerate that. So I would say in our quibble, that you have place to put that down the posterior cul-de-sac and it will be safe. Now, if you let her go do gymnastics or the trampoline tomorrow, that's on you. What is the real risk of re-torsion? I've actually never seen one. Now, I've seen people the kid have a little bit of pain the next day and somebody gets an ultrasound and but I personally have never gone back on an ovary. There is a paper that suggested it could be anywhere between 10 to 15%, but it doesn't stratify immediately thereafter or the kids that are already at risk for re-torsion. IE they're kids that you see who already had torsion three, four, five times, or they're a gymnast, or there's long ligaments, there's always a predisposing factor for them. I think there is a risk in edematous ovary, 100%, but I would say you need to give time for that edema to come down and try to preserve an ovary. In summary, when dealing with ovarian torsion, what might initially seem like a cystic area could actually be edema of the fallopian tube. It is essential to avoid an oophorectomy, even if some experts recommend it. The ideal approach is to untwist and preserve the ovary. For younger patients, it is vital to maintain the health and functionality of the fallopian tube, especially giving the risk of scarring, which can impact future fertility. Once the torsion is resolved, it is important to watch for potential underlying factors like paratubal or paraovarian cysts. Activities such as gymnastics can increase the risk of recurrence. So it is wise to be cautious and ensure sufficient recovery time. Thank you for watching this video. Don't forget to subscribe to the Stay Current MD YouTube channel, follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.