GYN #3 Management of an Adnexal Torsion with a Healthy Appearing Ovary with Dr. Lesley Breech

Global Cast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hi everyone. I'm M.Goti, research fellow at Cincinnati Children's Hospital Medical Center. Today we have a guest from Pediatric Gynecology Department here at Cincinnati Children's. Dr. Lesley Breach, and we will discuss the management of an adnexal torsion with a healthy appearing ovary with a case scenario. So our patient is a 10 year old female who comes with acute onset pelvic pain and vomiting. Ultrasound shows a hemorrhagic appearing mass. So this time there's a mass in the right adnexa adjacent to here. So we went to the OR for this patient. And here you can see this is the twisted infundibulopelvic ligament and this here is the fallopian tube. So we'll go ahead and untwist it and this is really, really you're trying to figure out like what you're trying to do during that time because you want to give enough time for re-perfusion. So this has been 30 minutes like this and this is what you see. Should you leave it or should you not? In general, when we talk about the ovary, we don't really ever want to take an ovary out. I really would prefer to retain fallopian tube as well, but really I think it's sort of weighing the long-term risk of developing things like a hydrosalpinx, in that circumstance the tube is really not going to be as functional. This can actually negatively impact your IVF success leading to ectopic pregnancies. As a pediatric gynecologist, I really don't want to be recommending that we just go into the OR when we're really flamboyant about going ahead and taking out a fallopian tube. But it's important to assess. If you really see a really horrible looking fallopian tube, you would detorse it or untwist it, watch it for a while and leave it. It's really something that you could photograph, you could document, really to give us who are caring for the patient more long term, a better idea of what you saw in the OR and really what to expect for the condition of that fallopian tube. Dr. Breach's goal for us all is to retain reproductive structures. However, the fallopian tubes are not as durable, strong, resilient as what ovaries are. I think and there are some circumstances when really the tube has had a lot of trauma and you don't see a lot of improvement in the health of the tube, that you might consider removal of the fallopian tube, and in that case that's really what would decrease the patient's further reproductive risk that could be associated with a poorly functional tube. If you're going to resect something, resecting it in its entirety is important. Wolfing duct remnants will come back. And that's where it's important to get the whole thing out, but preserve and protect the fallopian tube. And then we want to consider oophoropexy as an interval procedure option. I can't think of a time that I would want to recommend doing that at the time of detorsion. But in patients who have had recurrent torsions, thinking about an interval procedure can be extremely beneficial. Gynecologist call it recurrent as anytime more than once. And they will engage the family about where they are with that. After puberty, we can use medications to suppress the ovary. For instance, we can prescribe birth control pills and that way we can try to keep the ovaries small, minimize cyst and decrease the risk of recurrent torsion. But before puberty like 8-10 year olds, Dr. Breach says she doesn't really have that option. Oophoropexy is really the only thing for them. I'm so grateful for the pediatric surgery team's willingness to work with our team and to help support us when we're trying to backfill in some of our faculty. I think it also gives us an opportunity to work better together and to take the best care of the patients. Here comes the question. Are there any blood tests that providers should make sure they send prior? In that situation, I really don't think there's any specific blood test that we would be asking for. Those are really non-specific markers and levels like a CA-125 will likely be elevated and really just be somewhat confusing about management strategies. And then everyone's going to freak out because that might mean that there's a tumor. And actually that's due to the inflammation process that's happening. So I would say if you have a patient that you think may have a torsion, I really wouldn't be getting all those additional tumor markers. I would take patient to OR, detourse the structure and then deal with what you have to deal with at that moment, but then follow up later. So from a gynecologic standpoint, our goal is to preserve fertility in these young patients. So really, I would be taking the route of saying, let's wait, reassess and perform an interval procedure to perform an ovarian cystectomy if needed. In summary, it is safe to say, in pediatric cases of acute pelvic pain and suspected torsion, prioritize preserving ovaries and fallopian tubes to safeguard fertility. Resect severely damaged tubes carefully. Use oophoropexy for recurrent torsions, especially in pre-puberty. Avoid unnecessary removals and misinterpretation of inflammatory markers. Interdisciplinary collaboration is key for optimal care. 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.