Ovarian Torsion Rapid Fire: Update Course 2015

OK, so ovarian torsion. So 16 year old female come in with severe abdominal pain in the pelvis. Uh, you get an ultrasound immediately and shows a large cystic mass with a suspicion of torsion. And as many of you know, when you're reading these ultrasound reports, the, the, the blood flow and the, the description of the torsion can vary depending on your ultrasonographer and their experience. And then the next morning, you decide to do a laparoscopic uh drainage and detortion and possibly an oophorectomy. So in this, in these torsion cases, obviously we're always thinking about preserving the ovary and we wanna know what are the alternatives. Um, the other questions I wanted to bring up is, should you do these cases in the middle of the night? Uh, is there a bias towards doing them the next morning, um, because there will or will not be, uh, any difference in loss of the ovary, and can you drain or aspirate it without contamination, which we've already talked about previously. So, ovarian torsion of course is most common in teenage girls, but what, the way it's being seen is to be an urgent and not an emergent situation if you're always aiming to preserve the ovary, and I think as far as updates that when I was a fellow, I was that if it's black, you take it out and now what we're learning from some of our GYN colleagues is that many of these black colored ovaries are actually do have follicles in them that are viable and that ovarian preservation should be the goal. This is sort of the old criteria that we had for looking at um whether it's malignant or not malignant, whether the cyst was bigger than 8 centimeters, trying to decide what to do for it. And now we're moving more towards preserving it because again in these in these situations, you're always concerned if you have a cyst, if it's malignant, is it not? And this is just a really excellent review that was done in Indianapolis, looking at the components that help you decide whether you're gonna drain it, whether you're gonna detourse it, whether you're gonna take it out. Um, the solid component, the size being more than 10 centimeters and the positive markers are really the key as well as the calcifications. In addition, as far as ovarian preservation, your ability to preserve the ovary is gonna depend on these things over here on the left, the size of the mass, the size of the cyst being less than or greater than 10 centimeters, the presence or absence of the torsion, or if it's really just a a a torsion or they're having. Pain because of the size of the cyst and then the approach of being laparoscopic or not laparoscopic, uh, that is also gonna determine whether you have ovarian preservation. And again, the goal is for ovarian preservation, but these things can inhibit your ability to do that. So what about if you go ahead and do an oophorectomy, how much of what's gonna be in the specimen, how many of those specimens are gonna actually have ovarian tissue in them? And it turns out that most of them will have normal ovarian tissue, so these are all comers. These are cysts that have been removed for torsion, uh, but Uh, the, in the, uh, surgeon's opinion, the ovary was dead and therefore they removed the whole ovary and in that case, you have 76% of them that had normal tissue in them, but you have 13, only 13% that had no ovarian tissue and only only 11% where it was actually completely necrotic. So, microscopically, it looks very different uh than it does in the, in the norm in the um gross setting when you as a surgeon are looking at the, at the ovary. So if you do the ovarian preservation and you just, uh, detour set, do you do an orthopraxy, and this is part of the discussion that we should have? How many Pepy and if you do decide to do that, what are the consequences and most of the papers report pain uh in the girls as being consequence of doing a Pepsi and, uh, ovarian sparing, which usually is short-lived, usually only lives, uh, the pain resolves in a week or so. Uh, and also to remember that these black colored force. Ovaries and the ability for us to preserve ovarian function is related to age. So in our patients that are all pediatric patients, we wanna be really aggressive about trying to preserve the ovary. However, in older adults, there really aren't as many active follicles and it becomes a little uh less likely that you could preserve ovarian function. Um, and this is just a very old paper on the technique just showing how old this technique is as far as, uh, removing the cyst and preserving the ovary, uh, and this is the way I do it and try to remove what is torsd and leave what is remaining abnormal, uh, ovary, even if it's just a very thin layer, there are gonna be some follicles in there that. That will be able to be preserved. And here's an image of what looks sort of like a black colored ovary, I purposely put it in black and white, so you could see how black it was an attempt to try to preserve something that even in that area you could just over here on the left side by the fallopian tube, if you just want to preserve a little bit of that, you're gonna preserve enough follicles uh for function. So the recommendation for detortion without complete oophorectomy is the present recommendation, uh, and, uh, that's pretty much it. We'll go to questions and discussion. Yeah, let's do that. So I, I have a question. Let, let's go back now. So, uh, Jason, sorry, man, I'm gonna start with you. Uh, let's just go around the bend here. You get called. By the resident or the fellow that says, there is a patient here, she's 13 years old. She has a right lower quadrant pain. We have an ultrasound that shows uh uh 8 centimeter ovary, ovarian with a uh cystic ovary, OK? Heterogeneous, OK? Uh. Question is, how do you decide how fast you go in? Does an ultrasound help you? What is your usual timing if you're concerned about an ovarian torsion? Do you rush in or do you use the ultrasound to help you? Do you think the ultrasound adds anything? Um, and then I want to go rapid fire around the table, so I would, I would get tumor markers sent off. We won't get them back in time, but I get them off before I go to the OR, and I typically go to the OR in a more urgent fashion. I'm not gonna wait till 7:30 a.m. What if the ultrasound says there's good blood flow? I can't get 7:30 a.m. our time anyway, so I'm going to do it at night. So, uh, Lou, good blood flow on the, uh, I'm, I'm taking care of it the next day, as long as the blood flow's fine. I'm, I have an operative approach that I'm gonna try to do tissue preserving surgery anyway. And in the specimens, the studies that Andrea pointed out, these were not cases that were taken necessarily emergently to the operating room. So these were probably all comers and most of them were not taken urgently. So I think that there's viable. Tissue they're not going to the OR right away. So your answer is if the ultrasound shows blood flow, you're going to do it the next day. You're not coming in at 2 in the morning, Greg. Uh, we work with our gynecology team anyway, so that's more complicated de facto, de facto, but most of us would probably deal with it right away, right away, OK. Are you going to give the same answer? Right away. What if the ultrasound shows good blood flow, symptomatic right away, Mark. Samir, OK, I was under the impression that good blood flow means absolutely nothing. Uh, Dan's nodding his head. Go ahead, Dan. What are you, I would just say right away because I don't trust the ultrasound to tell me whether there's good blood flow or not. OK, Mac. So I've had pediatric radiologists who presidents of their national organization say ultrasound does not help you in this setting, right? OK. Uh, and, well, after hearing the discussion, all right, I'm sure I've done that in the past. Andrea, clarify this for us. I was on R4. activity and specificity is in the 50, 60% range. So you, you gotta, you gotta just go on your instinct, I think, I think the ultrasound, if they say there's blood flow or not blood flow, I, I take little stock in that. If the kid's in a lot of pain, you need to do it right away, in my opinion, if, you know, if it looks like they can be OK to. Morning then you could do it there, but I, I'm never surprised one way or the other whether there's blood flow or not in the, uh, in the stock. So, uh, go ahead, go ahead. And I think torsion, so not torsion secondary to mass, but torsion secondary to long ligaments, uh, where we might be swollen. Will you detours and then ultrasound in a few weeks and check it? Rather than trying to dissect it out as you were describing, oh yeah, me too. You're saying if there's no cyst associated with it, you do. He's saying, yeah, he wants basically do PEi. Uh, what do you do with there's no cyst to deal with. Yes, I try to, I try to PEI them. Um, I used to not Pepsi all of them and then I had a patient that I didn't PEI and then she came back again with a torsion on the other ovary, and then we are in a situation where there was one ovary that had been, um, mostly removed and we have a second torsion, so I, I, I Pexi them for that reason. Uh, I wanna make one comment back about the ultrasound. We just did a podcast that we'll be releasing with Jennifer Dietrich, uh, adolescent gynecologist who I, I never understood why the ultrasound didn't, why they, I mean, if they have blood flow, they have blood flow. It has to do with, I think the way she explained it was. It's twisted. If it's twisted, just because there's blood flow doesn't mean it's not twisted. It may mean at that point in time, it might have been not so tight, so there was some blood flow getting through, but a minute later when you lift up the ultrasound probe, it could be back again tight. So it doesn't tell you anything about torsion. It just tells you that at that point in time, it's, it's not complete occlusion of the blood flow. Is that, is that your understanding, Andrea? Yes, yes, it, it's, and it certainly is dependent on the, the pressure that the oceanographer is using, the, you know, how much the bladder is filled, etc. etc. OK. What about Pepsi? It, I bet you sounds like some people Pepsi and some people don't pull it. Who, who, so I'll tell you my answer first. I Pepsi if I don't see a cyst. If there's something to deal with, I don't Pepsi. If I see a normal ovary that was twisted, then I do a PEI. I'm curious, what do you do, Dan? Same, pretty much the same thing. I used to routinely Pepsi. I do not do that anymore. OK, not routine Pepsi. So I'm not sure if I'm using the word Pexi the same way that generally there's a long, uh, ligament and then you can try to foreshorten that ligament. That's a great point. Yeah, that's what I've done. Uh, does anyone do that? Shortening of the, is it the tubal ovarian ligament? What's the, the shortening of the ligament? It's the broad ligament. Uh, I was taught the same thing. What do you do? I only if I see a cyst. I don't don't see a cyst. Yeah, same thing, but IPEy. I just basically tag the two ovaries together posterior behind the uterus. Interesting. Does anyone else do that? Because that's actually where they naturally lie. If you think about it, you don't put it out laterally and actually for fertility reasons as I talked to one of our reproductive endocrinologists. And that's how I came up with that bowel can get through. Well, I worry about that a little bit, but it's not been an issue. Don't do it that often, but it's, it's tucked up underneath there. I can't imagine it'd be hard for a loop of bowel to get down there. Are you asking about the involved ovary? Based upon what Andrea said, since she saw it occur on the contralateral side, should we be doing a PEy on the other side as well? Yeah, so if you, so if you just tack the two ovaries together behind the uterus, you take care of them both, right? That's, I, I, that's, I've never heard of that. That's very cool. I tacked the ovaries behind the uterus, uh, in the setting of, of, uh, Hodgkin's or a malignancy where they're gonna radiate both pelvis, uh, but in these situations I pull them in a little bit, but I don't actually go all the way behind the uterus. I pull them in a little bit, but not all the way behind the uterus. And you do the contralateral side? Yeah, I do the contralateral side. Um, 00, Whitt wants to know what are you Pepsi too? Um, just the, the pelvic side wall, just the, you know, and we're back. I hope everyone had a nice little break.