Adnexal torsion in very young girls: diagnostic pitfalls

OBJECTIVE: Evaluation of cases of young girls diagnosed with adnexal torsion. STUDY DESIGN: Retrospective cohort study of 39 girls born between January 1980 and January 2000 who presented with acute abdominal pain and/or the diagnosis adnexal torsion in the Groene Hart Hospital. Seven patients, aged 6-13 years, with adnexal torsion were further evaluated. RESULTS: In three patients, it was possible to save the adnexa. Only the time relapse between the onset of complaints and the surgical intervention correlated with the presence of microscopic necrosis in the ovary. Bluish-black appearance of an ovary did not correlate with the presence of microscopic necrosis. CONCLUSIONS: Early recognition and treatment are essential to minimise the risk of decreased fertility after adnexal torsion in young girls. We therefore advocate prompt diagnostic laparoscopy and detorsion of the adnexa. In case a cyst is present, it should not be resected, but checked on a regular basis using ultrasound.     

Laparoscopic surgery in 12 cases of adnexal disease occurring in girls aged 15 years or younger

STUDY OBJECTIVE: To evaluate the treatment by laparoscopic surgery of adnexal disease occurring in young girls. DESIGN: Retrospective analysis (Canadian Task Force classification II-1). SETTING: Department of gynecology at a general hospital. PATIENTS: Twelve consecutive girls aged 15 years or younger. INTERVENTIONS: Laparoscopic surgery. MEASUREMENTS AND MAIN RESULTS: Seven patients had dermoid cysts, and three of these were associated with adnexal torsion. Two patients had ruptured lutein cysts with ovarian bleeding, and one of them was pregnant. Torsion of the tube with paraovarian cyst, torsion of normal ovary, and serous cystadenoma were noted in one patient each. Although the underlying diseases varied, the chief symptom in each of these patients was lower abdominal pain. Because the symptom is nonspecific, the clinical features were confusing, especially in emergency cases; in two patients with adnexal torsion with dermoid cysts and one patient with adnexal torsion of a normal ovary, there was substantial delay in diagnosis, and salpingo-oophorectomy was required as a result. CONCLUSION: Even in young girls, laparoscopic surgery can be performed in an acceptable manner using regular instruments designed for adults.     

Laparoscopic management of mature cystic teratoma of bilateral ovaries with adnexal torsion occurring in a 9-year-old premenarchal girl

BACKGROUND: Laparoscopic surgery is a minimal-access procedure with many advantages. However, reports of young girls with adnexal disease treated by laparoscopic surgery are limited in the literature. CASE: A 9-yr-old premenarchal girl presenting with acute abdomen was treated by emergency laparoscopic surgery. Bilateral adnexal torsion was noted. After detorsion, bilateral cystectomy was successfully performed and ovarian tissues were preserved. Pathological diagnosis was mature cystic teratoma of bilateral ovaries. CONCLUSION: Although adnexal torsion occurring in a premenarchal girl is an extremely rare disorder and bilateral adnexal torsion is even more rare, gynecologists should possess sufficient knowledge about the manifestations of such disorder for immediate diagnosis and treatment to preserve future fertility and, if available, laparoscopic approach should be chosen for a young girl.     

“Habitual Adnexal Torsions”—Recurrence after Two Oophoropexies in a Prepubertal Girl: A Case Report and Review of the Literature

BackgroundRecurrent adnexal torsion rarely affects girls. Various surgical techniques for its prevention are available. We describe a case of recurrent asynchronous bilateral torsions in a prepubertal patient.CaseAn 8-year-old girl first presented with a right adnexal torsion and underwent a laparoscopic untwisting. During the following 3 years, 4 additional laparoscopies were required for treatment of left adnexal torsions. Although undergoing bilateral utero-ovarian ligament plication twice, torsion recurred. After examining the various options, we fixated the left ovary to the sidewall just below the pelvic brim.Summary and ConclusionIn the absence of clear evidence, treatment should be flexible and dependent on the individual case. Thorough patient education is imperative in order to prevent a delay in diagnosis and treatment of recurrent adnexal torsion.     

Adnexal torsion involving hydatids of Morgagni: a rare cause of acute abdominal pain in adolescents

OBJECTIVE: Hydatids of Morgagni are common embryonal remnants of the müllerian duct and among the infrequent causes of adnexal torsion. The purpose of this study was to investigate the occurrence of adnexal torsion involving hydatids of Morgagni, as well as its possible mechanisms. METHODS: A database search was conducted for cases of adnexal torsion treated in our institution from January 2002 to July 2005. These cases were analyzed, focusing on a subgroup of adolescents with adnexal torsion involving the hydatids of Morgagni. RESULTS: There were 76 patients with adnexal torsion. The rate of hydatid of Morgagni torsion was 26% (4 of 15 cases, 95% confidence interval [CI] 0.15-0.51) in the adolescent subgroup (10-19 years old), compared with 0% (0 of 61 cases, 95% CI 0-0.048) in the adult subgroup. The difference between the hydatid torsion rates in the two subgroups was statistically significant (P = .01, 95% CI 0.001-0.532). The four patients with hydatid torsion (postmenarchal girls, aged 13-18 years) were managed with laparoscopic adnexal detorsion and cystectomy of the affected hydatid of Morgagni. At surgery, we noted three different mechanisms of hydatid torsion: torsion of the adnexa together with torsion of the hydatid of Morgagni, torsion of the hydatid of Morgagni with intact adnexa (n = 2), and entanglement of the hydatid's pedicle around the distal fallopian tube. The hydatids of Morgagni were observed on the preoperative transabdominal ultrasonogram in only one patient and appeared as a simple cyst. CONCLUSION: Adnexal torsion involving the hydatids of Morgagni appears to be more common in adolescents than previously thought. LEVEL OF EVIDENCE: III.     

Diagnosis of adnexal torsion and predictive factors of adnexal necrosis

OBJECTIVE: To determine the most relevant findings for diagnosis of adnexal torsion and predictive factors of adnexal necrosis. PATIENTS AND METHODS: Clinical, biological, ultrasound, pathologic and surgical findings in surgically confirmed cases of adnexal torsion treated over a five-year period in a gynaecologic emergency department were retrospectively reviewed. RESULTS: A total of 52 cases of adnexal torsion were studied. Abdominal pain was present in 80.8%, vomiting in 13.5% and fever only in 9.6%. Leukocytosis was noted in 19 (36.5%). The most frequent ultrasound findings were ovarian enlargement in 22 patients (42.3%), ovarian cysts in 26 (50%), and hyperechogenic parenchyma with follicles along the periphery of the ovary in 13 (25%). Age over 40 years and a delay to surgery longer than 10 hours were significantly associated with diagnosis of adnexal necrosis. DISCUSSION AND CONCLUSION: Prompt diagnosis of adnexal torsion requires a combination of clinical, biological and radiological evidence. No predictive factors of necrosis are found. Risk of adnexal torsion is potentially increased by waiting period for surgery and patient's age.     

Management of adnexal torsion by laparoscopic approach

The study aimed to evaluate the effectiveness and safety of laparoscopic management of adnexal torsion. Early minimal invasive surgical management of adnexal torsion with the main emphasis on an organ-preserving procedure can safely be recommended. Although the incidence of adnexal torsions has increased, the morbidity rate has declined due to safer diagnostics and operative strategies. This is a retrospective case–control study (Canadian Task Force classification II-3) of 33 cases of adnexal torsion over an 11-year period (December 1999–September 2010) in a gynecologic endoscopy unit of a university hospital. Interventions include early diagnostic laparoscopy and utmost protection of the surrounding tissue. Thirty-three cases of laparoscopically managed adnexal torsions were analyzed. Fifty-two percent had conservative organ-sparing procedures, while 48?% underwent resection of ovary, tube, or both. The mean operating time was 69.2?min. There were no complications or conversions to laparotomy. The most common predisposing factor was an adnexal mass with symptoms of pain. Torsion on the right tube is more common than on the left. Laparoscopic surgery is an effective, safe, and feasible method in the diagnosis and treatment of adnexal torsion.     

The conservative management of adnexal torsion--a case-report and review of the literature.

In clinical routine adnexal torsion tends to be subject to adnexectomy to prevent embolism of thrombosed ovarian veins and its sequelae. This therapeutic intervention can be derogatory especially for young women during the reproductive years. As seen in animal models with adnexal torsion, restitution of the adnexa next to reperfusion is possible until 36 h after interruption of venous and arterial blood perfusion. We report about the successful management of a case of adnexal torsion, which was detorsed laparoscopically. We also reviewed 214 cases with conservative management of adnexal torsions reported in the literature.     

Isolated torsion of fallopian tube in a premenarcheal 12-year-old girl

Isolated torsion of fallopian tubes should be considered even at premenarcheal ages in cases of acute pelvic pain, and prompt surgery can preserve the tube and thus fertility. It is an uncommon emergency event and a difficult condition to evaluate clinically. This report focuses on a 12-year-old premenarcheal girl who presented with acute pelvic pain of 2 days. Pelvic ultrasound showed an adnexal mass on the left side. Laparoscopy was performed and an isolated tubal torsion was discovered. The tube was necrotic and salpingectomy was performed. The appendix appeared to be hyperemic and erectile. Appendectomy was also performed to rule out appendicitis. It's our recommendation that in the differential diagnosis of acute lower abdominal pain of girls, isolated torsion of the fallopian tubes should be considered. Also, preservation of the tube and fertility should be possible with prompt surgical intervention.     

Ovarian neoplasms and the risk of adnexal torsion

Previous reports examining adnexal torsion suggested that benign ovarian neoplasms are more likely to undergo torsion than malignant ovarian neoplasms. To our knowledge, this clinical observation has not been quantified. To examine this hypothesis, we reviewed our experience with ovarian neoplasms found at the time of surgery over a 10-year period. Benign ovarian neoplasms had a 12.9-fold increased risk of undergoing adnexal torsion when compared with malignant ovarian neoplasms (95% confidence interval, 10.2 to 15.9). The histologic type of ovarian neoplasm does not appear to affect the rate of adnexal torsion. Adnexal torsion rarely involves cancer.     

Conservative laparoscopic approach to adnexal torsion

Objective To evaluate the conservative laparoscopic approach to adnexal torsion during reproductive age. Methods We present 18 patients with adnexal torsion between January 1997 and December 2005. Patients treated conservatively were controlled by ultrasonography during the postoperative period. Results Of 18 patients with adnexal torsion, 12 patients were treated by conservative laparoscopic surgery after detorsion, one patient with only tubal torsion had undergone laparoscopic salpengectomy. Laparoscopy was converted to laparotomy after laparoscopic detorsion in five cases. Of five patients in this group, four patients was performed cystectomy, one patient salpingo-oopherectomy. Conservative treatment was carried out in 16 of 18 cases with adnexal torsions. Conclusion Conservative management is a safe way to preserve the ovarian function during the reproductive period.     

48例卵巢囊肿蒂扭转的手术治疗分析

目的:探讨不同卵巢囊肿蒂扭转手术方式治疗的安全性及有效性。方法:选取2009年1月至2013年6月于山东省阳谷县人民医院行手术治疗的48例卵巢囊肿蒂扭转患者,其中26例行保留附件的囊肿剥除术(A组)和22例行患侧附件切除术(B组)。比较两组患者的发病时间、卵巢囊肿扭转周数、手术时间、术中平均出血量、术后住院时间、雌激素及孕激素水平。结果:A组的发病时间、囊肿扭转周数小于B组(P0.05),手术时间长于B组(P0.05),雌、孕激素水平恢复情况优于B组(P0.05);而两组的术中平均出血量、术后住院时间无统计学差异(P0.05)。结论:卵巢囊肿蒂扭转手术治疗中卵巢的去留由多因素决定,保留卵巢的保守性手术具有一定的安全性及有效性。     

The risk of malignancy in post-menopausal women presenting with adnexal torsion

OBJECTIVES: Adnexal torsion is usually diagnosed in pre-menopausal women and is less common in post-menopausal patients. The risk of malignancy in cases of torsion in menopausal patients is not known. We set out to describe our experience with adnexal torsion in post-menopausal women and to discuss issues related to management in this situation. METHODS: A retrospective chart review was conducted of all post-menopausal patients diagnosed with torsion of the adnexa from January 1990 through December 2005. Patient charts were reviewed for information regarding pre-operative signs and symptoms, pathology, demographics, surgical findings, procedure and outcome. As a control group, we chose a consecutive cohort of 29 pre-menopausal patients diagnosed with adnexal torsion during 2002. RESULTS: Twenty-seven patients were found to be menopausal at the time of diagnosis of adnexal torsion. Median age at presentation was 63 years (range 43-93). A median delay of 40 h was found between the time of hospital admittance to surgery for post-menopausal patients in comparison to the pre-menopausal ones. The cause of torsion was benign in pre-menopausal patients whereas 22% of post-menopausal patients were diagnosed with malignant disease. More adnexas were found to be necrotic in menopausal patients and this resulted in under-diagnosis of malignancy on frozen section analysis. CONCLUSION: The diagnosis of adnexal torsion is less evident in post-menopausal patients leading to delayed treatment. The high risk of malignancy is of major importance and should be taken into account when counseling patients and when using frozen section during surgery.     

Adnexal torsion: a literature review

This review of the literature focuses on the diagnosis and surgical management of adnexal torsion. Diagnosis of adnexal torsion is difficult and is based on a range of elements obtained by questioning, clinical examination and additional investigations. Pelvic and Doppler ultrasonography are often incapable of revealing this pathology. When adnexal torsion is suspected and diagnosis can only be achieved by surgery, arrangements should be made for laparoscopy as soon as possible. Treatment consists essentially of untwisting the adnexa, even when necrosed, and completed as required by treatment of any cyst present and/or ligamentopexy.     

Contribution of laparoscopy in young women with abdominal pain

This study retrospectively evaluates the laparoscopic treatment of acute abdominal pain in 120 young girls aged 13 to 25 years from 1990 to 1995. Seventy-two (60%) of all operations were emergency procedures. Of these, 55 had functional ovarian cysts, eight patients were operated on for adnexal torsion and nine patients had other adnexal conditions. Ovarian cyst resection was performed in 46 patients and ovarian cyst coagulation in 17 patients. In the rest of the 48 patients (40%), 31 (26.67%) cases had pelvic inflammatory disease, three (2.5%) benign ovarian tumors, two (1.6%) ectopic pregnancies, one (0.8%) a paraovarian cyst and 11 (5%) endometriosis. Laparoscopy appeared to be a safe and effective surgical procedure.     

Adnexal torsion and pulmonary embolism: case report and review of the literature.

The classical teaching was that twisted adnexa should be resected and not untwisted, so as not to increase the risk of pulmonary embolism (PE). A patient recently was seen who developed PE after adnexal resection. Because this complication followed the conventional management of salpingo-oophorectomy, the literature was examined for cases of adnexal torsion and PE to see if the operative management (untwisting vs. excision without untwisting) could be implicated as a contributing factor. Three hundred nine cases of adnexal torsion managed by untwisting and 672 cases treated by adnexectomy without detorsion (untwisting) were found. The incidence of PE after adnexal torsion was 0.2 percent, and this incidence was not increased when the adnexa were untwisted. Therefore, we conclude that detorsion of twisted adnexa does not increase the risk of PE, compared with excision without untwisting. PE does occur in cases in which adnexal resection is performed without untwisting. Thus, detorsion of twisted adnexa should be considered at laparoscopy or laparotomy without fear of increasing the incidence of PE.     

Sonographic findings in adnexal torsion: a report of 34 cases

Objective  The aim of this study was to correlate the preoperative sonographic findings and operation type in cases with surgically proven adnexal torsion in our clinic. Study design  This retrospective study included 34 postmenarchal patients with adnexal torsion who were examined with ultrasound and then operated between November 2003 and October 2007. Surgical procedures performed were divided into two groups: (1) detorsion followed by aspiration or detorsion combined with resection of the adnexal cyst, (2) resection of the whole adnexa. Patients with additional adnexal pathologies as a cause of adnexal torsion were excluded from the study. Results  Twenty-four out of 34 patients (71%) were treated with ovarian conservation and 10 (29%) with resection of the adnexa. Echogenic features of lesions identified in both patient subgroups were similar in appearance. The lowest resection rate was in the group with multicystic appearance (14%), and the highest in solid-cystic group (44.4%). The average mass size was not significantly different between resection (69.3 vs 86.1 mm) and conservation groups. The risk of adnexal resection was higher in cases with an adnexal mass larger than 60 mm (sensitivity 90%, specificity 54.1%) (P = 0.031). The blood flow was present in six of the 21 cases (28.5%). The number of cases who were treated with adnexal resection were significantly more in the group with absent blood flow (P = 0.045). Conclusion  Determination of preoperative sonographic appearance of the mass may be valuable, but it is not specific in the prediction of the operation type of the cases with adnexal torsion. The measurement of the diameter and assessment of blood flow in the adnexal mass might be helpful in detection of the cases who have high risk of adnexal resection.     

Ovartorsion nach In-vitro-Fertilisation

The risk for occurrence of adnexal torsion after IVF treatment is estimated to be about 0.1%. Due to the rarity of the condition and often unremarkable initial ultrasound findings, an adnexal torsion is frequently misdiagnosed and treatment delayed. The only effective therapy is immediate laparoscopy, retorsion, and reducing the size of the ovary.     

Laparoscopic oophoropexy for the treatment of recurrent torsion of the adnexa in pregnancy: case report and review

OBJECTIVE: To introduce a new surgical approach, oophoropexy to prevent recurrent adnexal torsion. DESIGN: Case report and review of the literature. SETTING: The obstetrics and gynecology department of a university hospital. PATIENT(S): A 29-year-old pregnant patient who had three events of torsion of the adnexa after stimulation. INTERVENTION(S): Laparoscopic oophoropexy. MAIN OUTCOME MEASURE(S): Incidence of torsion. RESULT(S): No more torsion events were registered during the ongoing pregnancy. CONCLUSION(S): Laparoscopic oophoropexy is recommended in emergency situations to increase adnexal salvage and to prevent a recurrence.