Long-term results of conservative management of adnexal torsion in children

Background/purpose

Adnexal torsion is a condition that may result in serious morbidity including adnexal removal. However, conservative management with preserving the torsed adnexa is not justified, and long-term outcomes remain unclear.

Methods

The records of 14 girls with ovarian torsion whose adnexal structures were preserved after detorsion were reviewed to evaluate the long-term results of conservative management. Data including age, previous history, duration of complaints, surgical findings and type of intervention, color Doppler ultrasound findings performed in the early and late postoperative periods, and final outcomes were collected.

Results

Mean age of patients was 11.5 ± 2.8 (range 6 to 15) years. Time interval between the onset of pain to surgery was 46.78 ± 35.5 (range 12 to 126) hours. Seven patients had a benign solitary cyst as an underlying cause for adnexal torsion. The intervention performed by open surgery in 9 and by laparoscopy in 5 patients included detorsion, simple cyst aspiration, unroofing and/or cystectomy in 7 patients with ovarian cysts, and oophoropexy in 9 of 14 patients. Follow-up ranged from 3 to 66 (mean 21.9 ± 20.1) months. Thirteen patients resumed normal size and folliculogenesis, whereas in 1 patient, the involved ovary atrophied. No recurrence or contralateral adnexal torsion was observed on follow-up.

Conclusions

Conservative management with untwisting the ovary and pexing both retained detorsed and contralateral ovaries especially in idiopathic torsions should be considered in cases of ovarian torsion in children.     

Minimally invasive management of the prenatally torsed ovarian cyst

Background: Fetal and neonatal ovarian cysts are detected frequently by ultrasonography. The presence of these lesions can result in adnexal torsion in utero with autoamputation. Historically, these have been removed at laparotomy. Methods: Retrospective chart review was performed at a single children's hospital from October 1996 to September 2001. Results: Six cases of torsion of ovarian cysts were removed laparoscopically. Five of the 6 patients had prenatal ultrasound diagnosis. The sixth had the cyst detected incidentally by magnetic resonance imaging (MRI) at 3 months of age. All cysts were complex by ultrasound criteria. All 6 procedures were performed via a 2-port laparoscopic approach. The average age at surgery was 3.7 months (range, 9 days to 7.5 months). There were no postoperative complications. Five patients were discharged on the day of surgery. Conclusion: Laparoscopy offers a safe, effective, and cosmetic means of managing perinatal torsion of ovarian cysts. J Pediatr Surg 37:1467-1469.     

Asynchronous bilateral ovarian torsion

Background

Pediatric ovarian torsion (OT) is a serious condition, especially in cases of asynchronous bilateral ovarian torsion (ABOT). The authors sought to evaluate the predisposing factors for ABOT and to evaluate the most appropriate treatment for ovarian torsion.

Methods

The authors retrospectively reviewed the charts of patients with ovarian torsion between 1980 and 2002. Data collected included age at presentation, type and duration of symptoms, ultrasound scan findings, interval to surgery, procedures, pathology report, and follow-up.

Results

Seventy-six patients had adnexal torsion confirmed at surgery, 4 of whom had ABOT. The mean age was 10 years. The mean duration of complaints before hospitalisation and interval to surgery were 56 and 33 hours, respectively. Thirty-five patients had simple tubo-ovarian torsion (46%), including all the patients with ABOT (11.4%), and 41 had an ovarian pathology (54%). All patients with ABOT underwent salpingo-oophorectomy at the first episode. They presented earlier for the second episode and had a shorter interval to surgery where detorsion with oophoropexy was performed. Follow-up ultrasound scan showed perfusion and follicles in the remaining ovary.

Conclusions

The diagnosis of ovarian torsion often is delayed, especially when a solid tumor is suspected. Conservative management should be strongly considered when there is no underlying ovarian pathology. Furthermore, oophoropexy of the ipsilateral and contralateral ovary should be considered to prevent a potentially devastating recurrence.     

Torsion of uterine adnexa in neonates and children: a report of 20 cases.

Twenty children under the age of 14 years with torsion of the uterine adnexa are discussed. Of the 14 postnatal cases, 8 were associated with additional ovarian pathology whereas in 6 cases the torsion was of normal uterine adnexa. Six additional cases had antenatal torsion with "pseudocyst" formation. All 14 postnatal cases presented as acute abdominal emergency requiring immediate surgery. Only 6 of the 14 had been correctly diagnosed preoperatively, the rest being mostly diagnosed as acute appendicitis. Sonographic studies can improve the preoperative diagnosis. Hemorrhagic necrosis of the adnexa (secondary to the torsion) was found in all cases except one, and necessitated adnexal resection. In only one case preservation of the adnexa was possible. Fixation of the contralateral ovary is recommended in cases of torsion of normal uterine adnexa. All six cases of antenatal torsion were diagnosed by routine ultrasonography during pregnancy between the 29th and 40th week of gestation. The "fluid-fluid" level sign is characteristic of this lesion. These neonates were born in no acute distress and were found to be completely asymptomatic. Hence, they did not require urgent surgery and underwent operation electively at the age of 2 weeks. Resection of the pseudocyst with fixation of the contralateral ovary is the treatment of choice in these cases.     

Maximizing ovarian salvage when treating idiopathic adnexal torsion

Idiopathic adnexal torsion threatens ovarian function. The best ways to maximize ovarian salvage have not been stressed widely. The authors describe 2 girls who illustrate the benefit of untwisting the torsion, limiting resection and performing bilateral gonadopexy to prevent both ipsilateral recurrence and contralateral occurrence.     

Oophoropexy, hyperbaric oxygen therapy, and contrast-enhanced ultrasound after asynchronous bilateral ovarian torsion

A girl with asynchronous, bilateral ovarian torsion with previous oophorectomy presented with her second torsion. A laparoscopic untwisting of the torsed ovary was performed, treatment with hyperbaric oxygen therapy was given, and the outcome was followed with contrast-enhanced ultrasound. After 1 month, a laparoscopic oophoropexy was performed. The detorsed ovary regained its circulation and decreased in size. It looked normal at the time for oophopexy and at follow-up. This case supports the evidence of an ovarian-sparing approach to ovarian torsion in children and supports oophoropexy after torsion of a detorsed, otherwise normal ovary in the premenarcheal girl.     

儿童卵巢扭转的MSCT表现

目的观察儿童卵巢扭转的MSCT表现。方法回顾性分析23例经手术或病理检查证实的儿童卵巢扭转MSCT资料,主要观察扭转后卵巢大小和形态、蒂扭转、子宫及附件周围血管异常改变。23例中,6例仅接受CT平扫,17例接受CT平扫及双期增强扫描。结果 23例患儿中,原发性卵巢扭转4例,继发性卵巢扭转19例;发生于左侧9例,右侧14例。23例中,MSCT示15例卵巢体积增大且密度增高,12例增大的卵巢表面可见数量不等的增大滤泡。23例中,11例(11/23,47.83%)可见卵巢蒂扭转。CT增强扫描动脉期及门静脉期均见卵巢扭转侧子宫及附件周围血管增多、增粗、走行异常。15例子宫不同程度变形、移位;11例可见盆腔内少量积液。结论儿童卵巢扭转的MSCT表现具有一定特征性,MSCT检查有助于提高卵巢扭转的检出率。     

The management of fetal ovarian cysts

Background/Purpose: Ovarian torsion causing the loss of an ovary represents the most common complication of fetal ovarian cysts and occurs more frequently before than after birth. Thus, treatment of fetal simple ovarian cysts should be performed antenatally; however, criteria for prenatal decompression still need to be evaluated. Previous experience of the authors showed that large simple cysts have a poor outcome, whereas preliminary attempts of their [ldquo ]in utero[rdquo ] aspiration were all successful and uneventful. The authors evaluated the outcome of fetal simple ovarian cysts after prenatal aspiration and considered criteria for this procedure. The outcome of cysts showing a prenatal ultrasound pattern of torsion also was studied. Methods: This prospective study includes 73 ovarian cysts (48 simple, 25 showing torsion) diagnosed in 72 fetuses from June 1992 to June 1999, and followed up until spontaneous resolution or surgery. Prenatal aspiration was performed in the case of simple cysts [ge ]5 cm in diameter. The outcome of these cysts was compared with that of similar cysts not aspirated in the authors' previous study ([Chi ]²).¹⁰ Cysts with an US pattern of torsion persisting at birth were operated on. The outcome of simple cysts less than 5 cm and cysts with a prenatal ultrasound appearance of torsion also was evaluated. Results: Prenatal decompression was performed without any complications in 14 cases: 12 (86%; 95% CI: 0.68 to 1.00) regressed subsequently; 2 (14%; 95% CI: 0.00 to 0.32) showed torsion postnatally. This outcome is significantly better than that of similar cysts not aspirated in the authors' previous study¹⁰ (P = .0002). Among the 34 simple cysts less than 5 cm, 26 (76%; 95% CI: 0.62 to 0.90) resolved spontaneously; 8 (24%; 95% CI: 0.10 to 0.38) had complications, 7 of which showing torsion (diameter at evidence of torsion, 4.4 cm [median]; range, 3.3 to 5.2 cm). Among the 34 cysts showing torsion (25 with initial US pattern of torsion + 9 subsequently complicated simple cysts), 24 (71%; 95% CI: 0.56 to 0.86) required oophorectomy; 9 (26%; 95% CI: 0.11 to 0.41) spontaneously disappeared at ultrasound, one of which required surgery for intestinal obstruction secondary to adhesion of a necrotic ovary; one patient (3%; 95% CI: 0.00 to 0.09) was lost to follow-up. Conclusions: Prenatal aspiration of ovarian cysts appears effective and safe: a [ldquo ]cutoff[rdquo ] of 4 cm should be investigated. Cysts with ultrasound pattern of torsion persisting postnatally require surgery; options for their management, when sonographically disappearing and asymptomatic, need to be investigated.     

Ultrasonographic diagnosis for potential contralateral inguinal hernia in children

Purpose: The authors describe the diagnostic approach and the reliability of the diagnosis using their ultrasonographic classification for potential contralateral inguinal hernia in children. Methods: In children presenting with unilateral inguinal hernia, the contralateral processus vaginalis in the inguinal canal was examined preoperatively by ultrasonography with a 10-MHz transducer. The findings, with increment and decrement of the intraabdominal pressure, were categorized into 6 types as follows: type I, the intraabdominal organ is observed in the inguinal canal; type II, the patent processus vaginalis (PPV) is seen cystlike at the internal ring of the inguinal canal; type III, the PPV is widened with abdominal pressure increment (the length of the PPV is longer than 20 mm); type IV, the PPV contains moving fluid without PPV widening; type V, the PPV is widened with abdominal pressure increment (the length is shorter than 20 mm); type VI, others. Types I through IV were regarded as potential candidates for inguinal hernia. The diagnostic performance of the clinical examination, with or without the assistance of ultrasonography was analyzed retrospectively. Results: The development rates of contralateral inguinal hernia following unilateral herniorrhaphy, before and after application of ultrasonographic diagnosis, were 10.2% (28 of 274 cases) and 1.5% (4 of 271 cases), respectively. The difference was statistically significant according to Fisher's Exact probability test. Conclusions: Contralateral herniorrhaphy should be performed on inguinal hernia candidates when ultrasonography shows types I through IV. J Pediatr Surg 38:224-226.     

Ovarian torsion in children: Management and outcomes

Background

The purpose of this study is to evaluate the clinical symptoms, diagnosis, management, and outcomes in children with ovarian torsion.

Methods

The charts of 50 patients with 53 cases of ovarian torsion treated between January 1989 and March 2012 were reviewed retrospectively. Long term follow up was available for 20 girls who had their ovaries left in the abdominal cavity after detorsion.

Results

In 22 cases ovaries were removed, and in 31 cases the torsion was relieved and the ovaries left in the abdominal cavity. Twenty-five of the salvaged ovaries were black-bluish and 10 bluish in color. Since 2005, after a change in preferred treatment, all ovaries treated by detorsion were left in the abdominal cavity. The long term results were observed clinically and by ultrasound in 20 girls. Multifollicular ovaries were found in 17 girls. One girl had a normal size paucifollicular ovary, a one-year-old girl had a normal size ovary with microfollicles, and one girl had no ovarian material detectable by ultrasound.

Conclusions

Long term analysis of the treatment of ovarian torsion revealed that ovaries treated by detorsion and left in the abdominal cavity preserved their normal anatomy and function. Conservative surgical treatment proved to be safe. None of the girls had thromboembolism or peritonitis, and no malignant tumors were found in the operated ovaries.     

Epithelial ovarian tumors in children: a retrospective analysis

Background/Purpose: Epithelial tumors of the ovary account for about 15% of pediatric ovarian masses. The authors reviewed a 14-year experience with ovarian masses to understand the spectrum of pathology, presentation, and outcome of children with epithelial lesions. Methods: All ovarian masses resected or biopsied at the authors' institution from 1988 to the present were reviewed retrospectively. Patient age, presenting symptoms, operative procedures, postoperative treatment, and outcome were obtained from the medical record. Results: A total of 240 cases were identified. A total of 123 (51.2%) were nonneoplastic in nature. Of the 117 neoplastic masses, 79 (67.5%) were germ cell tumors and nineteen (16.2%) were epithelial-derived tumors. Patients with epithelial tumors had a mean age of 13.9 [plusmn] 4 years. Ten patients (52.6%) presented with abdominal pain, and 9 (47.4%) presented with an asymptomatic mass. Eleven underwent oophorectomy, 6 underwent cystectomy, and 2 had biopsy alone. Four patients (21%) had ascites, and 1 (5.3%) had a pleural effusion. The histopathologic diagnoses for the epithelial tumors included 9 serous cystadenomas (47%) and 3 mucinous cystadenomas (16%), 3 mucinous cystadenocarcinomas (16%), and 4 serous tumors of borderline malignancy (21%). Two patients (11%) had bilateral disease. Four patients (21%) underwent a subsequent laparotomy for either staging or recurrence, and 2 patients (11%) required chemotherapy. One patient (5.3%) died of ovarian adenocarcinoma. Conclusions: Epithelial tumors comprise a small but significant proportion of pediatric ovarian masses. The pediatric surgeon must understand the biologic characteristics, operative management, and follow-up treatment of these tumors, and how these differ from germ cell lesions. J Pediatr Surg 38:331-335.     

Pediatric ovarian torsion: case series and review of the literature

Background

Ovarian torsion in children is an uncommon cause of acute abdominal pain but mandates early surgical management to prevent further adnexal damage. The clinical presentation mimics other pathologies, such as appendicitis. We sought to more completely characterize ovarian torsion with respect to pain and ancillary studies, such as urinalysis.

Methods

We performed a retrospective review of hospital charts of all patients aged 0–18 years with a diagnosis of ovarian torsion at the Children’s Hospital at London Health Sciences Centre, in London, Ont., from 1993 to 2008.

Results

We analyzed 13 charts of patients aged 7 months to 18 years. Most patients presented with peripheral leukocytosis, vomiting and right lower quadrant pain that did not radiate or migrate. On urinalysis, about half the patients demonstrated pyuria without bacteruria. Pelvic ultrasound revealed an ovarian cyst on the same side of the pain in 11 of 13 patients. Most were found to have a hemorrhagic cyst or ovary and underwent salpingo-oophorectomy or cystectomy within 48 hours of presentation.

Conclusion

Ovarian torsion should be considered in any female child with acute onset lower abdominal pain accompanied by vomiting. Pain can be characterized as constant or colicky, but unlike with appendicitis, does not typically migrate. Sterile pyuria is found in a substantial proportion of cases. Ultrasound is the most useful initial diagnostic modality, but the absence of flow on Doppler imaging is not always present. Conservative management with detorsion and oophoropexy is recommended.     

Management of pediatric ovarian torsion: evidence of follicular development after ovarian preservation

Purpose

This study reviews contemporary management and follow-up of pediatric ovarian torsion.

Omental infarction: risk factors in children

Purpose: A series of 4 cases of omental infarction are analyzed. It is shown that obesity, as well as idiosyncratic anatomy, are factors in the development of this rare clinicopathologic entity. Methods: The authors reviewed the preoperative and operative records of all patients. Results: All of the cases of omental infarction were seen in obese children. Other than persistent right-sided abdominal pain, there were no other signs or symptoms. None of the patients had an elevated white blood cell count, and none had fever. Conclusions: Computed tomography scanning is noted to be helpful in making the diagnosis. Laparoscopy is noted to be the procedure of choice, because standard incisions may preclude one from a proper exploration. J Pediatr Surg 38:233-235.     

Subsequent asynchronous torsion of normal adnexa in children

Children who have suffered from ovarian torsion may be at increased risk for a repetitive event. Torsion in a normal adnexa may be due to excessive mobility resulting from congenitally long supportive ligaments. Oophoropexy or shortening of the ligamentous support of the remaining functional ovary after torsion is recommended in attempt to prevent a subsequent torsion. The evaluation of young females with abdominal pain should always include the consideration of ovarian torsion. Preoperative ultrasonography is not invasive and could lead to earlier operative intervention resulting in salvage of ovarian tissue. Observation in these same children may allow a torsed edematous ovary to convert to a nonviable necrotic tissue necessitating oophorectomy. Laparoscopy is useful in cases in which the diagnosis is unclear.     

Ovarian torsion. Management and ovarian prognosis: a report of 45 cases

Background/Purpose

Ovarian torsion in childhood and adolescence is a rare entity. Traditionally, treatment is oophorectomy. The aim of this study was to evaluate ovarian outcome and to propose a decision-making protocol for suspected ovarian torsion.

Methods

Between January 1986 and December 2007, 45 ovarian torsion cases in 40 girls were operated on. In all the cases, when the ovary was preserved, patients were clinically and ultrasonographically followed up for several months.

Results

Median age was 11 years. Median delay between the first symptoms and surgical procedure was 3 days. There was a statistical difference (P = .0003) between the mean of the largest diameter of twisted normal ovary and the mean of the largest diameter of twisted diseased ovary. Underlying pathology was benign in 22 cases and low-grade malignancy in 2 (one grade II immature teratoma and one steroid cell tumor). Conservative management was performed in 26 cases. At follow-up, 17 ovaries were follicular, 7 being black-bluish during surgery.

Conclusions

Conservative approach after detorsion of black-bluish ovaries is safe and effective in children. Although very unlikely, the fear of missing malignancy must incite to proceed with caution and can lead, when the size of the twisted ovary is greater than 75 mm, to prefer laparotomy to laparoscopy.     

Femoral hernia repair with mesh-plug in children

Purpose: Femoral hernias (FH) are rarely seen in children, so there is no consensus on the age and sex distribution or the optimum method of repair. Recently, repair of the femoral hernias with mesh-plug has gained wide popularity in adults. The authors used this method in 4 children with FH and discuss its utilization in children. Methods: Four consecutive children with femoral hernia were treated using mesh-plug. Patients' characteristics and operative technique was described. Results: Plugging femoral defect with a mesh-plug was applied successfully in children. No complications were seen after a follow-up period for 2 years (range, 8 to 30 months). Conclusion: Repair of femoral hernias with mesh-plug is performed easily and successfully in children. J Pediatr Surg 37:1456-1458.     

Is contralateral exploration necessary in girls with unilateral inguinal hernia?

Background/Purpose: Routine contralateral groin exploration in girls with unilateral inguinal hernia (UIH) continues to be controversial. The aim of this study was to determine the incidence of contralateral hernia development in girls after UIH repair. Methods: Between 1972 and 2000, 391 girls underwent repair of UIH. Ninety-one (23%) of the 391 girls underwent routine contralateral exploration during UIH repair and were excluded from the study. The median age at operation in the remaining 300 girls was 3.3 years (range, 1 month to 14 years). Two hundred ten (70%) girls had right-sided and 90 (30%) had left-sided UIH. Familial history of hernia was identified in 8 (3%) patients. The follow-up ranged from 1.5 to 14 years. Mann-Whitney U test was used for intergroup comparison. Results: A contralateral hernia developed in 24 (8%) of the 300 patients who had unilateral repair of inguinal hernia. Median time from operation to occurrence of the contralateral hernia was 3 years (range, 1 to 4 years). Age at operation, side of hernia, and familial history did not influence the development of contralateral hernia. Conclusions: These data suggest that the low incidence of contralateral hernia development in girls undergoing UIH repair does not justify routine contralateral groin exploration. J Pediatr Surg 38:756-757. [copy ] 2003 Elsevier Inc. All rights reserved.     

Regional anesthesia is a good alternative to general anesthesia in pediatric surgery: Experience in 1,554 children

Background/Purpose: Although caudal and spinal blocks are modern and safe techniques, in many centers children still are operated on under general anesthesia (GA), or the blocks are used for postoperative analgesia after GA in infraumbilical operations. The authors aimed to document the results and the complications of 1,554 regional anesthesia cases, thereby assessing their validity. Methods: The analysis of 1,459 caudal and 95 spinal blocks cases collected until January 2001 in children from newborn to 12 years of age are documented retrospectively. The types of anesthesia analyzed in the study were caudal block (CB) only, CB plus GA, GA plus CB, GA plus spinal block, and spinal block only. Results: There were 1,338 caudal and 95 spinal block cases that clinically were satisfactory. Because the duration of CB was not sufficient in 39 cases, GA was used. Failure to produce a CB occurred in 82 cases (5.57%). There were 257 of 1,338 patients operated on under GA and supported by caudal block for postoperative analgesia. Conclusions: Caudal anesthesia seems to be an inexpensive, simple, and effective technique not only as a supplement for postoperative analgesia, but also as a single method of anesthesia. and the authors recommend its use in a wider setting of clinical entities in infraumbilical surgical procedures of children.     

Ovarian torsion in pediatric and adolescent patients: A systematic review

Objective

Ovarian torsion in pediatric patients is a rare event and is primarily managed by pediatric general surgeons. Torsion can be treated with detorsion of the ovary or oopherectomy. Oopherectomy is the most common procedure performed by pediatric general surgeons for ovarian torsion. The purpose of this systematic review by the American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee was to examine evidence from the medical literature and provide recommendations regarding the optimal treatment of ovarian torsion.