Emergency Management and Conservative Surgery of Ovarian Torsion in Children: A Report of 40 Cases

Department of Pediatric Surgery, Hopital Necker-Enfants Malades, Paris, France.
Journal of pediatric and adolescent gynecology (Impact Factor: 1.68). 08/2008; 21(4):201-6. DOI: 10.1016/j.jpag.2007.11.003
Source: PubMed


The authors describe and discuss the clinical and therapeutic features of 40 ovarian torsions (OT) in children with its urgent treatment that has advanced in recent years.
A retrospective study of 40 cases of OT in 38 children under 16 years of age, excluding adnexal torsions in neonates.
Abdominal and/or pelvic pain was the presenting symptom ; 8 of these children had pain between 2 to 9 months prior to surgery and 27/40 (67.5%) had associated vomiting. Before the procedure, ultrasound (US) diagnosed 29 ovarian lesions, related to 14 mature teratomas (MTE) and 10 cystadenomas (CA), one association of MTE and CA in the same ovary, 2 functional cysts and 2 malignant neoplasms. 19/40 torsions could benefit from conservative management. Eleven torsions occurred, 10/11 of these ovaries had an increased volume, and 5/11 had US evidence of small subcortical cysts. Three detorsions with incomplete removal of CA were followed by enlargement of the tumor and re-torsion in 2 of them. Five children had bilateral ovarian pathology which led to unilateral ovariectomy, while the other benefited from conservative treatment.
In any girl presenting with abdominal pain, the diagnosis of an ovarian torsion must be considered. US is performed emergently, but only surgery, most often a laparoscopic procedure, assures diagnosis. The treatment of the torsion is an emergency and must be as conservative as possible in order to preserve the ovarian function. Bilateral torsions are not unusual.

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    • "In a recent review article, Chang et al. state that this characteristic finding of a unilaterally enlarged ovary with peripheral follicles can be seen in up to 72% of ovarian torsion cases [5]. However, Rouseau et al. reported this appearance in just 45% of 11 torsion cases [23], and Chiou et al. reported the finding in only 12% of 18 torsion cases [10]. Lee et al. described a twisted vascular pedicle sign on pelvic US with reported sensitivity of 88% and specificity of 88% [21]. "
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    ABSTRACT: Evaluate the sensitivity and specificity of pelvic ultrasound (US) and abdominopelvic computed tomography (CT) for the identification of ovarian torsion in women presenting to the emergency department with acute lower abdominal or pelvic pain. This is a retrospective study of 20 cases of ovarian torsion and 20 control patients, all of whom had both US and CT performed in the emergency department. Two radiologists who were blinded to clinical data interpreted all studies as (1) demonstrating an abnormal ovary or not, and (2) suggestive of torsion or not. Sensitivity, specificity and interobserver variation were calculated for each imaging modality. Pelvic US was interpreted as demonstrating an abnormal ovary in 90.0% of ovarian torsion cases by reader 1, and in 100.0% by reader 2, whereas CT was interpreted as revealing an abnormal ovary in 100.0% of torsion cases by both readers. Pelvic US for ovarian torsion was 80.0% sensitive (95% CI, 58.4-91.9%) and 95.0% specific (95% CI, 76.4-99.1%) for reader 1, while 80.0% sensitive (95% CI, 58.4-91.9%) and 85.0% specific (95% CI, 64.0-95.0%) for reader 2. Interobserver agreement for pelvic US was fair (Kappa=0.60). Abdominopelvic CT for ovarian torsion was 100.0% sensitive (95% CI, 83.9-100.0%) and 85.0% specific (95% CI, 64.0-94.5%) for reader 1, while 90.0% sensitive (95% CI, 69.9-97.2%) and 90.0% specific (95% CI, 69.9-97.2%) for reader 2. Interobserver agreement was excellent (Kappa=0.85). The diagnostic performance of CT is not shown to be significantly different from that of US in identifying ovarian torsion in this study. These results suggest that when CT demonstrates findings of ovarian torsion, the performance of another imaging exam (i.e. US) that delays therapy is unlikely to improve preoperative diagnostic yield.
    European journal of radiology 01/2014; 83(4). DOI:10.1016/j.ejrad.2014.01.001 · 2.37 Impact Factor
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    • "Germ cell tumors were the most common malignant ovarian tumor in our cohort of patients, comprising 72.06% of all tumors. This incidence is apparently higher than that noted in previous reports [1,10,11]. Deprest et al. pooled data for 1364 patients ages 0 to 19 y and reported 62.2% of ovarian tumors were of germ cell histologic type [14]. In a review of 57 cases of ovarian tumors in 0 to 19 year olds, Hassan et al. reported that ovarian sex cord stromal tumors accounted for 12.3% of all tumors [1]. "
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    ABSTRACT: The true incidence of ovarian tumors in children is unknown. Few studies beyond case reports and case series have been published concerning pediatric ovarian tumors. Herein we review a large number of ovarian tumor cases. The charts of 203 patients who presented with adnexal masses were reviewed. The patient's ranged in age from 2 to 18 years (mean = 15.6 years), with 30 being premenarchal (14.8%). The incidence of ovarian tumor increases with age, especially in patients older than 14 years. The main complaint was abdominal pain or abdominal distension in 117 patients (57.7%). A high AFP level in a pre-pubic girl with an adnexal mass is indicative of a malignant ovarian tumor. The 214 adnexal masses (11 patients had bilateral cysts) consisted of benign tumorous oophoropathy (107 masses, 50.0%), borderline and malignant tumors (29 masses, 13.6%), and nontumorous oophoropathy (78 masses, 36.5%). Of the 136 neoplasia, germ cell tumors accounted for 71.5%. Surgical intervention was performed in 98.5% of cases. There were statistically decreased blood loss, surgery duration and days of hospitalization with the laparoscopic procedure when compared with open surgery. Abdominal pain is the most common complaint in young patients with adnexal masses. AFP is the most useful diagnostic biomarker of ovarian tumors in young females. Laparoscopic resection of ovarian cysts is an alternative operation approach.
    Journal of Ovarian Research 07/2013; 6(1):47. DOI:10.1186/1757-2215-6-47 · 2.43 Impact Factor
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    • "An enlarged, edematous torsed ovary makes the ovary hard to evaluate for a possible underlying malignancy and easy to resect without any perceived consequences. More recently, torsion has been treated with detorsion ± cystectomy with resultant ovarian salvage rates in pediatric literature ranging from 0 to 50%, regardless of surgeon specialty [2] [7] [9] [11] [29] [30]. Our overall salvage rate (11%) falls well within this range. "
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    ABSTRACT: Ovarian torsion remains a challenging diagnosis, often leading to delayed operative intervention and resultant ovarian loss. Charts of patients with ovarian operative cases were retrospectively reviewed at a free-standing children's hospital over 15 years. Torsion was based on intraoperative findings. Of 328 operative ovarian cases, 97 (29.6%) demonstrated torsion. Mean patient age was 9.2 years (2 days to 17 years, +/-0.54 SEM), with 52% occurring between 9 and 14 years. Of the patients, 97% presented in pain. Presence of a pelvic mass 5 cm or larger on imaging had 83% sensitivity for torsion: an ultrasound reading was only 51% sensitive. Elevated white blood cell count was the only preoperative characteristic associated with prompt operative intervention. Utilization of laparoscopy increased during the latter half of the study (18%-42%, P < .0434). There was a positive trend, although insignificant, in the use of laparoscopy and ovarian salvage. Pathology was overwhelmingly benign (infarction [46%], cysts [33%], and benign neoplasms [19%]). Torsion was responsible for one third of all operative ovarian cases. Sonography is not reliable in diagnosis or exclusion of ovarian torsion. Thus, a strategy of earlier and liberal use of Diagnostic Laparoscopy (DL), particularly with a pelvic mass of approximately 5 cm, may improve ovarian salvage. Because pathology is predominantly benign, the edematous detorsed ovary is safe to salvage.
    Journal of Pediatric Surgery 07/2009; 44(6):1212-6; discussion 1217. DOI:10.1016/j.jpedsurg.2009.02.028 · 1.39 Impact Factor
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