Clinicopathological features and surgical procedures of adnexal masses with abdominal pain in pediatric and adolescent patients.

PURPOSE: This study investigated the clinicopathological features and surgical procedures of adnexal masses with abdominal pain in pediatric and adolescent patients. Our objective was to better define the clinical presentation of adnexal torsion and to distinguish characteristics of those with torsion and those with an alternate diagnosis. METHODS: Retrospective cohort study of 212 pediatric and adolescent patients was performed who admitted for abdominal pain and presenting with an adnexal mass between March 2012 to December 2019.Medical records were reviewed for age at operation, including presentation of symptoms and signs; the levels of tumor markers; imaging examinations; pathologic findings; the size of masses; treatment; and outcome. Data management and descriptive analyses were performed using SPSS 26.0. RESULTS: The median age of the patients was 14.5 ± 3.6 years at the operation. 126 (59.4%, 126/212) patients presented with an abrupt onset of abdominal pain. A total of 82.1% (174/212) of the participants underwent adnexal conservative surgery. 179 (84.5%, 179/212) patients underwent laparoscopic surgery with an average tumor size of 7.7 ± 3.4 cm, while 33 patients ( 15.6%, 33/212) underwent laparotomy. Rupture of mass and ectopic pregnancy accounted for 7.5% (16/212) and 0.9%(2/212), respectively. Torsion was responsible for 36.8% (78/212) of all patients. Among the patients with torsion, the symptom of nausea and vomiting was more common among girls without torsion (P < 0.0001). 88.5% of the girls with torsion had acute onset of abdominal pain, while 92.3% had persistent pain that could not be relieved or occurred repeatedly, which significantly higher than that in the patients without torsion (P < 0.001). 69.2% of patients with torsion had fixed pain sites, compared with 42.2% in patients without torsion (P < 0.001). 88.5% of girls with torsion had an ovarian cyst/mass ≥ 5 cm, compared with 75.0% in girls without torsion (P = 0.038). 66.7% of girls underwent ovary-preserving surgery, compared with 92.2% in patients without torsion. The most common pathologic types were mature teratoma and simple cyst, accounting for 29.4% and 25.6%, respectively. The multivariate analyses confirmed that mass size greater than 5 cm (OR 4.134, 95% CI: 1.349-12.669,P = 0.013), acute onset pain (OR 24.150,95%CI: 8.398-69.444,P = 0.000), persistent or recurrent pain (OR 15.911,95%CI: 6.164-41.075,P = 0.000) were significantly associated with increased risk of torsion. CONCLUSIONS: Torsion which is a relatively rare event in the pediatric population was not an uncommon condition and responsible for more than one third of all pediatric and adolescent patients presented with adnexal masses and abdominal pain. Pain assessment in children and adolescents is important to distinguish characteristics of those with torsion and those with an alternate diagnosis.Thus, pediatric and adolescent patients particularly with a pelvic mass size greater than 5 cm, acute onset pain, persistent or recurrent pain have a benign cause and not missing the devastating condition that needs emergent attention. Thus, a strategy of earlier and liberal use of Diagnostic Laparoscopy (DL) may improve ovarian salvage.

Synchronous bilateral ovarian torsion followed by recurrent unilateral torsion in a patient undergoing fertility treatment: A case report and literature review.

BACKGROUND: Ovarian torsion (OT) is a gynaecological emergency and requires prompt recognition and treatment in order to prevent the loss of ovarian function. Patients who are undergoing fertility treatment are at an increased risk of developing OT. OBJECTIVE: The diagnosis of OT in patients undergoing fertility treatment can be challenging as they often present with abdominal pain and other non-specific symptoms. We highlight the importance of early diagnosis of suspected torsion and performed a literature review on cases of bilateral OT to review its presentation, investigation, and subsequent management. CASE REPORT: A 32-year-old nulliparous woman who was undergoing controlled ovarian stimulation presented with lower abdominal pain and was initially managed as ovarian hyperstimulation syndrome (OHSS). Her pain did not subside following conservative management and she proceeded to have a laparoscopy which demonstrated synchronous bilateral ovarian torsion (SBOT), both ovaries were detorted. Eight months later, she was preparing for her frozen embryo transfer (FET) cycle, patient again presented with significant right sided abdominal pain and was found to have a recurrent torsion of the right ovary which was again detorted successfully. CONCLUSIONS: Clinicians should have a low-threshold to investigate and rule out OT in patients who present with lower abdominal pain, especially in those with additional risk factors for torsion. Patients with confirmed torsion can be successfully managed with detorsion of the ovaries. Further research is needed to determine the best management option for patients with recurrent torsion episodes.

[A pregnant patient with acute abdominal pain]. / Een zwangere met acute buikpijn.

A 33-year-old 20 weeks pregnant woman with severe abdominal pain in the past 1,5 hour visits the emergency department. MRI suggested an appendicitis. Laparoscopy showed an adnexal torsion. The right ovary was twisted back, and a good revascularization was observed shortly after. Patient was discharged one day post-surgery and had an uneventful pregnancy.

Adnexal torsion in childhood and adolescence.

The incidence of adnexal torsion in childhood and adolescence is 4.9 per 100,000 girls. Torsion of the adnexa is caused by rotation of the ovary usually with the fallopian tube around the infundibulopelvic ligament. The torsion leads primarily to the interruption of both venous outflow and lymphatic drainage. It causes enlargement of the ovary due its edema with occurrence of hemorrhagic infarctions. Interruption of the arterial inflow leads finally to the necrosis of ovarian tissue. Torsion of the adnexa in childhood occurs usually in enlarged ovary, particularly by a cyst, or when the non-enlarged ovary is excessively mobile due to the extended infundibulopelvic ligament. The characteristic clinical symptoms of adnexal torsion are sudden pain in the lower abdomen with nausea and vomiting. The dia-gnosis of adnexal torsion is based on the typical symptoms, clinical course, and the results of physical and ultrasound examinations. Torsion of the adnexa should be considered in every girl with sudden abdominal pain. To preserve reproductive functions, an early surgery with detorsion of the adnexa should be performed.

Changing Practices in the Surgical Management of Adnexal Torsion: An Analysis of the National Surgical Quality Improvement Program Database.

OBJECTIVE: To evaluate trends in the surgical management of adnexal torsion and to evaluate these trends with respect to the updated American College of Obstetricians and Gynecologists (ACOG) guidelines. METHODS: We performed a retrospective cohort study using the National Surgical Quality Improvement Program database. Women who underwent surgery for adnexal torsion between 2008 and 2020 were identified on the basis of International Classification of Diseases codes. Surgeries were grouped as either ovarian conservation or oophorectomy with the use of Current Procedural Terminology codes. Patients were also grouped into year cohorts with respect to the publication of the updated ACOG guidelines (2008-2016 compared with 2017-2020). Multivariable logistic regression, weighted by cases per year, was used to assess differences between groups. RESULTS: Of the 1,791 surgeries performed for adnexal torsion, 542 (30.3%) involved ovarian conservation and 1,249 (69.7%) involved oophorectomy. Older age, higher body mass index, higher American Society of Anesthesiologists classification, anemia, and diagnosis of hypertension were significantly associated with oophorectomy. There was no significant difference in the proportion of oophorectomies performed before 2017 compared with after 2017 (71.9% vs 69.1%, odds ratio [OR] 0.89, 95% CI 0.69-1.16; adjusted OR 0.94, 95% CI 0.71-1.25). A significant decrease in proportion of oophorectomies performed each year was identified over the entire study period (-1.6%/y, P =.02, 95% CI -3.0% to -0.22%); however, the rates did not differ before and after 2017 (interaction P =.16). CONCLUSION: There was a modest decrease in the proportion of oophorectomies for adnexal torsion performed per year over the study period. However, oophorectomy is still commonly performed for adnexal torsion, despite updated guidelines from ACOG recommending ovarian conservation.

[Gallbladder torsion]. / Torsie van de galblaas.

BACKGROUND: Gallbladder torsion or gallbladder volvulus is a rare condition of the hepatobiliary system, defined as a rotation of the gallbladder along its long axis causing an interruption of the vascular and biliary flow. It clinically mimics acute cholecystitis which makes accurate preoperative diagnosis challenging. CASE DESCRIPTION: We present the case of an 81-year-old woman with a three day history of upper-right quadrant pain, nausea, vomiting and no evidence of cholelithiasis on imaging. Emergency cholecystectomy was performed, intraoperative findings included a necrotic gallbladder with complete torsion. After the secondary diagnosis of gallbladder torsion, the clinical and radiologic findings were reviewed retrospectively. CONCLUSION: The acute onset of abdominal pain without clear progression over time should initially be the trigger for differential diagnostic consideration of gallbladder torsion. This combined with the previously described risk factors and radiological characteristics could result in successful pre-operative diagnosis of gallbladder torsion.

Clinical and radiologic factors associated with adnexal torsion in premenarchal and menarchal children and adolescents.

BACKGROUND: Adnexal torsion is a gynecologic emergency in children and adolescents but remains a challenging diagnosis, with no consistent clinical or radiologic diagnostic criteria. Our objective was to identify risk factors associated with adnexal torsion in premenarchal and menarchal patients with surgically confirmed torsion compared with those without torsion. METHODS: We conducted a retrospective chart review of all patients who underwent surgery between January 2016 and December 2019 for possible adnexal torsion. Data on demographics, clinical characteristics, radiologic variables, and operative findings were compared using descriptive statistics. Independent predictors of torsion were then examined in multivariate logistic regression models. RESULTS: Of the 291 patients who underwent surgery, 168 (57.7%) had torsion. Patients with torsion were younger than those without torsion (11.9 vs. 14.2 years, P < .01). Vomiting was significantly associated with torsion for all patients (P < .001). Large adnexal volume and absent arterial Doppler flow were associated with torsion for the total population and menarchal subgroup. A logistic regression model for the total population that controlled for age and menarchal status found that vomiting (adjusted odds ratio [aOR] 5.92, 95% confidence interval [CI] 2.87-12.22), highest adnexal volume category (aOR 4.92, 95% CI 2.25-10.75), and absent arterial Doppler flow (aOR 2.674, 95% CI 1.28-5.60) were associated with torsion. CONCLUSIONS: Vomiting, enlarged adnexal volume, and absent arterial Doppler flow were associated with adnexal torsion. However, no single risk factor accurately diagnosed torsion, and multiple factors should be interpreted together. LEVEL OF EVIDENCE: Study of Diagnostic Test, Level II.

Inguinal hernia leading to omental torsion: Role of CT in differentiating from other clinical mimics - a case report and literature review.

Omental torsion is a very rare cause of acute abdomen. Clinically, it mimics other common pathologies such as acute appendicitis, acute diverticulitis and acute cholecystitis. It is therefore no surprise, that it was rarely diagnosed pre operatively before the advent and easy availability of modern imaging techniques. CT scan, in particular, can diagnose omental torsion with confidence pre operatively. This can make conservative treatment possible in cases of primary omental torsion and guide regarding the appropriate treatment in cases of secondary torsion. We present a case of a young male patient who presented to Emergency department with symptoms of acute abdomen. Clinical and laboratory findings were non-specific for any specific cause of acute abdomen. CT scan, however, showed omental fat stranding with whirlpool sign representing omental torsion which was seen to be secondary to left inguinal hernia. Patient was operated in emergency and necrotic omentum was resected and hernia repaired. Post-operative recovery was uneventful.

Omental torsion as a rare cause of pain in the right subcostal space - a case report.

Omental torsion is a rare cause of abdominal emergency. Due to its clinical presentation and according to its localisation it is seldom diagnosed preoperatively as it imitates other more common diagnoses leading to surgical revision quite precisely. In this case report the authors present omental torsion with partial omental necrotisation in the right upper quadrant, imitating acute cholecystitis. The condition was managed by laparoscopic resection with a good clinical course postoperatively.

Acute abdomen caused by torsion of the omentum: A pediatric case report.

RATIONALE: Torsion of the omentum and infarction are rare and unusual disorders that often present as acute abdominal pain in the population. The diagnosis of omental torsion is based on clinical and imaging examinations. PATIENT CONCERNS: A 7-year-old girl presented with acute right lower quadrant abdominal pain, with symptoms resembling acute appendicitis. DIAGNOSIS: The patient was diagnosed with omental torsion based on imaging and laparoscopy. INTERVENTIONS: Laparoscopic exploration was performed. OUTCOMES: The patient was discharged seven days after satisfactory postoperative recovery. LESSONS: Omental torsion should be included in the differential diagnosis of acute abdominal pain, particularly in patients with free hemorrhagic fluid in the abdominal cavity and pelvis.

Hiperenrollamiento con torsión del cordón umbilical como causa de muerte fetal: reporte de caso / Hypercoiled umbilical cord torsion as a cause of fetal death: case report

Resumen La torsión del cordón umbilical como causa de muerte fetal es rara, con pocos casos reportados. No se conoce con claridad la causa y se presenta principalmente en el segundo trimestre de embarazo. Los factores de riesgo descritos son la longitud del cordón umbilical y el aumento del número de giros. Se reporta el caso de una paciente de 37 años, grávida 2, para 1 con embarazo de 23 semanas, con hallazgo ecográfico de muerte fetal. En el estudio de histopatología se evidenció el cordón umbilical con hiperenrollamiento y torsión a nivel de la unión feto-umbilical con oclusión de la luz de los vasos umbilicales como causa de muerte fetal. Se requiere la investigación de esta patología para determinar los factores de riesgo y el riesgo de recurrencia en futuros embarazos con el fin de establecer métodos de vigilancia fetal antenatal.

Abstract Torsion of the umbilical cord as a cause of fetal death is a rare occurrence, with few reported cases. The cause is not clearly known, and it transpires mainly in the second trimester of pregnancy; the risk factors described are the length of the umbilical cord with increased number of twists. The case of a 37-year-old woman is reported, gravida 2 para 1, 23 weeks pregnant with ultrasound diagnosis of fetal death. Histopathology revealed hypercoiled umbilical cord torsion at the point where the umbilical cord attaches to the fetus, with occlusion of the lumen of the umbilical vein, as a cause of fetal death. Further research of this pathology is required to determine the risk factors and risk of recurrence in future pregnancies that will allow the preparation of antenatal fetal surveillance methods.

Ultrasonographic scoring system for the diagnosis of adnexal torsion.

PURPOSE: To establish the utility of an ultrasonographic scoring system for the diagnosis of adnexal torsion. METHODS: We retrospectively analyzing 358 adnexal torsion cases. Using Pearson's χ2 test we determined whether ultrasonographic signs were significantly associated with adnexal torsion. Receiver operating characteristic curves were used to evaluate the diagnostic efficacy of the system. Ultimately by using binary logistic regression we established a precise and convenient scoring system. RESULTS: The torsion score was based on five criteria that were identified to be independently associated with adnexal torsion: (1) abnormal position of the index adnexa (odds ratio [OR], 2.311); (2) presence of a mass or cyst (OR, 3.495); (3) unilateral ovarian enlargement (OR, 3.051); (4) vascular pedicle twisting (OR, 2.105); and (5) peripheral hypervascularity of the corpus luteum with ovarian edema(encapsulating cyst sign) (OR, 4.164).patients with torsion who scored 0, have a predicted diagnosis rate of 20.9%; patients whose scores were 1,2 have a predicted probability of 41.8% and 66.15%, respectively. For patients with torsion scores of 3, 4, and 5, predicted diagnosis rates were 84.16%, 93.52%, and 98.27%, respectively. CONCLUSION: The ultrasonographic scoring system is feasible and precisely diagnoses adnexal torsion using ultrasound.

Acute Adnexal Torsion: Is Immediate Surgical Intervention Associated with a Better Outcome?

OBJECTIVES: We aimed to investigate whether surgery for adnexal detorsion within 6 h from admission to the hospital was associated with less adnexal ischemia. DESIGN: This is a retrospective cohort study. PARTICIPANTS/MATERIALS, SETTING, AND METHODS: This retrospective study was conducted at two university-affiliated medical centers and assessed women aged 18-45 years with adnexal torsion who were hospitalized within 12 h from the pain onset and underwent surgery for detorsion within 24 h. The study group was divided into 2 groups: early, surgical intervention within less than 6 h and late, surgical intervention between 6 and 24 h. The primary outcome was the rate of macroscopic appearance of ischemic adnexa. RESULTS: Two hundred and twenty women fulfilled the inclusion criteria. In 101 women, the adnexa with the torsion appeared macroscopically ischemic. There was no difference in ischemic adnexa between the early and late intervention groups (48% vs. 40%; p = 0.269). No significant association was found between the physical examination or ultrasonographic findings and the rate of ischemic adnexa within each group. LIMITATIONS: The main limitations of our study are its retrospective nature. Much of the clinical and ultrasonographic data are subjective and operator-dependent. The decision to operate may vary from one surgeon to another. CONCLUSION: Immediate surgical intervention in patients with adnexal torsion is not associated with a lower rate of adnexal ischemia. These findings suggest that in acute adnexal torsion, there is a wider time window for a thorough evaluation before surgery.