1 00:00:00,000 --> 00:00:05,000 Global Cast MD, along with Cincinnati Children's Hospital, 2 00:00:05,000 --> 00:00:08,000 sharing knowledge to improve child health around the globe. 3 00:00:08,000 --> 00:00:16,000 Hello, Pediatric Surgery family. 4 00:00:16,000 --> 00:00:21,000 I'm Emgodi, a research fellow from Cincinnati Children's Hospital Medical Center. 5 00:00:21,000 --> 00:00:26,000 Our 11th annual update course in pediatric surgery was held past August. 6 00:00:26,000 --> 00:00:31,000 In this video series, we'll recap the sessions and share the main highlights with you. 7 00:00:31,000 --> 00:00:35,000 Today, we'll talk about ovarian torsion management with a sample case. 8 00:00:35,000 --> 00:00:39,000 Joining the discussions are Dr. Leslie Breach, a pediatric gynecologist, 9 00:00:39,000 --> 00:00:44,000 and Drs. Erin Ravel and Dan Wan-Alman, our both pediatric surgeons. 10 00:00:44,000 --> 00:00:46,000 Let's hear our case from Dr. Breach. 11 00:00:46,000 --> 00:00:53,000 So I just want to talk a little bit about a patient that you all might see more frequently than you might see from fertility preservation. 12 00:00:53,000 --> 00:01:00,000 So this is a five-year-old female, acute onset of pelvic pain and vomiting, comes to the emergency department, gets an ultrasound, large cystic mass, 13 00:01:00,000 --> 00:01:04,000 no blood flow to the right ovary, and you decide to take this patient's operating room. 14 00:01:04,000 --> 00:01:08,000 You find right ovarian torsion, and you can see this sort of dark purple ovary. 15 00:01:08,000 --> 00:01:12,000 You're in the OR and deciding, what are you going to do now? 16 00:01:12,000 --> 00:01:19,000 So this patient, you see a cystic area on ultrasound, but often when you get there, that's actually edema of the fallopian tube. 17 00:01:19,000 --> 00:01:24,000 What I really wanted to show you on this case is that oftentimes there isn't something to drain. 18 00:01:24,000 --> 00:01:28,000 You have a highly edematous ovary or edematous fallopian tube. 19 00:01:28,000 --> 00:01:33,000 So if there is a cyst, I see people have an appetite and want to go for it and aspirate things. 20 00:01:33,000 --> 00:01:43,000 So the important point, though, and I think this has been made several times over the last several years, is that you should not do an oophorectomy. 21 00:01:43,000 --> 00:01:49,000 And there are still colleagues who are saying they would do an oophorectomy. 22 00:01:49,000 --> 00:01:53,000 Anyway, I just think we need to drive home that point. 23 00:01:56,000 --> 00:01:57,000 My first hug of the day. 24 00:01:57,000 --> 00:01:58,000 Oh, all right, great. 25 00:01:58,000 --> 00:02:01,000 That's what happens when you work in the integrated gynecology team. 26 00:02:01,000 --> 00:02:04,000 Correct. We should be never doing an oophorectomy. 27 00:02:04,000 --> 00:02:10,000 And there isn't good data that would show us the timeline and the appearance that would say the ovary is not going to live. 28 00:02:10,000 --> 00:02:14,000 In this situation, you would always detour the ovary and leave it. 29 00:02:14,000 --> 00:02:24,000 In a recent review on a quality improvement project, there were some institutions where as many as 25 percent of the time, surgeons were taking out the ovary in similar cases. 30 00:02:24,000 --> 00:02:28,000 So Dr. Breach is recommended to avoid that. 31 00:02:28,000 --> 00:02:33,000 Now there's more questions about the fallopian tube, how to manage a blue-black fallopian tube. 32 00:02:33,000 --> 00:02:36,000 Take a look at the tube. If the tube is black, it's edematous. 33 00:02:36,000 --> 00:02:37,000 You have detour it. 34 00:02:37,000 --> 00:02:43,000 You've given it plenty of time, I would say, a consideration about what to do about that tube. 35 00:02:43,000 --> 00:02:47,000 If it's a pre-puberty girl, you have plenty of time to figure it out. 36 00:02:47,000 --> 00:02:53,000 But if the patient is an adolescent and it is edematous, there is some concern about the future. 37 00:02:53,000 --> 00:02:57,000 So the future function of the tube needs to be able to do this. 38 00:02:57,000 --> 00:03:02,000 You cannot have like a, you know, a lead pipe tube that's going to work well. 39 00:03:02,000 --> 00:03:03,000 And you have to have open fimbria. 40 00:03:03,000 --> 00:03:08,000 So scarring of the tube is a concern for the future and risk-react topics. 41 00:03:08,000 --> 00:03:12,000 There isn't anything causing the torsion. I know it's possible. 42 00:03:12,000 --> 00:03:20,000 Then I have a contingency plan, which is drain the cyst or cystectomy if there is something that clearly caused it and then hope for the best. 43 00:03:20,000 --> 00:03:24,000 If there's not, those are the couple of instances that have tried to attack PEXI. 44 00:03:24,000 --> 00:03:25,000 Oh, really? 45 00:03:25,000 --> 00:03:32,000 Yeah, really. Because otherwise, I think I haven't done anything differently that won't prevent it from recurring two hours from now. 46 00:03:32,000 --> 00:03:33,000 I love this. 47 00:03:33,000 --> 00:03:37,000 We'll start with saying a good percentage of the patients will have nothing wrong with the ovary. 48 00:03:37,000 --> 00:03:41,000 And so particularly in pre-puberty patients, we'll just detorce. 49 00:03:41,000 --> 00:03:44,000 It's a big chunky edematous ovary. You're like, oh, no, I'm going to do it. 50 00:03:44,000 --> 00:03:47,000 They're going to torsion again in 48 hours. You kind of tuck it down. 51 00:03:47,000 --> 00:03:56,000 Some people have talked about trying to reduce some of that edema by incising the cortex, having some release of that edema so that the swelling will come down. 52 00:03:56,000 --> 00:03:58,000 So understand that hesitance. 53 00:03:58,000 --> 00:04:04,000 However, with all that edema, it's hard to tell if there is something in that ovary that needs to be removed. 54 00:04:04,000 --> 00:04:14,000 So we would say most gynecologists untwist, leave things be, and do come back for some imaging to show you what's in that ovary that might have caused it. 55 00:04:14,000 --> 00:04:18,000 If you have a big paratubal cyst, that increases the risk of torsion. 56 00:04:18,000 --> 00:04:24,000 So if someone has a paratubal or parovarian cyst, yes, I agree with you. I want you to remove that baby. 57 00:04:24,000 --> 00:04:29,000 Don't aspirate that baby because we're coming back later to get that when the next torsion happens. 58 00:04:29,000 --> 00:04:34,000 And the highest risk of torsion in an edematous ovary is in a pre-puberty girl. 59 00:04:34,000 --> 00:04:39,000 In a puberty female, you have a posterior cul de sac that has plenty of room to house a four to five centimeter ovary. 60 00:04:39,000 --> 00:04:44,000 Quite frankly, has a cyst in an ovulation that happens monthly. And we tolerate that. 61 00:04:44,000 --> 00:04:50,000 So I would say in our quibble that you have a place to put that down in the posterior cul de sac and it will be safe. 62 00:04:50,000 --> 00:04:55,000 Now, if you let her go to do gymnastics or the trampoline tomorrow, that's on you. 63 00:04:55,000 --> 00:04:59,000 What is the real risk of retortion? I've actually never seen one. 64 00:04:59,000 --> 00:05:03,000 Now, I've seen people, the kid have a little bit of pain the next day and somebody gets an ultrasound. 65 00:05:03,000 --> 00:05:07,000 But I personally have never gone back on an ovary. 66 00:05:07,000 --> 00:05:15,000 There is a paper that suggested it could be anywhere between 10 to 15 percent, but it doesn't stratify immediately thereafter. 67 00:05:15,000 --> 00:05:18,000 Or the kids that are already at risk for retortion. 68 00:05:18,000 --> 00:05:24,000 I.e. there are kids that you see who already had torsion three, four, five times or they're a gymnast or there's long ligaments. 69 00:05:24,000 --> 00:05:27,000 There's always a predisposing factor for them. 70 00:05:27,000 --> 00:05:31,000 I think there is a risk in an edematous ovary 100 percent. 71 00:05:31,000 --> 00:05:36,000 But I would say you need to give time for that edema to come down and try to reserve an ovary. 72 00:05:36,000 --> 00:05:44,000 In summary, when dealing with ovarian torsion, what might initially seem like a cystic area could actually be edema of the fallopian tube. 73 00:05:44,000 --> 00:05:49,000 It is essential to avoid an oophorectomy, even if some experts recommend it. 74 00:05:49,000 --> 00:05:52,000 The ideal approach is to untwist and preserve the ovary. 75 00:05:52,000 --> 00:06:02,000 For younger patients, it is vital to maintain the health and functionality of the fallopian tube, especially given the risk of scarring, which can impact future fertility. 76 00:06:02,000 --> 00:06:09,000 Once the torsion is resolved, it is important to watch for potential underlying factors like pair tubal or pair ovary cysts. 77 00:06:09,000 --> 00:06:17,000 Activities such as gymnastics can increase the risk of recurrence, so it is wise to be cautious and ensure sufficient recovery time. 78 00:06:17,000 --> 00:06:19,000 Thank you for watching this video. 79 00:06:19,000 --> 00:06:23,000 Don't forget to subscribe to the Stay Current MD YouTube channel. 80 00:06:23,000 --> 00:06:29,000 Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. 81 00:06:29,000 --> 00:06:39,000 Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.