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      Recurrent ovarian and fallopian tube torsion: A case report

      case-report

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          Abstract

          Adnexal torsion is an emergency commonly presenting in women of reproductive age. Timely diagnosis and management are needed to preserve the ovary. Recurrence is more uncommon. This article presents a case of recurrent torsion, and reviews the literature to highlight the significance of early diagnosis and management. The case is presented of a nulliparous 31-year-old woman who presented on five occasions with symptoms of acute pain and vomiting. Adnexal torsion was suspected on clinical assessment and ultrasound scan. She was found to have left-sided isolated fallopian tube torsion twice, and tubo-ovarian torsion on two occasions. Detorsion was performed four times. Bilateral oophoropexy was performed during an emergency laparoscopy on the fourth presentation. The left ovary was conserved, but viability was doubted. She presented four weeks later with similar symptoms. An intraoperative finding was of an auto-amputated left ovary with no attachment to infudibulopelvic ligament. This ovary was removed. Operative management was performed promptly, but planned oophoropexy was delayed, and an earlier procedure may have resulted in conservation of the ovary. There is no standardised management for prevention of recurrent ovarian torsion. The benefits of oophoropexy to prevent further torsion versus risks lack evidence. There is also debate as to the method by which oophoropexy is done. There is no consensus or guideline regarding the best management approach for recurrent adnexal torsion. Further research is needed to obtain evidence to support clinicians in discussing management options with their patients.

          Highlights

          • Recurrent ovarian torsion and isolated fallopian tube torsion are rare.

          • Unlike ovarian torsion, there are no classical clinical characteristics or investigations for the diagnosis of isolated fallopian tube torsion.

          • Oophoropexy is an option to manage recurrent ovarian torsion, with various techniques used, but with a lack of evidence regarding the best approach.

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          Most cited references15

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          Pearls and pitfalls in diagnosis of ovarian torsion.

          Ovarian torsion is defined as partial or complete rotation of the ovarian vascular pedicle and causes obstruction to venous outflow and arterial inflow. Ovarian torsion is usually associated with a cyst or tumor, which is typically benign; the most common is mature cystic teratoma. Ultrasonography (US) is the primary imaging modality for evaluation of ovarian torsion. US features of ovarian torsion include a unilateral enlarged ovary, uniform peripheral cystic structures, a coexistent mass within the affected ovary, free pelvic fluid, lack of arterial or venous flow, and a twisted vascular pedicle. The presence of flow at color Doppler imaging does not allow exclusion of torsion but instead suggests that the ovary may be viable, especially if flow is present centrally. Absence of flow in the twisted vascular pedicle may indicate that the ovary is not viable. The role of computed tomography (CT) has expanded, and it is increasingly used in evaluation of abdominal pain. Common CT features of ovarian torsion include an enlarged ovary, uterine deviation to the twisted side, smooth wall thickening of the twisted adnexal cystic mass, fallopian tube thickening, peripheral cystic structures, and ascites. Understanding the imaging appearance of ovarian torsion will lead to conservative, ovary-sparing treatment.
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            Ovarian torsion: 10-year perspective.

            To define the presenting symptoms and clinical progress of surgically proven cases of ovarian torsion presenting to a tertiary women's hospital. A retrospective case review of surgically proven ovarian torsion at The Royal Women's Hospital, Melbourne between 8 May 1990 and 8 May 2000. Fifty-two cases were identified. Median age at presentation was 33.5 years (interquartile range [IQR]: 28.7-39.3). Known risk factors at presentation were found in 16 (30.8%, 95% CI: 26.9-34.6%) cases including 6/49 (12.2%, 95% CI 11.1-12.4%) with ovarian hyperstimulation syndrome. The main clinical features included: sudden pain (20/23, 87%, 95% CI 75-98.9%), nausea/vomiting (23/39, 59%, 95% CI 49.9-68.1%) and palpable abdominal mass (23/37, 62.2%, 95% CI 52.4-71.9%). Median symptom duration was 3 days (IQR: 1-7.25). Median time to diagnosis was 22 h (IQR: 7.8-55.0). The diagnosis was mostly made at surgery (36, 69.2%, 95% CI 60.5-77.9%) with clinically suspicion in 10 (19.2%, 95% CI 17.2-21.3%) and sonographic suspicion/confirmation in six (11.5%, 95% CI 10.5-12.5%) cases. Ultrasound was performed in 31 (59.6%, 95% CI 51.7-67.6%) cases. Underlying pathologies included: ovarian cysts (27, 51.9%, 95% CI 44.9-59.0%) and tumours (16, 30.8%, 95% CI 26.9-34.6%)--mostly benign. Ovarian preservation occurred in 16 (30.8%, 95% CI 26.9-34.6%) cases with no demonstrable association to patient age, time to diagnosis or known risk factors. The diagnosis of ovarian torsion remains challenging. Clinical characteristics lack sensitivity and specificity and ultrasound diagnosis is not definitive. Laparoscopy remains the investigation of choice. Despite delays in diagnosis this study demonstrates relatively high ovarian salvage rates compared with most published data.
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              Ovarian torsion: diagnostic features on CT and MRI with pathologic correlation.

              The CT and MRI features of ovarian torsion are illustrated with gross pathologic correlation. Ovarian enlargement with or without an underlying mass is the finding most frequently associated with torsion, but it is nonspecific. A twisted pedicle, although not often detected on imaging, is pathognomonic when seen. Subacute ovarian hemorrhage and abnormal enhancement is usually seen, and both features show characteristic patterns on CT and MRI. Ipsilateral uterine deviation can also be seen.
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                Author and article information

                Contributors
                Journal
                Case Rep Womens Health
                Case Rep Womens Health
                Case Reports in Women's Health
                Elsevier
                2214-9112
                13 December 2023
                March 2024
                13 December 2023
                : 41
                : e00575
                Affiliations
                Department of Obstetrics and Gynaecology, King's College Hospital NHS Foundation Trust, London SE5 9RS, UK
                Author notes
                [* ]Corresponding author. Lili.ellison@ 123456nhs.net
                Article
                S2214-9112(23)00099-1 e00575
                10.1016/j.crwh.2023.e00575
                10776903
                38204560
                816d1927-41ba-4cb9-bba5-45d760e23653
                © 2023 The Authors

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                : 15 November 2023
                : 9 December 2023
                : 11 December 2023
                Categories
                Article

                ovarian torsion,fallopian tube torsion,recurrent torsion,oophoropexy,case report

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