Quick Search
  Home Journal Information Current Issue Past Issues Services Contact Us  
Articles
Update on the management of ovarian torsion in children and adolescents 
 
Update on the management of ovarian torsion in children and adolescents
  Abdul Ghani Nur Azurah, Zakaria Wan Zainol, Ani Amelia Zainuddin, Pei Shan Lim, Aqmar Suraya Sulaiman, Beng Kwang Ng
 [Abstract] [Full Text] [PDF]   Pageviews: 10371 Times
 
Update on the management of ovarian torsion in children and adolescents
Abdul Ghani Nur Azurah, Zakaria Wan Zainol, Ani Amelia Zainuddin, Pei Shan Lim, Aqmar Suraya Sulaiman, Beng Kwang Ng
Kuala Lumpur, Malaysia
 
Author Affiliations: Department of Obstetrics and Gynaecology, UKM Medical Centre, Kuala Lumpur, Malaysia (Nur Azurah AG, Wan Zainol Z, Zainuddin AA, Lim PS, Sulaiman AS, Ng BK)
 
Corresponding Author: Abdul Ghani Nur Azurah, MBBS, MOG (UKM), MD, Department of Obstetrics and Gynaecology, UKM Medical Centre, Kuala Lumpur, Malaysia (Email: nurazurahag@gmail.com; azurah@ppukm.ukm.edu.my)
 
doi: 10.1007/s12519-014-0536-3
 
Background: Ovarian torsion is commonly seen in young girls. Unfortunately it is often misdiagnosed because of its non-specific symptoms and lack of diagnostic modalities. This article focuses on the diagnostic challenge and also the changes in the management of ovarian torsion.
 
Data sources: We reviewed original reports on the management of ovarian torsion in young girls published from 1984 till 2014. A literature search was conducted by electronic scanning of five electronic database: MEDLINE, EMBASE, SCI, SSCI and CINAHL. In addition, relevant papers and review articles were hand-searched. The search was limited to English language and human studies. The search was conducted by combining the textwords "ovarian torsion", "adnexal torsion", "adolescents" and "oophoropexy".
 
Results: There are no specific symptoms that can be identified as a pathognomonic feature of ovarian torsion. Ultrasound is a useful diagnostic tool, but it is not always reliable in absence of an enlarged ovary. Laparoscopic detorsion is recognized as the mainstay of treatment regardless the condition of the ovaries. Reports have shown favorable ovarian function after detorsion. The role of oopheropexy remains controversial.
 
Conclusions: Clinicians should be aware of ovarian torsion in girls presenting with abdominal pain. A timely management in this young population can help preserve their ovaries and fertility.
 
                                                                                                        World J Pediatr 2015;11(1):35-40
 
Key words: adolescents;
                    oophoropexy;
                    ovarian torsion
Introduction
Ovarian torsion as a rare entity in childhood and adolescence[1] is an emergency event requiring prompt surgical management. Its incidence ranges from 2/10 000 to 4.9/100 000.[2,3] It accounts for 2.7% of all causes of abdominal pain in children.[4]
Low abdominal pain, nausea, vomiting, low fever and leukocytosis are the usual presenting features. Because of its non-specific symptoms, ovarian torsion is difficult to be distinguished from other entities including acute appendicitis, ruptured ovarian cyst, renal colic and gastroenteritis. Hence, the diagnosis of ovarian torsion remains a great challenge to pediatric surgeons and adolescent gynecologists. A retrospective study[5] showed that misdiagnosis was more likely to make in premenarchal girls than in menstruating women. And absence of an enlarged ovary in this population contributed to the delay in diagnosis. Oltmann et al[6] reported that about 46% of ovarian torsions in children occurred in normal-appearing ovaries.
A literature search was conducted between 1984 and 2014 to provide the clinical symptoms, diagnostic modalities and treatment of ovarian torsion in this young population.
Pathophysiology of ovarian torsion
Ovarian torsion is associated with pathological changes of the ovary, but it might occur in the normal ovary.[7,8] The exact underlying mechanism of this entity remains poorly understood. Excess mobility in elongated fallopian tubes and ligaments, tubal spasm and sudden change in the intra-abdominal pressure have been postulated as possible causes.[9,10] Increased hormonal activity in the premenarcheal period or even in the perinatal period may be associated with the higher risk of ovarian torsion.[10-12]
Ovarian torsion occurs often at the right side of the ovary in a ratio of 3:2.[13] It has been postulated that the presence of the sigmoid colon in the left iliac fossa helps to reduce the motility of the tubal structure, while reducing the risk of left adnexal torsion. However, asynchronous bilateral lesions have also been reported.[7,14]
Mature cystic teratoma which is frequently found to be associated with torsion is followed by corpus luteal cyst and follicular cyst.[10,13] But malignant ovarian tumor associated with ovarian torsion is rare. A review of 424 cases revealed that the incidence of malignancy was only 1.8%.[15] Inflammation and fibrotic changes in malignancy have been postulated to cause adhesion, making the tumor less likely to be twisted.[16]
Implications of ovarian torsion
Similar to torsion of other structures, venous circulation of the ovary will be compromised followed by arterial circulation. If untreated, this will eventually lead to ischemia and necrosis of the ovary. The absence of unilateral ovaries and tubes in women has been investigated for subfertility. These women have never undergone any operative procedures. Undiagnosed ovarian torsion has been speculated as the cause of its absence.[17,18]
Fatal complications following ovarian torsion have also been reported. Fitzhugh et al[19] reported a case of a four-month-old infant with ovarian torsion and bowel necrosis that lead to cardiorespiratory arrest and eventually to the death of the infant. Havlik et al[20] also reported a case of sudden death from ovarian torsion and suggested that adnexal torsion should be included as a differential diagnosis in cases of sudden death in infancy.
Presentation and diagnosis of ovarian torsion
The common manifestations of ovarian torsion in post-menarchal adolescents include recurrent abdominal pain followed by nausea, vomiting and occasionally a palpable abdominal mass.[21] Studies[16,22,23] found right-sided pain in more than 50% of the patients, with vomiting in up to 70%; however, fever was found to be an uncommon association with ovarian torsion (16%-22%).[16,22,23] A recent review of 13 girls aged between 7 months and 18 years found that right lower quadrant pain with no pain radiation or migration was the most commonly reported manifestation.[24]
Diagnosis of ovarian torsion is mainly supported by symptoms and ultrasonographic evidence. However, basic laboratory investigations need to be performed to rule out other causes of acute abdominal or pelvic pain, which include urinalysis, pregnancy tests and full blood count. In suspected ovarian tumors, serum levels of tumor markers such as alpha-fetoprotein (¦ÁFP), beta-human chorionic gonadotropin (¦Â-HCG), carbohydrate antigen (CA) 125 and CA19-9 should be determined.[25,26]
Plain abdominal X-rays are less effective in detecting ovarian torsion but help to rule out bowel obstruction. The most useful investigation tool is a pelvic ultrasound scan. Diagnostic sonographic features are ovarian enlargement in contrast to the contralateral ovary, presence of multiple small peripherally placed follicles within the ovary, which reflect displacement caused by edema and the presence of fluid collection in the pouch of douglas.[27] Despite the presence of ovarian torsion, doppler ultrasonography[28-30] was normal in 60% of the cases because of the presence of a dual blood supply to the ovary.
Since ovarian torsion presents with non-specific abdominal pain, adolescents with this condition may undergo a CT scan as the first-line radiological investigation. Ultrasonographically, the enlargement of the ovary may be associated with the presence with an ovarian cyst. MRI has been shown to be useful when ultrasound is inconclusive as it has the advantage of identifying the early stages of ovarian edema and hemorrhagic infarction.[27] Although multiple radiological modalities are available, early ultrasound and doppler evaluation could make a prompt diagnosis with a minimal risk of radiation exposure for the patients.
Changing trends in the management of ovarian torsion
Ovarian torsion needs surgical intervention. In the past, laparotomy has been the surgical approach for the treatment of ovarian torsion. Over the years, laparoscopy has been popularized as it is more reliable than other clinical and radiological assessments. It has been shown to be safe even in young girls,[31-33] with similar outcomes but less morbidities as laparotomy.[34] Cohen et al[35] carried out a retrospective study comparing laparotomy and laparoscopy for ovarian torsion. The outcomes including post-operative ovarian function and macroscopic appearance during the second look surgery were similar in both groups. However, laparoscopy was superior to laparotomy in terms of shorter hospital stay, fewer febrile morbidities and lesser analgesic requirement post-operation.[35] Thus, laparoscopy can be used as a diagnostic tool and more importantly provides favorable outcomes for girls with ovarian torsion.
When laparoscopy surgery is done in extremely young patients, precautions should be taken into consideration. Insertion of a primary trocar through the umbilical region in a newborn of less than one month old should be avoided, as umbilical vessels may be patent. It is recommended to use a video-guided primary trocar to avoid vessel and visceral injuries. Smaller size trocar/cannula (size 1.7, 3 and 5 mm) should be used.[36,37] Gasless laparoendoscopic single-site surgery is a safe and reliable alternative to the multiport laparoscopic surgery.[38]
Traditionally, oophorectomy has been advocated for the treatment of ovarian torsion.[39,40] The rationale for such operation in the past was based on the following conditions: 1) The "blue-black" ovaries are non-viable; 2) A mere detorsion would trigger possible thromboembolic phenomenon; 3) There is fear of leaving malignant tissue behind.
Currently, there is a more conservative approach, i.e. detorsion, which is reported to be safe and effective in preserving fertility.[10,41,42] Normal appearance of the ovaries have been documented during the second look surgery after detorsion.[35,43-45] Post-operative sonographic assessment is promising as evidenced by the presence of follicles in more than 88% of the detorted ovaries.[1,35,41,42,46-50] Studies[35,43] reported the long-term follow-up results after detorsion. About 5% of the patients with subfertility problems required in vitro fertilization.[35,43] Oocytes were successfully retrieved from detorted ovaries, suggesting that there are functioning ovarian tissues.[35,43]
A study[51] also advocated additional procedures during detorsion, which include cystectomy, aspiration and bivalving. However, only detorsion is recommended to be performed in the "blue-black" ovaries. Cystectomy should be carried out probably six weeks later if the cyst persists. Technically it would be more difficult to enucleate the cyst from the gangrenous ovarian tissue and secure the hemostasis. Styer and Laufer[51] suggested bivalving for the detorted ovaries to reduce the ovarian intracapsular pressure while increasing arterial perfusion. They reported normal follicular function in 4 of the 5 patients who underwent bivalving.
Currently, the reported incidence of pulmonary embolism is only 0.2% in cases of adnexal torsion. But detorsion does not increase the incidence of thromboembolism.[1,35,47]
Ovarian malignancies constitute 1% of all malignancies in children.[13] And only 1.8% of the twisted ovaries are malignant.[15] Most histopathological studies showed that there are no underlying diseases with a low incidence of malignancy.[7,23,27,52,53] Intra-operatively, the ovaries were found to be enlarged because of edematous and ischemic changes after torsion.
In most cases of torsion, the tumor was found to be at early stage, thus it could be cured with surgical resection alone or even with delayed resection after several weeks. If the tumor is in an advanced stage, it can be diagnosed intra-operatively. Nevertheless, correct clinical judgment should be made by the attending surgeon as the ovary may be distorted because of torsion.[54] In case of macroscopic appearance of the bluish black ovary, it is difficult to differentiate a torsed ovary from a torsed teratoma; hence teratoma is diagnosed only after the second-look surgery. However, in case of constant diagnostic doubt, it may be necessary to prepare an intraoperative frozen section to exclude the torsion of a teratoma.[55]
Several factors are associated with malignancy in children. In those aged 1 to 8 years, the presence of abdominal mass or precocious puberty has the greatest percentage of malignancy.[13,53,56-60] Oltmann et al[61] reported that a mass of more than 8 cm in size with a solid area is more likely malignant. Tumor markers like ¦Â-HCG, ¦ÁFP, and CA125 can be used to detect malignancies. The levels of some of the markers can be elevated according to the subtype of the tumor.[62,63] However, a low level of tumor markers is not an absolute indicator to exclude presence of malignancies. There are cases of ovarian torsions with elevated levels of tumor markers in the presence of a benign tumor. Hence, these findings suggest that cautions should be taken during a radical operation in the presence of elevated levels of tumor markers.[64] No doubt, preoperative risk stratification could assist surgeons in their decision-making for preserving the ovaries.
Role of oophoropexy
Patients with ovarian torsion of the normal adnexa, treated conservatively with detorsion, are at an increased risk of recurrent torsion of the ipsilateral side and the contralateral adnexa.[65,66] Thus, oophoropexy is the most common procedure for the prevention of recurrence of torsion.[67]
Several techniques of oophoropexy have been reported.[68-71] But there is no unified technique nor any consensus about it. The techniques include suturing the ovary to the pelvic sidewall, usually at the level of the pelvic brim[68-70] or to the back of the uterus[71] or to the uterosacral ligaments.[14] In cases of particularly elongated utero-ovarian ligaments, the techniques used are plication of the utero-ovarian ligaments by either suturing the proximal and distal ends together[69,72] or by shortening the ligaments with placement of an endoloop (Ethicon, Somerville, NJ).[73] These procedures have been performed in recent years via laparoscopy; but measures must be taken to identify the iliac vessels and ureters before plication.[14,74] It is recommended that permanent, non-absorbable sutures be used for all procedures.[75] Surgical clips have also been used to pex the ovary to the sidewalls.[74]
Oophoropexy, however, is controversial over whether it should be performed, whether it should be done at emergency surgery or later, which method is better, and whether one or both sides should be fixed.[14,75] Oophoropexy has been shown to reduce future fertility because of interference with fallopian tubal blood supply or tubal function or with ovarian communication with the fallopian tubes.[21,64,68,76] Fuchs et al[75] followed up six patients after oophoropexy and found that torsion recurred only in one patient. The six patients resumed spontaneous menstruation and two of them conceived and gave a birth. Another consideration is the risk of an endoloop placement that leads to tissue necrosis.[75]
Plication of the utero-ovarian ligaments is the preferred technique of oophoropexy as it has less effect on future fertility. Besides, it is easy to perform with laparoscopy and appears to have few post-operative complications.[74-76] Although oophoropexy remains controversial in the treatment of primary ovarian torsion, it is feasible in certain clinical situation such as recurrent torsion, loss of contralateral ovary and anatomically vulnerable ovary.
Conclusions
Ovarian torsion should be suspected in girls with abdominal pain. Its diagnosis remains a great challenge because of its non-specific manifestations and lack of diagnostic tools. Laparoscopic detorsion is the treatment of choice regardless the color of the ovaries during the surgery. Oophoropexy should be individualized in patients with ovarian torsion.
Funding: None.
Ethical approval: Not needed.
Competing interest: The authors have no conflicts of interest relevant to this article.
Contributors: All authors did literature search and participated in the writing of the article.
 
 
References
1   Galinier P, Carfagna L, Delsol M, Ballouhey Q, Lemasson F, Le Mandat A, et al. Ovarian torsion. Management and ovarian prognosis: a report of 45 cases. J Pediatr Surg 2009;44:1759-1765.
2   Piper HG, Oltmann SC, Xu L, Adusumilli S, Fischer AC. Ovarian torsion: diagnosis of inclusion mandates earlier intervention. J Pediatr Surg 2012;47:2071-2076.
3   Guthrie BD, Adler MD, Powell EC. Incidence and trends of pediatric ovarian torsion hospitalizations in the United States, 2000-2006. Pediatrics 2010;125:532-538.
4   Hibbard LT. Adnexal torsion. Am J Obstet Gynecol 1985;152:456-461.
5   Chang YJ, Yan DC, Kong MS, Wu CT, Chao HC, Luo CC, et al. Adnexal torsion in children. Pediatr Emerg Care 2008;24:534-537.
6   Oltmann SC, Fischer A, Barber R, Huang R, Hicks B, Garcia N. Cannot exclude torsion--a 15-year review. J Pediatr Surg 2009;44:1212-1216; discussion 1217.
7   Beaunoyer M, Chapdelaine J, Bouchard S, Ouimet A. Asynchronous bilateral ovarian torsion. J Pediatr Surg 2004;39:746-749.
8   Smorgick N, Maymon R, Mendelovic S, Herman A, Pansky M. Torsion of normal adnexa in postmenarcheal women: can ultrasound indicate an ischemic process? Ultrasound Obstet Gynecol 2008;31:338-341.
9   Mordehai J, Mares AJ, Barki Y, Finaly R, Meizner I. Torsion of uterine adnexa in neonates and children: a report of 20 cases. J Pediatr Surg 1991;26:1195-1199.
10 Cass DL. Ovarian torsion. Semin Pediatr Surg 2005;14:86-92.
11 Hasson J, Tsafrir Z, Azem F, Bar-On S, Almog B, Mashiach R, et al. Comparison of adnexal torsion between pregnant and nonpregnant women. Am J Obstet Gynecol 2010;202:536.e1-536.e6.
12 Jeanty C, Frayer EA, Page R, Langenburg S. Neonatal ovarian torsion complicated by intestinal obstruction and perforation, and review of the literature. J Pediatr Surg 2010;45:e5-e9.
13 Cass DL, Hawkins E, Brandt ML, Chintagumpala M, Bloss RS, Milewicz AL, et al. Surgery for ovarian masses in infants, children, and adolescents: 102 consecutive patients treated in a 15-year period. J Pediatr Surg 2001;36:693-699.
14 Dumont T, Caccia N, Allen L. Pediatric synchronous bilateral ovarian torsion: a case report and review of the literature. J Pediatr Surg 2011;46:e19-e23.
15 Oltmann SC, Fischer A, Barber R, Huang R, Hicks B, Garcia N. Pediatric ovarian malignancy presenting as ovarian torsion: incidence and relevance. J Pediatr Surg 2010;45:135-139.
16 Kokoska ER, Keller MS, Weber TR. Acute ovarian torsion in children. Am J Surg 2000;180:462-465.
17 Uckuyu A, Ozcimen EE, Sevinc Ciftci FC. Unilateral congenital ovarian and partial tubal absence: report of four cases with review of the literature. Fertil Steril 2009;91:936.e5-e8.
18 Pabuccu E, Kahraman K, Taskın S, Atabekoglu C. Unilateral absence of fallopian tube and ovary in an infertile patient. Fertil Steril 2011;96:e55-e57.
19 Fitzhugh VA, Shaikh JR, Heller DS. Adnexal torsion leading to death of an infant. J Pediatr Adolesc Gynecol 2008;21:295-297.
20 Havlik DM, Nolte KB. Sudden death in an infant resulting from torsion of the uterine adnexa. Am J Forensic Med Pathol 2002;23:289-291.
21 Breech LL, Hillard PJ. Adnexal torsion in pediatric and adolescent girls. Curr Opin Obstet Gynecol 2005;17:483-489.
22 Meyer JS, Harmon CM, Harty MP, Markowitz RI, Hubbard AM, Bellah RD. Ovarian torsion: clinical and imaging presentation in children. J Pediatr Surg 1995;30:1433-1436.
23 Anders JF, Powell EC. Urgency of evaluation and outcome of acute ovarian torsion in pediatric patients. Arch Pediatr Adolesc Med 2005;159:532-535.
24 Poonai N, Poonai C, Lim R, Lynch T. Pediatric ovarian torsion: case series and review of the literature. Can J Surg 2013;56:103-108.
25 Cass DL. Ovarian torsion. Semin Pediatr Surg 2005;14:86-92.
26 Liu H, Wang X, Lu D, Liu Z, Shi G. Ovarian masses in children and adolescents in China: analysis of 203 cases. J Ovarian Res 2013;6:47
27 Wilkinson C, Sanderson A. Adnexal torsion -- a multimodality imaging review. Clin Radiol 2012;67:476-483.
28 Servaes S, Zurakowski D, Laufer MR, Feins N, Chow JS. Sonographic findings of ovarian torsion in children. Pediatr Radiol 2007;37:446-451.
29 Stark JE, Siegel MJ. Ovarian torsion in prepubertal and pubertal girls: sonographic findings. AJR Am J Roentgenol 1994;163:1479-1482.
30 Sasaki KJ, Miller CE. Adnexal torsion: review of the literature. J Minim Invasive Gynecol 2014;21:196-202.
31 Wolfman WL, Kreutner K. Laparoscopy in children and adolescents. J Adolesc Health Care 1984;5:261-265.
32 Steyaert H, Meynol F, Valla JS. Torsion of the adnexa in children: the value of laparoscopy. Pediatr Surg Int 1998;13:384-387.
33 Mayer JP, Bettolli M, Kolberg-Schwerdt A, Lempe M, Schlesinger F, Hayek I, et al. Laparoscopic approach to ovarian mass in children and adolescents: already a standard in therapy. J Laparoendosc Adv Surg Tech A 2009;19 Suppl 1:S111-S115.
34 Göçmen A, Karaca M, Sari A. Conservative laparoscopic approach to adnexal torsion. Arch Gynecol Obstet 2008;277:535-538.
35 Cohen SB, Wattiez A, Seidman DS, Goldenberg M, Admon D, Mashiach S, et al. Laparoscopy versus laparotomy for detorsion and sparing of twisted ischemic adnexa. JSLS 2003;7:295-299.
36 Esposito C, Garipoli V, Di Matteo G, De Pasquale M. Laparoscopic management of ovarian cysts in newborns. Surg Endosc 1998;12:1152-1154.
37 Ahn JH, Chung J, Lee TS. Succesful laparoscopic surgery for 14-month-old infant with ovarian torsion. Obstet Gynecol Sci 2014;57:160-163.
38 Takeda A, Imoto S, Nakamura H. Management of pediatric and adolescent adnexal masses by gasless laparoendoscopic single-site surgery. Eur J Obstet Gynecol Reprod Biol 2014;181:66-71.
39 Spigland N, Ducharme JC, Yazbeck S. Adnexal torsion in children. J Pediatr Surg 1989;24:974-976.
40 Emonts M, Doornewaard H, Admiraal JC. Adnexal torsion in very young girls: diagnostic pitfalls. Eur J Obstet Gynecol Reprod Biol 2004;116:207-210.
41 Shalev E, Bustan M, Yarom I, Peleg D. Recovery of ovarian function after laparoscopic detorsion. Hum Reprod 1995;10:2965-2966.
42 Aziz D, Davis V, Allen L, Langer JC. Ovarian torsion in children: is oophorectomy necessary? J Pediatr Surg 2004;39:750-753.
43 Oelsner G, Bider D, Goldenberg M, Admon D, Mashiach S. Long-term follow-up of the twisted ischemic adnexa managed by detorsion. Fertil Steril 1993;60:976-979.
44 Li YT, Kuon LC, Lee PN, Kuo TC. Laparoscopic detorsion of twisted ovary. J Chin Med Assoc 2005;68:595-598.
45 Harkins G. Ovarian torsion treated with untwisting: second look 36 hours after untwisting. J Minim Invasive Gynecol 2007;14:270.
46 Mage G, Canis M, Manhes H, Pouly JL, Bruhat MA. Laparoscopic management of adnexal torsion. A review of 35 cases. J Reprod Med 1989;34:520-524.
47 Oelsner G, Cohen SB, Soriano D, Admon D, Mashiach S, Carp H. Minimal surgery for the twisted ischaemic adnexa can preserve ovarian function. Hum Reprod 2003;18:2599-2602.
48 Wang JH, Wu DH, Jin H, Wu YZ. Predominant etiology of adnexal torsion and ovarian outcome after detorsion in premenarchal girls. Eur J Pediatr Surg 2010;20:298-301.
49 Parelkar SV, Mundada D, Sanghvi BV, Joshi PB, Oak SN, Kapadnis SP, et al. Should the ovary always be conserved in torsion? A tertiary care institute experience. J Pediatr Surg 2014;49:465-468.
50 Agarwal P, Agarwal P, Bagdi R, Balagopal S, Ramasundaram M, Paramaswamy B. Ovarian preservation in children for adenexal pathology, current trends in laparoscopic management and our experience. J Indian Assoc Pediatr Surg 2014;19:65-69.
51 Styer AK, Laufer MR. Ovarian bivalving after detorsion. Fertil Steril 2002;77:1053-1055.
52 Shadinger LL, Andreotti RF, Kurian RL. Preoperative sonographic and clinical characteristics as predictors of ovarian torsion. J Ultrasound Med 2008;27:7-13.
53 Templeman C, Fallat ME, Blinchevsky A, Hertweck SP. Noninflammatory ovarian masses in girls and young women. Obstet Gynecol 2000;96:229-233.
54 Beiner ME, Gotlieb WH, Korach Y, Shrim A, Stockheim D, Segal Y, et al. Cystectomy for immature teratoma of the ovary. Gynecol Oncol 2004;93:381-384.
55 Spinelli C, Pucci V, Strambi S, Piccolo RL, Martin A, Messineo A. Treatment of ovarian lesions in children and adolescents: a retrospective study of 130 cases. Pediatr Hematol Oncol 2013 Nov 25. [Epub ahead of print]
56 Brown MF, Hebra A, McGeehin K, Ross AJ 3rd. Ovarian masses in children: a review of 91 cases of malignant and benign masses. J Pediatr Surg 1993;28:930-933.
57 Billmire D, Vinocur C, Rescorla F, Cushing B, London W, Schlatter M, et al. Outcome and staging evaluation in malignant germ cell tumors of the ovary in children and adolescents: an intergroup study. J Pediatr Surg 2004;39:424-429; discussion 424-429.
58 Einarsson JI, Edwards CL, Zurawin RK. Immature ovarian teratoma in an adolescent: a case report and review of the literature. J Pediatr Adolesc Gynecol 2004;17:187-189.
59 Niedziela M. Virilizing ovarian tumor in a 14-year-old female with a prior familial multinodular goiter. Pediatr Blood Cancer 2008;51:543-545.
60 Morowitz M, Huff D, von Allmen D. Epithelial ovarian tumors in children: a retrospective analysis. J Pediatr Surg 2003;38:331-335; discussion 331-335.
61 Oltmann SC, Garcia N, Barber R, Huang R, Hicks B, Fischer A. Can we preoperatively risk stratify ovarian masses for malignancy? J Pediatr Surg 2010;45:130-134.
62 Baranzelli MC, Bouffet E, Quintana E, Portas M, Thyss A, Patte C. Non-seminomatous ovarian germ cell tumours in children. Eur J Cancer 2000;36:376-383.
63 Schultz KA, Sencer SF, Messinger Y, Neglia JP, Steiner ME. Pediatric ovarian tumors: a review of 67 cases. Pediatr Blood Cancer 2005;44:167-173.
64 Spinelli C, Buti I, Pucci V, Liserre J, Alberti E, Nencini L, et al. Adnexal torsion in children and adolescents: new trends to conservative surgical approach -- our experience and review of literature. Gynecol Endocrinol 2013;29:54-58.
65 Pansky M, Smorgick N, Herman A, Schneider D, Halperin R. Torsion of normal adnexa in postmenarchal women and risk of recurrence. Obstet Gynecol 2007;109:355-359.
66 Ozcan C, Celik A, Ozok G, Erdener A, Balik E. Adnexal torsion in children may have a catastrophic sequel: asynchronous bilateral torsion. J Pediatr Surg 2002;37:1617-1620.
67 Abeş M, Sarihan H. Oophoropexy in children with ovarian torsion. Eur J Pediatr Surg 2004;14:168-171.
68 Celik A, Erg¨¹n O, Aldemir H, Ozcan C, Ozok G, Erdener A, et al. Long-term results of conservative management of adnexal torsion in children. J Pediatr Surg 2005;40:704-708.
69 Djavadian D, Braendle W, Jaenicke F. Laparoscopic oophoropexy for the treatment of recurrent torsion of the adnexa in pregnancy: case report and review. Fertil Steril 2004;82:933-936.
70 Righi RV, McComb PF, Fluker MR. Laparoscopic oophoropexy for recurrent adnexal torsion. Hum Reprod 1995;10:3136-3138.
71 Crouch NS, Gyampoh B, Cutner AS, Creighton SM. Ovarian torsion: to pex or not to pex? Case report and review of the literature. J Pediatr Adolesc Gynecol 2003;16:381-384.
72 Nagel TC, Sebastian J, Malo JW. Oophoropexy to prevent sequential or recurrent torsion. J Am Assoc Gynecol Laparosc 1997;4:495-498.
73 Weitzman VN, DiLuigi AJ, Maier DB, Nulsen JC. Prevention of recurrent adnexal torsion.. Fertil Steril 2008;90:2018.e1-e3.
74 Rollene N, Nunn M, Wilson T, Coddington C. Recurrent ovarian torsion in a premenarchal adolescent girl: contemporary surgical management. Obstet Gynecol 2009;114:422-424.
75 Fuchs N, Smorgick N, Tovbin Y, Ben Ami I, Maymon R, Halperin R, et al. Oophoropexy to prevent adnexal torsion: how, when, and for whom? J Minim Invasive Gynecol 2010;17:205-208.
76 Germain M, Rarick T, Robins E. Management of intermittent ovarian torsion by laparoscopic oophoropexy. Obstet Gynecol 1996;88:715-717.
 
                                                       Received July 17, 2014  Accepted after revision September 5, 2014
 
  [Articles Comment]

  title Author The End Revert Time Revert / Count

  Username:
  Comment Title: 
 
   

 

     
 
     
World Journal of Pediatric Surgery

roger vivier bags 美女 美女

Home  |  Journal Information  |  Current Issue  |  Past Issues  |  Journal Information  |  Contact Us
Children's Hospital, Zhejiang University School of Medicine, China
Copyright 2007  www.wjpch.com  All Rights Reserved Designed by eb