By Rebecca H. Allen, MD, MPH, Editor
Ryles HT, Hong CX, Andy UU, Farrow MR. Changing practices in the surgical management of adnexal torsion: An analysis of the National Surgical Quality Improvement Program Database. Obstet Gynecol 2023;141:888-896.
In this national retrospective cohort study from 2008 to 2020, there were 1,791 surgeries for adnexal torsion, with 30.3% involving ovarian conservation and the remainder undergoing oophorectomy. The proportion of oophorectomies compared to ovarian conservation decreased slightly over the study period (average decrease, -1.6% per year; 95% confidence interval, -3.0%- to -0.22%).
Clinical guidelines recommend ovarian preservation, when possible, for the treatment of adnexal torsion. The authors of this study sought to estimate the trends in surgical management of adnexal torsion over time using a national database. They specifically wanted to assess adherence to the 2016 American College of Obstetricians and Gynecologists (ACOG) guideline on the issue, which recommended ovarian conservation for women who desire fertility.1
This was a retrospective cohort study from 2008 to 2020 that used the American College of Surgeons National Surgical Quality Improvement Program database. This database collects clinical and surgical data from 700 academic and community hospitals in the United States. The study included women aged 18 to 50 years who underwent surgery for adnexal torsion, which was defined as International Classification of Diseases, Ninth Revision (ICD-9) code 620.5 and ICD-10 code N83.5. The type of surgery and whether oophorectomy was performed were defined using the Current Procedural Terminology (CPT) codes 59840, 58720, and 58661 (if the ICD-10 code was associated with ovarian torsion rather than tubal torsion). Ovarian conservation was defined as fulfilling the following three criteria: no associated oophorectomy CPT code, no associated excluded CPT code, and the primary CPT code included a procedure consistent with conservative management, such as diagnostic laparoscopy or ovarian cystectomy.
Patients who underwent concomitant hysterectomy, myomectomy, bowel surgery, or pregnancy-related procedures were excluded. Patient demographics, clinical characteristics, and surgical data were collected. Oophorectomy and ovarian conservation rates were compared each year of the study and in two cohorts with respect to ACOG’s guidance (2008-2016 and 2017-2020).
In the study period, 2,503 patients underwent surgery for adnexal torsion, and 1,791 met the inclusion and exclusion criteria. The 2008-2016 cohort contained 402 patients (22.4%) and the 2017-2020 cohort contained 1,389 patients (77.6%). A total of 542 patients (30.3%) underwent ovarian conservation and 1,249 patients (69.7%) underwent oophorectomy. The median age of the patients was 32 years. Compared to patients undergoing ovarian conservation, patients who underwent oophorectomy were more likely to be older, have hypertension and anemia, have a higher body mass index (BMI), and have higher American Society of Anesthesiologists (ASA) classifications but were less likely to have surgery as an emergency case.
The overall proportion of oophorectomies was similar between the 2008-2016 and 2017-2020 cohorts (71.9% vs. 69.1%; odds ratio [OR], 0.89; 95% confidence interval [CI], 0.69-1.16), with little change after adjustment for anemia, BMI, and smoking (adjusted OR, 0.94; 95% CI, 0.71-1.25). There was a slight yearly decrease in oophorectomies over the entire study period (average decrease, -1.6% per year; 95% CI, -3.0% to -0.22%). However, there was no difference in the rates of change before 2016 and after 2016. There was no difference between the two groups in composite surgical complications, even after controlling for age, BMI, hypertension, emergency classification, and surgical approach (adjusted OR, 0.91; 95% CI, 0.52-1.57).
COMMENTARY
The authors of this study showed that the rates of oophorectomy in the treatment for adnexal torsion did not change meaningfully over time. In general, two-thirds of cases used oophorectomy for management and one-third preserved the ovary. Adnexal torsion, a twisting of the ovary or fallopian tube on its own supporting ligaments, is considered a surgical emergency to prevent ovarian or tubal ischemia and necrosis. Adnexal torsion is a surgical diagnosis, and patients are brought to the operating room for laparoscopic exploration when the combination of clinical and radiologic suspicion is high.2
There is no test that can confirm the preoperative diagnosis of torsion. In the past, oophorectomy often was performed for ovaries that appeared ischemic or necrotic because of the fear that leaving such an ovary in place could cause thrombosis or sepsis. Subsequent studies have shown that even necrotic-appearing ovaries can be left in place and, after the blood supply is restored by detorsion, they will regain their function.2,3 The appearance of the ovary should not be an indication for removal. As shown in this study, there is no difference in surgical complications by leaving the ovary in place compared to oophorectomy.
According to ACOG’s Practice Bulletin 174, “Evaluation and Management of Adnexal Masses,” published in 2016, “Adnexal torsion in women who want to remain fertile should be managed by reduction of the torsion with concomitant ovarian cystectomy for identified ovarian pathology.”1 Unfortunately, the authors of this study did not find any change in practice after this guideline was published. The conclusions of this study are, of course, limited by the data that were collected, since there may have been coding errors and unmeasured confounding factors. In addition, there was no way for the authors to determine how many patients did not desire fertility or had other issues that promoted a decision for oophorectomy, such as intraoperative findings.
The authors of this study focused on adult women. The preferred management of adnexal torsion in children and adolescents is much more accepted and practiced. Studies demonstrate that ovarian conservation rates in this population approach 95%.4 It is unclear why management patterns differ in younger and older patients; however, pediatric and adolescent gynecologists and surgeons are more accustomed to ovarian conservation and likely feel more comfortable with it.
In addition, there is greater urgency to saving the ovary in children and adolescents to preserve their fertility, and the risk of cancer is lower. In conclusion, this study did not demonstrate that modern recommendations on how to handle the ovary at the time of torsion surgery have been adopted nationally. It may take more time for this guideline to change clinical practice, since only three years of data were evaluated after it was published.
REFERENCES
- American College of Obstetricians and Gynecologists. Evaluation and Management of Adnexal Masses. Practice Bulletin Number 174. Published November 2016. https://www.acog.org/clinical/clinical-guidance/practice-bulletin/articles/2016/11/evaluation-and-management-of-adnexal-masses
- [No authors listed]. Adnexal Torsion in Adolescents: ACOG Committee Opinion No, 783. Obstet Gynecol 2019;134:e56-e63.
- Santos XM, Cass DL, Dietrich JE. Outcome following detorsion of torsed adnexa in children. J Pediatr Adolesc Gynecol 2015;28:136-138.
- Adeyemi-Fowode O, Lin EG, Syed F, et al. Adnexal torsion in children and adolescents: A retrospective review of 245 cases at a single institution. J Pediatr Adolesc Gynecol 2019;32:64-69.
