月经初潮前与初潮后卵巢扭转的临床表现与诊治分析

Clinical manifestations,diagnosis and treatment of ovarian torsion before and after menarche

目的探讨月经初潮前与初潮后卵巢扭转的临床特点与治疗方法。方法2014年5月至2019年12月金华市人民医院妇产科收治年龄<18岁的卵巢扭转患儿共52例。其中,月经初潮前患儿22例,年龄为(9.18±2.30)岁;月经初潮后患儿30例,年龄为(14.00±2.08)岁。记录患儿入院时年龄、是否月经初潮、临床表现、发病至入院时间、入院至手术时间、术前辅助检查结果、术中情况和术后随访等相关内容;所有患儿均在全身麻醉及心电监护下行腹腔镜探查术。结果月经初潮前患儿,术前在就诊年龄、体格检查发现盆腔包块、超声检查发现卵巢占位性病灶、扭转卵巢最大径及卵巢容积上均小于月经初潮后患儿,差异具有统计学意义(P<0.05)。月经初潮前与初潮后患儿,在卵巢扭转度数、扭转色泽为黑色或紫黑色例数、正常卵巢扭转例数方面的差异具有统计学意义(P<0.05),而月经初潮后患儿,卵巢扭转色泽为暗红色,术后卵巢囊腺瘤的例数多于月经初潮前患儿,差异具有统计学意义(P<0.05)。卵巢扭转复位后80.8%(42/52)的卵巢得到保留。月经初潮前患儿的术后病理以成熟囊性畸胎瘤[36.4%(8/22)]和卵巢囊肿[27.3%(6/22)]为主,约36.4%(8/22)无卵巢病理性改变;而月经初潮后患儿以卵巢囊肿[50.0%(15/30)]、囊腺瘤[30.0%(9/30)]和成熟囊性畸胎瘤[16.7%(5/30)]为主。月经初潮前8例正常卵巢扭转的患儿中,2例行扭转卵巢切除术;而卵巢占位合并卵巢扭转14例患儿中,5例行扭转卵巢切除术。术后平均随访时间为16个月,范围为5~24个月,均未出现切口感染、卵巢扭转复发、肺栓塞、健侧卵巢扭转等并发症;月经初潮后患儿中,仅1例在术后1年出现患侧卵巢成熟畸胎瘤复发,再次手术治愈。所有患儿中,保留卵巢的患儿在术后3个月复查子宫附件B型超声,与术前相比,扭转侧卵巢形态及大小基本恢复正常,月经初潮前患儿术前和术后3个月卵巢大小为(2.01±0.70)cm比(2.21±0.37)cm,差异无统计学意义(P>0.05);月经初潮后患儿术前和术后3个月卵巢大小为(3.08±0.58)cm比(3.22±0.53)cm,差异无统计学意义(P>0.05),且无卵巢萎缩情况。结论小儿卵巢扭转常表现为腹痛、恶心呕吐等非特异性症状,及早发现并制定合理治疗方案可使患儿卵巢得到有效保留,避免卵巢缺失。

Objective To explore the clinical characteristics and treatments of ovarian torsion before and after menarche.Methods From May 2014 to December 2019,a total of 52 children aged<18 years with ovarian torsion were admitted.Among them,there were 22 children pre-menarche with an age range of(9.18±2.30)years;30 children post-menarche with an age range of(14.00±2.08)years.Admission age,menarche,clinical manifestations,time from onset to admission,time from admission to surgery,results of preoperative auxiliary examination,intraoperative findings and postoperative follow-ups were recorded.Laparoscopic exploration was performed under general anesthesia and electrocardiographic monitoring.Results In children pre-menarche,presenting age,pelvic mass during physical examination,ovarian space-occupying lesions on ultrasonography,maximal ovarian diameter and ovarian volume were less than those post-menarche and the differences were statistically significant(P<0.05).The differences in degree of ovarian torsion,the number of cases with black or purple-black torsion color and the number of cases with normal ovarian torsion between children at pre/post-menarche had statistical significance(P<0.05)while color of ovarian torsion was dark red at post-menarche.The number of cases of postoperative ovarian cystadenoma was more than that at pre-menarche and the differences had statistical significance(P<0.05).And 80.8%(42/52)of ovaries were preserved after torsion reduction.The postoperative pathologies at pre-menarche were mature teratoma(36.4%,8/22)and ovarian cyst(27.3%,6/22)and(36.4%,8/22)showed no ovarian pathological changes;while at post-menarche,ovarian cyst(50.0%,15/30),cystadenoma(30.0%,9/30)and mature teratoma(16.7%,5/30)predominated.Among 8 children with normal ovarian torsion pre-menarche,2 underwent torsion oophorectomy;among 14 children with ovarian mass and ovarian torsion,5 underwent torsion oophorectomy.The average postoperative follow-up period was 16(5-24)months.None had such complications as incision infection,recurrence of ovarian torsion,pulmonary embolism or torsion of unaffected ovary.Among children post-menarche,only 1 had a recurrence of mature ovarian teratoma at 1 year postoperatively and was cured by reoperation.Ultrasonic reexamination of uterine adnexa was performed at 3 months postoperatively in children with ovarian preservation.Compared with that pre-operation,shape and size of torsion ovary basically normalized.Ovarian size was(2.01±0.70)cm vs.(2.21±0.37)cm at pre-menarche and 3 months postoperatively and the difference had no statistical significance(P>0.05);ovarian size was(3.08±0.58)cm vs.(3.22±0.53)cm at post-menarche and 3 months postoperatively and the difference had no statistical significance(P>0.05).There was no ovarian atrophy.Conclusions Ovarian torsion presents frequently with such non-specific symptoms as abdominal pain,nausea and vomiting in children.Early detection and devising a reasonable treatment protocol can effectively preserve the ovaries and prevent ovarian loss.