Changing Practices in the Surgical Management of Adnexal Torsion: An Analysis of the National Surgical Quality Improvement Program Database

Abstract

ABSTRACT Ovarian torsion occurs when the ovary twists on its own supporting ligaments, resulting in ischemia and possible necrosis. This is a surgical emergency to restore adnexal perfusion, and even in the setting of a necrotic-appearing ovary, conservative management with detorsion alone does not increase postoperative complications compared with oophorectomy. Traditionally, oophorectomy was performed in these cases, and despite the new evidence supporting ovarian conservation, oophorectomy remains common. Despite updated guidelines by the American College of Obstetricians and Gynecologists (ACOG) in 2016, it is unclear to what extent practice patterns have changed in the years since. This retrospective cohort study aimed to describe the trend in surgical management of ovarian torsion between 2008 and 2020 and to describe the changes in management before and after the publication of the updated ACOG guidelines. The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was used to identify women aged 18 to 50 years who underwent surgery for adnexal torsion between 2008 and 2020. Patients were classified as having undergone oophorectomy or ovarian conservation using ICD codes, and patients undergoing concurrent surgeries or procedures related to pregnancy or unrelated to adnexal torsion were excluded. Patients were then grouped into pre-ACOG guidelines (2008–2016) and post-ACOG guidelines (2017–2020). Patient demographics, clinical data, perioperative characteristics, and 30-day postoperative adverse events were queried and compared between year cohorts and surgical management groups. The primary outcome was proportion of oophorectomies, described as the number of oophorectomies over the total number of all torsion surgeries per year, with a 95% confidence interval (CI). Multivariable regression analysis was conducted to determine the odds of oophorectomy versus ovarian conservation between year cohorts while controlling for confounders. A total of 1791 patients were included in this study, with 402 (22.4%) in the 2008–2016 cohort and 1389 (77.6%) in the 2017–2020 cohort. Across both groups, 542 patients (30.3%) underwent ovarian conservation, and 1249 (69.7%) underwent oophorectomy. The overall proportion of oophorectomies was similar between the 2008–2016 and 2017–2020 cohorts (71.9% vs 69.1%; adjusted odds ratio, 0.94; 95% CI, 0.71–1.25). When evaluating the effects of time on odds of oophorectomy, a significant decrease in the odds of oophorectomy performed successively each year over the entire study period was found (average decrease, −1.6%/year; 95% CI, −3.0% to −0.22%), although the yearly successive decrease in the odds of oophorectomy remained similar before and after 2017. The median hospital length of stay was longer, and the hospital admission rates were high in the oophorectomy group compared with the ovarian conservation group. The results of this study demonstrate that 69.7% of surgeries for adnexal torsion involved oophorectomy rather than conservative management, although a modest statistical trend toward fewer oophorectomies over the study period was observed. No observable effect on the trend of oophorectomy versus ovarian conservation was observed before and after the publication of ACOG guidance recommending ovarian conservation.