Goran Augustin1, 2
(1)
Department of Surgery Division of Gastrointestinal Surgery, University Hospital Center Zagreb, Zagreb, Croatia
(2)
School of Medicine University of Zagreb, Zagreb, Croatia
Abstract
Isolated twisting of a Fallopian tube is an uncommon event. The incidence from previous reports is 1/1,500,000 women [1]. The diagnosis of isolated twisted Fallopian tube in pregnancy is also very rare; only 12 % of cases are found during this time [2]. Phupong and Intharasakda found incidence of 1/120,000 pregnancies from a 10-year period (1991–2000) in their institution [3]. The English language literature concerning twisting or torsion of the Fallopian tube and pregnancy available from Cumulative Index Medicus from 1962 to 1965 and Medline from the year 1966 to 2009 were reviewed. There have been nine publications reporting 15 cases [3–5]. All cases occurred in reproductive age (range 20–41 years). The condition occurred in the first trimester in 13.3 % of cases, in the second trimester in 20 %, in the third trimester in 60 %, and intrapartum in 6.7 % of cases.
13.1 Incidence
Isolated twisting of a Fallopian tube is an uncommon event. The incidence from previous reports is 1/1,500,000 women [1]. The diagnosis of isolated twisted Fallopian tube in pregnancy is also very rare; only 12 % of cases are found during this time [2]. Phupong and Intharasakda found incidence of 1/120,000 pregnancies from a 10-year period (1991–2000) in their institution [3]. The English language literature concerning twisting or torsion of the Fallopian tube and pregnancy available from Cumulative Index Medicus from 1962 to 1965 and Medline from the year 1966 to 2009 were reviewed. There have been nine publications reporting 15 cases [3–5]. All cases occurred in reproductive age (range 20–41 years). The condition occurred in the first trimester in 13.3 % of cases, in the second trimester in 20 %, in the third trimester in 60 %, and intrapartum in 6.7 % of cases.
13.2 Pathophysiology and Risk Factors
13.2.1 Pathophysiology
Collectively, the existing reports indicate that the mechanism underlying tubal torsion is apparently a sequential mechanical event. The process begins with the mechanical blockage of the adnexal veins and lymphatic vessels by ovarian tumor, pregnancy, hydrosalpinx, or pelvic adhesions after tubal infection or pelvic operation. This obstruction causes pelvic congestion and local edema with subsequent enlargement of the adnexa, which in turn induces partial or complete torsion [6].
13.2.2 Risk Factors
Torsion of the Fallopian tube can occur at any age, and most of the patients are under 30 years of age. Youssef et al. noted factors that could possibly influence the occurrence of Fallopian tube torsion and divided them into two categories: intrinsic factors such as congenital anomalies of the Fallopian tube and acquired pathology of the Fallopian tube, for example, hydrosalpinx, hematosalpinx, neoplasm, surgery, autonomic dysfunction, and abnormal peristalsis, and extrinsic factors, for example, changes in the neighboring organs such as neoplasm, adhesions, pregnancy, mechanical factors, movement or trauma to the pelvic organs, or pelvic congestion [7]. More detailed theories for tubal torsion can be classified as [3, 8–16]:
· Anatomic abnormalities: long mesosalpinx, tubal abnormalities, hematosalpinx, hydrosalpinx, hydatid of Morgagni, tubal ectopic pregnancy, paratubal cyst
· Physiological abnormalities: abnormal peristalsis or hypermotility of tube, tubal spasm, and intestinal peristalsis
· Hemodynamic abnormalities: venous congestion in the mesosalpinx (progesterone effects of edema and increased vascularity of tissues)
· Sellheim theory: sudden body position changes
· Trauma, previous surgery, or disease (tubal ligation, PID)
· Gravid uterus (direct mechanical cause and progesterone effects of edema and increased vascularity of tissues)
Many reports indicate that twisted Fallopian tube is more common on the right [8–18] than the left [3, 5]. This may be due to the presence of the sigmoid colon on the left [8, 9, 12, 14, 16] or to slow venous flow on the right side, which may result in congestion [16]. The other reason is that more cases of right-sided pain are operated because of the suspicion of appendicitis [9, 13], whereas left-sided cases may be missed and resolve spontaneously.
13.3 Clinical Presentation
The most common presenting symptom is pain, which begins in the affected lower abdomen or pelvis but may radiate to the flank or thigh [8–14, 16]. The onset of pain is sudden and cramp like and may be intermittent [9, 12, 14]. Other associated symptoms include nausea, vomiting, bowel and bladder complaints, and scant uterine bleeding [9, 11–14, 16]. Pelvic examination may reveal a tender, tense adnexal mass associated with cervical tenderness [19]. The case by Phupong and Intharasakda presented with only left lower abdominal pain and nausea and vomiting [3]. Because these signs, symptoms, and physical findings are associated with other common diseases, the diagnosis is never established before operation [8–18].
13.4 Diagnosis and Differential Diagnosis
13.4.1 Differential Diagnosis
The differential diagnosis includes [8, 9, 12–14, 16]:
· Acute appendicitis
· Ectopic pregnancy
· Pelvic inflammatory disease
· Twisted ovarian cyst
· Ruptured follicular cyst
· Degenerative leiomyoma
· Placental abruption
· Urinary tract disease
· Renal colic
13.4.2 Diagnosis
13.4.2.1 Laboratory Findings
The body temperature, white blood cell count, and erythrocyte sedimentation rate may be normal or slightly elevated [9, 11, 12, 14, 16].
13.4.2.2 Abdominal Ultrasound
There have been reports of using ultrasound in the diagnosis of twisted Fallopian tube [20]. The ultrasonographic appearance includes an elongated, convoluted cystic mass, tapering as it nears the uterine cornu and demonstration of the ipsilateral ovary [20] or normal ipsilateral ovary, free fluid, a dilated tube with thickened echogenic walls, and internal debris or a convoluted echogenic mass [21, 22]. High impedance, reversal, or absence of vascular flow in the tube has also been reported although, in practice, confident spectral Doppler analysis of the tubal wall may be difficult [23].
13.4.2.3 Abdominal CT
Reported CT findings of isolated tubal torsion include an adnexal mass, a twisted appearance to the Fallopian tube, dilated tube greater than 15 mm, a thickened and enhancing tubal wall, and luminal CT attenuation greater than 50 Hounsfield units consistent with hemorrhage. Secondary signs include free intrapelvic fluid, peritubular fat stranding, enhancement and thickening of the broad ligament, and regional ileus [21, 24].
The English language literature concerning twisting or torsion of the Fallopian tube and pregnancy available described 9 publications reporting 15 cases [3–5]. All of the cases were not able to be diagnosed as twisted Fallopian tube before surgery.
13.5 Treatment and Prognosis
13.5.1 Treatment
The management of this condition is early operation [9, 14, 18].
13.5.1.1 Types of Operation
If the tube is beyond recovery (gangrenous, suspected malignancy), then salpingectomy is necessary.
Indications for untwisting (detorsion) are:
· Twisting is incomplete or recent [8–10, 12, 14–16].
· Ischemic damage appears to be reversible [8–10, 12, 14–16].
· No malignancy and ruptured/unruptured ectopic pregnancy suspected [4].
13.5.1.2 Laparotomy/Laparoscopy
Laparotomy is often performed [8–12, 14–16, 18], but laparoscopic surgery has recently been described in the management of twisted Fallopian tube [3, 13] and is currently recommended as access of choice in general population [25]. A recent report confirmed that laparoscopic surgery is safe for use in the first trimester of pregnancy [26]. Recovery is much faster after laparoscopy than laparotomy. Laparoscopy also causes fewer pelvic adhesions which are particularly important for women of reproductive age who wish to preserve their fertility. If the patient is in her third trimester, most surgeons prefer laparotomy, because laparoscopy is technically very difficult [25].
13.5.2 Prognosis
The English language literature concerning twisting or torsion of the Fallopian tube and pregnancy consists of 9 publications reporting 15 cases [3–5]. There were no associated findings during operation in 26.7 % of cases, while reported associated findings were paratubal cyst in 20 %, ovarian cyst in 13.3 %, and 6.7 % of cyst of the mesosalpinx, cyst in the broad ligament, sactosalpinx, hydrosalpinx, hematosalpinx, and unruptured tubal ectopic pregnancy. Most of the cases were treated with salpingectomy of the affected tube. In all of the cases, the pregnancies ended with a favorable outcome (except tubal ectopic pregnancy).
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