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Loop electrical excision procedure

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Loop electrical excision procedure
Other namesLarge loop excision of the transformation zone
SpecialtyGynaecology

The loop electrosurgical excision procedure (LEEP) is one of the most commonly used approaches to treat high grade cervical dysplasia (CIN II/III, HGSIL) discovered on colposcopic examination. In the UK, it is known as large loop excision of the transformation zone (LLETZ). It is considered a type of conization. [1]

LEEP has many advantages including low cost and a high success rate.[2] The procedure can be done in an office setting and usually only requires a local anesthetic, though sometimes IV sedation or a general anesthetic is used.[3] Disadvantages include reports of decreased sexual satisfaction [4] and potential for preterm labor, though a meta-analysis suggested that in patients with existing CIN lesions as opposed to controls, the risk is not more than their baseline risk. [5]

Process

When performing a LEEP, the physician uses a wire loop through which an electric current is passed at variable power settings. Various shapes and sizes of loop can be used depending on the size and orientation of the lesion. The cervical transformation zone and lesion are excised to an adequate depth, which in most cases is at least 8 mm, and extending 4 to 5 mm beyond the lesion. A second pass with a more narrow loop can also be done to obtain an endocervical specimen for further histologic evaluation.[6]

The LEEP technique results in some thermal artifact in all specimens obtained due to the use of electricity which simultaneously cuts and cauterizes the lesion, but this does not generally interfere with pathological interpretation provided depth is not exceeded.[7] The thermal artifact can be a function of depth and time.

Complications

Complications are less frequent in comparison to a cold-knife conization but can include infection and hemorrhage. [8]

A survey study has indicated that the LEEP procedure does not appear to affect fertility.[9] On the other hand, a case-control study has found an association between surgical treatment of CIN lesions and risk of infertility or subfertility, with an odds ratio of approximately 2.[10] Scarring of the cervix is a theoretical mechanism of causing trouble conceiving. This scar tissue can be massaged or broken up in a number of ways, thus allowing the cervical opening to dilate back to normal size.

A cohort study came to the result that women with a time interval from LEEP to pregnancy of less than 12 months compared with 12 months or more were at significantly increased risk for miscarriage, with risk of miscarriage of 18% compared with 4.6%, respectively.[11] On the other hand, no increased risk was identified for preterm birth after LEEP.[11] However a large meta-analysis concluded that women with CIN have a higher baseline risk for preterm birth than the general population and that LEEP as the treatment for CIN probably increase this risk further. Also, the risk of preterm birth appears to increase with multiple treatments and increasing amounts of tissue removed.[12]

A study found that women reported a statistically significant decrease in sexual satisfaction following LEEP.[4]

A systematic review and meta-analysis published in 2014 which sought to examine the differences in preterm labor risk between patients who had a LEEP procedure and those who had CIN findings concluded that there is not a significant difference between those groups in terms of risk, as might previously have been suggested. The study determined that both groups have a higher likelihood for preterm labor than healthy controls, but suggests that a LEEP procedure in a CIN patient might not carry as significant of an increase in risk for preterm labor in future pregnancies as is generally understood.[5] This perspective carries significant implications when it comes to pregnancy timing and decision making in women of child bearing age who have cervical dysplasia and would like to decide whether they should have the lesions removed before or after pregnancy. As pregnancy is generally understood to be an immune suppressed state, the viral mediated character of cervical lesions might also inform revisions to treatment recommendations in such instances.[5]

See also

References

  1. ^ "Loop Electrosurgical Excision Procedure (LEEP): Pre-Procedure, Technique, Post-Procedure". 2022-12-22. {{cite journal}}: Cite journal requires |journal= (help)
  2. ^ "Loop electrosurgical excision procedure (LEEP) for abnormal cervical cell changes". Retrieved 2016-11-27.
  3. ^ Mayeaux, E.J. Jr. "Advantages of LEEP". Archived from the original on 2006-09-04. Retrieved 2007-12-28.
  4. ^ a b Inna, Namfon; Phianmongkhol, Yupin; Charoenkwan, Kittipat (1 March 2010). "Sexual function after loop electrosurgical excision procedure for cervical dysplasia". J Sex Med. 7 (3): 1291–1297. doi:10.1111/j.1743-6109.2009.01633.x. PMID 19968775.
  5. ^ a b c Conner SN, Frey HA, Cahill AG, Macones GA, Colditz GA, Tuuli MG (April 2014). "Loop electrosurgical excision procedure and risk of preterm birth: a systematic review and meta-analysis". Obstetrics and Gynecology. 123 (4): 752–61. doi:10.1097/AOG.0000000000000174. PMC 4113318. PMID 24785601.
  6. ^ Cornforth, Tracee. "LEEP Procedure — What is LEEP? — Loop Electrosurgical Excision Procedure". About.com. Archived from the original on 2007-05-02. Retrieved 2007-12-28.
  7. ^ Khunamornpong, S.; Raungrongmorakot, K.; Siriaunkgul, S. (2001-04). "Loop electrosurgical excision procedure (LEEP) at Maharaj Nakorn Chiang Mai Hospital: problems in pathologic evaluation". Journal of the Medical Association of Thailand = Chotmaihet Thangphaet. 84 (4): 507–514. ISSN 0125-2208. PMID 11460961. {{cite journal}}: Check date values in: |date= (help)
  8. ^ Jiang, Yanming; Chen, Changxian; Li, Li (2017-01-26). "Comparison of Cold-Knife Conization versus Loop Electrosurgical Excision for Cervical Adenocarcinoma In Situ (ACIS): A Systematic Review and Meta-Analysis". PLoS ONE. 12 (1): e0170587. doi:10.1371/journal.pone.0170587. ISSN 1932-6203. PMC 5268480. PMID 28125627.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  9. ^ Turlington WT, Wright BD, Powell JL (November 1996). "Impact of the loop electrosurgical excision procedure on future fertility". J Reprod Med. 41 (11): 815–8. PMID 8951130.
  10. ^ Spracklen, C. N.; Harland, K. K.; Stegmann, B. J.; Saftlas, A. F. (2013). "Cervical surgery for cervical intraepithelial neoplasia and prolonged time to conception of a live birth: A case-control study". BJOG: An International Journal of Obstetrics & Gynaecology. 120 (8): 960–965. doi:10.1111/1471-0528.12209. PMC 3691952. PMID 23489374.
  11. ^ a b Conner, S. N.; Cahill, A. G.; Tuuli, M. G.; Stamilio, D. M.; Odibo, A. O.; Roehl, K. A.; MacOnes, G. A. (2013). "Interval from Loop Electrosurgical Excision Procedure to Pregnancy and Pregnancy Outcomes". Obstetrics & Gynecology. 122 (6): 1154–9. doi:10.1097/01.AOG.0000435454.31850.79. PMC 3908542. PMID 24201682.
  12. ^ Kyrgiou M, Athanasiou A, Kalliala IE, Paraskevaidi M, Mitra A, Martin-Hirsch PP, Arbyn M, Bennett P, Paraskevaidis E (November 2017). "Obstetric outcomes after conservative treatment for cervical intraepithelial lesions and early invasive disease". The Cochrane Database of Systematic Reviews. 11 (11): CD012847. doi:10.1002/14651858.CD012847. PMC 6486192. PMID 29095502.
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