Loop electrical excision procedure: Difference between revisions

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The '''loop electrosurgical excision procedure''' ('''LEEP''') is one of the most commonly used approaches to treat high grade [[cervical dysplasia]] ([[Cervical intraepithelial neoplasia|CIN]] II/III, [[High grade squamous intraepithelial lesion|HGSIL]]) and early stage [[cervical cancer]] discovered on [[colposcopy|colposcopic]] examination. In the UK, it is known as '''large loop excision of the transformation zone''' ('''LLETZ'''). It is considered a type of [[Cervical conization|conization.]] <ref name="g323">{{Citecite journalweb |date last=2022-12-22Pflugner | first=Lindsey | title=Loop Electrosurgical Excision Procedure (LEEP): Pre-ProcedureBackground, TechniqueIndications, Post-Procedure | website=Medscape Reference | date=2024-03-21 | url=https://emedicine.medscape.com/article/1998067-overview?form | access-date=fpf2024-08-08}}</ref> It has been in use since the 1970s, after its invention by Dr. Sheldon Weinstein. <ref>{{Cite web |title=Loop Electrosurgical Excision Procedure (LEEP) {{!}} Embryo Project Encyclopedia |url=https://embryo.asu.edu/pages/loop-electrosurgical-excision-procedure-leep |access-date=2023-11-16 |website=embryo.asu.edu}}</ref>

LEEP has many advantages including low cost and a high success rate.<ref>{{cite web |url=http://www.webmd.com/cancer/cervical-cancer/loop-electrosurgical-excision-procedure-leep-for-abnormal-cervical-cell-changes |title=Loop electrosurgical excision procedure (LEEP) for abnormal cervical cell changes |access-date=2016-11-27}}</ref> 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.<ref>{{cite web |url=http://lib-sh.lsuhsc.edu/fammed/atlases/leep/leepadv.html |title=Advantages of LEEP |access-date=2007-12-28 |last=Mayeaux |first=E.J. Jr.|url-status=dead |archive-url=https://web.archive.org/web/20060904092302/http://lib-sh.lsuhsc.edu/fammed/atlases/leep/leepadv.html |archive-date=2006-09-04 }}</ref> Disadvantages include reports of decreased sexual satisfaction <ref name=":0">{{cite journal |last1=Inna |first1=Namfon |last2=Phianmongkhol |first2=Yupin |last3=Charoenkwan |first3=Kittipat |date=1 March 2010 |title=Sexual function after loop electrosurgical excision procedure for cervical dysplasia |journal=J Sex Med |volume=7 |issue=3 |pages=1291–1297 |doi=10.1111/j.1743-6109.2009.01633.x |pmid=19968775}}</ref> and potential for [[preterm labor]], though a meta-analysis published in 2014 suggested that in patients with existing CIN lesions as opposed to controls, the risk is not more than their baseline risk. <ref name="pmid24785601">{{cite journal |vauthors=Conner SN, Frey HA, Cahill AG, Macones GA, Colditz GA, Tuuli MG |date=April 2014 |title=Loop electrosurgical excision procedure and risk of preterm birth: a systematic review and meta-analysis |journal=Obstetrics and Gynecology |volume=123 |issue=4 |pages=752–61 |doi=10.1097/AOG.0000000000000174 |pmc=4113318 |pmid=24785601}}</ref> Approximately 500,000 LEEP procedures are performed in the U.S. annually. <ref>{{Cite journal |last1=Sklavos |first1=Martha M. |last2=Spracklen |first2=Cassandra N. |last3=Saftlas |first3=Audrey F. |last4=Pinto |first4=Ligia A. |date=2014 |title=Does Loop Electrosurgical Excision Procedure of the Uterine Cervix Affect Anti-Müllerian Hormone Levels? |journal=BioMed Research International |volume=2014 |pages=875438 |doi=10.1155/2014/875438 |issn=2314-6133 |pmc=3953513 |pmid=24707500 |doi-access=free }}</ref>

==Process==

When performing a LEEP, the [[physician]] uses a wire loop through which an [[electric current]] is passed at variable [[Power (physics)|power]] settings. Various shapes and sizes of loop can be used depending on the size and orientation of the lesion. The [[cervix|cervical]] transformation zone and [[lesion]] are excised to an adequate depth, which in most cases is at least 8&nbsp;mm, and extending 4 to 5&nbsp;mm beyond the lesion. A second pass with a more narrow loop can also be done to obtain an [[endocervical]] specimen for further [[histology|histologic]] evaluation.<ref>{{cite web |url=http://womenshealth.about.com/cs/surgery/a/leepprocedure.htm|title= LEEP Procedure — What is LEEP? — Loop Electrosurgical Excision Procedure|access-date=2007-12-28 |first=Tracee |last= Cornforth|publisher=About.com|archive-url=https://web.archive.org/web/20070502071454/http://womenshealth.about.com/cs/surgery/a/leepprocedure.htm|archive-date=2007-05-02}}</ref>

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 [[pathology|pathological]] interpretation provided depth is not exceeded.<ref>{{Cite journal |last1=Khunamornpong |first1=S. |last2=Raungrongmorakot |first2=K. |last3=Siriaunkgul |first3=S. |date=April 2001 |title=Loop electrosurgical excision procedure (LEEP) at Maharaj Nakorn Chiang Mai Hospital: problems in pathologic evaluation |url=https://pubmed.ncbi.nlm.nih.gov/11460961/ |journal=Journal of the Medical Association of Thailand = Chotmaihet Thangphaet |volume=84 |issue=4 |pages=507–514 |issn=0125-2208 |pmid=11460961}}</ref> The thermal artifact can be a function of depth and time.

==Complications==

Complications are less frequent in comparison to a [[cervical conization|cold-knife conization]] but can include [[infection]] and [[hemorrhage]]. <ref>{{Cite journal |last1=Jiang |first1=Yanming |last2=Chen |first2=Changxian |last3=Li |first3=Li |date=2017-01-26 |title=Comparison of Cold-Knife Conization versus Loop Electrosurgical Excision for Cervical Adenocarcinoma In Situ (ACIS): A Systematic Review and Meta-Analysis |journal=PLOS ONE |volume=12 |issue=1 |pages=e0170587 |doi=10.1371/journal.pone.0170587 |issn=1932-6203 |pmc=5268480 |pmid=28125627 |bibcode=2017PLoSO..1270587J |doi-access=free }}</ref>

LEEP effectively reduces the risk of cancer developing or spreading but it causes an increased risk of [[Preterm birth|premature birth]] in future pregnancies.<ref name=":1">{{Cite journal |last1=Athanasiou |first1=Antonios |last2=Veroniki |first2=Areti Angeliki |last3=Efthimiou |first3=Orestis |last4=Kalliala |first4=Ilkka |last5=Naci |first5=Huseyin |last6=Bowden |first6=Sarah |last7=Paraskevaidi |first7=Maria |last8=Arbyn |first8=Marc |last9=Lyons |first9=Deirdre |last10=Martin-Hirsch |first10=Pierre |last11=Bennett |first11=Phillip |last12=Paraskevaidis |first12=Evangelos |last13=Salanti |first13=Georgia |last14=Kyrgiou |first14=Maria |date=2022-07-25 |title=Comparative effectiveness and risk of preterm birth of local treatments for cervical intraepithelial neoplasia and stage IA1 cervical cancer: a systematic review and network meta-analysis |journal=The Lancet Oncology |language=en |volume=23 |issue=8 |pages=1097–1108 |doi=10.1016/S1470-2045(22)00334-5 |pmc=9630146 |pmid=35835138}}</ref><ref name=":2">{{Cite journal |date=2023-11-10 |title=Prevention of cervical cancer: what are the risks and benefits of different treatments? |url=https://evidence.nihr.ac.uk/alert/prevention-of-cervical-cancer-what-are-the-risks-and-benefits-of-different-treatments/ |journal=NIHR Evidence |type=Plain English summary |publisher=National Institute for Health and Care Research |doi=10.3310/nihrevidence_60599|s2cid=265201829 |url-access=subscription }}</ref><ref name="pmid29095502">{{cite journal |vauthors=Kyrgiou M, Athanasiou A, Kalliala IE, Paraskevaidi M, Mitra A, Martin-Hirsch PP, Arbyn M, Bennett P, Paraskevaidis E |date=November 2017 |title=Obstetric outcomes after conservative treatment for cervical intraepithelial lesions and early invasive disease |journal=The Cochrane Database of Systematic Reviews |volume=11 |issue=11 |pages=CD012847 |doi=10.1002/14651858.CD012847 |pmc=6486192 |pmid=29095502}}</ref> Following LEEP there is a 10% chance of cancer recurrence and 11% chance of preterm birth.<ref name=":1" /><ref name=":2" /> 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.<ref name="pmid24785601" />

A survey study has indicated that the LEEP procedure does not appear to affect [[fertility]].<ref>{{cite journal |vauthors=Turlington WT, Wright BD, Powell JL |title=Impact of the loop electrosurgical excision procedure on future fertility |journal=J Reprod Med |volume=41 |issue=11 |pages=815–8 |date=November 1996 |pmid=8951130 }}</ref> On the other hand, a [[case-control study]] has found an association between surgical treatment of CIN lesions and risk of [[female infertility|infertility]] or subfertility, with an odds ratio of approximately 2.<ref>{{Cite journal | last1 = Spracklen | first1 = C. N. | last2 = Harland | first2 = K. K. | last3 = Stegmann | first3 = B. J. | last4 = Saftlas | first4 = A. F. | title = Cervical surgery for cervical intraepithelial neoplasia and prolonged time to conception of a live birth: A case-control study | doi = 10.1111/1471-0528.12209 | journal = BJOG: An International Journal of Obstetrics & Gynaecology | volume = 120 | issue = 8 | pages = 960–965 | year = 2013 | pmid = 23489374 | pmc =3691952 }}</ref> 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.

Some women report a small decrease in sexual arousal and satisfaction following LEEP but there is a lack of high quality research showing how LEEP affects sexual function.<ref>{{Cite journal |last1=Litman |first1=Ethan A. |last2=Cigna |first2=Sarah T. |date=2022-04-07 |title=Female Sexual Dysfunction in Women After Treatment of Cervical Dysplasia |url=https://linkinghub.elsevier.com/retrieve/pii/S2050052122000221 |journal=Sexual Medicine Reviews |language=en |volume=10 |issue=3 |pages=360–366 |doi=10.1016/j.sxmr.2022.02.003|pmid=35400602 |s2cid=248029304 |url-access=subscription }}</ref>

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.<ref name=Chescheir2013>{{Cite journal | last1 = Conner | first1 = S. N. | last2 = Cahill | first2 = A. G. | last3 = Tuuli | first3 = M. G. | last4 = Stamilio | first4 = D. M. | last5 = Odibo | first5 = A. O. | last6 = Roehl | first6 = K. A. | last7 = MacOnes | first7 = G. A. | doi = 10.1097/01.AOG.0000435454.31850.79 | title = Interval from Loop Electrosurgical Excision Procedure to Pregnancy and Pregnancy Outcomes | journal = Obstetrics & Gynecology | volume = 122 | issue = 6 | pages = 1154–9 | year = 2013 | pmid = 24201682| pmc = 3908542}}</ref> On the other hand, no increased risk was identified for [[preterm birth]] after LEEP.<ref name=Chescheir2013/>

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.<ref name="pmid29095502">{{cite journal | vauthors = Kyrgiou M, Athanasiou A, Kalliala IE, Paraskevaidi M, Mitra A, Martin-Hirsch PP, Arbyn M, Bennett P, Paraskevaidis E | title = Obstetric outcomes after conservative treatment for cervical intraepithelial lesions and early invasive disease | journal = The Cochrane Database of Systematic Reviews | volume = 11 | issue = 11 | pages = CD012847 | date = November 2017 | pmid = 29095502 | pmc = 6486192 | doi = 10.1002/14651858.CD012847 }}</ref>

A study found that women reported a statistically significant decrease in sexual satisfaction following LEEP.<ref name=":0">{{cite journal|title=Sexual function after loop electrosurgical excision procedure for cervical dysplasia|first1=Namfon|last1=Inna|first2=Yupin|last2=Phianmongkhol|first3=Kittipat|last3=Charoenkwan|date=1 March 2010|journal=J Sex Med|volume=7|issue=3|pages=1291–1297|doi=10.1111/j.1743-6109.2009.01633.x|pmid=19968775}}</ref>

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.<ref name="pmid24785601">{{cite journal | vauthors = Conner SN, Frey HA, Cahill AG, Macones GA, Colditz GA, Tuuli MG | title = Loop electrosurgical excision procedure and risk of preterm birth: a systematic review and meta-analysis | journal = Obstetrics and Gynecology | volume = 123 | issue = 4 | pages = 752–61 | date = April 2014 | pmid = 24785601 | pmc = 4113318 | doi = 10.1097/AOG.0000000000000174 }}</ref> 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.<ref name="pmid24785601"/>

==See also==

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[[Category:Female genital procedures]]

[[Category:Surgical oncology]]

[[Category:Cervical cancer]]