Loop Electroexcision Research Articles

Cervical length regeneration after large loop electroexcision

Cervical length regeneration after large loop electroexcision

Margin status after loop electrosurgical excision procedure (LEEP) and laser excision in patients with high-grade cervical neoplasia

IntroductionEarly management of high-grade cervical intraepithelial neoplasia is one of the key steps in cervical cancer prevention after vaccination and screening. It relies on lesion removal by surgical excision, and the French National Cancer Institute (INCa) in 2016 recommend using a loop electro excision procedure (LEEP). However, the laser excision method seems to be as effective with similar rates of negative excision margins and postoperative clearance of HPV. ObjectiveThe main objective of our study was to compare the laser excision method to LEEP by evaluating the quality of the surgical margins. We also studied factors associated with the status of the margins and the depth of cones. MethodsWe conducted a retrospective unicentric study between 2009 and 2017. ResultsTwo hundred and thirty-one patients were included: 154 laser excisions and 77 LEEP. Negative surgical margin was achieved in 69.5 % of laser excisions and 72.7 % of LEEP (p = 0.649). Concerning factors predicting margin status, only a greater cone depth was associated with negative margins (OR: 0.91 (95 %CI: 0.84, 0.89); p = 0.02). The surgical technique was not found to be associated with the status of the margins (OR: 0.85 (95 %CI: 0.46,1.56); p = 0.61). Concerning factors predicting cone depth, only the LEEP was associated with a shorter cone depth (OR: 0.24 (95 %CI: 0.08, 0.69); p 0.008). Significant results are based on univariate analysis. ConclusionNo difference was found between the two technics concerning the rate of negative margins. However, LEEP seems to be associated with shorter cone depth in this study.

Management of Cervical Stenosis - Mechanical Dilatation Adjunct with Hormonal Therapy

Madam C was a 39-year-old primiparous lady having history of one IVF pregnancy delivered by Caesarean section (CS). She was found cervical intra-epithelial neoplasia (CIN) 2-3 with loop electro-excision procedure (LEEP) performed 6 months after her delivery while she was still breastfeeding. 1.8cm-thick, 2cmwide cervix was resected and diagnosed CIN 1. Two 6-monthly cervical smears were negative for CIN in the presence of transformation zone component. She presented to us 17 months after LEEP for severe lower abdominal pain which required pethidine for relief. She experienced hypomenorrhea with mainly brownish spotting, and intermenstrual spotting and dyspareunia since returning of menses 9 months after LEEP. Physical examination showed cervix was flushed with vault. Transabdominal (TAS) and transvaginal ultrasound scans (TVS) showed enlarged uterine cavity and endocervical canal filled with blood, up to 3.64cm. The clinical diagnosis was haematometra due to cervical stenosis after LEEP.

IMPROVEMENT OF CERVICAL EPITHELIUM REPAIR AND PREVENTION OF COMPLICATIONS AFTER ELECTROSURGICAL TREATMENT

The problem of optimization the management of women with cervical pathology after destructive methods of treatment is actual because of its high frequency. We used vaginal suppositories "Giaval" after loop electroexcision of the cervix to prevent complications and recurrences, accelerate the regeneration of the cervical epithelium, prevention of infectious complications.
 Aim. Study of the clinical effectiveness of the drug with hyaluronic acid to improve reparative processes in the cervical mucosa in the postoperative period.
 Materials and methods. The object for the prospective research of the clinical effect of the drug with hyaluronic acid "Giaval" were 50 women who underwent loop FOTEK E81MV loop electroexcision of the cervix with the presence of CIN I and CIN II according to cytomorphological examination and colposcopy and the presence of LSIL after histological examination. The work was carried out on the clinical basis of the Department of Obstetrics and Gynecology named after I.D. Lanovoho IFNMU. According to the principle of simple randomization, patients were divided into two equal clinical groups, depending on the prescribed treatment. The main (first) clinical group (n = 25) included patients who from 7 days after electroexcision were prescribed vaginal suppositories "Giaval" for 1 suppository in the vagina at night for 15 days. In the control (second) group, women received Methyluracil suppository twice a day for 10 days. The control examination, bacterioscopic, cytological examination and extended colposcopy were performed 6 weeks after treatment and then once every 3 months during the year. During the analysis of the effectiveness of treatment, the results of cervical epithelialization were evaluated according to the following criteria: full effect, absent or incomplete effect, recurrence. Variational and statistical processing of research results were performed using the programs SPSS Statistics 22 and StatSoft Statistica.
 Results. During examination patients of both groups, no significant difference in the anamnesis or objective data were found. In the patients of the first group already on the third day using of vaginal suppositories "Giaval" there was a sharp decrease in vaginal discharge in contrast to the control group, where the discharge was intensive and continued for about a week. Lower abdominal pain bothered 3 (12%) women in the control group. Six weeks after PEE in the main clinical group, complete epithelialization was observed in 23 women (92%) who received postoperative treatment with Giaval. At the same time, in patients of the control group complete epithelialization was observed in only 17 women (68%), in the rest incomplete epithelialization was observed on the background of inflammatory smear type. The period of complete repair of postoperative wound defects of the cervix was 39.3 ± 1.8 and 47.4 ± 2.3 days, respectively in patients of the first and second groups.
 Six months after treatment all women in the main group had normal colposcopy and cytology. Abnormal colposcopy and cytology after treatment, which was considered a relapse, was diagnosed in 2 (8%) patients of the second group. Cervical stenosis was also diagnosed in 6 (24%) patients in the same group.
 Conclusions. Using of vaginal suppositories "Giaval" improves the repair of the epithelium of the cervical mucosa, reduces the duration of vaginal discharge, normalizes the biocenosis of the vagina, which increases the effectiveness of treatment and reduces the frequency of postoperative complications, improve women's quality of life. The use of "Giaval" suppositories are safe and comfortable for women as it has no side effects.

Human Papillomavirus Vaccination Prior to Loop Electroexcision Procedure Does Not Prevent Recurrent Cervical High-grade Squamous Intraepithelial Lesions in Women Living With Human Immunodeficiency Virus: A Randomized, Double-blind, Placebo-controlled Trial.

Women living with human immunodeficiency virus (HIV), especially in sub-Saharan Africa, are at high risk for cervical high-grade squamous intraepithelial lesions (HSIL) and cervical cancer. These women have high HSIL recurrence rates after loop electroexcision procedure (LEEP). Retrospective studies suggest that human papillomavirus (HPV) vaccination improves response to treatment of cervical HSIL. We performed a double-blind, randomized clinical trial enrolling 180 women living with HIV in Johannesburg, South Africa, diagnosed with cervical HSIL by colposcopic biopsy. Women received quadrivalent HPV vaccine or placebo (1:1) at entry, week 4, and week 26. LEEP was performed at week 4. Colposcopic-directed biopsies and cervical cytology were performed at weeks 26 and 52. The primary endpoint, cervical HSIL by histology or cytology at either week 26 or 52, was compared between arms using χ 2 analysis. Participant characteristics included median age of 39 years and median CD4 count 489 cells/μL, and 94% had HIV suppression. One hundred seventy-four women completed the vaccine/placebo series and had evaluable results at week 26 or 52. The proportion experiencing the primary endpoint was similar in the vaccine and placebo groups (53% vs 45%; relative risk, 1.18 [95% confidence interval, .87-1.6]; P = .29). HSIL recurrence was associated with a LEEP biopsy result of HSIL and detection of HSIL at the margins of the LEEP sample. This study did not support HPV vaccination to prevent recurrent HSIL after LEEP in women living with HIV. Recurrent HSIL was high despite virologic suppression. Improved treatments are needed for HSIL to reduce the burden of cervical cancer among women living with HIV. NCT01928225.

A sustainable model for raising colposcopy expertise in low-to-middle-income countries

ObjectiveThe objective of the study was to assess the effectiveness of training low-to-middle-income countries' local healthcare providers using the Train-the-trainers model in basic colposcopy for cervical cancer prevention.MethodThis project was...

Sedoanalgesia with dexmedetomidine and ketamine during endoscopic resection of an obstructing tumor of tracheal bifurcation in the patient with lung cancer and its atelectasis

The technique of multimodal sedoanalgesia with dexmedetomidine (DMM) and ketamine in combination with lidocaine, which was used in 55 years old male patient for loop electroexcision of a tumor of the right main bronchus, originating from the right lung (adenocarcinoma), which caused atelectasis of this lung and prolapsing into the bifurcation region, is presented. The endotracheal fragment of the tumor periodically blocked the mouth of the left main bronchus, causing attacks of asphyxiation. DMM has the unique ability to cause efficient sedation and moderate analgesia in combination with an antistress effect, and most importantly, without spontaneous breathing depression. In similar situations, these properties of DMM make it an agent of choice for anesthetic management. When working in reflexogenic zones, the addition of small doses of ketamine can increase the effectiveness of the method due to analgesic properties and insignificant effect on respiration. Intravenous administration of lidocaine plus terminal anesthesia with this local anesthetic complements the anesthetic protection.

Endoscopic papillectomy and endoscopic papillosphincterotomy for benign diseases of the major duodenal papilla

The aim — to evaluate the possibility of clinical application of the major duodenal papilla resection by endoscopic techniques for various diseases.Materials and methods. 32 patients with benign stenosis and benign tumours of major duodenal papilla were treated in 2014 — 2017. Of these, 10 (31.25 %) women and 22 (68.75 %) men were between the ages of 36 and 64, the average age were 52 years. Depending on the nature of major duodenal papilla (MDP) lesions and their endoscopic treatment types, patients with MDP disease were divided into two groups: first group — 21 patients (65.6 %) with benign stenosis of the MDP and the second group with 11 patients (34.3 %) with benign tumours of MDP. Loop electro excision was performed in 9 patients, a combination of loop electroexcitation with sphincterotomy (EST) was performed in 13 patients, a combination of endoscopic papillectomy (EP) with argon‑plasma destruction in 6 patients, a combination of EP and electrical destruction in 5 patients. Endoprosthesis of the common bile duct was performed in 9 patients, 4 patients underwent endoprosthetics of the pancreatic duct, and endoprosthetics of both ducts were performed in 19 patients.Results and discussion. Complications were noted in 9 (28.1 %) patients. In the long‑term period, all patients are alive, functional disorders of the organs were not revealed.Conclusions. Endoscopic examination allows to determine the visual signs of MDP lesions (the papilla tissue changes). The diagnostic efficiency of ERCPG was 81.5 %. Clinical experience has shown that EPST can significantly reduce the number of repeated surgical operations on the biliary tract and significantly reduce the incidence of postoperative complications and mortality rate in patients with hepatopancreatoduodenal area pathology.

Cytologic-Histologic Discrepancies in Pathology of the Uterine Cervix: Analysis of the Clinical and Pathologic Factors.

Cytologic-histologic correlation (CHC) represents a documented effort to obtain and compare, when available, gynecologic cytology reports with an interpretation of high-grade squamous intraepithelial lesion or malignancy, with the subsequent histopathology report, and to determine the possible cause of any discrepancy. The correlation is influenced by multiple closely interdependent clinical and pathologic factors. Many of these factors including the sensitivity and accuracy of colposcopy-directed biopsy, the diligence of the colposcopist, and the attributes of the cervical lesion represent "preanalytical" factors which can significantly affect the CHC outcome, but are often less emphasized during CHC process. The status of "gold standard" of cervical biopsy histology will be less "golden" if clinicians miss, during colposcopy, the lesion which had been flagged by cytology. CHC also serves as one of the important assurance tools to monitor and improve the pathology laboratory overall quality, and the ability of the pathologists to enhance their diagnostic interpretation. As pathologists, we should make every effort to improve on CHC, by applying systematic approaches, both in technical laboratory and interpretive diagnosis, which increase yield and reduce diagnostic discrepancies. The widespread use of Human Papilloma Virus testing and p16 immunohistochemistry have significantly enhanced diagnostic accuracy both in cytology and in histology. Herein, we review the intimate relationships and factors that may govern discrepancies between cytology, colposcopy-directed biopsies, and biopsies with subsequent Loop Electroexcision Procedure for cervical squamous intraepithelial lesions. Ultimately the projected risk for high-grade squamous intraepithelial lesion and cancer and the suggested management guidelines are directly tied in with effective CHC.

Invasión del espacio linfovascular en lesión intraepitelial escamosa de alto grado de cérvix. ¿Realidad o artefacto?

Background The loop electro excision procedure is a simple and widely used diagnostic and therapeutic technique in cervical lesions. This procedure is usually performed in the ambulatory setting under local anaesthesia. Subjects and methods We describe a case of lymphovascular space invasion detected in the cone biopsy of a high-grade squamous intraepithelial lesion of the cervix. Conclusions Although the prognostic significance of LVSI is controversial, its identification precludes conservative treatments.

Role of HPV testing in the follow-up of women treated for cervical dysplasia

The aim of study was to investigate factors predicting persistence or relapse of disease after cervical conisation for high-grade squamous intraepithelial lesions (CIN 2 or 3). The study involved 78 women with high-grade squamous intraepithelial lesions, conservatively treated with loop electroexcision procedure for cervical conisation and subsequent with CO(2) laser-vaporisation of the cervical bed. Histological specimens were totally included and examined by an experienced pathologist. To evaluate the efficacy of treatment, the patients were examined with colposcopy and Pap smear 4 months after surgery and with PCR to search for and genotyping of HPV, 10 months after treatment. During the post-treatment follow-up, the cytologic examination showed persistent/relapsing disease in six patients (7.6%). In only 1 case, the deep margin of the cone was considered positive for CIN (16%).Ten months after treatment, viral typing revealed the persistence of high-risk HPV in all of these patients. Conversely, the viral follow-up of the other 72 patients without persisting/relapsing disease after treatment disclosed low-risk HPV genotypes in 6 cases, high-risk HPV in 2 cases (2.7%), whereas 7 cases had positive margins for CIN (9.7%). The risk of persistence and relapse of CIN in the group with positive margins was not statistically significant (P = 0.87), whereas it was in the group with HR-HPV positive (P = 0.000048). HPV testing is the most sensitive mean of identifying persistence or relapse early and is therefore capable of optimising follow-up after the treatment of high-grade CIN.

Linear array genotyping and hybrid capture II assay in detecting human papillomavirus genotypes in women referred for colposcopy due to abnormal Papanicolaou smear

The main objective of this study was to assess the feasibility of human papillomavirus (HPV) genotyping in women referred for colposcopy due to abnormal Papanicolaou (Pap) smear. A series of 248 women referred for colposcopy due to an abnormal Pap smear were analysed with the Roche Linear Array HPV genotyping test detecting 37 most frequent HPV types, and compared with hybrid capture II (HCII) assay for oncogenic (high-risk [HR] HPV) types as well as for p16INK4a expression using immunocytochemistry. All tests were performed in cervical samples collected in PreservCyt liquid media for liquid-based cytology (ThinPrep), and colposcopic biopsy and/or loop electro excision procedure cone biopsy was used as the gold standard. HPV16 was the single most frequent genotype (29/258; 11.7%), followed by HPV51 (4.4%), HPV66 (3.6%), HPV42, 52 and 56 (3.2% for all). Linear array genotyping test significantly predicts both abnormal colposcopy (odds ratio [OR] = 9.0; 3.12-25.93), high-grade squamous intraepithelial lesions (OR = 9.6; 1.26-74.17) and cervical intraepithelial neoplasia (CIN) 3+ (OR = 29.3; 3.95-218.06). In detecting CIN3, linear array was equivalent (97.6%) to colposcopy in sensitivity (SE), both being superior to HCII (92.7%). Concordance between linear array and HCII was moderate (Cohen's kappa kappa = 0.547; 95% confidence interval [CI]: 0.435-659). Specificity (SP) and positive predictive value (PPV) of linear array were significantly improved, if only HPV16 genotype was considered. Performance in the best balance is obtained, when linear array and colposcopy are combined, giving 82.9% SE, 93.9% SP, 73.9% PPV and 96.3% negative predictive value (NPV) as predictor of CIN3+ (OR 74.5; 95% CI: 27.36-202.72). In conclusion, linear array for HR-HPV is a highly sensitive test (97.6%) with high NPV (98.9%) in detecting CIN3+ lesions. HPV16 genotyping alone significantly improves SP and PPV of this test in management of women with abnormal cytology.

Risk Factors for Cervical Stenosis After Loop Electrocautery Excision Procedure

Obstet Gynecol 2000;96:657–60 The purpose of this study was to determine the frequency of cervical stenosis after loop electroexcision, and to attempt to identify risk factors associated with stenosis. The study group consisted of 164 women. Ten of these developed cervical stenosis following loop electroexcision. The procedure was performed utilizing a blended current. A second endocervical specimen was obtained only on some patients. Endocervical curettage was performed routinely . The authors performed univariant analysis of risk factors and then utilized a stepwise logistic regression model to determine independent predictors of cervical stenosis. Only the volume of tissue removed and the history of a prior loop excision were positively associated with cervical stenosis. Comment: Now that we have been using loop electroexcision for several years, it has become clear that cervical stenosis occurs following the technique in a small but important percentage of patients. The risk is probably somewhere around 5%, and it is quite similar to that of cryotherapy or cold-knife conization. The results of this study are certainly not unexpected. The larger the loop excision and the need to repeat the loop excision were the best predictors of stenosis compared to any other variables. I believe this article has great importance for clinicians. It is clear that the best way to prevent cervical stenosis following loop excision is not to perform the procedure in the first place. I see an ever-increasing number of women who have previously had 1 or 2 loop-excision procedures that still have a minimally abnormal cytology who are sent to me for a second opinion. In most cases, the reasons for the first excision are not at all clear. Many of these women are young and nulliparous. I believe this article underscores the need for us to consider carefully whether patients need to have minimally atypical lesions treated. (KLN)

A Comparison of Laser Ablation, Loop Electroexcision, and Cold-Knife Conization in Relation to Precise Specimen Excision in an Inanimate Model

A Comparison of Laser Ablation, Loop Electroexcision, and Cold-Knife Conization in Relation to Precise Specimen Excision in an Inanimate Model

Loop Electroexcision for Cervical Dysplasia

The loop electrosurgical excision procedure (LEEP) is an in-office treatment for cervical dysplasia that is performed with local anesthesia. In Europe,

Loop electrosurgical excision procedure for squamous intraepithelial lesions of the cervix: advantages and potential pitfalls

to evaluate the advantages and pitfalls of the loop electrosurgical excision procedure as applied to the diagnosis and treatment of cervical cancer precursors. Loop electrosurgical excision procedure using local anesthesia and colposcopic guidance was performed in an outpatient clinical setting in 1189 consecutive patients referred for colposcopy for an abnormal Papanicolaou smear during a period of 4 years. Of the 1189 patients, 915 (77%) were managed in one sitting with the "see and treat" approach, and in 274 patients endocervical curettage and cervical biopsies preceded loop electrosurgical excision procedure. One hundred nineteen (10%) patients were lost to follow-up. Twenty-one patients had either adenocarcinoma in situ (15) or microinvasive squamous cell carcinoma (six) in the loop electrosurgical excision procedure specimen, whereas the electroexcised specimens contained no lesional tissue in 166 (14%) patients. Cure (ie, disease-free at 6 months or longer) was observed in 92% of the 883 evaluable patients after a single treatment and 95% after a repeat loop electrosurgical excision procedure. High-grade squamous intraepithelial lesion was successfully treated with loop electrosurgical excision procedure in 287 (93%) of 309 patients. Complications, mainly intra- and postoperative bleeding, occurred in 7% of the patients. In most loop electrosurgical excision procedure-negative cases, the referral cytologic diagnosis or colposcopy and/or history were false-positive on review, or the biopsies performed before loop electrosurgical excision procedure removed smaller areas of abnormal tissue. Loop electrosurgical excision procedure using the see and treat approach should be limited to cytologically and colposcopically unequivocal intraepithelial lesions, and depth of excision should be controlled by colposcopy using loop electrodes of appropriate size. In doubtful cases, particularly in the young patient, disease should be ascertained by expert histology and colposcopy before definite therapy. Loop electroexcision represents an attractive means of diagnosing and treating cervical cancer precursors.

High long-term cure rate justifies routine treatment of cervical intraepithelial neoplasia grade I.

The long-term clearance of cervical intraepithelial neoplasia (CIN) Grade 1 after one treatment was studied retrospectively in 105 patients. Treatment was by CO2 laser vaporization (74 patients), cone biopsy (8), loop electroexcision (LEEP) (7), electrodiathermy (1) and hysterectomy (2); 79 of the 92 treated patients (85.9%) had normal cervical cytology and colposcopy on a mean follow-up period of 36.7 months (95% confidence interval between 33.1-40.4 months). Life table analysis showed that the probability of the cervix remaining disease free was 81% at 72 months of follow-up. Of the 13 patients with a cervical abnormality after the initial treatment, 4 had persistent CIN 1, 3 persistent human papillomavirus (HPV) infection, 2 recurrent CIN 1 and 4 had recurrent HPV infection. In contrast, of the 13 untreated patients with CIN 1, 7 (53.8%) continued to demonstrate an abnormality on the cervix after a mean follow-up period of 27.5 months (95% confidence interval between 18.8 and 36.3 months). No significant perioperative morbidity was recorded in the treated patients. The results of this study suggest that CIN 1 can be effectively eradicated in more than 80% of women with 1 treatment alone. The treatment should be considered for all these patients to spare them the psychological and emotional trauma of having to face repeated abnormal cervical cytology on follow up.

The effect of cervical loop electrosurgical excision on subsequent pregnancy outcome: North American experience

OBJECTIVE: Our purpose was to determine pregnancy outcome and parturition in women who were treatedby loop electrosurgical excision for squamous intraepithelial lesions. STUDY DESIGN: A series of 574 consecutive women of reproductive age (15 to 44 years old) were treated by loop electroexcision for low- and high-grade squamous intraepithelial lesions. The incidence of pregnancies was determined in these women within a 3-year period after therapy by comparing the “observed” number of pregnancies with the “expected” number of pregnancies in the study population, assumign that fertility rates in these women were the same as in the untreated general female population. Pregnancy outcome was correlated in the 53 women who were delivered of an infant with the posttreatment appearance of the cervix and birth weight with maternal smoking. RESULTS: The incidence of pregnancy in the study population was 8.5 per 100 woman years compared with 7.4 per 100 woman years in the untreated central population. Fifty-three women had 54 pregnancies, of which 46 (84%) were live births either at term (40) or between 37 and 39 weeks of gestation (6), and three patients are at present at 24, 34, and 36 weeks of gestation. There were two stillbirths and three first-trimester spontaneous abortions. Premature delivery was not observed. External os stenosis (one case), shortening of the cervix (one case), and repeat electroexcision (four cases) had no adverse effect on pregnancy and parturition. Smoking ≥ 10 cigarettes per day before and during pregnancy, rather than loop electrosurgical excision per se, was associated with lower-birth-weight babies than those of nonsmokers ( p < 0.01). CONCLUSION: Loop electrosurgical excision to a maximum depth of 1.5 cm and a mean frontal diameter of 1.8 cm does not appear to have adverse effects on subsequent pregnancy outcome and parturition.