Siegler Efraim, Zarfati Doron, Sjechter Eduardo, Bar-Am Amiram, Mushonov Rami, Bornstein Jacob
Israeli Society of Colposcopy and Cervical Pathology, Colposcopy Units of Rambam Medical Center, Western Galilee Hospital, Nahariya, Israel.
Harefuah. 2004 May;143(5):330-4, 392, 391.
Large loop excision of the transformation zone (LLETZ) is regarded as the treatment of choice in cases of Cervical Intraepithelial Neoplasia (CIN). Since the method is easy to learn and the equipment is inexpensive, many gynecologists now perform it in the clinic. Concern has been raised regarding the use of this procedure with insufficient indication by physicians who have not been adequately trained in performing LLETZ.
This article aims to verify whether the indications for LLETZ in Israel are similar to those accepted in the updated literature and to discuss the need for licensure to perform LLETZ. Licensure would limit the use of LLETZ only to professionals specifically trained to conduct this procedure.
A questionnaire was sent to gynecologists, heads of obstetrics and gynecology departments as well as managers of public and private hospitals, regarding LLETZ performed in 2001. Topics covered in the questionnaire included: the number of LLETZ procedures performed, the patient's age, pre- and post-operative histopathological diagnosis, complications, follow-up and recurrence rate. The physicians were asked to complete separate questionnaires for each of the clinics in which he or she worked.
The completed questionnaires comprised of 625 LLETZ procedures in eight public and three private colposcopy clinics. The ages of the women ranged from 18 to 70 years old, with 49% in the 18 to 34 age range. Most women (416) who underwent the LLETZ procedure had CIN grades 2 or 3. However, 128 women with CIN 1 were also treated. Among this group, 50% were confirmed CIN 1 according to the surgical specimen but 43 women had normal epithelium, 20 (15.6%) had high grade CIN (2-3) and one had invasive cancer. The most common post-operative short and long-term complication was heavy bleeding. Involvement of the surgical specimen borders was found in one fifth of the cases.
The finding that about half of the women who underwent LLETZ were below the age of 35 years is of particular significance since the health insurance agencies in Israel only cover a pap smear screening test for women between the ages 35-54, once every three years. Therefore, there is an indication to start screening from the age 18. Similar to other countries in the world, the main indication to perform LLETZ in Israel is CIN 2-3. However, performing LLETZ for CIN 1 in many cases, and administering general anesthesia in certain centers, calls for the introduction of licensure for performing LLETZ. Involvement of the margins of the specimen in the neoplastic process in one fifth of the patients was similar to that reported in the literature. The various centers in Israel have different approaches as to the required surveillance period for women following LLETZ. It is suggested that women with involvement of the surgical specimen margins by CIN should be under medical surveillance at colposcopy clinics for a period of at least eight years.
转化区大环形切除术（LLETZ）被视为宫颈上皮内瘤变（CIN）病例的首选治疗方法。由于该方法易于学习且设备成本低廉，许多妇科医生现在都在临床中开展此项手术。对于未接受过充分LLETZ操作培训的医生在指征不充分的情况下使用该手术的情况，人们已有所担忧。
本文旨在验证以色列LLETZ的指征是否与最新文献中认可的指征相似，并讨论实施LLETZ的许可需求。许可将把LLETZ的使用限制在经过专门培训以进行该手术的专业人员中。
就2001年实施的LLETZ手术向妇科医生、妇产科主任以及公立和私立医院的管理人员发送了一份调查问卷。问卷涵盖的主题包括：LLETZ手术的实施数量、患者年龄、术前和术后组织病理学诊断、并发症、随访及复发率。要求医生为其工作的每个诊所分别填写问卷。
完成的问卷涵盖了8家公立和3家私立阴道镜诊所的625例LLETZ手术。女性年龄范围为18至70岁，其中49%在18至34岁年龄段。接受LLETZ手术的大多数女性（416例）患有CIN 2级或3级。然而，也有128例CIN 1级的女性接受了治疗。在这组患者中，50%根据手术标本确诊为CIN 1级，但43名女性上皮正常，20名（15.6%）患有高级别CIN（2 - 3级），1名患有浸润癌。最常见的术后短期和长期并发症是大出血。五分之一的病例发现手术标本边缘受累。
接受LLETZ手术的女性中约一半年龄在35岁以下这一发现具有特别重要的意义，因为以色列的健康保险机构只为35至54岁的女性每三年提供一次巴氏涂片筛查测试。因此，有指征从18岁开始筛查。与世界上其他国家类似，以色列实施LLETZ的主要指征是CIN 2 - 3级。然而，在许多情况下对CIN 1级进行LLETZ手术，以及在某些中心实施全身麻醉，都需要引入LLETZ手术许可。五分之一的患者肿瘤过程累及标本边缘这一情况与文献报道相似。以色列的各个中心对于LLETZ术后女性所需的监测期有不同的做法。建议手术标本边缘被CIN累及的女性在阴道镜诊所接受至少八年的医学监测。
