Outcomes after microsurgical treatment of lymphedema: A systematic review and meta-Analysis

BACKGROUND: Microsurgical treatment options for lymphedema consist mainly of lympho-venous anastomosis (LVA) and vascularized lymph node transfers (VLNT). There are no standard measurements of the effectiveness of these interventions and reported outcomes vary among studies. METHODS: A systematic review and meta-analysis was performed based on a structured search in Embase, Medline, PubMed, Cinahl, Cochrane and ProQuest in October 2020, with an update in February 2022. Firstly, a qualitative summary of the main reported outcomes was performed followed by a pooled meta-analysis of the three most frequently reported outcomes using a random effects model. Randomized controlled trials, prospective cohort, retrospective cohort, cross-sectional and case-control studies that documented outcomes following microsurgery in adult patients were included. Studies of other surgical treatments (liposuction, radical excision, lymphatic vessels transplantation) or without reported outcomes were excluded. The study protocol was registered on PROSPERO (ID: hidden per double blind review policy). No external funding was received for this review. RESULTS: 150 studies including 6'496 patients were included in the systematic review. The qualitative analysis highlighted the three most frequently reported outcomes: change in circumference, change in volume and change in number of infectious episodes per year. The overall pooled change in excess circumference across 29 studies including 1002 patients was -35.6% [95% CI, -30.8 to -40.3]. The overall pooled change in excess volume across 12 studies including 587 patients was -32.7% [95% CI, -19.8 to -45.6] and the overall pooled change in number of cutaneous infections episode per year across 8 studies including 248 patients was -1.9 [95% CI, -1.4 to -2.3]. The vast majority of the studies included were case-series and cohorts which intrinsically expose to a risk of selection bias. CONCLUSION: The current available evidence supports lymphovenous anastomosis and vascularized lymph nodes transfers as effective treatments to reduce the severity of secondary lymphedema. Standardization of staging method, outcomes measurements and reporting is paramount in future research in order to allow comparability across studies and pooling of results.