A systematic review has demonstrated that microsurgical treatment for the prevention of lower-extremity lymphoedema (LEL) is safe, effective and durable, irrespective of disease stage. Published in the Journal of Vascular Surgery: Venous and Lymphatic Disorders (JVS-VL), the evidence synthesised in the review serves to inform the American Venous Forum (AVF) and American Vein and Lymphatic Society (AVLS) guideline committee in the development of clinical recommendations for lymphoedema management.
“Evaluation and treatment of chronic lymphoedema have advanced substantially over the past decades, driven by improvements in imaging, conservative therapy, and super microsurgical techniques,” note the authors, led by Peter Gloviczki (Semmelweis University, Budapest, Hungary). They add that, although several consensus statements and practice guidelines addressing lymphoedema management have been published, the methodological quality of said guidelines is low. In response to this, the AVF and AVLS collaborated to produce new evidence-based practice guidelines using data collected from the present review.
Looking to define indications for lymphatic microsurgery—which mainly includes lymphovenous anastomosis (LVA) and vascularised lymph node transfer (VLNT)—the review extracted data from electronic databases between the years 2010 and 2025. Twenty-six English-language systematic reviews and 14 meta-analyses were analysed; no randomised controlled trials were identified. Among included reviews, 20 evaluated the treatment of LEL, 16 of which included upper-extremity lymphoedema. Six assessed immediate lymphatic reconstruction (ILR) following tumour excision with inguinal lymphadenectomy.
The primary outcomes for LEL treatment were change in limb volume and/or circumference and change in episodes of cellulitis/lymphangitis. The authors note that percentage reductions refer to reductions in excess limb volume or circumference relative to baseline or the contralateral limb, unless otherwise specified. Secondary outcomes included patient-reported outcomes, namely pain and validated general or disease-specific quality-of-life measures, major and minor complications, and postoperative need for compression garments.
In determining eligible studies, the AVF and AVLS guideline committee prioritised seven clinical questions using the Patient, Intervention, Comparator, Outcomes (PICO) framework:
- Outcomes of microsurgical treatment compared with conservative management for LEL
- Outcomes of microsurgical treatment compared with conservative management of cancer-related LEL
- Outcomes of microsurgical treatment compared with conservative management of post-traumatic LEL
- Outcomes of microsurgical treatment compared with conservative management of primary LEL
- Comparative outcomes of LVA vs. VLNT for LEL
- Outcomes of ILR for prevention of LEL following tumour excision and lymphadenectomy
- Outcomes of ILR for prevention of LEL following excision of extremity dermatologic malignancies and lymphadenectomy
Results from the review demonstrated that microsurgical treatment of lower-extremity lymphoedema resulted in limb volume or circumference reduction that ranged from 34.16% to 46.8%, with follow-up periods spanning one month to eight years. Postoperative cellulitis decreased by a mean of 2.1 episodes per year.
Gloviczki and colleagues write that symptoms and/or quality of life improved in 50% to 100% of patients. Immediate lymphatic reconstruction performed at the time of lymphadenectomy reduced the risk of lymphoedema by 30.3 cases per 100 patients treated. The authors add that low-quality evidence had previously suggested a possible association between immediate lymphatic reconstruction and worse oncologic outcomes in patients with lower-extremity melanoma and squamous cell carcinoma.
Concerning patient-reported outcomes, the authors note that an improvement in quality of life was reported in six studies, although the magnitude of change “varied widely”. Mean preoperative-to-postoperative differences ranged from 2 to 5.3 for overall score, with large standard deviations across pooled estimates. Gloviczki et al state that greater quality-of-life improvements were seen in patients who underwent VLNT vs. LVA.
“Our umbrella review found that 18 of 20 systematic reviews consistently reported that LVA and VLNT are safe, effective, and durable, with meaningful reductions in limb volume or circumference. Significant decrease of cellulitis was recorded in 11 systematic reviews,” write the authors.
“Over the past two decades, super microscopic lymphatic surgery has undergone a substantial renaissance, expanding the safety, precision, and clinical applicability of both LVA and VLNT. These advances have not only enhanced therapeutic efficacy but have also enabled preventive strategies for lymphoedema, like using the lymphatic microsurgical preventive healing approach [LYMPHA]. Robotic microsurgery is poised now to further transform the surgical management paradigm of lymphoedema.”
Of limitations to their study design, Gloviczki and colleagues highlight the substantial heterogeneity across the primary studies, driven by variability in preoperative and intraoperative imaging protocols, surgical techniques, postoperative care and reporting. Further, they posit that future research should prioritise “well-designed” randomised controlled trials conducted to internationally accepted reporting standards.
