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Reply: Operative Treatment of Peripheral Lymphedema A Systematic Meta-Analysis of the Efficacy and Safety of Lymphovenous Microsurgery and Tissue Transplant

Basta, Marten N. B.S.; Gao, Lin Lin M.D.; Wu, Liza M.D.

Plastic and Reconstructive Surgery: September 2014 - Volume 134 - Issue 3 - p 492e–493e
doi: 10.1097/PRS.0000000000000436
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Plastic and Reconstructive Surgery, Perelman School of Medicine, University of Pennsylvania Health System, Philadelphia, Pa.

Correspondence to Marten N. Basta, Plastic and Reconstructive Surgery, University of Pennsylvania Health System, 3400 Spruce Street, 10 Penn Tower, Philadelphia, Pa. 19104, marten@mail.med.upenn.edu

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Sir:

We greatly appreciate Dr. Assaf Zeltzer’s commentary about our recently published article, “Operative Treatment of Peripheral Lymphedema: A Systematic Meta-Analysis of the Efficacy and Safety of Lymphovenous Microsurgery and Tissue Transplant.”1 Several observations are highlighted that deserve further discussion.

It is duly noted that comparing lymphovenous shunt procedures with vascularized lymph node transplant procedures is replete with limitations. There are differences between the lymphovenous shunt studies, including variations in the vessels being anastomosed and the configuration of those anastomoses. Furthermore, the five lymph node transplant studies do use different vascularized flaps and different recipient sites. As such, the primary outcome of our review was not a head-to-head comparison of outcomes by technique. Instead, we compared the quantitative change in lymphedema preoperatively versus postoperatively across all techniques to assess efficacy. Our secondary outcomes included subgroup comparisons of efficacy by operative technique and anatomical site of lymphedema. It is essential that the reader takes into consideration the variability of operative techniques when evaluating the subgroup results.

Another observation is the variability of reported complication rates by technique. Although we found generally low rates of complications regardless of technique, the only conclusion we can draw based on our results, unfortunately, is that there are significant deficiencies in complications reporting among the lymphovenous shunt studies. Regarding vascularized lymph node transplant studies, the follow-up period was insufficient in each study to determine an accurate assessment of donor-site complications. Indeed, donor-site lymphedema is the dreaded complication of vascularized lymph node transplant, from the surgeon’s perspective and from the patient’s perspective.2–4

Moving forward, we hope that our systematic review not only provides valuable information regarding the safety and efficacy of microsurgical treatment of lymphedema but also encourages stricter adherence to the International Society of Lymphology’s guidelines for assessing lymphedema and improved reporting of outcomes and complications.5 Until more accurate information is available regarding donor-site complications using vascularized lymph node transplantation, our results should be interpreted with great caution, particularly by young microsurgeons at the inception of their training.

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DISCLOSURE

The authors have no financial interest to declare in relation to the content of this communication.

Marten N. Basta, B.S.

Lin Lin Gao, M.D.

Liza Wu, M.D.

Plastic and Reconstructive Surgery

Perelman School of Medicine

University of Pennsylvania Health System

Philadelphia, Pa.

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REFERENCES

1. Basta MN, Gao LL, Wu LC. Operative treatment of peripheral lymphedema: A systematic meta-analysis of the efficacy and safety of lymphovenous microsurgery and tissue transplant. Plast Reconstr Surg. 2014;133:905–913
2. Pons G, Masia J, Loschi P, Nardulli ML, Duch J. A case of donor-site lymphoedema after lymph node-superficial circumflex iliac artery perforator flap transfer. J Plast Reconstr Aesthet Surg. 2014;67:119–123
3. Vignes S, Blanchard M, Yannoutsos A, Arrault M. Complications of autologous lymph-node transplantation for limb lymphoedema. Eur J Vasc Endovasc Surg. 2013;45:516–520
4. Viitanen TP, Mäki MT, Seppänen MP, Suominen EA, Saaristo AM. Donor-site lymphatic function after microvascular lymph node transfer. Plast Reconstr Surg. 2012;130:1246–1253
5. International Society of Lymphology. . The diagnosis and treatment of peripheral lymphedema: 2009 consensus document of the International Society of Lymphology. Lymphology. 2009;42:51–60
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